Ijmrhs Vol 3 Issue 2

DOI: 10.5958/j.2319-5886.3.2.
050
International Journal of Medical Research

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 2 (April - Jun)
Received: 10th Oct 2013
Coden: IJMRHS
Revised: 22nd Dec 2013
Copyright @2014
ISSN: 2319-5886
Accepted: 4th Jan 2014
Research Article
EFFECT OF AGE ON TEST PERFORMANCE IN COMMUNITY DWELLING ELDERLY PEOPLE:

6 MINUTES WALK TEST AND TEN STEPS TEST
*Mahajan Pallavi Janardhan1, Mistry Hetal M 2
Department of physiotherapy, Topiwala National Medical College, Mumbai, Maharashtra, India
*Corresponding author email: palsmahajan86@gmail.com
ABSTRACT
The data available in literature for test performance in elderly people are less and insufficient for use as a basis of
comparison. The aim of the study was to investigate age related changes in functional performance tests and to
determine criterion values depending on age in older adults who are functioning independently in the community.
Aim: To study the effect of age on test performance in 6 Minute Walk Test and Ten Step test in community
dwelling elderly people. Objectives: To assess 6 minute walk distance, time taken to perform ten step test and to
report data within age cohorts. Method: Total 90 subjects were included and divided into 3 groups according to
age group, A-(61-65), B-(66-70), and C-(71-75) in each 30 subjects. 6 Minute Walk Test and Ten Step Test were
performed on them. The data obtained was analyzed using one way ANOVA and post hoc test. Result: The mean
6 MWD in group A was 317.13 35.44 mts, in group B was 297.10 47.14 mts and in group C was 262.83
42.14 mts. The 10 Step Test time was found to be 11.36 2.06 sec in group A, 13.24 3.49 sec in group B and
14.74 3.16 sec in group C. The results showed that there is a progressive decrease in the 6 MWD and
progressive increase in the time taken to complete TST with increasing age. Conclusion: From the results it can
be concluded that there is a progressive decrease in the test performance (6MWT & 10 Step test) with age in
community dwelling elderly people. The results of this study can be used as reference values while performing
performance tests for elderly people in the community.
Keywords: 6 minute walk test, 10 step test, Community dwelling
INTRODUCTION
In recent years there has been an increasing
international awareness of health issues relating to
aging populations.1 There has been a sharp increase in
the number of older persons worldwide.2,3 According
to the Demographic Profile of Elderly, India carries
15% of world population. The fastest growing age
group by percentage is between 65 75 years of age.
With a decline in fertility and mortality rates,
compared with an improvement in child survival and
increased life expectancy, there is a progressive rise
in the number of elderly persons (accepting 60 years
of age as a practical demarcation for defining
elderly). Aging results in significant decline in
muscle power and exercise capacity. Therefore,

elderly often function at the limit of their capacity in
order to fulfill activities of daily living.
Determination of remaining physical capacity is
important in clinical decision making.4 Many
independent older adults often due to their sedentary
lifestyles, function dangerously close to their
maximum ability level during normal activities.
Climbing stairs or getting out of a chair requires the
use of near maximum efforts for many older
individuals. Early identification of physical decline
and appropriate interventions can help to prevent
228
Pallavi et al.,
Int J Med Res Health Sci. 2014;3(2):228-232
functional impairments such as in walking and stair

climbing that often results in fall and physical frailty.5
Quality of life in old age depends to a large extent on
being able to continue to do what you want without
pain as long as possible. Being able to perform
everyday activities like personal care, household
work requires the ability to perform functional
movements such as walking, stair climbing, and
standing. These functional movements in turn are
dependent on having sufficient physiological reserve
i.e. strength, balance, endurance, flexibility.
Functional fitness performance is having the
physiological capacity to perform normal everyday
activities safely and independently without undue
fatigue. 5 Many senior fitness instructors have been
frustrated with lack of tests available to assess the
functional fitness of older adults particularly tests that
have accompanying performance standards.
The ability to walk for a distance is a quick and
inexpensive measure of physical function and
important component of quality of life. It reflects the
capacity to undertake day to day activities. 6 Minute
Walk Test is used to measure the maximum distance
that a person can walk in 6 minutes. It is a sub
maximal test of aerobic capacity commonly used to
assess cardiovascular and pulmonary function.9 6
MWT can be performed by many elderly frail people
who cannot be tested with standard maximal cycle
ergometer or treadmill tests. 10 Step Test is a test that
measures the time taken by an individual to step up
10 times. It is a simple, reliable test and requires short
time.
However, there is little data available in literature
describing variation in test performance for older
adults who are functioning independently. The
available data are less and often difficult for
clinicians to use as a basis of comparison in
documentation because they are not presented in
terms of age and gender groupings. Hence a study is
needed which will give an accurate range of
measurements on these tests in different age groups.
Thus the aim of the study was to investigate aging
related changes in physical and functional,
performance and to determine criterion values
depending on age in community dwelling elderly
people.
METHOD
After the approval of the Institutional Ethics
committee TNMC, Mumbai, total 90 subjects were
included in the present study and they were divided

into 3 groups based on their age. Group A: age group
of 61-65 years, Group B: age group of 66-70 years
and Group C: age group of 71-75 years of age. N=30
in each group. Type of sampling was a convenience
sampling and the source was an urban population in
South Mumbai.
Inclusion criteria
1. Subjects between 60 to 75 years of age
2. Both male and female
3. Subjects who can tolerate standing, walking for at
least 6 minutes and stepping without any
complaints
4. Not dependent on assistance of another person or
supportive device for walking or stepping
Exclusion criteria
1. Use of any assistive device for walking or stair
climbing
2. Any acute illness in past 3 months
3. Subjects not willing to participate in the study
Outcome measures -1. 6 minute walk test, 2. 10 step
test
Subjects who fulfilled the inclusion criteria were
taken for the study. All procedure was adequately
explained to the patients and written consent was
taken from each one before starting the test.
Procedure: Case record form was filled and
demographic data collected from each subject.
Resting heart rate, respiratory rate, blood pressure
and rate of perceived exertion were taken.
The 6 minute walk test was conducted along a long
hallway. Standardized encouragement was given in
between at 1, 3, and 5 minutes interval. After
completion of test, heart rate, respiratory rate, blood
pressure and rate of perceived exertion were taken
immediately and after 1, 3 and 5 minutes to see the
recovery of subjects to baseline parameters
The 10 step test was conducted after the subject fully
recovered from previous test. The subject was asked
to step one foot onto a block of 10 cm height and then
quickly step down from the block. The same was
done with the opposite foot and was repeated 10
times. The subject was instructed to perform the
stepping sequence as quickly as possible. Similarly,
parameters were taken before and after the test to see
the recovery.
The 6 Minute Walk Test distance and Ten Step Test
time were statistically analyzed using one way
ANOVA with post hoc (Tukey) test.
229
Pallavi et al.,
RESULTS
Table.1: Table showing 6MWD (mts) in the 3 study groups:
Group A
Group B
Group C
Mean SD
317.13 35.44
297.10 47.14
262.8342.14
IQR
54.0
65.0
64.0
Min
254
198
176
Max
385
380
332
Upper
95% CI
330.37
314.7
278.57
Lower
95% CI
303.9
279.5
247.1
Table.2: Table showing comparison in between the groups in 6MWD

All Pair wise Multiple Comparison Procedures (Tukey Test):
Groups
P value
Group A vs. Group B
>0.05
Group B vs. Group C

Group A vs. Group C
*significant
<0.05*
<0.05*
Table.3: Table showing 10 step test time (sec) in the 3 study groups:
Group A
MeanSD
11.36 2.06
IQR Min
3.62 7.90
Max
16.06
Upper 95% CI
12.18
Lower 95% CI
10.59
Group B
13.243.49
2.73 9.11
25.00
14.54
11.94
Group C
14.743.16
3.45 10.00
21.62
15.92
13.56
Table.4: Table showing comparison in between the groups in TST time
All Pair wise Multiple Comparison Procedures (Tukey Test)

Comparison
P value
Group A vs. Group B
<0.05*
Group B vs. Group C
>0.05
Group A vs. Group C
<0.05*
*significant
Results show that 10 Step Test time increased
with increasing age in all three age groups. The
difference being significant in between groups A
& B and between groups A & C.
DISCUSSION
Results showed that there was a progressive

decrease in the 6 MWD with age. However, the
difference was
significant in between age
groups B & C (p<0.05) and between groups A &
C (p<0.05). This is supported by studies done by
Stephen & Hacker who in their study in 2002
provided reference data for 6MWT in elderly
people. Their study showed that there is a
progressive decline in the 6MWD with
increasing age. 8 6 MWT also depends on

muscular strength, postural balance, general
health, nutritional status, orthopedic and
cognitive function. As compared to western
population, the nutritional status, muscle strength
and general health are comparatively lower in
Indian population. This may be the reason for
lower values of 6MWT in our study.9
The results also showed that there was a
progressive increase in the time taken to
complete TST with age. However, the decrease
was more significant between group A & B
(p<0.05) and between group A & C (p<0.05).
Kenzo Miyamoto et al. in 2008 showed that there
is a progressive increase in the time taken to
230
Pallavi et al.,
complete TST with increasing age. The test also

showed high reliability as a test battery.10 Due to
age related changes, the aged are weaker, slower
and less powerful and hence, there is a reduction
in performances requiring the regulating and
coordinating functions of the nervous systems,
i.e. balance, reaction time, agility and
coordination. Hence, older people cannot
perform well in almost any type of activity,
except for low intensity activities in which
energy demands are easily met.6 This might be
the reason for increase in TST distance.
Cardiopulmonary fitness and skeletal muscle
mass progressively decline in aged population
and both factors contribute to weakness and
functional disability in elderly. These changes
might be responsible for the progressive decrease
in 6 MWT with increasing age in our study.
Cardiopulmonary exercise testing is a well
established procedure that provides peak oxygen
uptake as the gold standard in determining
exercise capacity but it is poorly accessible for a
large scale community based investigation.
Among the field tests, 6 MWT and TST are easy
to administer, inexpensive and safe tests that
provide a measure of sub maximal cardio
respiratory or endurance fitness.12
Steffen and Hacker in their study said that the
choice of measurement should be based on how
well the specific problems of a given patient
match the purpose of a given test.8 Rather than
selecting participants who were healthy (free
from any pathologies), older people were
selected who functioned independently without
assistive devices in the community. People who
were independently functioning seemed to be a
more realistic standard of comparison for the
elderly subjects seen by physical therapists. It
was anticipated that the range of performance on
the tests by such participants would show
substantial variation. Hence, while interpreting
the findings, the characteristics of the subjects
were kept in mind.
Thus, this study shows the age related changes in
functional performance in community dwelling
elderly people and provides a criterion related

reference values for functional performance tests
(6MWT and TST).
Clinical implications: To make a tailored
exercise program for elderly people, their
functional capacity should be known and
accordingly exercises should be prescribed. Most
of the Indian population is suffering from one or
the other pathology like osteoarthritis,
spondylosis, diabetes which is not taken into
consideration while planning an exercise
program. Such people seem to be a more realistic
standard of comparison for elderly subjects seen
by physical therapists. The reference values
available in litterateur are mainly for healthy
elderly people. If we apply these standard values
to community dwelling elderly, their functional
capacity might be overestimated. In this study,
subjects taken were independently functioning in
community without the use of assistive devices.
Hence, the reference values obtained from this
study can be used as a basis of comparison while
planning an exercise program for community
dwelling elderly people. No research has been
done yet by using combinations of these two
tests (6MWT and TST) in Indian population. The
two tests used in this study are simple to
understand and perform and does not require the
use of any equipment. Walking and stair
climbing are two basic forms of ambulation
required in day to day life. By testing
performance in these activities, one can come to
know the functional capacity of an individual.
Limitations: 1. The sample size was small. 2.
Comparison of test values between genders was
not analyzed. Females could have had a
confounding effect on the test results. 3. Subjects
were not compared with different age groups.
CONCLUSION
From the results it can be concluded that there is

a progressive decrease in the test performance
(6MWT & 10 Step test) with age in community
dwelling elderly people. The results of this study
can be used as reference values while performing
231
Pallavi et al.,
performance tests on elderly people in the

community.
ACKNOWLEDGEMENT
I sincerely thank my H.O.D. and Guide for

inspiring me and guiding me throughout this
project. I thank our Dean whose permission for
the study did it occur. I also thank all subjects
who willingly participated in my study without
whom my study would not be completed. I
would also like to thank my statistician who
helped and guided me in preparing my tables and
graphs.
REFERENCES
1. Szucs TD. Future disease burden in the

elderly: Rationale for economic planning.
Cardiovascular Drugs Ther 2001; 15:359
61.
2. Hafez G, Bagchi K, Mahaini R. Caring for
the elderly: a report on the status of care for
the elderly in the Eastern Mediterranean
Region. EMHJ July 2000; 6 (4):636-43.
3. World Population Prospects: The 2002
Revision, Highlights. New York: United
Nations Population Division; 2003.
(ESA/P/WP. 180).
4. Ivan Bautmanns , Margareta L, Tony M.
The six minute walk test in community
dwelling elderly: Influence of health status.
BMC Geriatrics. July 2004; 4:6
5. Jesse Jones, Roberta ER. Fitness of Older
Adults. Journal on Active Aging. 2002:2430
6. James Skinner. Exercise Testing and
Exercise Prescription for Special Cases. 2nd
Edition. USA: Williams and Wilkins; 2005
Pg no 85-98
7. Kenzo Miyamoto, Hideaki Takebayashi,
Koji Takimoto, Shoko Miyamoto, Shu
Morioka, Fumio Yagi. A New Simple
Performance Test Focused on Agility in
Elderly People: The Ten Step Test.
Gerontology 2008;54:365-72
8. Teresa S, Timothy A H, Louise M. Age and

Gender Related Test Performance in
Community Dwelling Elderly People: Six
Minute Walk Test, Berg Balance Scale,
Timed Up & Go Test and Gait Speeds.
American Physical Therapy Journal. Feb
2002;82(2):128-37.
9. Guidelines for Six Minute Walk Test.
American Journal of Respiratory and
Critical Care Medicine.2002;166:111-17.
10. Troosters T, Gosselink R, Decramer M.
Six minute walking distance in healthy
elderly subjects. Eur Respir J 1999;14:27074
11. Shin S, Demura S. Comparison and age
Level differences among various step tests
for evaluating balance ability in the elderly.
Archives of Gerontology and Geriatrics.
May June 2010;50(3): 51-54
12. Chien MY, Hsu KK, Ying TW. Sarcopenia,
Cardiopulmonary Fitness And Physical
Disability In Community Dwelling Elderly
People. American Physical Therapy Ass.
2010;90(9):1277-87
232
Pallavi et al.,
DOI: 10.5958/j.2319-5886.3.2.051

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Received: 19 Oct 2013
Revised: 22nd Nov 2013
Research Article
Copyright @2014
ISSN: 2319-5886
ROLE OF COLOUR DOPPLER SONOGRAPHY IN ADNEXAL MASSES

*Shazia Ashraf Khan1, Aamina Banoo2
1
MD Obstetrics & Gynaecology, Lalla Ded Hospital, Government Medical College, Srinagar
Associate Professor, Department of Gynaecology & Obstetrics, Government Lalla Ded Hospital, Government
Medical College, Srinagar
2
*Corresponding author email: shaziashrafkhan@rediffmail.com

ABSTRACT
Objective: To evaluate the role of colour Doppler sonography in differentiating between benign and malignant
adnexal masses. Materials & Methods: One hundred women diagnosed with adnexal masses underwent colour
Doppler sonography. Resistance index (RI) and Pulsatility index (PI) were calculated in each case and lowest RI
and PI obtained at any point in the mass were considered for analysis. Masses which were completely a vascular
were considered as benign. Histopathological diagnosis was obtained in each case. Sensitivity, specificity, positive
predictive value, negative predictive value and accuracy of colour Doppler were calculated. Results: Mean RI and
Mean PI were significantly lower in malignant masses (0.34 & 0.95 respectively) as compared to benign masses
(0.72 & 1.97 respectively). Out of 81 benign cases, Doppler could correctly diagnose 78 cases as benign, but
labelled 3 cases as malignant which were actually benign. Out of 19 malignant cases, 16 cases were correctly
diagnosed, whereas 3 cases were missed by Doppler. Our study showed a sensitivity of 84.2%, specificity of 96.3%,
positive predictive value of 84.2%, negative predictive value of 96.3% and accuracy of 94% for colour Doppler.
Conclusion: Colour Doppler sonography is helpful in differentiating benign from malignant adnexal masses.
Keywords: Colour Doppler, Adnexal mass, Sensitivity, Specificity.
INTRODUCTION
Adnexal masses represent a spectrum of conditions
from gynecological and non-gynecologic sources.1
Adnexal masses present a diagnostic dilemma; the
differential diagnosis is extensive, with most masses
representing benign processes.2 - 4 Most frequently,
adnexal masses refer to ovarian masses or cysts;
however, paratubal cysts, hydrosalpinx, and other nonovarian masses are also included within the broader
definition of adnexal masses.
Differentiation between benign and malignant ovarian
masses is necessary because ovarian cancer is lethal
and there are no proven screening techniques.
Clinicians must consider the patient's medical profile
(that is, risk factors, the size of the mass, clinical
Shazia et al.,
presentations) to critically evaluate the likelihood of

an ovarian cancer. Diagnostic screening must include
three components: an accurate medical history, a
careful physical examination and judicious use of
diagnostic procedures (for example ultrasonography,
computed tomography).5
Various diagnostic modalities have been introduced
over a period of time to diagnose and to differentiate
between benign and malignant adnexal masses.
Despite advances in diagnostic procedures, early
detection and differentiation between benign and
malignant adnexal masses still remains challenging.
Colour Doppler is a recent diagnostic modality in preoperative assessment of adnexal masses. Colour
233
Doppler visually reflects the state of blood flow to the

tumor. It is based on Folkmans theory of
neovascularization6 which states that tumor releases
the factor known as tumor angiogenesis factor which
stimulates rapid formation of new capillaries.
Neovascularisation occurs in malignant tumors and
results in lower pulsatile and resistance index.7
Resistance index is defined as the maximum systolic
velocity minus end diastolic velocity divided by
maximum systolic velocity. Pulsatility index is
defined as maximum systolic velocity minus end
diastolic velocity divided by mean systolic velocity.
Both indices increase with increasing distal vascular
resistance and the two indices have a high correlation.
A comparison of different studies shows that no
standard has been established concerning which
Doppler index to use or what cut off is most
appropriate. However the resistivity index less than
0.4-0.88 and pulsatility index less than 1 are generally
considered to be suspicious of malignancy. 8,9 Doppler
ultrasound has yielded variable results in
distinguishing benign from malignant mass with a
sensitivity of 50-100% and specificity of 46100%10,11,12. Different results are partly due to varying
threshold values and corresponding trade-offs between
specificity and sensitivity.
MATERIALS AND METHODS
This prospective study was conducted at Lalla Ded
Hospital, Government Medical College, Srinagar, over
a period of one and half year.100 patients (Women in
reproductive age group and postmenopausal women)
diagnosed with adnexal masses on pelvic examination,
conventional sonography and referred cases of
adnexal masses to our hospital were included in the
study. Prior to the study ethics committee permission
was obtained from our college. An inform consent
form was obtained from all the participants.
Exclusion Criterion
Unilocular anechoic small cyst (less than 5
centimeters) which resolves on follow up ultrasound
examination, Tubal gestation, Masses that were found
to arise from uterus .
All the patients were evaluated by colour Doppler
ultrasonography using a Philips IU-22 machine with
pulsed Doppler system and equipped with a colour
velocity imaging system for colour blood flow
codification. After characterizing masses by their
morphology, colour velocity imaging gate was
activated to identify blood flow. The resistance index
and Pulsatility index were calculated in each case. The
lowest pulsatility index and resistive index detected at
any point in the mass were considered for analysis.
The masses which were completely avascular with no
blood flow were considered as benign.
The Doppler findings were considered suggestive of
malignancy when:
Resistive index (RI) < 0.4513
Pulsatility index (PI) <1.08
The definitive histopathological diagnosis was
obtained in each case. Sensitivity, specificity, positive
predictive valve, negative predictive value and
accuracy of Colour Doppler ultrasonography were
calculated.
REULTS
The mean age of patients enrolled in the study was
37.5 years. 21 cases were postmenopausal and 79
cases were premenopausal. On histopathological
examination, 81 cases were found to be benign and 19
turned out to be malignant. Blood flow was detected
in 75 masses using Doppler whereas 25 masses were
avascular and despite efforts no vessel could be
identified for obtaining Doppler waveform. These
avascular masses were considered as benign. Among
81 benign masses, blood flow was seen in 57 cases
(70.37%) whereas 18 out of 19 (94.73%) malignant
masses were vascularised (p value <0.001).
Table 1: Vascularity of Masses

Present
Absent
HPE
p value
n
%
n
%
Malignant
18
94.75
1
5.26
<0.001 (Sig)
Benign
57
70.37
24
29.62
Mean RI for benign adnexal masses was 0.72 and for malignant masses it was 0.34.Mean PI for benign and
malignant adnexal masses was 1.97 and 0.95 respectively.
Shazia et al.,
234
Table 2: Mean RI and Mean PI in Benign and Malignant Adnexal Masses

95% Confidence Interval for Mean
n
Mean
p value
Lower Bound
Upper Bound
Malignant
18
0.34
0.30
0.39
<0.001
Doppler_RI
(Sig)
Benign
57
0.72
0.68
0.76
Malignant
18
0.95
0.71
1.18
Doppler_PI
<0.001(Sig)
Benign
57
1.97
1.83
2.11
Using Doppler study, 78 benign cases were correctly diagnosed whereas 3 cases were misdiagnosed as malignant
which were actually benign.16 out of the 19 malignant cases were correctly diagnosed and 3 malignant cases were
missed by Doppler
Tabel 3: Histopathological Diagnosis in comparison with Doppler
Malignant
Benign
Doppler Inference
p value
n
%
n
%
Malignant
16
84.2
3
3.7
<0.001 (Sig)
Benign
3
15.8
78
96.3
The sensitivity, specificity, positive predictive value ,negative predictive value and accuracy of colour Doppler was
84.2%.96.3%, 84.2%,96.3%and 94 % respectively.
DISCUSSION
The management of adnexal masses is a common and
controversial clinical problem.14 The differential
diagnosis of benign from malignant tumors is essential
in order to decide the optimal approach in each case.
Ultrasound has been extensively used in the preoperative evaluation of adnexal masses. It has been
shown to be sensitive but not specific. Most studies
have reported false positive rates higher than 20%.15
Recently Colour Doppler with pulsed Doppler
waveform analysis has been used as a tool to identify
neovascularity in malignant masses. Folkman et al6
demonstrated that tumor angiogenesis factors are
essential for the promotion of neovascularization in
malignant tumours6,16. Doppler waveform analysis
provides high sensitivity and specificity and is
superior to other methods for pre-operative evaluation
of ovarian masses. It can accurately discriminate
between malignant and non-malignant ovarian tumors
using a simple measurement of the pulsatility index
(PI) and resistivity index (RI) in the newly formed
intra-tumoral vessels.
In the present study, 94.73% of malignant masses
were found to be vascular compared to 70.37% of
benign masses In a study done by JL Alcazar et al13,
98.2 % of malignant tumors and 60.57% of benign
tumors were vascular. Using Doppler study, malignant
neoplasms offered a lower resistance to blood flow as
measured by resistance index (RI) and pulsatility
Shazia et al.,
index (PI). Mean RI and PI were significantly lower in

malignant masses compared to malignant masses (p
value <0.001). Mean RI for benign and malignant
masses in the present study was 0.72 and 0.34 while
mean PI for benign and malignant adnexal masses was
1.95 and 0.97 respectively. UM Hamper et al8 had
obtained mean RI for benign and malignant masses at
0.77 & 0.50 and mean PI of 1.93 & 0.77 respectively.
Fleischer et al17 also described a significant difference
between PI values of benign (1.80.8) and malignant
masses (0.80.6). Timor Tritsch et al18 have observed
PI and RI values for benign and malignant ovarian
tumours by using colour Doppler sonography as 1.17
& 0.64 respectively for benign and 0.52 & 0.39
respectively for malignant tumours. Despite different
opinions regarding cut off values, all authors agree
that recognition of angiogenesis as a reference point
for malignant changes within the ovary, has proved to
be a highly sensitive parameter. Although cut off
values presented in different studies have been
criticized, these thresholds are used for statistical
analysis.
Our study suggested colour Doppler sonography as a
precise tool with higher sensitivity and specificity for
pre-operative characterisation and discrimination of
benign from malignant adnexal masses. Sensitivity,
specificity, positive predictive value, negative
predictive value of colour Doppler in the present study
235
was 84.2%, 96.3% , 84.2% and 96.3% respectively.

Our results are consistent with the studies of Fleischer
et al17, Timor Tritsch et al18.
11.
CONCLUSION
Colour Doppler sonography has added to the
understanding and characterization of the adnexal
lesions, based on its depiction of the vascularity of the
masses. Doppler study is effective in the
differentiation of adnexal masses.
12.
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4. Gallup DG, Talledo E. Management of the
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8. Hamper UM, Sheth S, Abbas FM, Rosenshein
NB, Aronson D, Kurman RJ. Transvaginal colour
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and malignant lesions. Am J Roentgenol 1993;
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9. Stein SM, Laifer Narin S, Johnson MB, Roman
LD, Muderspach LI, Tyszka JM, Ralls PW.
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masses, relative value of gray scale colour
Doppler and spectral Doppler sonography. Am J
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10. Salem S, White LM, Lai J. Dopler sonography of
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18.
pulsatility index in benign and malignant diseases.

Am J Roentgenol. 1994; 163: 1147-50
Hata K, Hata T, Manalse A, Sugimora K, Kiato
M. A critical evaluation of transvaginal colour
studies, transvaginal sonography, MRI and CA
125 in detecting ovarian cancer. Obstet Gynecol
1992; 80: 922-26
Lerner JP, Timor Treitsch TE, Federman A,
Abramouich G. Transvaginal ultrasonographic
characterization of ovarian masses with improved
weighted scoring system. Am J Obstet Gynecol
1994; 170: 81-85
JL Alcazar, T Errasti, A. Zornoza, JA Minguez, M
J
Galan.
Transvaginal
colour
doppler
ultrasonography, and CA 125 in suspicious
adnexal masses. Int J Gynecol and Obstet 1999;
66: 255-61
Curtin JP. Management of the adnexal mass.
Gynecol Oncol 1994; 55: 542-46
Luxman D, Bergamn A, Sagi J, David M. The
postmenopausal adnexal mass: correlation
between ultrasonic and pathological findings.
Obstet Gynecol. 1991; 77: 726
Tekay A, Jouppila P. Validity of pulsatility and
resistance indexes in classification of adnexal
tumors with transvaginal colour Doppler
ultrasound. Ultrasound Obstet Gynecol. 1992; 2:
338-44
AC Fleischer, JA Cullinan, HW Jones, W Peery,
RF Bluth, DM Keppler. Serial assessment of
adnexal masses with transvaginal colour Doppler
sonography. Ultrasound in Medicine Biology.
1995; 21(4): 435-41
Timor-Tritsch LE, Lerner JP, Monteagudo A,
Santos
R.
Transvaginal
ultrasonographic
characterization of ovarian masses by means of
colour flow directed measurement and
morphologic scoring system. Am J Obstet
Gynecol 1993; 168: 909
236
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Coden: IJMRHS
Received: 11th Nov 2013
Revised: 24th Dec 2013
Copyright @2014
ISSN: 2319-5886
Research Article
GONIOSCOPIC CHANGES IN CONVENTIONAL ECCE VS MANUAL SICS: A COMPARATIVE

STUDY
Surya Joseph1, Sundararajan D2, *Rajvin Samuel Ponraj3, Srinivasan M4, Veluchamy5
1
Senior Resident, 2Associate Professor, 3Postgraduate,4Professor, 5Senior resident Dept of Ophthalmology,

Meenakshi Medical College, Kanchipuram, Tamilnadu, India
*Corresponding author email: samuelpnrj25@gmail.com
ABSTRACT
The aim of the study is to observe and compare the Gonioscopic changes in the angle of the anterior chamber of
the eye after surgeries namely; Conventional Extra capsular cataract extraction (ECCE) with Posterior chamber
Intraocular lens (PC IOL) implantation, Manual Small incision Cataract Surgery with PCIOL implantation. The
clinical study was undertaken after Institutional Ethical committee clearance, securing the inform consent, total
number of 100 patients were enrolled in the study. 50 ECCE; 50 SICS consisting of 57 Males and 43 Females
aged between 40 - 80yrs who were admitted and operated for Cataract at Meenakshi Medical college Hospital &
Research institute. The following parameters are studied: Gonioscopic changes in the angle, namely the PAS
formation in the quadrants, pigment dispersion in each of the methods. After this study, we arrive to a conclusion
that complications in the angle of anterior chamber occur mostly in Conventional with insignificant change in
manual SICS. So manual Small incision Cataract Surgery with PCIOL implantation is preferable over
Conventional ECCE with PCIOL implantation.
Keywords:
Gonioscopy, Peripheral anterior synechiae, Scheies classification, Pigment dispersion,
Malpositioning of the Superior Haptics
INTRODUCTION
Cataract is the leading cause of Reversible Blindness
in our country. The ultimate goal of a cataract surgery
is to restore and preserve the pre cataract vision and
to alleviate the other cataract related symptoms. In
the quest for perfection, the techniques and
approaches followed by cataract surgeons have
constantly changed over the years.
Hence the realistic portrayal of the trends in cataract
surgery can be best described as a wide spectrum,
ranging from Intra Capsular Cataract Extraction
(ICCE) to Phaco Emulsification. Such a diversity of
trend is governed by multiple factors, the most
pertinent of which are economical, patients'
awareness, surgeons caliber, availability of
equipments and the cataract backlog.
Surya et al.,
The current surgical trend for the majority of

surgeons in the developing world is towards
Conventional Extra capsular cataract extraction
(ECCE) with PC IOL implantation. Small Incision
ECCE techniques are becoming quite popular for
those who have accepted the challenges of transition
towards a better technique. Perhaps about 5-10% of
the cataract surgeons in India routinely perform
Phaco. The advent of Phaco emulsification has
minimized the size of the incision and its related
complications, with an added benefit of early
stabilization of refraction.
The main objective of this study is to observe and to
compare the Gonioscopic changes in the angle after
conventional ECCE with PC IOL implantation and
237
Small Incision Cataract Surgery with PCIOL. An

attempt has been made to note any progression of
these changes and the possible effects of these
changes over the Intra Ocular Pressure and Visual
Acuity.
Aim of the study: The main objective of this study is
to observe and compare the Gonioscopic changes in
the angle after
Conventional ECCE with PC IOL implantation
Manual Small incision Cataract Surgery (SICS) with
PC IOL implantation
An attempt has been made to note the progression of
these changes and the possible effects of these
changes over the Intra Ocular Pressure and
Postoperative Visual acuity.
The Scheies method of grading TM pigmentation

was followed. Larger numbers represent increasing
amount of pigmentation.
Scheie classification
Grade 0 Entire angle visible as far posterior as a
wide ciliary body band
Grade I - Last roll of iris obscures part of the ciliary
body
Grade II - Nothing posterior to trabecular mesh-work
visible
Grade III - Posterior portion of trabecular mesh-work
hidden
Grade IV - No structures posterior to Schwalbes line
visible6.
RESULTS
MATERIALS AND METHOD

This clinical study was undertaken in 100 Eyes- 50
ECCE; 50 SICS consisting of 57 Males and 43
Females aged between 40 - 80yrs who were admitted
and operated for Cataract at Meenakshi Medical
college Hospital & Research institute. After Securing
the inform consent, total number of 100 patients were
enrolled in the study.
Institutional Ethical clearance has been obtained
before initiating the study. Patients were enrolled
observing all proper inclusion and exclusion criteria.
Inclusion criteria: No past history of cerebrovascular
accidents, Diabetic patients with a duration of less
than 10 years, Non- Proliferative Diabetic
retinopathy, Best corrected visual acuity at least 6/9
Exclusion criteria: Cataract, Glaucoma, Vitreous
opacities or any evidence of optic atrophy, Peripheral
nervous system disease, Proliferative diabetic
retinopathy
Gonioscopic changes in the angle of the anterior
chamber by Shaffer grading while doing Goldmann 3
plane mirror gonioscopy. Based upon the most
posterior structure visible in the angle.
Namely
Peripheral Anterior Synechiae formation in the
quadrants, Pigment dispersion in ECCE as well as
SICS.
Partial or complete closure Grade 0
10 angle of approach Grade I AC < 1/4 CT
20 angle of approach Grade II AC = 1/4 CT
2035 angle of approach Grade III AC = 1/2 CT
3545 angle of approach Grade IV
Surya et al.,
Fig 1: Age-sex wise group distribution graph
Fig 2: Incidence of peripheral anterior synechiae in

ECCE
PAS formation was observed in 28 eyes of 50 cases,

which underwent conventional ECCE with PC IOL
implantation. Superior angle PAS noted in 23 eyes.
Inferior angle PAS in 5 eyes. No PAS was seen in
eyes that underwent SICS
238
Fig 3: As overlying the lens haptics pigment dispersion

in angle structure
20 eyes showed PAS overlying the Haptics of PC

IOL. Which accounts to 71.4%. Most of the lens
Haptics PAS were observed early in the Post
operative period (3 Months) and remain stable in size.
Fig 4: Incidence of pigment dispersion

DISCUSSION
The incidence of PAS in the present study was 56%,
which is comparable to 54% observed by Lis, Liao R,
Liu.Y, et al in Gonioscopic observation after
posterior chamber IOL implantation and 41.8%
observed by Maden A, Gunenc U, Erkin E et al10
Gonioscopic changes in eyes with PC IOL No PAS
was seen in eyes in which SICS was performed a
(Capsular Bag Fixation of IOL)
Involvement of the Superior angle is prominent as
suggested by 46% of PAS in the Superior angle due
to malpositioning of the Sperior Haptics (in the
ciliary Sulcus).
PAS were seen more frequently with Lens Haptics at
vertical position than in Eyes with horizontally
oriented Lens Haptics3.
PAS overlying the Haptics of PC IOL was observed
in 20 eyes (71.4%) in this study is comparable to 80%
Surya et al.,
observed by R Blair Evans PAS overlying the

Haptics of PC Lenses. The lens haptics PAS
possessed a distinct morphology characterised by
marked anterior displacement of peripheral iris with
broad iris apposition to the trabecular mesh-work and
more anterior angle structures.
Most of the lens haptic PAS were observed early in
the Postoperative period (3 months). However,
progression in size was not noted4. No Postoperative
rise in IOP attributable to Gonioscopic changes. No
changes in the postoperative Visual acuity were
observed secondary to these Gonioscopic changes.
Pigment dispersion is explained by the Continuous
chafing effect of the lens Haptics over the posterior
aspect of iris and also due to Surgical manipulation.
Interestingly, its also noted there is marked and well
limited clumping of pigment in the angle at 6 Oclock
in 40 eyes (40%) comparable to 57.2% observed by
Maden A, Gunenc Gonioscopic changes in eyes with
PC IOL. Inferior angle pigment clumping is seen
due to gravitational settling and aqueous circulation.
28 eyes with PAS had papillary deformation, which is
related to the position of IOL Haptics 71.4%
compared to 88% of eyes with PAS in Liao R; Lis,
Liu Y. Guoy & Pan H5
After three months, postoperatively the Residual
Cortex still existed in some cases of ECCE with
PCIOL.
This study was undertaken in response to the
suggestion that routine Postoperative Gonioscopy
should be performed after implantation of PCIOLs
CONCLUSION
Conventional Extra Capsular Cataract Extraction with
PC IOL implantation significantly and permanently
alters the Gonio Anatomy of the Eye when compared
to Small Incision Cataract Surgery. (P< 0.001)
Decrease in the incision size, anterior entry into the
cornea with a self- sealing Scleral tunnel incision
and a Corneal lip prevents the formation of PAS. In
the Bag fixation of IOL reduces Iris chafing related
pigment dispersion into the AC and lowers the
incidence of changes in the angle. (P <0.001)
Continuous Curvilinear Capsulorhexis (CCC) is
important for proper capsular bag fixation of the IOL.
(P <0.001)
239
REFERENCE
1. Chen Weirong ,LIU Yizhi, Wang Ningli Guo
Yan, HE Mingguang , Comparison of the efftypes
of intraocular lens, Chinese Medical Journal
2001;114(12):1286-89
2. Maden A, Gunenc V, Erkin E. Doc. Ophthalmol,
Gonioscopy changes in eye with posterior
chamber intraocular lens by. 1992, 82(3), 231-8.
3. Peripheral anterior synechiae overlying the
haptics of posterior chamber lenses Occurrence
and Natural history, Ophthalmology 1990, 97:
415-23.
4. Evans RB. Peripheral anterior synechiae
overlying the haptics of posterior chamber lenses.
Occurrence and natural history,Ophthalmology
1990: 97(4), 415-23.
5. LiaoR, LiS, LiuY, Guo Y, Pan H, Tao X. The
relation of the location of haptics of posterior
chamber intraocular lenses and peripheral
anterior synechiae by. Source: Medicine: PMID:
8575604, UI: 96148006.
6. Steven V. L Brown., Basic and Clinical Science
Cours e, Faculty, Section 10, Steven T. Simmons,
MD, Steven V. L. Brown, Consultants William
LH, Janis ER. Gonioscopy in the Management of
Glaucoma James A. Savage, MD , Focal Points
American
Academy
of
Ophthalmology.
2006;XXIV: (Section 3 of 3)
Surya et al.,
240
DOI: 10.5958/j.2319-5886.3.2.053

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Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Received: 13 Dec 2013
Revised: 8th Jan 2014
Copyright @2014
ISSN: 2319-5886
Research Article
HISTOLOGICAL AND HISTOMETRIC STUDY OF TESTIS IN ALBINO RATS TREATED WITH

AMLODIPINE
*Karthick S, Harisudha R
Department of Anatomy, Melmaruvathur Adhiparasakthi Institute of Medical Science & Research,
Melmaruvathur, Tamil Nadu, India
*Corresponding author email: drkarthick.anat@gmail.com
ABSTRACT
Amlodipine is the most common drug of choice to treat hypertension, one of its side effects is infertility and its
effect on the testis of male albino rats is not well documented. Aim: To observe the effect of amlodipine in testis
of male albino rats by the histological and histometric method. Materials& Method: we selected 12 adult male
albino rats divided into 2 groups, group 1 treated as control group 2 treated as experiment and amlodipine is
administered for 30 days. After 30 days testis were removed and analysed histologically and histometrically.
Result: Though there are no marked changes, but early degenerative changes and reduction in weight of testis of
experimental rats observed. Conclusion: Presence of vacuolated spermatogenic cells in some of the seminiferous
tubules indicates early degeneration and arrest of spermatogenesis.
Keywords: Hypertension, Infertility, Amlodipine Side Effects.
INTRODUCTION
Hypertension is one of the leading causes of the
global burden of disease. Approximately 7.6 million
deaths (1315% of the total) and 92 million
disability-adjusted life years worldwide were
attributable to high blood pressure in 2001.1
Hypertension doubles the risk of cardiovascular
diseases, including coronary heart disease (CHD),
congestive heart failure (CHF), ischemic and
hemorrhagic stroke, renal failure, and peripheral
arterial disease.1The burden of hypertension increases
with age and among individuals aged 60, its
prevalence is 65.4%. Amlodipine has become the
second drug of choice for hypertension2, though its
side effect on infertility has been proved to some
extent.3,4 The exact mechanism of amlodipine causing
infertility in male remains to be completely
elucidated moreover, its effect on the microscopic
structure of the testis is not well documented
Karthick et al.,
histometrically, and therefore it has been planned to

observe histological observation of testis, histometric
analysis of testis, determine the weight of testis.
A total of 12 adult male albino rats was obtained from
the central animal house, Rajah Muthiah Medical
College, Annamalai University, which were
maintained under standard laboratory conditions at
282C were provided with standard rat diet and
water ad libitum. After getting ethical committee
clearance, the animals were divided into 2 groups.
Group I comprised of 6 animals; Control: received
vehicle only (0.01% ethyl alcohol) and group II
comprised of 6 animals; Experimental (Test group):
received amlodipine orally (0.45mg/kg/day) given for
30 days. All the animals were sacrificed after 30 days
241
of the experimental period, the testis were removed,

trimmed free of adipose tissue and connective tissue.
The weight of the testis was recorded. The organs
were fixed in Bouins fluid for a total period of 24
hours. After fixation, the tissues were processed for
light microscopy, the tissues were stained with
Haematoxylin and Eosin and Massons Trichrome
stain for connective tissue. The stained sections of
testis were examined in low power (x 100) and high
power (x400). Qualitative evaluations of testicular
sections were supplemented by the use of the semi
quantitative testicular biopsy score count (TSBC) of
Johnson (1970) to estimate the extent of testicular
alterations. For histometric assessment the principles
emphasized by Hans Elias and Pauly (1996) as well
as Weibel and Hans Elias (1967) were strictly
employed for estimating the volume and surface area
of various tissue components. Volume of parenchyma
and stroma were estimated by point count using the
eyepiece reticule with low magnification. The
formula used for estimation of volume (Vi = Pi / PT)
Where Vi = volume of tissue component per unit
volume of tissue, Pi = number of points touching the
tissue component, PT = total number of points in the
reticule. The height of the secretory epithelium and
the diameter of tubules was measured using as ocular
micrometer with high magnification.
Statistical Analysis: Using latest HPSS software
Fig 2: Testis control and test (Massons trichrome stain

100X)
Fig 3: Sections of testis from control and test (Van

Giesons stain 100X)
Fig 4: Sections of seminiferous tubules from control , test

(H& E 400X)
Arrow (test) shows early fatty degeneration of

spermatogenic cells
RESULTS
There is a decrease in weight of the testis of the
experimental rats than the control rats presented in
table 1. Histological observation of testis revealed
there was no testicular alteration and the epithelium
was intact with normal spermatogenesis from
experimental animals, when compared with control
animals. However, on closer examination under high
power revealed an interesting finding in these test
group animals.
Fig 1: Sections of testis Control and test rats (H &E 100X)
Karthick et al.,
Fig 6: Seminiferous tubules from control, test (Massons

trichrome 400X)
Arrow (test) shows early fatty degeneration of

spermatogenic cells
Fig 7 : Seminiferous tubules from control, test (Van

Giesons 400X)
Arrow in (test) shows early fatty degeneration of

spermatogenic cells
242
Table 1 : Weight of testis, Volume of tissue components (values are expressed as Mean SEM)
Animal group
Testis
(grams)
Volume of tissue components

Seminiferous
tubules (mm3/mm3)
Connective tissue
(mm3/mm3)
Leydig cell
(mm3/mm3)
Diameter of
Seminiferous Tubules
(m)
Control
1.2595
0.7747 0.0216
0.1309 0.0245
0.0719 0.0075
279.64 10.922*
Test group
0.9109
0.6764 0.0233
0.2342 0.0233
0.0867 0.0087
268.45 16.19*
* - p < 0.05
There was the presence of vacuolated spermatogenic
cells interspersed among the seminiferous epithelium.
(Fig 2). Histometric data of testicular tissue
components are summarized in table 1. The
quantitative analysis of various tissue components of
the testis showed no significant change in any
component. But the diameter of seminiferous tubules
showed a significant increase in testis of experimental
(Test group) animals when compared to those of
control animals.
DISCUSSION
The anti-reproductive effect of amlodipine on male
reproductive organs varies from decrease in weight of
testis, epididymis, seminal vesicle and prostate,
decrease in hormone levels of testosterone, FSH and
LH, and partial / complete arrest of spermatogenesis
by de-regulation of Ca2+ homeostasis, loss of libido
and erectile dysfunction. In our present study, we
observed that sacrificed rats after 30 days of
treatment with amlodipine showed a reduction in the
weight of testis. This finding is in agreement with the
findings of many investigators. Rabia et al. 5 showed a
significant drop in absolute testicular weight, gonado
somatic index and serum testosterone levels in rats
after amlodipine treatment. Similar anti reproductive
effects were described by Ayodele O et al., Benoffet
al.6,7. They noticed altered serum parameters
(reduction in sperm count & motility) The drug may
not have a direct effect on Leydig cells, as the present
study shows that Leydig cells are not affected
histologically and histometrically in the treated
animals. It appears that, the mode of action of this
calcium channel blocker is through hypothalamo
hypophyseal testicular axis by altering either the
release of GnRH from hypothalamic neurons or the
release of gonadotrophins from the pituitary, this can
be augmented by the findings of Bourguignon JP, et
Karthick et al.,
al.8 Who showed that in the presence of calcium

channel blockers, the release of GnRH was marked
and reversibly reduced. Lee JH et al 9told nifidepine
causes male infertility by deregulation of Ca2+
homeostasis in testis of mice and arrest of
spermatogenesis. Juneja.R et al., Suresh C. Joshi et
al.10,11also told calcium channel blocker causes
decrease in sperm density, sperm motility and cellular
energy content in guinea pigs. Histopathological
findings exhibited partial arrest of spermatogenesis in
experimental animals. With above findings, we
carried the present work i.e degenerative changes
occurring in the seminiferous epithelium indicate that
the
amlodipine
causes
partial
arrest
of
spermatogenesis due to the deregulation of Ca2+
homeostasis. This partial arrest of spermatogenesis is
due to degeneration of spermatogenic cells observed
by us and is supported by reduction in weight of
testis. Although marked changes were not observed
in the histological structure of testis under low power,
early degenerative changes were noticed in the
seminiferous epithelium under high power this
indicates the beginning of the arrest of
spermatogenesis. Probably the complete arrest may
be noticed after long term treatment for more than 64
days as the spermatogonia takes 64 days to become
mature spermatozoa.
CONCLUSION
The following conclusions are arrived at from the
findings of our study on effect of amlodipine on testis
in albino rats. There is a marked decrease in weight
of testis, which may be correlated to decrease in
spermatogenesis as evidenced from the sparse content
of the spermatozoa presence of vacuolated
spermatogenic cells in some of the seminiferous
tubules indicates early degeneration and arrest of
spermatogenesis. Further the mode of action of the
243
drug is probably through hypothalamo hypophyseal

testicular axis as the Leydig cells parameters are not
disturbed in the experimental animals, and a long
term study is planned to identify the effects caused by
amlodipine.
ACKNOWLEDGEMENT
I will convey special thanks to my professor
Dr.J.P.GUNASEKARAN to given me an immense
support and valuable needy guidance for this work.
REFERENCES
and gene expression in peripubertal mouse testis.

Arch Androl., 2006; 52(4):311-8.
10. Juneja.R, I. Gupta, A. Wall, S.N. Sanyal, R.N.
Chakravarti, S. Majumdar. Effect of verapamil
on different spermatozoal functions in guinea
pigs A preliminary study. Contraception;
1990; 41 (2):179-87.
11. Suresh C. Joshi, Reena Mathur, Anita Gajraj,
Tripta Sharma. Influence of methyl parathion on
reproductive
parameters
in
male
rats.
Environmental Toxicology and Pharmacology ;
2003;14(3):91-98
1. Harrison. Principles of Internal Medicine. The

McGraw-Hill Companies, 2013;18th edi; 247
2. http://www.nhs.uk/Conditions/Blood-pressure(high)/Pages/Treatment.aspx
3. Almeida SA, Teofilo JM, AnselmoFranci JA,
Brentegani LG, Lamano TL. Antireproductive
effect of the calcium channel blocker amlodipine
in male rats. Exp Toxic Pathol 2000; 52: 353 56
4. Yoshida J. Amlodipine besylate. Eur J
Pharmacol. 2003;472:2331
5. RabiaLatif, Ghulam Mustafa Lodhi, Muhammad
Aslam. ffects of amlodipine on serum
testosterome, testicular weight and gonado
somatic index in adult rats. J Ayub Med Coll
Abbottabad 2008;20(4):8-10
6. Ayodele O, Morakinyo, Bolanle O, Iranloye,
Olufeyisipe A, Adegoke.Antireproductive effect
of calcium channel blockers on male rats. Reprod
med biol 2009;8(3): 97-102
7. Benoff S, Cooper GW, Hurley I, Mandel FS,
Rosenfeld DL, Scholl GM, Gilbert BR, Hershlag
A. The effect of calcium ion channel blockers on
sperm fertilization potential. Fertility Sterility.
1994 ; 62(3):606-11
8. Jean-pierre
bourguignon,
Arlettegerard,
Georgette debougnoux, Joan rose and Paul
franchimont. Pulsatile release of GnRH from the
rat hypothalamus in vitro: calcium and glucose
dependency
and
inhibition
by
superactiveGnRHanalogs.
Endocrinology
1987;121: 99399.
9. Lee JH, Kim H, Kim DH, GyeMC. Effects of
calcium channel blockers on the spermatogenesis
Karthick et al.,
244
DOI: 10.5958/j.2319-5886.3.2.054

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Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Research article
CLINICAL PROFILE AND ANTIBIOTIC SENSITIVITY PATTERN OF TYPHOID FEVER IN

PATIENTS ADMITTED TO PEDIATRIC WARD IN A RURAL TEACHING HOSPITAL
Sudharshan Raj C*
Dept. of Pediatrics MNR Medical College, MNR Nagar, Narsapur road, Sanga Reddy, Andhra Pradesh,
*Corresponding author email: neelimasudharshan@gmail.com
ABSTRACT
Introduction: Typhoid is a major endemic health problem among children in India. The last two decades have
witnessed the emergence and spread of multidrug resistance against conventional anti typhoid drugs (Ampicillin,
chloramphenicol and trimethoprim sulfamethoxazole) especially in the South and South-East Asia. Materials
and Methods: Children under twelve years of age with signs and symptoms suggestive of enteric fever were
included in this study. Blood cultures were carried by collecting aseptically 5ml of blood and inoculating into bile
broth and subcultured onto blood agar and Mac Conkey agar. Antimicrobial sensitivity performed according to
CLSI guidelines. Widal test was performed. Other investigations like haemoglobin, total count and differential
count of WBC, ESR were carried out. Results: The incidence of enteric fever in this study was 3%. The
maximum children were in age group more than 5 years. Maximum cases were admitted during June-September.
The most common symptoms were fever, anorexia, vomiting, and pain abdomen. The culture positivity of
Salmonella typhi (S.typhi) was 35.4%. The overall positivity of Widal test was 89.8%. Multidrug resistant isolates
in this study was 53.6%. Conclusion: Majority of the children were greater than 8 years old. Fever (intermittent
type), anorexia, vomiting were the three major symptoms. Among the signs spleenomegaly, hepatomegaly, coated
tongue and toxemia were common. Relative bradycardia was not seen. Widal test was found positive in the
majority of cases. Blood cultures were positive mainly in the first week of illness. The sensitivity pattern of
S.typhi revealed significant proportion of multidrug resistant strains and simultaneous presence of
chloramphenicol sensitive and resistant strains in the study.
Keywords: Typhoid, Salmonella typhi, multidrug resistant.
INTRODUCTION
Typhoid fever, also known as enteric fever is caused
by the Gram negative bacterium Salmonella enterica
serovar Typhi. The disease is mainly associated with
low socioeconomic status and poor hygiene, with
human beings the only natural host and reservoir of
infection. 1 Estimates for the year 2000 suggest that
there are approximately 21.5 million infections and 2,
00,000 deaths from typhoid fever globally each
year.2-4
Typhoid is a major endemic health problem among

children in India. The last two decades have
witnessed the emergence and spread of multidrug
resistance against conventional antityphoid drugs
(Ampicillin, Chloramphenicol and Trimethoprim
Sulfamethoxazole) among typhoid Salmonellae,
especially in South and Southeast Asia.5,6 Typhoid
fever caused by such multidrug-resistant (MDR)
strains of Salmonella enterica serotype Typhi
presents a serious problem in many developing
245
Sudharshan
countries.7,6 It has left fluoroquinolones as the

antimicrobial agents of choice for the treatment of
typhoid
fever.8
Fluoroquinolones,
especially
ciprofloxacin, have been in use for more than 18
years and have remained an important weapon
against typhoid infections. Effective antimicrobial
therapy is required to control morbidity and prevent
death from typhoid.
This study aims to know the clinical profile of
pediatric enteric fever and the sensitivity of the
disease to drugs in this region.
The prospective study was carried out in a rural
teaching hospital over a period of one year.
Data regarding admitted children below 12yrs of age
with signs and symptoms suggestive of enteric fever
and fulfilling any of the following criteria were
included in the study.
Inclusion criteria:
1. Positive culture for Salmonella typhi
2. Widal titre;TO and TH>=1:160
3. Fourfold or greater rise in Widal titres.
Thorough and detailed history, clinical examination
and laboratory investigations were done in all cases.
The following investigations were done:
Routine investigations: Haemoglobin estimation,
Total and differential count for white blood cells,
Erythrocyte sedimentation ratio, Urine and stool
examination, Other investigations such as a chest X
ray, liver function test, abdominal sonography were
done where ever required
Bacterial cultures: Blood cultures were carried out
by collecting aseptically 5ml of blood and added to
50ml of bile broth, incubated at 37C for 24hrs.
Initial subculture was made after 24hrs and if found
negative, further sucultures were made after 48hrs,
4days and 7 days. Positive growths were subjected to
standard biochemical tests.9 Species confirmation was
done by agglutination with high titre sera.
Stool specimens were plated directly onto
MacConkey and Salmonella, Shigella agar (SS), and
inoculated into Selenite F broth for enrichment. The
identity of isolates was confirmed by standard
biochemical tests9 and slide agglutination with
specific antisera.
Widal test: The Widal tube agglutination test was
performed according to the manufacturers
instruction, using Tidal (Span diagnostics) containing
O and H antigens of S. typhi and S. paratyphi A and

S.paratyphi B. Positive and negative serum controls
were included, a titre of 1/160 to either antigen in a
single serum specimen (in addition to the
seroconversion) was taken to be indicative of typhoid
fever. The results were correlated with blood culture
results and interpreted in conjunction with the
patients history and recent clinical presentation on
admission.
Antimicrobial susceptibility testing: Susceptibility
to antimicrobial agents was performed using the
Kirby Bauers disc diffusion method as described by
the Clinical and Laboratory Standards Institute.10
Antimicrobial agents (discs) tested and reported were
obtained from Hi media and included: ampicillin
trimethoprim
(10g),
sulfamethoxazole
(25/23.75g), chloramphenicol (30g), ceftriaxone
(30g) , ciprofloxacin (5g) , cefixime(30g) and
cephalexin(30g). MDR isolates of S. typhi were
those resistant to all three first line antityphoid drugs
(ampicillin, chloramphenicol and trimethoprim
sulfamethoxazole).
RESULTS
In this study a total number of 79 cases of enteric
fever in children 12 years or less, admitted to the
pediatric ward were studied. Total number of
admissions in the pediatric ward during this period
was 2601 so the incidence was 3%.
The maximum children were in the age group of
more than 5 years (50, 63.3%). The youngest child in
this study was 13 months old.
Among the children affected 42 were males and 37
females. The male to female ratio was 1.1:1. Cases
were admitted throughout the year showing the
endemicity of the disease. Maximum cases were
admitted during June-September 36 (45.6%)
(Table1).
The most common presenting symptom was fever 79
(100%) followed by anorexia 43 (54.4%) and
vomiting 38 (48.1%), pain abdomen 21 (26.6%),
loose motions 10 (12.6%), altered sensorium 10
(12.6%). In this study maximum cases 35 (49.3%)
had fever for 8-14 days prior to admission. Almost
half the cases 39 (49.4%) showed intermittent type of
fever. The signs of enteric fever in this study were
(table2).
246
Sudharshan
Complications seen in this study were bronchitis 9

(11.3%), encephalopathy 7 (8.9%), cholecystitis 5
(6.3%), enteric hepatitis 3 (3.8%), shock 2 (2.53%)
and paralytic ileus 1 (1.26%).
Routine investigations: In this study haemoglobin <
10gm/dl was found in 41.8% of cases. Majority of the
children had WBC count in the range 5000-10000/cu
mm (70.9%).
increased in 2nd and subsequent weeks (91.4% &

100% ) respectively. Among 15 cases which were
widal negative in first week 9 cases (60%) showed
rise in titres. The overall positivity of Widal test was
89.8%. The sensitivity of the Widal test was 71.4%.
Antibiotic resistance pattern in this study was (table
3)
DISCUSSION
Table 1: Month wise distribution of cases

Month
No. of cases
Percentage
January
05
6.3%
February
04
5.1%
March
04
5.1%
April
05
6.3%
May
07
8.8%
June
08
10.2%
July
08
10.2%
August
12
15.2%
September
08
10.2%
October
05
6.3%
November
06
7.6%
December
07
8.8%
Total
79
100%
The incidence of enteric fever in this study was 3%,

which was in accordance with the studies conducted
by Pohawalla et al who also reported an incidence of
3% 11 but Bavdekar etal reported 23%12 and Taneja
19%.13 The maximum children were in the age group
of more than 5years (63%) which is comparable to
that in Pandey K.K et al 86.5% 14 and Subindra
73%.15 The male to female ratio in this study was
1.1:1. Pandey etal reported 1.2:1.14
In this study cases were admitted throughout the year
showing the endemicity of the disease. Maximum
cases were admitted during June-September (45.6%).
This period coincides with the onset of monsoon and
increase in housefly population, which facilitates
faeco-oral transmission. Pandey K.K et al reported
maximum incidence between May-July14 and Arora
et al reported 40.6% cases in the period of
September-October.16
The most common symptoms were fever (100%),
anorexia (54.4%), vomiting (48.1%), pain abdomen
(26.6%), constipation (25.3%),
loose motions
(12.6%) and altered sensorium (12.6%). These
symptoms were also seen in studies conducted by
Taneja Sood et al 13 and Pandey KK et al. 14
In the present study maximum cases (44.3%) had
fever for 8-14 days prior to admission which was
comparable to that of Kapoor JP et al (51.6%).16
Almost half the cases (49.4%) showed intermittent
type of fever. No case in this study had stepped
ladder type of fever and this finding is same as
reported by Pandey KK etal14, Kapoor JP, et al. 17 The
use of antipyretics and antibiotics were probably
responsible for this pattern.
The common signs seen were spleenomegaly
(68.4%), hepatomegaly (55.7%), coated tongue
(51.9%), pallor (51.9%) which was also reported by
Kapoor JP et al 17. The other signs tachycardias, toxic
look, dehydration seen in this study were not reported
by others.
Table 2: Signs of enteric fever

Signs
Number
cases
Tachycardia
64
Spleenomegaly
54
Hepatomegaly
44
Coated tongue
41
Pallor
41
of Percentage
81%
68.4%
55.7%
51.9%
51.9%
Table 3: Antibiotic resistance pattern of

salmonella typhi
Antibiotic
Number n = Percentage
28
Multi drug resistant 15
53.6%
Chloramphenicol
18
64.2%
Ampicillin
25
89.3%
Co-trimoxazole
27
96.4%
Ciprofloxacin
28
00%
Ceftriaxone
28
00%
Cefixime
28
00%
Cephalexin
13
46.4%
In this study S.typhi was isolated in 28 out of 79
cases (35.4%), 17 (53.1%) cases were Widal positive
in 1st week showed TO & TH >1:160.The positivity
247
Sudharshan
In this study haemoglobin<10gm/dl was found in

41.8% of cases. This finding was seen in 64.5% by
Kapoor et al 16 and 62% by Arora etal.16 Majority of
the children (70.9%) had a WBC count in the range
of 5000-10000/cumm which was comparable to
67.9% and 85.6% as reported by Pandey et al 14 and
Mishra et al .18
The overall positivity of widal test in this study was
89.8% as comparable to 90% reported by Manchanda
et al.18 The culture positivity in this study was 35.4%
which is in concordance with that of Manchanda et al.
19
Among the 28 culture positive cases; Widal test
was positive in 20 cases (71.4%). In eight cases
Widal test remained negative on repeating after one
week. The sensitivity of the Widal test in the present
study was 71.4%.Use of antibiotics prior to admission
was probably responsible for low culture positivity
rates.
The present study found 53.6% isolates to be multi
drug resistant. Garg et al20 and Arora et al 16 reported
67% and 82.5% respectively. 64.2%. 89.3%, 96.4%
of the isolates were resistant to chloramphenicol,
ampicillin and co-trimoxazole. No resistance was
found to ciprofloxacin, Cefixime and ceftriaxone.
Lower percentage
of chloramphenicol (64.2%)
resistance may be due to re-emerging sensitivity as
reported by Urmila jhamb. 21 Widespread use of cotrimoxazole, ampicillin, cephalexin might be
responsible for resistance to these drugs.
In this study 37 cases (46.8%) were put on
ceftriaxone and 42 cases (53.2%) were given
ciprofloxacin. Among the ceftriaxone treated cases
the range for time to defervescence (TTD) was 2-6
days, the mean being 3.641.06 days.Urmila Jhamb
reported a TTD with ceftriaxone of 4 days.21 Among
the ciprofloxacin treated cases; the TTD ranged from
2-12 days. The mean being 3.560.99 days.
CONCLUSION
The disease is endemic and account for a significant
proportion of hospital admissions. Boys and girls of
all ages > 1 year were seen to be affected, majority
being >8 years old. Fever (intermittent type),
anorexia, vomiting were the three major symptoms.
Among the signs spleenomegaly, hepatomegaly,
coated tongue and toxemia were common. Relative
bradycardia
was
not
seen.
Bronchitis,
encephalopathy, hepatitis, and cholecystitis were
common complications. Widal test was found
positive in majority of cases. Blood cultures were

positive mainly in the first week of illness. The
sensitivity pattern of S.typhi revealed significant
proportion of multidrug resistant strains and
simultaneous presence of chloramphenicol sensitive
and resistant strains in the study. Both ciprofloxacin
and ceftriaxone were effective in the treatment with
no major adverse effects.
REFERENCES
1. Evanson Mweu and Mike English. Typhoid fever
in children in Africa. Trop Med Int Health.
2008;13(4): 53240
2. Crump J, Luby S, Mintz E. The global burden of
typhoid fever. Bulletin of the World Health
Organization. 2004;82:34653
3. Bhan M, Bahl R, Bhatnagar S. Typhoid and
paratyphoid fever. Lancet. 2005;366:74962
4. Bhutta Z. Current concepts in the diagnosis and
treatment of typhoid fever. British Medical
Journal. 2006;333:7882.
5. Chandel DS, Chaudhry R, Dhawan B, Paudey A,
Dey AB. Drug-resistant Salmonella enterica
serotype Paratyphi A in India. Emerg Infect Dis
2000; 6: 42021.
6. Rowe B, Ward LR, Threlfall EJ. Multidrugresistant Salmonella Typhi: a worldwide
epidemic. Clin Infect Dis 1997;24(1): S10609.
7. Ivanoff B,
Levine MM. Typhoid fever:
continuing challenges from a resilient bacterial
foe. Bull Inst Pasteur. 1997;95: 12942
8. Parry CM, Hien TT, Dougan G, White NJ, Farrar
JJ. Typhoid fever. N Engl J Med.2002; 34:1770
82.
9. Colle JG, Miles RS, Watt B. Tests for
Identification of bacteria. Mackie and Mc
Cartney Practical Medical Microbiology,
Churchill Livingstone 2008: 14th edition : 131149.
10. Clinical and Laboratory Standards Institute.
Methods for Disk Susceptibility Tests for
Bacteria that Grow Aerobically. Wayne, PA:
Clinical and Laboratory Standards Institute.
2005;7th edn, document M2A8
11. Pohawalla JN, Bhandari NR. Some observations
on typhoid encephalopathy in chidren. I. J. of
child health 1960;9:375-80.
248
Sudharshan
12. Bavdekar A, Chaudhari M, Bhave S, Pandit

A.Ciprofloxacin in typhoid fever. Indian j pediatr
1991;58(3):335-39
13. Taneja PN, Sood SC. Typhoid fever :Clinical
picture and diagnosis .I.J. of child health
1961;69-76.
14. Pandey KK, Srinivasan S, Mahadevan S, Nalini
P, Rao RS. Typhoid fever below five years.
Indian pediatr 1990;27(2):153-6.
15. Sudhindra BK. Enteric fever in young children.
Indian pediatr 1995;32:1127
16. Arora RK, Gupta A, Joshi NM, Kataria VK, Lall
P, Anand AC. Multidrug resistant typhoid fever:
Study of outbreak in Calcutta. Indian pediatr
1992;29(1):61-65
17. Kapoor JP, Man Mohan, Vibha Talwar, Daral TS,
Bhargava SK. Typhoid fever in young children.
Indian pediatr 1985;22(11):811-13
18. Mishra AK, Patwari VK, Anand PK, Pillai S,
Aneja J, Chandra, Sharma D. A clinical profile of
multidrug resistant typhoid fever. Indian pediatr
1991;28(10):1171-74
19. Manchanda SS, Harjit Singh, Chitkara HL. A
Review of 270 cases of enteric fever in children.
Ind J Child Health 1959; 8 : 273-80
20. Garg K, Mangal N, Mathur HC. Clinical profile
of multi drug resistant typhoid fever in Jaipur
city. Indian pediatr 1994;31(2):191-93
21. Urmila Jhamb. Multidrug resistant typhoid in
children. NCPID IAP 2001
249
Sudharshan
DOI: 10.5958/j.2319-5886.3.2.055

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Health Sciences
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Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Research Article
ANTIBIOGRAM STUDY OF AEROBIC BACTERIAL ISOLATES FROM UROPATHOGENS

Mallikarjuna Reddy C1, Himabindu M2, Maity Soumendranath3, Kanta R.C4, Kapur Indu5
1
Assistant Professor, 2Assistant Professor, 3Tutor, 4Professor, 5Professor & HOD Departments of Microbiology,
Mallareddy Institute of Medical Sciences, Hyderabad
*Corresponding author email: cpmreddy@gmail.com
ABSTRACT
Background: Bacteria are capable of invading and infecting humans, leading to disease and sometimes death.
Systems and tissues in human body are vulnerable to different organisms. Infection pattern is likely to differ by
geographical regions. Aim: This study was aimed to isolate and identify the type of aerobic bacteria causing
Urinary Tract Infections (UTI) in different age groups and sexes, and also in some predisposing conditions. Their
antibiogram also was done. Materials and Methods: Midstream urine sample collected aseptically from 276
patients were subjected for isolation and identification of aerobic bacteria by standard technique and subsequently
antibiogram was done by Kirby Bayer Method. Both sexes of patients with an age range of 10-70 years and
patients with diabetes (22), hypertension (8) and anemia (8) were also included in the study. Results: Escherichia
coli was the predominant organism(50%) among other isolates Klebsiella species (27.3%), Proteus
species(7.14%), Staphylococcus saprophyticus (5.95%), Staphylococcus aureus (3.57%), Enterococci (3.57%),
Pseudomonas species(2.38%). UTI was more common among patients of 60 and more years of age; however,
incidence was more in female patients (36.2 38.5%) compared with male patients (25-30%). Anemia, Diabetes
and Hypertension conditions were found to predispose UTI. Aminoglycosides and Quinolones were found to be
more effective against the isolates. Conclusion: The present study reveals in spite of the topographical diversity, the
infecting bacterial isolates from this area were found to be the same as from any other part of India.
Key words: UTI, Predisposing factors, Antibiogram.
INTRODUCTION
Urinary tract infection (UTI) is the commonest of all
infections seen in clinical practice. It is estimated that
10% of the patients visiting hospitals suffer from UTI.1
Both sexes of all age groups are vulnerable to UTI.
Women are especially prone to UTI. It is estimated
that 20% of women experience UTI in their life time.2
UTI is one major cause among hospital acquired
infections.2
Apart from socioeconomic reasons such as illiteracy,
ignorance and insanitation other factors are known to
predispose UTI which could be anatomical position of
the urethra, prostate hypotrophy, renal calculi, stricture

urethra, catheterization, and diabetes.3-5
UTI presents protein manifestations and may also be
asymptomatic.6 Reports indicates that different
spectrum of aerobic bacteria causes UTI. There seems
to be change in type of organisms in different areas.7
Hitherto study on isolation of aerobic bacteria and
their antibiogram associated with UTI has not been
done from this area. Hence this study was undertaken.
250
Mallikarjuna Reddy et al.,
MATERIALS & METHODS

This study was conducted in the department of
microbiology MNR Medical College and Hospital,
Sangareddy, Andhra Pradesh; from September 2008 to
August 2009. Two hundred and seventy six midstream
urine samples were collected in sterile container, from
patients from whom consent was obtained, with a
suggestive history of UTI. These patients were from
10 to 70 years of age; and of sex, 8 patients with
essential hypertension, 22 with diabetes mellitus and
36 with anemia. Pregnant women, women having
thyrotoxicosis, genitourinary procedure, carcinoma,
vaginitis, prostitis, recipient of renal transplant were
excluded from this study.
Midstream urine samples collected aseptically & with
all sterile precautions from the patients with symptoms
like fever, chills, frequency, and urgency of urination,
dysuria and suprapubic pain were inoculated onto
MacConkey Agar, Blood Agar and Urichrome Agar,
and incubated at 370C for 18-24 hours for isolation.
Identification of the aerobic bacteria was performed by
various biochemical reactions.8 Antibiotic sensitivity
was done by disc diffusion method (Modified Kirby
Bayer) on Mueller-Hinton agar9 using Amoxycillin
(AMC) 20mcg, Cefepime (CPM) 30mcg, Cefotaxime
(CTX) 30mcg, Amikacin (AK) 30mcg, Gentamicin
(G) 10mcg, Ofloxacin (OF) 5mcg, Ciprofloxacin (CIP)
5mcg, Norfloxacin (NR) 10mcg, Nalidixic Acid(NA)
30mcg,
Nitrofurantoin
(NIT)
300mcg
and
Cotrimoxazole (COT) 1.25mcg discs from Himedia
Pvt Ltd.
Ethical clearance: Clearance from institutional ethical
committee was obtained prior to conducting this study
RESULTS & DISCUSSIONS
Total of 276 midstream urine samples, collected
aseptically were processed for isolation of aerobic
bacterial isolates, using standard methods.8 Out of 276
samples, 84 (30.43%) yielded aerobic bacterial isolates
(Table 1). The results indicate that out of 84 positive
aerobic isolates, 42 (50%) Escherichia coli followed
by Klebsiella spp. 23 (27.38%), Proteus spp.6 (7.14%),
Staphylococcus
saprophyticus
5
(5.45%),
Staphylococcus aureus and Enterococci each 3
(3.57%) and the least isolate was Pseudomonas spp. 2
(2.33%).
Our findings 84 (30.43%) out of 276 were
considerably higher compared to the reports from Aziz
Marjan Khattak8 which were 6.2%. Present findings of

the percentage of UTI which are noticeably high is
probably due to illiteracy, ignorance on the part of the
population and also that the study region comprises of
many poorly sanitated towns & villages. It was also
observed that the public &personal hygienic
conditions are poor.
Table: 1 Aerobic bacteria isolated from urine
Aerobic bacterial No of isolates
%
isolates
Escherichia coli
42
50%
Klebsiella Spp
23
27.38%
Proteus spp
6
7.14%
S. saprophyticus
5
5.95%
S. aureus
3
3.57%
Enterococci
3
3.57%
Pseudomonas spp
2
2.38%
*Total number of samples studied = 276, number of
positive samples = 84
The present study indicates that the predominant
isolate was Esch. coli (50%). Various studies7,11-13
(Table:2) on aerobic bacterial isolates from urine
samples including both sexes and all age groups show
a wide range of percent isolates from 30 53%.
Table 2: Aerobic isolates from other workers
References
% of aerobic Predominant
isolates
organism
Acharya et al
30%
E. coli
Shobha Ram et al
45.5%
E. coli
Mandal et al
53%
E. coli
Ethel et al
53%
E. coli
Incidence of aerobic bacterial isolates from UTI in
male and female patients with age ranging from 10
70 years is shown in Table: 3.
Table 3: Incidence of aerobic bacterial isolates from
UTI among male and female of different age groups
Age
Male
Female
(Years) Tota +Ve %
Total +Ve %
l
10 - 20 20
5
25
16
6
37.5
21 30 22
4
18.1 52
19
36.5
31 40 32
6
18.7 36
14
38.5
41 50 16
4
25
25
8
32
51 60 13
3
23
23
8
34.7
>61
10
3
30
11
4
36.3
Incidence was moderately higher in female patients
than male patients and in the age group of 60 70
years in males, whereas prevalence is almost same in
251
all age groups in female patients.Our findings are

almost consistent with the findings of Marie-vic O
etal.14
Women are prone to develop UTI and 20% of women
are known to develop UTI sometime during their
lifetime. More incidences in males could be due to
retention of urine due to prostate enlargement as it is
known that residual urine as minimal as 2-3ml is likely
to cause UTI.
Predisposing factors such as some metabolic diseases
might play some role in UTI17. Hence the study was
done to know the role of diabetes, hypertension,
anemia,17 which are common ailments, nowadays.
Proven cases were considered for the study and the
results are depicted in Table: 4
The results indicate the association of these diseases
with UTI . However, more detailed study in this area
needs to be done. Studies conducted by Bahl et al
(1970)15, Hansen RO (1964)16on association of UTI
with diabetes and hypertension respectively throws
some message in this direction. Mandal et al. reported

64.3% diabetics having UTI.6
Table 4: Association of UTI with other conditions
Diseases
No of cases
No of +ve cases
studied
Diabetes
22
6 (23.2%)
Hypertension 8
2 (25%)
Anaemia
36
8 (22.2%)
Another important factor of the study was to evaluate
the antibiotic pattern of the bacterial isolates from the
UTI patients. The results are shown in Table 5.
Our study revealed that Esch. coli which was a
predominant isolate showing multidrug resistance,
particularly higher resistance to Nalidixic acid,
hitherto considered drug of choice for UTI. It
highlights the point that without confirming the
sensitivity pattern of the organism, it is not advisable
to use the drug for treatment. Klebsiella showed
resistance to almost all antibiotics used. Proteus was
found to be less resistant to the antibiotics used
Table 5: Antibiotic sensitivity of the isolate

Organism
Penicillin
Cephalosporins
Aminoglycosides
Quinolones
CPM
CTX
AK
OF
CIP
NR
NA
NIT
COT
19
8
3
16
10
4
15
8
4
24
17
5
33
19
5
18
13
3
15
9
3
22
14
4
8
17
4
26
7
2
14
6
1
AMC
E.coli
Klebsiella
Proteus
Staph.
sapro
Enterococci
18
The antibiotic pattern in this study correlates with the result of McFadyen et al . (AMC Amoxyclav, CPM
Cefepime, CTX Cefotaxime, AK Amikacin, G Gentamicin, OF Ofloxacin, CIP Ciprofloxacin, NR
Norfloxacin, NA - NAlidixic Acid, NIT - Nitrofurantoin, COT - Cotrimoxazole)
CONCLUSION
In spite of the topographical diversity the infecting
bacterial isolates from this area were found to be the
same as from any other part of India. Aerobic urinary
pathogens infectivity percentage is almost same as is
shown by other studies from different parts of our
country. Although incidence and infectivity pattern
match with other studies, antibiotic susceptibility
profile needs to be done for every isolate for proper
treatment.
ACKNOWLEDGEMENTS
We sincerely thank Dr. Chandrakanth Shirole, Dean,
Dr. Badhra Reddy and Dr. Preethi Reddy, Directors,
Mallareddy Institute of Medical Sciences, Mr. M. Ravi

Verma, Director, MNR Medical College for their
encouragement. We also thank Dr. Swarajya Lakshmi,
Associate Professor and Mrs. Madhuri, Assistant
Professor and Mr. Amar Kumar, Department of
Microbiology, MNR Medical College for their
guidance.
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253
DOI: 10.5958/j.2319-5886.3.2.056

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Coden: IJMRHS
Received: 12th Dec 2013
Revised: 18thJan 2014
Copyright @2014
ISSN: 2319-5886
Research Article
A STUDY ON RADIAL ARTERY IN CADAVERS AND ITS CLINICALIMPORTANCE

*Prakash KG1, Saniya K2
1
Associate Professor, 2Assistant Professor, Department of Anatomy, Azeezia Medical College, Meeyyannoor, Kollam,
Kerala, India
*Corresponding author email: drprakashkg@gmail.com
ABSTRACT
As the radial artery is the second most commonly used graft in coronary bypass (CABG)surgery(internal thoracic
artery first most common)and for transcatheter coronary interventions (angioplasty),cardiac surgeons should have
thorough knowledge about the normal anatomy and possible variations of it before these cardiac procedures.
Methods: 50 radial artery specimens(both right and left sided)were studied by dissection method in 25 cadavers
(20 male and 05 female). The data were tabulated in Microsoft excel and analysed by using Statistical Package for
Social Science (SPSS 17th version). Mean, Proportion, Standard deviation and Unpairedt test were applied for
analysing the data obtained. Results& conclusion: Radial artery in all the specimens take origin from brachial
artery at or just below the elbow joint in the cubitalfossa, running superficially and laterally, giving radial recurrent,
manycollaterals, radial carpal and superficial palmar branches; total mean length of artery from origin to wrist joint
is 20.63 1.96cm; mean luminal diameter at its termination 2 cm proximal to styloid process just above the wrist
joint is 2.14 0.28mm.This study revealed anomalies like tortuosity (30%)in distal 1/3rd segment and radio-ulnar
loops were not found in any specimens.
Keywords: Radial artery, Coronary bypass graft, Transcathetercoronary interventions (Angioplasty), Internal
thoracic artery.
INTRODUCTION
Graft patency is a fundamental predictor of long term
survival after coronary bypass graft (CABG) surgery.
Given its proven survival benefit, left internal thoracic
artery to left anterior descending artery (LITA-LAD)
grafting has become a fundamental part of CABG.
This grafting also led to increased use of other arterial
conduits, of which radial artery is most popular(second
most common next to internal thoracic artery).1
In 1973, Carpentier suggested the use of radial artery
as a conduit for coronary bypass graft surgery.2
Eventhough radial artery had been abandoned in early
1970s due to high rate of graft failure in postoperative period,butdue to the latest concepts of total
arterial revascularisation in coronary bypass surgery in
1989, it has been proved thatradial artery is as good as

an internal thoracic artery in CABG due to histological
similarities.3
Radial artery is nowadays commonly used for
transcatheter coronary interventions (angioplasty)
compared to transfemoral or transbrachial technique
due to the lower risk access site related complications.
Lower risk is because of the radial artery being
superficial; haemostasis can be easily achieved just by
local compression.4Harvesting radial artery for
CABG5or during transcatheterisation does not cause
any damage as there are no large veins or nerves exist
nearby it and even does not cause ischemia in hand as
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Prakash et al.,
Int J Med Res Helath Sci. 2014;3(2):254-262
there exist collateral circulation bypalmar arches

(ulnar artery).4
Normally, the radial artery is a smaller terminal branch
of the brachial artery, arises at the level of neck of
radius in the cubitalfossa. It runs superficial compared
to the ulnar artery, (another terminal branch of brachial
artery).During its course, at the beginning, it gives one
radial recurrent artery which takes part in anastomosis
around the elbow joint; it also gives numerous small
collateral or muscular branches which supplies nearby
muscles and finally giving a palmar carpal branch in
the lower part of the forearm. It leaves the forearm by
turning posteriorly and enters the anatomical snuffbox.
Just before it leaves, gives a superficial palmar branch
which completes the superficial palmar arch along
with the ulnar artery. 6
It is also observed that accessing radial artery in some
cases of transcatheter intervention fails due to its
anatomical variations. Therefore, anatomy and its
variations should be studied systematically for guiding
the
cardiologists
in
transcatheter
coronary
interventions and in coronary bypass surgery as a
graft.
MATERIALS & METHODS
After the approval of the Institutional Ethical
Committee, Azeezia Medical College, Meeyyannoor,
Kollam Dist, Kerala state, a total of 50 radial artery
specimens (25 right sided and 25 left sided) from 25
adults embalmed human cadavers (20 males and 05
females) with an average of 35-60 years, from 2008
2013 in the Department of Anatomy were studied.
In the cadavers, brachial and ante brachial regions
were dissected as per the Cunninghams Manual
Methods7 of Dissection.Radial artery was traced from
its origin to the termination at the wrist.
The specimens were numbered from 0150. Each
radial artery was studied with respect to its origin,
termination, branches and variations or any anomalies
like radio-ulnar loops, tortuosity or any other. Total
length of the artery was measured from its origin to
termination by nylon thread and measuring that thread
length using a long scale.
After dissecting the artery from its entire course and
studying, papaverine is injected in the distal segment
of the artery and cross sectional luminal diameter of
artery at the termination point 2cm proximal to
styloidprocess just above the wrist was measured in
millimetres using digital calliperse.
Fig 1: Measurement of radial artery with thread.

As radial artery is the second most common graft used
for coronary bypass surgery, the measurement of
luminal diameter of the radial artery should be studied
to guide the cardiac surgeons to know at what level, it
should be grafted to the coronary artery (same
corresponding luminal diameter level) to bypass the
block.
Fig 2: Electronic Digital Calliperse used for the

study.
All the measurements and observations were recorded
and tabulated. After the procedures, all the specimens
were preserved in 10% formalin solution. The radial
artery even though most commonly takes origin as a
branch from brachial artery just at or below the elbow
joint, sometimes may take origin directly from the
axillary artery above the elbow joint (high origin) or
sometimes may absent congenitally in which ulnar
artery and its branches will supply the territory of the
radial artery. The radial recurrent artery, which is an
usual important branch of the radial artery, may come
directly from brachial artery or from ulnar artery. The
radial artery, which usually terminates as a superficial
palmar branch in the hand, sometimes there may not
be any branch by its & therefore, no contribution of it
in forming the palmar arches in the hand.
STATISTICAL ANALYSIS:
Data were collected from 50 embalmed adult human
cadaveric specimens (05 female and 20 male)
belonging to both right and left sides and entered in
Microsoft excel and analysed by using Statistical
Package for Social Science (SPSS 17th version).
255
Prakash et al.,
Mean, Proportion, Standard deviation and Unpairedt

test were applied for analysing the data obtained.
RESULTS
The present study includes dissection of 50 specimens
of radial artery to observe the possible variations origin, course, branches, total length, luminal diameter
distally, its termination and any other anomalies that

may disrupt the transcatheter coronary interventions.
All these observations were recorded and tabulated as
follows. The data collected was computerised and
analysed by using Statistical Package for Social
Science (SPSS 17th version).
Table: 1. Radial artery; a study on cadavers and its clinical importance.

Total cadaver
25
Sex of the cadaver
20 Male & 05 Female
Total specimens
50 (25 right sided & 25 left sided)
Approx. Age (in years) 35 60 Yrs.
Above the elbow joint
(High origin)
Nil
Origin
At or just below the
All the 50 radial artery arises below the elbow joint as a
elbow joint
branch of brachial artery
Absent
Nil
Length (in cm) (from origin to wrist joint)
Luminal diameter (in mm)(at termination point 2
cm proximal to styloid process, just above wrist)
From upper 1/3rdsegment
Branches
From middle 1/3rd

segment
From lower 1/3rdsegment
Any variations
(Anomalies)
Course
20.63 1.96cm.( minimum 16.4 cm & maximum 23.4

cm)
2.14 0.28mm.( minimum 1.6 mm & maximum 2.6 mm)
In 39 specimens, radial recurrent artery is large arising from
radial artery. In 09 specimens radial recurrent artery arising
directly from brachial artery and in 02 specimens it arises
from ulnar artery. In addition, radial artery gives collateral
branches.
In 48 specimens, collateral branches supplying the muscles. In
02 specimens, we could not find out any collateral branches
All 50 specimens give collateral branches & radial carpal
branch. At its termination, all give superficial palmar branch.
Radioulnar loops
Tortuosity
In no specimen, loops found.

15 specimens radial artery show tortuous at the distal 1/3rd of
forearm. 35 specimens do not show any tortuosity.
Any other
Nil
49 specimens show normal course i.e. from its origin passes downwards to the wrist with
a lateral convexity and is overlapped anteriorly by brachioradialis in the upper part, skin
superficial fascia and deep fascia in the lower part. Posteriorly,it is related to tendon of
biceps and supinator in the upper part.Medially, pronatorteres proximally and flexor carpi
radialis distally (where the radial pulse is felt lateral to this tendon), and laterally
brachioradialis and radial nerve.
But in 01 specimen, radial artery at its origin passes behind the tendon of biceps. So the
tendon may compress the radial artery during muscle action.
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Prakash et al.,
Table: 2 statistical analysis of 50 samples (both males and females belonging to right and left sides)
Distance from interepicondylar line to Total length of artery Luminal diameter
origin(in cm)
(in cm)
(in mm)
50
50
50
Samples
3.39
20.63
2.14
Mean
0.09
0.28
0.04
Std.Error of Mean
0.63
1.96
0.28
Std. Deviation
0.39
3.82
0.08
Variance
2.40
16.40
1.60
Minimum
5.20
23.40
2.60
Maximum
The radial artery takes origin at a mean distance of
3.39cm (minimum: 2.4cm, maximum: 5.2cm) from
interepicondylar line, with standard deviation 0.63 and
standard error of mean 0.089. (Table 2). The mean
total length of the radial artery found to be 20.63
1.96cm (minimum: 16.4cm and maximum: 23.4cm)
with standard deviation 1.96 and standard error of

mean 0.28. (Table 2)
The mean luminal diameter of radial artery, 2 cm
proximal to styloid process is 2.14 0.28mm (minimum:
1.6mm and maximum: 2.6mm), with standard deviation
0.28 and standard error of mean 0.04. (Table 2)
Table: 3 Statisticalanalysis of Male samples (40)

Distance from interepicondylar line to Total length of artery
origin(in cm)
(in cm)
40
40
Samples
3.57
21.23
Mean
0.09
0.27
Std.Error of Mean
0.56
1.71
Std. Deviation
0.32
2.93
Variance
2.80
16.40
Minimum
5.20
23.40
Maximum
In the male specimens, the artery takes origin at a
mean distance of 3.57cm (minimum: 2.8cm and
maximum: 5.2cm) from interepicondyalr line, with
standard deviation 0.56 and standard error of mean
0.09. Similarly, the total mean length of the artery is
21.23 1.71cm (minimum: 16.4cm and maximum:
23.4cm), with standard deviation 1.71 and standard

error of mean 0.27. The total mean luminal diameter
of the artery is 2.16 0.28mm (minimum: 1.6mm and
maximum: 2.6mm) with standard deviation 0.28 and
standard error of mean 0.04. (Table 3)
Table: 4 Statistical analysis of Female samples (10)

Distance from interepicondylar line to Total length of artery
origin(in cm)
(in cm)
10
10
Samples
2.66
18.26
Mean
0.06
0.18
Std.Error of Mean
0.19
0.57
Std. Deviation
0.36
0.32
Variance
2.40
17.40
Minimum
3.00
19.20
Maximum
From 10 female samples, it was observed that, the
radial artery takes origin at a mean distance of 2.66cm
(minimum: 2.4cm and maximum: 3.0cm) from
Luminal diameter
(in mm)
40
2.16
0.04
0.28
0.08
1.60
2.60
Luminal diameter
(in mm)
10
2.06
0.094
0.29
0.09
1.60
2.60
interepicondyalr line, with standard deviation 0.19 and

standard error of mean 0.06. Similarly, the total mean
length of the artery is 18.26 0.57cm (minimum:
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Prakash et al.,
17.4cm and maximum: 19.2cm) with standard

0.29mm (minimum: 1.6mm and maximum: 2.6mm)
deviation 0.57 and standard error of mean 0.18. The
with standard deviation 0.29 and standard error of
total mean luminal diameter of the artery is 2.06
mean 0.09. (Table 4)
Table: 5 Statistical analysis of Male and Female comparison
Sex
Samples Mean
Std.Deviation Std.Error of Mean
M
40
3.57
0.56
0.09
Distance from interepicondylar line to
origin(in cm)
F
10
2.66
0.19
0.06
M
40
21.23
1.71
0.27
Total length of artery (in cm)
F
10
18.26
0.57
0.18
M
40
2.16
0.28
0.04
Luminal diameter (in mm)
F
10
2.06
0.29
0.09
Table: 6 Statistical analysis of Male and Female comparison (applying Unpairedt test)
Levenes Test
for Equality of
Variances
Equal variances
assumed
Equal variances
not assumed
Equal variances
assumed
Length of artery Equal variances
not assumed
Equal variances
assumed
Luminal diameter Equal variances
not assumed
Distance of
origin from
Interepicondyla
r line
Sig.
5.01
0.30
t-test for
Equality
of
Means
Mean SE
48
Sig.
(2 tailed)
0.00
t-test for
Equality of
Means
95% Confidence
Interval of the
Difference
Lower Upper
0.910.18
0.54
1.28
43.5
0.00
0.910.11
0.69
1.13
5.37
48
0.00
2.97 0.55
1.86
4.08
9.14
44.0
0.00
2.97 0.32
3.62
0.95
48
0.35
0.09 0.10
0.91
13.3
0.38
0.09 0.10
2.31
0.11
0.13
t
5.01
8.48
5.27
0.001
0.03
0.97
When Unpaired t test is applied (Ref Table 6) to the

sex and to the distance of origin of the artery from
interepicondylar line, sex and the total length of the
artery, sex and luminal diameter of the artery, the
distance between the origin of the artery and the
interepicondylar linebetween male and female, found
to be highly significant (P = 0.00, which is less than
0.05), total length of the artery among males and
females also highly significant (P = 0.00, which is less
than 0.05). Highly significant means that there is a
difference between males and females with respect to
the distance between the origin of the artery from
interepicondylar line and the total length of the artery,
whereas luminal diameter values found not to be
significant (P = 0.35, which is greater than 0.05) and
therefore, no sex variation with respect to the luminal
diameter.
Origin: All 50 radial arteries observed to take origin
from the brachial artery at or just below the elbow
t-test for
Equality of
Means
df
t-test for
Equality of
Means
0.29
0.32
joint in the cubitalfossa. No high origin or low origin

cases noted. In all the cases, the radial artery originates
from brachial artery just below the elbow joint at an
overall mean distance of 3.39 0.62cm from an
imaginary line joining the two epicondyles (medial &
lateral) of the humerus bone (interepicondylar line). In
males, it originates at a distance of 3.570.56cm and
in females, at a distance of 2.66 0.19cm.
Length: Total length of the radial artery from its
origin to wrist joint averaged to be 20.63 1.96cm,
minimum length being 16.4 cm and maximum length
being 23.4 cm. In males, total length averaged to
21.23 1.71cm and in females, it is measured to be
18.26 0.57cm.
Luminal diameter: Luminal diameter of radial artery
measured with digital calliperse at termination 2 cm
proximal to styloid process just above wrist joint, in
overall, varying from minimum 1.6 mm to maximum
2.6 mm, and luminal diameter averaged to be 2.14
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Prakash et al.,
0.28mm.In males, luminal diameter averaged to 2.16

0.28mm and in females, it is measured to be 2.06
0.29 mm.
Course: Radial artery from its origin passes
downwards to the wrist with a lateral convexity and is
overlapped anteriorly by brachioradialis in the upper
part; skin superficial fascia and deep fascia in the
lower part. Posteriorly, it is related to tendon of biceps
and supinator in the upper part. Medially,
pronatorteres proximally and flexor carpi radialis
distally and laterally brachioradialis and the radial
nerve. In 49 specimens, this normal course of radial
artery had been observed. But in 01 specimen, radial
artery passes behind the tendon of biceps after arising
from the brachial artery. In such a case, the tendon of
biceps may compress the radial artery during flexion
of elbow joint or supination of forearm.
Fig 3: Radial artery behind biceps tendon

Branches:
From upper 1/3rdsegment:In 39 specimens, radial
recurrent artery is arising from the radial artery, in 09
specimens it is arising directly from the brachial artery
and in 02 specimens from ulnar artery, all will be
participating in anastomosis around the elbow joint. In
addition, radial artery also gives some collateral
branches.
Fig5: Radial recurrent artery from brachial artery
Fig 6: Radial recurrent artery from ulnar artery

From middle 1/3rd segment: In 48 specimens, it has
been observed that many collateral branches arising
and piercing the muscles surrounding and supplying
them. In 02 specimens, we could not find out any
collateral branches.
From lower 1/3rdsegment:All the 50 specimens
showed collateral branches & radial carpal branch
arising before termination, and finally giving
superficial palmar branch at its termination.
Fig 7 - Radial artery Normal branches
Fig 4: Radial recurrent artery from radial artery

Prakash et al.,
Anomalies:
Radio-ulnar loops: In all 50specimens, no radioulnar loops connecting radial and ulnar arteries were
found.
Tortuosity: In 35 specimens, there was no tortuosity
found in its entire course from its origin to
termination. But, 15 specimens showed tortuosity at
the distal 1/3rd of forearm.
259
Fig 8: A tortuous radial artery

DISCUSSION
The study of radial artery has gained its utmost
importance as it is the second most commonly used
graft in CABG and its common use in transcatheter
coronary interventions (angioplasty) compared to
transfemoral or transbrachial technique due to very
less risk of access site related complications.
Bypass surgeries or angioplasty procedures are done to
bypass the occluded or nearby occluded coronary
arterial segments, to relieve ischemic symptoms,
persistent angina or congestive heart failure from
severe occlusive diseases of the coronary arteries.
A total of 50 radial artery specimens were studied by
the dissection method to know the possible variations
pertaining to its origin, length, course, branches,
termination and distal luminal diameter 2 cm just
above the wrist joint and this study will surely guide
the Cardiothoracic surgeons in transcatheter coronary
interventions (angioplasty) and harvesting it for
coronary bypass surgery as a graft.
A. Rodriguez-Baeza et al7in a study, a total of150
routine dissection of human upper limb from adult
cadavers noted 23 cases of variations in brachioantebrachial arterial pattern among which radial artery
was found to take high origin from axillary artery and
also from the upper third of brachial artery.
VA Jebara, C Acaret al3 in 1991 studied radial artery
in 40 subjects (30 patients undergoing CABG and 10
adult cadavers) observed that in all the cases artery
was originating from brachial artery at or just below
the elbow.
PoteatWL8reported a case of unilateral absence of the
radial artery, which is a very rare variation and there
was no deep palmar arch.
M.Rodriguez-Niedenfuhret al9, in their review study
explained the embryological reasons and basis for the
variations in the arterial patterns of the human upper

limb including radial artery.
Charles JJ10also reported the absence of radial artery
with an estimated incidence lower than 0.2% in which
the radial blood supply territory was supplied by the
anterior interosseous or the median artery.
In our present study of 50 specimens, all the
specimens of radial artery observed originating from
brachial artery at or just below the elbow joint.
Total length of the radial artery from its origin to the
wrist joint and the luminal diameter at its termination 2
cm proximal to the styloid process just above the wrist
was recorded and found to be similar with previous
studies as follows.
Table: 7. Measurement of length and diameter of
radial artery
Studies
Length
(in cm)
VA Jebara et al3
22.5 1.2
Naoyuki Yokoyama
------et al4
Byung-suYoo et al11
------Present study
20.631.96
Diameter
(in mm)
Richness
in
collateral
branches
2.7 0.06
2.6 0.5
+++
+++
2.6 0.41
2.140.28
+++
+++
VA Jebaraet al3 in their study reported that the radial

artery gives off many collateral branches that supply
adjacent muscles and the integument of the
anterolateral region of the forearm; and noted a large
recurrent collateral branch from radial artery near its
origin. They found very few collaterals in the upper
1 rd
/3 segment and two to three collaterals in distal1/3rd.
In our present study, it has been observed that large
radial recurrent artery arising from the radial artery at
its origin (upper1/3rd) in 39 specimens and taking part
in anastomosis around the elbow joint. In 09
specimens, radial recurrent artery arising directly from
brachial artery and in 02 specimens, arising from ulnar
artery and finally participating in the anastomosis
around the elbow joint. Many collateral branches also
seen arising from the upper 1/3rd segment. And most of
the specimens give collaterals from middle
1/3rd.Collaterals along with radial carpal branch found
arising from the lower 1/3rdsegment.All specimens
showed the presence of the superficial palmar branch
at its termination.
Variations and anomalies like radio-ulnar loops,
tortuosity etc. were studied in the specimens and
reviewed with the previous studies as follows:
260
Prakash et al.,
Table: 8. Anomalies of radial artery

Studies
Naoyuki Yokoyama
et al4
Byung-suYoo et al11
TS LO, Nolan et al12
Present study
Radioulnar
loops
0.9 %
37.1 %
------Nil
Tortuosity
5.2 % in proximal
1/3rd segment
23.3 %
4.2 % in proximal
1/3rd segment
30 % in distal 1/3rd
segment of artery
In 49 specimens, normal course of radial artery had

been observed. But, in 01 specimen, the radial artery
after arising from the brachial artery passes behind the
tendon of biceps brachii instead passing anterior to the
tendon. In such a case, the tendon of biceps may
compress the radial artery during flexion of elbow
joint or supination of forearm.
Richard F Brodman, Rosemary Frame et al5 from their
study recommended the use of one or both the radial
arteries as additional conduits along with the internal
thoracic artery for arterial revascularisation of the
coronary arteries because of potential benefit of
excellent long term patency, minimal morbidity and
mortality associated with the use of radial artery as a
graft in CABG and, they found high degree of
acceptance of radial artery by both patients and
cardiologists; patients experienced less pain and easier
ambulation post operatively and length of the hospital
stay is shorter for the patients comparatively.
In an angiographic study after CABG surgery by Peter
Collins, Carolyn M. Webbet al13 out of 103 patients,
98.3% radial artery grafts and 86.4% of saphenous
vein grafts were patent and graft narrowing occurred
in 10% of patent radial arterial grafts and 23% of
patent saphenous vein grafts.
In a similar study by Anoar Zacharias, Robert et al1
concluded that using the radial artery as a second
arterial conduit in CABG-LITA-LAD as opposed to
vein grafting improves long term outcomes.
In a study by Naoyuki Yokoyama et al4 recommended
for angioplasty, transradial Coronary Interventions
(TRI) as they found high success rate with very less
stenotic changes without any other precipitating a
major cardiac event including death and myocardial
infarction. And, no access site related complications
developed.
Similarly, in a study by Keimeneij F et al14-16 reported
that transradial artery coronary angioplasty has got
very high prognosis and good result, and no access site

related complications.
Other many previous studies also revealed less
complication and very less access related site risks
using radial artery for transcatheter coronary
interventions17-21
CONCLUSION
From the study of total of 50 dissected radial artery
specimens (both right and left sided;20 male and 05
female cadavers) and comparing the present study with
the previous works, it can be concluded that the origin
of artery takes usually from brachial artery at or just
below the elbow joint in the cubital fossa at an average
distance of 3.39 0.62cm from interepicondylar line
(male: 3.57 0.56cm, female: 2.66 0.19cm) and the
total length of the radial artery from its origin to wrist
joint is averaged to be 20.63 1.96cm (male: 21.23
1.71cm,female: 18.26 0.57cm); luminal diameter at
its termination 2 cm proximal to styloid process just
above the wrist joint is 2.14 0.28mm.(male: 2.16
0.28mm, female: 2.06 0.29mm)
Radial artery found to have a normal course running
superficially and laterally in all the cases giving
branches- radial recurrent artery at its origin, many
collateral branches supplying surrounding muscles,
radial carpal branch before termination and superficial
palmar branch at its termination.
Radial arteries anomalies like radio-ulnar loops (Nil)
and tortuosity (30%) in distal 1/3rd segment are noted
in the present study. This concludes that the radial
artery can be safely used as a route for transradial
coronary interventions (angioplasty) and as a graft in
coronary arterial bypass (CABG) surgery. Therefore,
the radial artery can be regarded as a useful vascular
access site for all the coronary procedures.
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Byung-suYoo, Junghan Yoon, Ji Yean Ko.
Anatomical consideration of radial artery for
coronary procedures. Inter J Cardiol. 2005; 101(3):
421-27
TS LO, Nolan J, Butler R , Fountzopoulos OE.
Radial artery anomaly and its influence on
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Peter Collins, Carolyn M. Webb, Chee F, Chong.
Radial artery versus Saphenous vein patency
randomised trial.Circulation. 2008; 117: 2859-64.
Keimeneij F, Laarman GJ, de Melker E.
Transradial artery coronary angioplasty. Am Heart
J.1995; 129:1-7.
Keimeneij F, Laarman GJ, Odekerken D,
Slagboom T. A randomised comparison of
percutaneous transluminal coronary angioplasty by
the radial, brachial and femoral approaches: the
access study. J Am Coll Cardiol. 1997; 29: 126975
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transradial artery approach for coronary palmazschatz stent implantation. Am Heart J. 1994; 129:
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17. Lotan C, Hasin Y, Mooseri M, Rozenman Y,
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approach for coronary angiography and
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18. Saito S. Update on coronary intervention through
the radial approach. J Intervent Cardiol.1998;
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19. HildickSmith DJR, Ludman PF, Lowe MD,
Stephens NG. Comparison of radial versus
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20. Ochiai M, Isshiki T, Toyoizumi H, Eto K,
Yokoyama N. Efficacy of transradial primary
stenting in patients with acute myocardial
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Research Article
METALLO BETA LACTAMASE MEDIATED RESISTANCE IN CARBAPENEM RESISTANT GRAMNEGATIVE BACILLI: A CAUSE FOR CONCERN
*Malini Jagannatha Rao1, Shruti A Harle1, Ravi J2, Padmavathy M1, Umapathy BL1, Navaneeth BV1
1
Department of Microbiology, ESIC-MC-PGIMSR, Rajajinagar, Bangalore, Karnataka, India

Senior Lecturer, Department of Periodontics, Vyedehi Institute of Dental Sciences and Research centre, Bangalore
*Corresponding author email: drsha13@hotmail.com

ABSTRACT
Introduction: The emergence of acquired metallo--lactamases (MBL) in Gram-negative bacilli is becoming a
therapeutic challenge, as these enzymes usually possess a broad hydrolysis profile that includes carbapenems,
extended-spectrum -lactams. Aim: To detect Extended spectrum -lactamases and metallo--lactamase in
carbapenem resistant Gram negative clinical isolates from various clinical specimens and to evaluate their antibiotic
susceptibility patterns. Material and Methods: A total of 100 non duplicates imipenem resistant isolates were
tested for the presence of extended spectrum -lactamases by phenotypic confirmatory test, metallo--lactamases
by Double disk synergy test with various distances from edge to edge (10mm,15mm,20mm), between the IPM and
EDTA and combined disc test. Result: Of the 100 IMP resistant isolates screened 30 (30%) were MBL positive by
phenotypic methods, i.e., double disk synergy test and combined disc test. Co-existence of Extended spectrum lactamases and MBL were detected in 3 (30%). All the 30 MBL positive isolates had shown synergy at (100%) at
10 mm distance, 27 (90%) isolates had shown synergy at 15 mm distance and 13 (43.4%) isolates were shown
synergy at 20 mm distance. All the 30 MBLs producers were multidrug resistant and 27 (90%) were sensitive to
colistin (CL). All MBL positive Pseudomonas aeruginosa were sensitive to polymyxin B (100g). Conclusion:
Microbiologists are now facing a challenge of drug resistance due to MBL production. Although CLSI guidelines
do not quote about the ESBL detection in Pseudomonas aeruginosa MBLs and ESBL have to be detected in them.
The use of combination tests would increase the sensitivity to detect the presence of MBL among the clinical
isolates of Gram-negative bacilli. The spread of MBL producing Gram negative organism can be prevented if they
are detected in all isolates and routinely adopted in all laboratories.
Keywords: Carbapenem, CDT, DDST, EDTA, ESBL, Gram negative bacilli
INTRODUCTION
Gram negative bacilli resistant to penicillin and
cephalosporin can be treated by carbapenems, but the
enzyme carbapenemase can hydrolyse most of the
betalactamases (extended- spectrum and Amp C beta
lactamases).1 Three major groups of such enzymes
are usually distinguished, class C cephalosporinases
(AmpC), Extended spectrum -lactamase (ESBL) and
different types of -lactamases with carbapenemase
activity of which so called metallo --lactamases

(MBL), are of great concern. 2 ESBLs are still
considered as a threat since they are coded by plasmid
and can be easily transmitted between species. ESBL
producing organisms are highly effective in
inactivating penicillins, most cephalosporins and
aztreonam. 3
263
Malini et al.,
We are facing a threat of the use of carbapenems

especially against the Ambler class B MBLs. Many
reports across the globe have shown high level
resistance to all betalactams.4
Genes like IMP, VIM and others code for these Class
B enzymes, for which divalent cation like zinc is
required for the enzymatic activity. MBL genes seem
to have disseminated from Pseudomonas aeruginosa to
other members of family enterobacteriaceae. 5 World
wide prevalence of MBL is seen with Pseudomonas
aeruginosa and also recently among Gram negative
bacilli. 6,7,8 The infection with these MBL strains
remains a challenge for treatment and can lead to
morbidity and mortality. Polymerase chain reaction is
the gold standard for MBL detection, but it may not be
available in all laboratory setups. Other non molecular
methods are available depending on the chelating
agents such as Ethylene diamine tetra acetic acid
(EDTA) or 2-mercaptopropionic acid for enzyme
detection may be used.9
Some of these tests like the double-disk synergy tests
(DDST) using EDTA with Imipenem (IPM) or
ceftazidime (CAZ), 2- mercaptopropionic acid with
IPM or CAZ, the Hodge test a combined disk test
(CDT) using EDTA with CAZ or IPM, the MBL E
test and a micro dilution method using EDTA and 1,
10- phenanthroline with IPM are available. 4
Since the infection caused by Gram negative bacilli
producing MBL is difficult to treat, detection should
be carried out.
Therefore the present study was undertaken to detect
MBL in carbapenem resistant gram negative bacilli by
two phenotypic methods i.e., the Double disk synergy
test (DDST) and Combined disc test (CDT) with
EDTA . The ideal distance between the IPM and
EDTA discs in the DDST was also carried out to look
for the optimal critical distance between the discs. An
attempt was made to detect ESBL among the MBL
positive isolates.
This prospective study was conducted in the
Department of Microbiology, ESIC-MC-PGIMSR,
from May 2011 to January 2012.
A total of 100 clinically significant, non duplicate,
IPM resistant, gram negative clinical isolates obtained
from pus/ wound swab, sputum, blood, catheter tip and
Malini et al.,
urine. The specimens were received from both

inpatients and outpatients.
The 100 IPM resistant isolates included Acinetobacter
spp. (n= 40), Pseudomonas aeruginosa (n= 34),
Klebsiella pneumoniae (n=10), Escherichia coli (n=
9), Proteus spp.(n=3), Enterobacter
spp and ,
Providencia spp. (n=2) each.
Standard microbiological procedure was carried out to
speciate all the clinical isolates.10 Antimicrobial
susceptibility testing was done by using commercially
available disc (Himedia, Mumbai, India) in accordance
with Kirby Bauer's disc diffusion method. 11
Piperacillin-tazobactam 100/10g (PT), gentamicin
10g (GEN), amikacin 30g (AK), ciprofloxacin 5g
(CIP) , trimethoprim-sulfamethoxazole 1.25/23.75g
(COT), ceftazidime 30 g (CAZ), ceftriaxone 30 g
(CTR), cefotaxime 30 g (CTX), imipenem 10g
(IPM), meropenem 10g (MR) , aztreonam 30 g
(AZT), colistin 25 g (CL), and polymyxin B
300U(PB) were used in the antibiotic susceptibility
tests..
Results were recorded and interpreted as per Clinical
and Laboratory Standards Institute (CLSI) guidelines.
12
and for colistin for Enterobacteriaceae results were
recorded as per Galani et al. 13 Escherichia coli ATCC
25922 and Pseudomonas aeruginosa ATCC 27853
strains were used for quality control.
The minimum inhibitory concentration (MIC) of IPM
was determined by Etest, according to the
manufacturers recommendations (Biomerieux SA,
France).
Escherichia coli ATCC 25922 and
Pseudomonas aeruginosa ATCC 27853 strains were
used as quality control.
Phenotypic detection of MBL: In all the 100 IPM
resistant GNB, MBL was detected by DDST and CDT.
DDST: Bacterial suspension corresponding to 0.5
McFarland was inoculated on a Mueller- Hinton Agar
(MHA) plate. IPM (10 g) disk was placed next to a
blank filter paper disc (6mm in diameter) at a distance
of 10mm, 15mm, and 20mm apart from edge to edge.
10l of 0.1 M (292 g) EDTA was added to the blank
disc. After incubation for 16-18 hours at 37 C, an
enhancement of the zone of inhibition between IPM
disc and EDTA disc was considered positive for MBL.
9
(Figure .1)
CD Test: A 0.5 McFarland bacterial suspension was
inoculated on MHA plate. Two 10 g IMP discs were
placed on the inoculated plate in which 10l of 0.1M
(292g) EDTA was added to one of the IMP discs.
264
After incubation for 16-18 hours at 37 C, an increase

in zone diameter of > 4mm around the IPM- EDTA
disc as compared to IPM disc alone was considered
positive for MBL. 9 (Figure .2)
ESBL detection: Phenotypic confirmatory test 12 was
used to evaluate all isolates resistant to ceftazidime (30
g) for ESBL production.
Bacterial
suspension
corresponding
to
0.5
MacFarlands was spread on an MHA plate.
Aseptically ceftazidime (30 g) and ceftazidime /
clavulanic acid (30 g/ 10 g) discs were placed on the
agar plate. 15mm distance was maintained between the
two discs (edge to edge). Overnight incubation of
these culture plates was done. Confirmation for the
production of ESBL was done by noting 5mm
increase in the zone diameter for the antimicrobial
agent which was tested in combination with clavulanic
acid, versus its zone diameter when tested alone. The
increase in the zone diameter was due to the inhibition
of the lactamse by clavulanic acid.
Antimicrobial susceptibility of MBL producers

showed that all of them were multidrug resistant, with
resistance to 4 or more drugs (aminoglycosides,
quinolones, third generation cephalosporins, and
carbapenems). In the present study, 29 (96.6%) MBL
positive isolates were resistant to aztreonam and 3
(10%) isolates were resistant to colistin. (Figure .5)
Besides these antimicrobials, polymyxin B was used
for Pseudomonas aeruginosa and showed 100%
sensitivity.
Coexistence of ESBL and MBL was seen in 3 (10%)
of the 30 MBL isolates.
RESULTS
100 consecutive GNB resistant to IMP (10 ug) and
Caz (30 ug) by the double disc diffusion method and
confirmed by doing MIC by IMP Etest strip were
obtained from clinical samples (one isolate per
patient).
Of the 100 IPM resistant Gram negative clinical
isolates screened for MBL, 30 (30%) isolates were
MBL producers by both DDST and CDT and 70
(70%) isolates were non MBL producers.
The predominant source of the 30 MBL positive
strains was from pus /wound swab12 (40%), followed
by urine 7 (23%), catheter tip 5 (17%), sputum 3
(10%), blood 2 (7%), and fluids 1 (3%). (Figure.3) Of
these, 26 (86.6%) isolates were from inpatients, and 4
(13.3%) isolates were from outpatient department.
Among the isolates from inpatient department, highest
numbers of strains were isolated from ICU 10 (38.4%)
followed by post operative ward 7 (26.9%), surgical
ward 6 (23%), medical ward 5 (19.2%), and pediatric
ward 2 (7.7%).
The commonest organism was Klebsiella pneumoniae
10 (33.3%), followed by Pseudomonas aeruginosa 9
(30%), Acinetobacter spp. 5 (16.6%), Escherichia coli
3 (10%), Enterobacter spp. 2 (6.6%) and Providencia
spp. 1 (3.3%). (Figure .4)
Fig 1: Double Disk Synergy Test
Fig 2: Combined Disc Test
Fig 3: Sample wise distribution of metallo betalactamase positive strains

265
Malini et al.,
%
10
6.6 3.3
Kl.pneumoniae
33.3
30
16.6
Ps.aeruginosa
Acinetobacter
sp
E.coli
Fig 4: Organism wise distribution of MBL isolates
Fig 5: Antibiotic resistance profile of MBL isolates

In the present study, we tried to alter the distance
between the IPM and EDTA discs to see the synergy
between IPM and EDTA discs. Of these 30 MBL
producers, all 30 (100%) isolates showed synergy at
10 mm distance, 27 (90%) isolates showed synergy at
15mm distance and 13 (43.4%) isolates showed
synergy at 20mm distance. (Table number.1)
Table 1: Metalo beta lactamase detection by Double
Disk Synergy Test, with various distances between the
imipenem and EDTA
EDTA and IPM

Total
Number
10mm
distance
15mm
Distance
20mm
Distance
30
30(100%)
27(90%)
13(43.4%)
DISCUSSION
Simple and rapid phenotypic methods are required to
screen and detect the MBL producing GNB which are
high in prevalence in many regions. These MBLs if not
detected and treated can disseminate in a hospital. 1
Malini et al.,
In the present study, of the 100 IPM resistant isolates

screened for MBL production, 30 (30%) were MBL
producers and remaining 70 (70%) were non MBL
producers. Other mechanisms of resistance like
reduced permeability of pores or active efflux
associated with class C -lactamases being
endogenously over produced could be the reason for
resistance to carbapenems seen in 70 MBL non
producers.
In earlier studies resistance of 12% was noted to IPM
and meropenem respectively in Pseudomonas
aeruginosa in hospitalized patients. 14
In various studies, across the world the prevalence of
MBLs among the carbapenem resistant cases ranged
from 44.5- 96.3 %. 15, 16, 17
In our results, all 30 MBL producers were positive by
both DDST and CD method. Accurate results may not
be obtained by any single test. Hence we undertook
these two techniques for screening purpose as they
were was simple to perform, the materials used were
cheap, nontoxic, easily available and helped the results
to be interpreted well. The use of combination tests
would increase the sensitivity, to detect the presence of
MBL among clinical isolates of GNB.
Since 24 (86.6%) MBL producing strains were
isolated from inpatients, this points to the fact that
MBL are largely a problem of hospitalized patients
who share numerous risk factors. A similar
observation was noted by Prashanth et al where the
major MBL producers were from the ICU and higher
prevalence of infection was associated with the length
of time the patient stays in the hospital. 5
All the MBL producers showed very high resistance to
all antimicrobials (beta lactams, aminoglycosides, and
fluroquinolones, ranges from 76.6% to 100%) and also
revealed (96.6%) resistance to aztreonam, showing
association with other types of resistance mechanism
like ESBL or Amp C. Association between MBLs and
ESBLs appear to be a rare event. However, in our
study co-existence of MBL and ESBL was noted in 3
(30%) of the MBL positive isolates. In our study the
isolates tested showed less resistance to antibiotics like
polymyxin and colistin. All MBL producing gram
negative bacilli showed (90%) sensitivity to colistin.
Pseudomonas aeruginosa isolates showed (100%)
sensitivity to polymyxin B.
In the present study, we have evaluated the different
distances between IPM and EDTA. In DDST the 10
266
mm distance between the IPM and EDTA disc

exhibited excellent synergy, increasing the distance of
the discs to 20mm resulted in the reduction of synergy.
Therefore, we found that 10mm to be optimal as
described by Arakawa et al. 18
The problem of broad spectrum resistance of these
MBLs also poses a problem because the location of
MBL genes encoded on plasmids also encodes
resistance to other antibiotics. Hence strains positive
for MBL shows resistance to betalactams,
aminoglycosides, and fluroquinolones. However, they
usually remain susceptible to polymyxins. 18
Although there are no guidelines for MBL detection,
in Providencia sp, isolate was found positive for MBL
by both methods, in the present study. However, this
number is too small to attribute significance and more
isolates need to be studied to correlate the same.
In the absence of therapeutic MBL inhibitors,
polymyxins have been shown to be effective in the
treatment of MDR P.aeruginosa. Polymyxin may not
be very toxic as initially quoted. However, they should
not be used in monotherapy. A combination therapy
must be preferred.19
In our study, 3(10%) Proteus spp showed resistance to
colistin. However colistin is not the treatment option
for Proteus spp. as they are inherently resistant to
them. 20
CONCLUSION
For infections caused by MBL producing GNB
therapeutic options are limited. The implementation of
simple and accurate laboratory method to detect MBL
production in Gram negative bacilli is useful,
particularly in countries where MBL strains are
increasingly reported. Our study highlights the
resistance mechanism in carbapenem resistant Gram
negative isolates. MBL producers may also be
associated with ESBL. This poses serious problem
choosing the right antibiotic for treatment. In order to
prevent MBL to emerge in a hospital/health care setup
and also to have a check on their spread, MBL should
be detected in all microbiology laboratories.
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9. Franklin C, Liolios L and Peleg AY. Phenotypic
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Koratzanis E, Deliolanis J et al. Colistin
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methods. Int J Antimicrob Agents. 2008; 31:43439.
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Malini et al.,
DOI: 10.5958/j.2319-5886.3.2.058

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Research Article
MORPHOMETRIC ANALYSIS OF SEPTAL APERTURE OF HUMERUS

*Raghavendra K1, Anil kumar Reddy Y2, V.S Shirol3, Daksha Dixit3, S P Desai3
1
Department of Anatomy, Akash Institute of Medical Sciences & Research, Bangalore, Karnataka, India
Department of Anatomy, KFMS & R, Coimbatore, Tamilnadu, India.
3
Department of Anatomy, J.N Medical College, Belgaum, Karnataka, India
2
*Corresponding author email: kumarlucky48@gmail.com

ABSTRACT
Introduction: Lower end of humerus shows olecranon and coronoid fossae separated by a thin bony septum,
sometimes it may deficient and shows foramen which communicates both the fossae called Septal aperture, which
is commonly referred as supratrochlear foramen (STF). Materials & Methods: We have studied 260 humeri (126
right side and 134 left side), measurements were taken by using vernier caliper, translucency septum was
observed by keeping the lower end of humerus against the x-ray lobby. Results: A clear cut STF was observed in
19.2% bones, translucency septum was observed in 99 (91.6%) humeri on the right side and 95 (93.1%) humeri
on the left sides respectively (Table 1). Clinical significance: The presence of STF is always associated with
the narrow medullary canal at the lower end of humerus, Supracondylar fracture of humerus is most common in
paediatric age group, medullary nailing is done to treat the fractures in those cases the knowledge about the STF
is very important for treating the fractures. It has been observed in x-ray of lower end of the humerus the STF is
comparatively radiolucent, it is commonly seen as a type of pseudolesions in an x-ray of the lower end of
humerus and it may mistake for an osteolytic or cystic lesions. Conclusion: The present study can add data into
anthropology and anatomy text books regarding STF and it gives knowledge of understanding anatomical
variation of distal end of the humerus, which is significant for anthropologists, orthopaedic surgeons and
radiologists in habitual clinical practice.
Keywords: Humerus, Sepatal aperture, Supratrochlear foramen, Medullary canal, anthropology
INTRODUCTION
A thin plate of bony septum (0.5 to 1 mm thickness)
is present between olecranon and coronoid fossae at
the distal end of the humerus. In some bones this
bony septum may shows several perforations and in
some bones it shows clear foramen named as Septal
aperture, which is commonly referred as
Supratrochlear foramen (STF), if this anatomic
variation is wider one can overextend the elbow
joint.1 It has been termed the septal aperture by
Hrdlicka.2 It also has been designated by a variety of
names, among the more well-known being
Supratrochlear foramen (STF), Septal aperture,

Intercondylar foramen, Olecranon foramen.3 Patience
and detailed look at the literature show that the STF
was first described by Meckel (1825)4, since then it
has been described in various animals like cattle,
dogs, hyenas and other primates.5
STF is always associated with narrow medullary
canal, in that case it is not easy to perform
intramedullary fixation of the humerus in traumatic
injuries and pathologic fractures is very difficult.
According to Hirsh etal.,6 and Morton the thin bony
269
Raghavendra et al.,
plate observed between the olecranon and coronoid

fossa is always present until the age of seven years,
after which the bony septum becomes absorbed to
form the STF.6
Various authors have been reported about STF and it
is evaluated radiologically for pathologic lesions and
abnormal cyst. Even though there are many studies
the occurrence of STF is variant based on races and
region. The present study focused to highlight the
percentage of incidence of STF, morphological
features and its clinical importance, which may be
useful for anthropologist, orthopaedic surgeons and
radiologist in day to day clinical practice.
The knowledge about the structure of humerus may
play vital role in the intramedullary fixation. The
medullary canal width at the entry point of a
retrograde intramedullary nail was statistically
smaller in humeri with foramen than in humeri
without it.7 Furthermore, the medullary canal of the
humeri with foramen ends more proximally than the
canal of non-foramen humeri.
Fig 2: Photograph showing various shapes of STF I).

Round II). Oval III). Triangular

The STF was studied in 260 (126 right side and 134
left side) macerated adult humeri of unknown sex and
age mostly of south Indians of Tamilnadu region.
These bones were collected from the bone bank of
Anatomy and Forensic Medicine departments of
Karpagam Medical College, Coimbatore, Tamilnadu.
Damaged and Pathologically defected bones were
excluded from the study, all these bones were
carefully screened to observe the presence of STF and
the shape of STF (Oval or Round) is also noted. The
Transverse and Vertical diameter of STF was
measured by using vernier caliper (Fig-1). The STF
varied in different shape such as round and oval (Fig
2). In some bones we observed translucency of
septum which was noted by placing lower end of
humerus against X-ray lobby (Fig -3).
Fig 1: Photograph: Showing measurements of STF

Raghavendra et al.,
Fig 3: Shwoing distal end of humerus against x-ray

lobby (A: Translucency septum, B: Opaque septum)
RESULTS
A Clear cut supratrochlear foramen was found in
19.2% of humeri (Figure No1 & 2). Septal apertures
are more common on the left humeri than the right
ones. Out of 260 humeri (126 right side and 134 left
side) 19.2% (50humeri) of bones showed septal
aperture, oval shaped (70%) foramens were more
common than vertical shaped (30%) ones. The
maximum transverse diameter of STF is 9.5 mm, 11
mm on the right and left sides, respectively. The
maximum vertical diameter of STF on the right is 6
mm and left side is 10 mm. The mean length of the
transverse diameter for supratrochlear foramen was
6.5 and 5.1 on the right and left sides, respectively
(Table 2). The mean length of the vertical diameter
for STF was 4.7 and 3.9 on the right and left sides,
respectively (Table - 2). STF was abscent in 210
(80.7%) humeri: in 108 (85.7%) humeri of the right
270
side and in 102 (76.1%) humeri on the left side. In

that most of the bones without foramen showed a
translucency septum and in some bones showed
opaque septum (Table 1). Translucent septum was
observed in 99 (91.6%) humeri on the right side and
95 (93.1%) humeri on the left sides respectively.
Table 1: Showing Frequency of STF and Translucent
septum
Side
Number Presence
Translucent Opaque
of bones of STF
septum
septum
18(14.2%) 72 (66.6%) 36(33.3%)
Right 126
134
32(23.8%) 76 (74.5%) 26(25.4%)
Left
Table 2: Showing Different Measurements of STF

Side
Transverse diameter Vertical diameter
(mm)
(mm)
MeanSD
MeanSD
Right 5.1 2.4
3.91.4
Left
6.52.5
4.71.6
DISCUSSION
The STF is a foramen of the bony septum, which
separates the olecranon and coronoid fossae at the
distal end of the humerus. Its occurrence in adults
varies from 6-47% in population of india. The STF,
since it was first described by Meckel in 18254, has
been identified in many groups, present study is
mainly focusing on presence of STF and its
morphological and morphometric analysis in south
Indians of tamilnadu region. There are previous
studies in the Indian population which reported the
incidence to be 32%, 28%, 27.5%, and 27.4% in
central Indians, south Indians, North Indians, and
Eastern Indians, respectively4 8 9 10 . Our study on
south Indians of tamilnadu population showed an
incidence of 19.2%, which is slightly lower
prevalence than earlier studies.
The incidences of STF are 14.2% and 23.8% on the
right side and left side, respectively, which is similar
to earlier studies. STF was absent in 80.7% of
humeri, in that 57% is showing translucent septum
which is similar to the studies by Anupamamahajan
(2011)8 and Sejal V. Patel et al (2013).
The STF of the humerus has been a neglected topic in
anthropology, standard anatomy and orthopedics text
books. The incidences of STF were not described
clearly, it may due to atrophy of septum or may be
mechanical. According to the opinion of previous
Raghavendra et al.,
authors the occurrence of STF is due to atrophy of the

bony septum after ossification; atrophy of the bony
septum is due to the impact pressure in cases of the
extension of the arm in straight line direction11 12. The
incidences of STF are most common in cattle, dogs,
hyena and other primates because of the posture used
by animals while tearing morsels of food. In cats
septal aperture is absent because supracondylar
aperture is most common in cats13. If the mechanical
stress is the causative agent, then it should be more
on right side. In contrast, it is more common on left
side according to the present and previous studies14. It
can be explained that it is a phylogenetic
characteristic feature frequently found in primates.
Racial incidence of the STF as shown in (Table-3)
represents evolutionary aspects of the foramen in
addition to its clinical significance and its
anthropological importance15. STF is found only in
mammals and is inconstant in various species.
Darwin mentions this foramen in humans as one of
the characteristic that show man's close relationship
to lower forms. Anthropologists say that STF is more
in ancient primitive people than recent civilization2 9
16 17
.
Table 3: Comparative data (in %) of septal aperture in
humerus, race-wise
Race
Percentage
Australians
46.5
Egyptians
43.9
Mexicans
38.7
Central Indians
32
American Indians
29.6
Eastern Indians
27.4
Eskimos
19.8
American negroes
18.4
Japanese
18.1
Koreans
11
Italians
9.4
Germans
8.8
American whites
6.9
Present study
19.2
Clinical significance: Supracondylar fractures most
common injuries in the paediatricage group16.
Intramedullary humeral nailing is done to treat
supracondylar fractures which become more difficult
in presence of STF leading to secondary fractures.
The distal portion of the medullary canal in humeri
with the STF was narrower and shorter than in
271
humeri without foramen. Therefore, the knowledge of

presence of STF may be important for preoperative
planning for treatment of supracondylar fractures and
perform antegrademedullary nailing rather than
retrograde medullary nailing.
X-ray is performed at the lower end of humerus to
detect bone cysts, tumors and other lytic lesions in
day to day clinical practice. It has been observed in xray of lower end of humerus the STF is
comparatively radiolucent, it is commonly seen as a
type of pseudolesions in an x-ray of the lower end
of humerus and it may mistake for an osteolytic or
cystic lesions7. So that, anatomical knowledge about
the STF may minimizes the wrong interpretation of xrays by radiolucent.
CONCLUSION
The presence of STF is an important variation in the
distal end of humerus, our study highlighted the
percentage of incidence of STF and its morphological
and morphometric analysis. The incidence is 19.2%
and it is more common on left humeri than right
humeri which agrees with previous others. The
present study can add data in to anthropology and
anatomy text books regarding STF and it gives
knowledge of understanding anatomical variation of
distal end of humerus, which is significant for
anthropologists,
orthopaedic
surgeons
and
radiologists in habitual clinical practice.
REFERENCE
1. Kate BR, Dubey PN. A note on the septal
apertures in the humerus in the humerus of cetral
Indians. Eastern Anthropologist. 1970; 33:10510.
2. Hrdlicka A: The Humerus; Septal aperture.
Anthropologie (prague), 1932; 10:31-96.
3. Paraskevas GK, Papaziogas B, Tzaveas A,
Giaglis G, Kitsoulis P, Natsis K. The
supratrochlear foramen of the humerus and its
relation to the medullary canal: a potential
surgical application. Med Sci Monit, 2010; 16(4):
119-123.
4. Meckel JH, Kate BR Dubey PN. A note on the
septal apertures in the humerus of central Indians.
Eastern Anthropologist. 1970;33:270-84.
5. Douglas H. Slatter, James L. Tomlinso, Fractures
of the humerus. Textbook of small animal
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
surgery, 2nd Edn, Vol 2, Publisher: year; 19041905.

Hirsh SI. Cited in Morton SH and Crysler WE.
Osteochondritisdissecans of the supratrochlear
septum. J Bone Joint Surg. 1945; 27-A: 12-24.
De Wilde V, De Maeseneer M, Lenchik L, Van
Roy P, Beeckman P, Osteaux M. Normal osseous
variants presenting as cystic or lucent areas on
radiography and CT imaging: a pictorial
overview. Eur J Radiol. 2004; 51: 77-84.
Anupama Mahajan A, Batra PS, Seema, Khurana
BS. Supratrochlear foramen: study of humerus in
North Indians. Professional Med J. 2011; 18(1):
128-132.
Singhal S, Rao V. Supratrochlear foramen of the
humerus. Anat Sci Int. 2007; 82:105-07.
Soubhagya R Nayak, Srijit Das S, Krishnamurthy
A, Prabhu LV, Potu BK. Supratrochlear foramen
of the humerus: Anatomico-radiological study
with clinicalimplications; Upsala journal of
medical sciences. 2009; 114(2): 90-94.
Haziroglu RM, Ozer M. A supratrochlear
foramen
in
the
humerus
of
cattle.
AnatHistolEmbryol. 1990; 19: 106-08.
Langley-Hobbs SJ, Straw M. The feline humerus
An antomical study with relevance to external
skeletal fixator and intramedullary pin
replacement. Ret Comp Ortho Traumator. 2005;
18:1-6.
Riesenfild A, Somon M. Septal apertures in
humerus of normal and experimental rats. Am J
Phys Anthropal 1975; 42(1): 57-61.
Sanders RA, Sackett JR. Open reduction and
internal fixation of delayed union and nonunion
of the distal humerus. J Orthop Trauma. 1990; 4:
254-59.
Mays S. Septal aperture of the humerus in a
mediaeval human skeletal population; Am J
PhysAnthropol. 2008; 136 (4): 432-40.
Houshian S, Mehdi B, Larsen MS. The
epidemiology of elbow fracture in children:
analysis of 355 fractures with special reference to
supracondylar humerus fractures. J OrhthoP Sci.
2001; 6: 312-15.
Akabori E. Septal apertures in the humerus in
Japanese, Ainu and Koreans. Am J
PhyAnthropol. 1934; 18: 395-400.
272
Raghavendra et al.,
DOI: 10.5958/j.2319-5886.3.2.059

&
Health Sciences
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Coden: IJMRHS
th
th
Revised: 28 Jan 2014
Copyright @2014
ISSN: 2319-5886
Accepted: 31st Jan 2014
Research Article
ESTIMATION OF DENTAL AGE BY NOLLAS METHOD USING ORTHOPANTOMOGRAPHS

AMONG RURAL FREE RESIDENTIAL SCHOOL CHILDREN
Nandlal B1, Karthikeya Patil2,*Ravi.S3
1
Principal & Professor in Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, Mysore,
Karnataka, India
2
Professor & Head Dept. of Oral Medicine & Radiology, JSS Dental College and Hospital, Mysore, Karnataka,
India
3
Associate Professor, Dept of Orthodontics, JSS Dental College and Hospital, Mysore, Karnataka, India
*Corresponding author email: raviortho11@gmail.com
ABSTRACT
Introduction: Teeth and dental restorations are resistant to destruction by fire and the elements are therefore
useful in identification. This permits accurate identification of a missing child or remains. The Rural Residential
free school at Suttur houses a large number of inmates and hence dental records are kept for their identification.
Objective: Estimation of Age of children. Methods: Orthopantomographs were used to study for estimation of
age of children, using a Nollas method of dental age estimation. Results: In this study Nollas method
underestimated the chronological age of the individuals and underestimation of age increased as the chronological
age of the individuals increased. Conclusion: Studies involving larger sample size and population specific data
needs to be developed.
Keywords: Age Estimation by teeth, Forensic Dentistry, Nollas Method, Orthopantomographs.
INTRODUCTION
Age estimation is useful in general dentistry and in
forensic dentistry. There are many methods of age
estimation which are tried and tested. Dental age
estimation in living individuals is done mainly by
non-invasive methods such as general physical
examination, intraoral examination and a panoramic
radiograph.1-3
The sequence of development of dentition can be
used in the determination of age in situations such as
attainment of maturity, criminal responsibility,
consent etc. in living individuals. Teeth are nondestructible and have the least turnover of its
structure, hence provide a vital clue for identification
of individuals in forensic Odontology. 4,5
Nolla devised a system of dental age assessment

using radiological appearances of maxillary teeth and
mandibular teeth. The present study was aimed at
estimation of the age of the children using Nollas
Method of Dental Age Estimation.
This study was conducted in a rural residential school
at Suttur, where all the inmates are provided a similar
nutrition and they shared same environment and
physical activities, hence an ideal place to do such a
study.
METHODOLOGY
The present study was conducted at JSS free rural
residential school of Suttur, a village in southern
273
Nandlal et al.,
India. It houses 3927 children studying from primary

to high school. 2801 children are free hostel children
and 1126 children are day scholars, for the present
study we included only free hostel children.
Purposive sampling was used to select children for
this study.
Ethical clearance was obtained from the Institutional
Ethical Review Board prior to conducting the study.
The selected subjects were explained in detail about
the procedures and a written informed consent was
obtained from parents/guardians to be a part of the
study. The data used in the study is, one year results
of a part of the longitudinal study being conducted at
JSS Dental College. The date on which the
orthopantomograph was taken and the Date of birth
provided in school records was used for calculation of
the chronological age of each subject. Calcification of
permanent
dentition
was
seen
on
the
orthopantomograph and dental age was calculated
according to Nollas method.
Selection of sample: List of all the students of 7 years
and 11 years was made from school records. Those
children who met the exclusion criteria as set were
excluded and met the inclusion criteria were selected
for the study.
Inclusion Criteria: 1. Younger children in the age of
6 to 7 years and Older children in the age of 10
to 11 years of age. 2. Children who are inmates of
residential school of Suttur. 3. Children with normal
growth and development. 4. No Clinical or
radiographic evidence of jaw pathologies.
Exclusion Criteria: 1. History of Extraction or
missing teeth 2. History of Orthodontic treatment.
The subjects were grouped into two groups. Younger
children included 7 years old, twenty individuals aged
between 6 years and 7 years in which 10 were
boys and 10 were girls. Older children included 11
years old, twenty individuals between 10 years and
11.6 years in which ten were boys and ten were girls.
The chronological age was calculated according to
the data provided in the school register.
For data analysis paired samplest tests were applied
to compare chronological age to Nollas age values,
for boys, girls and for total sample.
Nollas method of Dental Age Estimation6: Nolla
devised a method of age estimation by evaluating the
Calcification of the permanent dentition. The
Calcification of permanent dentition was divided into
10 stages such as 1) Absence of crypt. 2) Presence of

Crypt. 3) Initial Calcification. 4) 1/3rd Crown
completed. 5) 2/3rd crown completed. 6) Crown
almost completed. 7) Crown completed 8)1/3rd root
completed. 9) 2/3rds of Root Completed. 10) Root
almost Completed open apex. 11) Apical end of
root completed for each group of teeth like incisors,
canine, premolars and molars of maxillary and
mandibular arches separately. The radiograph of the
individual was matched with a comparative figure
given by Nolla. Each tooth was recorded with a
reading and a sum total is made for maxillary and
mandibular teeth. Later the sum total is compared
with table given by Nolla. Separate table was given
for boys and girls and including or excluding third
molars. 1,6,7
The opg of the subjects of younger children and older
children were matched with the figures of
calcification given by Nolla. Seven mandibular teeth
and seven maxillary teeth on the left quadrant were
recorded for stage of calcification with a reading.
Fig 1: Orthopantomograph used in the study

A sum total is made for seven mandibular and seven
maxillary teeth to derive a score for fourteen
maxillary and mandibular teeth. Later the sum total is
matched with the table given by Nollas for boys and
girls separately.
RESULTS
In the present study Nollas method of dental age
estimation was done and later checked with
chronological age.
When boys and girls of younger children was
considered together mean dental age, according to
Nollas was 6.48 0.73 years and the mean
chronological age was 7.3 0.12 years.
274
Nandlal et al.,
Table 1: Results of Younger children

Older children(11year old)
Younger children (7year Old)

Sex
Age
Mean
SD
Chronological 7.310.12
Nollas
6.700.42
Girls
Nollas
6.250.92
Total
Nollas
6.480.73
Note : ** significant at p< .01 level
Boys
Mean
diff
t
value
p
value
4.12
.003**
1.04
3.65
.005**
0.82
5.03
.000**
0.61
The mean dental age, according to Nollas in

Younger children Boys was 6.70 0.42 years while
the mean chronological age was 7.31 0.12 years. In
younger children Girls the mean dental age,
according to Nollas was 6.25 0.92 years and mean
In Younger children Nollas method underestimated
the age of subjects by 0.82 years, which was very
significant with p value of 0.000.
The mean dental age, according to Nolla in Older
children, boys, was 8.85 0.88 years and the mean
In Older children Girls the mean dental age,
according to Nolla was 9.55 1.77 years and mean
In older children, Nollas method underestimated the
age of subjects by 2.11 years, which was very
significant with p value of 0.000.
When boys and girls of older children was considered
together mean dental age, according to Nolla was
9.20 0.15 years and the mean chronological age was
11.31 0.15 years.
The results of the study showed that the dental age of
Nollas underestimated the age of the individuals
very significantly with p value of 0.000 in both the
groups.
DISCUSSION
Identification of an individual has been the mainstay
of civilization. Not only is identification of the
diseased a necessity, but also the living an important
integral part of our daily life.
It may be necessary to estimate an individuals age in
situations
such
as
identification,
criminal
responsibility, judicial punishment, consent, rape,
Mean SD
Mean
diff
11.300.16
2.45
8.850.88
11.320.15
1.77
9.551.17
11.310.15
2.11
9.201.07
t
value
p
value
8.518
.000**
5.053
.001**
9.019
.000**
criminal abortion, employment, attainment of

majority, kidnapping and prostitution, etc. for legal
requirements. 8,9 In India due to lower literacy status,
parents and their children do not have accurate
knowledge of their date of birth records which would
be required in legal matters concerning the age of the
individual.
The timing and sequence of various stages of tooth
development from first appearances of cusps to root
apical closure follow a rigid pattern. Hence the
developing dentition can be used for assessment of
age.
The
bone
development,
secondary
sexual
characteristics and stature or weight are other
developmental indicators apart from dentition, but
can be applied only after the inception of puberty.1,5
Age estimation using dentition could be done by two
methods such as 1) atlas method, where development
(mineralization) of dentition is compared with
published standards. 2) Scoring method, where the
development of dentition is divided into various
stages and are assigned scores and evaluated through
statistical analysis.
Nollas method6 is a scoring system for age estimation
by studying the calcification of permanent teeth. He
divided the calcification of permanent dentition into
stages such as 1) Absence of crypt. 2) Presence of
Crypt. 3) Initial Calcification. 4) 1/3rd Crown
completed. 5) 2/3rd crown completed. 6) Crown
almost completed. 7) Crown completed 8)1/3rd root
completed. 9) 2/3rds of Root Completed. 10) Root
almost Completed open apex. 11) Apical end of
root completed.
275
Nandlal et al.,
This is a realistic & no invasive method of age

estimation which was followed in this study and later
compared with chronological age.
In younger children among boys the underestimation
of Chronological age was 0.61 years and girls were
1.04 years.
In older children among boys the underestimation of
Chronological age was 2.45 years and girls were 1.77
years.
The dental age derived in this study was significantly
lower than the chronological age of the individuals in
both the groups and there was a difference between
boys and girls within the groups.
In both the groups, Nollas underestimated the
chronological age of the individual. The
underestimation of age increased as the chronological
age of the individual increased.
The causes for underestimation of age could be:
The timing of tooth development is highly heritable
and also population specific. Two different
populations were compared in a study concluded
that, distinct stages in tooth development differ
remarkably up to two years between different
ethnicities.10,11 Nollas method may not be applicable
to this population hence a population specific data
should be used for age estimation.
The possible influences of environment and
hereditary on dental age is also debatable.
Consistently low correlations indicate the lack of a
clear association between tooth formation and
parameters like social status, nutritional effects and
somatic development. 12,13
Dental development
shows no significant relationships with maturity
indicators such as menarche, peak height velocity or
skeletal maturity.14 These results imply that the
mechanisms controlling dental growth and
development are independent of general growth
mechanisms but closely approximate chronological
age.
Odontological age estimation is dependent on three
factors such as 1) the subject of age estimation. 2)
Appropriately chosen dental developmental survey &
3) legal consideration. Hence, to position an
individual upon a practical time scale, two or more
methods of age estimation should be considered
judiciously, giving wattage to the above trident
factors.
CONCLUSION
Nollas method of age estimation was not found to be
accurate in both the age groups. Studies involving
larger sample size and a population specific data for
the children of southern India for dental age
estimation should be developed.
ACKNOWLEDGEMENT
The authors wish to thank Dr. Mahima Patil,
Professor, Dept. of Oral Medicine & Radiology JSS
Dental College and Hospital, for valuable assistance
and help.
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1. Karjodkar FR. Role of dental radiology in
forensic odontology, Text book of dental and
maxillofacial radiology. New Delhi: Jaypee
Brothers Medical Publishers (P) Ltd, 2009:2nd
editon: 929963.
2. Masthan KMK. Age estimation by teeth.
Textbook of forensic odontology. New Delhi,
Jaypee Brothers Medical Publishers (P) Ltd,
2009: 9297.
3. Masthan KMK. Age and sex. Textbook of
forensic odontology. New Delhi: Jaypee Brothers
Medical Publishers (P) Ltd, 2009: 5965.
4. Panchbhai AS. Review Dental radiographic
indicators, a key to age estimation.
Dentomaxillofacial Radiology 2011; 40 :199-12
5. Achary AB, Sivapathasundharan B. Forensic
odontology. In: Rajendran R, Sivapathasundharan
B, (eds). Shafers textbook of oral pathology (6th
edn). India: Elsevier Private Ltd, 2009, pp 871
892.
6. Nolla CM. The development of permanent teeth.
J Dent Child 1960; 27: 25466.
7. Abou El-Yazeed M, Abou Zeid W, Tawfik W.
Dental Maturation Assessment by Nolla's
Technique on a Group of Egyptian Children.
Australian Journal of Basic and Applied Sciences
2008. 2(4): 1418-24.
8. Amandeep Singh, Gupta VP, Das Sanjoy.
Physiological changes in teeth as a tool to
estimate age. The Pacific Journal of Science and
Technology 2009; 10(2):956-65.
9. Chaudry K, Agarwal A,Rehani U. Applicability
of Demirjians Method for Dental Age
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10.
11.
12.
13.
14.
Estimation. Indian Journal of Dental Sciences

2010;4: 1-3.
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Estimation Methods: Comparative Validity and
Problems in Practical Implementation. Doctoral
thesis University of Wein 2007..
Olze A, Schmeling A, Taniguchi M, Maeda H,
Van Niekerk, Wernecke KD, Geserick G.
Forensic age estimation in living subjects: the
ethnic factor in wisdom tooth mineralization, Int.
J. Legal Med 2004. 118: 170-73.
Garn SM, Lewis AB, Blizzard Rm. Endocrine
Factors in Dental Development. J. Dent. Res
1965. 44 : 243-58.
Demirjian A, Goldstein H, Tanner JM. A new
system of dental age assessment. Hum Biol 1973;
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277
Nandlal et al.,
DOI: 10.5958/j.2319-5886.3.2.060

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
Received: 5th Jan 2014
Revised: 31st Jan 2014
Copyright @2014
ISSN: 2319-5886
Accepted: 4th Feb 2014
Research Article
THE DIAGNOSTIC UTILITY OF CELL BLOCK AS AN ADJUNCT TO CYTOLOGICAL SMEARS

*Bhavana Grandhi, Vissa Shanthi, Mohan Rao N, Chidananda Reddy V, Venkata Murali Mohan K
Department of Pathology, Narayana Medical College, Nellore, Dr. NTR University of Health Sciences,
Vijayawada, Andhra Pradesh
*Corresponding author email: drbhavana.grandhi@gmail.com
ABSTRACT
Objectives: Cytological examination of serous fluids is of paramount importance in detecting cancer cells.
Distinguishing malignant cells from benign reactive mesothelial cells in fluid cytology is an everyday diagnostic
problem. Cell blocks are valuable when the features in cytology are inconclusive. The motive of this study was to
assess the utility of this method in increasing the diagnostic yield of serous fluids. Methods: 225 (25%) effusion
fluids were analyzed carefully by both smear and cell block technique. Results: Among 225 fluids, 139 were
pleural, 84 peritoneal and 2 pericardial. In case of pleural fluids and ascitic fluids, maximum numbers of cases
were inflammatory. By the cell block technique, 5 additional cases of malignancy in pleural fluids and 7
additional cases of malignancy in ascitic fluids were diagnosed which could not be detected in the cytological
smears. In pericardial fluids both cases were inflammatory. Male predominance was noted in case of pleural
effusion and female predominance was noted in case of pericardial effusion and ascites. Maximum numbers of
cases were seen in the age group of 40-60 years. Conclusion: We conclude that the cell block technique when
used as an adjuvant to routine smear examination has increased the diagnostic yield because of better preservation
of the architectural pattern.
Keywords: Cytological smear, Cell block
INTRODUCTION
Cytological examination of serous fluids is of
paramount importance not only in detecting cancer
cells, but it also reveals information regarding various
inflammatory conditions of serous membranes,
various bacterial, viral, fungal infections and parasitic
infestations.1 The involvement of the serous cavities
by malignant neoplasms has important therapeutic
and prognostic implications. The most common
reason to submit an effusion fluid to cytopathology is
to determine whether or not it contains malignant
cells.2
Reporting a cell as malignant or benign reactive
mesothelial cell in fluid cytology is an everyday
diagnostic problem. The cytological diagnosis of
effusions has a lower sensitivity, which is attributed
to benign morphology of cells and changes incurred

during processing of these fluids. 1
Cell blocks technique or paraffin embedding of
sediments of fluids is almost the oldest methods of
preparing material for microscopic examination.1 Cell
blocks are helpful in situations where the cytological
abnormalities are ambigious like in reactive
mesothelial cells or in occasional well differentiated
adenocarcinoma.3 Apart from increased cellularity,
better morphological details are obtained by cell
block method as there is a better conservation of
architectural features like arrangement of cells ,
cytoplasmic and nuclear details. 1 Cell block method
has many advantages like a number of sections for
the same case can be made for further study like
immunohistochemistry.1 The cell block method is
Bhavana et al.,
278
one of the traditional method used for processing

cytological material and was described in the
literature as early as 1900.4 For the purpose of
fixation, 10% alcohol-formalin is used.The proteins
are cross-linked and a gel is formed by the action of
formalin, which cant be dissolved in any material
used for processing.5The present study was done to
valuate the utility of this method in increasing the
diagnostic yield of serous fluids.
comparative evaluation of smear versus cell block

technique was done.
RESULTS
225 effusion fluids were analysed, out of which 139
were pleural, 84 were peritoneal and 2 were
pericardial. In a total of 225 fluids received, males
were 116 (52%) and 109 (48%) were females. The
male to female sex ratio is 1:1.06.The maximum
numbers of cases were in the age group of 41-60
years, constituting 77 cases (35%) of the total cases
and least common incidence is 0-10 years,
constituting only 1 case (0.5%) (Table 1)
MATERIALS & METHODS

This study included 225 cases (effusion fluids were
analyzed, out of which 139 were pleural, 84 were
peritoneal and 2 were pericardial) from ASRAM
Medical College Hospital, Eluru and Narayana
Medical College Hospital, Nellore after obtaining
approval by the Institutional ethics committee. Cases
included patients who presented with complaints of
ascites, pleural effusion or pericardial effusion. The
patients were subjected to fluid analysis, by both
smear and cell block technique.5 The presenting
clinical features and the laboratory findings were
recorded. The fluid sample (ascitic, pleural or
pericardial) was divided into two parts. Half of the
fluid, about 5 ml was centrifuged, supernatant fluid
discarded, smears prepared and stained with H&E
and May-Grunwald-Giemsa. Papanicolaou and
Leishman stains were used wherever necessary. The
remaining sample was subjected to centrifugation at a
rate of 1500 rpm. The supernatant fluid was discarded
and the sediment or the cell button, thus obtained was
fixed for 24hrs in 10% formal-alcohol (combination
of ethyl alcohol and formalin) and then processed in a
histokinette like a routine histopathology sample. The
sections were stained with H&E and special stains
like PAS and Mucicaramine were used wherever
necessary. The slides were evaluated for cellularity,
arrangement, cytoplasmic and nuclear details. A
The pleural effusion cases were more in males i.e. 85

(61.15%) compared to females, 54 (38.5%) with male
to female ratio of 1.57:1. The number of
inflammatory cases were more i.e. 127 (91%)
compared to malignancy being 12 (9%). Maximum
numbers of cases were in the age group 41-50 years
and the least number in the age group 0-10 years.
(Table 2)
5 (3.60%) smears prepared from pleural fluid were
unsatisfactory / suspicious on cytology, where
malignancy was picked up by the cell block technique
(Figure1) showing that the diagnostic yield is
increased by cell block technique. (Table 3)
In ascitic fluid the number of inflammatory cases
were more i.e. 69 (82.14%) compared to malignancy
being 15 (17.85%) and female to male ratio is 1.54:1.
The maximum number cases were in the age group of
51-60 years and the least number of cases in the age
group of 71-80 years (Table 4).
7 (8.34%) smears prepared from ascitic fluid were
unsatisfactory / suspicious on cytology, where
malignancy was picked up by the cell block
technique. (Fig 2, 3) (Table 5)
Table 1: Distribution of the sample by age, sex for all fluids
Age group
0-10
11-20
21-30
31-40
41-50
51-60
61-70
71-80
Total
Pleural
M
1
3
19
16
17
11
13
9
89
F
3
5
8
12
9
10
4
50
Peritoneal
M
F
3
2
5
8
6
3
27
2
2
6
15
27
2
3
57
Pericardial
M
F
Total
1
11
28
35
52
55
28
16
225
279
Bhavana et al.,
Table 2: Distribution of the sample by diagnosis and sex for pleural fluids
Diagnosis
Inflammatory
Malignancy
Total
Male (%)
78(61.5%)
7(58.35%)
85(61.15%)
Female (%)
49(38.5%)
5(41.65%)
54(38.85%)
Total (%)
127(100%)
12(100%)
139(100%)
Table 3: Comparison of smear versus cell block in pleural fluids
Category
Inflammatory
Malignancy
Unsatisfactory/suspicious
Total
Smear diagnosis
127
7
5
139
Cell block diagnosis

127(including no cellularity)
7
5 (Positive for malignancy)
139
Table 4: Distribution of the sample by diagnosis and sex for Ascitic fluids
Diagnosis
Inflammatory
Malignancy
Total
Male
28(40.5%)
5(33.34%)
33(39.28%)
Female
41(59.5%)
10(66.67%)
51(60.72%)
Total
69(100%)
15(100%)
84(100%)
Table 5: Comparison of smear versus cell block in Ascitic fluid

Category
Inflammatory
Malignancy
Unsatisfactory/suspicious
Total
Smear diagnosis
69
8
7
84
Cell block diagnosis

69(including no cellularity)
8
7 (Positive for malignancy)
84
In the pericardial effusion cases both were inflammatory and were females in the age group 51-60 years. One had
predominantly mesothelial cells and the other had mixed inflammatory cells (Fig 4).
Fig 1: Cell block studied shows tumor cells arranged in

acinar pattern; pleural fluid (H & E, 40 x)
Fig 2: Cell block shows malignant cells arranged in cell

balls;ascitic fluid(H&E;100x)
Fig 3: Cell block shows malignant cells; ascitic fluid

(mucicaramine;40x)
Fig 4: Smear shows mixed inflammatory infiltrate;

pericardial fluid (Leishman stain; 100x)
280
Bhavana et al.,
DISCUSSION
The cell block method is the oldest method of
processing cytological material ,described by
Mandlebaum in 1900 for studying exudate.4 10%
alcohol-formalin is used for fixation and by the action
of formalin,the proteins are cross-linked and a gel is
formed which cant be dissolved in any material used
for processing.5
In the present study of 225 cases of cell block the
predominant lesion detected in the various fluids was
inflammatory 198 (88%) while malignancy was

detected in 27 (12%)
cases. The most common
effusion was pleural, followed by peritoneal and
pericardial effusion. Our results correlated with the
studies done by Foot et al6,7, van de Molengraft et al8,
Khan K et al9 and Sears & Hajdu10. In our study the
predominance of pleural fluids can be explained by
the high prevalence of tuberculosis in the region of
our study (Table 6).
Table 6: Distribution of the cases among various studies
Study done by
Foot et al7
Van de Molengraft8
Khan K et al9
Sears & Hajdu10
Present study
A(Pleural)
1301(64.12%)
171(67.32%)
32(55.17%)
1846(61%)
139(61.78%)
B(Ascitic)
700(34.5%)
83(32.68%)
25(43.1%)
1165(39%)
84(37.34%)
C(Pericardial)
28(1.4%)
1(1.72%)
2(0.88%)
D(Others)
-
Total
2029(100%)
254(100%)
58(100%)
3011(100%)
225(100%)
Table 7: Cellularity of smears: comparison of various studies
Inflammatory cases
Scanty cellularity
Predominantly neutrophils
Mixed inflammatory cells
Predominantly lymphocytes
Predominantly mesothelial cells
Blood
Total
Meenu3 Thapar et al
40(33.3%)
26(21.7%)
24(20.0%)
16(13.3%)
6(5.0%)
120(100%)
Table 8: Presentation of malignant ascites in various studies

Archana1 et al
Data
Steven9 A et al
Clinical Presentation
Age group
Primary in males
Primary in females
Ascites
51-60years
Lung
Ovaries
Ascites
44-75 years
Lung
FGT
Melamed11 et al
21(34%)
13(21%)
11(18%)
8(13%)
3(5%)
5(8%)
61(100%)
Present study
7(3.5%)
43(21.7%)
40(20.2%)
62(31.3%)
46(23.2%)
198(100%)
van de Molengraft8 et al
Ascites
45-65
Lung
Ovaries
Present study
Ascites
51-65years
Lung
Ovaries
Table 9: Age and sex distribution of malignant ascites in various studies
Parameter
Age group
Total
Females
Males
F:M ratio
Ringerberg4 QS et al
30-95
65
40
25
2:1
Khan3 K et al
41-60years
15
15
0
Present study
41-60years
15
10
5
2:1
Table 10: Comparison of the diagnostic yield of smear versus cell block in various studies
Total cases
Inflammatory
Positive for malignancy on smear
Unsatisfactory/negative on smear
Positive for malignancy on cell block
No cellularity on cell block
Archana1 et al
150
77
29
10
39
34
Sujathan19 et al
85
63
19
2
21
1
Present study
225
183
12
15
27
7
281
Bhavana et al.,
Cellularity of smears revealed predominantly

lymphocytes in 62 (31.3%) cases. In the studies done
by Meenu et al3 and Melamed et al11scanty cellularity
was seen in 40 (33.3%) and 21 (34%) cases
respectively (Table 7).
Leucocytes in pleural effusion are extremely
common. In this study, typical pleural effusion
caused by chronic inflammation had a high
proportion of lymphocytes and very few or no
mesothelial cells.
Koss describes that a characteristic feature of
mesothelial cells is the flattening of the opposite cell
membranes with the formation of clear gaps or
windows, which are most likely because of
microvilli separating the cells and are better
visualized in air dried smears.12 Bedrossian insists
that in benign mesothelial cells these microvilli are
slender, bushy and distributed evenly around the cells
whereas in adenocarcinoma, if present they are
concentrated at the poles and are short and stubby.13
In our study, 23.23% cases (46 cases) of
inflammatory effusion had a predominance of
mesothelial cells. Mesothelial cells appeared round
and had a single central or eccentric nucleus. Some of
the groups of mesothelial cells were showing clefts or
windows. These mesothelial cells form cell balls,
clusters and sometimes take a signet-ring cell
appearance thus closely mimicking malignancy.
Malignant cells have irregular nuclear membranes,
nuclear molding and prominent nucleoli with absence
of windows.
In our study, the most common clinical presentation
in malignancy was ascites and the commonest site of
the primary giving rise to effusion, was ovaries in
females and lung in males. 37% of cases were seen in
the age group of 41-60 years. The large number in
this age group can be attributed to increased
incidence of ovarian malignancies (Table 8)
Malignant ascites as the initial evidence of cancer is
more likely to occur in women. In the study done by
Khan K et al none of the 10 patients were males3 and
in the study done by Ringerberg QS et al maximum
number of cases were females (40 cases) when
compared to males (25 cases).4
In the present study, 15 cases of malignant peritoneal
fluid were diagnosed, in which 10 were women and 5
were men with female to male ratio 2:1. The most
common age group was (41-60 years) with a median
age of 51 years (Table 9)
The cell block is a helpful tool in the interpretation of

Grade I adenocarcinoma. These tumors have very few
malignant characteristics in smears, while the
presence of true acini in the cell block, together with
mucin, when stained for PAS is indicative of
malignancy.14
The cells of adenocarcinoma closely mimic reactive
mesothelial cells and the cells of malignant
mesothelioma. The typical carcinomatous cells in the
cell block are of variable sizes, exhibit nuclear
pleomorphism with overlapping of nuclei, prominent
nucleoli, occasional multinucleated cells and
intracytoplasmic vacuoles. Tumor cells form glandlike or tubular structures with central lumina also
referred by some as spheroids or hollow spheres.3dimensional clusters and complex papillary clusters
are also seen. The individual cells have moderate
amount of cytoplasm with hyperchromatic and
pleomorphic nuclei. The nuclei show granularity of
the chromatin, prominent nucleoli and abnormal
mitoses.1
Cell blocks have a number of advantages as they can
be utilized for immunohistochemistry. First, at least
ten sections can be cut which usually permits
evaluation of a large number of antigens. The storage
of cell blocks is easier compared to the smears. The
use of cell block sections enables the worker to know
in advance the exact nature of tissue available for
study. It thus appears that cell blocks have much to
offer in the utilization of immunocytochemistry.15
In general, Calretinin, CK 5/6, WT1, and Podoplanin
are considered to be the best positive mesothelioma
tissue markers and CEA, MOC-31, B72.3, and BerEP4 the best negative markers for distinguishing
between
epithelioid
mesotheliomas
and
16
adenocarcinomas.
D2-40, a recently available monoclonal antibody has
been accurate like calretinin and better than
cytokeratin 5/6 and WT1 and helps in distinguishing
epithelioid
malignant
mesothelioma
versus
adenocarcinoma.17
Out of 150 cases studied by Archana et al,1 39 (26%)
were positive for malignancy by cell block method,
while by routine method only 29 samples were
reported as positive for malignant cells. Thus it was
found that there was significant difference between
the results obtained by direct smears method and
cell block method. 34 cell blocks had no cellularity.1
Bhavana et al.,
282
In the study by Sujathan et.al, 18 out of 85 samples

studied, 21 (24.71%) cell blocks showed malignancy.
Two samples diagnosed as negative for malignancy
by smear technique, were diagnosed as malignancy
by cell block method. Thus the use of cell block
increased the diagnostic yields of malignancy from
19 to 21 samples. Only one cell block had no
cellularity out of 85 samples.18
In the present study, out of 225 cases, 27 cases of
malignancy were detected by using cell block
method, while by using routine methods; only 12
cases were diagnosed to be malignant. Only 7 cell
blocks showed no cellularity. The reason for the lack
of cellularity may be due to technical errors such as
inadequate sampling (less than 5 ml of serous fluid
sent to the laboratory) or degenerated samples
1. Archana KB, Parate N, Wadadekar A, Bobhate

SK, Munshi MM. Diagnostic utility of cell block
preparation in reporting of fluid cytology. Journal
of Cytology 2003;20(3):133-35
2. Khan N, Sherwani RK, AFroz N, Kapoor S.
Cytodiagnosis of malignant effusion and
determination of primary site. Journal of
Cytology 2005;20(3):107-10
3. Meenu Thappar, Mishra K, Amit Sharma,Vikas
Goyal, Vibhuti Goyal. Critical analysis of cell
block versus smear examination in effusions.
Journal of Cytology 2009;26(2):60-64
4. Elizabeth A. McGrew. The role of exfoliative

cytology in the diagnosis and treatment of
malignant disease. Postgrad. Med. J.1961;37:45667
5. David Hopwood. Fixation and fixatives. In: John
D Bancroft & Marilyn Gamble, editors. Theory
and practice of histological techniques.5th edition,
Churchhill Livingstone, Printed in China.pg6384.
6. Foot NC. Identification of types and primary sites
of metastatic tumors from exfoliated cells in
serous fluids. Am. J. Pathol 1954; 30(4): 661-77
7. Foot NC. The identification of neoplastic cells in
serous effusions. Am J Pathol 1956; 32: 961-77
8. Fred JJM, van de Molengraft, Peter Vooijs G.
The interval between the diagnosis of malignancy
and the development of effusions, with reference
to the role of cytologic diagnosis. Acta
Cytologica 1988;32(2):183-87
9. Sharma G, Singh PK, Singh SN. Myelomatous
pleural effusion. Journal of cytology 2005; 22(3)
135-36
10. Donald Sears, Steven IH. The cytologic diagnosis
of malignant neoplasms in pleural and peritoneal
effusions. Acta Cytol 1987;31(2):85-89
11. Myron R. Melamed. The cytological features of
malignant lymphomas and related diseases in
effusions. Cancer 1963;16:413-31
12. Effusion in the absence of cancer. In : Leopord G.
Koss, MyronR. Melamed, editors. Diagnostic
cytology and its histopathological bases:Vol.2,5th
ed. Lippincott Williams & Williams, 2006.
Printed in USA.pg 919-20
13. Pauri Murugan, Neelaiah Siddiraju, Syed
Habeebullah, Debdatta Basu. Significance of
intercellular spaces(windows) in effusion fluid
cytology:A study of 46 samples. Diagnostic
Cytopathology 2008;36(9):628-32
14. Dekker A, Bupp PA. Cytology of serous
effusions. An investigation into the usefulness of
cell blocks versus smears. Americal Journal of
Clinical Pathology 1978:70;855-60
15. Ignatius TM, Kung, Siu-Kwong Chan, Elena
SFLo. Application of immunoperoxidase
technique to cell block preparations from fine
needle aspirates. Acta Cytol 1990;34(3):297 -03
16. Wilentz, Goldman & Spitzer. Asbestos-related
Diseases.
http://www.mesothelioma.org/
understandingmeso/asbestos-diseases.asp
Bhavana et al.,
CONCLUSION
We conclude that the cell block technique when used
as an adjuvant to routine smear examination has
increased the diagnostic yield because of better
preservation of the architectural pattern, particularly
in cases where there is a diagnostic dilemma between
the
malignancy
and
reactive
changes.
Immunohistochemistry also gives better results on the
tissue in the cell block than cytological smears which
will be helpful to arrive at the accurate diagnosis.
ACKNOWLEDGEMENT
I am very grateful to Dr.Vissa Shanthi for helping me
in writing this article. I also thank Dr.P.V.B.
Ramalakshmi, my teacher who is at present Professor
and Head at Maharaja Institute of Medical Sciences,
Vizianagaram, Andhra Pradesh.
REFERENCES
283
17. Albert Y Chu, Leslie A Litzky, Theresa L Pasha,

Geza Acs and Paul J Zhang Utility of D2-40, a
novel mesothelial marker, in the diagnosis of
malignant mesothelioma. Modern Pathology.
2005;18:10510
18. Sujathan K, Kannan S, Mathew A, Pillai KR,
Chandralekha B, Nair MK. Cytodiagnosis of
serous effusions: A combined approach of
morphological features in Papanicolaou and
MGG stained smears and a modified cell block
technique. Journal of cytology 2000;17(2):89-95
284
Bhavana et al.,
DOI: 10.5958/j.2319-5886.3.2.061

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
st
Revised: 5th Feb 2014
Copyright @2014
ISSN: 2319-5886
Research Article
COMPARISON OF P4, NUMERICAL PAIN RATING SCALE AND PRESSURE PAIN THRESHOLD IN
PATIENTS HAVING CHRONIC LOW BACK PAIN- AN OBSERVATIONAL STUDY
*Shah Stuti S1, Sheth Megha S2, Vyas Neeta J3
1
Post graduate student, SBB College of physiotherapy, Ahmadabad, Gujarat, India

Lecturer, SBB College of physiotherapy, Ahmadabad, Gujarat, India
3
Principal, SBB College of physiotherapy, Ahmadabad, Gujarat, India
2
*Corresponding author email: stuti_ss@yahoo.com

ABSTRACT
Background: Pain is a multidimensional experience, with low back pain (LBP) being the most common.
Numerous pain measures exist to assess pain intensity, though the systemic quantification is a rare clinical
practice. P4, numerical pain rating scale (NPRS) and pressure pain threshold (PPT) measure pain intensity, which
is necessary for its effective management. Objective of the study was to assess and compare pain measured by P4,
numerical pain rating scale and pressure pain threshold in LBP patients. Methodology: A prospective
observational study was conducted at SBB College of physiotherapy, VS Hospital, Ahmadabad. A convenience
sample of (N=50) patients, according to inclusion and exclusion criteria were recruited. P4: pain intensity
measured at four times over the past 2 days and NPRS: pain intensity over last 24 hours was graded subjectively
by the patient & PPT was measured over tender point. Level of significance was kept at 5%. Results: Pearson
correlation coefficient was used to correlate P4 and PPT, NPRS and PPT. Moderate negative correlation was
present between P4 and pressure pain threshold (r = -0.623, p=0.001) and mild negative correlation was present
between numerical pain rating scale and pressure pain threshold (r=-0.372, p<0.05) which was found to be
statistically significant. Conclusion: P4 had a moderate inverse correlation with pressure pain threshold &
numerical pain rating scale had mild inverse correlation with pressure pain threshold which was found to be
statistically significant.
Keywords: Pain measurement, Low back pain, Numerical pain rating scale, P4, Pressure pain threshold.
INTRODUCTION
Pain is a multidimensional experience and that is a
prominent feature of many musculoskeletal
disorders.1 It is a major cause of morbidity, with low
back pain (LBP) being one of the most common
locations of symptoms.1The lower back is commonly
defined as the area between the bottom of the rib cage
and the buttock creases. Some people with nonspecific low back pain may also feel pain in their
upper legs, but the low back pain usually
predominates.2Pain has a considerable impact on both

the individual suffering and society at large.3
Pain can be measured by-verbal, numeric self-rating
scale, behavioural observation scale and objective
measures.4 A study done by Maria et al5 in 2011had
tried to find validity of four different pain scales
using hand immersed in the cold-pressor apparatus
which showed that small variations in water
temperature result in significant differences in pain
intensity ratings, with numerical rating scale being
Stuti et al.,
285
the most responsive, followed by visual analogue

scale, verbal rating scale and faces pain scalerevised.5
Goals for the pain assessment are to measure the
individuals pain experience in a standardized way,
determine type of pain and possible etiology, state its
effect and impact, form a basis to develop treatment
plan to manage pain, and to aid communication
between interdisciplinary team members.6Pain is not
synonymous with function or quality of life, and
other tools covering these important outcome
dimensions should complement the assessment of
pain, especially in patients with chronic symptoms.1
Numerical Pain Rating Scale (NPRS) is an ordinal
and subjective scale which can be used for older or
less literate, or for the one having sustained trauma.
NPRS is quicker to score and therefore used in
greater range of patients7.Although having several
advantages; capacity to detect the change is less. (i.e.
self-report function).
The pain threshold or tenderness resistance is the
point at which a stimulus is perceived as pain which
can be measured by pressure algometers. When a
particular site of the body is pressed with a rubber
disk having an area of 1 cm2, the device displays the
pressure.8 Pressure pain threshold (PPT) is an
objective and gold standard method, measured by
pressure algometer giving accurate value, but its use
is limited, as it is expensive.9
A new measure P4, which measures pain intensity at
four-different times over the past 2 days in less than 1
minute by patient and scored by clinicians in 5
second by clinicians, was introduced by Spandoni GF
et al(2004).10
So, there is a need to know which instrument does the
accurate assessment of pain, which is a prerequisite
for its effective management, as the systematic
quantification is a rare clinical practice. The aim of
this study was to measure and compare pain by P4,
numerical pain rating scale and pressure pain
threshold in patients having low back pain.
METHODOLOGY
The study was a prospective observational study,
done at SBB College of physiotherapy, Orthopedic
OPD, VS hospital, Ahmadabad.200 patients of age 18
years or above were screened using convenience
sampling, from which 5o patients with low back painradiating and non-radiating, with ability to lie prone
Stuti et al.,
or side-lying, presence of tender point, not attending

specific centres for patients with chronic pain were
included in the study.
The study was reviewed & approved by Institutional
Ethics Committee, SBB College of Physiotherapy, V
S General Hospital, Ahmadabad, Gujarat. Ethical
letter no.:PTC/IEC/21/2013-14.
Subjects having average PPT< 4kg/cm2 which
indicates
fibromyalgia
syndrome
tendency,
undergoing
psychological
treatment,
having
pregnancy, suspected tumour, and cauda-equina
syndrome, known dependency of drugs, alcohol or
smoking were excluded. Written informed consent
was taken from all the participants.
After taking demographic data, patients were asked to
score P4 which inquires about the pain in the
morning, afternoon, evening, and during activity
throughout the day for the past 2 days on a scale
which consisted of 11 points. The anchors were no
pain and pain as bad as it can be. Study was
conducted from July 2013 till September 2013.
Item scores were summed to yield a total score from
0 to 40.10,11 Second measure NPRS inquired about the
pain as follows: Over the past 24-hours, how bad
has your pain been?. NPRS had 11 points and the
anchors were no pain (0) and pain as bad as it can
be (10) giving a score from 0 to 10. 11
Third measure used was the pressure pain threshold
by pressure algometer. Patient was taken in prone or
side lying position on the examination table with both
forearms over the sides.12Rate of pressure was kept at
constant rate of 1 kg/cm2. 12 When pressure was
applied; person being tested was required to say yes
at the moment of change from pressure to pain
was experienced. 12 It was measured thrice after every
10 seconds, over the tender point and average of the 3
readings was taken into consideration. PPT was
measured in kg/cm2.
RESULTS
Statistical analysis was done using SPSS version
16.0.There were 11 males (22%) and 39 females
(78%) in the age group of 18-79 years (mean:
39.986.234). Correlation was done using Pearsons
correlation coefficient between P4 and pressure pain
threshold and between numerical pain rating scale
and pressure pain threshold. Pearsons correlation
was used as the data was found to be parametric by
normal frequency distribution.
286
Moderate negative correlation was present between

P4 and pressure pain threshold (r = -0.623, p<0.001)
and mild negative correlation was present between
numerical pain rating scale and pressure pain
threshold (r=-.372, p<0.05)which was statistically
significant.
.
Fig 1: Correlation of P4 with pressure pain
threshold
Fig 2: Correlation of numerical pain rating scale

with PPT.
DISCUSSION
The current study was conducted to measure the
intensity of pain and find an accurate pain intensity
measurement tool. P4 was a new subjective measure
which measures the pain at four different durations
which gives the precise pain measurement in
comparison to numerical pain rating scale showed
high reliability.8 PPT measured by pressure algometer
was an objective measurement of pain, but it would
be costly and time consuming as compared to P4
which can be computed in less than 5 seconds.
As found by Spandoni10 et al the P4s MDC90, a
measure of clinical significance, was substantially
less than those associated with the single-item NPRS.
MDC90 was applied to quantify true change. The
subscript 90 was used to signify a 90% confidence
level. They also found that the smaller measurement

error associated with the P4 also resulted in increased
efficiency when considering sample size for a clinical
trial.
Giburm Park8 et al showed that the digital pressure
algometer showed high reliability. Jensen13 et
al(1999), using a similar scale composition to the P4,
examined test-retest reliability and sensitivity to
change in patients with chronic pain and found that it
was greater for the composite measures, but the
observed differences using the scale were not
statistically significant.13
Krebs EE14 et al (2009), developed a 3-item PEG
[average pain intensity (P), interference with
enjoyment of life (E), and interference with general
activity (G)] ultra-brief pain measure to assess
chronic pain which showed good reliability and
construct validity in comparison to brief pain
inventory (BPI). It was sensitive to change and
differentiated between patients with and without pain
improvement at 6 months, and therefore was a
practical and useful tool to improve assessment and
monitoring of chronic pain in primary care.This tool
is comparable to the P4 tool used in the above study.
Downie WW15 et al (1978), did a study to find the
degree of correlation between the pain score
registered on four different pain rating scales which
showed that 11-point (0-10) numerical rating scale
performs better than both a 4-point simple descriptive
scale or a continuous (visual analogue) scale.
The present study is in accordance with findings of
Goldsmith16 et al (1993), who have shown that the
magnitude of an important change is greater for an
individual in the construct validation process,
depending on which this study found the correlation
in context with the individual. On this basis it was
seen that the pain measured by the standard gold
method i.e. pressure pain threshold and by numerical
pain rating scale and P4 had a mild and moderate
correlation respectively which was statistically
significant at (p<0.05 and p<0.001).
The limitation of this study was that the comparison
between P4 and numerical pain rating scale was not
done. Test-retest reliability studies using P4 can be
done for the specific conditions using the large
sample. P4 can be used as a measure of pain in future
studies.
287
Stuti et al.,
CONCLUSION
P4 has a moderate inverse correlation with pressure
pain threshold and numerical pain rating scale has
mild inverse correlation with pressure pain threshold
which concludes that P4 is a better subjective pain
measurement tool and has the capacity to measure
individual change in comparison with numerical pain
rating scale and pressure pain threshold, which is an
expensive tool, in spite of an objective
measurement.The current work represents only one
step in determining the extent to which the P4 is a
valid and useful measure for the myriad of conditions
and clinical settings in which the assessment of pain
intensity is an outcome of interest. P4 had a high
correlation with the gold standard method which
implies that it can be used for pain assessment for the
clinical purpose.
Conflict of interest: Nil.
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Stuti et al.,
DOI: 10.5958/j.2319-5886.3.2.062

&
Health Sciences
www.ijmrhs.com
Received: 2nd Jan 2014
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
Research Article
EFFECTIVENESS OF PEER-COUNSELING FOR PROMOTING OPTIMAL COMPLEMENTARY

FEEDING PRACTICES AMONG INFANTS BELONGING TO URBAN SLUMS OF DELHI
Sabharwal Vandana, Passi Santosh Jain
Assistant Professor in Nutrition, Institute of Home Economics, Former Director, Institute of Home Economics
Department of Foods and Nutrition, Institute of Home Economics, (University of Delhi), F-4 Hauz Khas Enclave,
New Delhi
*Corresponding author email: vandanasabharwal25@gmail.com
ABSTRACT
Background: Promotion of appropriate complementary feeding practices is important in reducing malnutrition in
infants and young children. Yet, India has dismal rates of optimal complementary feeding practices which are not
rising. Aim: This study aimed to find the impact of the educational intervention directed through peer counselors
to promote optimal complementary feeding practices. Methods and materials: This is an Interventional study,
which has been conducted in an urban slum of Delhi using multi-stage random sampling. From the study area two
sectors were randomly selected. From one sector, 54 pregnant women were selected who were not given any
counselling forming the non-intervention group. From the other sector, 159 pregnant women were selected to
form the intervention group (Igr) which were further divided into 3 sub-groups; one sub-group was imparted
counselling by a nutrition professional (Igr A; n=53) and the other two (Igr B1;n=53 and Igr B2; n=53) by the peer
counselors who where the local health workers trained for promoting optimal infant feeding practices. The infants
were followed up till their first birthday and in order to study the impact of counseling, the complementary
feeding practices of the intervention and the non-intervention groups have been compared Results: In the
intervention groups, the prevalence of exclusive breastfeeding at 6 months was significantly higher as compared
to the non-intervention group (67.5 % vs. 4.2 %). In the intervention groups, 2.6 per cent infants received semisolid/ solid foods before the age of 6 months, 75.1 percent between 6 - 7 months and the rest by the age of 9
months. However, in the Non-Igr, the respective figures were 48.9, 19.4 and 25.4 per cent; and at the age of one
year, 6.4 per cent infants were still being given predominantly mothers milk. 99.3 per cent infants in the Igrs as
compared to 82.3 per cent in the Non-Igr (P<0.05) continued to receive breast milk till the age of 12 months.
Conclusions: The promotion of optimal complementary feeding through appropriately trained peer counselors is
feasible, although it is can only be achieved through consistent efforts and adequate training/monitoring of such
interventions.
Keywords: Complementary feeding, Breastfeeding, Infant and young child feeding, Peer counselling.
INTRODUCTION
Malnutrition has rightly been called The Silent
Emergency. The proportion of malnutrition among
children in India is one of the highest in the world.
Despite unprecedented economic growth during the
last decade, improvements in nutritional status of the
children in our country have been rather very slow.

Data from the National Family Health Survey-3
(NFHS-3) 1, indicate that about 46 percent of the
children under 5 years of age are moderately to
severely underweight (thin for age), 38 percent are
289
Sabharwal et al.,
Int J Med Res Health Sci. 2014;3(2): 289-296
moderated to severely stunted (short for age), and

approximately 19 percent are moderated to severely
wasted (thin for height). The World Bank2 estimates
that, after Bangladesh, India ranks 2nd in the world
with respect to the number of children suffering from
malnutrition. In India, the prevalence of underweight
in children is among the highest in the world and
nearly double than that of Sub-Saharan Africa.
Malnutrition affects people of every age, although
some segments of the population are at a greater risk
of under nutrition. Identifying and understanding the
most vulnerable groups is crucial in order to design
an effective strategy to overcome malnutrition. Most
of the growth faltering occurs between the ages of 6
to 24 months when the child is no longer protected by
exclusive breastfeeding and is rather exposed to
disease/ infection through contaminated food and
water. Even a child adequately nourished after 24
months of age is unlikely to recover growth lost in
the first two years as a result of malnutrition3. Thus,
this is the critical window of opportunity when the
quality of a childs diet has a profound, sustained
impact on his/ her health as well as physical growth
and mental development.
Optimal infant and young child feeding (IYCF)
practices help ensure young children get the best
possible start in life. These include early initiation of
breastfeeding;
colostrum
feeding;
exclusive
breastfeeding from birth till six months, followed by
the addition of adequate amounts of mushy, semisolid or solid complementary foods drawn from the
local diet; coupled with continued breastfeeding
sustained well into or beyond the second year along
with gradually increasing the amount of
complementary foods4.
In spite of numerous efforts, in India, the prevalence
of optimal infant feeding practices remains low. As
per the DLHS-3 data (2007-8)5, the exclusive
breastfeeding rates among children under 6 months is
merely 46.4%, initiation of breastfeeding within one
hour of birth, 40.2% and introduction of
complementary feeding at 6 months (in children aged
6-9 months) is only 23.9%. The NFHS-3 (2005-6)
data also reflects that only 21 percent of the children
aged 6-23 months confer to all the three quality
parameters of IYCF recommended by WHO that is
timely, adequate and safe feeding of the infants. Only
44 percent of breastfed children are fed at least there
commended a minimum number of times and only
half of them consume food from three or more food

groups. Feeding recommendations are even less
likely to be followed for the non-breast-fed infants/
children aged 6-23 months.
The existing efforts for promotion of complementary
feeding must be strengthened as well as mainstream
and scaled up through adequate resource allocation,
capacity development, and effective communication.
There is evidence to suggest that individual and group
counselling is an effective tool to improve duration of
exclusive breastfeeding6 but there is minimal
evidence available for improving complementary
feeding practices using skilled counselling. In view of
this, the present intervention study has been
undertaken for promoting optimal complementary
feeding through peer counselling and assessing the
impact of counselling on aspects related to
complementary feeding practices of the nursing
mothers belonging to urban slums.
METHODOLOGY
This is an Interventional study, which has been
conducted in an urban slum of Delhi. Before
implementing the intervention, a cross-sectional
survey was conducted in the study area in order to
understand the prevailing infant feeding practices in
the area. The results of this study highlighted that
most women were following sub-optimal infant
feeding practices and along with this there was a high
prevalence of malnutrition among the infants7. This
made this area appropriate setting for examining the
potential benefits of counseling on optimal infant
feeding practices.
Multi-stage random sampling was used for enrolling
the subjects (pregnant women in the 6th month of
pregnancy). The study area was divided into 4
sectors, from which two sectors were randomly
selected for the study. These sectors were quite
similar in their socio-demographic profile, but were
not so near that the intervention imparted to the
subjects from one sector could affect the infant
feeding practices followed by the subjects belonging
to the other sector. From these two sectors all the
households with pregnant women in their second
trimester were identified with the help of the records
of a local NGO. From one sector, 54 pregnant women
in their 6th month of gestation were randomly selected
which formed the non-intervention group, who were
not given any counselling. From the other sector, 159
290
Sabharwal et al.,
pregnant women were selected forming the

intervention group (Igr) which were further divided
into 3 sub-groups based on physical demarcation of
the area; one sub-group was imparted counselling on
optimal infant and young child feeding practices by a
nutrition professional (Igr A; n=53) and the other two
(Igr B1;n=53 and Igr B2; n=53) by the peer counselors
who where the local health workers trained for
promoting optimal infant feeding practices by the
nutrition professional. Thus, in view of the inclusion
and exclusion criteria, 213 pregnant women (in the 6th
month of pregnancy) were enrolled in the present
study. Data was collected from 426 participants (213
pair of mother and infant in each household). Of the
213 pregnant mothers enrolled in the study, data from
6-12 months pp were available for 198 mother-infant
dyads (Igr A: n=51;Igr B1: n=50, Igr B2: n=50 and
Non-Igr: n=47)
Counselling was conducted in three sessions during
pregnancy (7th, 8th and 9th month) to cover issues
related to early initiation of breastfeeding, colostrum
feeding, avoidance of prelacteal feeding and
promoting exclusive breastfeeding to till six months
pp (the results of this part of the study will be
presented in a separate paper). Further, two
counseling sessions were conducted during the 5th
month postpartum. During these sessions the mothers
were imparted knowledge about variety and
consistency of complementary foods, responsive
feeding, safe preparation and storage of
complementary foods as well as continuation of
breastfeeding for two years or beyond. Recipes of
some easy to prepare home-made complementary
foods were shared and the cooking method
demonstrated. In addition to this, home visits were
made within 48 hours of the childbirth as well as once
during 5 - 7 days pp and thereafter bimonthly till the
first birthday of the infant to reinforce the messages
and counsel relatives of these women. The women in
the non-intervention area, however, were not
imparted any counselling. Thus, dual approach was
employed for counselling the pregnant women, one
by the nutrition professional herself and second by
the peer counselors.
After enrolling the subjects, survey questionnaire
with open and closed ended questions was used to
elicit information on background details. The survey
questionnaire was administered face to face by the
nutrition professional and the peer counselors. Before
implementing the structured questionnaire, consent

form in the local language was used to elicit written
informed consent from all the participants. Afterbirth
of the baby, child record cards were maintained that
included bimonthly information regarding dietary
practices/ nutrient intake of children as well as
monthly anthropometric measurements. Data on the
dietary intake of children were gathered using one
day 24 hour recall method and further analysed using
DIETFOFT. Data on feeding techniques and
strategies and hygiene/ sanitation practices followed
during complementary feeding were also gathered
through observation both at the 9th and 12thmonths pp.
In order to study the impact of counseling imparted
by the nutrition professional/ peer counselors,
complementary feeding practices of the intervention
and the non-intervention groups have been compared.
Further, within the intervention groups, infant feeding
practices have been compared for the group
counseled by the nutrition professional vs that by the
peer counsellor-1 /peer counsellor-2.
The data were statistically analyzed using SPSS
software. Descriptive analyses of all variables were
conducted. In order to compare the difference
between the variables in the intervention groups vs
the non intervention group students t test was
conducted and to understand the difference among
the three intervention groups and the non-intervention
group inferential statistical test of ANOVA was
applied.
RESULTS
Data on socio-demographic profile of the
household: The results of the intervention study
reveal that there were no significant differences with
regard to socio-demographic profile of the subjects
from all the groups. The age of subjects (pregnant
women) ranged from 17 - 36 years; about 50 per cent
being between 20 and 25 years. Majority of the
respondents were illiterate or functionally literate;
only 7.5 percent were reportedly employed, mostly as
labourers, maids, or were engaged in small-scale
work at home. Most of them were natives of UttarPradesh, Bihar or Haryana. Majority of the subjects
were Hindus belonging to lower caste/SC/ST
category and had been residing in the area for three
years or more. Among the study groups, there was no
significant difference in the mean age at marriage
291
Sabharwal et al.,
(17.63 1.82 yrs) and the mean age at first childbirth

(19.05 2.05 yrs) of the subjects.
Data on breastfeeding practices till six months
post partum (pp): With regard to breastfeeding
practices, it was found that the mothers in the Igrs
initiated breastfeeding earlier as compared to the
Non-Igr; the mothers who initiated breastfeeding
within one hour of childbirth was 63.4 per cent (Igr
A), 55.8 per cent (Igr B1) and 60.8 per cent (Igr B2),
as against only 3.8 per cent in the Non-Igr. Further, in
the intervention groups, the majority (83.9 %) of the
infants received mothers milk as their first feed,
whereas in the non-intervention group; 80.6 per cent
infants had received prelacteals like honey, buffalos
milk, cows milk, gur, tea water among others. At one
month, a significantly higher proportion of mothers
(80.6 %) in the Igrs were practicing exclusive
breastfeeding as compared to Non-Igr (13.5 %;
P<0.05). Similar significant differences were reported
at 60 2 days, 90 2 days, 120 2 days, 150 2
days and 180 2 days pp (P <0.05). At the end of six
months, the number of exclusively breastfed infants

was 67.5 per cent in the Igrs, against only 4.2 per cent
in the Non-Igr.
Data on time of introduction of semi solid/ solid
foods: Of the 213 pregnant mothers enrolled in the
study, data from 6-12 months pp were available for
198 mother-infant dyads (Igr A: n=51;Igr B1: n=50,
Igr B2: n=50 and Non-Igr: n=47). In the Igrs, 2.7
percent children were introduced to semi solid/solid
foods before the age of six months; about two third
infants started receiving semi solid/ solid foods
between 6 - 7 months and the rest latest by the 9th
month. In the Non-Igr, 48.9 per cent were receiving
semi-solid/ solid foods before 6 months, 19.4 percent
started receiving these feeds between 6 - 7 months
and another 25.4 percent at a later age, while 6.4 per
cent infants were still not being given any semi-solids
by the age of one year (Table 1). Hence, with regard
to timely introduction of complementary foods, a
significant difference (P<0.05) existed in the Igrs vs.
Non-Igr.
Table 1: Distribution of infants by age and introduction of semi-solid/solid foods

Infants age (months)
Igr A (n=51)
Igr
B1 Igr
B2 Non-Igr
(n=50)
(n=50)
(n=47)
1(1.9)
2(4.0)
1(2.0)
23(48.9)
<6m
39(76.4)
37(74.0)
39(78.0)
9(19.4)
6<7 m
9(17.6)
9(20.0)
8(16.0)
5(10.6)
7<8 m
2(3.9)
2(4.0)
2(4.0)
2(4.2)
8<9 m
0(0.0)
0(0.0)
0(0.0)
3(6.4)
9<10m
0(0.0)
0(0.0)
0(0.0)
2(4.2)
10<11 m
0(0.0)
0(0.0)
0(0.0)
0(0.0)
11<12 m
Till 12 months
51(100.0)
50(100.0) 50(100.0) 44(93.6)
Note: Figures in parentheses indicate percentages
as compared to Igrs (5.9 %). In the Igrs, vegetables
Data on food group and nutrient intake of the
infants: With respect to the type of foods, the
and fruits were fed to 57.6 per cent and 63.5 per cent
intervention group was encouraged to prepare
infants respectively as compared to 23.3 per cent and
complementary foods (from the family pot) having
42.5 per cent in the Non-Igr. Commercial foods were
thick/ soft consistency that provides satiety and
fed to 14.9 per cent infants in the Non-Igr whereas in
nourishment to the child. Data on food group
the Igrs no mother was using it. The data gathered
frequency was computed using a monthly three day
from 24 hours dietary recall was further used to
24 hours dietary recall method which indicated that
calculate the intake for macro and micronutrients
between 6-12 months compared to the Non-Igr, the
from complementary foods. The data relating to
intake of cereal-legume gruel mixes was higher in
energy intake from non-breastmilk sources indicate
Igrs (37.1 % in Igrs vs 6.4 % in Non- Igr). While
that the proportion of energy from these increased
almost all the mothers were feeding their infants with
with the Childs age in all the study groups.
cereal and pulses in the Igrs, only 73.5 percent
Compared to the Igrs the mothers in the Non-Igr had
mothers were doing so in the Non-Igr. Dilution of
low breastfeeding frequency and were given more top
milk was a common practice in the non-Igr (87.2 %)
feeds/ foods, but the quality and quantity of top foods
292
Sabharwal et al.,
was poor (Table 2). At 9 and 12 months energy intake

from complementary foods was higher in the Non-Igr
as compared to the Igrs (P<0.05 at 9 months and NS
at 12 months). However, during 9 and 12 month, the
mean frequency of breastfeeding was higher in the
Igrs than in the Non-Igr; hence it can be assumed that

the total energy intake (breast milk and non breast
milk sources) was higher in Igrs than the Non-Igr.
Table 2: Data on frequency of breastfeeding and energy intake from the complementary foods only birth
till 12 months (24 hour dietary recall)
Month
Freq. of BF
180 2
days
210 2
days
240 2
days
270 2
days
3002
days
330 2
days
360 2
days
Energy
intake
from CF
Freq. of BF
Energy
intake
from CF
Freq. of BF
Energy
intake
from CF
Freq. of BF
Energy
intake
from CF
Freq. of BF
Energy
intake
from CF
Freq. of BF
Energy
intake
from CF
Freq. of BF
Energy
from CF
intake
Igr A
N
(mean SD)
51
11.47 2.12
(4-15)
4
369.94230.5
(342-510)
51
11.47 2.12
(4-15)
39
162.85101.7
(107-510)
51
10.80 1.88
(4-13)
48
211.07117.9
(80-559)
51
8.78 1.60
(5-13)
48
258.14187.2
(201-559)
51
8.55 1.38
(4-11)
51
325.56159.7
(202-752)
51
8.14 1.11
(6-10)
51
414.58171.7
(313-538)
51
7.40 1.29
(5-10)
51
502.28164.9
(425-623)
Igr B1
N (mean SD)
50 10.86 2.22
(0-13)
7
314.63 186.73
(178-541)
50 10.86 2.32
(0-13)
38 182.1295.26
(120-481)
50 10.40 2.29
(0-14)
48 210.24 108.91
(89-481)
50 8.92 1.97
(0-13)
47 251.64 124.03
(181-506)
50 8.60 1.94
(0-11)
50 311.71 129.72
(245-597)
50 8.30 1.75
(0-11)
50 404.34130.65
(239-660
50 7.84 1.87
(0-11)
50 495.33 165.24
(433-759)
* Figures in the parentheses indicate the range

Comparison
of
micronutrient
intake
from
complementary foods indicates that at 9 and 12
months the intake of calcium, phosphorus, folate,
vitamin A and B group vitamins was statistically
higher in the Non-Igr (P<0.05) while the intake of
iron and vitamin C was higher (although not
significant) in the Igrs. This may be attributed to
higher consumption of vegetables/fruits in the Igrs.
Since during these months, the consumption of breast
milk- a rich source of most micronutrients, was
significantly higher as judged from the number of
breastfeeding episodes and their duration in the
Igr B2
N
(mean SD)
50 11.26 2.34
(3-14)
6
286.22 170.92
(86-510)
50 1.26 2.34
(3-14)
41 183.63 33.96
(106-481)
50 10.30 2.02
(3-13)
48 208.80 111.69
(89-481)
50 8.24 1.90
(2-13)
48 272.51 163.16
(224-785)
50 7.88 1.38
(5-11)
50 302.13 152.98
(118-491)
50 7.45 1.12
(4-9)
50 382.95 132.26
(342-717)
50 6.88 1.24
(3-9)
50 448.22 23.66
(398-606)
Non-Igr
N
(mean SD)
48
6.46 3.56
(0-14)
39
259.28113.56
(68-464)
48
6.46 3.56
(0-14)
44
319.85130.54
(46-502)
48
5.42 2.87
(0-11)
45
337 133.19
(165-443)
48
5.33 2.83
(0-10)
45
388.71161.54
(210-642)
48
4.96 2.94
(0-10)
44
426.93175.70
(212-582)
47
4.77 3.03
(0-11)
44
446.03178.27
(268-644)
47
4.62 2.63
(0-10)
44
527.09 99.73
(417-694)
intervention groups, it is envisaged that the overall

intake of energy and micronutrients could be higher
in the Igrs than the Non-Igr.
Data on extended breastfeeding status of the
infants: In this study, breastfeeding was almost
universal in the intervention groups, although in the
non-intervention group also 87.5 and 82.3 per cent
mothers were breastfeeding their babies at 9 and 12
months respectively (Table 3). Thus, an increased
number of women were able to successfully
breastfeed from 6 - 12 months pp in the Igrs vis--vis
293
Sabharwal et al.,
Non-Igr, significant differences were recorded at 9 12 months (P<0.05).

Table 3 Distribution of the infants by extended breastfeeding status
Infants age Igr A
(months)
Number (%)
Index
Older
Child
Child
n = 51
Igr B1
Number (%)
Index
Older
Child
Child
n = 50
Igr B2
Number (%)
Index Older
Child Child
n = 50
Non-Igr
Number (%)
Index Older
Child Child
n = 48
6-<9 months
Breastfed
Not breastfed
49
(98.0)
1
(2.0)
50
(100.0
0
(0.0)
43
(89.4)
5
(10.6)
51
(100.0)
0
(0.0)
n = 51
9-<12 months
Breastfed
Not Breastfed
45
(88.2)
6
(11.8)
43
(86.0)
7
(14.0)
n = 50
51
44
49
(100.0)
(86.3)
(98.0)
0
7
1
(0.0)
(13.7)
(2.0)
Data on maternal attitude/ behaviour regarding
complementary
feeding
of
the
infants:
Observations regarding self-feeding at 9 and 12
months indicate that in the Igrs significantly higher
proportion of infants had learned to feed themselves
than those in the Non-Igr (P<0.05), but the difference
was less pronounced at 12 months, possibly because
these skills generally get develop by this age. It was
also found that in the Igrs,the mothers were more
conscious of the childs hunger cues throughout the
period of 6 - 12 months (P<0.05). A significantly
higher percentage of mothers in the intervention
groups also reportedly took appropriate steps if the
child refused to eat and actively encouraged him/ her
to eat. At 9 and 12 months, other behaviours/practices
compared between the intervention and the nonintervention group included - feeding the child from
his/her own bowl (P<0.05), sitting with the child
when he/she is eating (P<0.05), feeding with love and
affection (P<0.05) and allowing the infant to eat food
on his/ her own accord (P<0.05). Though all the
subjects in the study groups (n=198) reportedly
washed their hands after defecating, only about threefourth washed their hands before cooking meals.
With regard to washing the infants hands before
feeding him/ her, significantly more mothers from the
intervention groups followed the practice (P<0.05). A
positive impact of counselling was also seen on the
practice of washing utensils before feeding the baby
(P<0.05) and rewarming of foods before feeding
(P<0.05).
44
(88.0)
6
(12.0)
n = 50
42
(84.0)
8
(16.0)
50
(100)
0
(0.0)
42
(87.5)
6
(12.5)
n = 47
39
(78.0)
11
(22.0)
39
(82.3)
9
(17.7)
39
(82.3)
9
(17.7)
DISCUSSION
Among the study population in urban slum of Delhi,
counselling directed through nutrition professional
and trained peer counselors, had a significant effect
on promoting infant feeding practices especially
complementary feeding practices. The groups
counseled by the nutrition professional and the peercounselors were almost similar in bringing about a
positive change in these practices. This study, thus,
highlights that educational intervention directed
through
the
peer-counselors
can
improve
complementary feeding practices as well as energy/
other nutrient intake from locally available foods. The
intervention has proved useful for educating the
mothers about appropriate complementary feeding
practices, method of preparing complementary foods,
improving their feeding skills and the overall
hygienic practices.
With regard to breastfeeding practices, it was found
that as compared to the Non-Igr, the mothers in the
Igrs initiated breastfeeding earlier, the majority of the
infants received mothers milk as their first feed and
at the end of six months, the number of exclusively
breastfed infants was higher. In the WHO Child
Growth Standards study, trained lactation counselors
supported the mothers to prevent and manage
breastfeeding difficulties from soon after birth and at
specified times during the first year after birth. By
using this strategy, good compliance to exclusive
breastfeeding was achieved in all the participating
294
Sabharwal et al.,
countries including India9. A Cochrane review on

support for breastfeeding mothers concluded that
training on infant and young child feeding, which in
turn led to more qualified professional and lay
support to the mothers, resulted in prolonged
breastfeeding duration10. The promotion of
breastfeeding intervention trial (PROBIT) has also
documented a significant improvement in the rates of
exclusive breastfeeding in the intervention group,
who received skilled, counselling support from the
trained health workers11. Bhandari et al (2003) 12
conducted a cluster randomized controlled trial in
Haryana, India to assess the effect of a 3 day training
programme.
Improved
rates
of
exclusive
breastfeeding and reduction of diarrhoea was
documented. A field experience in Lalitpur district
has shown such training is feasible and doable at a
scale and within 2 years practices have shown a
positive change apart from gain in motivation of
workers and their knowledge and skills13. In the
present study, with regard to timely introduction of
complementary foods, a significant difference existed
in the Igrs vs. Non-Igr. The quality and quantity of
the complementary foods being given to Igrs was also
better than the non-Igrs and so was the frequency to
continued breastfeeding. An earlier study to promote
optimal infant feeding practices in rural Haryana also
indicated that energy intake from complementary
foods overall was significantly higher in the
intervention group at 9 months (p<0.001) and 18
months (p<0.001)14.
There is increasing recognition that optimal
complementary feeding depends not only on what is
fed, but also on how, when, where, and by whom the
child is fed15. The educational intervention in the
present study also had a significant positive effect in
improving
maternal
behaviour
regarding
complementary feeding particularly responsive
feeding and hygienic practices. WHO also
emphasizes that the complementary feeding program
should take up a holistic approach to breastfeeding
and transitional foods, including matters related to
child feeding behaviors and food safety16.
Breastfeeding should be continued after six months as
it still remains to be an important source of energy
and high quality nutrients through the first and second
year of life as well as beyond.In this study,
breastfeeding was almost universal in the intervention
groups, but in the non Igr few mothers had already
ceased breastfeeding. Previous longitudinal studies

have demonstrated that in developing countries, a
longer duration of breastfeeding is associated with
greater linear growth when the data are analysed
appropriately to eliminate the influence of
confounding variables and reverse causation 17, 18.
CONCLUSION
The study indicates that it is possible to promote
optimal complementary feeding practices through
adequately trained and motivated peer counselors
along with back-up mechanisms rendering the
necessary support. Follow-up supervision of the peercounselors is also essential to monitoring their
progress as well as addressing the challenges these
peer-counselors are not able to handle.
Improving optimal infant feeding practices among
mothers requires behavioural change which is a
continuum and changes at different stages in the
infants/ young childs life, hence the timing of
interventions is also critical. It is thus important that
the interventions are inducted at a time, which is as
close as possible to the time of desired responses. Our
findings support a counselling schedule of two
sessions just prior to the introduction of
complementary foods (5th month postpartum) coupled
with monthly contacts thereafter as per the feasibility
or the individual mothers needs. Mothers who,
despite counselling failed to adopt optimal
complementary feeding practices indicate that these
mothers/ family due to their other problems require
extra counselling sessions. Participation of influential
family members such as mothers-in-law and
husbands in these counselling sessions would perhaps
enhance effectiveness of the counselling process as
indicated in some other studies. Thus, there is an
urgent need to educate the women as well as create an
enabling environment for practicing optimal
complementary practices with special emphasis on
timely, adequate and appropriate complementary
feeding and continued breastfeeding for two years or
beyond. The study, therefore, advocates a dire need
for positioning the system of peer counselling for the
mothers during lactation for ensuring timely
introduction of nutritious complementary foods from
the family pot.
295
Sabharwal et al.,
ACKNOWLEDGEMENTS
The authors wish to acknowledge the Indian Council
of Medical Research, India for financial support for
the study
REFERENCES
1. International Institute for Population. Sciences
(IIPS) and Macro International. 2007. National
Family Health Survey (NFHS-3), 200506: India.
2. World Bank Report on Malnutrition in India
2009. Available from: http://web.worldbank.
org/WBSITE/EXTERNAL/COUNTRIES/
SOUTHASIAEXT/0,content
MDK:20916955~page
PK:146736~piPK:146830~theSitePK:223547,00.
3. UNICEF. Understanding Malnutrition. Technical
notes. 2011 www.unicef.org/nutritioncluster
/files/M03P2.doc
4. National Guidelines on Infant and Young Child
Feeding, Food and Nutrition Board, Department
of Women and Child Development, Ministry of
Human Resource Development, Government of
India,
2006.
URL
http://wcd.nic.in/
nationalguidelines.pdf
5. District Level Household and facility Survey
(DLHS-3) 2006-2007. Ministry of Health and
Family Welfare. International Institute for
Population Sciences, India, 2007
6. Bhutta ZA, Ahmed T, Black RE, Cousens S,
Dewey K, Giugliani E et al. What works?
Interventions
for
maternal
and
child
undernutrition and survival. Lancet 2008;
371(9610):417- 40.
7. Sabharwal P, Passi
SJ. Reasons for not
practicing exclusive breastfeeding for the first six
months in urban slums of Delhi. The Indian
Journal of Nutrition and Dietetics 2013; 50
(12):500-06.
8. WHO Multicentre Growth Reference Study
Group. WHO child growth standards:
Length/height-for-age, weight-for-age, weightfor-length and body mass index for age: Methods
and development. World Health Organisation,
Geneva, 2006
9. WHO Multicentre Growth Reference Study
Group. Breastfeeding in the WHO Multicentre
Growth Reference Study. Acta Pdiatrica 2006;
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10. Britton C, McCormick FM, Renfrew MJ, Wade

A, King SE. Support for breastfeeding mothers.
Cochrane
Database
Syst
Rev.
2007;24;(1):CD001141.
11. Kramer MS, Chalmers B, Hodnett ED,
Sevkovskaya Z, Dzikovich I, Shapiro S et al.
PROBIT
Study
Group
(Promotion
of
Breastfeeding Intervention Trial). Promotion of
Breastfeeding Intervention Trial (PROBIT): a
randomized trial in the Republic of Belarus.
JAMA.2001;24-31;285(4):413-20.
12. Bhandari N, Bahl R, Mazumdar S, Martines J,
Black RE, Bhan MK(Infant Feeding Study
Group). Effect of community-based promotion of
exclusive breastfeeding on diarrhoeal illness and
growth: a cluster randomized controlled trial.
Lancet 2003; 361(9367): 1418-23.
13. Reaching the Under 2's. Universalizing delivery
of nutrition interventions in district Lalitpur,
Uttar Pradesh. Available at http://www.bpni.org/
BFHI/
Reaching-the-under-2S-UniversalisingDelivery-of-Nutrition-Interventions-in- LalitpurUP.pdf
14. Bhandari N, Mazumber S, Bahl R, Martines J,
Black RE, Bhan MK. An educational intervention
to promote appropriate complementary feeding
practices and physical growth in infants and
young children in rural Haryana, India. J. Nutr
2004; 134: 2342-48.
15. Pelto G, Levitt E, Thairu L. Improving feeding
practices: current patterns, common constraints
and the design of interventions. Food Nutr Bull
2003;24:4582
16. WHO. Complementary feeding of young infants
in developing countries. http://www.who
.int/nutrition/publications/infantfeeding/cf_dev_c
ountries_chap8.pdf
17. Simondon KB, Simondon F, Costes R, Delaunay
V, Diallo A. Breast-feeding is associated with
improved growth in length, but not weight, in
rural Senegalese toddlers. Am J Clin Nutr
2001;73: 959-67.
18. Roy SK, Fuchs GH, Mahmud Z, Ara G, Islam S,
Shafique S, Akter SS and Chakraborty B.
Intensive nutrition status of moderately
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PopulNutr 2005 Dec ; 23 (4) : 320-30.
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DOI: 10.5958/j.2319-5886.3.2.063

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
Research Article
A STUDY ON PREVALENCE OF DISCHARGE AGAINST MEDICAL ADVICE IN A TERTIARY

CARE HOSPITAL IN NIGERIA
*
Onankpa BO1, Ali T2, Abolodje E2
Senior Lecturer/ Consultant Paediatrician , Department of Paediatrics, Usmanu Danfodiyo University Teaching
Hospital, PMB 2370 , Sokoto, Sokoto State, Nigeria.
2
Senior Registrar, Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital,
PMB 2370, Sokoto, Sokoto State, Nigeria.
*Corresponding author email: benonankpa@yahoo.com.
ABSTRACT
Background: The length of hospital stay for every neonate admitted for care is more often than not at the mercy
of the parents/caregivers. Aims: To determine the pattern of request for discharge against medical advice of
neonates. Methodology: A 5-year cross-sectional study at the Special Care Baby Unit (SCBU) of Usmanu
Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria. All babies that were discharged against
medical advice (DAMA) between January, 2008 and December, 2012 were recruited. Both baby/maternal
information and the indications for the discharge were documented. Statistical analysis was done using SPSS
version 20.0 Results: Admission to SCBU for the period was found to be 2,426 (20.2%). Forty two (1.7%) babies
were DAMA; males 17 (40.5%), females 25 (59.5%); M: F; 0.7:1.5. Twenty seven (64%) delivered in UDUTH,
15 (36%) outside the facility. Birth weights ranged from 1.0 4.8kg with mean SD of 3.03 0.8. 36 (85.7%)
were spontaneous vertex deliveries, and term babies accounted for 78.6%. Babies delivered vaginally had more
DAMA. Birth asphyxia was the commonest diagnosis. The mean duration of hospital stay was 8.2 5.4 days.
Nineteen babies (45.2%) were DAMA in the first 8 days of admission, majority of these were from the low and
middle income groups. Four neonates (9.5%) were re-admitted. The commonest reason for DAMA was financed
(45.2%) and father was the main signatory to the DAMA (92.9%). Conclusions: Discharge against medical
advice remains a paediatric problem in the study area despite adequate counselling.
Keywords: Discharge against medical advice, Tertiary hospital, Nigeria
INTRODUCTION
Medical practitioners and more worrisome,
paediatricians are likely to face the challenge of
parents asking for discharge against medical advice
(DAMA) of their wards. It might be impossible to
eliminate because the length of hospital stay in
children depends on their parent(s) or caregivers. 1,2
Discharge against medical advice is still a major
health concern in health care delivery in Nigeria.3
There is a high rate of readmission with subsequent
longer stay in hospital amongst babies DAMA. 4-6
Concerning DAMA, children are not part of the

decision making, and parents of neonates contribute
more to DAMA.3,7-9 The Millennium Development
Goal report for 2008 feared that achieving goal
number 4 may be negatively affected by DAMA.10
Common reasons for DAMA include financial
constraints, parents perception that the child is well,
disruption of family activities, poor clinical outcome,
option of traditional medication, and hopeless
perception of the clinical status. 4,11
297
Onankpa et al.,
Access to quality medical care, especially in the

public sector is still poor in low-resource settings of
many African countries, including Nigeria, and due to
the harsh economic situations amongst other reasons,
parents frequently ask for DAMA.
In this study, we therefore, looked at the prevalence
of this problem and the possible causes of discharge
against medical advice at UDUTH, Sokoto, Nigeria.
METHODOLOGY
Usmanu Danfodiyo University Teaching Hospital,
Sokoto, Nigeria, serves as the referral centre to three
of its neighbouring States and Niger republic. The
study was a 5-year cross-sectional, retrospective
study (January 2008 December 2012) of neonates
admitted into our SCBU. The parents/caregivers pay
for prepacked drugs/admission packs except for
emergency cases that payment is made later. When
parents/caregivers insist on discharge despite
counselling by the unit consultant and/or the most
senior nurse, they are made to sign the discharge
form. Parents bare the cost of all treatments in full
except those on the National Health Insurance
scheme that pay only part of the cost. The following
information were obtained from the admission files;
gestational age, gender, weight at birth, place of
delivery, mode of delivery, ethnicity, admitting
diagnosis, length of hospital stay and reason(s) for
discharge. The Oyedeji system of classification was
used to classify parents into high (classes I and II),
middle (class III) and low income groups (classes IV
and V).12 Ethical approval was obtained from the
Ethics committee of UDUTH.
Data was manually sorted out for completeness and
entered into Microsoft excel spread sheet. The
analysis was done using SPSS (statistical package for
the social sciences) version 20.0. The results were
presented in the form of means, ratio and percentages.
The statistical significance was set at P < 0.05.
RESULTS
Total deliveries for the study period were 10,578;
admitted to SCBU was 2,426, there were 42 cases of
DAMA (1.7% prevalence). There were 17 males and
25 females; M: F ratio of 0.7:1.5. Twenty seven
(64%) of the babies were delivered in UDUTH while
15 (36%) were born outside the facility. Table I
shows the birth characteristics of the babies. Birth
weights ranged from 1.0 4.8kg with a mean SD of

3.03 0.8. Thirty six (85.7%) were spontaneous
vertex deliveries, and term babies were the majority
33 (78.6%). Babies delivered vaginally were more
likely to DAMA due to early maternal ambulation;
the difference when compared to other modes of
delivery was not statistically significant (p = 0.06).
Table 1: Birth and gender characteristics of 42
neonates DAMA.
Number of neonates %
Gender
Male
17
40.5
Female
25
59.5
Total
42
100
Mode of delivery
SVD
34
80.9
C/s
6
14.3
Other
2
4.8
Total
42
100
Gestational age (weeks)
28-32
2
4.8
33<37
6
14.3
38-42
33
78.6
>42
1
2.3
Total
42
100
Age on admission
24 hours
32
76.2
2-7 days
18
42.9
>7 days
2
4.8
Total
42
100
SVD = spontaneous vertex delivery, C/s = Caesarean
section
Table 2depicts the duration of hospitalization prior to

DAMA and socioeconomic class of the parents. The
mean length of Hospital admission was 8.2 5.4
days. Nineteen babies (45.2%) were DAMA in the
first 8 days of admission; all from low-in-come
groups. Thirty seven babies (88.1%) were in the low
and middle income class; DAMA were observed
more in this group (p < 0.015). Four neonates (9.5%)
were re-admitted within 72 hours after DAMA; all
from the high income group. For the re-admitted
cases, the observed complications included severe
dehydration in three babies and one baby with severe
anaemia
298
Onankpa et al.,
Table 2: Duration of hospitalization prior to

DAMA and socio-economic class of parents
Number of neonates Percenta
ge
Duration of hospitalization (days)
1
2
4.8
2-7
8
19.1
8-14
28
66.7
>14
4
9.5
Total
42
100
Social-economic class of parents*
Upper
5
11.9
Middle
14
33.3
Lower
23
54.8
Total
42
100
P=0.015
Birth asphyxia, neonatal sepsis, and low birth weight
accounted for most DAMA (Table 3). Eight babies,
all females had multiple morbidities.
Table 3: Clinical diagnosis of 42 neonates DAMA
Clinical Diagnosis
Number
of %of
Total
neonates
Perinatal asphyxia
Neonatal
septicaemia/sepsis
Low birth weight
Neonatal jaundice
Small-forgestational age
Respiratory distress
syndrome
Hemolytic disease
of the newborn
Total
22
11
52.4
26.1
5
1
1
11.9
2.4
2.4
2.4
2.4
42
100
Table 4: Reasons given by parents/caregivers for

neonates DAMA
Reason(s)
Number of % of
neonates
Total
Lack of finance
19
45.2
Perceived improvement
9
21.4
To
seek
traditional 4
9.6
medication
No improvement
3
7.1
Distance too far
2
4.8
Elsewhere
2
4.8
Multiple *
3
7.1
Total
42
100
*More than one reason for DAMA

Table 4 shows the reasons for DAMA amongst the
study subjects. Poor financial stand of parents was the
commonest reason for DAMA (45.2%) and the father
was the main signatory (92.9%).
DISCUSSION
The prevalence was 1.7% for DAMA in the studied
neonates. This was similar to other previous studies
from Nigeria for DAMA though, in general
Paediatrics.1,4 A prevalence of 1.6% was also reported
in neonates studied in Saudi Arabia.2 We therefore
assume that neonates are still at the risk for DAMA in
most centres. However, a higher prevalence of 4.3%
was reported in a study from Nigeria3 and 12.2% in a
study from a teaching hospital in North Western
Ethiopia.13 These differences, we attributed to the
many factors that influence DAMA including
gestational age, socioeconomic class, ethnicity,
cultural issues amongst others.2,14 Facts from the
literature has put the prevalence of DAMA to be
between 1% and 6% globally; 1,15 In these studies,
finance and clinical outcome were considered as
strong factors in taking the decision for DAMA in
poor resource centers.1,3,13 In Nigeria, prevalence is
often affected by finance as health care to a large
extent is provided by parents. However, this factor
(finance) was not considered an issue in most studies
outside Nigeria.2,5,7
Babies born outside the study facility accounted for
64.3%, this was comparable to findings observed in
similar
studies
from
southern
Nigeria.3,4
Parents/caregivers of referred babies from peripheral
hospitals might have exhausted their finances, and
most importantly such babies will be very ill
therefore making DAMA in this group a frequent
occurrence.
Parents with term and bigger babies are more likely
to ask for DAMA more than those with small preterm babies as postulated in other studies. 2,3 It was
observed in this study that DAMA was highest for
babies delivered vaginally; their mothers probably
had earlier ambulation, and discharged earlier than
those who had caesarean sections.
Life threatening conditions like perinatal asphyxia,
neonatal
septicaemia/sepsis
and
low
birth
weight/prematurity were the most prevalent diagnosis
among babies discharged AMA. This agreed with
299
Onankpa et al.,
facts from the literature. 3,16 Previous Nigerian studies

have also observed these conditions, 2,3, and by WHO
were identified as the greatest cause of mortality in
newborns in the developing world. 17
Nineteen babies (45.2%) were discharged within the
first week of life while, most DAMA (65.8%)
occurred after the first week of hospital admission. It
has been observed that patients that were discharged
AMA have higher rates of re-admission with longer
stay in the hospital, and poor clinical outcome18, 19,20
The readmission rate in our study was low, only four
babies (1.7%) were re-admitted. This figure is low
compared to the value (16.2%) reported from Benin
City,1 but, similar to the reported from Port Harcourt,
all in Nigeria.3 These differences might be due to
finance and perception of parents. Some of the
newborns in this study that required re-admission
may have been readmitted into other wards due to age
factor (babies older than 28 days are not admitted into
our SCBU). In most cases, parents/caregivers are
faced with issues like disfranchise, fear of reproach
from health workers, and thus are discouraged from
returning to hospital for re-admission. Discharge
AMA was more frequent amongst patients in the low
income class (45.2%). Outside this major factor for
DAMA in this study, others included falsely
perceived clinical improvement of babies by parents
and opting for traditional medication.
Fathers
(92.9%) were the main signatory to the discharge
form, this is similar to an earlier work in a Nigeria
study.1 Issues of gate-keeping by fathers in the study
area is also a big factor in decision making
concerning DAMA; many mothers do not work
outside their homes and some cannot take such
decisions.
Parents spend an average of N10, 850 (80 Dollars)
per week for treatment in our SCBU outside other
logistics, the cost implications are, therefore,
definitely not within the reach of most parents who
are not on National Health Insurance Scheme (NHIS).
CONCLUSION
The major contributory factors to DAMA in the study
were poverty, perceived improvement and other
multiple social problems making DAMA in neonates
still is a serious public health issue with resultant
increase in morbidity and mortality.
Recommendations:
Physicians,
specifically
paediatricians, are often torn between wishes of the
parents/caregivers asking for DAMA and what is best
for the patient despite keeping legal issues at view. It
is, therefore, important for health care providers to
include ethical, legal and moral issues in the
management of patients especially in dealing with
cases of DAMA. There is also the need to improve
female education and empower women so that
mothers can contribute to decision making
concerning the health of their wards, and also to
poverty alleviation.
Conflict of interest: None
ACKNOWLEDGEMENT
We acknowledge the contribution of Hajara Ahmed
the matron-in-charge of SCBU, and the Paediatric
records officer Malam Lawali for sorting out the files
we used for the study.
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MT, O'Shaughnessy MV. Leaving hospital
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DOI: 10.5958/j.2319-5886.3.2.064

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
th
Received: 6 Jan 2014
Revised: 9 Feb 2014
Copyright @2014
ISSN: 2319-5886
Research Article
PREVALENCE OF CLOSTRIDIUM DIFFICILE TOXIN IN DIARRHOEAL STOOL SAMPLES OF

PATIENTS FROM A GENERAL HOSPITAL IN EASTERN PROVINCE, SAUDI ARABIA
*Sue Elizabeth Shajan1, Mohammed Faisal Hashim2, Michael A3
1
PhD Scholar, Dept of Microbiology, School of life Sciences, Karpagam University, Coimbatore, Tamil Nadu,
India & Currently affiliated to Department of Microbiology, Al Mana General Hospital, Al Jubail, Saudi Arabia.
2
Department of Medicine, Al Mana General Hospital, Al Jubail, Saudi Arabia.
3
Department of Microbiology, PSG College of Arts& Science, Coimbatore, Tamil Nadu, India.
*Corresponding author email: sueshajan@gmail.com, sueshajan@yahoo.com
ABSTRACT
Introduction: Clostridium difficile is anaerobic spore- forming bacillus, produces two major toxins (Tcd A and
Tcd B). Disease caused by toxigenic C.difficile (Tcd) varies from mild diarrhea to fulminant disease and death.
Aims and Objectives: - This study describes the prevalence of C.difficile toxins (CDT) in stool samples from in
patients and outpatients of all age groups. Materials and Methods:- A total of 146 samples were examined from
2011 to 2012 were analyzed for the presence of CDT tests, DNA amplification test, and the stool samples were
cultured anaerobically on CCFA selective medium for growth- Morphology, identification and other tests. The
patients details are collected from the medical records. Results: - Out of 146 specimens, only 20 (13.7%) were
positive for C.difficile toxins. Male and female were 12 (60%) and 8(40%) respectively, with the majority of them
aged between 16 to 71 years. Majority of them were from out patient units (n = 5, 25%) with rest from intensive
care units (n = 3, 15%), male medical ward (n =3, 15%) and surgical wards (n = 1, 5%). All the CDT positive
patients had history of prior antibiotic usage before the detection of toxin. Mean duration of antibiotic usage was a
16.75 (12.75) days, and the mean duration of diarrhea was 4.21 (4.85) days, 16 patients had underlying medical
illness, like hypertension, diabetic mellitus etc; Stool with pus cells and occult blood test was positive among
that 18 patients were positive for CDT. The hospitalized patient duration was 20.96 (16.25) days. Conclusion: The detection of CDT in the diagnosis of CDI requires vigilance by both clinician and microbiologist to look out
for possible infected patients. Antibiotic usage is a known risk factor; thus restricted use of antibiotics may results
the reduction of CDI.
Keywords: C.difficile toxins (CDT), C.difficile infection (CDI), C.difficile associated diarrhea (CDAD)
INTRODUCTION
Clostridium difficile is widely distributed in nature
and is particularly prevalent in hospitals. 1, 2 Less
commonly it is acquired in the community from an
unknown source. C.difficile was first described in
1935 as part of the intestinal micro flora in neonates,
but was not identified as a causative agent of human
disease until 1978.3 The toxin mediated C.difficile
(CDT) is the main cause of infectious diarrhea that

develops following hospitalization and antibiotic
treatment with incidence ranging from 3% to 29%. 4
C.difficile is the most commonly identified organism
as the causal agent for antibiotic associated diarrhea.3
In recent years the incidence of C.difficile associated
diarrhea (CDAD) has risen dramatically, due to the
302
Sue et al.,
frequent use of broad spectrum antibiotics, especially

in North America and Europe.5,6 In addition to
recognized risk factors, like old age, hospital
admission, and antibiotic exposure, there have been
recent reports of the occurrence of CDAD in young
seemingly healthy adults and children in the
community, some of them without antimicrobial
exposure.7, 8
Immunocompromised state also as a risk factor for
CDAD.9-11 Acid suppression, especially with proton
pump inhibitors (PPI), and in adults taking the
antidepressants Mirtazapine and Fluoxetine acts as an
increased risk of C.difficile infection.12-14 Two related
longitudinal studies were referred as an increased risk
of CDI.15, 16 Symptoms of CDI may start on the first
day of antibiotic therapy and up to 8 weeks after
termination of therapy. Complications of C.difficile
include toxic mega colon, bowel perforation, immune
suppression, gastric acid suppression, inflammatory
bowel diseases (IBD), sepsis, shock and death.17, 18
CDI also caused major outbreaks in many medical
centers.13 Annual data from the state of Ohio in 2006
(Ohio department Health), United States (US)
hospitals and long term care facilities had about 500,
00 CDI cases per year with an estimated 15,000 to
20,000 death. Most of the prevalence and morbidity
studies of C.difficile are from the Western countries.
C.difficile infection (CDI) occurs primarily in
hospitalized inpatients, causing 3 million cases of
diarrhea and colitis per year. Annually 14,000
Americans death is due to CDI.19 More and more
studies has been challenged the nation, that though
CDI is primarily a hospital associated infection, but
nowadays as more cases are being seen in the
community. 18, 20, 21 From 1991 to 2005 a study from
Olmsted country, Minnesota, 41% of C.difficile
infection were community and hospital associated
were increased significantly. 18 In 2003 to 92.2 cases
per 100,000 populations of CDI were quadrupled in
Canadas Estrie region of Quebec. The incidence of
C.difficile in hospitalized patients was 41 per 100,000
patient days in a survey of 97 hospitals from 34
European countries;22 Worldwide, CDI cases were
also increasing.23 Prevalence of CDI in Taiwan
estimated around 12.4%.26 In 2005, a C.difficile strain
B1 / NAP1 / 027 were responsible for a large number
of infections in North America and Canada8, 24. Our
local data regarding CDI prevalence is not yet
available. On 1994; C.difficile toxin was found in
9.5% of patients from a study of the causes of

gastroenteritis at a major referral centre in Saudi
Arabia; but it was not specified as C.difficile
associated disease. In Saudi Arabia, the annual
incidence rates of CDAD in a hospital was to be
around 2.4 and 1.7 per 10,000 patient days in 2007
and 2008, respectively.25
Objective: - This study investigated the prevalence
of C.difficile toxins (CDT) in loose stool samples.
The demographic and clinical parameters of the
patients were also examined.
This was a retrospective study of all inpatients and
outpatients from our hospital, from Jan 2011 to Dec
2012, whose stool samples [Based on Bristol Stool
Chart) were sent to Clinical Microbiology for
C.difficile toxin A& B testing. 146 specimens from
patients with diarrhea were sent. These stool samples
were sent for typhoid, other enteric pathogens and
parasites clearance investigation; and these from
patients below the age of 2 years were excluded from
the study. The hospital records of the corresponding
patients were retrieved and clinical data were noted.
Demographic and clinical data including age, sex,
duration of hospitalization and ICU stay of inpatients,
duration of diarrhea, clinical features, associated and
underlying illnesses (inflammatory bowel disease,
prior
abdominal
surgery,
malignancy,
immunosuppressive state and use of antidepressant
were recorded. Cancer chemotherapy, exposure to
antibiotics and PPI was noted. Sigmoidoscopy or
Colonoscopy findings and histopathology report,
whenever done were included. All patients with
positive stool for C.difficile Immunocard toxin A& B
were included in our study. However, only one
positive specimen per patients was included in the
analysis. Enzyme linked immunosorbent assay
[ELISA]; (Meridian Bioscience Inc., Cincinnati,
Ohio, USA), was used for the rapid, qualitative,
horizontal flow Enzyme Immunoassay (EIA) for
detecting C.difficile toxin A& B in human stool.27
This assay is used as an aid in the diagnosis of
C.difficile-associated diarrheal disease. The procedure
was carried out according to the manufacturers
instructions.
Steps for processing stool to reduce the amount of
normal fecal organisms:303
Sue et al.,
Culture of stool for C.difficile, followed by a

toxigenic assay to confirm the presence of the toxins,
can be done; however, the time involved in this
procedure renders it impractical for many
laboratories. Culture is very important if
epidemiological studies are being employed. If
culture is done, an attempt is made to reduce the
amount of normal bacteria present in stool first by
processing a portion of the stool as follows:Mix0.5gm of stool with 0.5 ml of 95% ethanol.
Incubate for one hour at room temperature. Inoculate
two drops of the suspension onto a selective medium,
cycloserine-cefoxitin-fructose agar, to isolate
C.difficile, incubate anaerobically for 48 hrs at 37C.
The presumptive identification was done by colony
morphology, for typical colonies of C.difficile; white,
spread, flat colonies with a hallo in the medium that
exhibit a horse barn odor. The gram stain
demonstrates gram positive bacilli with oval sub
terminal spores. Identification are confirmed by
biochemical kit systems[ Fermentation of glucose,
hydrolysis of gelatin and esculin and other
differentiation tests like lecithinase, lipase activity,
aero tolerance test, fluorescence under long
wavelength ( 365nm) UV light, urease, indole and
motility tests]. Antibiotic sensitivity tests for that of
the resistant strains. Once identified as C. difficile, the
isolate should be tested for the presence of toxins, for
the detection of the cytotoxigenic strain of C. difficile
in stool specimens by using DNA amplification
assay. Stool may be hemoccult positive in severe
colitis; Colonoscopy is more useful; Antibiotic
associated colitis 3rd generation cephalosporin, coamoxiclav and quinolones are associated with an
increased incidence of C.difficile infection. C.difficile
infection is seldom self-limiting; No treatment is
required
if
asymptomatic
or
improving
spontaneously. Suspect cases are treated and isolated
without waiting for laboratory confirmation of the
diagnosis.
RESULT
146 stool samples were tested during the period from
January 2011 to December 2012; the year wise break
up was 2011 = 68, 2012 = 78. Each patient's stool
was tested only once. Out of 146 specimens, only 20
(13.7%) were positive for C.difficile toxins. Among
the toxin positives, 12 (60%) were males and 8 (40%)
were females. The mean age ( SD) was 37.5
(18.29) years with a median age of 37.5years. There
were no pediatric case and 10 (50%) were inpatients
aged 38years or older. [Table: 1, 2] In 2011, annual
positivity rates were 17.6% (12 out of 68) and in
2012, 10.2% (8 out of 78). In our hospital the annual
prevalence rates of C.difficile infection were
estimated around 0.3 and 0.2 per 10,000 patient days
in 2011 and 2012, respectively. Patients in the male
medical ward 5% of the positive patients 15% were
from female wards, 5(25%) were from intensive care
units and 10(50%) were outpatient unit. From these
units, 5% of cases were from the hospital, 50% were
from the community and 45% were with the onset
from the community to the health care settings due to
unnecessary and irregular use of antibiotic from other
health care facility, and were admitted with
symptoms and clinically suspected with Clostridium
difficile associated diseases. There was a significant
association between history of previous antibiotics
treatment from other health care facility and positive
detection of C.difficile toxin (P < 0.035). Of the
cases, 19 (95 %) patient are exposed to antimicrobial
drugs for past 3 months prior to the test the remaining
patients with underlying disease, like inflammatory
bowel disease. 3 (15%), proton pump inhibitors 2
(10%) and 1 (5%), with no antibiotic exposure.
Cephalosporins were the most common antibiotic
used (n =12, 60%) Fluoroquinolone (n = 6, 30%) and
Augmentin (amoxicillin/clavulanate potassium) 2
(10%)
Table1: Clinical Parameters of Patients with Clostridium difficile Toxin (CDT)

2011 CDT (N= 12)
2012 CDT (N= 8)
t-Stats (df)
Clinical Parameter
Mean SD
Mean SD
According to Age
4 3
2. 6 3. 05
0. 178
According to Nationality
3 3. 5
2 1. 6
0. 524
According to IP/OP
3 1. 4
3 1.4
1. 41
P Value
0. 8607
0. 606
0. 175
304
Sue et al.,
Indian
Filipino
2
Pakistani
3
Out Patient
Clinic
Saudi
10
Male
Surgical
Ward
Male Female
Male
Medical
Ward
1
>65
Wards
Nationality
10
Female
Ward
16-29 30-60
Sex
8
13
6
12
Intensive
Care Unit
Age Group
Fig 1: Characteristics of Patients with Positive Clostridium difficile Toxin

DISCUSSION
Patients presenting with diarrhea after hospitalization
for three or more days should be tested for C.difficile.
In many parts of the world hospitalization with a
discharge diagnosis of CDI increased significantly. 28,
29
Most previous studies about CDAD in India have
shown prevalence rates ranging from 7.1% to 26.6%.
Three prospective studies in hospitalized patients
developing acute diarrhea showed prevalence rates of
11.1%, 22.6%, and 26.6%; and five year prevalence
found 7.1%.30, 31 In our study the prevalence of
CDAD was 0.3 and 0.2 per 10,000 patient days in
2011 and 2012, respectively. This rate is lower than
the prevalence rates reported from the other countries.
In Thailand the prevalence rate of CDAD has been
reported to be 7.1 8.7% and 8.4%.32 In a Spanish
study, the mean annual incidence rate was 41.2 per
100,000 discharges. The prevalence of CDAD in
Saudi Arabia was 2.4 and 1.7 per 10,000 patient days
in 2007 and 2008; respectively.25 However, the rate of
CDAD varies from one hospital to another and from
one region to other. The prevalence in our hospital is
low, due to the lack of requisition of this test from the
patient samples. This study we used EIA, culture
method and toxigenic detection by [DNA
amplification method]. The majority of our CDT
positive patients were between 18 to 70 years age.
Few of our patients had underlying medical illness
and had been administered multiple drugs, including
a broad spectrum antibiotics such as amino
glycosides, II and III Cephalosporins and
Fluoroquinilones group. Middle age group and

certain underlying medical illness are both known
causes of C. difficile infection. Other risk factors
reviewed in our study were the history of unnecessary
and irregularly used antibiotic treatment with
extended antibiotic treatment. The mean duration of
hospitalization and antibiotic treatment were 21.96 (
16.25) days and 16.75 ( 12.75) days, respectively;
which showed that patients with CDT positive in
community and hospital facility had prolonged
antibiotic treatment. In Our study, 5% of CDI from
the hospital, 50% were from the community and 45%
were with the onset in the community due to multiple
antibiotic treatments from the other health care
facility settings. The incidence might be increasing
among person living in the community, including but
not limited to, healthy person without recent
healthcare contact.33 No history of recent
hospitalization and thus defined as community
associated, although a much larger proportion of
these patients received prior antimicrobial therapy
95%.Karlstrom et al34 Similarly, Svenungsson et
al.,35 investigating the epidemiology of hospitalized
C.difficile positive patients, found that 28% were in
fact community associated, as the study of Noren et al
22%.36 In addition, in a study from Canada,
community associated C. difficile infection
constituted about 20% of all cases.37 Likewise
C.difficile in the community reveals severe public
health impact and was useful for the future studies.25
305
Sue et al.,
Other risk factors are based on the age, especially >65

years. The mean age of this study of the patients was
much lower at 38 years. When compared to the
previous study held in Saudi Arabia 2007 and 200825;
describes the community associated infections were
younger than those with health care facility
associated infection. 38 This study had some
limitation, because only to one center, with a small
number of infections. The discontinuation of the
offending antibiotic therapy and specific treatment
with oral metronidazole or vancomycin are essential
steps in the management of more serious cases of C.
difficile induced antibiotic associated colitis (George
1984, Bartlett 1981, 1984) these observations have
made an etiologic diagnosis of antibiotic associated
colitis, important for the hospitalized patients.
Measures taken into hospital dealing with an outbreak
of Ribotype O27, strong restriction of certain
antibiotic including Fluoroquinolones. So inter
hospital transmission is limited. In this study, by
(LAMP method) we were able to isolate Ribotype
O27 from the toxigenic C. difficile strains, are
resistant to Quinolones. The quality control compared
with that of toxigenic strains of ATCC 9689; also
Ribotype O27.
CONCLUSION
The detection of C. difficile toxin in the diagnosis of
C. difficile infection requires vigilance by both
clinicians and clinical Microbiologist for optimize the
patient care. Each hospital must use antibiotic
guidelines to encourage the rational use of antibiotics
and reducing the unnecessary use of antibiotics helps
to slow down the evolution of microbial antibiotic
resistance. Antibiotic usage has known risk factors
for C. difficile infection; thus restricted use of
antibiotics may result to lower the statistic of C.
difficile infection and to encourage the use of
alternative antibiotics, which are less toxic and less
expensive.
Conflict of Interest: The authors declare that they
have no conflict of interests.
ACKNOWLEDGEMENTS
The authors are grateful to the members and Franz .L
in the department of Microbiology, Al Mana General
Hospital, Eastern province, Saudi Arabia and the help
and support of Sri Rekha teacher and Remya .
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DOI: 10.5958/j.2319-5886.3.2.065

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
Research Article
BACTERIOLOGICAL STUDY OF URINARY TRACT INFECTION IN ANTENATAL CARE PATIENTS
Srivastava Ritu1, *Singh Brij N2, Begum Rehana3, Yadav Ramesh2

1
Student, 3HOD & Professor, Department of Microbiology, Teerthankar Mahaveer Medical College, Moradabad
U.P., India
2
Tutor, Department of Microbiology, G.S.V.M. Medical College, Kanpur, India
*Corresponding author email: bn4786@gmail.com
ABSTRACT
Aims & Objective: To isolate and diagnose the Uropathogens and its antibiotic sensitivity pattern in anti-natal
care patient suffering from Urinary tract Infections. Material and Methods: 150 samples were collected by
consent pregnant women between the age group of 18 to 40 years. A midstream clean catch is adequate, provided
by all pregnant womens through given careful instructions. For enumeration of bacteria we perform standard
loop techniques method. The number of colonies counted or estimated, and this number used to calculate the
number of viable bacteria per ml of urine. The bacterial strains were identified by colonies character stick, gram
staining, morphological and biochemical character. The bacterial strains identification was done up to genus and
species level. The antibiotics sensitivity test of bacterial strains was done as per CLSI guidelines by Kirby-Baure
Disc Diffusion Methods. Results: The significant bactiurea was found in 50 patients among 150 patients used.
The most commonly isolated bacteria was Escherichia coli 23(40%) Klebsiellaaerogens 11 (22%)
Staphylococcus aureus 10 (20%) Pseudomonas aerugenosa 4(8%).The incidence of bacteriuria among in their
first pregnancy was 22.2%.The higher incidence of UTI in 2nd and 3rd trimester was found to have 31.4% & 40%.
These studies were showing high level of resistance to first line antibiotics such as Cotrimaxozole. Conclusion:
To minimizing the complication of the pregnant women should be educated about the physiology of pregnancy
clinical presentation includes asymptomatic bacteria, acute cystitis & pyelonephritis. Pregnant women should be
screened for asymptomatic bacteriuria by urine culture and treated with appropriate antibiotics. After the post
treatment pregnant women should be examine again to confirm post treatment urine sterility.
Keywords: Pregnancy, Antimicrobial, UTI, Antenatal, Uropathogens.
INTRODUCTION
Urinary Tract Infection is an infection caused by the
presence and growth of microorganism in the urinary
treat. Urinary Tract Infection is the second most
common type of infection that affects millions of
people numbers times during life time. It is perhaps
the single most common bacterial infection of
mankind.1,2 Urinary tract including the organs that
collect the store urine and release it from the body
which include kidneys, uterus, urinary bladders
&urethra both in community & hospital settings and
have been reported in all age groups in both

sexes.3UTI is the second most common cause of
bacteremia in hospitalized patients.4,5
Women tend to have UTI more often than man due to
the short and wider female urethra and its proximity
to anus. Bacteria may easily travel up to the urethra
and cause infection from the rectum2, 5 moreover, the
main factors predisposing married women to bacteria
are pregnancy and sexual intercourse.6The chances of
bacterial contamination of the female urethra
309
Srivastava et al.,
increasing due to sexual activity. UTIs may cause in

women because bacteria can be pushed into the
urethra after intercourse. Once the bacteria may enter
the urethra they travel upward, causing infection in
the urinary bladder and other parts of the urinary
tract.
The Pregnant women have increased risk for UTIs at
the beginning in week 6thof
gestations.
Approximately 90% pregnant women develop
urethral dilatation, increased bladder volume and
decrease bladder tone, along with decreased ureteral
tone contribution to increased urinary stasis and
ureter vesicle reflux.7 More than 70% of pregnant
women develop glycosuria, which promote the
bacterial growth in the urine. The increased level of
progesterone and estrogens in urine may lead to a
decreased the ability of invading the bacteria. This
decreased ability may also cause by contract ureteral
tone.8,9 These factors may all present to the
development of UTIs during pregnancy.
Significant bacteriuria may exist in asymptomatic
patients. In 1960s Kass noted the subsequent high
risk of developing pyelonephritis in patients with
asymptomatic bacteria. The significant bacteriuria has
been historically defined by finding more than
105cfu/ml of urine. 10,11In recent studies the pregnant
women with acute dysuria have showed the presence
of significant bacteriuria with lower colony
counts.12,13
The sign and symptoms of UTI may be varying to
age, sex and location of the infection. The urine may
develop an unpleasant odour. Women feel lower
abdominal discomfort and experience sensations like
there bladder is full. Women may have an STD
(sexual transmitted disease) and urethral infection
may also complain of a vaginal discharge. Dysuria,
frequency and urgency, other symptoms may include
rectal, testicular, penile or abdominal pain may be
complained by man.
MATERIAL AND METHODS
Study Area: This study was done in Department of
Microbiology at Teerthankar Mahaveer Medical
College, Moradabad (U.P., India) in 2011 to 2012
after the approval of Institutional Ethics committee. A
total of 150 urine sample were collected from
pregnant women between the age group of 18 to 40
years. The urine sample was obtained by informed
consent of the pregnant women.The Demographic
and clinical information of the subjects were obtained

by chart abstraction and recorded on prepare data
collection form.
Sample collection: Midstream clean catchurine is
requisite; the samples were collect by all patients by
given instructions. The instructions are as follows:
First the labia spread with one hand and then.
With the other hand, wipe the urethral meatus
downward toward the rectum with the help of
towelette, and then discard the towelette.
Then release initial portion of urine and collect the
second part of urine in void mouth sterile
containers approx 10-15 ml and then release the
excess urine in to the toilet.
The clean catch specimen should not be reduces or
eliminate the possibility of cross- contamination from
the urethra and vagina. More than two organisms in a
culture usually indicate a contaminated specimen.
Culture, Enumeration, Isolation & identification
of Uropathogens: The culture was done on
MacConkey Agar, Sheep Blood Agar and Mueller
Hinton Agar was used for Antibiotics sensitivity. For
enumeration of bacteria we perform standard loop
techniques method. An inoculating loop of standard
dimension is used to take up a small, approximately
fixed and known volume of mixed un-centrifuged
urine and spread it over a plate of agar culture
medium. The plate is incubated, the number of
colonies counted or estimated, and this number used
to calculate the number of viable bacteria per ml of
urine. Thus, if a 0.004 ml loop full of urine yields 400
colonies, the count per ml will be 105, (2501,00,000)
or just indicative of significant bacteriuria.
The bacterial strains were identified by Colonies
character stick, Gram Staining, Morphological and
Biochemical character. The bacterial strains
identification was done up to genus and species level.
The antibiotics sensitivity test of bacterial strains was
done as per CLSI14guidelines by Kirby-Baure Disc
Diffusion Methods14.
RESULTS
Table 1: Showed Incidence of UTI in relation of
age Distribution of Pregnant women
Age Group
No. of Tested No. of Positive
21-25
40
7 (17.5%)
26-30
45
15 (33.3%)
31-35
35
4 (11.4%)
36-40
30
24 (80.0%)
Total
150
50 (33.3%)
310
Srivastava et al.,
Table 2: Incidence of UTI by No. of Pregnancy.

Parity
No.of tested
No.of Positive
1st Pregnancy
45
10 (22.2%)
2nd Pregnancy
55
15 (27.3%)
3rd & Above
50
25(50.0%)
Table 3: Frequency of UTI in different gestational
periods
Age of Pregnancy
(In Months)
3
4
5
6
7
8
9
No.
Tested
10
25
15
30
30
25
15
of No.
of
Positive
0(0.0%)
2 (8.0%)
5(33.3%)
15 (50.0%)
13(43.3%)
10(40%)
5(33.3%)
Table 4: Various bacteria isolated from Urine samples

Isolates
No.of positive Samples
Eschericheia coli
23 (46%)
Klebsiella spp.
11 (22%)
Pseudomonas aeruginosa 4 (8%)
Staphylococcus aureus
10 (20%)
mixed Culture
2 (4%)
Total
50
Table 5: Antibiotics Pattern of E coli (n=23)
Name of Antibiotic
Sensitivity
Polymyxin B (300unit)
19(82.6%)
Nitrofurantoin (300g)
17 (73.9%)
Levofloxacin (5g)
15 (65.2%)
Chloroamphenicol (30g)
13 (56.5%)
Amikacin (30g)
12 (52.2%)
Cefoperazone (75g)
11 (47.8%)
Ampicillin (10g)
10 (43.5%)
Gentamicin (10g)
8 (34.8%)
Norfloxacin (10g)
7 (30.4%)
Co-Trimoxazole (25g
6 (26.1%)
Table 6: Antibiotics Pattern of Klebsiellaaerogens n=11
Name of Antibiotic
Ciprofloxacin(5g)
Ceftazidime(30g)
eCefotaxime(30g)
Chloroamphecol(30g)
Gentamicin(10g)
Levofloxacin(5g)
Ampicillin(10g)
Norfloxacin(10g)
Meropenum(10g)
Co-Trimoxazole(25g)
Sensitivity
10 (90.9%)
9 (81.8%)
9 (81.8%)
8 (72.7%)
7 (63.6%)
5 (45.5%)
3 (27.3%)
2 (18.2%)
2 (18.2%)
1 (9.1%)
Table 7: Showed Antibiotics Pattern of staphylococcus

aureus n=10
Name of Antibiotic
Nitrofurantoin (300g)
Levofloxacin (5g)
Ciprofloxacin (5g)
Gentamicin (10g)
Ceftazidime (30g)
Imipenam (10g)
Cefoperazone (75/10 g)
Tobramycin (10g)
Amikacin (10g)
Norfloxacin (10g)
Sensitivity
9 (90.0%)
9 (90.0%)
8 (80.0%)
8 (80.0%)
7 (70.0%)
7 (70.0%)
6 (60.0%)
5 (50.0%)
5 (50.0%)
3 (30.0%)
Table 1: Showed the higher percentage of UTIs was

obtained in the age groups of 36-40 (80.0%) years
followed by the age groups 26-30 (33.3%). The
highest number of bacterial isolates was found in
subject of 36-40 years followed by 26-30 years.
Comparatively, lower number of bacterial isolates
was obtained from age groups 21-25 and 31-35 years.
Table 2: Showed the highest percentage of UTIs
occurrence is 50% in there 3rd and above pregnancy
followed by 27.3% in 2nd pregnancy and the lowest
incidence of UTIs 22.2% in the 1st pregnancy.
Table 3: Showed the prevalence of UTIs by
gestational age (age of pregnancy) revealed that
women in the 6th and 7th months of their pregnancy
had the highest prevalence of 50.0% and 43.0%
respectively while women in the early month of their
pregnancy had no specific bacterial growth and
shows no sign of UTIs.
Table 4: Out of 50 isolates, Gram negative bacteria
were more frequently then gram positive bacteria.
These
include
Escherichia
coli
(46%),
Klebsiellaaerogens (22%), Pseudomonasaeruginosa
(8%). Gram positive bacteria account with
Staphylococcus aureus (20%). The rate of isolation of
Klebsiellaaerogens and Staphylococcus aureus was
higher in spcimen collected from pregnant women.
DISCUSSION
During the period from January 2011 to December
2012a total of 150 urine specimens were collected
from pregnant women and processed. Significant
bacteria colony forming units (cfu) 105 was found in
50 patient among 150 patients used. The most
commonly isolated bacteria was Escherichia coli 23
(40%) Klebsiellaaerogenes 11 (22%) Staphylococcus
311
Srivastava et al.,
aureus 10 (20%) Pseudomonas aerogenes 4 (8%) and

mix culture Klebesiella& Staphylococcus 2 (4%). In
pregnant study out of 50 positive urine samples, gram
negative bacteria were more prevalent 78% then gram
positive bacteria 22%. Which was similar from
previous study gram negative bacteria (61.9%) then
gram positive bacteria (38.1%), (Sabrina J.
2009).15Thesimilar finding have been also reported by
Bloomberg et. Al 2005as well as elsewhere Gebre
Selassie, 1998, Delzell&Lefevre, 2000; Nicolle,
2001; Schnarr&Smaill, 2008.16-20
The incidence of bacteria among women in their first
pregnancy is 22.2%. This figure is higher than the
prevalent role of 2-9% reported by Nicolle (2003)21
and lower than in a similar study on pregnant women
the number of pregnancy is one of the possible
factors affecting the incidence & prevalence rate of
UTIs among women.22 Present study also showed that
women in their pregnancy had the higher incidence of
UTI while women on their early month of the
pregnancy had no specific bacteria growth & shows
no signs of UTIs.
In the present study, women in their 2nd and 3rd
trimester were found to have the higher incidence of
UTI 31.4% & 40% respectively, but it was lower than
the previous study in 2nd trimester 41.4% and in 3rd
trimester 55% (Okonko et.al 2009)22
This study showed high levels of resistance to first
line antibiotic such ascotrimaxozole. These finding
correlated with finding from previous studies (Gupta
et. Al, Arrendondo Garcia, et al.23-25
CONCLUSION
It is obvious from this limited study that significant
bacteria in pregnancy are common and a serious
causes of maternal and perinatal morbidity and
mortality. To minimize the complication of
pregnancies regular antenatal care showed be taken.
The pregnant women should be educated about the
physiology of pregnancy clinical presentation
includes asymptomatic bacteria.
Acute cystitis and pyelonephritis pregnant women
should be checked for asymptomatic bacteria by urine
culture and treated with appropriate antibiotics. All
women should be confirming post treatment urine
sterility by reviewing the urine culture. When intake
an
antibiotics
the
pharmacokinetics
and
bioavailability of the individual drug in pregnancy
must be considered alone with the resistance profiles
of microorganism in the local antenatal population. It

is established a vital use of treatment with safety
profile, without teratogenic risks.
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2. Ebie MY, Kandaki-Olukemi YT, Ayanbadejo J,
Tanyigna KB. Urinary Tract Infections in
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15(1): 31-37
3. Hooton TM, Winter C, Tiu F, Stamm WE.
Randomized Comparative Trial And Cost
Analysis of 3 Days Antimicrobial Regmains for
Treatment of Acute Cystitis in Women.
JAMA.1995; 273: 41-51
4. Stamm WE. Scientific and Clinical challenges in
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5. Kolawole AS,Kolawole OM, Kandaki- Olukemi
YT, Durowade KA, Kolawole CF. Prevalence of
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7. Stamm WE, Hotton TM. Management of Urinary
Tract Infection in adults. Engl J. Med.
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8. Patterson TF, Andriole VT. Bacteriuria in
Pregnancy. Infect Dis Clin North American.1987;
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9. Lucas MJ, Cunningham FG. Urinary Infection in
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10. Griebling TL, LitwinMS,Saigal CS. Chapter 18:
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11. Malek RS, Elder JS. Xanthogranulomatus
Pyelonephritis: A critical analysis of 26 cases and
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Castro MG, Perez MD. Xanthogranulomatus
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Management of acute pyelonephritis in Adults.
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William A. Craig, Michael N. Dudley, George M.
Eliopoulos, David W. Hecht, Et al,Methods for
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Samuel Y, Maselle. Bacterial isolates and drug
susceptibility patterns of Urinary Tract Infection
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Hospital. Journal of Health Research. 2009;12.
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Urassa WK, Fataki M, et al. High Rate of Fatal
cases of Pediatric septicemia caused by Gram
negative Bacteria with extended spectrum betalactamase. Journal of Clinical Microbiology.
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Emmanuel O, Ejembi J, Udeze A, et al. Incidance
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DOI: 10.5958/j.2319-5886.3.2.066

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Research Article
ASSOCIATION OF OBESITY AND PHYSICAL ACTIVITY WITH LUNG CAPACITY IN ADULT

WOMEN
Eman E. Fayed1, Mohamed E. Khallaf 2, *Suneetha Epuru 3
1
Lecturer, Department of Physical Therapy, College of Applied Medical Sciences, University of Hail, Hail, Saudi
Arabia
2
Lecturer, Department of Physical Therapy for Neuromuscular disorders and its surgery, Faculty of Physical
Therapy, Cairo University, Egypt
3
Assistant Professor, Department of Clinical Nutrition, College of Applied Medical Sciences, University of Hail,
Hail, Saudi Arabia
*Corresponding author email: sunny11sai@gmail.com
ABSTRACT
Background: Obesity and poor respiratory function are associated with morbidity and mortality. Obesity affects
lung function, however the impact of all degrees of obesity on lung function need to be explored in different
populations and genders. Aims and Objectives: The authors investigated the relation of BMI, waist circumference,
physical activity with lung function in Hail City, Saudi Arabia. Materials and Methods: This analysis included
359 females aged 1844 years with no known preexisting serious illness and who had complete anthropometric
(height, weight and waist circumference) and forced vital capacity (FVC) using simple spirometry and chest
measurements. Physical activity was measured using International Physical Activity Questionnaire (IPAQ).
Results: Both FVC and predicted FVC along with chest expansion measurements were linearly and inversely
related across the entire range of body mass index (BMI) and waist circumference (WC) and positively associated
with physical activity in study subjects even after adjusting for age confirming our hypothesis. However, BMI and
physical activity explained the greatest proportion of variance for both FVC and chest expansion in regression
analysis as compared to WC. Conclusion: In the general adult female population, obesity may play a role in the
impairment of lung function even from BMI 35 kg/m2 while even moderate physical activity can positively affect
lung function.
Keywords: body mass index; chest expansion; forced vital capacity; physical activity; waist circumference
INTRODUCTION
Today obesity is the most significant contributor to
mortality and morbidity globally, by being able to
virtually affect almost any organ or tissue of the
human body.1 Estimations suggest that in 2008, a
whooping 146 billion adults globally were overweight
and 502 million adults among them were suffering
from clinical obesity thereby escalating enormously
health burden of the world.2 Kingdom of Saudi Arabia
(KSA) ratifies globesity trends after its recent

economic and nutrition transition. A review published
in 2011 suggests an astounding two thirds to three
quarters of Saudi adult population being either
overweight or obese.3 Hail City in KSA is reportedly
having highest prevalence of obesity in the entire
kingdom.4
314
Fayed et al.,
Available literature confirms the strong inverse

association between severe obesity and lung
complications including respiratory diseases such as
chronic obstructive pulmonary disease and asthma.5
Although less established than other non
communicable diseases, recent research focus on lung
capacity connotes multilayered association with the
morbidity and mortality.6 Studies identifying major
etiological factors responsible for diminished lung
capacity and its affect on long term health and quality
of life are relatively sparse except for association with
smoking. It is also being increasingly documented in
research that lung function can be positively
influenced by other lifestyle factors like habitual
physical activity, physical fitness and healthy body
weight.7
Obesity can influence lung capacity by creating
alterations in respiratory mechanics, decrease in
respiratory muscle strength and endurance, decrease in
pulmonary gas exchange, lower control of breathing,
and limitations in pulmonary function tests and
exercise capacity.8 Extra adipose tissue deposition in
the chest wall and abdominal cavity can result in a
decrease in lung volumes and an overload of
inspiratory muscles by decreasing diaphragm
displacement, decrease in lung and chest wall
compliance, and an increase in elastic recoil.9 These
changes are worsened by an increase in the BMI10 and
the associations vary in different subpopulations.11
However, impact of lesser degrees of obesity and/or
fat distribution on lung capacity is limitedly reported
making it difficult to extract any inferences out of
these studies. The importance of understanding these
phenomena is slowly gaining attention of researchers
around the world.
Body mass index (BMI) is the most commonly used
measure of obesity in most epidemiological studies.
However, BMI is not a dependable index for
understanding distribution of fat in the body and/or for
differentiating between muscle mass and fat mass both
of which can influence pulmonary function.12 There
are few studies which evaluated the relation of central
adiposity indices like waist circumference (WC) and
waist to hip ratio (WHR) with pulmonary function but
reported
conflictory
results
for
gender
stratification.13,14 However its difficult to infer from
these studies that whether predicted results are
applicable to all degrees of obesity and to both genders
in all racial populations. Also, another important
confounding variable physical activity influencing

lung capacity has not been studied to a large extent in
most of these studies.
In view of the foregoing discussion, we conducted a
study to examine the relation between pulmonary
function and BMI, waist circumference and physical
activity in a given sample of female population. Based
on review of literature, we hypothesized that
pulmonary function may be positively associated with
physical activity and negatively associated with BMI
and WC in females.
The present cross sectional study was carried out at the
University of Hail (UOH) female campus with a target
population of students and employees with a minimum
age of 18 and who were free of any physical
deformity. Patients with history of acute or chronic
pulmonary disease, neuromuscular disorders, heart
failure, severe or poorly controlled hypertension,
chronic kidney disease, diabetes mellitus and systemic
corticosteroid use were excluded from the study. A
total of 359 females fulfilling inclusive criteria
participated in the present study after signing informed
consent form. We measured height, weight, BMI, WC,
physical activity, chest expansion and forced vital
capacity of the subjects to examine the study
objectives. University of Hail research committee
approved the study.
Anthropometric variables considered for the study
included body weight, height, BMI and WC. Body
weight was measured without shoes and with minimal
clothing to the nearest 100 g using a calibrated scale
(GIMA Pegaso Electronic Body Scale-Italy). Height
was measured to the nearest cm while the subject was
in the full standing position without shoes using a
calibrated stadiometer attached to the body weight
scale. WC was recently reported to be the best simple
measure of fat distribution, since it is least affected by
sex, race, and overall adiposity.15 WC was measured
horizontally using a non stretchable measuring tape at
the level of the umbilicus and at the end of gentle
expiration. When measuring WC, the tape was snug,
but did not compress the skin. BMI was calculated as a
ratio of weight in kg by height squared in meters. We
used WHO adults cut-off points for BMI.16
Chest expansion (CE) was measured by the tape
measurement at the level of the 4th intercostals space.
Subjects were asked to inspire maximally from her
315
Fayed et al.,
nose with closed mouth to fill her lung by air. This is

done a minimum of twice and the greater excursion
recorded. The participants were asked please take a
deep breath in as far as you can, hold, and then breathe
out as far as you can.
Physical activity is bodily movement produced by the
skeletal muscles that results in energy expenditure
above the resting value.17 Because of its complexity,
physical activity is difficult to accurately assess under
free-living conditions. However, physical activity
intensity, duration, and frequency can be measured
using either subjective or objective methods.18 The
International Physical Activity Questionnaire
(IPAQ) is one such tool used to obtain internationally
comparable data on health-related physical activity.
The IPAQ was previously shown to have a high
reliability and an acceptable validity.19 The
questionnaire checked for the frequency and duration
of physical activity level (PAL) including vigorous,
moderate physical exercise, walking and sitting period
for the preceding week. PAL was classified into three
levels: High: PAL: 3 days/week heavy activities that
make one breath much harder than normal or any
cumulative PAL; seven days/week of any combination
of walking and moderate or vigorous exercise.
Moderate: PAL: 3 days/week and 20 min/day, of
moderate exercise or walking: 5 days/week and 30
min/day; Low, when adequate PALs were not
achieved to be in categories of moderate or high.
For measuring forced vital capacity (FVC), simple
spirometer (12, 1710 Base line Spirometer-China) was
used. The participants were seated comfortably.
Before measurement the purpose of the test was
explained to the participants by well trained students.
The participants had some practice attempts before the
readings were taken to be familiar with the measuring
spirometer. The participants were encouraged to keep
blowing out so that maximal exhalation can be
achieved. The total number of attempts was limited
(practice and for recording) to eight or less at each
session. A clean, disposable, one-way mouthpiece was
attached to the spirometer. For each participant a fresh
mouth piece was used. The participants were asked to
breathe in as deeply as possible and hold their breath
just long enough to seal their lips. The participants
were asked to blow the breath out, forcibly, as hard
and as fast as possible, until there is nothing left to
expel. The measurement of the FVC was recorded
from the spirometer as the maximum reading was

reached. The procedure was repeated for three times to
take an accurate measurement.
Statistical analysis:
The data set was cleaned and edited for
inconsistencies. Missing data were not statistically
computed. The Social Package for Social Sciences
(SPSS) version 16.0 (SPSS Inc, Chicago, IL, USA)
was used to analyze data. Descriptive statistics such as
means and standard deviations were calculated for the
continuous variables and frequencies for qualitative
data. Analysis of variance (ANOVA), student's t-test
and linear regression analysis were used to examine
differentials in variables. Results were expressed as
mean SD. All reported P values were 2-sided and
differences were considered statistically significant at
P<0.05.
RESULTS
Table 1: Baseline Characteristics of subjects (N=359)
Age
(yrs)
BMI
(kg/m2)
WC
(cm)
Physical
Activity
Level
18-24
25 - 44
Normal (18.5-24.99)
Overweight (25-29.99)
Obesity I (30-34.99)
Obesity 2 (35 - 39.99)
Morbid Obesity (40 )
80 cm
80.1 cm
Low
269
90
149
45
107
44
14
207
152
74.9
25.1
41.5
12.5
29.8
12.3
3.9
57.7
42.3
244
68.0
Moderate
115
32.0
Table 1 shows the baseline characteristics of the study

population of 359 female subjects. Approximately 75
percent of the study population was in the age group of
18-24 yrs (median 24 yrs). There were no underweight
subjects in the study sample. Only around 42 percent
of subjects were having normal BMI and
approximately 58 percent of the study population was
having waist circumference 80 cm. Majority of the
study population reported Low PAL (68 %) during
preceding week while high PAL activities were
reported in none of the participants.
316
Fayed et al.,
Table 2 Mean age, anthropometric and Spirometry test variables of the Study Subjects
MeanSD
95% CI for mean
Minimum
Maximum
Lower bound
Upper bound
Age (yrs)
23.605.61
23.02
24.19
18
44
Height (cm)
159.165.44
158.32
160.01
145
170
Weight (kg)
71.9716.78
69.36
74.58
45
133
2
BMI (kg/m )
28.296.38
27.63
28.95
19.14
51.95
WC(cm)
80.4313.57
79.02
81.84
57
127
CE (cm)
2.630.83
2.55
2.72
1
5
FVC (L)
2.050.59
1.99
2.11
0.5
3.8
% FVC Predicted
61.381.76
59.55
63.21
14.97
113.77
Table 2 presents the mean age, anthropometric and
subjects ranged between 19.14 and 51.95 kg/m2 with a
spirometry test variables of study subjects. The mean
mean of 28.296.38 kg/m2. WC, CE, FVC and % FVC
age was 23.605.61 years and the mean body height
predicted values ranged from 57 to 127 cm; 1 to 5 cm;
and weight of study subjects was 158.175.44 cm and
0.5 to 3.8 L and 14.97 to 113.77 respectively.
71.5216.78 kg respectively. The BMI of the study
Table 3 ANOVA for age, WC, CE, FVC and % FVC predicted with stratified BMI groups
MeanSD
BMI Groups#
Frequency
WC
Age
CE
FVC
Normal (18.5-24.99)
149
21.863.22 71.288.22 3.060.83 2.170.55
22.643.41 78.0212.89 2.720.63 2.160.49
Overweight (25-29.99)
45
Obesity I (30-34.99)
107
25.116.51 85.8710.50 2.320.67 1.990.62
Obesity II (35 39.99)
44
25.307.81 93.6510.92 2.090.60 1.810.59
Obesity III (40 and
14
28.368.43 102.5010.33 1.890.56 1.560.52
above)
BMI vs. Variables
10.345**
75.794**
27.666**
6.967**
F Value
**p significant at 0.0001
# WHO adults cut-off points for BMI were used to create BMI groups 16.
Table 3 shows the ANOVA test for age, WC, CE,
FVC and % FVC with stratified BMI groups. All the
tested variables were significantly differing in their
mean values for BMI groups. Post-hoc Tukey HSD
analysis for stratified BMI groups (results not
presented) showed that: a) age for normal and
overweight groups was significantly lower than all the
obesity groups; b) WC measurements and chest
expansion varied significantly for normal BMI groups
% FVC
65.0216.56
64.8014.78
59.8018.54
54.1117.85
46.6215.48
6.967**
as compared with overweight and obesity groups; c)

FVC and % FVC predicted for normal and overweight
groups were significantly higher than obesity II and III
groups.
T test for WC groups also indicated that all the tested
variables varied significantly (Table 4). Both chest
expansion and FVC were significantly higher in WC
group with 79 cm which is considered normal cutoff
for Asian populations 20.
Table 4 T-Test for age, WC, CE, FVC and % FVC predicted with stratified WC groups
MeanSD
WC Groups
Frequency
BMI
Age
CE
FVC
79 cm
207
22.113.50 24.694.45 2.890.83 2.140.58
80 cm
152
25.647.12 33.195.26 2.290.69 1.930.59
WC vs. Variables
-6.190**
-16.534**
7.228**
3.438**
T Value
**p significant at 0.0001; *p significant at 0.001
% FVC
64.0917.25
57.6917.59
3.438**
317
Fayed et al.,
Table 5 T-Test for age, BMI, WC, CE, FVC and % FVC predicted with stratified PAL groups
PAL
Groups
MeanSD
Frequency
Age
23.535.60
23.765.65
-0.355
Low PAL
Moderate PAL
BMI
28.026.39
28.846.36
-1.128
244
115
PAL vs. Variables
T Value
**p significant at 0.0001
For PAL groups however significant mean differences
were found only for variables CE, FVC and % FVC
predicted (Table 5). In the present study no subjects
reported having high PAL. Results suggest that
WC
CE
80.2013.72 2.500.82
80.9113.29 2.910.77
-0.461
-4.409**
FVC
1.940.54
2.270.62
-5.082**
% FVC
58.2416.29
68.0518.63
-5.082**
probably BMI and WC do not necessarily get

influenced with the current activity level of the
subjects as contrasted with lung capacity indices
studied
Table 6 Regression Coefficients for Adiposity Markers and PAL entered into separate models (each model
adjusted for age) predicting % FVC predicted and CE.
B
PAL
BMI
WC
10.205
-4.493
-0.410
% FVC predicted
SE
p
1.871
1.016
2.348
0.267
-0.291
-0.011
0.000
0.000
0.861
0.151
Table 6 summarizes the regression coefficients for

adiposity markers and PAL that were entered
individually into % FEV predicted and CE linear
regression models adjusted for age. Overall, there were
negative associations of each adiposity markers with
Chest Expansion
SE
B
0.474
0.078
0.263
0.000
-0.355
-0.111
0.042
0.098
-0.486
-0.066
0.000
0.258
R2
0.336
% FEV predicted and CE however the associations

were not statistically significant for WC. PAL was
significantly associated positively with both % FEV
predicted and CE.
DISCUSSION
Available normative lung function tests data for
Kingdom of Saudi Arabia (KSA) population is
relatively scarce and is mostly limited to subjects from
coastal areas.21 Lung function can vary interindividually depending on gender, age, height,
ethnicity and geographic factors like altitude, dry and
humid climates and hence is important to research
lung function test data and factors influencing it from
various regions. The present study is conducted in
UOH from Hail City, Saudi Arabia. Hail city is in
northern part of KSA at an elevation of approximately
1000 meters with typical arid desert climate. Humidity
is very low, with average rainfall of less than 125
millimeters per year. To the best of our knowledge
there are no studies reporting on lung capacity test
values from northern part of KSA. 22
In the current study, we assessed the correlation of
BMI, waist circumference and physical activity with
lung capacity in 359 women (age range from 18 to 44
years) who were nonsmokers and had no previous
history of pulmonary diseases or serious illnesses.

Two well-known simple methods estimating lung
capacity have been employed; 1) the measure of chest
expansion as an index of lung capacity and 2) FVC
spirometer readings as the accurate measure of lung
capacity.
Our mean FVC readings were lower as compared to
other studies which reported for female subjects from
Saudi Arabia 21, 22 and other parts of the world.23 - 25 To
our knowledge we couldnt find any chest expansion
reference values from KSA emphasizing for the need
for more such studies from the region. We found
inverse associations for BMI and WC with lung
capacity while physical activity was positively
associated even after adjusting for age confirming our
hypothesis. However, BMI and physical activity
explained the greatest proportion of variance for both
FVC and chest expansion in regression analysis as
compared to WC.
318
Fayed et al.,
Adequate expansion of lungs and chest is very

important for sufficient ventilation. Any interference
with free airflow in the respiratory system can result in
relative insufficiency in ventilation or fatigued
respiratory muscles. Recent literature is increasingly
focusing its interest in conceptualizing disease
etiology within a life course framework.26 Saudi
Arabia is reportedly having very high prevalence rates
for obesity 3 and low physical activity culture among
its citizens27 both of which can influence lung
capacity. Poor life style factors like obesity can cause
restrictive conditions of the chest wall and can result in
decreases in lung volumes such as the FVC or the
forced expiratory volume in one second (FEV1)
without impeding airflow or the ratio between FVC
and FEV1.28 In contrast regular exercise can promote
normal development of lung function and can even
limit its decline upon ageing.29 It is therefore
interesting to study how these opposing lifestyle
factors contribute for lung function.
In the present study no subjects reported having
vigorous physical activity. However our results
indicated that even moderate activity can have positive
effect on both spirometry and chest expansion tests.
Previous studies observed physical activity to be
positively correlated to changes in FVC over a long
period.29, 30 The possible beneficial role of physical
activity could be in counteracting or slowing down the
process of loss of lung elastic recoil and/or stiffening
tendency in the chest wall, both of which have been
associated with ageing process.31 Physical activity
possibly can also enhance inspiratory muscle
endurance.32 Given that our present study results
support beneficial effects of even moderate activity
and other studies strongly suggesting that higher
physical activity slower decline in pulmonary function
29
, there is a definite need for implementing physical
activity friendly environments across KSA.
We also studied the relation of obesity as defined by
its indices BMI and WC with lung function. There
were no underweight subjects and we couldnt analyze
its relation with lung function. However, comparisons
between normal, overweight and obese I, II and III
categories have definitely supported other studies
which reported obesity having inverse association with
lung function.33-35 One previous study 34 which studied
progressive impact of obesity on lung function by
combining normal and overweight BMI groups into
one group and comparing it with obese class I, II, III
Fayed et al.,
(BMI 40 to 44.9 kg/m2; BMI 45 to 50.9 kg/m2 and

BMI 51 kg/m2), concluded that changes in lung
function were better demonstrated when BMI is
45 kg/m and even more evident when BMI is
> 50.9 kg/m. In the present study we compared
normal BMI group with overweight and obese I, II and
III (BMI 40 kg/m2). We couldnt further subdivide
obese III into further classifications because of less
number of subjects in that category (we had only 14
subjects). However our study in contrast to the
mentioned study found that FVC and % FVC
predicted for normal and overweight groups were
significantly better even from BMI 35 kg/m.
However our study samples were only females while
the mentioned study sample included both males and
females and both mean absolute and relative values of
FVC were higher as compared to the present study.
Our study, however, could not establish very strong
negative relationship between WC and lung capacity.
Two epidemiological studies including both genders
suggested strong negative associations for WC and
waist hip ratio even after adjusting for potential
confounding factors.36, 37 However one recent metaanalysis has concluded that the effect of WC on
pulmonary function in men as larger than that in
women owing to differences in body shape (apple vs
pear-shaped).38 The present study sample included
much younger women (18 to 44 yrs) and majorities
were below 25 yrs. This probably could be a reason for
not finding stronger relation for WC with lung
capacity.
The present study had several limitations. Because of
the non availability of digital spirometer, we only
recorded the forced vital capacity using simple
spirometer. Another limitation included usage of
questionnaire method for collecting data on physical
activity, and sedentary behavior. Including both
genders in sample frame could have generated more
meaningful understanding of the results. An important
limitation of this study is probably clinical application
value of these results rather being confined to limited
populations and less generalizable to other populations
or ethnic groups. However the data definitely adds to
global research which tries to understand regional
influences on pulmonary function.
CONCLUSIONS
Obesity and physical activity are important
determinants of lung function, and it is of greater
319
importance to keep oneself physically active through

their life for more than one health reason. It is also
important for future research venturing to finding out
determinants of pulmonary function to consider
inclusion of physical activity as a co-variable along
with various obesity indices which can be potential
confounding factors.
10.
11.
ACKNOWLEDGEMENT
The authors are deeply grateful for Dr. Ibraheem
Ashankyty Dean, Collage of Applied Medical
Sciences, University of Hail, KSA for his valuable
support and continued encouragement.
12.
13.
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DOI: 10.5958/j.2319-5886.3.2.067

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
st
Copyright @2014
ISSN: 2319-5886
Accepted: 22nd Feb 2014
Research Article
STUDY OF SERUM MALONDIALDEHYDE, NITRIC OXIDE, VITAMIN E LEVELS IN PATIENTS

WITH RHEUMATOID ARTHRITIS
*Jambale Triveni A1, Halyal SS2, Jayaprakash Murthy DS3
1
Assistant Professor, Department Of Biochemistry, ESIC MC, Gulbarga, India

Department of Biochemistry, SIMS, Tumkur, Karnataka, India
3
Department of Biochemistry, OMC, Bangalore, Karnataka, India
2
*Corresponding author email: trivenijambale@gmail.com

ABSTACT
Background: Rheumatoid arthritis (RA) is a chronic progressive autoimmune disorder characterized by
symmetric erosive synovitis and sometimes shows multisystem involvement. The long-term outcome of the
disease is characterized by significant morbidity and increased mortality. Elevated free radical generations in
inflamed joints and impaired antioxidant system have been implicated in RA. Nitric oxide (NO) can also induce
tissue damage, especially after conversion into peroxynitrite radical (ONOO). Aims: To estimate the serum
levels of MDA, Nitric Oxide (NO) and Vitamin E in patients with Rheumatoid Arthritis. Materials and
Methods: The study includes 50 RA patients who were fulfilling the American Rheumatism Association 1987
revised criteria for classification of RA and 50 age and sex matched healthy subjects without any major illness
were considered as controls. MDA, NO and Vitamin E were estimated in serum. Results: The estimated mean
levels (mean SD) of serum MDA, NO, Vitamin E, in control group were 3.55 0.30, 36.23 7.03, 14.61
1.74, respectively and in patients with RA they were 5.39 0.79, 78.81 8.56, 10.56 1.72, respectively. The
statistical analysis by unpaired t-test shows that the levels of serum MDA and NO significantly increased (p<
0.001) and the vitamin E levels were significantly decreased (p < 0.001) in RA patients when compared to healthy
controls. Conclusion: The serum values of MDA, NO and Vitamin E all together provided fairly useful index of
oxidative stress in RA patients. The results of current study support the concept of oxidative stress leading to
tissue damage.
Keywords: Malondialdehyde, Nitric oxide, Vitamin E, Rheumatoid arthritis
INTRODUCTION
Rheumatoid arthritis is a common inflammatory
arthritis. It is one of the preventable disability
conditions. The clinical features are symmetrical
arthritis, both small and large joints are affected and
associated with extra-articular manifestations.1 It
affects approximately 1 to 2% of general population
world wide2 and in India its incidence is 0.75%.3
Women are affected three times more often than men.
The onset is most frequent during the fourth and fifth

decade of life. 4
It is believed that RA is an auto-immune disease,
triggered by exposure of a genetically susceptible
person to an arthritogenic factor. It involves the
activation of CD4 + helper cells mainly. Then the
local release of inflammatory mediators occurs which
ultimately damages the joint. 5 The cytokines also
322
Triveni et al.,
Int J med Res Health Sci. 2014;3(2):322-325
stimulates endothelial cells, macrophages and

polymorphonuclear leukocytes to produce NO.6
Although characteristic feature is persistent
inflammation, the elevated generation of free radicals
in inflamed joints and impaired antioxidant systems
has been implicated in RA.7 With this background
this study was designed to estimate the serum MDA,
NO and vitamin E in RA patients and apparently
healthy
controls from Davangere district of
Karnataka.
Fifty Rheumatoid arthritis patients who are fulfilling
the American Rheumatism Association 1987 revised
criteria for classification of RA20, age from 20 to 70
years and both sex and age, controls (N=50) were
included in the present study from Bapuji Hospital
and Chigateri General Hospital, Davangere (Both
these hospitals are attached to teaching institute,
J.J.M Medical College, Davangere) and also from
general population. The study was approved by
Ethical and Research Committee of J.J.M. Medical
College, Davangere to use human subjects in the
research study.
Exclusion criteria: Patient with Osteoarthritis,
Tubercular arthritis, Arthritis other than RA fitting
into any syndromes and any other chronic systemic
disorders like cardiovascular disorders, diabetes
mellitus, liver diseases and kidney diseases are
excluded from the study.
Venous blood from all the subjects was collected
aseptically from anticubital vein; serum was
separated by centrifuging at 3,000 RPM for 10
minutes and kept at 40C until analysis was carried
out.
Estimation of Serum Malondialdehyde (MDA):
Thiobarbituric acid method8
Auto-oxidation of unsaturated fatty acids lead to the
formation of semistable peroxides which then
undergo a series of reactions to form short chain
aldehydes like malondialdehyde. One molecule of
MDA reacts with 2 molecules of Thiobarbituric acid
(TBA) with the elimination of 2 molecules of water
to yield pink crystalline pigment with an absorption
maximum at 530 nm. Results are expressed as
mol/L
Estimation of Serum Nitric Oxide (NO): Kinetic
Cadmium-Reduction method 9
Nitrate, the stable product of nitric oxide is reduced to

nitrite by Cadmium reduction method after
deprotinization with Somogyi reagent. The nitrite
produced is determined by diazotization of
sulphanilamide and coupling to naphthylene ethylene
diamine. The color complex precipitated is measured
at 540nm wavelength using colorimeter. Results are
expressed as mol/L
Estimation of Serum Vitamin E (Tocopherols):
Baker and Frank method10
Serum tocopherol is measured by their reduction
property. They reduce ferric ions to ferrous ions
which are then reacts with , -dipyridyl to form a
red colored complex. First tocopherols and carotenes
are extracted by xylene and the reading is taken at
460 nm. A correction for the carotenes is made by
adding ferric chloride and then again reading is taken
at 520 nm. Results are expressed as mg/L
Statistic analysis: Results are expressed as mean
SD. Unpairedt test was used for intergroup
comparison and pairedt test for intra group
comparison. p < 0.05 was considered as statistically
significant.
RESULTS
Table1: Age and sex-wise distribution of controls
and RA patients
Controls
Cases
Mean SD Mean SD
Age (yrs)
41.9 13.6 46.2 13.3
Gender
Male
18
14
Female 32
36
Table 2: Serum levels of MDA, NO, Vitamin E in
patients with RA and healthy controls.
Controls
Cases
Mean
difference
t-value*
p-level
MDA
(mol/L)
3.55 0.30
5.39 0.79
1.84
15.44
< 0.001, HS
36.23 7.03
78.81 8.56
42.58
Vit.E
(mg/L)
14.61 1.74
10.56 1.72
4.05
27.19
< 0.001, HS
11.68
< 0.001, HS
NO (mol/L)
*Unpaired t-test
p<0.001=HS (Highly
significant) p>0.05=NS (Not significant)
323
Triveni et al.,
DISCUSSION
In the present study, the serum level of MDA is
highly statistically significantly increased (p < 0.001)
in patients with RA when compared to controls. In
RA patients activated macrophages and neutrophils
release oxidants in high concentrations that lead to
oxidative stress. This will cause damage to lipids,
proteins, carbohydrates and DNA. The unsaturated
fatty acids of cell membranes undergo lipid
peroxidation and MDA is released which acts as a
oxidative stmarker.11 MDA reacts with lysine
residues in protein to produce immunogenic
molecules, which can exacerbate inflammation. 12
Increased serum MDA concentration in RA suggests
the role of free radicals in pathogenesis of
inflammatory arthropathy and supports the need for
studies assessing the therapeutic role of free radical
scavengers in RA.2
NO is a pleiotropic mediator of inflammation which
was discovered as factor released from endothelial
cells that caused vasodilatation by relaxing vascular
smooth muscle and was therefore called
endotheliumderived relaxing factor.14 NO is a short
lived radical and lipid and water soluble gas which as
a potent inflammatory mediator. Because of it reacts
with oxygen, superoxide and iron-containing
compounds strongly.15 NO is generated by the nitric
oxide synthasase (NOS) enzyme from molecular
oxygen and the terminal guanidine nitrogen of the
amino acid l-arginine, yielding l-citrulline as a coproduct. In our study, the serum NO level is highly
statistically significantly increased (p<0.001) in RA
patients as compared to healthy controls.There may
be two possible causes for the increased serum levels
of NO in RA. One is enhanced synovial
inflammation, which results in increased levels of NO
in synovial fluid which ultimately enters systemic
circulation. Another possible cause may be
production of NO by systemic vasculature and other
cells.6
Nitric oxide can induce tissue damage, especially
after conversion into peroxynitrite radical (ONOO.).25
Peroxynitrite can be directly cytotoxic and it can also
decompose to give range of products, including
hydroxyl radicals ( OH ) and nitronium ion (NO2+).
NO produced within the inflamed joint may
contribute to the peri-articular bone loss in RA.16
For cell membrane lipids and lipoprotein vitamin E

serves as a chain breaking free radical trapping
antioxidant. It reacts with the lipid peroxide radical
before the establishment of chains lipid peroxidation
reactions occurs. In this process vitamin E produces
tocopheroxyl free radical which is unreactive and
results in forms nonradical compound synthesis.17 In
our study the levels of serum vitamin E is highly
statistically significantly reduced (p<0.001) in
patients with RA when compared to controls. The
decrease in vitamin E level may be the for preventing
oxidative stress , turnover of vitamin E can occur
more in RA.18 An epidemiological study suggested
that low alpha-tocopherol status is a risk factor for
RA independently of rheumatoid factor status.19
CONCLUSION
The enhanced oxidation plays a significant role in the
tissue damage and inflammation perpetuating process
in rheumatoid synovium. The oxygen free radicals
lead to lipid peroxidation and bone loss. The results
of current study support the concept of oxidative
stress leading to tissue damage. As a consequence of
the present understanding of the etiopathogenesis of
RA, exogenous antioxidants i.e., Vitamins and other
nutrients, appear to be potential agents for therapeutic
management.
ACKNOWLEDGMENTS
I sincere thank to everyone who have helped me
during the course of my research study including all
staffs, post graduate students and technical persons of
Biochemistry and Orthopedics dept, JJMMC,
Davangere. Finally, my thanks to all patients who
was part of the study for their kind cooperation.
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edn. Vol.2. New York: McGraw Hill Medicine;
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5. Andrew E, Rosenberg MD. Bones, Joints and
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Increased concentrations of nitrite in synovial
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7. Ozkan Y, Sepici A, Keskin E. Oxidative status in
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11. Hagfors L, Leanderson P, Skoldstam L,
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rheumatoid arthritis. Nutrition J 2003; 3:1-11
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Kumbar KM, Ankush RD. Oxidative stress and
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13. Jaswal S, Mehta HC, Sood AK, Kaur J.
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Abbas, Fausto, ed. Robbins and Cotran
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DOI: 10.5958/j.2319-5886.3.2.068

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Coden: IJMRHS
rd
Revised: 22nd Feb 2014
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ISSN: 2319-5886
Research Article
PROSPECTIVE ASSESSMENT OF NSAIDs INDUCED ADRs IN ORTHOPAEDIC IN-PATIENTS

*
Padmanabha T S1, Bhaskara K2, Nandini T3
1*
Department Of Pharmacology, Bidar Institute of Medical Science, Bidar, Karnataka, India.

Department Of Orthopaedics, Bidar Institute of Medical Science, Bidar, Karnataka, India.
3
Department Of Pharmacology, Sri Siddhartha Medical College, Tumkur, Karnataka, India.
2
Corresponding author email: padmanabhatsp@gmail.com
ABSTRACT
Background and Objectives: nonsteroidal anti-inflammatory drugs (NSAIDs) are one among the most widely
used medications to treat pain and inflammation condition. But inadvertent use of NSAIDs have resulted in
gastric upset and even death. Hence to minimize such consequences and to identify the incidence of the Adverse
drug reaction (ADR)s due to NSAIDs in orthopaedic in-patients to promote rational prescribing. Materials and
Methods: A prospective study was done in one hundred orthopaedic in-patients of a tertiary care hospital for 3
months from June-Augest 2012. The ADRs pattern were noted with respect to age, gender and drugs involved .
The causality of ADRs were assessed by Naranjos Algorithm. Results: Among one hundred inpatients 16%
developed ADR due to NSAIDs and 1.92% due to Antimicrobial agents (AMAs). The ADRs were more in males
(11%) than females (5%). Most prescribed NSAID was Diclofenac (76 %), and least was nimesulide (2%). Others
were Paracetamol (16%), Ibuprofen (3%) and Etoricoxib (3%) . Out of 16 ADRs Tablet (Tab) Diclofenac
accounted for maximum number {87.5%, (n=14)} of ADRs, followed by Tab. Paracetamol {12.5 % (n=2)}.
Conclusion: ADR incidence rate in orthopaedic in-patient due to NSAIDs was 16%. Educating, establishment
and encouragement of Pharmacovigilance system among medical and non-health professionals including medical
undergraduates improve ADRs identification and to identify the drugs causing it, therefore prolonged
hospitalization, treatment cost, morbidity and mortalities can be minimized. Hence, further ADRs due to
particular drugs can be reduced in other patients with rational prescription.
Keywords: Adverse drug reactions, NSAIDs, Pharmacovigilance, Naranjos Algorithm, rational prescription.
INTRODUCTION:
In the year 1972 WHO defined Adverse drug reaction
(ADR) as a response which is noxious and
unintended, and which occurs at doses normally used
in humans for the prophylaxis, diagnosis, or therapy
of disease, or for the modification of physiological
function.1
ADRs are usually associated with significant
morbidity, permanent disability, mortality and huge
financial burden on the patients to treat the same due
to prolonged hospitalization.2
NSAIDs are one of the most widely used medications

to treat pain and inflammation in patients with
various musculoskeletal conditions.
The benefits and adverse effects of NSAIDs are due
to the inhibition of either COX-1 or COX-2 enzymes.
NSAIDs inhibit both COX-1 and COX-2, but the
extent of inhibition differs between NSAIDs.3
In general NSAIDs acts by inhibiting both
cyclooxygenase-1 (COX-1) and COX-2 involved in
prostaglandin synthesis to exert analgesic, anti326
Padmanabha et al.,
inflammatory and antipyretic effects. Conventional or

traditional COX-1 maintains normal gastric mucosa
and helps in homeostasis. Inhibition of COX-1
produces undesirable gastric side effects. Inducible
COX-2 mediates inflammatory process and selective
COX-2 inhibition reduce gastric adverse reactions.
Thus, the most classic NSAIDs
block both
isoforms, but the so-called coxibs preferentially
inhibits COX-2 and hence better tolerability due to
reduction in gastrointestinal side effects.4, 5
Various studies have shown that the Gastrointestinal
and cutaneous ADRs including hepatic and renal
toxicity are the well known ADRs associated with
NSAIDs therapy.6, 7, 8
However, recent studies have shown an unequivocal
increase in risk of cardiovascular thrombotic event
even with selective COX-2 inhibitors.
The thalidomide catastrophe and serious adverse drug
reactions to high estrogen oral contraceptives around
1960s probably the main reason which led to the
establishment of a spontaneous reporting system.9, 10
Monitoring and evaluation of ADR reports have
become a more important component in hospitals11.
And ADR related information may be useful for
identifying and minimizing the preventable causes of
ADR which intern enhances the ability and
confidence of prescribers to manage ADRs more
effectively.12, 13
Hence, with the above background present study was
undertaken among orthopaedic inpatients to
i) Determine the frequency of ADRs related to
NSAIDs and Antimicrobial agents (AMAs)
ii) Find out the drug causing it.
iii) Report the most common clinical feature
associated with these ADRs.
A prospective study was carried out among one
hundred orthopaedic inpatients of District Hospital,
Bidar a 350 bedded tertiary care teaching hospital.
The study was conducted for 3 months from June
2012 to August 2012 after obtaining institutional
ethical clearance. All the patients of either sex, of age
group 18 years and above who is being treated with
NSAIDs therapy namely diclofenac (50mg),
paracetamol (500mg), ibuprofen (200mg), nimusulide
(100mg),
etoricoxib
(90mg)
for
various
musculoskeletal conditions for a minimum of 2 days
and patient on AMAs were included in the study .
And patients who are having hepatic problems, renal

problems, cardiovascular disease, Gastrointestinal
problems, patients not willing to give consent;
pregnant women and lactating mothers were
excluded.
Demographic details, diagnosis, detailed history of
ADR and concomitant medication were recorded in
the Proforma. Causality assessment for evaluating
adverse drug reaction was done by one of the
frequently used method, i.e., Naranjos algorithm,
which consists of objective type of questions with
three types of answer i.e yes/no/dont know. Scores
were drawn and total score: > 9; in-between 5 to 8
and 1 to 4 were classified as definite, probable and
possible respectively. Follow-up of the patients
were not done. Data was collected and analyzed by
using the Chi-square with two-tailed test. A P value
of <0.05 was considered as significant. Numerical
values were expressed in percentages.
RESULTS
Among 100 inpatients, 16 patients suffered from
ADRs. Male to female ratio was 2.2:1 (table-1). Out
of 16 patients who suffered ADRs 14% were males
and 2% were females (table-1). With respect to age
groups, between 18 and 65 years, 11% of ADRs
were noted and 5% of ADRs were above 65 years
(table-1) and was found to be statistically significant
(p <0.05). In our study gender had no statistical
significance (p >0.05) with respect to the occurrence
of ADRs caused by NSAIDs prescribed.
Out of 16 ADRs, 15 (93.75%) were due to diclofenac,
and one (6.25%) was due to paracetamol. No ADR
was found due to ibuprofen, nimesulide and
etoricoxib, that were prescribed less frequently
compared to diclofenac and paracetamol. Along with
NSAIDs gastroprotective agents were prescribed in
76 patients, ranitidine and pantoprazole were
prescribed in 74 and 2 patients respectively (table-2).
Antibiotics were prescribed in 52 patients and one
had developed skin rashes due to ceftriaxone (table2). Causality assessment by Naranjos algorithm
revealed that out of 16 ADRs, 9 were possible, 5 were
probable and 2 were doubtful in nature. Most
common ADR was Gastritis and GI distress, and 9
patients had experienced it, 3 had abdominal pain, 2
had nausea, one each had vomiting, Skin rashes and
were managed symptomatically (table-3).
327
Padmanabha et al.,
Table 1:Patients Demographic Profile, Gender,

Distribution details of Adverse Drug Reactions.
Age
(years)
18 to 65
>65
Total
Males
(%)
71
12
83
Females
(%)
14
3
-
17
With
ADR (%)
11
5
Without
ADR (%)
74
10
14
2
69
15
Table 2: Drugs Prescribed And Adverse Drug

Reactions.
Class of drugs
Drug name
No.of
patients
(%)
No.of
ADR
(%)
NSAIDs
Diclofenac(50mg)
Paracetamol(500mg)
Ibuprofen(200mg)
Nimusulide(100mg)
Etoricoxib(90mg)
76
16
3
2
3
15
1
0
Pantoprazole(40mg)
Ranitidine(150mg)
Ceftriaxone(1gm)
2
74
52
0
0
1
COX
2
Inhibitors
Gastroprotec
tive Drugs
Antibiotic
Table3: ADRs Detected And Implicated Drugs

ADR
Nausea
Vomiting
Gastritis
&
distress
Abdominal pain,
Skin rashes
GI
Total no of
patients
(%)
2
1
9
3
1
The
drug
causing
ADR
diclofenac
diclofenac
Diclofenac,
paracetamol
Diclofenac
Diclofenac
DISCUSSION
In the present study incidence rate of ADRs in
orthopaedic inpatients due to NSAIDs was found to
be 16% and was low when compared to other three
studies made in Brazil 14, Mumbai 15 and Delhi 16
which reported that 25%, 26% and 26 to 33% of
Orthopaedic inpatients respectively developed an
ADR. Low incidence of ADR in the present study can
be attributed to rational therapy and appropriate
NSAIDs selection based on individual illness and
medical history.
Age is one of a major risk factor for the occurrence
of ADRs17 and few other important risk factors
includes any history of duodenal ulcer or gastric
ulcer, indigestion, unnecessary use of corticosteroids
Padmanabha et al.,
and anticoagulants, use of multiple and high dosage

of Nonsteroidal anti-inflammatory agents and
coexisting illness.18 Age had significant association
with the occurrence of ADRs due NSAIDs in the
present study and 5 (%) of 15 patients above 65 years
and 11 (%) of 85 patients between 18-65 years who
received NSAIDs, experienced ADR. These results
were on par with the other studies done in Brazil,
Gujarat and Chennai.14,19,20 And showed adult
predominance, but was incongruous with Egger et al
study 21, which reported the highest incidence of
ADRs in elders.
In our study diclofenac was the most commonly
prescribed NSAIDs followed by paracetamol,
ibuprofen, nimesulide and etoricoxib. Out of 76
patients who received diclofenac 15 (93.75%)
developed ADRs which was in accordance with other
2 studies at Gujarat and Chennai 19, 20 implying that
proportion of diclofenac prescribed was more when
compared to other NSAIDs. Diclofenac was more
easily available and economical with lesser degree of
side effects. In addition, a study done in Brazil14
reported analgesic caused highest ADRs followed by
antibiotics.
In the present study besides diclofenac, paracetamol
was prescribed for 16 patients, of which one
experienced gastritis and one of 52 patients who
received antibiotics had a skin rash and the drug
responsible was ceftriaxone, which was similar to
studies done in north Brazil.14
No ADR was found in patient who were receiving
ibuprofen, nimesulide, and etoricoxib.
ADR affecting the male was quite higher than female
in the present study, but gender factor was
statistically insignificant with the occurrence of
ADRs.
Totally 76 patients received Gastroprotective agents
of which 74 received ranitidine and 2 received
pantoprazole.
Limitation of the study was, it was undertaken in a
single department, i.e., orthopaedic and the duration
was short and the number of patients screened was
less. Further studies may take up larger study groups
involving
various
departments.
So
that
pharmcovigilance can be practiced more efficiently.
CONCLUSION
The ADR incidence rate in orthopaedic inpatient due
to NSAIDs and antimicrobial agents was 16% and
328
1.92% respectively. Incidence of ADRs due to

NSAIDs was found to be satisfactory when compared
to other studies.
Strict adherence to the
Pharmacovigilance guidelines and practices will
reduce ADRs and cuts down the economical burden
on patients too. Hence establishment and
encouragement of pharmacovigilance system in
various specialties helps in reducing the ADRs and
improves rational prescribing and good clinical
practice.
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1. The Uppsala Monitoring Centre. Definitions:
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Flocco MA, Pelaia G, et al: Retrospective
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13. Wu WK: Evaluation of outpatient adverse drug
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15. 15.Shahani S, Nerleker S. Adverse drug reactions
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16. Gor AP, Saksena M. Adverse drug reactions of
non-steroidal anti-inflammatory drugs in
orthopaedic patients. J Pharmaco Pharmacother.
2011 Jan-Mar;2 (1): 26-29.
17. Notteerman DA: Farmacoterapia Peditrica,
Farmacologia em Terapia Intensiva. Rio de
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18. Fry RB, Ray MN, Cobangn DJ, Weissman NW.
Racial / ethnic disparities in patient reported
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Arthritis. 2007;57: 1539-45.
19. Pragnesh Gor, Miti Saksena. Adverse drug
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Padmanabha et al.,
DOI: 10.5958/j.2319-5886.3.2.069

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th
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ISSN: 2319-5886
Research Article
STUDY ON THE PREVALENCE AND UNDERLYING FACTORS OF MYOPIA AMONG THE

STUDENTS OF A MEDICAL COLLEGE IN KERALA
*Shiny George1, Biju Baby Joseph2
1
Associate professor, Department of Physiology, Azeezia Institute of Medical Sciences and Research, Kollam,
Kerala, India
2
Senior lecturer, Department of Oral Medicine and Radiology, Azeezia College of Dental Sciences, Kollam,
Kerala, India
*Corresponding author email: shinybiju57@yahoo.co.in
ABSTRACT
Background: Few decades earlier, wearing spectacles was a province of adults over 40 years of age. Now we see
more children and adolescents with spectacles/contact lenses. Various studies in Asian population show a
dramatic increase in refractive error, especially myopia among school and college students. More advanced levels
of education like medical education that involves extensive near work such as reading and writing have been
repeatedly associated with greater myopia prevalence Objective: To study the prevalence and the underlying
factors of myopia in MBBS students of a Medical college in Kerala. Research methodology: One hundred and
sixty two MBBS students (2009 - 2012 batches) were examined. 40 students were selected from each class by
systematic random sampling technique, their visual acuity was checked using Snellens Chart and Diopters were
obtained. Details of factors were obtained using a questionnaire. Results: Prevalence of myopia was observed as
39.5%. First and second year students had a greater percentage of myopia with 40% & 52.5% respectively.
40.6% of myopics had positive family history of myopia (p = 0.003). Duration of TV watching and computer use
showed a significant relation with myopia. (p = 0. 033, 0.009). Reading hours, type of light used, playing or
texting with cell phone and sleeping habits of students were not significant. Conclusion: Prevalence of myopia
was high among medical students (39.5%). Significance of genetic predisposition was well appreciated in our
study.
Keywords: Myopia, refractive error, visual acuity
INTRODUCTION
Myopia is the most prevalent ocular disorder
throughout the world.1 The myopic rate is 0.12% to
3.8% in Africa, 24% to 27.8% in Europe, 30% in
Japan 40% in Egypt, 30% in the United States and
33% in China (more than 300 million people).2,3,4 The
prevalence of myopia in places such as Hong Kong
and Singapore is even higher and has been
documented to be 60% to 80%. 5,6,7
Shiny et al.,
Myopia (nearsightedness or short-sightedness) is one

of the three commonly detected refractive errors; the
other two being hypermetropia (long-sightedness)
and astigmatism. Refractive errors occur when the
rays of light entering the eye are not focused correctly
onto the retina. In myopia, light rays entering the eye
fall in front of the retina and as a result near objects
may be seen clearly but objects in the distance appear
blurred. This most commonly occurs when the
330
eyeball is abnormally long or the cornea does not

properly bend the light rays entering the eye.
There has been a dramatic increase in myopia
prevalence rates over the past few decades in
different parts of Asia8. The increase in rates has been
remarkable in very young Asian children, too,
suggesting that early lifestyle risk factors may have a
large impact on the early myopia development and
the overall population prevalence rate of myopia9.
Specifically, the lifestyle factors which may play a
role in myopia development include reading for
pleasure10, variations in lighting,11 watching
television and playing video games,12 uses of the
computers,13 time spent indoors, and less time spent
in sport.14
In addition, some reports, published at the end of the
last century created an alarming response to show that
the academically active professionals are the major
sufferers of this disease15. Prominent among the
hypothesized myopia risk factors is a role for close up
work, such as reading and related visual tasks 16. It is
generally believed that myopia is more commonly
seen in highly educated persons compared to those
who are not myopic 17.. Medical students are
particularly such a select group which spends
prolonged periods of time on reading and near work
required by their intensive study regimen that spans
many years 18. Myopia is the most common vision
condition affecting approximately 50 % of European
medical students19 and around 90 % of Chinese
medical students in Singapore 20 and Taiwan21. The
prevalence rate of myopia is 50.3% in Norwegian
medical students.22
It is estimated that 49.3 million of those aged < 15
years may have refractive errors and under corrected
refractive error is the most common cause of
reversible blindness in India23. As there are no
studies reported among the medical students in
Kerala, we made an attempt to find out the prevalence
of myopia among the medical students.
The study was conducted on 162 MBBS students
(45 males and 117 females) of Azeezia Medical
College. The study was conducted in four batches,
admitted in the years from 2009 to 2012. After
getting informed consent from each student, they
were examined for their height, weight and visual
acuity. The anthropometric scale and weight machine
Shiny et al.,
were used to collect the data about height and weight

of the individual student and represented in
centimeters and kilograms, respectively. The body
mass index was calculated using the formula as
follows. Body Mass Index = Height (m2) /Weight
(Kg). Snellens chart was used to test the visual
acuity for distant vision. The refractive values were
collected based on the information furnished by the
students themselves or collected from their current
spectacle prescription, wherever available. Newly
diagnosed students were sent to ophthalmology
department and their power was checked. Students
were asked to fill up a questionnaire regarding their
different habits. The family histories pertaining to
refractive errors in their parents were also collected
by individual interrogation of each student.
Statistical analysis was carried out by Chi square test
and studentst-test. One way ANOVA was also
done. P value of <0.05 was considered statistically
significant.
RESULTS
One hundred and sixty two (162) medical students
(45 males and 117 females) were examined. The
prevalence of myopia came out to be 39.5 % in
medical students. Second year students had a greater
percentage of myopia with 52.5% of the students
being myopic.
33 students, developed myopia 2 5 years back,
whereas 11 students developed it 6 10 years back
and only 15 students developed it one year back.
There was a strong relation with years after
diagnosing myopia (p=0.000) which indicates that
majority of them developed myopia in less than 5
years (figure 3). Out of 64 myopic students, 26 had
positive family history (history of parental myopia),
whereas 38 myopics did not show any family history.
Among the 26 myopic students with positive family
history, for 7 students both the parents were myopic
and for 19 students single parent was myopic.
Statistically it showed a strong significant
relationship (p 0.003) (table 1). 23 students with
myopia had siblings with myopia which was
statistically significant (p=0.004).
64% of the students watched television for more than
1 hour to 5 hours per day 9% more than 5 hours per
day and only 27% watched for less than 1 hour/day.
Among the myopics, 29 students used to watch TV
for more than 2 hours and 22 students for 1-2 hours
331
and only 13 students for less than 1 hour. Statistically

with myopia is more in the 2011 and 2012 admission,
it showed a significant relationship (p 0.033).
which indicates a definite increase in no. of students
Similarly, our study showed a significant relationship
in the recent years. But there was no significant
between the duration of computer use and myopia
difference in the occurrence of myopia and batches
(p=0.009). 47% of the students were using computer
of MBBS students by one way ANOVA (p 0.149).
for <1 hour , 40 % between 1-2 hours, 10% for 3-5
When 2009 -10 batch is compared with batch 2010hours , 1.2 % for >5 hours /day and 1.8% were not
11and 2012-13 there was no significant difference in
using computer at all. 43% (28 students) of the
the occurrence of myopia between these batches by t
myopics were reading for 2-3 hours/day, 45% (29)
test (p= 0.346, 0.220) but there was a significant
for 4-5 hours /day 12% (7) for >5 hours/day. But our
difference with batch 2011-12 (p= 0.022). When
study did not show any significant statistical
batch 2010 compares with 2011-12 and 2012-13
relationship between reading hours per day , type of
batches, there was no significant difference (p=0.
lights used during reading, playing or texting with
182, 0.786). Similarly, there was no significant
cell phone and sleeping habits of students (p =0.470,
difference between batch 2011-12 and 20120.663, 0.332 and 0.274 ) .
13batches (p=0. 281)
Visual acuity by snellens chart 6/9 is taken as
In our Study the age of the myopic students ranged
altered distant vision/ myopia. 64 students (39.5%)
between 18 and 25 years (mean age 20.8 1.454).
had myopia (figure 1). As per the lens power the
For the 2012-13 batch, there was a statistically
students were divided into three groups of mild
significant relationship between their age and myopia
myopia (power< -2 diopters), moderate myopia
(p=0.007). Their mean age was 19.1 0.906. Mean
(power >-2to-5 diopters) and high myopia (power > age of 2011-12 batch was 20.53 0.877, 2010-11
5 diopters). Among 128 eyes of
64 myopic
batch 21.40.841and batch 2009-10 batch
students, 128 eyes showed myopia. Of these, 78 eyes
22.250.809. Years after diagnosing myopia also
(39 students both eyes) had low myopia (24.1%), 40
showed a very high significant relationship with
eyes (20 students both eyes) had moderate myopia
myopia in the same batch (p=0.000) means that
(12.3%) and 10 eyes (5 students both eyes) had high
majority of them developed myopia in 2-5 years.
myopia (3.1%) (Figure 2)
There was no significant relationship between BMI
Out of total 64 students suffering from myopia 11
and myopia in all the medical students (p= 0.111). On
students were in 2009-10 batch (27.5%), 15 students
the other hand, batch wise analysis showed a
in 2010-11batch (37.5%), 21 students in 2011significant relationship between myopia and BMI in
12batch (52.5%) and 17 students in 2012-13 batch
2011-12 batch of students (p= 0.041).
(40.5%) (Figures 4,5,6,7). The percentage of students
Table 1: Different variables in myopics and emmetropes
VARIABLES
Year of admission
Age of students
Years
after
diagnosing
Refractive error
Family H/O myopia
Shiny et al.,
2012 (Ist year)

2011 (IInd year)
2010 (IIIrd year)
2009 ( Final year)
18-19 years
20-21 years
22-23 years
24-25 years
Total
< 1 year
2-5 years
6-10 years
> 10 years
Yes
No
Total
No.of students
with myopia
17
21
15
11
20
29
14
1
64
15
33
11
5
26
38
64
Emmetropes
Total
P Value
25
19
25
29
16
42
39
1
98
92
5
1
0
17
71
88
42
40
40
40
36
71
53
2
162
107
38
12
5
43
109
152**
0.149
0.129
0.000*
0.003*
332
VARIABLES
Educational
qualification
father
of
Educational
qualification
Mother
of
Occupation of father
Occupation
Mother
H/O
myopia
of
parental
Reading hours per

day
Types of light used
Duration of T V
watching
Duration
computer use
of
Duration of play /
Texting with cell
phone
Total
sleep
duration
*P < 0.05
Shiny et al.,
of
Illiterate
10th standard
12 standard
Degree
Post graduation
Illiterate
10th standard
12 standard
Degree
Post graduation
No job
Labourer / Farmer
Govt. Employee
Business
Professionals
in
private sector
NRI
No job
Labourer / Farmer
Govt. Employee
Business
Professionals
in
private sector
NRI
Neither myopic
Only father myopic
Only mother myopic
Both myopic
2-3 hrs
4-5 hrs
6-7 hrs
> 7 hrs
Dim light
Moderate
Bright
<1 hr
1-2 hrs
3-5 hrs
> 5 hrs
<1 hr
1-2 hrs
3-5 hrs
> 5 hrs
Not done
< 30 min.
30 min to 1 hr
2-3 hrs
> 3 hrs
< 6 hrs
6 hrs
7 hrs
8 hrs
> 8 hrs
No.of students
with myopia
2
10
8
29
15
0
10
20
25
9
4
4
18
21
13
Emmetropes
Total
P Value
4
27
15
41
11
2
33
24
32
7
3
21
32
28
10
6
37
23
70
26
2
43
44
57
16
7
25
50
49
23
0.222
4
45
0
10
4
5
4
71
1
23
0
3
8
116
1
33
4
8
0
37
9
10
7
28
28
7
1
2
38
24
13
22
20
9
31
22
9
1
4
22
24
8
6
5
27
17
12
3
0
81
5
3
9
55
32
10
1
1
57
40
30
45
17
6
45
42
8
1
16
30
31
13
8
19
25
30
15
9
0
118
14
13
16
83
60
17
2
3
95
64
43
67
37
15
76
64
17
2
20
52
55
21
14
24
52
47
27
9
- significant, *p < 0.05 significant,
0.490
0.158
0.259
0.007*
0.470
0.663
0.047*
0.009*
0.332
0.274
** 10 parents of emmetropes had hypermetropia
333
Fig 1: Frequency of Myopia among medical students
Fig 6: Frequency of Myopia in 2011 Batch
Fig 2: Degree of Myopia among medical students
Fig 7: Frequency of Myopia among 2012 Batch

Students
DISCUSSION
Fig 3: Relationship of Myopics with years after

diagnosing Myopia
Fig 4: Frequency of Myopia in 2009 batch
Fig 5: Percentage of Myopia in 2010 Batch
Shiny et al.,
Myopia, a common type of ammetropia is one of the

leading causes of vision loss around the world24.
Present study was conducted amongst 162 medical
students to know the prevalence among medical
students who are a high risk population for the
development of myopia. Out of these 64 (39.5%)
were myopic. A previous study done in128 Singapore
medical students revealed that 82% of these students
were having myopia.5 Similarly, a study of 345
medical students in Taiwan showed a prevalence rate
of more than 90%, whereas a prevalence rate of 50%
was seen in a study on 147 medical students in
Denmark and 50.3% in a Norwegian study on 140
medical students19,22. These differences in myopia
prevalence rates in medical students across different
countries may be attributable to ethnic variations and
different genetic predispositions
The range of myopia among all medical students in
our study was from -0.5 to -6.0 D. Mean age of
students was 20.8 years with a standard deviation of
1.45 years; minimum 18 and maximum 25 years. An
age group of 20 22 years had maximum number of
students with myopia. In a study conducted by
medical students in Norway, a clear relationship was
detected between myopia and the age of onset of
myopia. 22
There are studies showing a relationship between
height, obesity and several eye conditions 25,26. In a
334
previous study in Israeli military recruits, no

relationship was detected between anthropometric
measurements and myopia27. In another study,
myopic Finnish males were found to be taller than
nonmyopics 28. In a study, Saw et al 29 observed that
obese children have more tendencies for
hypermetropia, and had shorter vitreous chambers.
Thus the gender as well as body measurements may
have some contribution in respect to refractive errors.
But in the present study, we did not get any
significant relationship between myopia and BMI.
Relationship with year of study was significant
among second year medical students. Out of total 40
second year students, 21 students were myopic
(52.5%). The percentage was statistically significant
(p = 0.02) .This was followed by first year students
who had 40% myopics . From this it is evident that
students recently joining M.B.B.S have more
frequency of myopia than the students who joined 3 4 years back.
Similarly, occupation of father and mother was not
related to myopia among their children studying in
the medical college (p = 0.07 and 0.242 respectively).
50.4% of the myopics developed myopia 2 5 years
back, whereas 40.2% developed it 6 10 years back
and only 8.4% developed it one year back. In a
similar study carried out in Istanbul, Turkey, adult
onset myopia group comprised 14.7% of all myopia
cases.30 It shows that development of myopia occurs
mostly in school going children during adolescent age
and with the passage of time, reporting of new
myopia cases decreases.31 However, adult onset
myopia is not an infrequent occurrence. Out of 64
myopic students, 26 (40.6%) had positive family
history whereas 38 (59.4 %) myopics did not show
any family history. Statistically it showed a strong
significant relationship (p = 0.003). A strong genetic
role is evident from the racial differences in myopia
prevalence between different countries and, in
Singapore, between different racial groups.32 Apart
from that a consistent association between a parental
history of myopia and development of myopia has
been documented. 33 And also data from twin studies
show significantly greater concordance in myopia
rates among monozygotic compared to dizygotic
twins.34 Finally, genetic studies have identified
several loci for certain pathological variants of
myopia35. Similarly the results of our study also
suggest a strong familial predisposition of myopia.
Shiny et al.,
The reading hours per day of the myopics and

students with no ocular disease was statistically
insignificant (p = 0.470). Duration of watching
television and computer working showed a significant
statistical relationship with myopia. (p=0. 047,0.009).
Several environmental risk factors for myopia,
including higher educational attainment, higher
socioeconomic status and increased amount of near
work activities like in carpet weavers, visual display
terminal workers and microscopists are well
documented .36,22 However, the exact mechanism of
how these factors induce the development and
progression of myopia remains controversial.
The results of our study revealed a significant
relationship between lifestyle factors like duration of
TV watching and Myopia. In our study around 9.3%
students, developed myopia after their admission in
medical college (1 year back) whereas majority of the
students developed it before their admission in
medical college. The intensive study regimen of
medical college involves extensive near work activity
and it can lead to progression of myopia in medical
students who have already developed the condition.
But our students did not show more frequency of high
myopia. This can also be due to the fact that as age
advances, myopic progression slows down and the
refractive status of the individual gets stabilized.
CONCLUSION
Prevalence of myopia was high among our students
(39.5%) even though not as much as in other
countries like Singapore, Taiwan, Norway and
Denmark. 1st and 2nd year students had a greater
percentage indicating that it is increasing in the
younger age group. This indirectly depicts that
excessive work which newer students have to
undertake when they enter the professional course
leads to early development of myopia. Besides, the
significance of genetic predisposition was well
appreciated in our study. Amount of near work
involved in reading did not show any significant
relationship with myopia. It may be due to
stabilization of the refractive status of the majority of
the students who developed the error many years
back.
Relatively high prevalence of myopia among medical
students is alarming. Further studies are required in
this regard as it is going to be a threat to the nation in
future.
335
ACKNOWLEDGEMENT
We acknowledge the immense help received from the
scholars whose articles are cited and included in
references of this manuscript.
13.
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DOI: 10.5958/j.2319-5886.3.2.070

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
st
Received: 21 Nov 2013
Copyright @2014
ISSN: 2319-5886
Research Article
CYSTIC SWELLINGS OF SCROTUM: MANAGEMENT

*Subith Kumar K1, Sasikumar J2, Seetharamaiah T3, Ajay Kumar B3, Venugopalacharyulu N CH4
1
Senior Resident, 2Professor, Department of Urology, Mamata Medical College & General Hospital, Khammam,
3
Professor in General Surgery, Mamata Medical College & General Hospital, Khammam,
4
Professor in Anesthesia, Mamata Medical College & General Hospital, Khammam,
*Corresponding author email: ksubithkumar@gmail.com
ABSTRACT
The cystic swellings of scrotum are one among the commonest clinical entities faced by a surgeon in day to day
practice and a cause of concern to the patient more with his fertility. Presenting with varied etiology they can
represent a wide range of medical issues. Gold standard for the management of such cystic swellings of scrotum
continues to be surgical extirpation of the lesion. Objective: To identify the cause, mode of presentation, various
modalities of treatment and outcome of these with their complications. Method: A total of 170 cases of cystic
swellings of scrotum fulfilling the methodology criteria were subjected to the preformatted study. Diagnosis was
mostly by clinical examination and supported by ultrasonography. All cases were treated surgically with the
appropriate surgical procedure. Results: Maximum patients were in the age group of 31-50 years and presented
with scrotal swelling (59%) and more commonly affecting the right side. The commonest cause for cystic
swelling of the scrotum was primary vaginal hydrocele (55%). Surgical procedure using Lords Plication was
found to be simple, effective and associated with minimum post operative complications; the other conventional
techniques like Partial/sub-total excision of sac, everson of sac were associated with more complications like
haematoma, scrotal edema and infection. Majority of patients were discharged on 7th Post-operative day.
Conclusion: The present study, primary vaginal hydrocele was the commonest cystic swelling of scrotum and
treated surgically showed good results. Lords procedure was associated with the less post-operative
complications, minimal tissue handling and good haemostatic control.
Keywords: Cystic swellings of scrotum; Lords plication.
INTRODUCTION
Cystic swellings are the most common surgical
problem of the scrotum. They affect the physical well
being and resulting in mental agony for him. They
can be the reason for sexual and marital life of
patients. They can also increase the economic and
psychological burden of patients and their families.1
The spectrum of cystic scrotal swellings consists of
hydrocele (most common), epididymal cysts,
spermatocoele, haematocoele, pyocoele, chylocoele,
parasitic cyst and sebaceous cysts. Indications for
treatment include pain, discomfort, cosmetic

appearance of the scrotum and the patients wish.2
Surgical treatment of hydrocele include basic
techniques3 like Lords plication4, Jaboulays eversion
of the sac5, Winkelmanns partial excision and
eversion of the sac and radical excision of the sac.
Treatment of epididymal cyst and spermatocoele
consists of the excision of the cysts.6,7
Since, Surgeries on cystic scrotal swellings are one of
the most commonly performed procedures in our
338
Subith et al.,
hospital, a prospective study of 170 cases of cystic

swellings of the scrotum was undertaken to find out
the ideal treatment modality for a given type of cystic
scrotal swelling.
MATERIALS & METHODS
This study was undertaken on 170 cases with cystic
swelling of scrotum, admitted to the surgical wards
from April 2009 to March 2011 in the departments
Surgery and Urology, Mamata General Hospital,
Khammam. This study was carried with the prior
approval from the Institutional Ethics Committee.
Inclusion criteria: The cases with cystic swellings
arising from the testis and its coverings, epididymis
and spermatic cord are included in this study.
Exclusion criteria: The exclusion criteria included
the inguinoscrotal swellings and swellings from
scrotal skin. Detail history, clinical examination and
routine
laboratory
investigations
including
Ultrasound of scrotum was recorded. Surgical
treatment is performed according to the merits of the
case as decided by attending surgeon. The details of
operative findings and management of post operative
complications are recorded. Strict follow-up
schedules are maintained.
All 170 cases were surgically treated after taking
informed-written consent and explaining about the
study and disease. Corrugated drain was used in most
of the cases and removed after 48 hours. Postoperative scrotal support was given to most of the
cases. While discharging patients were told regarding
the importance of follow-up.
RESULTS
The present study includes 170 cases, where the
youngest patient was a 4 years child and the oldest
being 76 years. More than 68 (40%) cases were seen
in the age group of 31 40 years. Out of 170 cases
with cystic swellings of the scrotum 54 (32%) were
manual laborers, followed by farmers and
businessmen. Most of them were from poor socialeconomic class. Scrotal swelling was the presenting
complaint in 100 cases (59%) and associated pain in
48 cases (28%). The duration of the swelling was 1-2
years in 78 cases (46%), followed by 6-12 months in
39 cases (29%) and 29 (17%) cases (29) were with
duration of 2 years and above. Majority of the
patients presented within 2 years of onset of
symptoms. Swelling in right scrotum was seen in 90
cases (53%), compared to 44 (26%) patients with the

left scrotal swelling and bilateral scrotal swellings in
36 (21%) cases. Primary vaginal hydrocele was seen
in 39 patients (55%), followed by secondary
hydrocele in 27 cases (16%), pyocele (11%),
congenital hydrocele (8%) and epididymal
cyst/encysted hydrocele (10%) of the cases.
Cystic scrotal swellings were seen in the age group of
30- 40 years. Primary vaginal hydrocele was seen in
the age group of 40-60years, secondary hydrocele in
30-50years, Pyocele in 50-60 years, congenital
hydroceles in 5-15years.
Spinal anesthesia was used in 132 (78%) cases and
general anesthesia in younger age group of patients.
Local anesthesia was used in 10% of the cases who
were considered to be high-risk patients for spinal or
general anesthesia.
Jabouleys eversion of sac was done for primary
vaginal hydrocele in 62 cases (36%) with a large and
tense swelling with thin sac. Partial/subtotal excision
and eversion of sac was done for bigger hydroceles
with thick sac and for secondary hydroceles in 30
cases (18%). Lords plication was done in 21 cases
(12%), which had small swelling and thin sac.
Epididymal cyst was excised in 17cases (10%).
Herniotomy was done in 14cases (8%). Incision and
drainage was the treatment in 18 patients (10%). High
Orchidectomy in 5 cases (3%). In 3 cases (2%)
evacuation of clot was done.
Post operatively pain was noticed in almost all cases;
In Lords Plication, it was comparatively less. Scrotal
edema was observed in 32 (19%) cases. Scrotal
edema was least following Lords Plication when
compared to other conventional techniques.
Haematoma was observed in 15% of the cases and it
was seen following Jabouleys and subtotal excision
of sac, whereas no haematoma was observed in
Lords plication and herniotomies. Most of
haematomas were managed conservatively with
antibiotics, analgesics and scrotal support. Two
patients required re exploration. Wound infection was
observed in 10% of the cases.
Per-operatively, testis was normal in 145 cases and
19 cases showed flattening of testis in hydrocele.
Testis was enlarged in 3 cases of secondary hydrocele
secondary to testicular malignancy. Inflamed testis
was seen in 3 cases of pyocele. Per-operatively,
normal epididymis was observed in 153 cases (90%);
17 cases (10%) showed thickened epididymis (10
339
Subith et al.,
cases of secondary hydrocele and 7 cases of

epididymal cysts). Eighty patients were discharged
between 0-5 days, 81 patients were discharged
between 6-10 days. Those patients who developed
hematoma or infection in the post operative period
had a longer post-operative stay 7days and beyond.
Patients who underwent Lords procedure had a
record of early discharge of maximum 6 days than
compared to other procedure for primary vaginal
hydrocele.
DISCUSSION
This study comprised of 170 cases of cystic swelling
of scrotum admitted and operated at Mamata General
Hospital, Khammam over the span of 2 years. The
study was compared with available literature and
other studies. Cystic swellings of the scrotum
presented in various age groups. Most of the patients
were in the age group of 31-40 years, followed by 4150 years age group, together 78 (46%) cases out of
the total 170 cases. This age distribution of scrotal
swellings is similar to the reported mean age of
presentation 36 years by Srinath et al in their study8.
Scrotal swelling alone was the main presenting
complaint in 100 (59%) cases and the weight of the
scrotum causing dragging sensation. These
complaints are similar to the report of Srinath et al 8.
However, many other had scrotal swelling with pain
or pain alone as a complaint, few presented with fever
with swellings.
On clinical examination most of the swellings were
oval in shape or globular. Cystic swellings of scrotum
were more common on the right side compared to
left side and comparable to study reports of
Agbakwuru et al (2008)9. Bilateral swellings were
found in 21% of the cases. In most cases scrotal
rugocity was lost in hydroceles. Swellings were cystic
in consistency and fluctuant. Transillumination was
negative in all cases of haematocele, secondary
hydrocele and Pyocele may be due to the opaque
nature of their contents and long standing hydrocele
and fibrous walls. The diagnosis was confirmed by
scrotal ultrasonography after scrotal examination.
This study showed primary vaginal hydrocele as the
most frequent cause for cystic swelling of the scrotum
in 94cases (55%). The other causes were secondary
hydrocele in 27 cases (16%), Pyocele in 19 (11%),
congenital hydrocele in 13 (8%), Epididymal cyst in
7 (4%), Encysted hydrocele of cordin 7 (4%) and
Hematocele in 3 (2%). Similar distribution of cystic

scrotal swellings was reported by Agbakwuru et al in
their study of 50 patients9. Three cases of malignant
teratoma presenting with hydrocoele were treated by
high orchidectomy and were referred to higher centre
for further management.
Surgery was employed in all the cases. Spinal
Anaesthesia was used in 132 cases (78%), general
anaesthesia in 20 cases (12%) and local anaesthesia in
10% patients with 2% xylocaine and Midazolam, as
per the merit of the patient. In the treatment of
Primary vaginal hydrocele, Lords Plication was found
to be simple, effective and associated with least post
operative complications. The other conventional
techniques like Partial/sub-total excision of sac,
Eversion of sac were associated with increased
incidence of complications like haematoma, scrotal
oedema and infection.
Intra operatively normal testis was observed in 145
cases (85%) and 19 cases showed flattening of testis
in Primary vaginal hydrocele (11%). Inflamed testis
was seen in 3% of cases. Similar results are seen in
the study done by Dandapat et al10, on 120 cases of
big unilateral hydrocele and reported no pressure
effect from the hydrocele on the structure of the testis
in 70%, flattening of testis in 22% and atrophy of
testis in 8% of cases. Srinath and co-workers8 also
reported no atrophy of testes due to vaginal
hydroceles in his study of 25 patients. Congenital
hydroceles were managed by performing herniotomy
while Epididymal cysts and encysted hydrocele of the
cord were treated with excision of cyst. Haematocele
were treated by evacuation of clot and eversion of
sac. Pyocele was treated by incision and drainage.
Pus was sent for culture and sensitivity and treatment
was done with specific antibiotics as per sensitivity
report. All the patients were given tight scrotal
support and appropriate analgesics. Corrugated drain
was removed after 48 hours.
The common post operative complications observed
were pain, scrotal oedema and haematoma, managed
conservatively by analgesics scrotal support and
antibiotics. Two patients were re-explored following
hematoma development. Scrotal oedema was found
in few patients and haematoma post operatively in 15
cases. This was the result of sac separation and
dissection. Patients who underwent Lords plication
where no dissection was done showed less post op
complications resulting in early discharge from the
340
Subith et al.,
hospital. However this procedure was not employed

in long standing, large hydrocele with thick sac,
where in subtotal excision or eversion was chosen.
The post operative results and complications of the
present study are comparable to that of the previous
series. Patients who underwent Lords placation in
the literature available showed hematoma as post op
complication in one case in each report compared to 6
to 14 cases in patients who underwent excision/
eversion9, 11, 12. However scrotal edema and wound
infection were very uncommon.
Most of patients were discharged between 5-7 days,
except who developed scrotal edema or infection was
kept for 10 days. The results of the present study are
comparable to Usman et al 13 in his series of 25 cases
were kept for 3 days and Efferman et al12 reported 5
days hospital stay in his report of 29 cases. In another
series of 50 cases from Rai et al 11 it was 3-8 days
stay compared to the present study (170 cases) 5-7
days.
On discharge patients were asked to maintain strict
follow up. Follow up period was 2-4 months. In
general it was poor due to rural background, illiteracy
and ignorance. Cases which were followed regularly
showed no recurrence. Minimal tissue handling and
good haemostatic control is the key to prevention of
post operative complications. Scrotal edema and
haematoma were the most common complications in
postoperative period. No complications occurred in
Lords placation may be due to no sac separation and
dissection. Post operative hematoma could be
minimized by meticulously over sewing all raw edges
of the sac after its excision. Lords Plication was
simple, effective, safe and economical for treatment
of small, lax hydroceles.
CONCLUSION
To conclude from the present study, primary vaginal
hydrocele was the commonest cystic swelling of
scrotum and treated surgically showed good results.
Lords procedure was associated with the less postoperative complications, minimal tissue handling and
good haemostatic control.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Marriageability from Orissa, India. PLoS Negl

Trop Dis. 2009 April; 3(4): e414.
Ku JH, Khim ME, Lee NK, Parle YH. The
excicional placation and internal drainage
techniques: a comparision of the results for
idiopathic hydrocele. BJU Int. 2001;87(1):82
Brunicardi FC, editor. Schwartzs Principles of
Surgery. 8th edition. McGraw-Hill; 2004.
Lord P.H. A bloodless operation for the Radical
Cure of Idiopathic hydrocele. British Journal of
Surgery. 1964; 51: 914-16
Olumi FA, Richie PJ. Urologic surgery. Chap 77.
Section XIII. Sabiston textbook of surgery. 18th
edition.Vol 2; 2008: 2272-73
Goldstin M. Surgical Management of Male
infertility and other scrotal disorders. Vol. I.
Campbells urology, Patrick C. Walsh, Alan B
Retik, Vaughan ED. 10th edition. Edinburgh: WB
Saunders Company 2002; 313-16
Farquharson M, Brendan M. Surgery of the Groin
and External genitalia. Chap 24. Farquharsonss
Text book of Operative general surgery. 9th
edition; 2004: 466-74.
Srinath C, Ananthakrishnan N, Lakshmanan S,
Kate V. Effect of tropical vaginal hydroceles on
testicular morphology and histology. J Urol 2004;
20: 109-12
Agbakwuru EA, Salako AA, Olajide AO, Takure
AO and Eziyl AK. Hydrocelectomy under local
anaesthesia in a Nigerian adult population. Afr
Health Sci. Sep 2008; 8(3):160-62.
Dandapat MC, Padhi NC, Patra AP. Effect of
hydrocele on testis and spermatogenesis. British
Journal of Surgery. 1990;77: 1293-94.
Rai. Plication operation for hydrocoele. Indian
journal of Surgery 1978; 40:481-84.
Effrman G, and Sharkey CG. The Lords
operation for hydrocele Surgery Gynaecology
and Obstetrics. 1967; 125: 603-06
Usman L, Quddus R, Muhammad AB, Tajammal
AS and Abid R. Hydrocele; Surgery Vs
Sclerotherapy. Prof Med J. Mar 2008; 15(1): 12528
REFERENCES
1. Babu BV, Mishra S, Nayak AN. Marriage, Sex,
and Hydrocele: An Ethnographic Study on the
Effect of Filarial Hydrocele on Conjugal Life and
341
Subith et al.,
DOI: 10.5958/j.2319-5886.3.2.071

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Accepted: 2nd Mar 2014
Research Article
STUDENT EVALUATION OF AN OSCE IN GENERAL MEDICINE AT MAMATA MEDICAL

COLLEGE, ANDHRA PRADESH
*Dharma Rao V1, Pramod Kumar Reddy M2, Rajaneesh Reddy M3 , HanumiahA1, Shyam Sunder P4, Narasingha
Reddy T5, Kishore Babu SPV6
1
Professor, 3Assistant professor, Department of General Medicine, Mamata Medical College, Khammam
2
Associate Professor, Department of Psychiatry, Mamata Medical College, Khammam, AP, India
4
Professor, Department of Dermatology, Mamata Medical College, Khammam, AP, India
5
Assoc Professor, Department of Radio Diagnosis, Mamata Medical College, Khammam, AP, India
6
Professor, Department of Pulmonary Medicine, Mamata Medical College, Khammam, AP, India
*Corresponding author email: mamatakhmm@gmail.com
ABSTRACT
The assessment of students clinical competence is of paramount importance, and there are several means of
evaluating student performance in medical examinations. The OSCE is an approach to student assessment in
which aspects of clinical competence are evaluated in a comprehensive, consistent and structured manner with
close attention to the objectivity of the process. The faculty of general medicine in collaboration with other
clinical departments, Mamata Medical College, Khammam first implemented the objective structured clinical
examination (OSCE) in the final MBBS Part-II examination during the internal assessment examination for the
2011-2012 academic years. The study was set out to explore student acceptance of the OSCE as part of an
evaluation of final MBBS students. A self-administered questionnaire was completed by successive groups of
students immediately after the OSCE. Main outcome measures were student perception of examination attributes,
which included the quality of instructions and organization, the quality of performance, authenticity and
transparency of the process, and usefulness of the OSCE as an assessment instrument compared to other formats.
There was an overwhelming acceptance of OSCE in general medicine with respect to comprehensiveness (90%)
transparency (90%) & authenticity of required tasks. Students felt that it was a useful form of examination.
Students feedback was invaluable in influencing faculty teaching curriculum direction and appreciation of
student opinion and overall the students were agreeable with newer form of OSCE. The majority of the students
felt that OSCE is a fair assessment tool compared to traditional long and short cases and it covers a wide range of
knowledge and clinical skills in general medicine.
Keywords: Objective structured clinical examination, Final MBBS.
INTRODUCTION
In the last two decades, there has been a rapid and
extensive change has occurred in the assessment
methods of medical education. Several new methods
of assessment have been developed and implemented.
These newer methods focused mainly on clinical
Dharma Rao et al.,
skills, communication skills, procedural skills and

professionalism. Despite the availability of various
assessment methods worldwide, the clinical
examination in India has remained largely
unchanged, especially in this part of our country.
342
Several weaknesses of the present method of

assessment have been pointed out. The need for a
more objective approach to the assessment of clinical
competency was felt. 1 The Objective Structured
Clinical Examination (OSCE) is a versatile
multipurpose evaluation tool that can be utilized to
assess health care professionals in a clinical setting. It
assesses competency, based on objective testing
through direct observation.
OSCE was introduced by Harden and his colleagues
in 1975. OSCE consists of a series of stations that
examines the competency of students in taking
histories, practicing specific clinical tasks, and
interpreting some clinical data. It provides a uniform
marking scheme for examiners and consistent
examination scenarios for students. It also generates
formative feedback for both the learners and the
teaching program. Immediate feedback collected may
improve students competency at subsequent stations
and even enhance the quality of the learning
experience. Finally, it can objectively assess other
important aspects of clinical expertise, such as
physical examination skills, interpersonal skills,
technical skills, problem-solving abilities, decisionmaking abilities, and patient treatment skills. OSCE
is being used worldwide to provide formative and
summative assessments in various disciplines.2, 3 But
in India, OSCE is used only in very few medical
colleges as part of assessments.
The study was designed to evaluate student overall
perception of OSCE, determine student acceptability
of the assessment method and to collect feedback.
SUBJECTS AND METHODS
Study Design and Participants
This study was carried out by faculty of general
medicine in collaboration with other clinical
departments at Mamata Medical College, in the final
MBBS Part-II examination during the internal
assessment examination for the 2011-2012 academic
year. In the present study, a total of one hundred and
twenty nine students were participated in the
assessment process and were randomly divided into
Five groups (n=26). The study protocol was approved
by the ethics committee and the college academic
council. The students were briefed about the
assessment procedure by one of the investigators six
months before the internal examination.
OSCE consisted of eight stations and all these

stations covered different aspects of clinical
examination, e.g., eliciting a focused history,
examination of system, problem solving oriented
around the patient, interpretation of lab data and
charts, reading X-rays, instruments, drugs and
photographic material.
The
clinical
examination
station
included
examination of cardiovascular system, respiratory
system, gastrointestinal system, nervous system. Four
stations had 5 minute duration, two had 10 minutes
and two had 15 minutes duration. The 15 minute
duration was given for system examination. Two
minute break was given for rest to reduce student and
patient fatigue. One minute was allowed for change
of station and reading instructions.
Data Collection: The data was collected using a 32
item questionnaire as described by De Lisle (2001)
and Russell et al., 2004.4,5 The questionnaire consists
of four parts. First part is to evaluate the content,
structure and organization of OSCE and the second
part is to rate the quality of performance and
objectivity of OSCE process. The third and fourth
part is to collect the students opinion about the
usefulness of OSCE as an assessment instrument
compared to the previous format.
RESULTS
Data was collected from a total of one hundred and
twenty nine students who appeared the 2nd internal
assessment of final MBBS part II. All the students
responded to the questionnaire representing 100%
(129/129).
OSCE Evaluation: The majority of the students
responded positively about the new assessment
method. They agree that the OSCE covers a wide
range of knowledge (90%) and clinical competencies
(82%). 86 % of the students felt that the assessment
was well structured and sequenced. Nearly three
fourth of the students felt that the assessment process
helped them to identify weaknesses and gaps in their
clinical competencies (Table 1).
67% of the patients felt that the assessment process
allowed them to compensate in some areas but only
40% agreed that the chances of failing with OSCE are
minimized and less stressful compared to other
formats of assessments.
343
Dharma Rao et al.,
Table 1: OSCE evaluation

Question
Exam was fair

Wide knowledge area
covered
Needed more time at
stations
Exams well
administered
Exams very stressful
Exams well structured
& sequenced
Exam minimized
chance of failing
OSCE less stressful
than other exams
Allowed student to
compensate in some
areas
Highlighted areas of
weakness
Wide range of clinical
skills covered
Agree
%
Neutral
%
Disagree
84
10
95
90
10
7.5
78
12
10
40
50
10
86
10
40
30
30
(%)
40
40
20
67
21
12
78
13
86
Table 2: OSCE Performance Testing

Question
Fully aware of nature

of exam
Tasks reflected those
taught
Time at each station
was adequate
Setting and context
at each station felt
authentic
Instructions were
clear and
unambiguous
Tasks asked to
perform were fair
Sequence of stations
logical and
appropriate
Exam provide
opportunities to learn
Not at
all %
Neutral
%
To
great
extent
%
38
22
40
23
73
44
35
21
18
24
58
24
24
52
27
70
13
30
57
11
21
69
Majority of the students (84%) were of the opinion

that the assessment was fair. However, the students
felt that they needed more time at stations.
Performance Testing: The majority of students felt
that the required tasks were consistent with the active
curriculum that they were taught. More than half of
students were satisfied with conduct, organization
and administration of OSCE (Table 2).
Perception of Validity and Reliability
Only fifty per cent students felt that the OSCE scores
were standardized and 43 % were of the opinion that
the assessment provided the true measure of essential
clinical skills (Table 3).
Table 3: OSCE Perception of validity and reliability
Question
Not at
all %
OSCE exam scores

provide true measure
14
of essential clinical
skills
OSCE scores are
8
standardized
OSCE practical and
4
useful experience
Neutral
%
To
great
extent
%
43
43
37
55
23
73
Comparing Assessment Format

Three-fourth of the students considered OSCE as the
fairest assessment format (76%) compared to long
and short case (24%). OSCE was considered the most
useful and practical experience compared to other
assessment formats.
Students were of the opinion that the opportunity for
feedback helped them to know the gap in their
knowledge; mistake committed and thus will help in
driving the learning process.
DISCUSSION
When OSCE was first introduced medical students
used to interact with a series of simulated patients in
stations that may involve history-taking, physical
examination, counselling or patient management,6 as
time passed on the OSCE examination has been
broadened in its scope and a lot of modification were
done to suit peculiar circumstances7,8 including an
assessment of communication skills. Most reputable
colleges of medicine in United Kingdom, United
States, Canada and in several other countries have
344
Dharma Rao et al.,
adopted the OSCE and is the standard mode of

assessment of competency, clinical skills, and
counselling sessions, complementing cognitive
knowledge testing in essay writing and objective
examination.9,10 In India, the state medical
universities have yet to adopt the OSCE examination.
However, the Medical Council of India has started
the initiative to include its assessment methods in the
undergraduate curriculum and has also included
OSCE in teachers training program level 1.
In the traditional clinical examination a narrow range
of clinical skills are tested under the observation of
normally two examiners in a given clinical case and
therefore, the scope of the examination is basically
related to patient histories, demonstration of physical
signs, and assessment of a narrow range of technical
skills. It has been shown to be largely unreliable in
testing students performance and has a wide margin
of variability between one examiner and the other11, 12
Data gathered by the National Board of Medical
Examinations in the USA (19601963), involving
over 10,000 medical students showed that the
correlation of independent evaluations by two
examiners was less than 0.25.11
The advantages of OSCE apart from its versatility
and ever broadening scope are its objectivity,
reproducibility, and easy recall. In our study, most of
the students agree that OSCE is standardized, fair and
transparent method of assessment. Few students felt
that instructions were not clear and were ambiguous;
time provided was not sufficient; and the examination
was stressful. However, no examination method is
flawless and some of the difficulties experienced by
the students can be corrected. Allen et al in their
study found that the OSCE can be a strong anxietyproducing experience, and that the level of anxiety
changes little as students progress through the
examination.13
CONCLUSION
In summary the study shows that OSCE is the fairest
assessment format compared to long and short cases;
is more transparent, authentic and valid. The OSCE
can be introduced for undergraduate clinical
assessment.
REFERENCES
1. Stokes JF. The Clinical Examination. Medical
Education Booklet No. 2. Dundee, Association
for the Study of Medical Education, 1974.
2. Fowell SL, Bligh JG. Recent developments in
assessing medical students. Postgrad Med J.
1998;74:18-24
3. Carraccio C, Englander R. The objective
structured clinical examination, a step in the
direction of competency-based evaluation. Arch
Pediatr Adolese Med. 2000, 154:736-41
4. De Lisle J. OSCE student evaluation form. Mount
Hope, Trinidad. The Centre for Medical Science
Education, Faculty of Medical Sciences; 2001.
5. Russell B Pierre, Andrea Wierenga, Michelle
Barton, J Michael Branday, Celia DC Christie.
Student evaluation of an OSCE in paediatrics at
the University of the West Indies, Jamaica. BMC
Med Educ 2004;4:22
6. Harden RM, Gleeson FA. Assessment of clinical
competence using an objective structured clinical
examination (OSCE). Med Educ 1979;13(1):4154
7. Hodges B. OSCE! Variations on a theme by
Harden. Med Educ 2003, 37(12):1134-40.
8. Jain SS, DeLisa JA, Eyles MY, Nadler S,
Kirshblum S, Smith A. Further experience in
development of an objective structured clinical
examination for physical medicine and
rehabilitation residents. Am J Phys Med Rehabil
1998, 77(4):306-310. .
9. Stillman PL, Wang Y, Ouyang Q, Zhang S, Yang
Y, Sawyer WD. Teaching and assessing clinical
skills: a competency-based programme in China.
Med Educ 1997;31(1):33-40
10. Leichner P, Sisler GC, Harper D. A study of the
reliability of the clinical oral examination in
psychiatry. Can J Psychiatry 1984, 29(5):394-97.
11. Hubbard JP, Levit EJ, Schumacher CF, Schnabel
TG. An objective evaluation of clinical
competence. N Engl J Med 1965, 272:1321-28
12. Barman A. Critiques on the Objective Structured
Clinical Examination. Ann Acad Med Singapore
2005;34(8):478-82.
13. Allen R, Heard J, Savidge M, Bittengle J,
Cantrell M, Huffmaster T. Surveying students'
attitudes during the OSCE. Adv Health Sci Educ.
1998;3:197206.
345
Dharma Rao et al.,
DOI: 10.5958/j.2319-5886.3.2.072

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Revised: 28thFeb 2014
Copyright @2014
ISSN: 2319-5886
Accepted: 4th Mar 2014
Research Article
EVALUATION OF RECEPTIVITY OF THE MEDICAL STUDENTS IN A LECTURE OF A LARGE

GROUP
*Vidyarthi SurendraK1, Nayak RoopaP2, Gupta Sandeep K3
1
Associate Professor, 2Professor and Head, 3Assistant Professor, Department of Pharmacology, Dhanalakshmi
Srinivasan Medical College and Hospital, Siruvachur, Perambalur, Tamil Nadu
*Corresponding authormail: skvmanju9208@yahoo.co.in
ABSTRACT
Background: Lecturing is widely used teaching method in higher education. Instructors of large classes may
have only option to deliver lecture to convey informations to large group students.Aims and Objectives: The
present study was to evaluate the effectiveness/receptivity of interactive lecturing in a large group of MBBS
second year students. Material and Methods: The present study was conducted in the well-equipped lecture
theater of Dhanalakshmi Srinivasan Medical College and Hospital (DSMCH), Tamil Nadu. A fully prepared
interactive lecture on the specific topic was delivered by using power point presentation for second year MBBS
students. Before start to deliver the lecture, instructor distributed multiple choice 10 questionnaires to attempt
within 10 minutes. After 30 minutes of delivering lecture, again instructor distributed same 10 sets of multiple
choice questionnaires to attempt in 10 minutes. The topic was never disclosed to the students before to deliver the
lecture. Statistics: We analyzed the pre-lecture & post-lecture questions of each student by applying the paired ttest formula by using www.openepi.com version 3.01 online/offline software and by using Microsoft Excel Sheet
Windows 2010. Results: The 31 male, 80 female including 111 students of average age 18.58 years baseline (prelecture) receptivity mean % was 30.99 14.64) and post-lecture receptivity mean % was increased upto 53.51
19.52). The only 12 students out of 111 post-lecture receptivity values was less (mean % 25.8 10.84) than the
baseline (mean % 45 9.05) receptive value and this reduction of receptivity was more towards negative side.
Conclusion: In interactive lecture session with power point presentation students/learners can learn, even in
large-class environments, but it should be active-learner centered.
Key words: Receptive level, Lecture, Large Group.
INTRODUCTION
The term, Lecture is derived from Latin word "lectus
past participle of legere - to read a discourse given to
an audience or class for instruction". The origin of the
lecture is, probably, from pre-date the printing press
by centuries. Though, books were scarce and
valuable, making the lecturer the gatekeeper of
knowledge, which the student had to commit to
memory.1 Lecturing is widely used teaching method
in higher education. Instructors of large classes may
have only option to deliver lecture to convey

informations to large group students.2We assume that,
lecturing is the only way to teach a large group and to
a small group.2 The conventional style of lecture have
many challenges to both teachers and learners in most
of the large classes. Though a conventional lecture
format may be effective for efficiently delivering a
large content to a large number of students, these oneway exchanges often facilitate passive and superficial
346
Vidyarthi et al.,
learning and even, conventional lecture fails to

encourage student motivation, confidence, and
enthusiasm. 3,4 Thus, consequentially, the
conventional lecture model often lead to students
completing their undergraduate education without
skills.5,6 Thus, lecturing in large class environments
are still a critical dimension of research that how we
can change lecturing session from ineffective to more
effective and what was post-lecture outcome.
Aims and Objectives: The primary objective of the
study was to evaluate receptivity of the MBBS
second year medical student in a lecture of large
group.
MATERIAL and METHODS
using various statistical methods. This study was

conducted in the month of November 2013.The Pretest and post-test Questionnaire sets were same.
Statistics analysis; The statistical calculation was
done by applying the paired t-test formula by using
www.openepi.com
version3.01
online/offline
software and by using Microsoft Excel Sheet
Windows 2010.
RESULTS
The 111 students (including 31 male and 80 female)
participated in the study and their average age was
18.58 year. The baseline (pre-test) receptivity mean
% of the students was 30.99 (Standard Deviation=SD
14.64) and post-test receptivity mean% of the same
students was increased upto 53.51 (SD19.52) (See
table1, 2). The 8, 55, 35, 1 students post-test
receptivity was 0%, 1-30%, 31-60%, 61-90%
respectively. There is no one achieved 91-100%
receptivity (See Fig.1). Thus, there was 22.51% mean
receptivity of the students increased after the large
group lecture. Only 12 students out of 111post-test
receptivity values was less (mean % 25.8, SD10.84)
than the baseline (mean % 45, SD9.05) receptive
value, and this reduction of receptivity was more
towards negative side.
After getting approval from the Institutional Ethics

Committee, the present study was conducted in
Dhanalakshmi Srinivasan Medical College and
Hospital (DSMCH), Tamilnadu. The study subjects
were MBBS 2nd year students of the DSMCH. The
lecture theater was well equipped with audiovisual;
air-conditioned with good seating arrangement.
Before starting a lecture on the specific topic among
111 MBBS second year students, instructor
distributed questionnaire of Pre-test (Pre-lecture)
multiple-choice-ten-questions set to each student.
Approximately10 minutes time given to attempt the
questions. The pre-test questionnaires sets were recollected from the students after the10minutes. The
instructor started to deliver lecture upto 30 minutes
by using power point presentation. The lecture
session was interactive to make the students attentive.
This lecture contents were not disclosed and even
students had never attended the same topic elsewhere
before the pre-test. After end of the lecture, instructor
again distributed same set of post-test (post-lecture)multiple-choice ten-questionnaires for ten minutes.
Fig1: Number of Students showed Receptivity
After, that each paper was evaluated and analyzed by
Table 1: Pre-test, Post-test Receptivity Mean % and its p-value
Mean
95%
CI 95% CI
Sample size
Mean SD (Receptivity %)
Difference
Lower
limit
Upper Limit
Pre-test
111
30.9914.64
Post-test
111
53.5119.52
Result
t statistics
p-value1
220
<0.0000001
-22.52
204
<0.0000001
-22.52
df(numerator, denominator)
F statistics
110,110
Test for equality of variance2 1.77778
1
2
p-value (two-tailed), Hartley's f test for equality of variance.
Results from OpenEpi, Version3, open source calculator-t_test mean
Equal variance
Unequal variance
-9.72389
-9.72389
df
-27.0842
-27.0863
Pvalue1
0.002789
-17.9558
-17.9537
347
Vidyarthi et al.,
Table2: Pre-test, Post-test Receptivity Mean % and its Differences Mean % of the only 12 Students who scored less
than Baseline Receptive level
Sample size
Pre-test
Post-test
Result
Equal variance
Unequal variance
12
12
t
statistics
4.71
4.71
Mean SD (Receptivity %)
459.05
25.810.84
df
p-value1
22
21
F statistics
0.0001066
0.0001192
Mean
Difference
19.2
19.2
df(numerator, denominator)
11,11
Test for equality of variance
1
p-value (two-tailed), 2Hartley's f test for equality of variance
Results from OpenEpi, Version3, open source calculator-t_test mean
95%
CI
Lower limit
10.746
10.7226
p-value1
0.5595
95% CI
Upper Limit
27.654
27.6774
DISCUSSION
Theory is nothing but the statements that connect the
things and their purpose".7 When theory does not
helpful for the answer, then the theory can be turned
into a provocative question that will helpful to learn
by organize & applying present data that should be
relevant with field work experience.8 In the present
study we were interested to activate knowledge
processing in learners by giving informative
questioning method. We asked 10 questions
(Appendix1; Fig.1) based on the lecture content,
before and after the lecture, each question given four
multiple- choice options. Asked all students to
attempt the correct option, after evaluation of each set
of questionnaire, analyzed the obtained marks by
using paired t-test. When we give multiple-choice
Questions to attempt the correct options, the students
select the relevant informations, by organize the
knowledge material and integrate it mentally to
choose the correct option. So, in the present study we
evaluated receptivity of the students with test
questions on a variety of kinds of knowledge covered
in the lecture content. In the present study baseline
(pre-test) and post-test receptivity mean % of the
students was 30.99, 53.51 respectively. So, the
improvement of the receptivity of the students was
only 22.51 %mean (p<0.0000001); obviously this
improvement was more. We already know that
lectures as a rule have little educational value. People
learn by doing, not by watching and listening. The
only 12 students out of 111post-test receptivity
values was less (mean % 25.8, SD 10.84) than the
baseline (mean % 45, SD 9.05) receptive value.
Probably, it could be possible that students, who were
Vidyarthi et al.,
not attentive during lecture session and at the time of

attempting the questions, scored less marks. Apart
from 12 students, another eight (8) student of the
study receptive levels were 0% percent; i.e.; their pretest receptive level were same as post-test, probably
they could not be attentive or they were not taking
much interest to listen the lecture or they were not
understanding the contents of the lecture or could be
possibility that instructor not explained properly.
Even, Phillip Wankat wrote, that anything you can
do in a large class you can do better in a small one9
The lecture was interactive to make students more
attentive in the present study and even, (Bloom,
1984) reported that, the best formats for teaching is
one-to-one interaction between an teacher and
learner. In this setting, teacher can easily take
possible feedback and providing the student to work
at his/her own pace and level and the teacher to guide
the lesson as per the needs of the students. Close
interaction among the teacher and learner also helps
to engage learners and stimulates them to become an
active learner in the learning process.10
CONCLUSION
So, our main conclusion of this study is interactive
lecture session with power point presentation
students/learners can learn, even in large-class
environments. It is true that, large group classes with
lecture-centered give limited opportunities for
students to interact with the instructor. It is possible to
deliver lecture effectively and needs more effort in
large group class, even if you're not a big-league
entertainer. It is necessary to make logistical
arrangements far enough in advance, provide plenty
348
of active learning experiences in the classroom

instead of depending on straight lecturing.
Limitations of the study:In the large group lecture
within one hour, it is impractical to interactevery
student interms of knowing their understanding
ability. Thus, it is difficult to justify, why the posttest receptivity was less than the baseline receptive
value of few (12 students in this study) students of
this study, it could be possible that students who were
not attentive during lecture session and at the time of
attempting the questions. Apart from 12 students,
another eight (8) student of the study receptive levels
were 0% percent; i.e.; their pre-test receptive level
were same as post-test, probably they could not be
attentive or they were not taking much interest to
listen the lecture or they were not understanding the
contents of the lecture or could be possibility that
instructor not explained properly.
Conflict of the interest: None.
6.
7.
8.
9.
10.
Brighter Economic Future. Committee on

Prospering in the Global Economy of the 21st
Century: An Agenda for American Science and
Technology, (2007) Washington, DC: National
Academies Press.books.nap.edu/openbook.
Wright R, Boggs J. Learning cell biology as a
team: a project-based approach to upper-division
cell biology. Cell Biol. Educ.2002; 1:14553.
LeCompte, Preissle J, Tesch R. Ethnography and
Qualitative Design in Educational Research.
(2nded.) Orlando, FL: Academic Press.1993
Wolcott H.F. TheArt of Fieldwork. Walnut
Creek, CA, AltaMira Press.1995
Felder RM. How About a Quick One?Formats for
in-class exercises. North Carolina State
University.Chem. Engr. Education. 1992;26(1),
18-19
Bloom BS. The search for methods of group
instruction as effective as one-to-one tutoring.
Educ. Leadership, 1984;41(8), 417
ACKNOWLEDGEMENTS
I acknowledge with gratitude to all MBBS second
year students and management of the DSMCH for the
cooperation of the study. I also acknowledge to
Department of Pharmacology team members who
encouraged to conducting the study systematic.
REFERENCES
1. McKimm
J.
Clinical
Teaching
Made
easy:Improve your lecturing - British Journal of
Hospital Medicine. 2009;70(8):466
2. Brown S, Philip R. Improve your Lecturing:
British Journal of Hospital Medicine.2009;
70(8,): 466.
3. Brans ford JD, Brown AL, Cocking RR. How
People Learn: Brain, Mind, Experience, and
School. Committee on Developments in the
Science of Learning. (2000)Washington, DC:
National
Academies
Press.http://www.nap.edu/catalog/9853.html.
4. Weimer M. Learner-Centered Teaching: Five
Key Changes to Practice, (2002)San Francisco,
CA:
JosseyBass.docushare3.dcc.edu/docushare/dsweb/.../Lea
rner-Centered-Teaching1.pdf
5. NRC. Rising Above the Gathering Storm:
Energizing and Employing America for a
349
Vidyarthi et al.,
DOI: 10.5958/j.2319-5886.3.2.073

&
Health Sciences
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Coden: IJMRHS
th
Revised: 2nd Mar 2014
Copyright @2014
ISSN: 2319-5886
Research Article
PLACENTAL HISTOMORPHOLOGY: A PREDICTOR OF FOETAL OUTCOME IN MULTIPAROUS

WOMEN
*Mongia Shashi M1, Chauhan Puja1, Mongia Mahima2
1
Department of Anatomy, SGRRIMHS, Patel Nagar, Dehradun, Uttarakhand, India

Department of Dentistry, SGRRIMHS, Patel Nagar, Dehradun, Uttarakhand, India
*Corresponding author email: drshashimunjal@yahoo.in

ABSTRACT
Anaemia being a constant feature of the multigravida mothers causes significant changes in placenta which are
responsible for early termination of pregnancy, resulting in low birth weight babies and an increase in perinatal
mortality and morbidity. Methods In this study, we have correlated the decreased gestational period of ninety
multigravida mothers with that of the same number of primigravida mothers by evaluating the histomorphological
features of placenta in these groups. Here we have taken anaemia as the lone factor for the change in
histomorphological pattern of placenta thus leading to poor foetal outcome. Result Our study concludes that, with
the increase in parity there is a significant increase in the severity of anaemia during pregnancy, and consequent
decrease in the gestational period of the mother resulting in poor foetal outcome.
Keywords: Perinatal mortality, Pregnancy anaemia, Placental morphology, Placental histology
INTRODUCTION
The changes seen in the histomorphology of placenta
in pregnancy anaemia are also seen in multigravida
mothers. This is because high parity of mother results
in high grade anaemia1, which is primarily caused by
repeated blood loss in multigravida mothers2. It is
seen that the histomorphological features of the
placenta change according to the level of maternal
haemoglobin so as to compensate hypoxia. As WHO3
has put forward a critaria that, level of haemoglobin
below 11gm/dl is an indication of anaemia in
pregnancy the multigravida mothers were labelled
anaemic as they were found to have haemoglobin
level below 11gm/dl.
Although placental histomorphology changes with
the
change in pregnancy anaemia so as
to
compensate the hypoxia
caused due to low
hemoglobin but still there comes a level below
which histomorphological changes in placenta are
Mongia et al.,
not sufficient to sustain pregnancy further, thus

leading to poor foetal outcome.
This is a Case Control study for which ethical
clearance was taken before conducting study on 180
placentae, procured from mothers delivered in
Indresh hospital Dehradun.
Placenta of
Primigravidae i.e. (control group N=90) and
Multigravidae i.e. (study group N=90) were taken for
study, where most of the mothers were of third or
fourth gravida and Mean age of both groups was
between 25-35 yrs.
General particulars of mother were taken in both the
groups with detailed history and general examination
with routine investigations was done and
haemoglobin level was noted in all the cases. The
placenta, after their delivery were cleaned and
350
prepared for histomorphological examination.

Weight, volume and number of cotyledons in
placenta were noted for morphology. Then the tissue
of the size of 2 microns was prepared for staining
with haematoxylin and Eosin dyes and mounted on
glass slides for histological study. Observations thus
obtained were analyzed statistically and P Values
were found out by using Microsoft excel.
A)
Primigravidae B) Multigravidae Size is
smaller than the control group, and showing fewer
cotyledons.
As shown in fig 1 the number of cotyledons in
placenta decrease with the increase in parity of the
mother i.e. in multigravida [study group].
RESULTS
Table 1:
Showing ratio of anaemic and
nonanaemic cases in both groups
Groups
Primigravida Group
Multigravida Group
Anaemic
Group
33%
[67%
Non-anaemic
Group
67%
33%
As shown in table 1, anaemia in primigravida

mothers was found to be in less number of cases
[33%] as compared to anaemic cases of multiparous
mothers [67%] .
Whereas in the multigravida group of mothers the
ratio of anaemic and nonanaemic cases was just the
reverse.
Table 2: Mean placental weight and volume in
both groups
Group
Primigravida
Multigravida
Mean Placental
weight (gms)
480+/-8
300+/-10
Mean Placental
Volume(cc)
360+/-6
290+/-8
P value
<0.005
<0.005
According to table 2, shown here the mean placental

weight and volume of the placenta decreases to 300
Gms and
290 cc respectively in multigravida
mothers as compared to the mean placental weight
and volume of 480 grams, and 360cc respectively in
primigravida mothers, considering Mean SE
Fig 1: Gross morphology of the maternal surface of

placenta.
Mongia et al.,
.
Fig 2: Showing comparative analysis of foetal
outcome in primi and multigravid mothers
The foetal outcome showed a significant difference in
both the groups i.e. the control and the study group,
when taking anaemia as the lone factor under
consideration.
As mentioned in Fig 2, the foetal outcome was very
poor in multigravida [study group] as compared to
primigravida [control group].It was observed that
[74%] of primigravida mothers gave birth to full term
normal babies [10%] to low birth weight babies [9%]
to premature babies and [7%] to intrauterine dead
babies. Whereas in the group of multigravida mothers
(27%) gave birth to intrauterine dead babies, (23%)
gave birth to premature babies, again (23%) had low
birth weight babies with only (27% having full term
normal delivered babies
Fig 3:
Photomicrograph of placental villi with
intervillous spaces of the study group (multigravida)
showing severe syncytial knots (400X)
351
Fig 4: Photomicrograph of placental villi with

intervillous spaces of study group (multiparous)
Showing one villous under [100X] with dilated and
increased no.of capillaries per villus with their
thinned out basement membrane. In Fig 3 the
photomicrograph shows that there is an increase of
syncitial knots in the placenta of multigravida
mothers, whereas Fig 4 shows that there is also an
increase in the capillaries per villi, and their dilatation
with thinning of basement membrane in the placenta
of multigravida mothers.
DISCUSSION
Our study goes in line with the findings of Pritchard
Jack2, according to whom blood loss during repeated
pregnancies causes high grade anaemia Our study
was also similar to the findings of Olga4who was of
the opinion that maternal anaemia is associated with
significant reduction in volume of terminal villous
tree and surface area,mostly thought to be due to the
physiological stress caused by hypoxia.
According to P N Singla5 there is less septation of
placenta in hypoxic conditions caused by pregnancy
anaemia, thus leading to decreased number of
cotyledons, which is also seen in multigravida
mothers. Burton6 has also found in his studies that
raised capillary density and dilatation of sinusoids
with accompanied thinning of villous membrane is
the principle adaptation to hypoxia.
The criteria for labelling the foetal outcome in our
study were also seen to be stated by Cunningham7
which was based on gestational age and weight of
baby. According to him foetal death beyond 28 wks
of gestation was termed as intrauterine death, baby
born before the end of 37weeks of gestation was
considered as premature and after 37 weeks of
pregnancy it was taken as full term normal delivered
Mongia et al.,
baby. Taking weight as the criteria baby born with a

birth weight of <250gms was labeled as low birth
weight baby.
Hughes8 in his study has also reported of similar
findings of shorter duration of gestation in pregnancy
anaemia. To determine the placental abnormalities
leading to poor foetal outcome
with perinatal
mortality, different method have been used by many
researchers with the Doppler velocimeters of the
uterine and umbilical arteries.9&10 Also, some of the
researchers have correlated this with sonographic
studies.11 Our study also correlates with other
researchers on altered histomorphology of placenta in
pregnancy anaemia, where according to them
anaemia is the cause for altered placental
histomorphology leading to placental malformation.12
CONCLUSION
In the present study the histomorphological changes
of placenta in multigravida mothers, correlates to the
hypoxic effects of anaemia, caused because of
repeated blood loss during parturition in subsequent
pregnancies.
These changes in placenta lead to early maturity of
placenta, resulting in poor foetal outcome as
prematurity, low birth weight babies or even
intrauterine deaths. It was hence concluded that the
increase in parity causes an increase in anaemia and
results in an increase in prematurity and low birth
weight babies or intrauterine deaths, which is further
attributed to early maturity of placenta in hypoxic
conditions again attributed to anaemia in multigravida
mothers.
REFERENCES
1. Armitage P, Boyd JD, Hamilton WJ and Crowe
B. A Statistical Analysis of a Series of Birth
Weights and Placental Weights. London School
of Hygiene and Tropical Medicine. Anatomy
Department University of Cabridge. Anatomy
Department Charing Cross Hospital Medical
School, London; 1961 : 430-42.
2. Pritchard JA and Mac Donald PC. Anaemia in
Pregnancy. In: Williams Obstetrics 16th Edition.
Appleton Century Crofts. New York Printed in
the United States of America 1976 : 712-15.
3. WHO Report. Report of working group on
Anaemia.1992; 11: p 212 15.
352
4. Olga S, Reshetnikova, Burton GJ and Tereshkova

OV.
Placental
Histomorphometry
and
Morphometric Diffusing capacity of the Villous
Membrane in Pregnancy Complicated by
Maternal Iron Deficiency Anaemia. American
Journal Obstetrics Gynecology. Sept 1995; 173(I)
- 3: 724 27
5. Singla PN, Chand S, Khanna S and Aggarwal
KN. Effect of maternal anaemia on the placenta
and the new born infant. Acta Paediatr Scand.
1978; 67:64548
6. Burton GJ, Reshetnikova OS, Milovanov AP and
Teleshova OV. Stereological evaluation of
vascular adaptation in human placental villi to
differing forms of hypoxic stress. Placenta.
1996;17: 4955
7. Cunningham, Macdonald, Giant le vano, Gilstrap
L, Hawkins, Clark. The Placenta and Foetal
Membranes. Williams. Obstetrics 20th edition.
Printed in the United States of America; 1997:95
-120
8. Hughes EC. The Relationship of the Chorion to
the Fetus in Normal and Abnormal Prgnancy.
American
Journal
of
Obstetrics
and
Gynaecology. 1959 ;77: 880 90
9. Vora S, Shetty S, Khare M, Ghosh K.Placental
histomorphology in unexplained foetal loss with
thrombophilia. Indian Journal of Medical
Research. 2009;129 (2), 144-49
10. Rohini M,Yogesh AS, Goyal M, Kurrey P.
Histological Changes in the Placentae from
Severe Anaemic Mothers. Int J Med Health Sci.
2013,2(1):1-6
11. Thuring, Ann LU ; Marsal, Karel LU and Laurini,
Ricardo LU. Placental ischemia and changes in
umbilical and uteroplacental arterial and venous
hemodynamics. The journal of maternal-foetal &
neonatal medicine. 2012;25:750-55
12. Jerzy S, Hypoxic Patterns of Placental Injury: A
Review. Archives of Pathology & Laboratory
Medicine: May 2013;137(5):706-20
Mongia et al.,
353
DOI: 10.5958/j.2319-5886.3.2.074

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
nd
Received: 2 Feb 2014
Revised: 4th Mar 2014
Copyright @2014
ISSN: 2319-5886
Research Article
INDIAN MUSIC THERAPY: COULD IT BE HELPFUL IN THE MANAGEMENT OF MENTAL

DEPRESSION?
Mounika Akkera1,*Srilatha Bashetti2, Neetha Kundoor3, Krishnaveni V Desai4, Radha Kishan N2, Aparna V
Bhongir5
1
Student final MBBS, 2 Tutor , 3Assitant Professor, 4Professor, Department of Biochemistry, Apollo Institute of
Medical Sciences, Hyderabad, Andhra Pradesh
5
Professor & HOD, Mediciti Institute of Medical Sciences, Ghanpur, Andhra Pradesh
* Corresponding author email: srilathabasetty@gmail
ABSTRACT
The literature shows evidence that music is an effective means of aiding in treatment of mental depression.
However, Indian classical music which has been widely used as an adjuvant therapy in mental depression lacks
the scientific research to establish a proper area of medical treatment. Hence an attempt was made to study the
effect of few selected ragas of Indian Classical Music on mental depression. The study was conducted on 40
clinically diagnosed mentally depressed patients, in the age group of 15- 45 years who were not undergoing any
medical treatment. These patients were given music therapy for 45-60 minutes each day for a period of 15 days.
Patients were analyzed based on the Goldberg questionnaire before and after the therapy. Clinically diagnosed
severe depressive patients were excluded from the study. We found a profound decrease in the levels of
depression in an individual, post-therapy, based on the Goldberg Depression Questionnaire scoring. The results
showed, the significant difference in the pre-therapy to post-therapy score favoring a decrease in the level of
depression (P < 0.0001). According to the Goldberg Depression Questionnaire, a 5 point change in the score is
significant. Further studies based on biochemical parameters could show more accurate results in the future and
effect of music therapy on other vital parameters of the body and experimenting with the variation in the effect in
correlation with the type of music used could show great promise.
Keywords: Music therapy, Mental Depression, Indian Classical Music, Goldberg questionnaire
INTRODUCTION
A low mental state owing to anxiety, irritation,
hopelessness, disinterest, loneliness is known as
depression.1 High stress levels, loss of loved ones,
decreased social support, or traumatic incidences can
be a few conditions that are expected to trigger
depression. Though it is a highly underestimated
condition, it slowly and thoroughly deteriorates ones
quality of life and may even end tragically with
suicide. A survey conducted by WHO where over
89,000 inhabitants were interviewed across 18
Srilatha et al.,
countries, states that, with 36% of its population

being affected by it yearly, India surfaces as the
worlds most depressed country with a suicide rate
of 10.5% which highlights the special attention
required for depression in India. Despite the high
prevalence of depression worldwide, only two-thirds
of the population seek medical help.1 In developing
countries like India, where the rise in depression is
believed to be due to the sudden and rapid change of
lifestyles and families from joint to nuclear settings,
354
such obstacles pose a great challenge and tackling

this could bring down its associated mortality rates.
Music is a well known ancient method to heal various
ailments; communicating a gush of emotions, energy
and the ability to reach the soul. Music therapy
provides a simple, cost effective and safe method to
tackle mental depression. There are a few studies
Workplaces, colleges, schools and other settings,
which are a common source of depression can easily
incorporate music into the ambience to reduce the
level of work stress. Thus music therapy tackles the
issues of social stigma, medication adverse effects
and expenses, lack of psychiatric health care facilities
and provides a means of prevention of depression.
provided with booklets to note down their day to day

feedback on their experience for each day. After a
period of fifteen days, the participants were asked to
fill out the same questionnaire again to obtain the
post-therapy score and the results of both pretherapy and post-therapy were compared and
analyzed using student t-test by SPSS software
(version 17.0).
RESULTS
METHODS AND MATERIALS

The present study was a cross sectional, experimental
and qualitative study conducted on 40 clinically
diagnosed mentally depressed patients within the age
group of 15-45 years, who were not undergoing any
medical treatment, with their consent, approval from
institutional ethical committee at Mediciti Institute of
Medical Sciences, Andhra Pradesh, and Student
ICMR STS project (Reference Number 2011-01428).
We used a self administered questionnaire-the
Goldberg Depression Questionnaire (developed by
American psychiatrist Ivan K. Goldberg contains 18
questions which cover various aspects of the patients
quality of life), as a means of assessing the levels of
mental depression before and after the therapy.
Clinically diagnosed severe depressive patients were
excluded from the study. The subjects who had
willfully participated in the study were subjected to
approximately an hour of receptive music therapy in a
common setting using various ragas from Indian
Classical Music for fifteen days each. These ragas
were selected on the basis of their exclusive use for
mental depression by music therapy professionals and
includes Raag Desh, Raag Brindavana Sarang, Raag
Neelambari, Raag Bhoopali, Raag Hamsadhwani.
The participants were allowed to lie down in any
position comfortable to them with the only
requirement being that they listen to the music in a
relaxed position. The room for the therapy was
arranged with a pleasing ambience with fresh flowers
and sandalwood fragrance. The lights were dimmed
down and made suitable for the participant to relax
without any distraction. Participants were also
Fig 1: Pre-therapy participant counts by grade

*According to the Goldberg depression questionnaire
score regime the 40 participants were divided into the
following six groups score regmie
Grade-1: 0-9 No Depression Likely

Grade-2: 10-17, Possibly Mildly Depressed
Grade-3: 18-21, Borderline Depression
Grade-4: 22-35, Mild-Moderate Depression
Grade-5: 36-53, Moderate-Severe Depression
On grouping, it was found that 14 subjects were
included in No depression likely, 13 subjects in
Possibly mild depression, 5 subjects fell in
Borderline depression, 3 in Mild to Moderate
depression and 5 in Moderate to severe depression
as shown in Fig 1.
Fig 2: Post-therapy participant counts by grade

Grade-1: 0-9 No Depression Likely
355
Srilatha et al.,
Grade-2: 10-17, Possibly Mildly Depressed

Grade-3: 18-21, Borderline Depression
Grade-4: 22-35, Mild-Moderate Depression
Grade-5: 36-53, Moderate-Severe Depression
After the therapy, upon similar grouping, the number
of subjects with No depression likely showed an
increase to 25, those with Possibly mild depression
were 11, and no one fell in Borderline depression
and 2 subjects each in Mild to moderate depression
and Moderate to severe depression. Scores of
individual subjects pre and post therapy is presented
in Chart 2.
The mean values of the pre-therapy and post therapy

results of each group were analyzed and displayed in
the table1. Thus the above values show that the
average improvement of a subject, on undergoing
music therapy is a least 4.93 points. And according to
the Goldberg Depression Questionnaire, a change in 5
points is significant.
*Grouping of the subjects based on the above

improvements according to Goldberg questionnaire.
Group A- No depression likely to No Depression

likely
Group B- Possibly Mild Depression to No Depression
likely
Group C- Mild/Moderate depression to No
Depression
Group D- Possibly Mild Depression to Possibly Mild
Depression
Group E- Borderline Depression to Possibly Mild
Depression
Group F: Mild/Moderate Depression to Possibly Mild
Depression
Group G- Moderate/Severe Depression to Possibly
Mild Depression
Group H- Mild/Moderate Depression to Borderline
Depression
Group
IModerate/Severe
Depression
to
Mild/Moderate Depression
Group
JModerate/Severe
Depression
to
Moderate/Severe Depression
Table 1: Grouping of the subjects based on the above
improvements and averages of the pre-therapy and
post-therapy scores in each group according to
Goldberg depression questionnaire.
(*P < 0.0001)
Number Average Pre- Average
Group
(N=40)
Post-Therapy
Therapy
Group A
Group B
Group C
Group D
Group E
Group F
Group G
Group I
Group J
Mean
14
10
1
3
5
2
1
2
2
6.64
12.60
35.00
14.00
19.60
30.00
44.00
45.50
46.00
17.025*
3.50
5.20
3.00
11.67
15.00
15.50
12.00
26.00
39.50
9.700*
Fig 3: Average Pre and Post therapy scores of

individual subjects by groups
We can appreciate the improvement in terms of
scores, by comparing the pre-therapy mean value
with the post-therapy mean value in each group
shown in Fig 3.
DISCUSSION
In our study 40 subjects who underwent the therapy,
all showed an improvement in their level of
depression based on the comparison of their pretherapy and post-therapy scores on the Goldberg
Questionnaire. The results showed, a significant
difference (P < 0.0001 t = 6.1812; df = 39).
According to the Goldberg Depression Questionnaire,
a 5 point change in the score is significant. The
feedback given by the subjects also showed their selfsatisfaction and improvement in various aspects, of
which the most striking feature was improvement in
the sleep habits, (peaceful sleep during the therapy
and their ability to fall asleep faster at nights). The
study, which was conducted by Bradt J et al, on 1891
mentally depressed patients with cancer showed an
improvement in anxiety, mood and pain by music
interventions when compared with the standard
medical care 2. In our study many subjects noted an
increase in their energy levels and work productivity,
while some even reported better emotional control
356
Srilatha et al.,
and anger management. However, the only Goldberg

questionnaire was used to analyze the above effects.
Hanser SB et al, also observed the same effect of
music therapy on depressed older adults using
Goldberg questionnaire 3.
Yet another study
conducted by Field T, Fox NA et al, reported a direct
impact of rock music on the brain 4,5. The present
study being a questionnaire based study, the results
collected could show variation from time to time and
perhaps further biochemical investigations such as
serum cortisol, etc; may provide us with more
accurate data. Due to the limitation in the time period,
it can be assumed that the effects of the therapy may
be more beneficial if the time period was prolonged.
Though the opportunity to undergo the therapy was
open to a wide population of people, only a smaller
fraction of the participants turned out to have
noticeable depression. Perhaps the social stigma or
lack of interest which is holding back patients with
depression to seek medical attention in society was
the same contributing factor. Music therapy is cost
effective and safe home based method. Increasing the
awareness about this simple means of treatment may
help tackle issues (social stigma) and act as a means
of reaching out to such individuals.
REFERENCES
1. http://www.who.int/mental_health/manageme
nt/depression/definition/en/index.html
2. Bradt J, Dileo C, Grocke D, Magill L. Music
interventions for improving psychological
and physical outcomes in cancer patients.
Cochrane
Database
Syst
Rev.
2011;10;(8):CD006911.
3. Hanser SB, Thompson LW. Effects of a
music therapy strategy on depressed older
adults. J Gerontol. 1994;49(6): 265-69
4. Field T, Martinez A, Nawrocki T, Pickens J,
Fox NA et al. Music shifts frontal EEG in
depressed
adolescents.
Adolescence.
1998;33(129):109-16
5. Jones NA, Field T. Massage and music
therapies attenuate frontal EEG asymmetry in
depressed
adolescents.
Adolescence.
1999;34(135):529-34
CONCLUSION
From the above data it is clear that the hypothesized
result has been obtained from this study. Every
participant showed a significant improvement in their
level of depression. Hence, in can be concluded that
music therapy with Indian classical music definitely
has a positive effect on the mind. Music therapy is an
upcoming field in health care which deserves
attention and adequate research as it proves to show
great potential. It is a means of promoting the healthy
mental status and preventing depression in a safe and
easy manner. Indian classical music further is an
interesting topic of research as it follows a systematic
and scientific pattern and it's correlation with the
functioning of the brain could provide us with new
possibilities in the area of music therapy.
ACKNOWLEDGMENT
We would like to thank ICMR for encouraging the
students to do research through ICMR STS projects.
357
Srilatha et al.,
DOI: 10.5958/j.2319-5886.3.2.075

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nd
Revised: 4 Mar 2014
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ISSN: 2319-5886
Research Article
MUSCULOSKELETAL PROBLEMS AMONG PREGNANT WOMEN: A FACILITY BASED SURVEY

IN ODISHA
Yasobant S1, Nibedita S2, Saswata S2, Arnansu M2, Kirti S2
1
Indian Institute of Public Health-Gandhinagar, India

Neelachal Institute of Medical Sciences, Bhubaneswar, India
*Corresponding author email: dryasobant@gmail.com

ABSTRACT
Background: Chronic medical conditions are in focus for the development of strategies aimed at improving
population health worldwide. This is also true for chronic pain conditions leading to impaired or non-existent
ability to exercise, as physical inactivity is associated with the development of chronic diseases. Musculoskeletal
disorders constitute an estimated 90% of all chronic pain, of which back pain contributes to a high extent. During
the time of pregnancy many hormonal and anatomical changes that affect the musculoskeletal system in the
female body, which may cause various musculoskeletal complaints, predispose to injury, or alter the course of
pre-existing conditions. Though Obstetric physiotherapy is an essential part of maternal health care and
promotion; still it is not well known in developing countries like India. So this current study aimed to address
common musculoskeletal complaints arising among the women during prenatal period in Odisha. Methodology:
A cross sectional study was designed in rural & urban area health facilities targeting the pregnant women of
Odisha. Total of 410 pregnant women from selected facilities of two different regions of Odisha- Eastern (Urban)
and Western (Rural) were interviewed with a structured validated questionnaire. Statistical analysis compared the
independent variables of participants with Musculoskeletal Pain using independent sample t-test for continuous
variables and chi-square for ordinal/nominal variables has been reported considering null hypothesis to be
significant if p-value is <0.05 which is level of significance. Results: About half (50.7%) of the participants
reported symptoms at least in one part of their bodies, over the pregnancy period. Among these, acute Low back
pain was the highest of 55.6% and 35.4% of chronic, followed by acute ankle pain (25.9%) and knee pain
(16.6%). Neck pain (4.9%), Shoulder pain (4.4%) were the least reported among all participants. The MSDs pain
is more among the urban population (54.4%), compared to rural community (45.6%), which shows statistically
significant with p-value of 0.003.Conclusion:Low back pain is the commonest of all, prevailing around more
than half of subjects from our sample. A mixed research method strongly recommended to conduct, including
both pre and post-natal period women, for generalizability and other facilities from all over the globe should be
focused.
Keywords: Musculoskeletal problems, Pregnant Women, MSDs Pain
INTRODUCTION
Chronic medical conditions are in focus for the
development of strategies aimed at improving
population health worldwide. This is also true for
chronic pain conditions leading to impaired or nonexistent ability to exercise, as physical inactivity is
associated with development of chronic diseases.
358
Yasobant et al.,
Musculoskeletal disorders constitute an estimated

90% of all chronic pain, of which back pain
contributes to a high extent.
During the time of pregnancy, many hormonal and
anatomical changes that affect the musculoskeletal
system in the female body, which may cause various
musculoskeletal complaints, predispose to injury, or
alter the course of pre-existingconditions1.
Biomechanical factors also play a larger role with
hormonal influences to produce symptoms in mild to
late pregnancy2.Usually weight gain experienced
during pregnancy results in postural changes that
produce pain and musculoskeletal complaints in
pregnant women. Exaggerated lordosis of the lower
back, forward flexion of the neck, and downward
movement of the shoulders typically occur to
compensate for the enlarged uterus and change in
center of gravity. A significant increase in the
anterior tilt of the pelvis occurs, with increased use of
hip extensor, abductor, and ankle plantar flexor
muscles3.
It is estimated that most of all women experience
some degree of musculoskeletal problem during
pregnancy and at least 25% have temporarily disabled
symptoms4. 70% of all women suffer low back pain
during pregnancy Lower extremity pain is also
common in pregnant women1, 5. The common
musculoskeletal complaints during pregnancy include
low back pain, sacroiliac joint pain, carpal tunnel
syndrome, de Quervainsstenosing tenosynovitis,
pelvic pain, stress incontinence etc1. Physiotherapy
can play a vital role in obstetrics. The principles of
physiotherapy in obstetrics were first developed by
Miss Minnie Randall OBE, who was a great
physiotherapist in the early 20th century6.
Most of the musculoskeletal problems that arise
during pregnancy can be prevented and treated with
physiotherapy treatment. The 2003 joint statement of
the society of Obstetrics and Gynaecologists (SOGC)
and the Canadian Society of Exercise Physiology
(CSEP) recommended various therapeutic exercises
associated with the resistance exercises in addition to
aerobic exercises for pregnant women7.
The population is becoming aware to understanding
the benefits of exercise and a healthy lifestyle. It is
important for the physician to understand the effects
of exercise on the mother and her unborn child, thus
many women wants to continue their exercise
regimens throughout their pregnancies1. Pregnant

women with uncomplicated pregnancies should be
encouraged to continue and engage in physical
activities because pregnancy is not a state of
confinement. As pregnancy is associated with
profound anatomical and physiological changes so,
proper and individualized exercise may help to
prevent and combat many of the musculoskeletal
complications associated with pregnancy7.
In Odisha the promotion of proper maternity care is
still remains a great challenge. Though Obstetric
physiotherapy is an essential part of maternal health
care and promotion; still it is not well known in
Odisha. Research makes the profession strongest and
this study can show the need to establish the skills of
physiotherapists particularly in the Gynaecology and
Obstetrics area.
The study aimed to address common musculoskeletal
complaints arising among the women during the
prenatal period in Odisha, with the following
objectives;
1. To explore common pregnancy related
musculoskeletal complains arising among
pregnant women at selected hospitals in Odisha.
2. To identify the prevalence of low back pain
among the pregnant women in Odisha.
3. To find out association between various factors
like physical activity level, BMI, gestational age,
various age groups etc. Among the pregnant
women.
4. To spread the awareness regarding common
antenatal musculoskeletal problems and their
prevention by using physiotherapy approaches.
5. To educate the clients regarding various
strengthening and stretching techniques which are
beneficial for them to do to their activities of
daily living more efficiently during & after
delivery.
METHODOLOGY
After the approval of Institutional Ethics

Committee the cross sectional study was
conducted in rural & urban area health facilities
targeting the pregnant women of Odisha. As this was
a survey on common pregnancy related
musculoskeletal complaints arising among the
women during the prenatal period, a researcher was
interested to collect data from the pregnant women
359
Yasobant et al.,
who came for clinical check-up as an outpatient at

Obstetrics &Gynaecology Department in different
hospitals throughout their pregnancy, so study site
were selected health facilities of the Eastern (Urban)
as well Western (Rural) Odisha for the study, with
purposive sampling. The actual sample size of this
study was calculated as 288, with Prevalence=35%
from previous research, but totally we enrolled
around 410 pregnant women for the current study. All
pregnant women are selected randomly with inclusion
criteria of Multigravida or primigravida both were
selected to identify the frequency of pregnancy
related musculoskeletal complaints in both gravida,
irrespective of age and trimester status of pregnancy.
They are provided with written informed consent.
Questionnaire is provided to only those clients who
have given their consent to cooperate with our
research procedures. Those who did not fulfil the
inclusion criteria were excluded such as subjects who
were medically unstable or having Persistent or
previous pathological and traumatic history of
musculoskeletal system of the body. A structured,
validated Questionnaire was administered among the
clients in presence of their respective Family
members, which contains: Demographic Data with
Personal History and Ergonomic hazards, objectively
two internationally (Nordiac Musculoskeletal
Questionnaire and The Quebec Back pain disability
scale) standardized tools have been used for
collecting data. At the end of data collection, clients
are demonstrated with various antenatal exercises for
strengthening and stretching the weak and tight
musculature. A printed version of Pre-natal and postnatal common exercises template has been provided
to all participants for future reference.
Data were summarized using the descriptive statistics
of mean, standard deviation and percentages.
Statistical analysis compared the independent
variables of participants with Musculoskeletal Pain
using independent sample t-test for continuous
variables and chi-square for ordinal/nominal variables
has been reported considering null hypothesis to be
significant if p-value is <0.05 which is level of
significance. The data analysis carried out using R
version 3.0.1 software
RESULTS
Table 1 explains the demographic statistical value of
women. The mean age, height, weight and body mass
index of all respondents were 25 4 years, 158

6.12 cm, 58 9 Kg and 23.22 3.9 Kg/m2
respectively. The mean education of participants was
12th class, with average family income of more than
18,000 per month.
Table1: Descriptive Statistics of Participants
Variable
Age (yrs)
Education
Height (cm)
Weight (Kg)
BMI (kg/m2)
Monthly Income (INR)
Mean SD
25 4
12 2
158 6.12
58 9
23.22 3.9
18,845 9236
Min-Max
18-40
0-13
125-169
30-90
13.01-36.26
4,000-50,000
About half (50.7%) of the participants reported

symptoms at least in one part of their bodies, over the
pregnancy period. Among these, the acute Low back
pain was the highest (55.6%) and 35.4% chronic,
followed by acute ankle pain (25.9%) and knee pain
(16.6%). Neck pain (4.9%), Shoulder pain (4.4%)
were the least reported among all participants as
shown in Figure-1.As the age of pregnancy increases
the chances of getting muscular pain also increases,
which clearly resulted in Table-2. The MSDs pain is
highest in late age pregnancy i.e. 35-49yrs (72.7%) as
compared to 20-34 yrs. (63.2%) and 15-19yrs
(53.8%) pregnancy. Similarly as the gestational age
increases the perception of musculoskeletal disorders
(MSDs) pain too increases simultaneously. The
MSDs lowest only 49% in 1st trimester, increased to
64.6% as women move to 2nd trimester and reach the
highest in 3rd trimester as 70.2%, which may be due
to the physiological as well as hormonal changes. The
relation between BMI and MSDs pain, which shows a
controversial interpretation. As the MSDs pain high
in underweight (69.2%) BMI as well in obese (72%)
BMI, might be due to some of confounders in among
the participants. Its least as the BMI is normal (60%).
The interesting finding was physical inactivity leads
to higher chances of MSDs pain (70%). But those
women who involved them in some kind of physical
activity the MSDs pain perception is least (63.1%).
Similarly, as the pain increases the disability too
occurs during daily activities. As 95.9% women with
pain have a moderate disability compared to 56.1%
women with mild disability, which resulted poor
quality of life during pregnancy period.
The Table-2 analysis describes the variables which
have significant contribution towards pain
360
Yasobant et al.,
development during pregnancy. The MSDs pain is

more among the urban population (54.4%0, compared
to rural community (45.6%), which shows
statistically significant with p-value of 0.003. Same
time those having some present / past medical
history, they are susceptible to developing pain as p-
value shows 0.000 and 0.001 respectively. A strong

co-relation found in gestational age with pain
increment as p-value 0.000. Similarly, disability also
shows significant relation as severe disability leads to
activity limitation, further (p-value= 0.000).
Table 2: Relation between different variables with Musculoskeletal Disorders (MSDs) Pain
Variable
Category
No MSDs (n=151)
MSDs (n=259)
Age
15-19yrs (n=13)
6 (4%)
7 (2.7%)
20-34yrs (n=386)
142 (94%)
244(94.2%)
35-49yrs (n=11)
3 (2%)
8 (3.1%)
p-Value
0.632
Religion
Hindu (n=383)
Others (n=27)
143 (94.7%)
8 (5.3%)
240(92.7%)
19 (7.3%)
0.001
Occupation
Housewife (n=401)
Working (n=9)
150(99.3%)
1(0.7%)
251(96.9%)
8(3.1%)
0.098
Education
No Education (n=38)
Primary (n=87)
Secondary/ Higher(n=285)
10(6.6%)
25(16.6%)
116(76.8%)
28(10.8%)
62(23.9%)
169(65.3%)
0.048*
Gestational Age
1st Trimester(n=98)
2nd Trimester (n=144)
3rd Trimester (n=168)
Vegetarian(n=103)
Non-Vegetarian(n=307)
No (n=4)
Yes(n=406)
50(33.1%)
51(33.8%)
50(33.1%)
37(24.5%)
114(75.5%)
1(0.7%)
150(99.3%)
48(18.6%)
93(35.9%)
118(45.5%)
66 (25.5%)
193(74.5%)
3(1.2%)
256(98.8%)
0.000***
No (n=4)
Yes(406)
No (n=352)
Yes(n=58)
1(0.7%)
150 (99.3%)
132(87.4%)
19(12.5%)
3(1.2%)
256(98.8%)
220(84.9%)
39(15.1%)
0.003**
155(59.8%)
104(40.2%)
16(6.2%)
228(88.1%)
15(5.7%)
189(73%)
70(27%)
0
55(21.2%)
129(49.8%)
75(29%)
27(10.4%)
147(56.8%)
67(25.9%)
18(6.9%)
118(45.6%)
141(54.4%)
0.000***
Dietary Habit
Physical Activity
Recreational
Activity
Past
Medical
Disorders
Current Medical No (n=293)

138(91.4%)
Disorders
Yes(n=117)
13(8.6%)
USG Info
Abnormal (n=19)
3(2%)
Normal (n=348)
120(79.4%)
Not Available(n=33)
28(18.6%)
QBP
Disability Mild(n=337)
148(98%)
Score
Moderate(n=73)
3(2%)
Severe(n=0)
0
Family Monthly <10,000 (n=87)
32(21.2%)
Income (INR)
10,000-20,000(n=202)
73(48.3%)
>20,000(n=121)
46(30.5%)
BMI
Underweight(n=39)
12(7.9%)
Normal(n=245)
98(64.9%)
Overweight(n=101)
34(22.5%)
Obese(n=25)
7(4.6%)
Community
Rural(n=165)
47(31.1%)
Urban(n=245)
104(68.9%)
Signif. Codes: *significant, ** Highly significant, *** extreme significant
0.066
0.530
0.001**
0.000***
0.000***
0.944
0.400
0.003**
361
Yasobant et al.,
Musculoskeletal Pain complained among Pregnant Women

Neck
Shoulder
Acute
Chronic
Upper Back
MSDs Region
Elbow
Wrist
Lower Back
Hip
Knee
Ankle
0
10
20
30
40
50
60
Percentage of MSDs Pain complained among Pregnant Women
Fig 1: Distribution of MSDs Pain in different body region

DISCUSSION
The aim of the study was to identify common
pregnancy related musculoskeletal complaints arising
among the women during the prenatal period in
selected hospitals in Odisha. There were 410 samples
in this study. The majority of the respondents almost
35-49yrs (72.7%) and in 3rd trimester as 70.2%
reported MSDs pain in their body region. The most
complained MSDs was acute Low back pain (55.6%),
followed by acute ankle pain (25.9%) and knee pain
(16.6%). Whereas a study of Swedish women, almost
69% of the participants reported suffering from low
back pain during their pregnancy8. According to
Hills950-90% women suffered from low back pain in
the prenatal period. In a study, 59% of Iranian women
suffered from low back pain during their pregnancy10.
The results of these studies support the current study
result of low back pain among the pregnant women in
Odisha.
The current study also found the socio-cultural
variation of MSDs pain during pregnancy, as the pain
found in Urban was high 54.4%, compared to rural
45.6%, also highest in Hindu religion (92.7%). Also
an important factors this study came with that as the
pain increases the disability of life increase
simultaneously, which reflected from Quebec Back
Pain (QBP) disability score of pregnant women,
ultimately affects the quality of life11-15.
In this study researcher only took the pregnant

women who came for check-up at selected hospitals
in Odisha. So for further study researcher strongly
recommended to include other hospitals from all over
country. In this study, musculoskeletal complaints of
prenatal period only focused; so need for further
research to explore the prevalence of musculoskeletal
complaints in the postnatal period. It is recommended
for further study to generalized physiotherapy
treatment among the pregnant women to prevention
and treatment of musculoskeletal complaints in
women both in prenatal and postnatal period
CONCLUSION
From this research, we conclude that among various
musculoskeletal complaints during pregnancy, low
back pain is the commonest of all, prevailing around
more than half of subjects from our sample. For the
ensuring of the generalizability of the research it is
recommended to investigate with large samples.
Acknowledgment: NIMS, Participants
Conflicts of Interest: The authors declare that they
have no competing interests.
Funding: NIL
362
Yasobant et al.,
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8. Koirala A, Khatiwada P, Giri A, Kandel P,
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Pinault J, Feldman P and Laperriere L. Perineal
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DOI: 10.5958/j.2319-5886.3.2.076

&
Health Sciences
www.ijmrhs.com
th
Coden: IJMRHS
th
Revised: 4 Mar 2014
Copyright @2014
ISSN: 2319-5886
Research Article
THE CHARACTERISTICS AND DETERMINANTS OF MAXIMAL EXPIRATORY PRESSURE IN

YOUNG ADULTS FROM TRIPURA
*Dipayan Choudhuri1, Soma Choudhuri2
1
Department of Human Physiology, Tripura University (A Central University), Suryamaninagar, Agartala,

Tripura, India
2
Department of Physiology, Tripura Medical College & Dr. B.R. Ambedkar Teaching Hospital, Hapania,
Agartala, Tripura, India.
*Corresponding author email: dipayanchoudhuri@gmail.com
ABSTRACT
Objective: To obtain values for normal maximal expiratory pressure (MEP) in adolescent subjects (age 17-21yrs)
of Tripura and to correlate the normal values of MEP with different anthropometric and respiratory parameters of
the subject.Materials and Methods: Seventy (70) male and sixty seven (67) female subjects were included in the
study through a randomized method of sampling. The height, weight, chest circumference, mid upper arm
circumference, hip and waist circumference, blood pressure, heart rate, forced vital capacity (FVC), forced
expired volume in 1 second (FEV1), peak expiratory flow rate (PEFR) were recorded in the subject. Maximal
expiratory pressure was recorded by using a modified Blacks apparatus. Results: MEP recorded in adolescent
subjects from Tripura was comparable with those recorded in previous study for the similar age group. MEP
correlated significantly with Age, Body weight, BMI, Chest expansion, and FEV1 of the subjects. Conclusion:
The results of the study can be used to predict respiratory muscle strength in adolescent subjects. Methodology
employed in the study will serve as a means for simple assessment of respiratory muscle strength of the subjects
with lung disorder and also aid in planning the treatment strategy.
Keywords: MEP, Age, Weight, Chest expansion, BMI, FEV1.
INTRODUCTION
Maximal expiratory pressure (MEP) evaluates the
strength of respiratory muscles and is utilized for
diagnostic and prognostic values in various
neuromuscular and cardiovascular diseases by
clinicians.1,2 It is useful to detect and quantify
respiratory muscle weakness associated with
malnutrition and physical work capacity.3 Procedure
for measurement of respiratory pressure is very
simple and can be performed in field condition
without much difficulty.4Bothphysical characteristics
and ethnicityare reported to play important role in
determining maximal expiratory pressure in different
population study.5 No previous study has provided
reference values for MEP using randomly selected

healthy adolescent from population of Tripura. With
this purpose, we evaluated various anthropometric,
physiological and respiratory parameters in
adolescent subjectsfrom a population of Tripura, a
North Eastern state of India. Correlation between
various anthropometric and respiratory parameters
with maximal expiratory pressure was also evaluated.
The study was conducted on 137 randomly selected
adolescent subjects of both sexes aged17 21
yearsfrom Tripura. 70 of them were male and 67 were
364
Dipayan et al.,
female. The study included only healthy non-smoking

subjects.
Subjects
with
any
respiratory,
neuromuscular, cardiac and endocrine disorders were
excluded from the study. The study protocol was
approved by Institutional ethical committee. Each
participating subject signed an informed consent
before volunteering for the study.
Age (yr), standing height (cm), body weight (kg),
chest circumference (cm), mid upper arm
circumference (cm), waist hip ratio were measured
using standard procedure.6 Height was measured to
nearest of 0.1 cm and weight was measured to nearest
of 0.1 kg. Chest circumference was recorded both
during normal respiration and maximal expansion.
Waist circumference was measured by placing the
tape between coastal margin and iliac crest of the
subject. Body mass index was calculated by formula
from height and weight of the subject.7
Physiological parameters recorded included resting
heart rate, respiratory rate and blood pressure. Forced
Vital capacity (FVC) and forced expiratory volume
during 1st second of expiration (FEV1) were recorded
according
to
American
Thoracic
Society
(ATS)8guidelines by using an expirograph (Helios
401, RMS, India). Peak expiratory flow rate (PEFR)
was recorded by using Wrights peak flow meter.
For measurement of maximal expiratory pressure
(MEP) of the subject, a modified Blacks apparatus
was used. For the purpose, the subject expired from
total lung capacity after a maximal expiration. All the
recordings were taken in sitting posture. Maximum of
three trials with an interval of one minute between the
trials were allowed for each subject. The highest
value was accepted for computation.9
All parameters were recorded during morning hours
(7.30am to 9.30am) to minimize possible diurnal
variation. First, the manoeuvres were demonstrated
and then the subjects were asked to perform the
manoeuvre. During the measurements of respiratory
parameters the subjects were asked to use the nose
clip.
All the values were presented as mean SD. Level of
significance was assessed by using unpaired students
t test. A linear associationwas established by using
Pearsons correlation. The statistical analysis was
performed using software SPSS version 19.0.
RESULTS
Values of various anthropometric, physiological and
respiratory parameters recorded in both male and
female subjects are presented in Table 1.
Table 1: Various Anthropometric parameters recorded
in subjects.
Parameters
Male Subject Female Subject
Age ( years)
19.68 1.583 19.0 1.288
Height (cm)
155.61 1.29 143.95 1.79
Weight (kg)
56.96 1.94 52.12 2.67
Arm circumference 34.80 1.26 26.51 1.53*
(cm)
Hip circumference 89.33 1.59 86.80 1.85
(cm)
Waist circumference 78.29 1.12 82.79 1.23
(cm)
Chest expansion
4.78 0.57 2.60 0.62*
( cm )
Hip : Waist Ratio
1.358 0.18 1.879 0.62
BMI (kg/sq.mt )
24.57 2.6
22.76 2.1
(Values are Mean SD, * p < 0.01)

All the parameters including BMI are within the
normal range for the age and sex of the subjects. Data
on various physiological and respiratory parameters
recorded are presented in Table 2.Blood pressure and
heart rates of the subjects are within the normal
range. Respiratory parameters like VC, FEV1 and
PEFR are found to be significantly lower in female
subjects in comparison to male subjects.
Table 2: Physiological and Respiratory parameters
recorded in subjects.
Parameters
Male subject
Female subject
Heart Rate
77.93 3.48
79.47 2.91
(beats/ min)
SBP (mmHg)
123. 89 5.42 118.73 6.89
DBP (mmHg)
78.30 4.27
71.68 5.92
Vital Capacity (ml) 2896.5937.68 1968.3435.58*
FEV1 (%)
86.93 1.78
76.24 1.95*
PEFR (ml/min)
530.42 17.82 372.60 19.46*
MEP(mm Hg)
93.39 2.74
71.23 1.97*
SBP=Systolic Blood Pressure, DBP= Diastolic

Blood Pressure, PEFR= Peak expiratory flow rate,
MEP= Maximal Expiratory Pressure, (Values are
Mean SD, * p < 0.01)
Maximal expiratory pressure (MEP) recorded in male
and female adolescent subjects of Tripura are93.39
1.74 and 71.23 0.97 respectively. Recorded MEP
value in female is significantly less than the male
value.
365
Dipayan et al.,
Regression equations of MEP values using a linear

regression model with anthropometric variables like
age, body weight, chest expansion, BMI and
respiratory variable FEV1 are proposed for young

adult subjects from Tripura and are presented in
Table 3.
Table 3: Regression Equations using various Predictors of Maximal Expiratory Pressure in Male and Female subjects
PREDICTOR
Male subject
Female subject
MEP = 38.4779 + 2.986 AGE
MEP = 40. 221 + 1.717 AGE
AGE (years)
( R2 = 0.092 , SEE = 8.353 , F 0.05 = 3.911 ) ( R2 = 0.464 , SEE = 4.682 , F 0.05 = 3.982
MEP = 11.1449 + 1.228 Weight
Body
Weight MEP = -33.2011+2.394 WEIGHT
( R2 = 0.402 , SEE = 6.78, F 0.05 = 90.609 ) ( R2 = 0.464 , SEE = 4.682 , F 0.05 = 3.982 )
(Kg)
MEP = 16. 483 + 2.347 CHEST EXPANSION
Chest Expansion MEP = 45.775 + 8.204 Chest Expansion
(cm)
( R2 = 0.415 , SEE = 4.889 , F 0.05 = 3.982 ) ( R2 = 0.440 , SEE = 4.785 , F 0.05 = 3.982 )
BMI
FEV 1
MEP = - 86.225 + 7.575 BMI

(R2 = 0.774 , SEE = 4.162 , F 0.05 = 3.911
MEP = 7.4 + 0.896 FEV1
( R2 = 0.612 ,SEE = 5.458, F 0.05 = 3.911 )
MEP = - 14.249 + 3.408 BMI

( R2 = 0.687 , SEE = 3.574 , F 0.05 = 3.982 )
MEP = 15.998 + 0.656 FEV1
( R2 = 0.668 , SEE = 3.572 , F 0.05 = 3.982 )
DISCUSSION
The strength and function of respiratory muscles in
young subjects can easily be assessed by recording of
maximal expiratory pressure.8Establishment of
reference values for respiratory muscle pressures
have been undertaken among different population
groups by various researchers.2-4 Wide variations are
reported in predicted values and reference equations
proposed for different groups of people. Differences
in methods used and motivation of the subjects to
perform the manoeuvre are considered as prime cause
behind such variations.10
The modified Blacks apparatus used in our study is
easy to use with minimum leakage through the
mouthpiece.11 All our subjects were motivated and
enthusiastic to perform the manoeuvre. Values of
maximal expiratory pressure recorded in young adult
subjects from Tripura are found to be comparable
with the values reported in literature for subjects of
the similar age group.12In our study, we observed a
significantly lower MEP value for female subjects in
compassion to male subjects. This finding is
corroborated by previous research with similar
subjects.13
Anthropometric characteristics, nutritional status and
physical fitness and biotype of the subject plays very
important role in determining maximal expiratory
pressure (MEP) in different groups of subjects.14
MEP, in our study, is found to be positively
correlated with age, body weight, chest expansion
and BMI of the subject in both the sexes. Age, in
most of the previous studies, is found to be a good
predictor of respiratory pressure in both male and

female subjects.15 Both body weight and height are
found to be correlated with MEP of the subjects in
various studies.16A positive correlation of MEP with
body weight, both in male and female subjects was
reported by Harik-Khan and Leech.17 However, a
negative correlation of height with an MEP in female
subjects was observed by Wilson and Harik-Khan.18
MEP, in our study, showed a negative correlation
with height and a positive correlation with body
weight of the subjects from both the sexes. MEP of
our subjects correlated positively with BMI of the
subject, though there was no correlation with waistto-hip ratio. Increase in muscle mass with higher
body weight and BMI may explain the influence of
body weight and BMI on MEP.19In our female
subjects MEP correlated positively with their mid
upper arm circumference, the similar correlation was
not observed in male subjects. The present
observation also revealed a positive correlation of
MEP with ability of the subjects to expand the chest
during deep inspiration.
Similar observation
regarding the relationship of MEP and chest
circumference is also reported by several other
authors.20,21
The relationship between respiratory pressure and
vital capacity of the subject is studied by various
authors under different conditions. Most of these
studies revealed a correlation between vital capacity
and respiratory pressure.22The relationship of MEP
with other respiratory parameters in our study
366
Dipayan et al.,
revealed that MEP of the subjects correlated

positively with FEV1. But it does not correlate with
either vital capacity or PEFR of the subject. Studies
in patients with COPD showed a significant positive
correlation between both MIP and MEP with
anthropometric
parameters
and
FEV1.23
Nishimura,et.al., have also reported a decreasing
relationship between respiratory mouth pressure and
FEV1.24Vimal G, et.al., recently found a positive
correlation of MEP with FEV1.25
CONCLUSION
The maximal expiratory pressures obtained in the
present study for a sample of 17 to 21 years old
subjects from a population of Tripura are comparable
with reported values on subjects from other region of
India. The present study will provide important
insight into the characteristics and determinants of
maximal expiratory pressure in young adults from
Tripura. However, it is also important to note that
further studies are still necessary, involving a greater
sample of subjects including a wide age and
socioeconomic range from various regions and
different ethnic groups of Tripura.
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pressure in healthy 20-89 year-old sedentary
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R, Angelio P. Maximal respiratory static
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MJ. Respiratory muscle strength in older adults.
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Normative values for maximal respiratory
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12. Maruthy KN, Vaz M. The development and
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DOI: 10.5958/j.2319-5886.3.2.077

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Research Article
CONTRIBUTION OF FREQUENCY MODULATIONS TO THE PERCEPTION OF SPECTRALLY

SHIFTED SPEECH IN QUIET AND NOISE
Somashekara HS1, Nisha Krishnani2, Jayashree S Bhat3, *Arivudai P Nambi4
1
Assistant Professor, 3Professor, 4Assistant Professor, Department of Audiology and Speech Language Pathology,
Kasturba Medical College, Manipal University, Mangalore, Karnataka, India.
2
Clinical Audiologist and Speech language Pathologist, Nisha Speech and Hearing centre, Ahmednagar,
Maharashtra, India
*Corresponding Author email: arivudai.nambi@manipal.edu
ABSTRACT
Cochlear implant is electronic device which is surgically implanted into the cochlea to provide the sense of
hearing for hearing impaired individual who may not benefit from hearing aids. The current days cochlear
implant codes only the temporal envelope cues. Speech perception simulation studies have shown that, adding
frequency modulation cues to the amplitude modulation improves the speech recognition under adverse listening
condition. A similar processing cannot be incorporated in the cochlear implant as it would result in spectral
mismatch. The current study evaluated the effect of such mismatch on speech recognition scores. Method: The
study involved the subjects with normal hearing who listened to the spectrally shifted HINT sentences having
only amplitude modulation (AM) cues and amplitude modulation with frequency modulations (FM). Sine wave
vocoders were used to synthesize the signals with only AM and AM with FM cues. For simulating the spectral
mismatch, carrier frequencies were decided based on Greenwoods map. Sine wave vocoded speech was
presented with and without background noise. Results: Pairedt test showed significant main effect of FM on
spectrally shifted speech in quiet as well as noise. Mean scores significantly improved when the speech was
processed with AM+FM spectral shift than AM spectral shift alone in both the conditions. Conclusion: The
results of the current study indicated the importance of frequency modulation cues even in the spectrally
mismatched conditions.
Keywords: Cochlear implant, Spectral shift, Amplitude modulations (AM), Frequency modulations (FM)
INTRODUCTION
The cues for speech recognition can be broadly
classified as spectral and temporal cues.
The
contribution of this spectral, temporal envelope and
temporal fine structure cues for speech recognition
has been studied extensively in recent decades. The
envelope cues from as few as four bands are
sufficient for good speech recognition in quiet1.
Increasing the number of spectral channels improves
the speech perception. Adding fine structure cues
along with envelope significantly improves the

perception in adverse listening conditions2. Envelope
is a slow fluctuation in the amplitude that rates below
50Hz and the fine structure is a fast frequency
fluctuation that rates above 500Hz. Figure 1 depicts
the envelop and fine structure of a speech signal.
Contemporary cochlear implants code only the
spectral and temporal (envelope) information. The
spectral information is coded by number of
369
Somashekara et al.,
stimulating electrodes and electrode position in the

cochlea and temporal information is coded by
presenting the band specific envelope to each
corresponding electrodes3. But in the cochlear
implants the spectral information is presented to
wrong place of the auditory nerve array, due to the
fact that electrodes can only be inserted part of the
way into the cochlea. This partial insertion causes
spectral shift in the speech signal carried by the
auditory nerves. The effect of this insertion depth is
difficult to study in cochlear implantees due to the
interaction of following variables such as duration of
deafness, age of implantation, insertion depth across
individuals, cognitive and linguistic performance and
the amount of neuronal survival. So, efforts have
been made to simulate the effect of insertion depth by
shifting the spectrum towards high frequencies. There
is a significant decrement in the performance when
the spectrum is shifted towards the high frequencies
to mimic the basal position of the electrodes in
cochlear implant4,5
Amplitude
0.2
-0.2
0.1
0.2
0.1
0.2
0.1
0.2
Amplitude
0.3
0.3
0.4
0.5
0.3
0.4
0.5
0.3
0.4
0.5
Time (sec)
0.2
0.1
Amplitude
Time (sec)
-1
Time (sec)
Fig 1: Representing the envelope and fine structure of

the speech signal
The effect of spectral shift on speech recognition is

explored in quiet and as well as in noisy situation
using the speech stimuli containing only envelope
cues. But, it is shown that temporal envelope cues
Somashekara et al.,
alone are not sufficient for speech recognition in

noise 1,6,7. It has been reported that adding frequency
modulation along with envelope improves the
perception under adverse listening condition8. Adding
frequency modulations will help the listeners to
utilize the fine structures which is essential for speech
perception in noise especially, ecologically relevant
conditions such as speech perception in fluctuating
noise.
TFS cues are used for speech perception in
fluctuating noise is through the process of dip
listening 9. Normally hearing listeners identify target
speech better in fluctuating noise than steady
background noise 10,11. This occurs because of
masking release due to dip listening 12. Dip
listening refers to the ability to take a snapshot of
target signal when fluctuating background noise
levels momentarily decrease relatively preserving the
signal. Dip listening seems to depend at least partly
on TFS information. 9,11,13,14. TFS of the target signal
in the dips of the fluctuating noise is important to
determine the target signal.9 It is found that for
individuals with poor TFS sensitivity, speech
perception is similar in steady and fluctuating noise.
This could be because they are not able to use
information in dips to enhance speech perception.
Nie, Zeng & Stickney 2proposed a method to encode
the frequency modulations in the cochlear implants.
The proposed method was to frequency modulate the
fixed pulse width carrier with the slow varying
frequency modulations extracted from the speech
signal. In earlier approach only envelop cues were
extracted from one carrier band and presented to
wrong place of the cochlea. However this method
will present both AM as well as FM cues to the
wrong place of the cochlea, thus resulting in a
perception of spectrally shifted speech. Inline with
this, the present study compared the sentence
recognition scores in AM spectrally shifted speech
with AM+FM spectrally shifted speech (Spectrally
shifted conditions were produced to simulate 25mm
insertion depth and the active length of the electrode
array was considered to be 15mm).
METHOD
Subjects: The current study is in accordance with the
ethical standards of the Helsinki declaration of 1975
(revised in 1983) 15. It followed an experimental
study design with non-random convenient sampling.
370
A group of 39 (19 males, 20 females) normal hearing

individuals within the age range of 18 to 25 years
participated in the present study. They further divided
into group1 and group 2. The group1 involved 24
individuals (12 males, 12 females) who were
subjected to experiment 1 which assessed speech
recognition abilities for the speech stimulus having
amplitude modulations alone and amplitude
modulations with frequency modulations in quiet,
whereas in group 2 the other 15 ( 7 males, 8 females)
individuals were assessed the same in presence of
noise. All the subjects had hearing thresholds better
than 15dBHL at audiometric test frequencies from
250 to 8000Hz and were exposed to English language
at least for 5 years.
Stimuli: Two lists each containing 10 English
sentences taken from HINT sentences16 were used.
The familiarity of the sentence lists was ascertained
by individuals with exposure to English language at
least for ten years. In each list three key words were
identified, with a total of 30 key words. Female
speaker with Indian English accent spoke the speech
stimuli. The stimuli were recorded digitally on a data
acquisition system at 44.1 kHz sampling frequency
and using a 16-bit A/D converter in a sound treated
room. Responses were scored using loose method
in which, only the key words were considered for
scoring. The correct identification of the key word
received a score of one. 17
Signal processing: Eight channel sine wave vocoders
were used to simulate cochlear implant speech
processing. Speech signals were band pass filtered
into 8 frequency bands with a slope of 24dB/octave.
From each band pass signal AM and FM was
extracted in two different pathways. For AM
extraction the sub-band signals were subjected to full
wave rectification and low-pass filtering at 160Hz. In
another pathway the sub-band signals were sent
through phase orthogonal demodulation filter to
extract slowly varying frequency modulation at
400Hz or at filters bandwidth. The extracted FM was
used to frequency modulate the center frequencies of
the shifted band. The output of the two pathways
were multiplied to produce the speech signal with
AM and FM. For spectral shift conditions the
envelope was extracted from 80 - 8000 Hz at
24dB/octave and modulated on a frequency band of
490Hz to 5060Hz. The center frequencies were
calculated based on greenwoods map18. Both the
Somashekara et al.,
sentence list were processed for both the conditions i.

e., spectral shift with AM alone and spectral shift
with AM+FM. Signal processing for experiment1 and
experiment2 was same except that, for experiment2
Four talker babble was added to input speech at
0dBSNR prior to frequency amplitude modulation
encoding (FAME) processing.
Procedure: The experiments were performed on a
PC equipped with a Creative Labs SoundBlaster 16
soundcard. The subjects listened to the sentences via
Senheiser stereo headphones at a comfortable level
set by the subjects themselves. The processed stimuli
lists were presented in a randomized fashion, where
half of the individuals within the group listen to the
AM spectrally shifted sentences alone in the list 1 and
other half of the subjects listened to the list 2, which
was AM+FM spectrally shifted. Subjects were
instructed to listen to the sentences and write down
the responses. Scoring was according to the correct
key word identification through written mode.
Subjects were also encouraged to write down the
perceived words of the sentences, if not a complete
correct sentence.
RESULTS:
The number of correctly identified key words were
counted for both the conditions (AM spectrally
shifted and AM+FM spectrally shifted) in quiet and
noise. The maximum possible raw score for each
condition was 30. Then the scores were converted
into rationalized arcsine units. The rationalized
arcsine transformation was considered as the
inferential statistics assumes that given dependent
variable on interval scale. The rationalized arcsine
transformation arranges the raw scores on an interval
scale and also accounts for ceiling & floor effects that
are inherent in the conventional scoring method19.
Scores obtained in both experiments were converted
into rationalized arcsine units (RAU) score using
following equations.
x is the raw speech recognition scores; n is

maximum possible score. In the current n=30
371
RAU scores were subjected to further statistical

analysis. Shapiro Wilks test of normality was
administered to investigate whether data were
normally distributed. Statistical analysis revealed
that, speech recognition scores in quiet (W24= 0.92,
p>0.05) speech recognition scores in noise (W15 =
0.97, p>0.05).Paired t test was used to investigate the
main effect of addition of FM cues on speech
recognition in quiet as well as noise. Results revealed
that, there was a significant effect of addition of FM
cues on speech recognition ability in quiet (t14 = 5.35,
p=0.00) as well as noise (t24 = 6.86, p=0.00). Addition
of FM cues significantly improved speech recognition
ability in both quiet and noise. Mean and standard
deviation of speech recognition scores in quiet and in
noise is represented in figure 2 & 3 respectively.
However, scores represented the figure raw scores not
RAU scores. Maximum possible raw score was 30.
Fig 2: The mean and standard deviations of speech

recognition abilities of Group1 for spectrally shifted
AM (amplitude modulations) + FM (frequency
modulations) and spectrally shifted AM alone in quiet.
Fig 3: The mean and standard deviations of speech

recognition abilities of group2 for spectrally shifted
with AM (amplitude modulations) + FM (frequency
modulations) and AM alone in noise.
Error bars show improved scores when the speech

was processed with AM+FM spectral shift than AM
spectral shift alone in both quiet and in noise. These
results indicate that the AM cues alone are not
sufficient for speech recognition as it was earlier
reported2,8. FM added speech showed enhanced
speech recognition ability. Thus it is observed that
speech is perceived better when the FM is added to
the spectrally shifted speech. However, even with FM
added none of the subjects achieved 100% scores.
Rosen Faulkner & Wilkinson 17reported that speech
material such as sentences and vowels requires
effective transmission of spectral information for
good performance when compared to consonants.
DISCUSSION
The results of the study reveal that spectrally shifted
speech with both AM and FM was significantly better
than spectrally shifted speech with only AM. The AM
only condition has limited cues, which codes the
fundamental frequency and without coding other
critical cues such as, transition and formants etc. But
amplitude with frequency modulation can account for
this phenomenon. Adding frequency modulation to
the amplitude modulation codes the transition,
formant bandwidth2,8. Since the spectrally shifted
speech with FM contained rich acoustic cues the
speech perception is better with spectral shifted
speech of frequency plus amplitude modulation.
Rosen, Faulkner & Wilkinson, 17 reported that speech
material such as sentences and vowels requires
effective transmission of spectral information for
good performance when compared to consonants.
Even though additional cues were provided by FM,
they were transmitted through different spectral
channels. This could be the reason for not obtaining
100% scores even with the addition of FM.
TFS helps in speech understanding in noise is through
stream segregation mechanism. When target and
masker sentences occur to form the mixed signal,
some distinctive envelope peaks of each are
separately preserved while others combine. If only
amplitude modulation is used, it impairs the subjects
ability to segregate speech and noise. However, when
TFS cues are used it allows the segregation of target
envelope into one stream and masker envelope into
another stream 2. Poor stream segregation for
harmonic complex tone by cochlear hearing loss has
been earlier demonstrated by 20. Inability to use TFS
372
Somashekara et al.,
could be a possible reason for poor stream

segregation ability observed in cochlear impaired
individual. Poor TFS based stream segregation could
contribute to the difficulties experienced by
individuals with cochlear loss in understanding
speech when the competing signal is also speech or
music 20,21.
Over the decades the major concern was to enhance
the speech intelligibility through improved signal
processing in auditory prosthesis. The superior
performance of the normal hearing subjects observed
in earlier studies2,8 on speech recognition when AM
were supplemented with the FM suggested the
importance of the FM cues in addition to AM cues.
However, application of these results to the actual
cochlear implant is not straight forward as they have
not focused on the spectral shift and overall
bandwidth compression that are inherent in actual
cochlear implant. The current study accounted for
these inherent properties of the cochlear implant,
thereby designating the advantage of frequency
modulations even under spectral shifted condition.
The addition of frequency modulations mainly
indicated to be imperative in speech perception under
the background noise. The FM cue lets the
individuals to segregate the speech and noise to a
separate perceptual stream22. Current study focused
on the effect of spectral shift only in the quiet
conditions. However it is crucial to evaluate the
advantages of the frequency modulation cues in
spectrally shifted carrier in the presence of
background noise. Adding Frequency modulation
cues codes rich temporal fine structure (TFS) which
helps in speech perception in noise9.One possible
mechanism by which TFS helps in speech
understanding in noise is through stream segregation
mechanism. When target and masker sentences occur
to form the mixed signal, some distinctive envelope
peaks of each are separately preserved while others
combine. If only amplitude modulation is used, it
impairs the subjects ability to segregate speech and
noise. However, when TFS cues are used it allows the
segregation of target envelope into one stream and
masker envelope into another stream 2. Individuals
exhibit poor stream segregation if they have poor
sensitivity to temporal fine structure20. Poor TFS
sensitivity has been attributed to poor stream
segregation by cochlear hearing loss individuals 20,21.
CONCLUSION
Current study compared the sentence recognition
scores in normal individuals under spectrally shifted
speech having only AM cues and AM as well as FM
cues in quiet condition. The results indicated that,
significant superior performance of the subjects when
the frequency modulations were augmented with the
amplitude modulations in spectrally shifted speech.
Current study derives an important clinical
implication that, addition of FM cues along with AM
cues might improve the perception in cochlear
implants even the spectral shift is present.
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Otolaryngol. 2008;9(4):399406.
14. Hopkins K, Moore BCJ, Stone MA. Effects of
moderate cochlear hearing loss on the ability to
benefit from temporal fine structure information
in speech. J Acoust Soc Am. 2008;123(2):1140
53.
15. Carlson R V, Boyd KM, Webb DJ. The revision
of the Declaration of Helsinki: past, present and
future. Br J Clin Pharmacol. 2004;57:695713.
16. Nilsson M, Soli SD, Sullivan JA. Development of
the Hearing in Noise Test for the measurement of
speech reception thresholds in quiet and in noise.
J Acoust Soc Am. 1994;95(2):108599.
17. Rosen S, Faulkner A, Wilkinson L. Adaptation
by normal listeners to upward spectral shifts of
speech: implications for cochlear implants. J
Acoust Soc Am. 1999;106:362936.
18. Greenwood DD. A cochlear frequency-position
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Acoust Soc Am. 1990;87:2592605.
19. Studebaker GA. A rationalized arcsine
transform. J Speech Hear Res. 1985
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20. Grimault N, Micheyl C, Carlyon RP, Arthaud P,
Collet L. Perceptual auditory stream segregation
of sequences of complex sounds in subjects with
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2001;35:17382.
21. Rose MM, Moore BC. Perceptual grouping of
tone sequences by normally hearing and hearingimpaired listeners. J Acoust Soc Am.
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DOI: 10.5958/j.2319-5886.3.2.078

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
Received: 12th Feb 2014
Copyright @2014
ISSN: 2319-5886
Research Article
MOLECULAR DETECTION OF RIFAMPICIN AND ISONIAZID RESISTANCE IN CULTURE

ISOLATES OF NEWLY DIAGNOSED TB PATIENTS
Vanisree R1, Kavitha Latha M2, *Neelima A3, Prasanti2
1
Dept. of Microbiology, Osmania medical college, Hyderabad, Andhra Pradesh, India

Dept. of Microbiology, Gandhi medical college, Secunderabad, Andhra Pradesh, India
3
Dept of Microbiology, Mediciti Institute of Medical Sciences, Andhra Pradesh, India
2
*Corresponding author email: neelimasudharshan@gmail.com

ABSTRACT
Introduction: Multidrug-resistant tuberculosis (MDR-TB) is an emerging public health problem in many regions
of the world, particularly in developing nations. Accurate and rapid diagnosis is essential in the management of
MDR-TB, not only to optimize treatment but also to prevent transmission. Aims: To evaluate drug resistance in
culture isolates by conventional and molecular methods and detect drug resistance gene in MDR-TB patients.
Material and Method: 100 newly diagnosed pulmonary tuberculosis (TB) diagnosed patients attending TB
Clinic, Gandhi Hospital, Secunderabad were included in the study. Two sputum samples collected from the
patients were subjected to sputum microscopy, culture, Drug Susceptibility Testing (DST). Geno Type
Mycobacterium Tuberculosis Drug Resistance (MTBDR) plus assay was done on the culture isolates to detect
Rifampicin and Isoniazid (INH) resistance. Results: Out of 100 samples, 48 % smear positivity by Ziehl Neelsen
(ZN) method, 51 % culture positivity on LJ medium,11.7% multi drug resistance for Rifampicin and Isoniazid
with conventional drug susceptibility Proportion method,17.6 % drug resistance by molecular method Geno
Type MTBDR plus was observed. Among the 4 Rifampicin (Rif) resistant isolates 2isolates showed mutation
(mut) at D516V and in other 2 isolates only wild type (WT) was missing but no mut was seen . In the 1 Isoniazid
(INH) resistant isolate WT was missing, but no mutation was seen. Among the 4 Rif +INH resistance all showed
mut at S531L for RIF and at S315T1. Conclusion: The Genotype MTBDR assay is a rapid and reliable tool for
the routine direct detection of MTB strains and of strains resistant to INH and RIF in smear positive, highly
infectious patients. The rapid turn around time of the test enables the optimization of the therapy of these patients
before confirmatory culture results are available. The test does not require viable organisms and thus reduces the
biohazard risk in the laboratory.
Keywords: Mycobacterium Tuberculosis, Drug Resistance, Genotype MTBDR assay.
INTRODUCTION
Tuberculosis is the leading cause of mortality in
adults due to an infectious agent and accounts for 26
% of all preventable adult deaths globally.1 At present
global incidence of this disease is increasing at the
rate of 0.4% per year. It is currently regarded as the
seventh most important cause of premature mortality
and is going to be one of the first ten leading causes
of disease burden even in the year 2020.2 In India, out

of one billion population, each year about two
million develop active tuberculosis and up to half
million die . Its prevalence and incidence in India is
30.4% and 1.2% respectively.3
Multidrug-resistant tuberculosis (MDR-TB) is an
emerging public health problem in many regions of
375
Neelima et al.,
Int J Med res Health Sci. 2014;3(2):375-380
the world, particularly in developing nations. Multidrug resistant tuberculosis strains are generally
considered to be those resistant to at least two
drugs,such as INH and Rifampicin. From a
microbiological perspective, the resistance is caused
by a genetic mutation that makes a drug ineffective
against the mutant bacilli. MDR-TB is a man-made
phenomenon poor treatment, poor drugs and poor
adherence lead to the development of MDR-TB.4The
frequency of multi drug resistance varies
geographically and acquired resistance is more
common than primary resistance.
Accurate and rapid diagnosis is essential in the
management of MDR-TB, not only to optimize
treatment but also to prevent transmission. Mutations
confined to a short 81 bp DNA region in the rpoB
gene, encoding the -subunit of the RNA polymerase,
have been found in 95% of Rifampicin-resistant
strains. Mutations in this region are an excellent
marker for MDR-TB.4 The successful treatment of
tuberculosis depends on timely diagnosis and
selection of an adequate treatment strategy. Use of
molecular techniques decreases the time necessary for
the detection of drug resistance from several weeks to
a few days or even less, and a patients treatment
regimen can be adjusted more rapidly to account for
any detected drug resistance .5
Sample size: Two early morning sputum samples
from 100 cases of clinically suspected newly
diagnosed adult pulmonary tuberculosis attending TB
clinic, Gandhi Hospital, Secunderabad for over a
period of one year were included in the study. 20
cases of clinically non tuberculous etiology were
included as controls. The study was approved by
Institutional Ethics committee of Gandhi Medical
College, Secunderabad
Inclusion criteria: (more than any two of the below
to be fulfilled) Fever and cough with expectoration
for more than 3 weeks not responding to antibiotics,
Gradual weight loss, Loss of appetite, Abnormal
findings in chest radiograph
Exclusion criteria: Cases already on anti
tuberculosis treatment (ATT) or had been confirmed
as having Tuberculosis were excluded.
Collection of sample: Two early morning sputum
samples were collected in a sterile leak proof
container.
All the samples were subjected to decontamination

and concentration by Modified Petroffs method 6
Smears were made from the purulent portion of
sputum and stained by Ziehl Neelsen method for
Microscopy and grading was done as follows (Table
1)
Table 1: Grading of sputum smears
No. Of AFB
seen
10 AFB/OIF
1-10AFB/OIF
10-99AFB/OIF
1-9AFB/OIF
Result
grading
Positive
Positive
Positive
Scanty
NO. OF AFB
in 100 OIF
negative
3+
2+
1+
Record exact
number
-----
Fields
examined
20
50
100
200
100
Note: AFB Acid fast bacilli, OIF oil immersion

field
All the samples were inoculated onto Lowenstein
Jensen (LJ) media and incubated at 37C for a
maximum of 8 weeks. In case of any growth of
Mycobacteria, date of first appearance of colony was
noted and was further incubated for further growth.
All the culture positive strains were identified by Para
Nitro Benzoic Acid tests and Nitrate reductase test. 6
Drug Susceptibility testing was done by the
molecular method - GenoTypeMTBDR plus assay
and compared with conventional Proportion method.
Proportion Method 6: The proportion method
calculates the proportion of resistant bacilli present in
the medium with the drug. Two appropriate dilution
of the bacilli, 10 2 and10 4dilutions (undiluted = 106
to 108 CFU/ml), were inoculated on drug-containing
and drug-free media, in order to obtain countable
colonies on both media. The ratio of number of
colonies observed on the drug -containing media to
drug-free medium indicates proportion of resistant
bacilli present in the strain. Drug Concentration of
Rifampicin added to LJ Media was 40 g/ml and INH
added to LJ media was 0.2 g/ml .
Incubation and Reading: Inoculated slopes were
incubated at 37C. Growth is read at 28 days.
Growth is recorded Confluent = 3+; More than 100
colonies = 2+; Record actual number of colonies = 1100 cols.6
Interpretation of the test
1. First reading is taken at 28th day after
inoculation.
2. Colonies only on the slopes are counted.
376
Neelima et al.,
3. The average number of colonies obtained from

the drug-containing slopes indicate the number of
resistant bacilli contained in the inoculum.
4. Dividing the number of colonies in drug
containing slopes by that in drug free slopes gives
the proportion of resistant bacilli existing in the
strain. Below a certain value the critical
proportion the strain is classified as sensitive;
above that value, it is classified as resistant. The
proportions are reported as percentages.
5. If, according to the criteria indicated below, the
result of the reading made on the 28th day is
resistant, no further reading of the test for that
drug is required: the strain is classified as
resistant. If the result at the 28th day is
sensitive, a second reading is made on the 42nd
day only for the sensitive strain.
6. If growth on the control media is poor even after
six weeks (i.e., few or no colonies on the 10-4
bacterial dilution), the test should be repeated.
GenoType MTBDR plus (Hain Lifescience,)
Methodology
The Geno Type MTBDR plus test is based on the
DNA STRIP technology and permits the molecular
genetic identification of the Mycobacterium
tuberculosis complex and its resistance to Rifampicin
and/or Isoniazid from cultivated samples or
pulmonary smear-positive clinical specimens. The
identification of Rifampicin resistance is enabled by
the detection of the most significant mutations of the
rpoB gene (coding for the -sub-unit of the RNA
polymerase). For detection of high level Isoniazid
resistance, the katG gene (coding for the catalase
peroxidase) is examined and for detection of low
level Isoniazid resistance, the promoter region of the
INHA gene (coding for the NADH enoyl ACP
reductase) is examined.
Procedure:
It is divided into three steps1. DNA extraction
2. A multiplex amplification with biotinylated
primers
3. Reverse hybridization.
Procedure was done and results were interpreted
according to the protocol provided by the
manufacturer.7
RESULTS
Age wise distribution of cases shown in Table 2. The
majority of the patients were found to be in the range
of 30-39 yrs (34%). Out of 100 patients included in
the study, 71 were males and 29 females. Comparison
of results of microscopy versus culture on LJ media
(Table 3). In this study 44 (48 %) were smear positive
by Ziehl Neelsen (ZN method), 55 (51 %) were
culture positive on LJ medium. All the isolated
strains belonged to Mycobacterium Tuberculosis
(MTB) complex. The minimum time taken for growth
on LJ media by any strain was 17 days and maximum
period taken was 39 days. Maximum number of
strains (34) showed visible growth between 22- 28
days. Mean duration of incubation for isolation was
25.66 days.
6 (11.76%) isolates showed drug resistance by
convention method (proportion method). Out of 6
drug resistant isolates, 3 isolates showed resistance to
only Rif and 3 isolates showed resistance to both
drugs.
Out of 51 isolates, 6 isolates (11.7%) were multi
drug resistant for Rifampicin and Isoniazid with
conventional drug susceptibility Proportion method,
and 9 isolates (17.6%)were drug resistant
by
molecular method Geno Type MTBDR plus . The
ratio of resistance to both drugs by the two methods is
3:4
Among 4 Rif resistant isolates - 2 showed mut at
D516V and in remaining 2 isolates only WT was
missing, but no mut seen.1 INH resistant isolate
showed WT missing but no mut was seen Among 4
Rif +INH resistant isolates - All showed mut at
S531L for Rif, and at S315T1 for INH
Table 2: Age wise distribution of cases
Distribution
age in yrs
0-9
10-19
20-29
30-39
40-49
50-59
60 and above
total
of No. of cases
01
10
19
34
13
12
11
100
percentage
1%
10%
19%
34%
13%
12%
11%
100%
377
Neelima et al.,
Table 3: Comparison of results of microscopy versus

culture on LJ media
Culture +ve
Culture -ve
total
Smear +ve
42
02
44
Smear -ve
13
43
56
total
55
45
100
Table 4: Comparison of drug resistance by

conventional dst and genotype mtbdr plus method
TEST
DST
Geno Type
Rifampicin
Only
3
4
Rifampicin
+ INH
3
4
INH
only
1
Tota
l
6
9
Table 5: ANALYSIS OF RIF AND INH RESISTANCE
Sample no
16
28
46
52
62
64
rpoB
WT 3,4
8
8
3,4
8
Missing
rpo B mut
MUT
MUT 3
MUT3
MUT
MUT3
1
1
Codon
513 - 530-533 530-533 513 - 530-533
analysed
519
519
Mutation
D516V S531L
S531L
D516V S531L
katG
WT Missing Missing Missing Missing
Missing
kat G mut
MUT1
MUT1
Codon
315
315
analysed
Mutation
S315T1 S315T1
inh A WT
inh A MUT
Codon
analysed
Mutation
RESISTANCE Rif
Rif+INH Rif+INH Rif
INH
Rif+INH
Note: WT-wild type; MUT-Mutation; KatG-gene; Rif- Rifampicin; INH- Isoniazid
73
8
83
7
98
7
MUT3
530-533
NO
MUT
-
NO
MUT
-
S531L
Missing
MUT1
315
S315T1
-
Rif+INH Rif
Rif
DISCUSSION
Drug resistance is a threat to TB control programs. It
is a major public health problem because treatment is
prolonged and complicated, cure rates are well below
those for drug- susceptible TB, and patients may
remain infectious for months or years, despite
receiving the best available therapy. Rapid detection
of drug resistance would help not only to optimize
treatment of MDR-TB, but also breaking the chains
of transmission and identification of any hot spot
regions for proper implementation of the TB control
programs.
The youngest patient included in this study was 21
years old while the oldest was 80 years old.
Maximum number of patients suffering from
tuberculosis were in the age group of 30-39 years
(34%) followed by 20-29 years (19%). Thus more
than half (53%) of patients were in the age group of
20-39 years. Robert etal7 reported 62% of cases.
In this study out of 100 cases, 71 were males and 29

females. The male to female ratio was 2.4:1 which is
in accordance with the study conducted by
V.K.Dhingra 8 who reported 2.2:1.
The smear positivity in this study was 42% by
standard ZN staining. S Rishi etal 9 reported 54.3%
smear positivity while Negi SS etal 10 reported
33.79% smear positivity.
The present study showed 51% culture positivity on
LJ media, which correlated with a study conducted by
Rishi et al 9 who reported 50.6%. The mean duration
of incubation time for Mycobacteria on LJ media was
25.6days while Rishi s etal9 and Negi S et al 10
reported 28.8 and 24 days as mean duration of
isolation respectively.
This study showed cavities in 48% of patients which
is in comparison with Dhingra et al 8 who reported
44% on chest X ray.
378
Neelima et al.,
In this study it was found that 3 isolates (5.88 %)

were resistant to Rifampicin alone and 3 isolates
(5.88 %) were resistant to both Rifampicin and INH
by Proportion method. None of the isolates showed
resistance to INH alone. This study correlated with
W.C Yam et al 11 who reported 39 to be multi drug
resistant among 352 isolates 18 isolates (5.11 %)
were resistant to only Rif and 21 isolates (5.96 %)
resistant to both the drugs. Meera Sharma et al 12
conducted study on 200 isolates and 14 isolates
(7.0%) were resistant to only Rif and 15 isolates (7.5
%) resistant to both the drugs, and 1 isolate (0.5 %)
showed resistant to only INH. Naga Suresh et al
13
studied 56 isolates Out of which 5 isolates (8.9 %)
were resistant to only Rif and 3 isolates (5.35 %)
were resistant to both the drugs.
In this study the 51 isolates were subjected to Geno
Type MTBDR plus. 4 isolates (7.8 %) were resistant
to Rifampicin, 4 isolates (7.8 %) were resistant to
both Rifampicin and INH and 1 isolate (1.96 %) was
resistant to INH alone. 4 isolates showed absence of
rpoB WT8, codon 531 with rpoB MUT3 i.e
mutation at S531L with absent katG WT , codon
315 showing katG MUT 1 mutation at S315T1 . 2
isolates showed absence of rpoB WT 3 ,4 with rpoB
MUT 1 i.e mutation at 513 -519 codon mutation at
D516V 2 isolates showed absence of rpoB WT7 with
no mutation.1 isolate showed absence of only katG
WT with no mutation .
This study correlated with Bahram Nasr et al 14who
reported 3 isolates (7.2 % ) resistant to Rifampicin
and 6.8 % to both the drugs , with absence of
rpoBWT8 with rpoB MUT3 i.e mutation at
S531L and absent katG WT showing katG MUT
1 mutation at S315T1 and absence of rpoB WT 3 ,4
with rpoB MUT 1, mutation at 513 -519 codon i.e
mutation at D516V was seen. Doris Hillemann et al
15
reported 9.2 % of strains resistant to Rifampicin
and 8.1 % isolates showed resistance to both the
drugs. Mutations were seen in 531 codon for rpoB
315 for katG, 13.6 % and in 526, 516 codon.5 isolates
showed absence of wild types with no mutation.
Paolo Miotto et al 16 reported in 3.8 % of isolates
showed D516V substitution in rpoB and 4.4 % in
S531L region.
In this study with Proportion method drug resistance
was seen in 6 isolates and with rapid molecular
method Geno Type MTBDR plus 9 isolates were
drug resistant. As compared to the conventional
method which showed 3 isolates to be resistant to

both the drugs, the Geno Type MTBDR plus assay
showed 4 isolates to be resistant to both the drugs. 3
isolates were resistant only to Rifampicin by
conventional method and 4 isolates showed resistance
only to Rifampicin by the GenoType MTBDR plus
assay, the ratio being 3:4. Our study correlated with
Doris Hillemann et al 15who reported 3.2: 4 ratio in
comparison of both methods. Guessan Kouassi et al 17
showed 1: 6 ratios. Girts Skenders et al 18 reported
1:7 ratio of both methods. In addition, one isolate
showed resistance to INH alone by GenoType
MTBDR plus method which was not shown by
Proportion method.
CONCLUSION
The results of the present study have shown that the
MTBDR plus assay is easy to perform and has the
capability for the rapid detection of Rifampicin - and
INH-resistant M. tuberculosis. MTBDR plus assay
has been proven to be suitable for application for
culture isolates .MTBDR assay can identify the most
frequent mutations involved in resistance to RIF and
INH and can reveal the presence of additional
mutations by negative hybridization results with the
wild-type probes. MTBDR assay identified 100% of
the phenotypically resistant strains for Rifampicin
and Isoniazid resistance.
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DOI: 10.5958/j.2319-5886.3.2.079

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Research Article
VENTRICLES OF BRAIN: A MORPHOMETRIC STUDY BY COMPUTERIZED TOMOGRAPHY

Brij Raj Singh 1, Ujwal Gajbe1, Amit Agrawal2, *Anilkumar Reddy Y1, Sunita Bhartiya1
1
Department of Anatomy, J.N.M.C, Sawangi, Meghe, Wardha, Maharashtra, India

Dept of Neurosurgery, Narayana Medical College, Nellore, Andhra Pradesh, India
*Corresponding author email: kumarlucky48@gmail.com,

ABSTRACT
Introduction: As the human brain ages, characteristic structural changes occur that are considered to be normal
and are expected. Thus the thorough knowledge of the age related normal changes that occur in the brain is
required before any abnormal findings are analyzed. As ageing advances, the brain undergoes many gross and
histopathological changes with regression of the brain tissue leading to the enlargement of the ventricles.
To understand these changes the knowledge of normal morphometry and size of normal ventricular system of
brain is important. Materials & Methods: For the present study 358 (Males - 207 and Females - 151) individuals
Computerized Tomography (CT) images of brain studied. Measurements of fourth ventricle, third ventricle and
lateral ventricle were noted down from CT images and it was statistically analyzed. Results: After analysis it was
observed that the height and width of the fourth ventricle was larger in males as compared to females. The length
of the third ventricle was observed to be greater in females than in males. The width of the third ventricle it was
observed to be greater in males than in females. Antero-posterior extent of the left frontal horn (males = 26.26
2.94, 95% CI 25.86 - 26.66 mm and females = 26.53 3.38, 95% CI 25.99 - 27.08 mm) was greater than that of
the right ones (males = 25.00 3.18, 95% CI 24.57 - 25.44 mm and females = 25.34 3.50, 95% CI 24.78 - 25.90
mm). Conclusion: Advances in sensitive imaging techniques like the Computerized Tomography helps in
dramatic expansion of our understanding of the normal structure of brain. The present study has defined the
morphometric measurements of the lateral ventricles, third ventricle, and fourth ventricle of the brain which has
clinical correlations in diagnosis and for further line of treatment.
Keywords: ventricular system, morphometric study, human brain
INTRODUCTION
Man has long been fascinated with workings of
human brain. The structure of human brain is
complicated and not yet fully understood. As the
human brain ages, characteristic structural changes
occur that are considered to be normal and are
expected. Thus the thorough knowledge of the age
related normal changes that occur in the brain is
required before any abnormal findings are analyzed.
There have been a great number of studies examining
the anatomical structure of the human brain and the
age related changes that occur normally. As ageing

advances, the brain undergoes many gross and
histopathological changes with regression of the
brain tissue leading to the enlargement of the
ventricles.1 Both imaging and autopsy studies
revealed that there is correlation with increase in
cerebrospinal fluid spaces and reduction in cerebral
volume accompanying normal human ageing.2, 3 Due
to these changes that occurs normally with ageing,
the diagnosis of diseases in elderly patients is often
381
Brij et al.,
complicated. So, the two major changes that may

occur in elderly individual without neurologic deficits
is enlargement of ventricles and cortical atrophy.
However surprisingly, there is lack of clinical,
radiologic and pathologic information regarding these
changes in humans. The normal ventricular size
during life was previously unknown.
In the past, the pneumoencephalogram was the most
valuable test for determining ventricular size during
life. Advances in sensitive imaging techniques like
the Computerized Tomography helps in dramatic
expansion of our understanding of the normal
structure of brain without the use of contrast media.
Computerized Tomography also provided a
revolutionary means for morphologic study of the
brain in vivo. Some authors found gender differences
in brain atrophy with ageing and revealed that the
degree of change was milder in women than in men.5
Enlargement of cerebrospinal fluid spaces during
ageing is generally diffused.6 There is regression of
thalamic nuclei after 50 years of age which explains
demonstration of early third ventricular enlargement.4
There is more shrinkage with age in the frontal
cortex, brain stem and dienchephalic structure7. Also
the left lateral ventricle is normally larger than the
right.8 Various studies clearly shows an increase in
the CSF spaces in dementia especially in Alzheimers
disease and Parkinsons disease.9 This was due to
reduction in size of the nerve cells.10 ventricular
enlargement to be a more sensitive indicator of
cortical atrophy due to increasing age and
dementias.11 Studies show there was enlarger of the
lateral ventricles in epilepsy and also in depression.12
To understand these changes the knowledge of
normal morphometry and size of normal ventricular
system of brain is important.
Aims and objectives
1) The aim of the study to analyze the morphometric
measurements of ventricular systems of the brain in
different age group individuals of both genders.
2) To study the symmetry of lateral ventricle on
either side and to compare the result of this study
with previous study.
This was the prospective study in which
Computerized Tomography images of total 358
(Males - 207 and Females - 151) in which 270 adult
individuals (Age Group 20-60 years) and 88 ageing
individuals (Age above 60 years) of either sex

attending the Department of Radiodiagnosis,
A.V.B.R.H., Jawaharlal Nehru medical college from
the year between January 2010 to august 2011. The
criteria for exclusion of individuals in this study
were:
1) Individuals below 20 years of age
2) Any history of local mass lesion in brain
3) Any history of cerebral infarction
4) Any history of hydrocephalus
5) Any history of alcoholism, drug abuse and trauma
or previous history of intracranial surgery
Computer tomography of these patients was
performed on PHILIPS BRILLIANCE MULTI
SLICE (16 SLICE) MULTI DETECTOR SPIRAL
CT SCANNER with a scan time of 1-10 sec and
slice thickness of 5 mm in the posterior cranial fossa
and 10 mm in above region. Study protocol was
submitted to the institutional ethical committee and
their permission was obtained. The patient was placed
on the Computerized Tomography table in supine
position and head was centered to the cris-cross point
of the light beam was made to coincide with the
orbito-meatal line. This position represented the zero
table position.13 The Computerized Tomography scan
images of the brain taken up to the highest level of
cranial vault and it was statistically analyzed.
The following measurements were made from the CT
images which obtained by the standard protocol made
by the radiological society. :
1. Measurement of the fourth ventricle
a). Vertical diameter - Greatest vertical distance
length (mm) of the fourth ventricle (from upper
margin of pons to lower limit of open part of medulla
oblongata). (Figure no. 4 and 5)
b). Transverse diameter - Greatest transverse
diameter measures in mm (maximum transverse
distance along the coronal plane). (Figure no.3)
2) Measurement of third ventricle (Figure no.4)
a) Greatest vertical diameter - height (mm) in
transverse plane in antero-posterior extent.
b) Greatest transverse diameter - transverse diameter
measures in (mm) maximum in coronal plane.
3) Measurement of lateral ventricle of right and left
side. (Figure no.5)
a) Greatest anterior-posterior extent measures in
(mm) for frontal horn of the lateral ventricle.
382
Brij et al.,
b) Greatest anterior-posterior extent measures in mm

for frontal horn and including body of the lateral
ventricle.
RESULTS
Table no. 1 shows the measurements of height of
fourth ventricle. After analysis it was observed that
the height of the fourth ventricle was larger in males
(12.18 1.54, 95% CI 11.97 - 12.39 mm) as
compared to females (12.13 1.41, 95% CI 11.91 12.36 mm), which was statistically insignificant
(T=0.314
p= 0.753). Table no. 1 shows the
measurements of maximum width of fourth ventricle.
The width of the fourth ventricle was observed to be
greater in males (11.07 1.54, 95% CI 10.85 - 11.28
mm) than in females (11.05 1.31, 95% CI 10.8411.26 mm), which was also statistically insignificant
(T= 0.129 p=0.897).Table no. 2 shows the
measurements of length of third ventricle. The length
of the third ventricle was observed to be greater in
females (18.86 8.36, 95% CI 17.52 20.21 mm)
than in males (17.97 2.76, 95% CI 17.59 -18.35
mm), which was statistically insignificant (T= -1.429
p= 0.154). Table no. 3 show the measurements taken
of the third ventricle. After analysis of the width of
the third ventricle it was observed to be greater in
males (3.47 1.07, 95% CI 3.32 - 3.62 mm) than in
females (3.31 0.94, 95% CI 3.16 - 3.46 mm) and
this difference was statistically insignificant (T=
1.470
p= 0.164).Table no. 4 shows various
measurements taken of the lateral ventricles. On
analyzing these it was observed that the anteroposterior extent of the left frontal horn (males = 26.26
2.94, 95% CI 25.86 - 26.66 mm and females =
26.53 3.38, 95% CI 25.99 - 27.08 mm) was greater
than that of the right ones (males = 25.00 3.18, 95%
CI 24.57 - 25.44 mm and females = 25.34 3.50,
95% CI 24.78 - 25.90 mm). Same thing also observed
in the antero-posterior extent of the left lateral
ventricular body including its frontal horn (males =
56.70 6.61, 95% CI 55.79 - 57.61 mm and females
= 56.28 7.59, 95% CI 55.06 - 57.50 mm) was
greater than the right one (males = 55.78 6.15, 95%
CI 54.94 - 56.63 mm and females = 55.10 6.99,
95% CI 53.97 - 56.22 mm).Table no. 5 shows the age
wise distribution of the length of right sided lateral
ventricle frontal horn with body, right sided lateral
ventricle frontal horn, width of the third ventricle and
width of the fourth ventricle. It was observed that as
the age advances dimensions of the ventricles also
enlarges and this difference was statistically
significant by ANOVA test for length of right Lateral
Ventricle (Frontal horn with body) f=26.77
p=0.000, length of right Lateral Ventricle (Frontal
horn) f=15.46 p=0.000, Width of third ventricle
f=3.89 p=0.021 and for the Width of fourth ventricle
value is f=0.49 p=0.614 (Not significant).
Table 1: Measurements of Fourth Ventricle (mm)

Height
width
Mean SD Units
Males (n=207)
12.18 1.54
Females (n=151)
12.13 1.41
Males (n=207)
11.07 1.54
Females (n=151)
11.05 1.31
95% CI (L)
11.97
11.91
10.85
10.84
95% CI (U)
12.39
12.36
11.28
11.26
T Value
0.314
0.129
P Value
0.753
0.897
Table 2: Measurements of Third Ventricle (mm)

Length
Mean SD
95% CI (L)
95% CI (U)
T Value
P Value
<0.05 (Not significant)
width
Males (n=207)
Females (n=151)
Males (n=207)
Females (n=151)
17.97 2.76
17.59
18.35
-1.429
0.154
18.86 8.36
17.52
20.21
3.47 1.07
3.32
3.62
1.470
0.164
3.31 0.94
3.16
3.46
<0.05 (Not significant)
383
Brij et al.,
Table 3: Measurements of Lateral Ventricle (mm)

Fourth Ventricle
Frontal horn
Males (n=207)
Females (n=151)
Females (n=151)
Mean SD
25.003.18
26.262.94
25.343.50 26.533.38 55.78 6.15 56.70 6.61 55.10 6.99 56.28 7.59
95% CI (L)
24.57
25.44
25.86
26.66
24.78
25.90
95% CI (U)
Frontal horn + body

Males (n=207)
25.99
27.08
54.94
56.63
L
55.79
57.61
53.97
56.22
L
55.06
57.50
Table No. 4: Ventricular enlargement (age wise distribution in mm).

Age
Length of Rt. Lat. Length of Rt. Lat. Width
of
3rd Width
of
4th
groups Ventricle
(Frontal Ventricle (Frontal ventricle
ventricle
horn with body)
horn)
(Yrs)
Mean SD
Mean SD
Mean SD
Mean SD
20-40
52.234.80
23.932.34
3.220.76
10.931.46
41-60
55.80
6.18
25.44
3.20
3.33
0.90
11.09
1.38
>61
57.73
6.92
25.92
3.77
3.61
1.30
11.06
1.53
Fig 1: Maximum upper extent of the fourth ventricle

for vertical dimension
Fig 3: Maximum width of the fourth ventricle for

vertical dimension
Fig 2: Maximum lower extent of the fourth ventricle

for vertical dimension
Fig 4: a b = maximum antero-posterior dimension

of third ventricle, c d =maximum width of third
ventricle
384
Brij et al.,
Fig 5: a b = maximum antero-posterior dimension

of right frontal horn with body at the level of
interventricular foramina of the lateral ventricle, c d
=maximum antero-posterior dimension of left frontal
horn with body at the level of interventricular
foramina of the lateral ventricle
DISCUSSION
The human nervous system is the most complex,
widely investigated with recent advance tools like CT
and MRI scan but yet poorly understood physical
system known to the mankind.14-18 many studies
reveals that brain regression involving cerebrum and
cerebellum usually begins at the age in the beginning
of seventh decade and thereafter accelerated as age
advances. Lateral ventricular contours are relatively
constant, except for the occipital horns.19 The
ventricular system can be better visualized by using
modern computerized x-ray tomography, which
allows easy and safe noninvasive study without
complications and it can be used as a screening
procedure for many pathological conditions.4, 20-23
Roberts et al revealed that the value in evaluating
dementia and its use in excluding brain diseases like
neoplasms,
subdural
hematomas,
and
cerebrovascular disease that may mimic like
dementia.23 The ventricular size changes in the brain
encountered in routine clinical practices can mislead
to most of the physicians and surgeons to take proper
decision. However, there is likely to be an increasing
number of circumstances in which precise
measurements will be needed. Gawler et al13 (1976)
revealed that the greatest distance between the roof
and the floor of the fourth ventricle was less than 1.2
cms with a mean of 1.08 cms; however in the present
study this distance is significantly larger in males
(12.18 1.54, 95% CI 11.91 - 12.39 mm) than in
females (12.13 1.41, 95% CI 11.91 - 12.36 mm)
(Table no. 1). In the present study, the height of the

fourth ventricle was found to be greater than the
width in both genders. Width of the fourth ventricles
is more in males (11.07 1.54, 95% CI 10.85 - 11.28
mm) than in females (11.05 1.31, 95% CI 10.8411.26 mm) (Table no. 2).Brinkman et al 24 (1981),
Soininen et al 25 (1982), D'Souza e Dias Medora C.et
al 26 (2007) found that the maximum width of the
third ventricle had a mean of 0.46 cms, 0.59 cms,
0.92 2.71 cms and 0.45 0.29 cms respectively,
with higher values in males. In the present study this
measure was found to be significantly higher in males
(3.47 1.07, 95% CI 3.32 - 3.62 mm) as compared to
females (3.31 0.94, 95% CI 3.16 - 3.46 mm) (Table
no. 3).According to Glydensted 8(1977), Gomori et
al 27 (1984) Takeda and Matsuzawa 28 (1985),
Goldstein et al 29 (2001) and D'Souza e Dias Medora
C. et al 26 (2007) the left lateral ventricle was larger
than the right one and both were larger in males. In
present study, the anteroposterior extent of the left
frontal horns (males = 26.26 2.94, 95% CI 25.86 26.66 mm and females = 26.53 3.38, 95% CI 25.99
- 27.08 mm) was greater than that of the right ones
(males = 25.00 3.18, 95% CI 24.57 - 25.44 mm and
females = 25.34 3.50, 95% CI 24.78 - 25.90
mm).The antero-posterior extent of the left lateral
ventricular bodies including their frontal horns (males
= 56.70 6.61, 95% CI 55.79 57.61 mm and
females = 56.28 7.59, 95% CI 55.06 57.50 mm)
was greater than the right ones (males = 55.78 6.15,
95% CI 54.94 56.63 mm and females = 55.10
6.99, 95% CI 53.97 56.22 mm) (Table no. 5).
CONCLUSION
The structure of human brain is complicated and yet
not fully understood till date. As the human brain
ages, characteristic structural changes occur that can
be considered normal and are expected too. Advances
in sensitive imaging techniques like the
Computerized Tomography helps in dramatic
expansion of our understanding of the normal
structure of brain. The purpose of this study was to
examine the different dimensions of ventricular
system.
The present study has defined the morphometric
measurements of the lateral ventricles, third ventricle,
and fourth ventricle of the brain which has clinical
correlations in diagnosis and for further line of
treatment.
385
Brij et al.,
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15. Dekaban AS, Sadowsky D. Changes in brain
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17. Pakkenberg H, Voigt J. Brain weight of the
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19. Taveras J, Wood . Intracranial pneumography.
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DOI: 10.5958/j.2319-5886.3.2.080

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Research Article
COMPARATIVE EVALUATION BETWEEN 20% EDTA-S & ORNIDAZOLE GEL AS ROOT

BIOMODIFICATION AGENT ASEM STUDY
*Prashant V Khairnar, NilkanthMhaske, NeelimaRajhans, NikeshN Moolya, Sudeep HM
Late Shree Yashwantrao Chavan Memorial Medical & Rural Development Foundations Dental College,
Vadgaongupta, Ahmednagar, Maharashtra
*Corresponding author email:drprashantkhairnar7@gmail.com
ABSTRACT
Background: It should be well understood that the root surface receptiveness to clot formation & initial
periodontal wound healing decides the nature of the connective tissue attachments. This study was carried out to
assess the initial wound healing events after the application of 20% EDTA-S & Ornidazole gel and assess the
formation of fibrin network following blood. Material& Method: Thirty multi-rooted teeth indicated for
extraction due to periodontal disease were selected & divided into group A (20%EDTA-S), group B (Ornidazole
gel (1% W/V)), group C (7.4pH phosphate buffer saline), group D (20%EDTA-S+ Blood), group E (Ornidazole
gel+ Blood), group F (7.4pH) phosphate buffer saline+ Blood). Following root planning, the root surface was cut
using diamond disc under copious irrigation. Samples from each group were subjected for root conditioning agent
application by passive method. Specimens were then subjected to scanning electron microscopic study. Smear
layers removal were analysed by Sampaia et al index. Results: 20%EDTA-S removed the smear layer better than
ornidazole gel. Fibrin network formation was seen with specimen treated with 20% EDTA-S + Blood.
Conclusion: Use of 20% EDTA-S as root conditioning agent has a beneficial effect on initial wound healing
events, which are important for periodontal regenerative therapies.
Keywords: Root bio-modification, 20% EDTA-S, Ornidazole gel, Fibrin network formation
INTRODUCTION
The purpose of periodontal therapy is to re-establish
the tooth supporting tissue affected by periodontal
illness to their unique architectural form.
Conventional surgical & non-surgical therapies plan
at arresting periodontal illness by elimination of
plaque from illness affected roots. Sufficient
elimination of plaque, calculus and cytotoxic
substances from the diseased root surface appears to
be necessary for periodontal rejuvenation.1
Howevertotalelimination with only mechanical
debridement is not always sufficient.2
Instrumentation of the root surface has been exposed
to direct development of smear layer of mutually
organic & inorganic matter. 3This layer is supposed to

be physical barricades to periodontal rejuvenate. The
demineralised root surface may also provide as a
reservoir and preservation site for biologically
dynamic extracellular medium proteins and
development factors that could certainly have an
effect on the wound curingatmosphere.4,5 To triumph
over the above precincts of using only mechanical
root instrumentation, chemical root surface
conditioning has been introduced. Root surface
conditioning by topical application of acidic solutions
has been shown to remove the smear layer resulting
from root instrumentation.6,7 For chemical root
388
Prashant et al.,
surface management, a variety of compounds have

been used: Sulphuric acid, Hydrochloric acid, Lactic
acid, Maleic acid, Phosphoric acid, Citric acid,
Ethylenediaminetetraaceticacid
(EDTA),
and
Tetracycline hydrochloride.
In an in vitro study Islik et al compared the usefulness
of dissimilar application techniques of tetracycline
Hcl on root surfaces & examined the resultant surface
under SEM. STERRETT and BAIN revealed a "shag
carpet" look of intensely tufted fibrils, using a
burnishing method by rubbing the dentin surface with
a cotton pellet drenched in citric acid, more
intertubular fibrils were uncovered and dentinal
tubules widened to a superior level compared to
passive application of the acid.8
Ideally, the demineralization step should have an
even-handedfierceness
to
eradicate
all
instrumentation debris and to dissolve the smear layer
and the Mineral stage, properly exposing dentin
matrix proteins although not changing the structural
and biochemical properties of the exposed proteins.6
In endodontology, EDTA is used to unlock calcified
canals, to remove smear layer with likely infection9
and to reduce potential microleakage10. Smear layer
elimination is achieved with dissimilar arrangements
of EDTA, such as liquid, paste11or gel application
forms. 12 The aim of this study was to build up a root
conditioning agent that can demineralize and detoxify
root surfaces.
MATERIAL&METHOD
Thirty multi-rooted teeth indicated for extraction due
to periodontal disease were obtained from the
department of oral surgery at the Late Shri
Yashwantrao Chavan Memorial Medical& Rural
Development
Foundations
Dental
College
&Hospital, Ahmednagar. After extraction teeth were
stored in container with normal saline to avoid
dehydration of specimens. All the selected teeth were
caries free & were not subjected to scaling & root
planning. Then all selected teeth were subjected to
scaling & root planning. After scaling & root
planning teeth were divided into three groups (Group
A-20% EDTA-S, Group B-Ornidazole gel & Group
C- 7.4pH phosphate buffer saline {control}). Each
group contains ten teeth.
The apical third of the root &the crown portion below
the cement - enamel junction was cut & discarded.
The remaining mid root portion of each tooth was

sectioned longitudinally bucco-lingually with
diamond disc under copious irrigation with normal
saline. All the teeth were stored in small containers
filled with 7.4 pH phosphate buffer saline at 40C until
further use.
The samples sectioned mid-root was segregated into
six treatment groups (TABLE 1). EDTA-S treatment
done using a burnishing technique which involved the
application of 20% EDTA-S solution with the help of
cotton pellet to the external surfaces of mid root.
The cotton pellet changed every 30 seconds for three
minutes. Ornidazole gel treatment also made using a
burnishing technique. Phosphate buffered saline
treatment was done by immersing the teeth for 5
minutes in phosphate buffered saline.
Some samples from group A,B,C were subjected to 35 minutes washes in phosphate buffered saline. Fresh
human whole peripheral blood obtained from a
healthy human donor with informed consent was
applied & allowed to clot on the blocks for 20
minutes. Following samples were subjected to
scanning electron microscope study.
TABLE 1:- Table listing the different treatment
group from A-F
Group
A
B
C
D
E
F
TREATMENT
20% EDTA-S
Ornidazole gel (1% W/V)
7.4 pH Phosphate buffered saline
20% EDTA-S + Blood
Ornidazole gel 1% W/V + Blood
7.4 pH Phosphate buffered saline + Blood
Immediately after final rinsing, samples were fixed in

1% formaldehyde phosphate buffer saline solution for
15 minutes. Then all samples were rinsed &
incubated for 10 minutes in 0.02M glycine in
phosphate buffered saline. Sample were post fixed in
2.5% glutaraldehyde in phosphate buffered saline for
30 minutes & dehydrated through a graded ethanol
series 25%, 50%, 75%, 95% & finally 100% alcohol.
Samples were dried overnight using silica gel
crystals.
Data Analysis: Smear layer removal was evaluated
according to Sampio et al index.3
1. Root surface without smear layer, with the
dentinal tubules completely opened, without
evidence of smear layer in the dentinal tubules.
2. Root surface without smear layer, with the
dentinal tubules completely opened, but with
389
Prashant et al.,
3.
4.
5.
6.
some evidence of smear layer in the dentinal

tubules entrance.
Root surface without smear layer, with the
dentinal tubules partially opened.
Root surface covered by a uniform smear layer
with evidence of dentinal tubules opening.
Root surface covered by a uniform smear layer
without evidence of opening the dentinal tubules.
Root surface covered by an irregular smear layer,
with the presence of grooves & or scattered
debris
RESULTS
In group in which 20% EDTA-S was used, there was
an increased smear layer removal compared to the
associated groups (Fig.1), in which ornidazole gel
(group B; Fig.2), 7.4 pH phosphate buffered saline
(group C;Fig3) used. For smear layer removal
according to Sampiaoet al3
Group A: 4, Group B:6, Group C:6
Fig 1: 20% EDTA-S passive application for 5 min root

surfaces were covered by smear layer with evidence of
dentinal tubules opening.
Fig 2:Ornidazolegel passive application for 5 min

presence of heavy smear layer.
Fig3: PBS (Control) passive application for 5 min,

presence of smear heavy smear layer.
There was fibrin network formation with 20%

EDTA-S(Fig.4). There were no fibrin network
formation seen with ornidazolegel(Fig.5)& 7.4 ph
phosphate buffered saline(Fig.6).
Fig 4: The root surfaces treated with 20%EDTA-S +

blood, there was fibrin network formation
Fig 5: The root surfaces treated withOridazole gel+

blood, there was no fibrin network formation
390
Prashant et al.,
Fig 6: The root surfaces treated with PBS+ blood; there

was no fibrin network formation
DISCUSSION
Scaling and root planning are widely used methods in
periodontal therapy to eradicate irritants from the
surfaces of the teeth and also to decrease tooth
surface unevenness which may help the accumulation
of irritants (Waerhaug1956). It has turned out to be
gradually more apparent that the most vital feature of
periodontal therapy is the elimination of all accretions
from tooth surfaces exposed by periodontal illness
(Aleo&Vandersall1980, Axelsson & Lindhe 1978,
Caton et al. 1982, Hughes &Caffesse 1978, Lindhe et
al. 1973, 1975, Listgarten et al. 1978, Rosling et al.
1976, Theilade et al. 1966, Waerhaug 1978b).
Schaffer (1956) reported that teeth regularly scaled
and root planed were established to have deposits
residual, particularly in surface defects.
Fibroblasts do not affix & develop on diseased root
surfaces, nor does new attachment form on them, due
to presence of bacterial toxins.13-16It was
recommended that a smooth root surface would be
less prone to colonization by oral bacteria, thus
delaying the development of a fresh biofilm on the
treated root surfaces. This was based on a trial
performed by Waerhaug in dogs. 17The idea of this
chapter was to measure the preliminary wound
healing after the application of 20% EDTA-S &
Ornidazole gel & calculate the fibrin arrangement
pattern. Several authors have shown that 3 minutes
etching with EDTA is enough for the elimination of
smear layer compared to 10, 20, 30, 40 sec & 1 &2
minutes.18Soft soap broadly used in the medical
ground to get rid of incrustation in scaly skin. Soft
soap + water used as enema& this signifies its effect
with mucous membrane & degree of protection.
Hence effort was made to include the advantage of

EDTA & detergent, decreases the surface
strain.3Batista et al, obtained better results with 15%
EDTA-T in comparison to plain EDTA.
This study also exposed that smear layer elimination
after application of EDTA-S was valuable, which was
in conjunction with the study by Pilatti et al (2005)
&Shrirangrajan study et al (2012).
Pathogenic microorganisms may not be eliminated in
deep periodontal pockets due to poor access for
mechanical debridement, root anatomical difficulty20,
21
& the capability of the microorganisms to infect &
live in the periodontal tissue. 22
Some patients do not initially express, or maintain, as
enviable a clinical response as expected or desired.
For such patients, the adjunctive use of an antibiotic,
either simultaneously with scaling and root planning,
or during another stage of therapy is essential to
attain control of the disease. The assortment of a
suitable antibiotic follows a diagnosis and clinicians
decision to incorporate chemotherapeutic into
management. A variety of antibiotics were identified
that achievement levels in the gingival crevice fluid
that exceeded the MICs of the objective bacteria, e.g.
Amoxicillin and amoxicillin + clavulanic acid23, the
tetracyclines24-26, clindamycin27, metronidazole28, 29.
Systemic antimicrobial agents might guide to possible
side effects such as development of resistant
bacteria30& gastrointestinal intolerance. 31These
drawbacks would be noticeably reduced if
antimicrobial agents applied in the vicinity could be
used. Recognition that subgingival plaque exists as a
biofilm comparatively opposed to chemotherapeutic
agents is a significant concept when considering the
adjunctive use of an antibiotic or other antimicrobial
agent in the treatment of periodontitis. Ornidazole
have immune stimulatory activities, anticoagulant
properties, antibacterial & antifungal action & for its
action as a promoter of wound healing in the field of
surgery. 32,33
CONCLUSION
Though Ornidazole show antimicrobial & anticoagulase activity; it does not help in smear layer
removal as well as fibrin network formation. 20%
EDTA-S is effective in both smear layer removal and
fibrin network formation.
391
Prashant et al.,
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2. Leary OT, Karfrawy A. Total cementum
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3. Lasho DJ, Leary O, Karfrawy AH.A scanning
electron microscope study of the effects of
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root
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Periodontal
1983;54:210-20
4. Karp W, Sodek J, Aubin JE, Melcher AH. A
comparison of fibronectin & laminin binding to
under mineralised & demineralised tooth root
surfaces J Periodontol Research 1986;21:30-38
5. McAllister B, Narayanan AS, Miki Y, Page RC.
Isolation of fibroblast attachment protein from
cementum. J Periodontol Research 1990;25:99105
6. Polson AM, Fredrick GT, Ladenhein S, Hanes PJ.
The production of root surface smear layer by
instrumentation &its removal by citric acid. J
Periodontol 1984;21:322-29
7. Wikesjo ME, Pamela JB, Lars AC, Robert JG,
Raymond M. A biochemical approach to
periodontal regeneration: Tetracycline treatment
conditions dentin surfaces.
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Research 1986;21:322-29
8. Sterret JD, Bain CA. Citric acid burnishing of
dentinal root surfaces. A preliminary scanning
electron microscopy report. J. Can. Dent. Assoc
1987 ; 53 : 395-397
9. Aktener BO, Bilkay U. Smear layer removal with
difference concentration of EDTA. J Endodontics
1993;19:228-31
10. Czonstkowsky M, Wilson EG, NolsteinFA. The
smear layer in endodontics. Dent Clin North Am
1990;34:13-25
11. Hulsmann M, Heckendorff M, Lennon A.
Chealating agents in root canal treatment: Mode
of action & indication for their use. Int.
Endodontics Journal 2003;30:707-11
12. Boveda C, Fajardo M, Millan B. Root canal
treatment of invaginated maxillary lateral incisor
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a
C-shaped
canal.
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Int.1993;30:707-11
13. Aleo JJ, De Renzis FA, Farber PA, In vitro

attachment of human gingival fibroblasts to root
surfaces. J Periodontol 1976;46:639-45
14. Polson AM, Caton J. Factors influencing
periodontal repair &regeneration. J Periodontol
1982;53:557-625
15. Cogen RB, AI-Joburi A, Gantt DG, Denys FR,
Effect of various root surface treatments on the
attachment & growth of human gingival
fibroblast: histologic & scanning electron
microscopic evaluation. J Clin Periodontol
1984;11:531-39
16. Olson RH, Adams DF, Layman DL, Inhibitory
effect of periodontally diseased root extracts on
the growth of human gingival fibroblasts. J
Periodontol1985;592-94
17. Waerhaug J, Effect of rough surface upon
gingival tissue. J Dent Res 1956;35:323-25
18. Blomlof J, Lindskog S, Root surface texture &
early cell & tissue colonization after different
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19. Batista CV, Sampaio JE, Pilatti GL, Shibli JA,
Efficacy of EDTA-T gel for smear layer removal
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20. Caffesse RG, Sweeney PL, Smith BA. Scaling&
root planning with & without periodontal flap
surgery. J Clin Periodontol 1986;13:205-10
21. Nordland P, Garrett S, Kiger R, Vanooteghem R,
Hutchens LH, Egelbery J. The effect of plaque
control & root debritment in molar teeth. J Clin
Periodontal 1987;14:231-36
22. Sandros,
Pappanou
P.
Porphyromonas
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Periodontal Res, 1993;28:219-26
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Amoxicillin and clavulanic acid concentrations in
gingival crevicularfluid. J Clin Periodontol 1997:
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24. Gordon JM, Walker CB, Murphy JC, Goodson
JM, Socransky SS. Tetracycline levels achievable
in gingival crevicefluid and in vitro effect on
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DOI: 10.5958/j.2319-5886.3.2.081

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ISSN: 2319-5886
Research Article
CIRCLE OF WILLIS AND ITS VARIATIONS; MORPHOMETRIC STUDY IN ADULT HUMAN

CADAVERS
Raghavendra1, Shirol VS2, Daksha Dixit2, *Anil Kumar Reddy Y3, Desai SP2
1
Department of Anatomy, Akash institute of Medical Sciences & Research, Bangalore, Karnataka, India
Department of Anatomy, J.N Medical College, Belgaum, Karnataka, India
3
Department of Anatomy, J N Medical College, Sawangi, Meghe, Wardha, Maharashtra, India
2
*Corresponding author email: kumarlucky48@gmail.com

ABSTRACT
Background and Objectives: Circle of Willis plays a vital role in collateral circulation and redistribution of
blood to all areas of the brain. Variation in circle of Willis is known to cause grave disorders like cerebrovascular
disorders, subarachnoid haemorrhage, cerebral aneurysm and schizophrenia. The objectives of the present study
are to study the formation and branching pattern of circle of Willis and also to study the distribution of variations.
MATERIALS & Methods: The study was conducted on 50 adult brain specimens. Each brain was removed in
one piece by dissection and the circle of Willis was observed for its formation, pattern and variations. Results:
Among the 50 specimens studied, 28 cases (56%) had a normal pattern of circle of Willis and variations were
observed in the remaining 22 cases (44%). More number of variations was observed on the right side than on the
left side. The most common variation observed was hypoplastic posterior communicating artery (7 cases, 31.8%).
Posterior communicating artery was found to be the most variable vessel while middle cerebral artery was the
least variable vessel. Interpretation and Conclusion: The results with respect to the circle of Willis and all its
component arteries were consistent with the results in the available literature. The only exception was the
increased incidence of absence of both the anterior and posterior communicating arteries. This finding is of
clinical significance to neurologists and neurosurgeons in this geographical location of north Karnataka. A higher
incidence of variations in the communicating arteries is likely to manifest as a higher incidence in disorders like
migraine, schizophrenia and cerebrovascular disorders due to compromised collateral circulation and poor
redistribution of blood.
Keywords: Circle of Willis, Anterior Cerebral Artery; Middle Cerebral Artery; Posterior Cerebral Artery;
Anterior Communicating Artery; Posterior Communicating Artery
INTRODUCTION
Circle of Willis is the arterial anastomosis at the base
of the brain which is also referred as Circulus
Arteriosus cerebri. The pattern of arterial
arrangement & communication forms a unique
arterial network connecting the principle arteries
supplying the brain.1
Circle of Willis was named after a popular British

Anatomist-Physician Thomas Willis (1621-1673)
who was the first to describe it completely2. Though
called a circle, it is precisely a nonagon or a nine
sided polygon3. The circle of Willis is a large arterial
anastomosis which unites the internal carotid and
vertebro-basilar systems. It lies in the subarachnoid
394
Raghavendra et al.,
space within the interpeduncular cistern, and

surrounds the optic chiasma and infundibulum.
Anteriorly, the anterior cerebral arteries, derived from
the internal carotid arteries, are linked by the small
anterior communicating artery. Posteriorly, the two
posterior cerebral arteries, formed by the bifurcation
of the basilar artery, are joined to the ipsilateral
internal carotid artery by a posterior communicating
artery.4, 5
There is considerable individual variation in the
pattern and caliber of vessels that make up the
circulus arteriosus. Although a complete circular
channel almost always exists, one vessel is usually
sufficiently narrowed to reduce its role as a collateral
route and the circle is rarely functionally complete.
The haemodynamics of the circle are influenced by
variations in the caliber of communicating arteries
and in the segments of the anterior and posterior
cerebral arteries which lie between their origins and
their
junctions
with
the
corresponding
communicating arteries. The greatest variation in
caliber between individuals occurs in the posterior
communicating artery, which is normally very small,
so that only limited flow is possible between the
anterior and posterior circulations.1
Brain depends on continuous and uninterrupted
supply of blood as its source for oxygen, glucose and
other nutrients for its normal functioning. The
rapidity of unconsciousness in common syncope,
more traumatically induced but mercifully swift in
judicial hanging, are dramatic reminders of the
precarious aerobic balance in which the parenchyma
of the brain survives6.
It is a well established fact that the adequacy and
compliance of collateral circulation plays a vital role
in the course and severity of a cerebrovascular
disorder. Analysis and establishing the pattern of
circle of Willis is one of the most important
prerequisites of various diagnostic & therapeutic
neurovascular procedures. In case of complete
unilateral vascular occlusion or thrombosis,
expansion of anastomotic channels and collateral
circulation in circle of Willis is life saving8.
Aneurysms are balloon-like swellings which occur on
as a result of defects in the arterial wall. They are
most commonly found on the vessels of the circle of
Willis particularly at or near the junctions of vessels.
The normal pattern of circle of Willis is relatively
uncommon. Various studies in the past have revealed
Raghavendra et al.,
that a significant lack of consistency exists in the

pattern and branching of circle of Willis. Circle of
Willis shows a considerable degree of individual
variation which may justify the fact that, its
functional efficiency differs widely in different
individuals.
All these facts put together makes this present study
all the more interesting and important. The present
study is an effort to gather a substantial knowledge
and information about the variations in circle of
Willis in population of North Karnataka.
MATERIAS & METHODS
The present study is based on 50 adult brains
dissected from embalmed cadavers in Department of
Anatomy, Jawaharlal Nehru Medical College,
Belgaum. Each brain was removed in one piece by
dissection. Only complete and intact specimens were
used for the study. Observations were made in 50
such specimens were later preserved in 10% formalin
solution. Each circle was examined in the intact brain
and a drawing was made. After removing the
meninges carefully from the base of the brain, the
circle of Willis was observed in situ and a detailed
study of the circle and associated arteries was made.
The findings were noted and tabulated. The arteries
and the circles were studied under the following
parameters:
1. Origin of cerebral and communicating arteries.
2. Branching pattern of cerebral and communicating
arteries.
3. Position and course of the above arteries.
4. Shape of the arterial circle.
5. Abnormalities if any.
A thorough search was again made for any variations
in the cerebral arteries, their branches and
communicating arteries. A search was also made for
aneurismal dilatations under magnification. A
magnifying lens was used whenever required. High
resolution photographs were taken using Nikon 8.0
megapixel digital camera with 3X optical
magnification at various convenient angles.
RESULTS
Among the 50 specimens of circle of Willis dissected
and observed in the present study, typical description
of normal circle was seen in 28 cases (56%).
Variations were found in the remaining 22 cases
(44%).
395
Of the 22 variations seen, 7 variations (31.8%) were

seen in the anterior circulation and 15 variations
(68.2%) were seen in the posterior circulation. More
variations were seen on the right side than on the left
side. 14 variations (63.6%) were observed on the
right side as compared to 5 variations (22.7%) on the
left side. 3 variations (13.6%) were seen in the
anterior communicating artery.
Anterior cerebral artery variations were seen in 4
cases (18.2%) among the 22 variations found.
Hypoplastic (string like) A1 segment (Picture 1) in 3
cases (13.65%). In one case it was on the left side and
in two cases on the right side. Hypoplastic (string
like) A2 segment was seen in one case (4.55%) on the
right side (specimen no. 36). In this case the right
cerebral hemisphere was predominantly supplied by
branches from an enlarged A2 segment of left
anterior cerebral artery.
Among the 22 variations found in the study, 4
variations (18.2%) were seen in posterior cerebral
arteries. Absence of P1 segment was seen in one case
(4.55%) on the right side. Hypoplastic P1segment
(Picture 2) (foetal or embryonic type) was seen in 3
cases (13.65%). On all the 3 occasions the variation
was present on the right side. 3 variations (13.6%)
were seen in Anterior communicating artery.
Complete absence of anterior communicating artery
(Picture 3) was seen in 2 cases (9.1%), duplication
(Picture 4) was seen in 1 case (4.55%). Highest
number of variations was seen to be associated with
posterior communicating artery. 11 variations among
the 22 variations (50%) were found to be exclusively
due to posterior communicating artery. Complete
absence and hypoplastic (string like) artery were the
variations seen in this artery. 4 cases (18.2%) had
complete absence of posterior communicating artery
(Picture 5). In 2 cases it was seen on the right side
and in 2 cases on the left side. 7 cases (31.8%) had a
hypoplastic (string like) posterior communicating
artery. In 5 cases it was on the right side (Picture 6).
In 2 cases it was seen on the left side. 50% of the
variations were seen in the posterior communicating
artery. Hence it is the most variable and least
consistent vessel in the present study. No aneurysms
were seen in any of the arteries in any of the cases.
No other unusual or unreported variations were seen
in the study sample. No cases had bilateral variations.
Double, triple or multiple variations in a single
specimen were not seen. Hence, all the variations
were singular and no associated variations were

found in any specimen.
Fig 1: Photograph Showing Hypoplastic A1 segment of

Right ACA
ACA Anterior cerebral artery, AcoA Anterior

communicating artery, MCA Middle cerebral
artery, PcoA Posterior communicating artery, PCA
Posterior cerebral artery
Fig 2: showing Hypoplastic P1 segment of right PCA
P1 - Pre-communicating part of Posterior Cerebral

Artery, PCA Posterior cerebral artery
Fig 3: Picture 3: Photograph showing Absence of ACoA
AcoA Anterior communicating artery, Ab Absent,

PCA Posterior cerebral artery, ACA- Anterior
cerebral artery, MCA- Middle cerebral artery
396
Raghavendra et al.,
Fig 4: Showing duplication of Anterior communicating

artery (AcoA)
Fig 5: Picture 5: Photograph showing Absence of left

PcoA
PcoA Posterior communicating artery, A - Absent
several countries employing various methods across

different geographical and racial background, there is
no clarity as to how and why the variations occur.
Different studies have quoted different facts and
figures which have led to a spectrum of findings. In
the following discussion, findings of the present study
have been compared with those of the other authors
under each individual constituent artery.
In about one third of all individuals, one of the
posterior cerebral arteries arises from the internal
carotid artery. Such anomalous condition suggests
persistence of embryological origin of the posterior
cerebral artery.4
Sometimes the anterior communicating artery
becomes double, on occasions the proximal part of
one of the anterior cerebral arteries is unusually small
and in such condition anterior communicating artery
assumes a large caliber.4
The arterial circle is thought to equalise the blood
flow to the different parts of the brain and under
normal condition little interchange of blood takes
place across anastomotic channel due to equality of
blood pressure. However, in case of occlusion of one
of the large feeder arteries, the blood crosses the
midline through the communicating branches and
maintains nutrition of the opposite half of the brain
by contra lateral flow.4
In the present study, of the 50 brain specimens
observed 28 cases (56%) had normal pattern of circle
of Willis.
Table 1: Studies on Circle of Willis reported by various
authors
Author name
Normal
Variations
Pattern (%) (%)
Fig 6: Showing Hypoplastic right Posterior

communicating artery (PCoA)
DISCUSSION
The circle of Willis and its branches are subjected to
numerous variations. The variations not only differ
from person to person but also on the two sides of the
same individual. Various dissection and angiographic
studies by several workers have shown that variations
occur in a very high proportion of cases. Inspite of
numerous studies conducted over several decades in
Fawcett and blachford

Blackburn
Alpers et al.
Riggs (1963)
Vare AM & Bansal PC
Raja Reddy et al.
Jayasree & Sadasivan
Kamath S
P N Jain and V Kumar
Stephen and John
Macchi et al.
Hartkamp et al.
Present study
96.1%
29.5%
52.3%
19%
26.86%
53.3%
18%
56%
19.45%
52%
41%
42%
56%
3.9%
70.5%
47.7%
81%
73.14%
46.7%
82%
44%
80.55%
48%
59%
58%
44%
397
Raghavendra et al.,
Thus the findings of the present study are

approximately similar to the findings of Alpers et al.
(1959)7, Raja Reddy et al. (1972)8, Kamath S (1981)9,
Stephen and John (1991)10 with respect to normal
pattern of circle. Of the 50 brain specimens observed
in the present study, 22 cases (44%) had variations in
the pattern of circle of Willis. Thus the findings of the
present study are approximately similar to the
findings of Alpers et al. (1959)7, Raja Reddy et al.
(1972)8, Kamath S (1981)9, Stephen and John
(1991)10 with respect to incidence of variations in the
circle.
In the present study, it was observed that variations
were approximately twice as common in the posterior
circulation (15 cases, 68.2%) as compared to the
anterior circulation (7 cases, 31.8%), Similar studies
reported by P N Jain and V Kumar (1990)11 and
Hartkamp et al. (1998)12 with respect to location of
variations.
In the present study, hypoplastic A1 segment of
anterior cerebral artery was seen in 3 cases (13.65%)
among the 22 cases with variations. In 1 case it was
on the left side and in 2 cases on the right side. Thus,
the findings of the present study are approximately
similar to the findings of Lippert (10%) (1985)13 and
Arthur et al. (10.4%) (1996)14 with respect to
hypoplastic A1 segment of anterior cerebral artery.
Hypoplastic A2 segment of anterior cerebral artery
was seen on the right side in one case (4.55%) among
the 22 cases with variations. The right cerebral
hemisphere was predominantly supplied by branches
from an enlarged A2 segment of left anterior cerebral
artery.
A similar variation where a single median anterior
cerebral artery is formed by the joining of both the
right and the left anterior cerebral arteries has been
reported by Vare A M and Bansal P C (1.7%)
(1970)15, N Jayasree and G Sadasivan (2%) (1981)16,
Kanchan Kapoor (0.9%) (2001)17.
Hypoplastic P1 segment of posterior cerebral artery
was seen in 3 cases (13.65%) among the 22 cases
with variations, all on the right side. The findings of
the present study are similar to the findings of Alpers
et al. (15%) (1959)7, P N Jain and V Kumar (16%)
(1990)11 and Van overbeeke et al. (14%) (1991)18
with respect to hypoplastic P1 segment of posterior
cerebral artery. Complete absence of P1 segment of
posterior cerebral artery on the right side was seen in
one case (4.55%). Here the basilar artery continued as
the left posterior cerebral artery. The posterior

circulation on the right side was maintained by an
enlarged right posterior communicating artery. Such
absence of P1 segment was reported by Vare A M
and Bansal P C (1970)15 in 19.4% cases.
Duplication of anterior communicating artery was
seen in one case (4.5%) among the 22 cases with
variations in the present study. Thus, the findings of
the present study are approximately similar to the
findings reported by Fawcett and blachford (1905)19
in 7.2% cases, Raja Reddy et al. (1972)8 in 7% cases
and P N Jain and V Kumar (1990)11 in 5.5% cases,
with respect to duplication of anterior communicating
artery.
Absence of anterior communicating artery was seen
in 2 cases (9.1%) among the 22 cases with variations
in the present study. A higher incidence of absence of
anterior communicating artery has been observed in
the present study in comparison to the results of
various other studies.
Absence of posterior communicating artery was seen
in 4 cases (18.2%) out of 22 cases with variations, In
2 cases it was seen on the right side and in 2 cases it
was seen on the left side. A higher incidence of
absence of posterior communicating artery has been
observed in the present study as compared to the
results of previous studies.Hypoplastic posterior
communicating artery was seen in 7 cases (31.8%)
among the 22 cases with variations. In 5 cases it was
on the right side and in 2 cases it was seen on the left
side.
The findings of the present study are
approximately similar to the findings of Pedroza et al.
(34%) (1987)20. No variations were observed in the
main trunk of middle cerebral artery with respect to
the circle of Willis in any of the 50 cases.
Collectively it was observed that the findings of the
present study are approximately similar to the results
of various other larger and significant studies
conducted previously. The only exception being
increased incidence of absence of both the anterior
and posterior communicating arteries in the present
study.
Scope for future work : An exclusive study of the
anterior and posterior communicating arteries
conducted on a larger sample size and by avoiding
the possible confounding factors of age and sex could
possibly strengthen the present findings and establish
a significant geographical correlation to the
distribution of variations.
398
Raghavendra et al.,
CONCLUSION
REFERENCES
On observing the 50 specimens of circle of Willis in

the present study the following inferences were
drawn.
The normal pattern of circle of Willis was observed
in 28 cases (56%) cases and the remaining 22 cases
(44%) had one or the other variations. 7 cases
(31.8%) cases had variations in the anterior
circulation and 15 cases (68.2%) had variations in the
posterior circulation. Thus, the prevalence of
variations is approximately twice in the posterior
circulation compared to anterior circulation.
14 cases (63.6%) had variations on the right side
compared to 5 variations (22.75%) on the left side. 3
cases (13.65%) had variations in the anterior
communicating artery. Thus, the variations are more
prevalent on the right side than on the left side. No
variations were observed in the middle cerebral artery
and basilar artery. Thus, they are the most consistent
and least variable vessels in this study. All variations
were singular and unilateral. Thus no multiple
variations were observed in this study. No aneurysms
were observed in any of the specimens. The most
common variation observed in the present study is
hypoplastic posterior communicating artery (7 cases,
31.8%).
The most variable artery in the present study is
posterior communicating artery (11 cases, 50%). The
most consistent blood vessel in the present study is
middle cerebral artery. No significant deviation has
been observed in the study results from what has been
reported in the literature. The only exception is the
increased incidence of absence of both the anterior
and posterior communicating arteries in the present
study. This finding is of potential clinical significance
to neurologists and neurosurgeons in this
geographical location of North Karnataka. A higher
incidence of variations in the communicating arteries
is likely to manifest as a higher incidence in disorders
like migraine, schizophrenia and cerebrovascular
disorders due to compromised collateral circulation
and poor redistribution of blood. Thus, an exclusive
study focusing on the variations of the anterior and
posterior communicating arteries with a larger sample
size can further establish the higher prevalence of
variations of communicating arteries in this
geographical area.
1. Susan Standring, editor in chief. Grays

Anatomy: The Anatomical Basis of Clinical
Practice. 40th ed. London, UK: Churchill
Livingstone Elsevier; 2008: 248-52.
2. Samuel M. Wolpert. History of the circle of
Willis. American Journal of Neuroradiology.
1997 June; 18;1033-34.
3. Anne Osborn. Diagnostic Cerebral Angiography.
2nd ed. New York: Lippincott. Williams and
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4. Datta AK. Essential of Neuroanatomy. 3rd ed.
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nd
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DOI: 10.5958/j.2319-5886.3.2.082

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Revised: 8thMar 2014
Copyright @2014
ISSN: 2319-5886
Accepted: 12thMar 2014
Research Article
SOURCE OF STRESSORS AND EMOTIONAL DISTURBANCES AMONG UNDERGRADUATE

SCIENCE STUDENTS IN MALAYSIA
*Ali Sabri Radeef1, Ghasak Ghazi Faisal2, Syed Masroor Ali1, Maung Ko Hajee Mohamed Ismail1
1
Department of Psychiatry, Kulliyyah of Medicine, International Islamic University Malaysia

Department of Basic Medical Science, Kulliyyah of Dentistry, International Islamic University Malaysia
*Corresponding author email: alisabri1973@yahoo.com

ABSTRACT
Introduction: Higher education is considered as a stressful period in students life which they have to cope with
since they are facing a variety of demands such as living away from their families, a heavily loaded curriculum,
and inefficiency in both mentor- mentee and health education programs. This will make them more vulnerable to
emotional disturbances such as stress, anxiety and depression. Methodology: A total of 194 undergraduate
students from Kulliyyah (Faculty) of Science, International Islamic University Malaysia participated in
questionnaire-based study using the Depression Anxiety, Stress Scale (DASS-21) to assess the severity of
emotional disturbances Results: The overall prevalence of depression, anxiety and stress was 64.4%, 84.5% and
56.7% respectively. Regarding the severity of the symptoms, it was found that 13.9%, 51.5 % and 12.9% of the
students have clinically significant depression, anxiety and stress respectively. Young students aged 21 years and
below had a statistically significant association with depression, anxiety and stress. While first year students had
significant association with depression. Regarding the source of stressors, the top ten stressors decided by the
students were mainly academic and personal factors. Conclusion: Emotional disturbances in the form of
depression, anxiety and stress are existing in high rate among undergraduate science students that require early
intervention. Factors including feeling of incompetence, lack of motivation to learn and difficulty of class work
can be considered as source of stressors that may precipitate for depression anxiety and stress.
Keywords: Depression, anxiety, stress, DASS-21, Science students, Malaysia
INTRODUCTION
Higher education is considered as a stressful period in
students life which they have to cope with since they
are facing a variety of demands such as living away
from their families, a heavily loaded curriculum,
inefficiency in both mentor- mentee and health
education programs. This will make them more
vulnerable to emotional disturbances such as stress,
anxiety and depression.1
A mentally healthy student is the one who thinks
clearly and logically, able to initiate proper social
relationships, eager to learn with substantial ambition

to implement his/her plans in the future. However,
since the students are at a crucial stage of
development, being in the transition from
adolescence to adult, they are more subjected to
experience mental illnesses. 2
Major depression is a mood disorder that is defined
by the American Psychiatric Association in the
Diagnostic and Statistical Manual of Mental
Disorders Text Revision (DSM-IV-TR) as a disorder
Ali Sabri Radeef et al.,
401
that is characterized by either a depressed mood or

markedly diminished interest in pleasure activity in
addition to at least four other symptoms within a
duration of at least two weeks, these symptoms
include, impaired appetite, disturbed sleep, poor
concentration, loss of energy, psychomotor agitation
or retardation, feeling of worthlessness or
inappropriate guilt, thoughts of death or recurrent
suicidal ideation.3
Although the onset of depression can be at any stage
of life, the prevalence of major depression is
increasing during adolescence and young adulthood.4,
5
In a study conducted in United States of America,
the prevalence of depression among undergraduate
student was found to be 23%.6
Anxiety is a condition that is characterized by intense
feeling of dread, accompanied by somatic symptoms
that indicate a hyperactive autonomic nervous system
such as tachycardia, sweating, dry mouth, frequent or
urgent micturition and diarrhea. Anxiety impairs
cognition and may produce distortions of
perception.7Since college students are subjected to
various stressors such as academic, social or time
management problems that may provoke anxiety
symptoms which may affect their performance, it is
vital for the educators and mental health providers to
have interventions to reduce anxiety and improve the
quality of mental health education.8
Stress is defined as the bodys non-specific response
to demands placed on it, related to disturbing events
in the environment.9, 10Stress during education can
lead to mental distress and have a negative impact on
cognitive functioning and learning11. The potential
negative effects of emotional distress on students
include impairment of functioning in classroom
performance and clinical practice, stress-induced
disorders and deteriorating performance. 12, 13
Studies on emotional disturbances such as stress,
depression and anxiety among students have found
that these disorders are under diagnosed which may
lead to increase probability of mental disorders which
may have serious effects on their careers and social
live.14,15Therefore, this study aimed to determine the
prevalence of emotional disturbances in the form of
depression, anxiety and stress among undergraduate
Science students throughout the different stages of
their study and to identify the sources of stressors and
their relationship with emotional disturbances.
A cross sectional, questionnaire-based study was

conducted among undergraduate science students
from Kulliyyah(faculty) of Science, International
Islamic University Malaysia (IIUM) during the period
from March 2013 to June, 2013.
A research grant sponsored by the Research
Management Centre, International Islamic University
Malaysia was obtained for conducting this research
and ethical approval was obtained from International
Islamic University Malaysia Research Ethical
Committee prior to conducting the study. The
participation was entirely on a voluntary basis; the
researchers introduced themselves to the students in
each grade and informed them about the aims of the
study, guarantees of anonymity and confidentiality.
Consent was obtained from the students. The study
was conducted in middle of the course before the
examination period so as to minimize the extra stress
symptoms.
The inclusion criteria were agreed to participate in the
study and the students should be registered as
undergraduate science students of IIUM, while
students who fail to give consent, and those who were
not conversant in English were excluded from the
study.
The socio-demographic characteristics of the
participants were obtained; the gathered information
was about the nationality, age, marital status, gender,
year of study, accommodation during study and
household income.
Research Questionnaires:
1)
The Depression Anxiety, Stress Scale
(DASS-21): It is a short version, self- rated
questionnaire that is designed to assess the severity of
the symptoms of depression, anxiety and stress; it
consists of statements referring to the past week.
Each item is scored on a 4-point scale (0 = Did not
apply to me at all, to 3 = Applied to me very much or
most of the time) 16.
Subjects were asked to use 4-point severity/frequency
scales to rate the extent to which they have
experienced each state over the past week. Scores for
depression, anxiety and stress are calculated by
summing the scores for the relevant items. Each
subscale was categorized into normal, mild,
moderate, severe and extremely severe. In this study,
we classified further those who have severe and
402
extremely severe
symptoms
as
clinically
significant and those with mild and moderate as
subclinical.
2)
The source of stressors: The students were
given a list of the most possible source of stressors
which were chosen depending on previous studies.1721
The list was composed of a variety of stressors that
are related to living and accommodation, personal,
academic, environmental and social factors. The
respondents were asked to check each item
throughout the list and tick yes for the item that
they considered as the most stressful factor which
they experienced during the current academic year.
Statistical Analysis
We used the statistical package for social science
program, version 20.0 (SPSS 20.0) for analyzing the
data. The analysis of qualitative variables such as age
group, gender, nationality, monthly household
income, marital status, year of study and type of
accommodation were presented in number and
percentage. Mann-Whitney U test and Kruskal-Wallis
test were used to determine the effects of the sociodemographic characteristics on the emotional
disturbances among undergraduate science students.
The association between the ten stressor factors and
the emotional disturbances were evaluated using
Pearson Chi-squared test followed by Fishers exact
test. A P-value of less than 0.05 was considered
statistically significant and the results were reported
as odds ratios (OR) with 95% confidence interval
(CI).
prevalence of stress was 56.7%. Regarding the

severity of depression, stress and anxiety symptoms
among science students, it was found that 50.5%
(n=98) of the students had subclinical depression
while 13.9% (n=27) were having clinically significant
depression. For anxiety, it was found that 33% (n=64)
of the student had subclinical anxiety while 51.5 %
(n=100) of them with clinically significant anxiety.
Regarding stress, it was found that 43.3% (n=85) had
subclinical stress while 12.9% (n=25) were had
clinically significant stress (table 1).
Table 1: The severity of emotional disturbances:
Subclinical
Clinically
significant
No. of
affected
students
Grand Total
Depression
(N %)
98 (50.5)
Anxiety
(N %)
64 (33.0)
Stress
(N %)
85 (43.8)
27(13.9)
100 (51.5)
25 (12.9)
125 (64.4)
164 (84.5)
110 (56.7)
194
194
194
The total response rate in this study was 58.3% (194

out of 333 science students).The female students
represent the majority of the sample (71.1%).
Regarding the age of the students, more than half of
the students (57.2%) were aged 21 years and below.
For the year of the study of the students, about half of
the sample (51.5%) represented the second year of
the study followed by the third (30.9%) and first year
(17.5%) respectively. About 44.8 % of the students in
this study had a monthly household income of (RM
1501-5000 per month).Almost all of the students in
this study were of Malaysian nationality, single, and
living in the hostel.
The overall prevalence of depression was found to be
64.4 % and anxiety was 84.5%, while the overall
In studying the association between gender and the

presence of emotional disturbances among the
participants, although the male students showed
higher mean scores in all three parameters
(depression, anxiety and stress) than female students,
however, the results were statistically not significant.
Age wise, it was found that the mean scores for
depression, anxiety and stress were significantly
higher among younger students group ( 21years).
When comparing the emotional disturbances
between different stages of the study, it was found
that year one students had significantly higher mean
score in depression than year two and three students.
Although year two students showed the highest mean
score for anxiety and stress but it was statically not
significant when compared with year one and three
students. Other factors such as household income and
family support did not have significant impact on the
emotional disturbances among the students (table 2).
Concerning the source of stressors (Table 3), the top
ten among a list of stressors that have identified by
the students as the most stressful factors they faced
during the current academic year were fear of failing
91.2% (n=177) followed by 87.1% (n=169) for
examination and grades, then study pressure and
obligation was found to be 81.4% (n=158) followed
by time management problems to be the fourth factor
RESULTS
403
with 80.4% (n=156). The fifth factor was the fear of

employment /unemployment after graduation as
77.8% (n=151) of the students stated to be. Feeling of
incompetence was the sixth factor stated by 75.8%
(n=147) of the students, this was followed by the
academic overload factor with a rate of 75.3%
(n=146), then followed by the factor of amount of
assigned class work to be the eight factors by 74.7%
(n=145) of the students. The ninth factor was lack of
motivation which was rated by 71.6% (n=139) of the
students then the tenth factor was difficulty of class
work to learn with a rate of 71.1 %(no=138).
In assessing the association between the top ten
stressor factors and depression, the following stressor
factors namely, time management problems, feeling
of incompetence, lack of motivation to learn and
difficulty of class work have statistically significant
association with depression (Table 4).While in
assessing the association between the top ten stressor
factors and anxiety, the following stressor factors
namely, feeling of incompetence, time management

problems, lack of motivation to learn, fear of failing,
amount of assigned class work, study pressure,
obligation and difficulty of class work and difficulty
of class work have statistically significant association
with anxiety (Table 5,6).
Table 2: List of top 10 factors which are
considered stressors by the students:
Stressor
N (%)
Fear of failing
177 (91.2)
Examination and grades
169 (87.1)
Study pressure and obligation
158 (81.4)
Time management problems
156 (80.4)
Fear
of
employment
after 151 (77.8)
graduation or unemployment
Feeling of incompetence
147 (75.8)
Academic overload
146 (75.3)
Amount of assigned class work
145 (74.7)
Lack of motivation to learn
139 (71.6)
Difficulty of class work
138 (71.1)
Table 3: Factors determining significant emotional disturbances among undergraduate science students
Gender
Male
Female
Age
21
>21
Household income
RM1500
RM 1501-5000
>RM 5000
Year of study
Year 1
Year 2
Year 3
Family support
No
Yes
No.
Mean
Depressive
Level
56
138
14.36
11.83
0.127*
16.18
15.81
0.902 *
16.75
16.65
0.750 *
111
83
14.00
10.63
0.005*
16.86
14.65
0.047 *
17.62
15.42
0.029 *
63
87
44
12.92
11.89
13.36
0.354**
16.51
15.33
16.23
0.599 **
15.94
16.55
18.00
0.411 **
34
100
60
14.71
13.28
10.13
0.028*
15.41
16.84
14.67
0.243 **
16.76
17.34
15.53
0.209 **
81
12.99
0.667 *
16.47
0.483 *
16.64
0.995 *
113
12.25
P Value
Mean
Anxiety
Level.
15.52
P Value
Mean Stress
Level
P Value
16.71
* Mann-Whitney U test (for two independent samples).** Kruskal-Wallis test (for several independent samples).
Significant, Highly significant ,
404
Table 4: Association of the top ten stressors with depression

Stressors
Depression(N= 194)
Abnormal (N=125)
Normal (N=69)
Yes
No
108 (86.4)
17 (13.6)
48 (69.6)
21 (30.4)
P
value*
OR
95% CI
Lower Upper
0.005
2.78 1.35
Yes
107 (85.6)
40 (58.0)
0.000 4.31 2.16
No
18 (14.4)
29 (42.0)
Yes
101 (80.0)
38 (55.1)
0.000 3.43 1.79
No
24 (19.2)
31 (44.9)
Yes
111 (88.8)
58 (84.1)
0.345
1.50 0.64
No
14 (11.2)
11 (15.9)
Fear of failing
Yes
115 (92.0)
62 (89.9)
0.613
1.29 0.47
No
10 (8.0)
7 (10.1)
Fear of employment after graduation or unemployment
Yes
99 (79.2)
52 (75.4)
0.538
1.25 0.62
No
26 (20.8)
17 (24.6)
Yes
94 (75.2)
51 (73.9)
0.843
1.07 0.55
No
31 (24.8)
18 (26.1)
Academic overload
Yes
95 (76.0)
51 (73.9)
0.747
1.12 0.57
No
30 (24.0)
18 (26.1)
Yes
104 (83.2)
54 (78.3)
0.397
1.38 0.66
No
21 (16.8)
15 (21.7)
Yes
95 (76.0)
43 (62.3)
0.044 1.92 1.01
No
30 (24.0)
26 (37.7)
* Pearson Chi-Square test followed by Fishers Exact test, OR: odd ratio, CI: confidence interval
Significant, Highly significant, Extremely significant
Table 5: Association of the top ten stressors with Anxiety
Stressors
Anxiety (N= 194)
P value* OR 95% CI
Abnormal(N= 164) Normal N=30)
Lower
Yes
134 (81.70)
22 (73.3)
0.288
1.62 0.66
No
30 (18.3)
8 (26.7)
Yes
133 (81.1)
14 (46.7)
0.000
4.90 2.17
No
31 (18.9)
16 (53.3)
Yes
124 (75.6)
15 (50.0)
0.004
3.10 1.39
No
40 (24.4)
15 (50.0)
Yes
143 (87.2)
26 (86.7)
1.000
1.05 0.33
No
21 (12.8)
4 (13.3)
Fear of failing
Yes
153 (93.3)
24 (80.0)
0.030
3.48 1.18
No
11 (6.7)
6 (20.0)
5.73
8.60
6.58
3.52
3.58
2.51
2.09
2.19
0.89
3.62
Upper
3.99
11.09
6.89
3.30
10.28
405
Stressors
Anxiety (N= 194)

P value* OR 95% CI
Normal
N=30)
Abnormal (N= 164)
Lower
Upper
Yes
129 (78.7)
22 (73.3)
0.519
1.34 0.55
3.27
No
35 (21.3)
8 (26.7)
Yes
126 (76.8)
19 (63.3)
0.118
1.92 0.84
4.39
No
38 (23.2)
11 (36.7)
Academic overload
Yes
125 (76.2)
21 (70.0)
0.468
1.37 0.58
3.25
No
39 (23.8)
9 (30.0)
Yes
136 (82.9)
22 (73.7)
0.214
1.77 0.71
4.37
No
28 (17.1)
8 (26.7)
Yes
122 (74.4)
16 (53.3)
0.019
2.54 1.14
5.65
No
42 (25.6)
14 (46.7)
* Pearson Chi-Square test followed by Fishers Exact test. OR: odd ratio, CI: confidence interval
Significant, Highly significant , Extremely significant
Table 6: Association of the top ten stressors with Stress
Stressors
Stress (N= 194)
P value* OR 95% CI
Abnormal (N=110) Normal (N=84)
Lower Upper
Yes
97 (88.2)
59 (70.2)
0.002
3.16 1.50
6.66
No
13 (11.8)
25 (29.8)
Yes
97 (88.2)
50 (59.2)
0.000
5.07 2.46
10.47
No
13 (11.8)
34 (40.5)
Yes
88 (80.0)
51 (60.7)
0.003
2.56 1.36
4.91
No
22 (20.0)
33(39.3)
Yes
100 (90.9)
69 (82.1)
0.071
2.17 0.92
5.12
No
10 (9.1)
15 (17.9)
Fear of failing
Yes
106 (96.4)
71 (84.5)
0.004
4.85 1.52
15.48
No
4 (3.6)
13 (15.5)
Yes
87 (79.1)
64 (76.2)
0.630
1.18 0.59
2.34
No
23 (20.9)
20 (23.8)
Yes
90 (81.8)
55 (65.5)
0.009
2.37 1.23
4.59
No
20 (18.2)
29 (34.5)
Academic overload
Yes
88 (80.0)
58 (69.0)
0.080
1.79 0.93
3.46
No
22 (20.0)
26 (31.0)
Yes
98 (89.1)
60 (71.4)
0.002
3.27 1.52
7.01
No
12 (10.9)
24 (28.6)
Yes
88 (80.0)
50 (59.5)
0.002
2.72 1.44
5.15
No
22 (20.0)
34 (40.5)
* Pearson Chi-Square test followed by Fishers Exact test. OR: odd ratio, CI: confidence interval,
Significant, Highly significant, Extremely significant
406
DISCUSSION
In this study, the overall prevalence of depression,
anxiety and stress was found to be 64.4%, 84.5% and
56.7% respectively. The rate of depression in this
study is higher than other previous studies in
Malaysia that reported it to be 37.2% and 41.8
respectively.22, 23 This rate is also higher than similar
studies in other countries such as a study done by
Beck and Young in 1978 reported that 25% of student
population has symptoms of depression at any given
time.24Kumaraswamyreported that 31% of medical
students had anxiety and depression25however, the
rate of depression in this study is close to a study
done in Pakistan which stated it to be 60%.26
Regarding the severity of depression, it was found
that 50.5% (n=98) of the students had subclinical
depression while 13.9% (n=27) were having
clinically significant depression. This result is lower
than a study done by Lowe GA which revealed that
40% of university students were clinically
depressed.27This difference in the rate of clinical
depression may be due to use different assessment
tool, cultural differences, type of course studied.
Regarding anxiety, the prevalence is also higher than
other studies done in Malaysia and India that reported
a rate of 60% and 63% and 46% respectively22,23,
28
.While a study done in Brunei found a slightly
lower rate of 79%29.Despite this high overall rate of
anxiety, its clinically significant in 51.5% only.
The reasons behind getting higher rates of depression
and anxiety may be due to the use of different
assessment tools, type of course studied, difficulty in
curriculum and cultural differences
The rate of stress is comparable to other studies done
in Singapore and Brunei 14,29but it is higher than a
previous study in Malaysia that reported it to be
37.3%23. On the other hand, other studies gave a
higher stress rate of 63%and 70.1% respectively30, 31.
Only 12.9% of the participating students had
clinically significant anxiety.
This high rate of emotional disturbances among
undergraduate students require attention from health
care providers to provide proper psychoeducation for
both students and academic staff in order to increase
awareness about symptoms of depression, anxiety
and stress, also about the importance of early
consultations and follow-up. A study done by
Vredenburg K et al have found that college-student
depression, though mild in severity but considered as

a serious problem.32
In assessing some of the factors that determine the
emotional disturbances among undergraduate science
students, we found that younger students aged
21years and below were experiencing significantly
higher rates of depression, anxiety and stress. The
reasons behind these results may be due to younger
students have less experience, changes in life style,
time management problems, inability to adjust to the
new environment and academic overloads. This
finding is similar to previous studies concerning
stress and anxiety among college students.30,
33,34
However, the result of our study concerning
depression is inconsistent with previous studies as
they found that depression is more common among
older students.22, 35, 36while other study had revealed
that there is no significant association between age
and depression among college students.37,38
Depression is significantly higher among year one
students in our study which is consistent with other
studies, 26, 37, 39while another study had shown no
significant association between depression and year
of study.40Theses differences in findings may be due
to implementing different diagnostic tools, sample
size, or course studied. Other factors have been
assessed like gender, household monthly income and
family support. However, they did not show any
significant association with depression, anxiety and
stress.
Academic and personal factors played an important
role as source of stressors since most of the top ten
stressors chosen by the students were related to them.
This finding is comparable with other studies in
which the academic related factors were considered
as the main sources of stressors.17, 19, 41, 42
In assessing the association between the top ten
stressor and depression, the result had revealed that
four stressors have significant association with
depression namely, time management problems,
feeling of incompetence, lack of motivation to learn
and difficulty of class work. While the four stressors
that have significant association with anxiety are
feeling of incompetence, lack of motivation to learn,
fear of failing and difficulty of class work.
For stress, this study has found there is significant
association between stress and the following stressors
407
namely, time management problems, feeling of

incompetence, lack of motivation to learn, fear of
failing, amount of assigned class work, study pressure
and obligation and difficulty of class work.
Overall, three stressors that are related to academic
and personal factors which are lack of self-efficacy,
lack of motivation to learn and difficulty of class
work can be considered as determinants for
emotional disturbances as these three stressor factors
have statistically significant association with all three
subscales (depression, anxiety and stress).
CONCLUSION
We conclude that emotional disturbances in the form
of depression, anxiety and stress are existing in high
rate among undergraduate science students that
require early intervention. Factors including feeling
of incompetence, lack of motivation to learn and
difficulty of class work can be considered as sources
of stressors that may precipitate for depression
anxiety and stress.
One of the ways to help the students to overcome
these difficulties in their academic life is to enhance
the mentor/mentee programs and implement them on
regular basis and aim to discuss thoroughly the
students problems which will help them to release
the pressure applied on them and motivate them to
put a better effort in their study. Another important
aspect to be considered is the frequency and difficulty
of the assignments that are given to students so that
the students will not be overloaded which will
exhaust them physically and mentally.
ACKNOWLEDGEMENTS
We wish to extend our sincere gratitude to
International Islamic University Malaysia for funding
this project and to the administrative personnel in the
Kulliyyah (Faculty) of Science generally and the
department of Computational and Theoretical
Sciences specifically for the kindness of giving
permission to conduct this study and for their
cooperation. We also would like to express our
appreciations to all students in department of
Computational and Theoretical Sciences for their
participation and consent.
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DOI: 10.5958/j.2319-5886.3.2.083

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Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Research Article
DEHYDROEPIANDROSTERONE LEVELS IN TYPE 2 DIABETES

*Rathna Kumari U1, Padma K2
1
Assistant Professor, Department of Physiology, Govt., Kilpauk Medical College, Chennai

Director, Institute of Physiology and Experimental Medicine, Madras Medical College, Chennai
*Corresponding author email: uratna_1986@yahoo.co.in

ABSTRACT
Background: Dehydroepiandrosterone (DHEA) is a steroid hormone secreted by the adrenal cortex. Recent
research reports show that DHEA has various beneficial effects including, enhancing insulin sensitivity. This is
still under study and yet to be proved in humans. Aim: To estimate the levels of DHEA and HbA1c in men with
Type 2 diabetes, in comparison with normal subjects of the same age group. Materials and Methods: A cross
sectional comparative study of sixty participants (60 to 70 years of age), thirty men with uncomplicated Type 2
diabetes for at least five years duration and thirty non-diabetic controls was done. Informed consent was obtained.
Serum levels of DHEA were estimated for all the participants by ELISA method. Their glycemic status was
determined by HbA1c levels. Statistical analysis was done using an unpaired T-test. Significance level was fixed
at p < 0.05. Results: A significant decrease in the DHEA level was observed in Type 2 diabetes individuals
(55.8 11.9) compared with normal subjects (153.3 49.7). A Significant increase in the HbA1C level was
observed in diabetic individuals (8.14 0.66) compared to normal (6.01 0.32). Conclusion: In cases with type
2 diabetes significantly lower levels of Serum DHEA was associated with significantly poorer glycemic control in
comparison with normal subjects.
Keywords: Dehydroepiandrosterone sulphate, Glycosylated haemoglobin
INTRODUCTION
Dehydroepiandrosterone (DHEA) is a steroid, mainly
of adrenal origin, that is found in relatively high
concentrations in human plasma. It serves as a
precursor of both androgenic and estrogenic steroid
hormones. In the circulation, DHEA exists both free
and bound to sulphate (DHEA-S). Thus, DHEA-S
serves as the principal storage form of DHEA.
DHEA-S has many intrinsic effects like anti aging,
anti obesity, anti diabetic, anti atherogenic and
neuroprotective effects.1 A progressive decrease in
circulating levels of DHEA with age has long been
recognized, with peak levels occurring between the
third and fourth decades of life and decreasing
progressively thereafter by about 90% over the age of
85. The decline in circulating DHEA levels occurring

with aging has been linked to the gradually increasing
prevalence of atherosclerosis, obesity, and diabetes in
elderly individuals.2 Normal blood levels of DHEAsulfate can differ by sex and age.3
Table 1: Typical normal ranges for Male & females
Age
in
years
18 19
20-29
30-39
40-49
50-59
60-69
Above 69
Males (g/dl)
Female (g/dl)
108 - 441
280 - 640
120 - 520
95 - 530
70-310
42-290
28-175
145 - 395
65 - 380
45-270
32-240
26-200
13-130
17-90
411
Rathna et al.,

The present study was conducted in the Institute of
Physiology and Experimental medicine, Madras
Medical College, Chennai after obtaining the
approval of The Institutional Ethics Committee of
Madras Medical College before starting the study.
After obtaining informed consent, sixty male subjects
aged between 60 and 70 years were selected for the
study. The reason behind sample selection was that,
DHEA-S levels show a considerable decline in many
subjects above 60 years, though there is a huge interindividual
variation.8,9
Thirty
men
with
uncomplicated, well controlled Type 2 diabetes for at
least five years duration, who were on oral
hypoglycaemic agents and were on regular monthly
follow-up and thirty non-diabetic, age and sex
matched controls were selected from the population
attending outpatient unit of Internal Medicine
department, Govt. General Hospital, Chennai. We
explained the scope and details of the study to the

subjects. The subjects underwent routine clinical
examination and biochemical tests to satisfy the
selection criteria. Fasting blood samples of the
subjects were obtained for estimation of DHEA-S and
HbA1c levels. Fasting blood samples were obtained
under strict aseptic precautions, by venepuncture of
the antecubital vein. The blood samples were drawn
during the early hours of the day. The serum was
separated and stored in the deep freezer at -200 C. The
serum levels of DHEA-S was measured using ELISA
kits based on the principle of competitive binding and
microplate
separation
viz.
serum
Dehydroepiandrosterone sulphate estimation supplied
by cal biotech Inc (California). HbA1c levels were
estimated by HPLC (high performance liquid
chromatography). HbA1c levels less than 6.0% was
considered as good control.
Statistical analysis: The various parameters that
were measured in this study were recorded and
statistically analyzed using Microsoft office Excel
and SPSS 7.0. Statistical analysis was done using
unpaired t test and coefficient of correlation.
Significance level was fixed at p < 0.05.
RESULTS
In our study, we observed a decrease in the DHEA
level (g/dl) in Type 2 diabetes individuals (55.8
11.9) compared with normal subjects (153.3 49.7)
(graph 1). It was also observed that the decrease was
significant (p < 0.05). A significant increase in the
HbA1C level (%) was observed in diabetic individuals
(8.14 0.66) compared to normal (6.01 0.32) (Fig
2).
A significant negative correlation was observed
between DHEA and HbA1C levels (r = - 0.76) (Fig 3)
DHEA levels
200
153.32
150
g/dl
Insulin resistance is a major metabolic abnormality in

obesity as well as in noninsulin-dependent diabetes
mellitus (NIDDM) and is commonly observed in
individuals with glucose intolerance, hypertension,
dyslipidemia, and arteriosclerosis.4, 5 Administration
of DHEA has been reported to have striking
beneficial effects on obesity, hyperlipidemia,
diabetes, and atherosclerosis in obese rodents.6 It has
been demonstrated that DHEA reduces weight gain
and food intake and ameliorates hyperinsulinemia in
obese Zucker rats.7 Short-term therapy with 50 mg
per day of DHEA is safe for older women in relation
to cardiovascular risk factors.8 Another study showed
improved insulin sensitivity, endothelial function and
fibrinolytic activity for middle-aged men with high
cholesterol taking 25 mg per day for 12 weeks.9 A
recent study found that DHEA supplementation may
help reduce abdominal fat, which is associated with
insulin resistance. Twenty eight men and 28 women,
aged 65-78, supplemented with 50 mg per day of
DHEA for six months, DHEA therapy induced
significant decreases in visceral and subcutaneous fat.
Insulin action was also improved.10
Dehydroepiandrosterone (DHEA) has been shown to
modulate glucose utilization in humans and animals,
but the mechanisms of DHEA action have not been
clarified. We undertook the following study to find
whether there is any link between DHEA levels and
glycemic status in Indian population.
100
50
55.84
0
type 2 DM
controls
Fig 1: DHEA levels (g/dl) in controlled Type 2

Diabetes in comparison with normal subjects.
412
Rathna et al.,
HbA1C
10
8.14
6.01
6
4
2
0
type 2 DM
controls
HbA1C (%)
Fig 2: HbA1C levels (in %) in controlled Type 2

Diabetes in comparison with normal subjects.
10
9
8
7
6
5
4
3
2
1
0
0
100
200
300
400
DHEA (g/dl)
Fig 3: correlation between DHEA (g/dl) and HbA1C
levels (%). A negative correlation (r = - 0.76) was
observed.
Table 2: Showing Mean levels of DHEAS in g /dl and
HbA1C in %.
DHEAS
TYPE 2 DM
Mean
CONTROLS
55.8 11.9
153.3 49.7
0.00**
8.1 0.7
6.0 0.3
0.00**
P value
(g/dl)
HbA1C
** Highly significant
DISCUSSION
In the early 1980s, Coleman ET al.8, 10, 11 reported that
dietary administration of DHEA to Mice induced
remission of hyperglycaemia and largely corrected
insulin resistance in these animals. More recently,
DHEA was shown to protect against the development
of visceral obesity and muscle insulin resistance in
rats fed a high-fat diet. In addition, DHEA has been
shown to restore insulin sensitivity in obese Zucker
rats.12 Oral administration of DHEA to insulinresistant rats for 2 weeks resulted in increased
glucose uptake by adipocytes compared with
untreated animals.13
Genetically diabetic (db/db) mice develop obesity and
glucose intolerance associated with insulin resistance,
and subsequently exhibit cell necrosis and islet
atrophy. Supplementing their diet with DHEA
prevented these pathologic changes and effected rapid
remission of hyperglycaemia, cell dysfunction, and
insulin resistance13. Adiponectin gene expression in
adipose tissue and serum adiponectin levels were
elevated in DHEA-treated rats by activation of
peroxisome proliferators activated receptor (PPAR
).14, 15
Other recent studies have demonstrated that DHEA
increases glucose uptake rates in human fibroblasts
and rat adipocytes16,17 and have suggested that this
effect may be mediated by activation of PKC and PI
3-kinase. DHEA treatment of human adipocytes
results in enhanced glucose transport rates through
GLUT4 and GLUT1 transporter translocation to the
cell surface. In vitro, the DHEA infusion is known to
enhance insulin action18.
Villareal and Holloszy reported a significant increase
in an insulin sensitivity index in response to DHEA in
the elderly. DHEA treatment can reduce body weight
and serum TNF-, and also may increase insulin
sensitivity and slow progression of type 2 diabetes.18
In a recent study, enhanced insulin sensitivity and
glucose disposal were found in hyperandrogenic
women treated orally with DHEA, under conditions
in which the treatment increased plasma DHEA and
DHEAS.19
Insulin resistance is central to the metabolic
syndrome, which has received increasing attention in
the past few years as a concurrence of CVD risk
factors including abdominal obesity, impaired
glucose tolerance, dyslipidemia, and hypertension.20,
21
Low DHEA concentrations are associated with
development of central obesity, while decreased
serum concentrations of DHEA may contribute to
insulin resistance. Patients with type 2 diabetes
mellitus often show clustering of risk factors, which
puts them at particularly high risk for CVD. Low
levels of DHEA seen in type 2 diabetes might be the
triggering factor for these risk factors. Administration
of metformin is reported to increase serum DHEA-S
413
Rathna et al.,
secondarily to alleviation of hyperinsulinemia seen in

insulin resistance.22
CONCLUSION
As an aim to find an association between DHEA
levels and type 2 diabetes, we found that lower
DHEA level was linked to poor glycemic control.
Recently, there has been a resurgence of interest in
DHEA, because it has been suggested that it might
have anti-ageing effects. Hence, Type 2 diabetes and
its associated complications which are considered as
an expanded spectrum of accelerated ageing can
attribute a part of its pathogenesis to lowering DHEA
levels. Clinical trials on the effects of DHEA
supplementation in humans with type 2 diabetes are
still in their early stages. Further research on this
topic can derive clues to pathogenesis of diabetes and
ageing.
5.
6.
7.
8.
9.
Competing interests: Nil
ACKNOWLEDGEMENTS
We thank the Institute of Physiology and
Experimental medicine, Madras Medical College,
Chennai and the Internal Medicine department, Govt.
General Hospital, Chennai for their permission and
providing the subjects for our study. We also thank
the postgraduate students and the technicians for their
support.
10.
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DOI: 10.5958/j.2319-5886.3.2.084

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Coden: IJMRHS
Received: 27th Feb 2014
Copyright @2014
ISSN: 2319-5886
Research Article
PREVALENCE AND IMPACT OF PRIMARY HEADACHE DISORDERS AMONG STUDENTS AND

WORKING POPULATION IN 18-25 YEARS AGE GROUP
*Gowri Aishwarya S1, Eswari N1, Chandrasekar M2, Chandra Prabha J3
1
Final year MBBS Student, 2Vice Principle and Head, Department of Physiology, 3Post graduate in Physiology,
Meenakshi Medical College and Research Institute, Kanchipuram, Tamilnadu, India
*Corresponding author email:aishu2493@gmail.com
ABSTRACT
Background: Headache or cephalalgia is defined as pain in the head. Headache is an extremely common
symptom that may have a profound impact on peoples functioning and quality of life. According to International
Classification of Headache Disorders (ICHD), they are Primary and Secondary headaches. Primary Headaches are
triggered by stress, alcohol, changes in sleep pattern, anxiety, poor posture, all of which are part and parcel our
day-to-day life. The study was performed to investigate the prevalence of primary headache disorders and its
severity of impact among students and working population in the age group 18-25. Methods: The study was
conducted on 718 subjects of which 483 subjects were medical and engineering students from the age group 1821 and 235 subjects were working people from the age group 22-25. Written consent was taken from each of
them. Headache Impact Test-6 (version 1.1) and the HARDSHIP Questionnaire by Timothy Steiner et al. were the
questionnaires used to diagnose the severity of impact and the type of headache respectively. The study was
ethically approved by Ethical Clearance Board of MAHER University. People suffering from psychiatric illness
were excluded from the study. Result: There was increased prevalence of migraine in the age group 18-21 and
tension type headache in the age group 22-25.Over 50%of subjects from both the age groups had headaches that
have substantial to severe impact on their lives. There was no significant gender variation in headache prevalence.
Keywords: Migraine, tension type headache, stress, headache, anxiety
INTRODUCTION
Headache or cephalalgia is a pain in the head1.The
pain is caused by irritation or inflammation of
structures that surround the brain like meninges,
periosteum and muscles since the brain has no nerve
fibres to sense pain. The pain may be of various
types like throbbing, dull ache, continuous, sharp or
intense2.
According to International Classification of
Headache Disorders (ICHD), they are Primary and
Secondary headaches. Primary headaches are
migraines,
tension-types
headaches,
cluster
headache
and
other trigeminal autonomic
cephalalgias. Secondary headaches are based on
Gowri et al.,
their etiology and not on their symptoms. These

include those that are due to head or neck trauma
such as whiplash injury, intracranial hematoma, post
craniotomy or other head or neck injury3.
Sample: Subjects from the age group 18-25 were
divided into two categories. Age group 18-21 which
consisted of students from medical and engineering
colleges and the age group 22-25 which consisted of
working people from medical and engineering fields.
The duration of the study was from October 2013 to
December 2013.
416
METHOD: 718 subjects responded YES to above

question and were asked to fill the questionnaires
after getting informed consent from them. Out of the
718 subjects, 483 cases were students in the age
group 18-21 (45% males and 55% females) and 235
cases were working people in the age group 22-25
(47% males and 53 % females).
Questionnaire: There were two questionnaires. The
first one Headache Impact Test-6 (version 1.1)5 is a
tool used to measure the impact headache has on
your ability to function. Based on the scoring the
subjects were divided into little/no impact, moderate
impact, substantial impact and severe impact. The
other one is the HARDSHIP Questionnaire which
stands for Headache-attributed restriction, disability,
social handicap and impaired participation
questionnaire6,7. It is used to diagnose the type of
headache. It consists of questions which gives
information about the onset, duration, type and
characteristics of pain along with its associated,
relieving and aggravating factors.
Statistical analysis: The obtained data was analyzed
for statistical significance using Studentst test.
p>0.05 was considered the level of significance.
Graph pad Prism 4 was the software used
RESULTS
The results of the Headache Impact Test-6
(Version1.1) questionnaire showed that over 50% of
subjects from both the age group have headaches
that have substantial to severe impact on their lives
(Fig 1 &2). The results of HARDSHIP questionnaire
showed that there was increased prevalence of
Gowri et al.,
Percentage
migraine (57%) in the age group 18-21 (Fig 3) and

increased prevalence of tension type headache (42%)
in the age group 22-25 (Fig 4). Taking p>0.05, there
was no significant gender variation in headache
prevalence in both the age groups.
35%
30%
25%
20%
15%
10%
5%
0%
33%
22%
25%
20%
Severity of Impact
Fig1 : Severity of impact of headache based onHIT-6
questionnaire in the age group 18-21
Percentage
Ethical clearance: The study was ethically

approved by Ethical Clearance Board of MAHER
University.
Consent: Written informed consent was taken from
all the subjects.
Inclusion criteria: The subjects were asked if they
had a headache in the past year not related to flu,
hangover, cold or head as recommended by earlier
studies4. Those who said YES to the screening
question were alone included in the study.
Exclusion criteria: Those who were suffering from
psychiatric illness were excluded from the study.
Those having headaches associated with refractive
errors, aural problems and dental problems were also
excluded.
40%
35%
30%
25%
20%
15%
10%
5%
0%
34%
26%
21%
19%
Severity of Impact
Fig 2: Severity of impact of headache based on
HIT-6 questionnaire in the age group 22-25
1%
7%
Migraine
35%
TTH
57%
Migraine+TTH
Cluster
Fig 3: Distribution of different types of headaches

in the age group 18-21
417
CONCLUSION
1%
21%
36%
Migraine
TTH
Migraine+TTH
42%
Cluster
Fig 4: Distribution of different types of headaches

in the age group 22-25
DISCUSSION
Headache is the most common neurological problem
that has a profound impact on peoples life. Tension
type headache (TTH) is characterized by bilateral
non-pulsating pain which may be described as
tightness like a band around the head. Migraine is
described by unilateral pulsating headache
associated with nausea, vomiting, and photophobia.
World Health Report 2001 by World Health
Organization ranked headache among the top 20
causes of healthy life lost to disability8. In India,
given the population load, headache has been and
continues to be underestimated in scope and scale,
and remains under-recognized and under-treated
everywhere. TTH and migraine ranked respectively
as second and third most common diseases in the
world (behind dental caries) in both males and
females9.The Global Burden of Disease Study which
was updated in 2004 found that migraine account for
1.3% of years lost due to disability (YLD)10.
A study conducted by Mayo Clinic showed that the
common triggers for migraine are hormonal changes
in women, foods like cheese, salty foods and
processed foods, skipping meals or fasting, alcohol,
especially wine, stress, changes in wake-sleep
pattern, physical exertion, weather changes11. Stress
is the most commonly reported trigger for tension
headaches 12. The other common causes of TTH
reported are anxiety, depression, poor posture, and
lack of sleep13.
Headaches are not only painful, but also disabling.
They impair the quality of life, damage family life
and social life. They may predispose the sufferers to
other illnesses. For example, people suffering from
migraine have three times increased risk of
depression compared to the healthy individuals.
Gowri et al.,
My study showed that migraine (57%) and tension

type headache (42%) is most commonly compared
to other types of headaches in the age group 18-21
and 22-25 respectively. Headache disorders are
associated with personal and societal burdens of
pain, disability, damaged quality of life and financial
cost. Since the symptoms and management of each
type of headache is different, it is wise to know
about them before treating them with over the
counter medications like aspirin which will do worse
than good.
ACKNOWLEDGEMENT
We are grateful to all the subjects for their
cooperation and patience. We sincerely thank all the
professors from the Department of Physiology,
neurology and social and preventive medicine from
Meenakshi Medical College and Research Institute
for their guidance, encouragement and support.
REFERENCES
1. Headache (hedk):
Dorlands
Illustrated
st
Medical Dictionary. 31 edn,pp:835.
2. Jay W. Marks. http://www.medicinenet.com/
headache/article.htm#what
is_a_headacheon
5/16/2013.
3. Headache Classification Committee of the
International
Headache
Society.
The
international
classification
of
headache
rd
disorders.Cephalalgia.2013; 3 edn, 15:629808
4. Lipton RB, Stewart WF, Diamond S. Prevalence
and burden of migraine in the United States:
data from the American Migraine Study II.
Headache. 2001; 41:646-57
5. Kosinski M, Bayliss MS, Bjorner JB, et al. A
six-item short-form survey for measuring
headache impact: the HIT-6. Qual Life Res.
2003; 12: 96374
6. Steiner TJ. Lifting the burden: the global
campaign to reduce the burden of headache
worldwide.Headache Pain. 2005; 6:373-77
7. Timothy
J
Steiner,GopalakrishnaGururaj, Colette
Andre,, ZazaKatsarava. Diagnosis, prevalence
estimation and burden measurement in
population surveys of headache: presenting the
418
8.
9.
10.
11.
12.
13.
HARDSHIP
questionnaire.J
Headache
Pain. 2014; 15(1): 3
World Health Organization. The World Health
Report. WHO, Geneva.2001;pp 19-45.
Stovner LJ, Hagen K, Jensen R, Katsarava Z,
Lipton R, Scher AI, et al. The global burden of
headache: A documentation of headache
prevalence
and
disability
worldwide.
Cephalalgia. 2007; 27:193-210.
Headache disorders. Fact sheet N277, October
2012
http://www.who.int/mediacentre/
factsheets/fs277/en/.
Mayo Clinic Staff. Mayo Clinic Guide to Pain
Relief.
http://www.mayoclinic.com/health/
migraineheadache/DS00120/Dsection=causes
Mayo Clinic Staff. Diseases and Conditions
Tension headache. http://www.mayoclinic.com/
health/tension headache/DS00304/ DSECTION
=causes.
The migraine trust. http://www.migrainetrust.
org/factsheet-tension-type-headache-1088
Gowri et al.,
419
DOI: 10.5958/j.2319-5886.3.2.085

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Research Article
SERUM ANTI MULLERIAN HORMONE LEVELS: A BETTER HORMONAL MARKER OF

OVARIAN RESERVE
*RadhaVembu1, Sanjeeva Reddy Nellapalli2, Anjalakshi Chandrashekar3, Nalini Ganesan R4
1
Associate Professor, 3Professor & Head Department of Obstetrics & Gynecology, Sri Ramachandra University,
Tamil Nadu, India
2
Professor & Head Department of Reproductive Medicine, Sri Ramachandra University, Tamil Nadu
4
Professor, Department of Biochemistry, Sri Ramachandra University, Tamil Nadu
*Corresponding author email: ganesh_radha@yahoo.in
ABSTRACT
Aim: To determine whether Serum AMH is a better hormonal marker of Ovarian Reserve. Objectives: 1. To
correlate AMH with FSH and maternal Age and whether AMH is a better predictor of ovarian response than FSH.
Materials & Methods: A total of 246 women enrolled for IVF-ICSI fulfilling the selection criteria were recruited
for the study at a tertiary ART centre. On day 3 of the cycle serum AMH, FSH were assayed along with LH, E2,
TSH and Prolactin. Within 3 months they were subjected to IVF-ICSI. Serum AMH and FSH levels were
compared with Age and Oocytes retrieved. Results: All the 246 women enrolled were analysed. The mean age of
the women was 30.7 4.5, average number of oocytes retrieved was 11.8 7.1. There was a negative correlation
of AMH with age (r= -0.28) which is statistically significant where as FSH showed a positive correlation (r= 0.27). With regard to retrieval of mature oocytes, AMH showed a high positive correlation (r= 0.60) which is
statistically significant (p <0.000) when compared to serum FSH (r = -0.26). Conclusion: AMH is a better
hormonal marker of Ovarian Reserve and a better predictor of Oocytes retrieved than serum FSH levels.
Key words: AMH, Ovarian reserve, ovarian response
INTRODUCTION
The success of IVF-ICSI depends on the number and
quality of mature oocytes retrieved after controlled
ovarian stimulation. Ovarian reserve is currently
defined as the number and quality of follicles left in
the ovary at any given time 1 , 2 It is also defined as
an estimate of oocytes remaining in the ovary that are
capable of fertilization resulting in a healthy and
successful pregnancy.3
In this era of advanced maternal age at the time of
first child birth due to delaying child bearing have
lead to increase in the incidence of infertility related
to female reproductive ageing 4
The conventional measure of assessing ovarian

reserve by chronological age and FSH has several
drawbacks. With age, there is a decline in ovarian
reserve due to apoptotic loss of follicles and not due
to ovulation 5. So biological age of the ovary is not
same as chronological age. FSH assay shows wide
intra individual variability 6. Clinically there is a need
to identify women of relatively young age with
reduced ovarian reserve as well as women whose
fertility is naturally impaired by age who may still
have satisfactory ovarian potential.
The present study is done to evaluate whether a)
Serum AMH is a better hormonal marker of ovarian
reserve than Serum FSH and Age. b) To determine
420
Radha et al.,
whether serum AMH is a better predictor of ovarian

response than serum FSH levels.
This was a prospective Observational study
conducted at Infertility unit at a tertiary care centre
from January 2011 to August 2013. A total of 246
women enrolled for IVF-ICSI were recruited for the
study. Women in the age group of 20-45 years, with
bilateral ovaries were included in the study and those
women more than 45 years, hypogonadotropic
hypogonadotropism were excluded. The informed
consent was taken from all the participants and the
Institutional Ethical committee approval was
obtained. (IEC NI/10/JUNE/17/17)
A detailed history and physical examination was
done. On day 3 of cycle serum FSH, LH, Estradiol
were assayed by the immune enzymometric assay
ELISA technique. On the same day, serum sample for
AMH assay was separated within one hour of
venepuncture and was stored in aliquots at -40 C.
The sample was later assayed in batches by AMH
generation II assay, the analytical sensitivity was
0.14ng/ml and intra- assay and inter- assay CVs were
<12.3 and < 14.2% respectively. These patients were
subjected to Controlled Ovarian Stimulation within
three months as per the unit protocol.
RESULTS
Fig 1 : Correlation of Age with AMH and FSH level
Correlation of Age with FSH showed a negative

correlation (r= -0.27) where as with AMH (fig 1)
showed a positive correlation (r=0.28) which is
significant (p < 0.000)
All 246 patients enrolled in the study were analysed.

Among them, 72.8% were primary infertility; the
female factor was the commonest indication for ICSI
(32%) of which tubal factor accounted for 48%. This
is followed by Male factor (24%), both (22%),
Unexplained (14%), Donor (8%). The baseline
characteristics are shown in table 1
Table 1: Baseline characteristics to include as table
Values (n= 246)
Parameters
Mean Age (years)
30.7 4.5
Infertility duration (years)
7.2 3.9
BMI (kg/m)
26.5 4.7
FSH (mIU/ml)
7.2 2.4
AMH (ng/ml)
4.5 3.3
Mature Oocytes retrieved
11.7 7.2
Fig 2 - the mean plasma levels of AMH and FSH

according to age.
AMH levels show a decline after 30 years and FSH
levels increase only after 35 years of age (fig 2).
421
Radha et al.,
Fig - 3; Correlation of AMH and FSH with Oocytes

retrieved
AMH showed a statistically strong positive
correlation (fig 3) with the mature oocytes retrieved
(r=0.60, p value 0.000) than FSH which showed a
negative correlation (r=-0.26)
Statistical analysis: The collected data were
analysed with SPSS 16.0 version. To describe about
the data descriptive statistics frequency analysis,
percentage analysis, means and standard deviation
were used. To find significance difference in the
multivariate analysis, the one way ANOVA with
Tukeys Post - Hoc test was used. To assess the
relationship between the variables Pearsons
Correlation was used. To find the significance in
categorical data Chi - Square test was used. In all the
statistical tools, the probability value of p<0.05 is
considered as significant level.
DISCUSSION
In this study the authors investigated the value of
AMH as a marker of ovarian reserve in comparison
with Age and FSH levels. As expected FSH levels
rise and AMH levels decrease with increasing age.
Interestingly, the sub group analysis of Age with
AMH and FSH showed a static value with both till
approximately 30 years of age at which point AMH
levels showed a steady decline from 5.2ng/ml to 3.2
Radha et al.,
ng/ml by 37 years. Conversely the rate of change in

FSH was discernable which started rising only after
35 years. This correlates with the study of de Vet et
al, 7 a study of 41 women between 20 35 years
showing a rapid decline in AMH levels with age.
Another study of 238 patients with normal FSH
values5 also showed a similar decline in AMH by
50% from 20-10pmol/L between 29 to 37 years of
age and minimal changes in FSH values with age.
This observation is very useful in this current trend of
postponing the first child birth to the third decade for
various social reasons. So early identification of
diminished ovarian reserve by AMH assay in these
individuals before it becomes critical will give the
women a timely opportunity to advance the
pregnancy plans, thereby maximising the chances of
successful outcomes.
This study showed a statistically significant
correlation between plasma AMH levels on day 3 of
cycle and the ovarian response to controlled ovarian
stimulation. This correlates with a pilot study done by
Singh Neeta in the Indian population8 which showed
a significant correlation between day 2 serum AMH
levels and the oocytes retrieved in patients going for
IVF. Our data strongly supports the previously
published studies dealing with AMH levels and the
marker of ovarian reserve and better hormonal
predictor of ovarian response to controlled ovarian
stimulation in Assisted Reproductive Technology
ART cycles. It is an important, non invasive
hormonal marker for early identification of
diminished ovarian reserve than FSH levels. As this
hormonal assay of AMH can be done any day of the
cycle with less intercycle variability unlike FSH, it
can be considered as an important tool for counselling
the women who desire to post pone the first child
birth, there by maximising the chances of successful
outcome.
CONCLUSION
AMH is a better hormonal marker of Ovarian Reserve
and a better predictor of Oocytes retrieved than serum
FSH levels.
ACKNOWLEDGEMENTS
Sri Ramachandra University for financial support
through GATE Project& for material support.
Special thanks toSRL Religare Lab for AMH
assay.
422
REFERENCES
1. Broekmans FJ, Kwee JD, Hendriks DJ, Mol BW,
Lam CB. A Systematic review of tests predicting
ovarian reserve and IVF outcome. Hum Reprod
update 2006;12(6):685 -718
2. Marc A. Fritz, Leon Speroff. Clinival
Gynecologic Endocrinology and Infertility. 8th
edition, page No 1147
3. Ruma Satwik, Mohinder Kochhar, Shweta M
Gupta and Abha Majumdar. Anti Mullerian
Hormone cut off values for predicting poor
ovarian response to exogenous ovarian
stimulation in invitro fertilization. J Hum
Reproduct Sci. 2012;5(2):206-12
4. ESHRE Capri workshop Group. Fertility and
ageing. Hum Reprod update 2005; 11:261-76
5. Kelton P. Tremellen, Michele Kolo, Alan
Gilmore and Dhamawijaya N. Lekamge.
ANZJOG 2005; 45: 20-24
6. Sharif K, Elgendym, Lashen H, Afnan M. Age
and basal FSH as predictors of Invitro
fertilisation outcome. BrJ Obstet Gynaecol 1998;
105: 107-12
7. De Vet AM, Laven JSE, de jong FH, Themmen
APN, Fauser BCJM. Anti MullerianHormone
serum levels: A putative marker for ovarian
ageing. Fert Steril 2002; 77: 357 -62
8. Singh N, Malik Ekta, Banerjee Ayan, Chosdol
Kunzang, Sreenivas, Mittal suneeta. Anti
Mullerian Hormone: for Ovarian Response in
Controlled Ovarian Stimulation for IVF Patients:
A first pilot study in the Indian Population. J of
Obstet Gynecol 2013; 63(4): 268 -72
423
Radha et al.,
DOI: 10.5958/j.2319-5886.3.2.086

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
st
Received: 1 Mar 2014
Copyright @2014
ISSN: 2319-5886
Research Article
CARBAPENEM RESISTANCE PROFILE AMONGST ESCHERICHIA COLI AND KLEBSIELLA

PNEUMONIAE IN A TERTIARY CARE HOSPITAL IN AHMEDNAGAR, MAHARASHTRA
*Shraddha Prasad Gunjal1, Prasad Niranjan Gunjal1, Nagaraju Vanaparthi2, Kher Sudheer3
1
Assistant Professor, 2Tutor, 3Professor & Head, Department of Microbiology, PDVVPFs Dr.Vikhe Patil Medical
College& Hospital, Vadgon Gupta, Ahmednagar, Maharashtra, India
* Corresponding author email: shraddhaprasadgunjal@gmail.com
ABSTRACT
Introduction: Carbapenem-resistant Enterobacteriaceae (CRE), specially three species of the Enterobacteriaceae
family, the Klebsiella, Enterobacter and Escherichia have developed resistance to a group of antibiotics called
Carbapenems, which are often used as the last line of treatment when other antibiotics are not effective in
treating infections caused by them. Aim of the study: The present study was carried out to detect carbapenem
resistance profile among Escherichia coli & Klebsiella pneumoniae. Materials & Methods: Cultures were
obtained from consecutive specimens like urine, pus, sputum and blood collected from indoor as well as outdoor
patients of our hospital. Specimens were processed for culture and identification according to standard techniques.
Cultures yielding only Escherichia coli & Klebsiella pneumoniae were included in the study. Antimicrobial
susceptibility testing was performed on Mueller-Hinton agar plates by the standard Kirby-Bauer disk diffusion
method recommended by CLSI against imipenem and meropem. The diameters of zone of inhibition were
recorded as sensitive, resistant or intermediate sensitive according to the CLSI criteria. Results & Observations:
Total 206 isolates were surveyed. Urine & pus were the commonest specimens which isolated Escherichia coli &
Klebsiella pneumoniae. 58.82% & 8.82% E. coli were resistant to meropenem & imipenem respectively.
Similarly, 53.84% & 30.76% K. pneumoniae were resistant to meropenem & imipenem respectively. Conclusion:
K. pneumoniae and E. coli are commonly encountered pathogens from clinical specimens and exhibit resistance to
carbapenems. E. coli and K. pneumoniae isolates showed higher resistance to meropenem (58.82% and 53.84%,
respectively) as compared to imipenem (8.82% and 30.76% respectively). K. pneumoniae shows greater
resistance to carbapenems as compared to E. coli.
Keywords: Imipenem, Meropenem, Carbapenem-resistant
INTRODUCTION
Gram negative
bacilli
belonging to the
Enterobacteriaceae are the most frequently
encountered bacterial isolates recovered from clinical
specimens. Members of the Enterobacteriaceae may
be associated with virtually any type of infectious
disease and recovered from any specimen received in
the laboratory. Microbiologist must be alert in the
emergence of any Enterobacteriaceae that are
resistant to multiple antibiotics. Detecting these
resistant strains is not only important in treating the

patient from whom the isolate is recovered but also
has important implications for surveillance of
nosocomial
infections.1
Carbapenem-resistant
Enterobacteriaceae (CRE), specially, the Klebsiella,
Enterobacter and Escherichia, have developed
resistance to a group of antibiotics called
Carbapenems, which are often used as the last line
of treatment when other antibiotics are not effective
424
Shraddha et al.,
in treating infections caused by them.2 Moreover, the

prevalence
of
carbapenem
resistance
in
Enterobacteriaceae (CRE) isolated from clinical
samples continues to increase throughout the world.3
The present study was therefore carried out to detect
carbapenem resistance profile among Escherichia
(E.) coli and Klebsiella (K.) pneumoniae.
This retrospective study was carried out with
clearance from institutional ethical committee, in the
bacteriology
laboratory
of
department
of
Microbiology, of Padmashree Dr. Vitthalrao Vikhe
Patil Medical College, Ahmednagar, Maharashtra.
The time period of this study was January 2012 to
January 2013.
Cultures were obtained from consecutive specimens
like urine, pus, sputum and blood, collected from
indoor as well as outdoor patients from all clinical
departments of PDVVPFs hospital, which is a 700
bed tertiary care hospital. Specimens were processed
for culture and identification according to standard
techniques.1 Cultures yielding only Escherichia (E.)
coli and Klebsiella (K.) pneumoniae were included in
the study. All repeat isolates from the same patient
were excluded from the study irrespective of the type
of specimen. Antimicrobial susceptibility testing of

isolates was performed on Mueller-Hinton agar plates
by the Kirby-Bauer disk diffusion method
recommended by CLSI4 against imipenem
(10g/disc) and meropenem (10g/disc). The
antibiotic disc of imipenem and meropenem were
purchased from Hi-Media Laboratories Pvt. Ltd.
Mumbai, Maharashtra. The growth inhibition zone
diameter was recorded and interpreted as sensitive
(Imipenem & Meropenem is 16 mm), resistant
(Imipenem & Meropenem is 13 mm) , or
intermediate sensitive (Imipenem & Meropenem is 14
mm), by the criteria of CLSI.4 Intermediate sensitive
isolates were included in resistant isolates for final
analysis. Strain of E. coli ATCC 25922 was used as
control.
RESULTS
A total of 206 isolates were surveyed. Table 1
Indicates details of type of specimens from which
isolates were obtained. Resistance pattern of E. coli to
meropenem and imipenem, where total isolates of
Escherichia coli are 102. Table no. 2, 3 shows
resistance pattern of Klebsiella pneumoniae to
meropenem and imipenem, where total isolates of K.
pneumoniae are 104.
Table 1: Details of type of specimens from which isolates were obtained
Sr. no.
1
2
3
4
5
Specimen
Urine
Pus
Sputum
Blood
Total
E. coli n (%)
46 (54.76)
47 (55.95)
07 (24.13)
02 (22.22)
102
K. pneumoniae n (%)
38 (45.23)
37 (44.04)
22 (75.86)
07 (77.77)
104
Total = n
84
84
29
09
206
Table 2: Resistance pattern of Escherichia coli (n=102) to meropenem and imipenem.
Sr. no.
1
2
3
4
5
Specimen(n)
Urine(46)
Pus(47)
Sputum(7)
Blood(2)
Total(102)
Meropenem n (%)
25 (54.34)
27 (57.44)
06 (85.71)
02 (100 )
60(58.82)
Imipenem n (%)
04 (8.69)
05 (10.63)
00 (00)
00 (00)
09(8.82)
Both n (%)
04 (8.69)
02 (4.25)
00 (00)
00 (00)
06(5.88)
Table 3: Resistance pattern of Klebsiella pneumoniae (n=104) to meropenem and imipenem.

Sr. no. Specimen (n)
Meropenem n (%)
Imipenem n (%)
Both n (%)
1
Urine(38)
23 (60.52)
12 (31.57)
09 (23.68)
2
Pus(37)
19 (51.35)
09 (24.32)
06 (16.21)
3
Sputum(22)
08 (36.36)
08 (36.36)
06 (27.27)
4
Blood(7)
06 (85.71)
03 (42.85)
02 (28.57)
5
Total(104)
56(53.84)
32(30.76)
23(22.11)
425
Shraddha et al.,
DISCUSSION
Urine and pus were the most common specimens
which isolated E. coli and K. pneumoniae. Out of the
total 206 isolates 84(40.77%) each were E. coli and
K. pneumoniae, followed by 14.07% isolates from
sputum and 4.36% isolates from blood. This is well in
accordance with Nagaraj S et al.5 who also reported
42% carbapenem isolates of E. coli and K.
pneumoniae from urine. Parveen RM 6 reported
37.86% isolates of K. pneumoniae from urine.
Out of 102 isolates of E. coli, 60(58.82%) were
resistant to meropenem. Nagaraj S et al. 5 reported
higher resistance of 80% of E. coli to meropenem.
Out of 102 isolates of E. coli 9(8.82%) were resistant
to imipenem. These findings are quite similar to Datta
S et al.7, who reported 6% isolates of E. coli resistant
to imipenem.
As far as K. pneumoniae is concerned 56(53.84%) out
of 104 isolates were resistant to meropenem. This is
fairly in accordance with Parveen RM et al.6 who
reported 43.6% K. pneumoniae isolates resistant to
meropenem. On the other hand these findings are low
as compared to Nagaraj S et al.5 who reported
29(80.55%) out of 36 isolates of K. pneumoniae
resistant to meropenem, whereas, are extremely high
as compared to Bora A et al.8 who reported 19
(9.22%) out of 206 isolates of K. pneumoniae
resistant to meropenem and imipenem. Out of 104
isolates of k. pneumoniae, 32 (30.76%) were resistant
to imipenem, which is well in accordance to Parveen
RM et al. (6), who reported 32% isolates of K.
pneumoniae resistant to imipenem & varies from
Datta S et al.7, who reported 52 % resistant isolates.
Finally, 5.88% E. coli & 22.11% K. pneumoniae
isolates were resistant to both meropenem and
imipenem. K. pneumoniae exhibits greater resistance
to carbapenems.
Carbapenems are one of the important antibiotics in
the treatment of serious infections caused by
members of the family Enterobacteriaceae.9 High
level of carbapenem resistance in K. pneumoniae is
due to combination of different factors like lactamase production, porin OmpK 35/36 Insertional
inactivation and down-regulation of the phosphate
transport porin and changes in penicillin-binding
proteins.10
Resistance in K. pneumoniae mediated by K.
pneumoniae carbapenemase (KPC) can accompany
other Gram negative resistance mechanisms. The

genes of which enzymes are usually present on
plasmids and hence can spread easily.11
This makes it important to constantly keep a check on
the prevalence of resistance to antibiotics in
commonly encountered pathogens. The present study
was conducted keeping this concept in mind.
In the era of molecular approaches for the study of
genes which mediate carbapenem resistance, the
present survey serves as a pilot study. Also it inspires
us to carry out further extensive research in view of
drug resistance periodically which may include the
ICU and the non-ICU sections, demographic aspects,
clinical aspects etc.
CONCLUSION
K. pneumoniae and E. coli are commonly
encountered pathogens from clinical specimens and
exhibit resistance to carbapenems. E. coli and K.
pneumoniae isolates show higher resistance to
meropenem (58.82% and 53.84% respectively) as
compared to imipenem (8.82% and 30.76%
respectively). Imipenem shows better sensitivity invitro as compared to meropenem. K. pneumoniae
shows greater resistance to carbapenems as compared
to E. coli. This emerging resistance may an alarming
situation and indicates need of judicious use of
antibiotics and keeping a constant check on
susceptibility of pathogens to various antimicrobials
including the carbapenems. So that, should the need
arise, methods can be implemented to control the
spread of such resistant strains in the hospital
environment. Also it gives an insight to carry out
more extensive research.
ACKNOWLEDGEMENT
Authors acknowledge the Principal, Management of
Dr. Vikhe Patil Memorial Hospital and Medical
College, Ahmednagar, Maharashtra, India, for their
kind permission & support to carry out the study.
REFERENCES
1. Washington WC Jr., Allen SD, Janda WM,
Koneman EW, Gary PW, Schreckenberger PC,
Woods GL. Color Atlas and Textbook of
Diagnostic
Microbiology.
6th
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2.
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Philadelphia:
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Chapter
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Carbapenem-resistant
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[Updated 2014 Jan 30; Cited 2014 Feb 17].
Available from: http://www.dhs.wisconsin.gov/
/ARO/CRE.htm
Prabaker K, Weinstein RA. Trends in
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Performance
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supplement. CLSI document M100-S21.Wayne,
PA: CLSI; 2011.
Nagaraj S, Chandran SP, Shamanna P, Macaden
R. Carbapenem resistance among Escherichia
coli and Klebsiella pneumoniae in a tertiaty care
hospital in South India. Indian J Med Microbiol
2012; 30:93-95.
Parveen RM, Harish BN, Parija SC. Emerging
Carbapenem Resistance Among Nosocomial
Isolates Of Klebsiella pneumoniae in South India.
Int J Pharma. Bio. Sci. 2010; 1 (2):1-10
Datta S, Wattal C, Goel N, Oberoi JK,
Raveendran R, Prasad KJ. A ten year analysis of
multi-drug resistant blood stream infections
caused by Escherichia coli & Klebsiella
pneumoniae in a tertiary care hospital. Indian J
Med Res. 2012; 135: 907-12
Bora A, Ahmed G. Detection of NDM-1 in
Clinical Isolates of Klebsiella pneumoniae from
Northeast India. Journal of Clinical and
Diagnostic Research. 2012; 6 (5) :794-800.
Prakash S. Carbapenem sensitivity profile
amongst bacterial isolates from clinical
specimens in Kanpur city. Indian J Crit Care
Med. 2006; 10 (4) :250-53
Frank MK, Fadia DH, Wenchi S, Thomas DG.
High-level Carbapenem Resistance in Klebsiella
pneumoniae Clinical Isolates is Due to the
Combination of blaACT-1-Lactamase Production,
Porin OmpK35/36 Insertional Inactivation, and
Down-Regulation of the Phosphate Transport
Porin PhoE. Antimicrob. Agents Chemother.
2006; 50 (10) :3396-406
11. Tenover FC, Rajinder KK, Williams PP, Carey

RB, Sheila S, David L. Carbapenem Resistance
in Klebsiella pneumoniae not detected by
automated susceptibility testing. Emer Infect Dis.
2006; 12 (8) :1209-13
427
Shraddha et al.,
DOI: 10.5958/j.2319-5886.3.2.087

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
Received: 26th Dec 2013
Copyright @2014
ISSN: 2319-5886
Review article
REVIEW OF NRF2-REGULATED GENES INDUCED IN RESPONSE TO ANTIOXIDANTS

*Ahmed Atia, Azman Abdullah
Department of Pharmacology, Faculty of Medicine, University Kebangsaan Malaysia, Jalan Raja Muda Abdul
Aziz, 50300 Kuala Lumpur, Malaysia.
*Corresponding author email: elbadri83@yahoo.com
ABSTRACT
Nuclear factor (erythroid-derived 2) -like 2 (Nrf2) is a transcription factor that plays an important role in the
cellular protection against free radical damage and reduce the incidence of radical derived degenerative diseases
such as cancer. Nrf2 is referred to as the "master regulator" of the antioxidant response due to the fact that it
modulates the expression of several genes including phase-2 and antioxidant enzymes playing a crucial role in
detoxification of electrophiles and reactive oxygen species (ROS), including glutathione-S-transferase (GST),
gamma-glutamyl cysteine ligase (-GCL), glutathione-S-reductase (GSR), NAD(P)H:quinoneoxidoreductase-1
(NQO1), heme oxygenase-1 (HO-1), etc. Following dissociation from it obligatory partner Kelch like ECHassociated protein 1 (Keap1), Nrf2 translocates to the nucleus and transactivates the antioxidant response element
(ARE) in the promoter region of several antioxidant genes. In this review, we discuss the role of the Nrf2 system,
with particular focus on Nrf2-controlled target genes.
Keyword: Nrf2- keap1- ROS- Cytoprotective genes.
INTRODUCTION
Oxidative and electrophilic stresses provoke
physiological responses that induce the expression of
severalcytoprotective genes.1 The transcription factor
Nrf2 was identified as the main regulator of the
cytoprotective genes encoding phase 2 detoxification
and antioxidant enzymes.2 Nrf2 originates from
studies of -globin gene expression with the
description of locus control region as possessing
substantial regulatory activities, and relates to
transcription factor activating protein-1(AP-1).3
During the last few years,the role of Nrf2 has been
increasingly studied to show that Nrf2 activation can
protect against various human diseases such as
cancer. Using dietary or synthetic compounds to rise
Nrf2-mediated cellular defence responses, Nrf2 has
been progressively studied in diseases prevention.4
Numerous Nrf2 activators have been recognized and
their efficacy in cancer prevention has been

established both in animal and human experiments.5,6
Nrf2 functions to promptly alter the sensitivity of
cells to oxidative and electrophilic compounds by
stimulating the transcriptional activation of various
cytoprotective and detoxification genes, including the
antioxidants ferritin7, glutathione-S-reductase (GSR),
gamma-glutamyl
cysteine
ligase
(-GCL)8,
NAD(P)H:quinoneoxidoreductase-1 (NQO1), and
heme oxygenase-1 (HO-1).9 In homeostatic status,
Nrf2 is constantly ubiquitinated through its inhibitory
partner Keap1. In response to electrophiles or ROS
stress, cytosolic Nrf2 liberates itself from
sequestration or negative regulation of Keap1,
thereby releasing Nrf2 from proteasomal degradation
and translocates into the nucleus. Once in the nucleus,
Nrf2forms a heterodimer complex with various
428
Atia et al.,
transcriptional regulatory proteins such as small

Maf(sMaf) protein. This protein complex then binds
to the ARE, which is located in the upstream
promoter regions, leading to the induction of diverse
target cytoprotective genes.10
THE NRF2:INRF2 (OR KEAP1) SYSTEM
The transcription factor Nrf2 is the master of redox
homeostasis because it regulates basal and inducible
expression of several antioxidants and cytoprotective
genes, providing protection against several diseases,
such as
renal, pulmonary,
cardiovascular,
neurodegenerative diseases and cancer.11 Nrf2 is a
member of the cap n collar (CNC) family basic
region-leucine zipper transcription factor that also
includes NF-E2, Nrf1, Nrf3, Bach1, and Bach2.12
Nrf2 protein has six NRF2-ECH homology domains
designated as Neh1-Neh6 respectively.13 These
proteins serve as heterodimeric transcription factors
by dimerizing with other bZIP proteins such as the
sMaf.14 As shown in fig. 1, the first conserved
domain, Neh1, is located in the half C-terminal of the
molecule,constitutes the basic DNA binding domain
and the leucine zipper for dimerization with other bZip proteins.15 Neh2 consists of the amino-terminal
region of the Nrf2 and serve as a negative regulator of
Nrf2.16 Neh3, in turn,located at the C-terminal end of
the protein and required for transcriptional activation
of Nrf2.12 Both Neh4 and Neh5 are considered as
transactivation domains, act cooperatively to bind
another transcriptional co-activator, the cAMP
response element-binding protein (CREB)-binding
protein (CBP), in orderto organize the start of
transcription.17 Neh6 is a redox-insensitive degron
which is essential for negative regulation of Nrf2.16
Fig 1: Nrf2 and Keap1 domains.
Upper panel: in Nrf2, Neh1 is the basic DNA binding

domain and the leucine zipper for dimerization. Neh2
Atia et al.,
is the Keap1 binding domain. Neh3 is required for

transcriptional activation of the protein. Neh4 and
Neh5 domains are important for binding to ARE.
Neh6 is required for the negative control of Nrf2.
Lower panel: in Keap1, BTB domain serves as a
substrate adaptor protein for a Cul3-dependent
ubiquitin ligase complex. IVR domain is a domain of
intervention which is distinguished for its high
number of cysteine residues. DGR domain is
associated with actin filaments, giving stability to
Keap1 (Adapted from Yoichiro et al).18
It has been demonstrated that Nrf2 through its Neh2
domain interacts with Keap1 protein, also known as
inhibitor of Nrf2 (INrf2), and negatively controls
Nrf2 function.13 Keap1, as shown in fig.1, is
composed of five major domains: an N-terminal
region (NTR), broad complex, tramtrack, and bric-abrac domain (BTB), a cysteine-rich intervening
region (IVR), the double glycine repeat region (DGR)
or Kelch domain, and a C terminal Kelch region
(CTR). Keap1 forms a homodimer and each dimer
binds one molecule of Nrf2 by its two Kelch
domains, with one high affinity binding site (ETGF
motif) and one weak affinity binding site (DLG
motif). Both motifs are located in Neh2 domain of
Nrf2.19 The ETGF motif has a higher affinity for
Keap1 than the DLG motif, and this is the so-called
hinge-and-latch model.20 Keap1 contains several
reactive cysteine residues that serve as sensors of
intracellular redox state, among which C273 and
C288, connected to IVR, are critical for the
dissociation of Nrf2 from Keap1 under basal
conditions and their modulation by inducers may
diminish the rate of ubiquitination and degradation of
Nrf2. Cysteine residues C151, in the BTB domain, is
essential for repression of Nrf2 ubiquitination by
electrophiles or oxidants.21 Oxidative or covalent
modification of thiols in some of these cysteine
residues cause Nrf2 to be released from keap1
sequestration with consequent translocation to the
nucleus.22 Once in the nucleus, Nrf2 heterodimerizes
with the sMaf protein in the upstream promoter
regions of the ARE, leading to the induction of genes
encoding antioxidant and phase 2 detoxifying
enzyme.15,23 These cytoprotective enzymes are crucial
for cell defence by improving the removal of ROS
and, thus, plays a protective role against oxidative
stress.24 Furthermore, Nrf2 is a key transcription
factor
involved
in
cytoprotection
against
429
inflammation due to its ability to antagonize the

transcription factor nuclear factor-kB (NF-kB), which
coordinates the expression of inflammatory genes.25
Additionally, studies have suggested BTB and CNC
homology-1 (Bach1) as another control mechanism
for Nrf2 activation. Bach1 is known to bind to the
Nrf2 site as a heterodimer with sMaf.26 Upon
induction, Bach1 is substituted by Nrf2, leading to
activation and suggesting competition between Bach1
and Nrf2 for the same DNA binding site in various
cellular conditions.27
NRF2 TARGET GENES
NRF2, as mentioned, is a transcription factor that
controls the expression of phase 2 detoxification
genes. It heterodimerizes with members of the Maf
family of transcription factors and binds to the ARE
in the promoter regions of various phase 2 genes. The
impacts and functions of some of the main Nrf2target genes will be discussed below. However, it is
not easy to distinguish which particular genes
activated by Nrf2 are most significant for its
cytoprotectiverole;nevertheless it is clear that the
coordinated induction of those genes has a dramatic
effect on cellular homeostasis.
Glutamate-cysteine ligase (GCL). GCL, also known
as -glutamylcysteinesynthetase, is an enzyme
composed of two subunits: a modifier subunit
(GCLM) and a catalytic subunit (GCLC), both of
which contain ARE
sequences
in
their
promoters.4,5GCLcatalyzes the first step in
glutathione synthesis (GSH), the most significant
non-protein thiol in the cell. GSH maintains
intracellular redox balance and plays an important
role in detoxifying of xenobiotics, electrophiles and
protection of the cell from reactive molecules and
oxidative insults. GSH can also detoxify chemicals
through enzymatic conjugation by glutathione-Stransferases.28,29 Since GCL is a master determinant of
the total capacity of GSH synthesis, regulation of
GCL subunits has been subjected to extensive
research.30 Studies have identified that GCL has
different levels of regulation, at the kinetic, post
translational and transcriptional levels, which
ultimately affect either the catalytic or modifier
subunits or both.31 The regulation of GCL at the
transcriptional level provides morepersistent effect
and thus is essential for the maintenance of GSH
homeostasis in response tooxidative stress.32The
Atia et al.,
Nrf2/ARE signalling is one of the major regulatory

pathways. Both of GCLC and GCLM contain AREs
in their promoters.33 Further, manytranscription
factors have been reported to bind ARE, such as Nrf2
family members(Nrf1/2/3), sMaf (maf G/K/F), AP-1,
and Fos family members (c-Fos, FosB, Fra1, Fra2).34
Among them, ARE-dependent GCLC gene
expression is highly dependent upon Nrf2.35In
addition, researchers have identified that levels of
GCLC and GCLM are decreased in Nrf2 knockout
mice, this leads to lack in GSH synthesis which is
lethal during embryogenesis.36
Glutathione-S-transferases (GST). GSTs are multigene family of phase II detoxification enzymes that
catalyse the conjugation of several endogenous and
exogenous electrophilic compounds with GSH.37
GSTs are largely distributed in nature, being
presented in all eukaryotes and in various
prokaryotes.38 In mammals, GSTs are divided into
numerous cytosolic, mitochondrial and microsomal
GST isoenzymes, also known as MAPEG (membrane
associated proteins in eicosanoid and glutathione)
proteins, according to their homologies and
properties.39 The cytosolic enzymes are encoded by
five related gene families (known as; alpha, mu, pi,
sigma, and theta GST), while the membrane-bound
enzymes and microsomal GST are encoded by single
genes and both have originated separately from the
soluble GST.37 It has been suggested that phase II
conjugation enzymes, particularly GSTs,are Nrf2
target genes with an extremely transactivational
ARE-like motifs demonstrated on the gene
promoter.24 Studies have revealed that Nrf2 knockout
mice exhibited reduced constitutive and inducible
expressions of many GST isoforms in livers.40
Moreover, induction of hepatic and intestinal GST
isoforms by Butylatedhydroxytoluene (BHA) and
ethoxyquin is also reduced in the absence of Nrf2.41
NAD(P)H quinoneoxidoreductase 1 (NQO1). NQO1
is a cytosolic homodimericflavoprotein that is widely
expressed in many tissues, and its expression is
regulated by the ARE both in basal and during
oxidative stress conditions.42 NQO1catalyzes two
electron-reduction and detoxification of a wide range
of substrates, most prominentlyquinones and its
derivatives, protecting cells from reactive forms of
oxygen, oxidative stress, and neoplasia.43 However,
in many cases, the reduction of quinones by NQO1
leads to the formation cytotoxic hydroquinones which
430
play a key role in targeting NQO1-rich cancer

cells.44NQO1 is expressed predominantly in all the
tissues, and its level of expression differs among
human tissues. NQO1 is expressed at relatively high
levels in several tumor tissues including lung, liver,
colon, breast and pancreatic tissues, and its
expression induced in response to a variety of
xenobiotics, antioxidants, oxidants, and heavy
metals.45 Mutations and deletions in the NQO1 gene
promoter aided in recognizing the core ARE
sequence.32 ARE is basically needed for expression
and coordinated induction of NQO1 and other
detoxifying enzyme genes. Nrf2 bind ARE and
regulate expression and induction of NQO1 gene.
Meanwhile, Nrf2 knockout exhibited reduction in the
constitutive expression of NQO1 and impairs its
induction.42In addition, treatment with BHA, known
Nrf2 inducer, increases hepatic and intestinal NQO1
levels in wild-type, but not in Nrf2 knockout
mice.45All of these data confirm a role for Nrf2 in the
expression of NQO1 in various tissues.
Superoxide dismutases (SODs). SODsare the first
and most significant line of antioxidant enzyme
defence systems against several ROS,particularly
superoxide anion radicals. SOD is an extremely
efficient enzyme, catalyses the dismutation of two
superoxide radicals to form hydrogen peroxide and
oxygen. Product of this gene is suggested to defend
the lungs and other tissues from oxidative stress.46 In
mammalians, three distinct isoforms of SOD have
been identified;cytoplasmic (SOD1), mitochondrial
(SOD2), and extracellular (SOD3).47 SOD1 is a
soluble cytoplasmic protein that binds zinc and
copper ions, and works as a homodimer. SOD2, a
protein found in mitochondria in a homotetramer
form, binds the superoxide byproducts of oxidative
phosphorylation and converts them to hydrogen
peroxide and diatomic oxygen. SOD3, in turn, is
secreted into the extracellular space and forms a
glycosylated homotetramer that is linked to the
extracellular matrix and cell surfaces via an
interaction with heparin sulfate proteoglycan and
collagen.46 Researchers have identified that SOD3 but
not SOD2 and SOD1 is induced by antioxidants, and
is regulated through Nrf2. Therefore, SOD3
suggested as an important gene in defence against
oxidant stress and in the prevention of estrogenmediated breast cancer.48
Atia et al.,
Epoxide hydrolases (EHs).EHs are multifunctional

enzymes that are essential for both the activation and
inactivation of reactive species. EHs catalyse the
hydrolysis of epoxides, which formed by the
cytochrome P450-dependent monooxygenase (CYP)
superfamily, to a diol (known as dihydrodiols) by the
addition of water.49 Two mammalian enzymes,
microsomal (mEHor EPHX1) and soluble epoxide
hydrolase (sEHor EPHX2), have been characterized
to play diverse roles in xenobiotic metabolism. mEH
is expressed in two types. Type-I mEHis typically
located in the hepatic endoplasmic reticulum to
oppose epoxides of polycyclic aromatics and make
them into diols. Type-II mEH is positioned in the
hepatocyte plasma membrane, where it controls the
absorption of bile acids in the liver in association
with a taurocholate binding protein. Meanwhile,
Soluble epoxide hydrolasealso forms diols from
different endogenous and exogenous epoxides, and is
expressed in most tissues such as; liver, lung and
kidney. sEH regulates many pathways linked to
endogenous systems including; fatty acid and
leukotriene epoxide metabolism, and is involved in
blood pressure regulation and inflammatory
responses.50 There are some evidence indicated that
EHs are regulated by the Nrf2 system. The mRNA
expression of mEH has shown to be decreased in
various tissues of Nrf2 knockout mice. In addition,
treatmentof Nrf2 knockdown mice with prototypical
Nrf2 inducers, oltipraz, have not been found to induce
mEH in compare to the wild type. These results
highlights a role for Nrf2-mediated control.51,52
Heme oxygenase-1 (HO-1). HO-1 is the extremely
inducible rate-controlling enzyme of heme
catabolism.53 It catalyzes the rate-limiting step in the
degradation of heme into biliverdin, carbon monoxide
(CO), and free iron.54HO-1 has antioxidant,
cytoprotective, anti-inflammatory, and immunemodulatory activities. These activities are suggested
to be due to its ability to reducehigh levels of
potentially toxic heme within cells and to alter heme
to less reactive iron which can be stored in the
nontoxic form of ferritin.55HO-1 plays a crucial role
in the maintenance of cellular redox homeostasis and
subsequentlyhinders transformation of normal cells to
malignant cells by abolishing ROS-mediated
carcinogenesis.56 However, increased levels of HO-1
and Nrf2 have been demonstrated in several types of
human malignancies. Studies have reported that Nrf2
431
regulates the induction of HO-1 in response to diverse

forms of cellular stress, including oxidative,
hemodynamic, and endoplasmic reticulum stress.
Additionally, Nrf2-knockout animals have been
found to express HO-1 at low levels, further
implicating Nrf2 in the induction of HO-1.57
Multidrug resistance-associated proteins (MRPs):
MRPs are ATP-dependent efflux transporters known
to transport a variety of compounds, particularly
glutathione, glucuronide, and sulfate conjugates, out
of cells. Four MRP transporters (MRP2, 3, 4, and 6)
of the eight MRPs are expressed to a significant
extent in liver.58 MRP2 is the only MRP localized to
the canalicular membrane and involves in excretion
of chemicals into bile. While, MRP3, MRP4 and
MRP6 are localized to the basolateral membrane and
serve as an efflux pump transporting chemicals from
hepatocytes into blood.59 MRPs play major roles in
hepatic removal of metabolites, and modification of
MRPs expression in liver can convert drug
disposition.60 MRPs have been demonstrated to be
induced by various Nrf2 activators, including BHA,
oltipraz, and ethoxyquin.61 Moreover, other
transcription factors, such as NF-B, have been
implicated in MRPs regulation, suggesting that
another regulatory mechanisms might control MRPs
induction.62
Beside the mentioned genes that are regulated by
Nrf2, there are many other genes regulated by this
process that we cannot possibly include them in this
review. But, what has shown in this section is the
most known genes that regulated by this
signallingmechanism, addressingtheir implication
with Nrf2 in cytoprotection against ROS-mediated
carcinogenesis.
SUMMARY
Transcription factor Nrf2 regulates basal and
inducible expression of phase II detoxification genes
that protect animal cells against toxic effects of
electrophiles and ROS. Under normal physiological
conditions, Nrf2 is sequestered in the cytoplasm by
Keap1, a multi-domain, cysteinerich protein that is
bound to the actin cytoskeleton. Keap1 acts both as a
repressor of the Nrf2 transactivation and as a sensor
of phase 2 inducers. Electrophiles and oxidative stress
loose the interaction between Nrf2 and the Keap1
protein, allowing Nrf2 to translocate to the nucleus,
where it forms a heterodimer bound with its
Atia et al.,
obligatory partner sMaf protein, and eventually

activates ARE-dependent gene expression. These
genes are essential for detoxification of xenobiotics
and endogenous reactive intermediates.
Conflicts of Interest: The authors declare that they
have no conflict of interests.
ACKNOWLEDGMENTS
This work is funded by the National University of
Malaysia Grant FF-176-2013.
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DOI: 10.5958/j.2319-5886.3.2.088

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Health Sciences
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Coden: IJMRHS
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Copyright @2014
ISSN: 2319-5886
Review article
A SIMPLIFIED CLASSIFICATION SYSTEM FOR PARTIALLY EDENTULOUS SPACES

*
Bhandari Aruna J1, Bhandari Akshay J2
Department of Prosthodontics, Dean, Dental Faculty, Rural Dental College, Pravara Institute of Medical Sciences
(DU), Loni, Ahmednagar, Maharashtra, India
2
MBBS, Pravara Institute of Medical Sciences, Loni, Ahmednagar Maharashtra, India
*Corresponding author email: drarunajb@gmail.com
ABSTRACT
Background: There is no single universally employed classification system that will specify the exact edentulous
situation. Several classification systems exist to group the situation and avoid confusion. Classifications based on
edentulous areas, finished restored prostheses, type of direct retainers or fulcrum lines are there. Some are based
depending on the placement of the implants. Widely accepted Kennedy Applegate classification does not give any
idea about length, span or number of teeth missing. Rule 6 governing the application of Kennedy method states
that additional edentulous areas are referred as modification number 1,2 etc. Rule 7 states that extent of the
modification is not considered; only the number of edentulous areas is considered. Hence there is a need to
modify the Kennedy Applegate System. Aims: This new classification system is an attempt to modify Kennedy
Applegate System so as to give the exact idea about missing teeth, space, span, side and areas of partially
edentulous arches. Methods and Material: This system will provide the information regarding Maxillary or
Mandibular partially edentulous arches, Left or Right side, length of the edentulous space, number of teeth
missing and whether there will be tooth borne or tooth tissue borne prosthesis. Conclusions: This classification
is easy for application, communication and will also help to design the removable cast partial denture in a better
logical and systematic way. Also, this system will give the idea of the edentulous status and the number of
missing teeth in fixed, hybrid or implant prosthesis.
Key words: Partially edentulous spaces, Classification System, Edentulism, Removable Partial Denture
INTRODUCTION
Various types of edentulous situation or partial
edentulism is seen. Edentulism means state of being
without teeth or lacking teeth.1 There may be loss of
one or more teeth but not all the teeth in partially
edentulous or semi edentulous situation. Unless and
until actual case or a cast is seen, one will not know
exactly how many teeth and also which teeth are
missing. These various partially edentulous situations
are difficult for remembering and memorization.
Therefore a system of classification is required2
Aruna et al.,
Which will help to group or specify the situation and

design them in such a way, so as to give the exact
idea of the missing tooth. For any type of situation,
the requirements of an acceptable method of
classification include the following criteria.3,4
Classification
should
permit
immediate
visualization of the type of partially
edentulous arch being considered.
Classification
should
permit
immediate
differentiation between the tooth-borne and the
tooth-tissue supported removable partial denture.
436
It should be universally acceptable.

It should serve as a guide to the type of design to
be used.
Several classification systems have been designed
till date5 but perhaps the best known and commonly
used is the classification of the partially edentulous
dental arch proposed by Edward Kennedy of New
York in 1923 which is based on the relationship of
the edentulous areas with the remaining natural
teeth6. Widely accepted Kennedy Applegate
classification does not give the idea of missing
number of teeth and the extent of the modification.
Situations like Kennedy Class I, II, III or IV will not
mention about the number and type of teeth missing
on one or both sides. Also Kennedy Class II
modification 2 will not give any idea about the side
and number of the missing teeth and where the
edentulous areas are located. Rule 6 governing the
application of the Kennedy method states, that
additional edentulous areas other than those
determining the classification are referred
as
modifications and designated by their number as 1,2
etc. Also Rule 7 states that extent of the modification
is not considered only the numbers of edentulous
areas are considered.7
This new classification system will provide the exact
information regarding Maxillary or Mandibular
partially edentulous arches, Left or Right side, length
of the edentulous space, number of teeth missing and
whether there will be tooth borne or tooth tissue
borne prosthesis.
Abbreviations used:
Maxillary (Mx), Mandibular (Md), Left Side (L),
Right Side , CI (Central Incisor), LI (Lateral
Incisor), C (Canine), P (Premolar) and M (Molar)
Rules governing the classification:
1. The posterior most edentulous area will govern
the classification.
2. 3rd molars will not be included in the
classification because most of the times it is not
replaced.
3. Classification system follows the extraction.
4. Missing teeth will be considered as Type.
5. Classification System will have Class I, II, III and
IV with Type 1, 2, 3, 4, 5, 6, or 7.
6. Maxillary and Mandibular arch will be
considered as Mx. and Md. respectively.
Aruna et al.,
7. Additional missing teeth other than the Type will

be denoted by FDI System 8. [World Dental
Federation Notation]
8. Side determination included will be L for Left
and R for Right side.
9. Classification system will be applicable only for
permanent dentition.
New
Classification System for Partially
Edentulous Arches:Class-I
Type 1. Bilateral 2nd molars missing. (M2)
Type 2. All bilateral molars missing. (M2, M1)
Type 3. All bilateral molars and 2nd pre-molar
missing. (M2, M1, P2)
Type 4. All bilateral posterior teeth missing. (M2,
M1, P2, P1)
Type 5. All bilateral posterior teeth & canines
missing. (M2, M1, P2, P1, C,)
Type 6. All bilateral posterior teeth, canines and
lateral incisor missing. (M2, M1, P2, P1, C, LI )
L & R: - If missing teeth are on either left (L) or right
(R) side.
Md. Class I ,Type 4
Md . Class I, Type 5
Md . Class I, Type 6
Fig 1: CLASS I
Class -II
Type 1. Unilateral 2nd molar missing. ( M2 )
Type 2. Unilateral both molars missing. ( M2, M1 )
Type 3. Unilateral both molars and 2nd pre-molar
missing. ( M2, M1, P2 )
Type 4. Unilateral all posterior teeth missing (
M2, M1, P2, P1 )
Type 5. Unilateral all posterior teeth and canine
missing. ( M2, M1, P2, P1,C.)
Type 6. Unilateral all posterior teeth , canine and
lateral incisor missing. ( M2, M1, P2, P1, C, LI. )
437
Type 7. Unilateral all posterior teeth , canine,

lateral incisor and central incisor missing. ( M2, M1,
P2, P1, C, LI, CI. )
L & R : If missing teeth is on either left (L) or right
(R) side.
Type 3. Bilateral anterior teeth missing. (CI, LI, C)

Type 4. Bilateral anterior teeth and both 1st premolars missing. (CI, LI, C, P1)
Type 5. Bilateral anterior teeth and both pre-molars
missing. (CI, LI, C, P1, P2)
Type 6. Bilateral anterior teeth, both pre-molars and
both 1st molars missing. (CI, LI, C, P1, P2, M1)
L & R : If missing teeth is on either left (L) or
right (R) side.
Fig 2: CLASS II
Class-III
Type 1. Unilateral 1st molar missing. ( M1 )
Type 2. Unilateral 1st molar and 2nd pre-molar
missing. ( M1, P2 )
Type 3. Unilateral 1st molar and both pre-molars
missing. ( M1, P2, P1 )
Type 4. Unilateral 1st molar, both pre-molars and
canine missing. ( M1, P2, P1, C )
Type 5. Unilateral 1st molar, both pre-molars, canine
and lateral incisor missing. (M1, P2, P1,C, LI .)
Type 6
Unilateral 1st molar, both pre-molars,
canine, lateral incisor and unilateral central incisor
missing. ( M1, P2, P1, C, LI, CI )
L & R :- If missing teeth is on either left (L) or right
(R) side
Fig 3: CLASS III

Class-IV
Type 1. Bilateral central incisor missing. (CI)
Type 2. Bilateral central and lateral incisors missing.
(CI, LI )
Aruna et al.,
Fig 4: Class-IV
Modification examples: Additional missing tooth,
teeth or edentulous spaces will be demarked by FDI
System [Federation Dentaire Internationale (1971).
In case if there are situations where teeth lost are not
uniform e.g.
If in maxillary arch on left side two molars and
on right side two molar teeth and in addition two
right premolar teeth are missing then it will be
written as Mx. Class I, Type 2, 14,15.
If in maxillary arch if two teeth one premolar and
one molar of right side are missing and in
addition there are two additional teeth like right
lateral incisor and left first premolar is missing
then it will be written as Mx. Class III, Type 2R,
12, 24.
If in maxillary arch posterior two teeth on right
side are missing and one left first premolar is
missing then it will be denoted as Mx. Class II,
Type 2R, 24.
If in mandibular arch canine to canine teeth are
missing and in addition right
side, both
premolars and one molar are missing, it will be
denoted as Md. Class IV, Type 3, 44,45,46.
If mandibular bilateral first molars are missing,
then it can be denoted as Md. Class I, Type 1R,36
or Md. Class I, Type 1L,46.
438
Fig 5: Modification examples:

DISCUSSION
Different types of partially edentulous arches seen
in our day to day practice. Several classification
systems exist to group the situation and avoid
confusion. Classifications based on edentulous areas,
finished restored prostheses, type of direct retainers
or fulcrum lines are there. There is no single
universally accepted classification system that gives
the exact idea about length, span, side or number of
teeth missing.
Dental literature abounds with
proposed classification systems
beginning with
Cummers System that is earliest on record till date.
Although many classification systems have merits,
but none has been without critics and has unanimous
acceptance.
Perhaps the best known and widely accepted is the
Kennedy - Applegate classification based on the
relationship of the edentulous areas with the
remaining natural teeth9. The main drawback of
Kennedys classification is that it does not give any
information regarding missing teeth and the length of
edentulous area. In 1928 Bailyn introduced a
classification system based on whether the prosthesis
is tooth borne, tissue borne or both. Friedman in
1953 introduced an ABC system based on three
essential segment types like A for anterior space, B
for bounded posterior and C for canty lever or
posterior free end space. ICK or Implant corrected
Kennedy classification is based on the number and
position of implants to be placed. 10 Some
classification systems are based on the types of the
Fulcrum lines11 or on the diagnostic criterias12
Each classification gives some information about the
edentulous situation of the patient or the type of the
prosthesis. But for proper understanding and
Aruna et al.,
treatment planning it is better to know the exact

situation of the edentulous arch.
This new classification system will specify the
actual clinical condition and just by reading will
give an exact idea of missing teeth in the
following respect:1 Maxillary or Mandibular partial edentulous arch.
2 Left or Right side of the arch can be understood.
3 Length of the edentulous space can be
determined.
4 Number of teeth missing can be determined.
5 Immediate visualization of the type of missing
teeth.
6 Tooth borne or Tooth -Tissue borne can be
determined.
The primary purpose of a classification for RPD
designing is to simplify the description of potential
combination of teeth to ridges so that communication
to colleague, students and laboratory technique is
improved 13. This will simplify the identification of
the edentulous arches and will help to enhance in
teaching. Exact partially edentulous status will help
to design the prosthesis by knowing the forces
exerted on the remaining abutment teeth of a
removable partial denture, as it plays a critical role in
determining the prognosis of the remaining teeth.14
This will help to design the removable cast partial
denture in a better logical and systematic process15 in
relation to:a. Selection of abutment, b. Location of rest, c.
Location of guide planes, d. Selection of major
connector, e. Placement of minor connector, f:
Selection of retentive, bracing and reciprocal
elements g: Placement of denture base retentive
elements, h. Selection of replacement teeth.
LIMITATIONS
1. Mobility status of the remaining teeth is not

considered.
2. Abutment status is not considered.
3. Oral health status is not considered.
4. System does not denote the span which gets
changed with drifting or bodily shifting of
abutment teeth.
CONCLUSION
Various types of partially edentulous situations are
seen which create confusion for remembering,
designing and memorization. There is no single
439
universally employed classification system that will

specify the exact partially edentulous situation. This
new classification system will provide the exact
information regarding Maxillary or Mandibular
partially edentulous arches, Left or Right side, length
of the edentulous space, number of teeth missing and
whether there will be tooth borne or tooth tissue
borne prosthesis. This classification is easy for
application, communication and will also help to
design the removable cast partial denture in a better
logical and systematic way. Also, this system will
give the idea of the edentulous status and the number
of missing teeth in fixed, hybrid or implant
prosthesis.
ACKNOWLEDGEMENT
partially edentulous arches. J. Prosthet. Dent.

2008; Aug 6: 502 - 7.
11. Tibor Fabion, Peter Herman et al. The
Prosthetic
classification
of
partially
edentulous dental arches and its use in
treatment planning. J. Prosthodont.1979:1-14
12. Classification system for partial edentuluism.
J Prosthodont 2002; 11(3):181-93
13. Donald A, Thomas A. et al. Incidence of
various classes of removable partial dentures.
J Prosthetic Dent.1992; May 67(5) : 664-67
14. Kawata T, Takeshi. Effects of a Removable
Partial Denture and its Rest location on the
forces exerted on an abutment tooth in vivo.
International J. of Prostho.2008; 21:50-52
15. Russell Stratton. An Atlas of RPD Design.
Wiebelt. 1988; 12:
Authors would like to thank all the staff members and

PG students of Department of Prosthodontics, Rural
Dental College, Loni, for their timely interaction and
help.
REFERENCES
1. The Academy of Prosthodontics. The

Glossary of Prosthodontic terms; J. Prosthet
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5. Sharad Gupta.Terminology and classification
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440
DOI: 10.5958/j.2319-5886.3.2.089

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Health Sciences
www.ijmrhs.com
Received: 2nd Sep 2013

Case report
Coden: IJMRHS
Revised: 8th Oct 2013
Copyright @2014
ISSN: 2319-5886
Accepted: 13th Nov 2013
RETINOBLASTOMA IN A 12 YEAR OLD GIRL: A CASE REPORT

Odogu V1, Udoye E2, *Azonobi IR3
1
Diete Koki Memorial Hospital, Yenagoa, Bayelsa State, Nigeria

Dept of Anatomical Pathology, Niger Delta University Teaching Hospital, Okolobiri,Bayelsa State, Nigeria
3
Dept of Ophthalmology, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State, Nigeria
2
*Corresponding author email:doctorazonobi2002@ymail.com

ABSTRACT
Retinoblastoma, although a common ocular childhood tumour is rare in the older age groups. It present commonly
as leucocoria and strabismus especially in the younger age groups. However in older children, its presentation
may be atypical. We report a case of retinoblastoma in a 12 year old girl who initially presented with features of
non specific inflammatory external ocular disease and later with proptosis and weight loss. Non response to ealier
treatment prompted an enucleation whose specimen reveal a histological diagnosis of retinoblastoma.
Keywords: Retinoblastoma, Enucleation, Proptosis
INTRODUCTION
Retinoblastoma is the commonest intraocular
malignancy of childhood.1 Its incidence varies
between 1 in 3300to1 in 20,000 live birth.2,3 Average
age at diagnosis is 12 months for unilateral cases and
24 months for bilateral cases.4 However it has been
reported in older children up to the age of
16years.5,6Cases of retinoblastoma have also been
reported in adults up to the age of 37 years.7,8The
tumour have been found to be due to a mutation in
the retinoblastoma gene(RB1),located in the 14 band
of chromosome 13.9,10Being a tumour suppressor
gene,its loss is said to lead to tumour formation.
Clinically, the tumour commonly presents as
leucocoria(60%) and strabismus(20%) and rarely as
secondary
glaucoma,
pseudouveitis,orbital
inflammation, proptosis, metastatic features and
raised intracranial pressure in trilateral cases among
others (20%).11,12We report one of these rare
presentation in a 12 year old Nigerian girl.
CASE REPORT
A 12 year old girl, presented in the eye clinic of Diete
Koki Memorial Hospital, Yenagoa Bayelsa State
accompanied by her mother. She complained of an
inability to see with her right eye for the past 2 years,
dull intermittent and non radiating pain and the eye
being more prominent than the fellow eye. Symptoms
started gradually and there was no family history of
similar ocular problems. She was the only child of a
single mother, whose occupation was petty trading.
They had visited other health care providers including
faith healers, traditional healers and patent medicine
stores, prior to presenting to the eye clinic.
Examination revealed an emantiated moderately pale
girl with peripheral lymphadenopathy. On ocular
examination, visual acuity in the right eye was no
perception of light. There was mild lid retraction,
moderate temporal sclera injection and clear cornea
in same eye. The anterior chamber was of normal
441
Azonobi et al.,
depth, pupils were fixed and dilated and there was a

white pupillary reflex. Fundal view was not possible.
Intraocular pressure was 2mmHg .The left eye was
normal.
A working diagnosis of chronic scleritis
[scleromalacia] was made, with differentials of
possible non specific orbital inflammatory disease,
toxocariasis and late onset retinoblastoma.
An urgent ocular B-scan showed an unknown solid
ovoid mass with regular border and a central calcified
lesion measuring 3.4 x 2.9cm.Serology for
toxocariasis was not done on account of non
availability. Other investigation requested included a
Full blood count, Blood film analysis and Erythrocyte
sedimentation rate which were all normal.
At follow up it was noted that she had deteriorated
clinically, and also not responded to the medication
given earlier, and had developed a non-axial
proptosis.
At this point, the diagnosis was reviewed, with the
possibility that it may be an intraocular mass. The
family was counseled and options discussed including
enucleation of the eye. With informed consent, an
enucleation was done under general anaesthesia.
Histopathological
assessment
macroscopically
revealed a tan white tumour mass measuring 3.5cm
by 2cm covered by opaque fibrous conjunctiva with a
haemorhagic posterior surface.The cut surface
showed focal necrosis
Fig 1(a)
Fig 1(b)
showing loose trabeculae and nesting formations.

Also seen were many rosettes (Flexner-wintersteiner
type) within the tumour. Tumour seedings within the
optic nerve was also noted. A histopathological
diagnosis of retinoblastoma was made.
Fig 2: Retinoblastoma showing highly cellular

neoplasm with scanty stroma (H/E., X100)
Fig 3: Retinoblastoma showing malignant small

round cell tumour with typical rosettes (arrows). (
H/E. X400)
Fig 1: (a) Eyeball in retinoblastoma showing

distinct tumour nodules. (b) Cut section of eyeball
showing solid tumour nodules with areas of
haemorrhage and necrosis.
Microscopically, it is highly cellular and composed of
dense masses of small round cells with
hyperchromatic nuclei and scanty cytoplasm. There
were wide irregular areas of tumour necrosis and
associated areas of calcification.There were areas
Fig 4: Irregular areas of necrosis (right half of slide), a

common finding in retinoblastoma as the tumour tends
to outgrow its blood supply. ( H/ Estain. X100)
442
Azonobi et al.,
inflammation associated with visual blurring and

proptosis in the older age group.
REFERENCES
Fig 5: Wide areas of dystrophic calcification in

retinoblastoma ( H/E stain Mag. X100)
The child was referred for chemotherapy and/or
radiotherapy but was not commenced on financial
grounds. She developed severe anorexia and vomiting
1 month after surgery and died.
DISCUSION
When seen in older children, retinoblastoma is
typically unilateral and sporadic13.It occurs in a single
somatic cell which becomes malignant. Comparative
genomic studies in older children have shown more
frequent and complex genetic abnormalities than in
younger children14.
Karciogluetal15
found
both
clinical
and
histopathologic features were atypical in older
children as were the findings in this patient which
showed Flexner wintersteiner differentiation albeit
fewer than would in younger patients.
In all patients with retinoblastoma the risk of
metastases is increased in patients with advanced
tumour, retro-laminar optic nerve invasion, anterior
chamber involvement, late presentation and orbital
spread. This patient presented late, and histology
showed evidence of optic nerve invasion.
Sometimes as in this case retinoblastoma can present
a confusing clinical scenario16.Features of localized
external ocular inflammation as in this case may add
to the confusion. This external localized ocular
inflammation may be due to a subtle orbital invasion
as evidenced by B scan Ultrasonography findings.A
high index of suspicion is therefore required to
diagnose retinoblastoma in the older age group.
CONCLUSION
Retinoblastoma should be considered in the
differential diagnosis of an external ocular
1. Abdul-salam AA, Adenipekun AA, Akinlade BJ,

ElumeluTN. Pattern of Paediatric malignancies
seen at the Radiotherapy department of
University College Hospital,Ibadan,Nigeria.Nig
QJ Hosp Med. 2007:152-4.
2. Freedman J, Goldberg L. Incidence of
retinoblastoma in the Bantu of South Africa.Br J
Ophthalmology. 1976;60:655-56.
3. Suckling RD, Fitzgerald PH, Stewart J, Wells E.
The
incidence
and
epidemiology
of
retinoblastoma in New Zealand: a 30 year
survey.Br J cancer 1982;46:729-36.
4. American Academy of Opthalmology series
5. Karcioglu ZA, Abboud EB, Al-Mesfer SA, AlRashed W, Pilapil DH. Retinoblastoma in older
children. JAAPOS 2002;6:26-32.
6. Park JJ, Gole GA, Finnigan S, Vandeleur K. Late
presentation of unilateral sporadic retinoblastoma
in a 16 year old girl. Aust NZJ Ophthalmol
1999;27:365-8.
7. Shrestha
A,
Adhikari RC, Saiju R.
Retinoblastoma in a 37 years old man in Nepa: a
case report. Kathmandu univ Med J 2010;8:24750.
8. Biwas J, Mani B, Shanmugam MP, Patwardhan
D, Kumar KS, Badrinath SS. Retinoblastoma in
adults. Report of three cases and review of the
literature. Surv Ophthalmol 2000;44:409-14.
9. Dryja TP, Rapaport JM, Joyce JM , Peterson RA.
Molecular detection of delections involving band
q14 of chromosome 13 in retinoblastoma. Proc
Nati Acad Sci USA.1986;83:7391-94.
10. Cavenee WK, Dryja TP, Phillips RA. Expression
of recessive allele by chromosomal mechanism in
retinoblastoma. Nature 1983;305:779-84.
11. Abrahamson DH, Frank CM, Susman M.
Presenting signs of retinoblastoma. J Paediatr.
1998;132:505-8.
12. Kanski JJ. Clinical Ophthalmology: a systematic
approach. Butterworth Heinemann. Elsevier,
2007.6thed.Edinburgh.P545.
13. Shields CL, Shields JA, Shah P. Retinoblastoma
in older children: ophthalmology 1991;98:395-9.
443
Azonobi et al.,
14. Sussanne Herzog. Marked differences in

unilateral isolated Retinoblastoma from young
and older children studied by comparative
genomic
hybridization.
Human
genetics.
2001:108(2): 98-104.
15. Karcioglu ZA, Emad Abboud MD, Saleh A , AlMesfer,
Waleed
Al-Rashed,
Delia
Pilail.Retinoblastoma in older children.Journal of
American
Association
of
Paediatric
Ophthalmology and Strabismus 2002;6(1):26-32.
16. Park JJ, Gole GA, Finnigan S, Vandeleur K.Late
presentation
of
a
unilateral
sporadic
retinoblastoma in a 16year old girl. Aust NZJ
Ophthalmology. 1999; 27: 365-8.
444
Azonobi et al.,
DOI: 10.5958/j.2319-5886.3.2.090

&
Health Sciences
www.ijmrhs.com
Received: 12th Nov 2013
Coden: IJMRHS
Revised: 28th Dec 2013
Copyright @2014
ISSN: 2319-5886
Case report
SPORADIC HEMIPLEGIC MIGRAINE: A RARE PRESENTATION IN CHILDREN

*Sangavi Santhan1, Jehangir HM2, Mugunthan3
1
PG Resident, 2Professor and HOD, Dept of Paediatrics, Meenakshi Medical College Hospital &Research
Institute , Enathur, Kancheepuram,Tamilnadu, India
3
Asst Professor, Dept of Neurology, Meenakshi Medical College Hospital &Research Institute, Enathur, Kanchee
puram, Tamilnadu, India
*Corresponding author email: sangavis@gmail.com
ABSTRACT
We report a 12 year old girl with a history of migraine presenting with recurrent episodes of hemiparesis preceded
by headache, which fulfilled the diagnostic criteria for sporadic hemiplegic migraine in ICHD 2 [international
classification of headache disorders 2].
Key words: Childhood, headache, migraine, recurrent hemiplegia.
INTRODUCTION
One of the commonest causes of headache in children
is migraine. Hemiplegic migraine is a rare condition
often linked to a genetic abnormality. The symptoms
of which include temporary weakness along one side
of the body which can last from 5 minutes up to
several days accompanied by sensory symptoms in
the form of tingling and numbness, speech
disturbances and visual symptoms. Severe headache
is almost always associated. Hemiplegic migraine
comes under migraine with aura and is further
classified into Familial and Sporadic by the
international headache society.1
CASE REPORT
12 year old right handed girl presented at our hospital
(Meenakshi medical college and research institute)
with weakness of left upper and lower limbs on
awakening from bed in the morning. She had a
history of severe throbbing left sided headache
preceded by aura in the form of visual perceptions the
previous day after returning from school, which was
followed by heaviness and pain on the left side of the
body. She took some analgesics and slept. She had
been suffering from migraine with aura once or twice

a week for the past 3 years for which she was not on
any regular medications. The headache was
precipitated by stress, lack of sleep and relieves with
sleep or some analgesics. There was no history of
seizures, fever, head trauma, loss of consciousness, or
congenital heart disease in the past. The childs
mother was known to suffer from migraine during her
childhood.
Examination revealed a left upper motor neuron type
of facial palsy with left hemiparesis with a power of
2/5. She was unable to speak. No signs of raising
increased intracranial tension were seen. Fundus
examination was normal. Following admission she
recovered within few hours without any medical
intervention. She suffered from a similar episode on
the next day while she was eating, which lasted for 15
minutes, which was not preceded by headache,
followed by uneventful recovery.
Investigations revealed a normal hemogram, renal
function test, lipid profile and coagulation profile.
ANA was weakly positive while dsDNA was negative.
Normal
pyruvate,
lactate
and
creatinine
445
Sangavi et al.,
phosphokinase.Normal protein C, protein S, and

antithrombin III. Cerebro-spinal fluid analysis was
normal. Her Electrocardiogram and cardiac imaging
were normal. EEG (electroencephalogram) was
normal. Contrast enhanced MRI (magnetic resonance
imaging) with MR angiography revealed no
abnormality. Carotid vertebral Doppler was normal.
TP1A2, and SCN1A8.

SHM attacks may include confusion, hemiparesis, he
misensory symptoms, fever, lethargy and dysphasias.
SHM, attacks usually have all 4 of the typical aura sy
mptoms, including visual, sensory, dysphasic and mot
or symptoms with the most common being visual dist
urbance3. It is noted that the motor weaknesses were
usually one sided and most often involving the upper
limbs. The diagnostic criteria are laid down in ICHD2. The patient was started on antimigraine prophylaxi
s with propanalol, and is under regular follow up with
us for more than a year, during which no further epis
ode occurred.
CONCLUSION
Fig 1: MRI with MRA taken at the time of admiss

ion which was normal
DISCUSSION
A diagnosis of sporadic hemiplegic migraine was ma
de after ruling out other possibilities. Differential diag
noses include stroke, Alternating hemiplegia of child
hood, Familial hemiplegic migraine, Todds palsy, mi
tochondrial encephalopathy with lactic acidosis and st
roke-like episode (MELAS), vasculitis, hypercoagulat
ion states, Moya Moya2 disease and sickle cell anemi
a3,4.
Space occupying lesions and Structural/ vascular ano
malies were ruled out as the neuroimaging studies we
re normal. Cardiac anomalies were ruled out as the ch
ild did not present with any history suggestive of card
iac disease and cardiac evaluation was normal. Todd
s palsy was ruled out as the patient did not present wit
h seizures and EEG was normal. Alternating hemiple
gia in childhood (AHC)5,6 was ruled out as they prese
nt during the infantile period with a high prevalence o
f associated neurological abnormalities which worsen
s with age. MELAS were not considered as they prese
nt with stroke, muscle weakness in between attacks a
nd high lactate/ pyruvate level7.
Familial hemiplegic migraine has an autosomal domi
nant mode of inheritance, however, in the present cas
e, though there is a family history of 1st degree relativ
e suffered from migraine there was no motor weaknes
s. The genes associated with FHM are CACNA1A, A
The diagnostic criteria for hemiplegic migraine (famil

ial and sporadic) has been laid down by the internatio
nal classification of headache disorders in 2004.1 The
diagnosis of sporadic hemiplegic migraine is usually
made after ruling out other possible causes. The treat
ment of acute SHM attacks as well as prevention in c
hildren still remains an unresolved issue.
Competing interest none stated
REFERENCES
1. Headache Classification Subcommittee of the
International Headache Society. The International
Classification of Headache Disorders. 2nd Ed.
Cephalalgia. 2004;24(Suppl 1): 8-160.
2. Moyamoya disease presented with migrainelike
headache in a 4-year-old girl. J. child neurol.
2003;18(5):361-3.
3. Chakravarty A, Sen A. Sporadic hemiplegic
migraine in Children: Report of two new cases.
Neurol India. 2010;58:648-50.
4. Bhatia R, Desai S, Tripathi M, Garg A, Padma
MV, Prasad K, et al. Sporadic hemiplegic
migraine: report of a case with clinical and
radiological features. J Headache Pain.
2008;9:385-88
5. Swoboda KJ, Kanavakis E, Xaidara A, Johnson
JE, Leppert MF, Schlesinger-Massart MB.
Alernating hemiplegia of childhood or familial
hemiplegic migraine?: A novel ATP1A2 mutation.
Ann Neurol. 2004;55: 884
6. Verret S, Steele JC. Alternating hemiplegia in
childhood: a report of eight patients with
446
Sangavi et al.,
complicated
migraine
beginning
in
infancy.Pediatrics. 1971;47:675
7. Ohno K, Isotani E, Hirakawa K. MELAS
presenting as migraine complicated by stroke.
Neuroradiology. 1997;39:781-4
8. Chakravarthy A, Mukerjee M. Sporadic
hemiplegic migraine, Indian pediatrics. 2012; l49;
150-51
9. Pienczk-Reclawowicz K, Pilarska E, Lemka M.
Sporadic hemiplegic migraine in children. Neurol
India. 2010; 58:512-13
447
Sangavi et al.,
DOI: 10.5958/j.2319-5886.3.2.091

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Case report
SYNOVIAL HEMANGIOMA OF THE KNEE JOINT: A RARE CASE REPORT

Amita K, Rajani R, Vijayshankar S, Shobha SN
Department of Pathology, Adichunchanagiri Institute of Medical Sciences, BG Nagara, Karnataka, India
*Corresponding author mail: dramitay@rediffmail.com
ABSTRACT
Synovial hemangioma is a rare entity characterized by the presence of normal or abnormal blood vessels, arising
from the synovial lining of the tendon sheath or joint space. Nonspecific symptoms and lack of awareness of the
condition often leads to delay in diagnosis. We report a case of 25 year old young female presented with recurrent
swelling and pain over the left knee joint since 15days. Repeated aspiration yielded only blood. Arthrotomy with
synovectomy was done. Histopathology of the resected specimen showed a synovial hemangioma.
Keywords: Synovium, Hemangioma, Knee, Joint
INTRODUCTION
Synovial hemangiomas (SH) though recognized
entity, is rare. There are only 250 cases reported in
the English literature till date. 1 They have essentially
resulted from the abnormal vessels located in the
articular capsule or synovial membrane. 2 Patients
usually present with recurrent hemarthrosis, and
nonspecific symptoms like swelling or pain in the
joint.3, 4 As a result, there is always an element of
delay in diagnosis. More so even X ray findings are
nonspecific.5 Though MRI is the diagnostic modality,
histopathological examination is mandatory for the
definitive diagnosis.6 Even at histopathology,
synovial hemangioma needs to be differentiated from
hemophilic, post traumatic arthropathy nonspecific
synovitis with congestion, granulation tissue
formation and mass lesions especially pigmented
villonodular tenosynovitis also needs to be
differentiated. The risk of recurrence following
surgery is high. 7 Early institution of therapy is must
to prevent joint damage and hence reduce morbidity.
CASE REPORT
25 years old young female presented in the
orthopaedics department of Adichunchanagiri
Institute of Medical Sciences, with swelling and pain

over the left knee joint since 15 days. There was
history of trauma 10 years back. On examination a
cystic swelling was noted in the left knee joint
measuring 10 x 5 cm. The swelling was non tender
and immobile. No scars, abrasions or laceration was
noted on the skin. No knee joint deformity was seen.
Range of movement was restricted in flexion and
extension. There was a slight limp on walking. Gross
fluctuation test was positive. Repeated aspiration
yielded only blood. X ray demonstrated nonspecific
findings without any bony erosion. A clinical
diagnosis of hemarthrosis was made. On exploration
blood clot was noted with lateral miniscal thickening.
Synovial and miniscal tissue were sent for
histopathological examination.
Specimen consisted of two irregular tissue bits larger
measuring 10 cms across and smaller measuring 2.5
cms across.
Histopathologically sections studied show vascular
channels of venous caliber (Figure 1 A) along with
sinusoidal blood vessels (Figure 1 B) which were
filled with RBCS and at places showing herniation
448
Amita et al.,
and thrombus formation (Figure 1 C and D). The

sinusoidal vessels were seen intercommunicating
with each other. The surrounding stroma was loose
edematous, at places myxoid and showed many
histiocytes. The lesion was confined by synovial
lining. Final diagnosis of Synovial hemangioma was
made.
Fig1A: Photomicrograph showing vascular channels of

venous caliber. (H & E, 400), 1B: Photomicrograph
showing sinusoidal blood vessels. (H & E, 100), 1C:
Photomicrograph showing herniation. (H & E, 400), 1D:
Photomicrograph show thrombus formation. (H & E,
400)
DISCUSSION
The term hemangioma is used to embrace a benign
reactive process comprising of normal or abnormal
appearing vessels. Nonetheless, it has to be
recognized that most of these lesions are rather true
malformations or hamartomas. These taxonomic
distributions have been made even more difficult by
the fact that clinicians, radiologist and pathologist use
different classifications relying on a malange of
parameters. From a pathologists point of view, the
nomenclature relies on the type of blood vessels
present.8
Hemagioma of the synovium is a rare entity.
Theoretically, it may arise from the synovial lining of
the tendon sheath or in the joint space. Those arising
from the tendon sheath are not always confined by
the synovium, hence some authors argue against
calling these as true hemangiomas. Hemangiomas
arising in joint space are persistently lined by
synovial membrane and are true synovial
hemangiomas (SH).2
SH occur typically in 1st and 2nd decade of life. 8
Knee joint is invariable the most common joint
affected, followed by elbow, hip and rarely
temperomandibular joint.9 Classical symptoms

include recurrent episodes of pain, swelling and joint
effusion. These symptoms mimic synovitis or
medical miniscal injury as in our case. Subsequent to
this there is an element of delay in diagnosis. Sequels
to it are the chances of degenerative changes setting
up due to recurrent episodes of bleeding, leading to
permanent deformity and thus considerable
morbidity. At times, patient presents with recurrent
hemorrhagic joint effusions. 3
History of trauma is rarely elicited. On examination
as in hemangiomas of another site, a compressible
spongy mass which decrease in size with elevation
can be palpated in the joint. X ray findings are
nonspecific and do not lead to a specific diagnosis. 5
However, MRI has been found to be a precise
diagnostic tool for evaluating hemangiomas, although
the findings are usually confounded in chronic cases
by the findings in hemophilic arthropathy. MRI holds
priority not only in suggesting the diagnosis but also
in planning, management by delineating the size,
extension and relation to surrounding structures.
However no diagnostic modality other than
histopathologic examination holds true in diagnosing
a SH. 9
Histologically, these lesions are of cavernous type
composed of venous caliber blood vessels separated
by fibromyxoid hyalinised stroma. The presence of
synovial lining above the lesion confers the lesion as
SH. The lesion, however, needs to be differentiated
from hemophilic and post traumatic arthropathy.
Clinical history and coagulation profile aids in ruling
out hemophilic arthropathy. Nonspecific synovitis
with congestion, granulation tissue formation and
mass lesions, especially pigmented villonodular
tenosynovitis also needs to be differentiated. 10
Recognizing the fact that underlying vessels are far
more numerous for the area in question helps to make
an accurate diagnosis.8
Controversy exists over the taxonomy and
pathogenesis of hemangioma which resembles the
normal vessels to such an extent that it is difficult to
classify them as malformations, tumors or
hamartomas. Whatever may be the pathogenesis,
treatment depends on the configuration as to focal or
diffuse. Focal lesions require simple extirpation.
Diffuse lesions are difficult to eradicate completely
and may require small doses of radiation. 8
449
Amita et al.,
CONCLUSION
Because of the implications of complications due to
delayed diagnosis, SH is an important consideration
in the differential diagnosis of recurrent hemorrhagic
joint effusion with or without a history of trauma.
REFERENCES
1. Silva RT, De Souza Laurino CF, Moraes VY.
Intraarticular synovial hemangioma of the knee:
an unusual cause of chronic pain in a sportsman.
Clinical Journal of Sport Medicine. 2007;17:50406
2. Kenneth D, Vinh TN, Sweet DE. Synovial
hemangioma: A report of 20 cases with
differential diagnostic considerations. Hum
Pathol. 1993;24:737-45.
3. Bruns J, Eggers G, Von Torklus D. Synovial
hemangioma a rare benign synovial tumor.
Knee surgery, Sports traumatology, Arthroscopy.
1994;2:186-9.
4. Vakil- Adli A, Zandieh S, Hochreiter J, Huber M,
Ritshechl P. Synovial hemangioma of knee joint
in a 12- year- old boy: a case report. Journal of
medical case reports. 2010;4:105.
5. Enzinger FM, Weiss SW. Benign tumors and
tumor-like lesions of blood vessels. In : Soft
Tissue Tumors. St Louis: MO, Mosby; 1988. p.
489-53
6. Ramseier LE, Exner GU. Arthropathy of the knee
joint caused by synovial hemangioma. Pediatr
Orthop. 2004;24:8386
7. Yilmaz E, Karkurt L, Ozdemir H, Serin E, Incesu
M. Diffuse synovial hemangioma of colon a case
report. Acta Orthop Traumatol Tur. 2004;38;22428
8. Moon NF. Synovial hemangioma of the knee
joint. Clin Orthop. 1973;90:18390
9. Llauger J, Monohil JM, PAalmer J, Clolet M.
Synovial hemangioma of knee: MRI findings in
two cases. Skeletal Radiology. 1995;24:579-81
10. Jaswal TS, Singh S, Gupta V, Purwar P, Sangwan
SS, Arora B. Synovial hemangiomaa case
report. Indian J Pathol Microbiol.2001;44:353-54
450
Amita et al.,
DOI: 10.5958/j.2319-5886.3.2.092

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
st
Copyright @2014
ISSN: 2319-5886
Accepted: 22nd Jan 2014
Case report
BILATERAL VARIANT OF SCIATIC NERVE EXHIBITING INTRA-PELVIC DIVISION

*Rejeena P Raj1, Kunjumon PC2, More Anju B3
1
Tutor, 2Professor and Head, 3Associate professor, Dept. of Anatomy, Sree Mookambika Institute of Medical
Sciences, Kulasekharam, Tamilnadu, India
*Corresponding author email: as.anju@yahoo.in
ABSTRACT
Context (background): In case of high division of the sciatic nerve in the pelvis its, common peroneal component
may pierce the Piriformis muscle. This anatomical variant can explain many clinical findings. Aims: Its objective is
to report a case of high division of the sciatic nerve in order to contribute towards better anatomical understanding
of the gluteal region. Methods and Material: Routine undergraduate dissection of a male cadaver revealed bilateral
variation in sciatic nerve. Results: Sciatic nerve is dividing into tibial and common peroneal components in the
pelvis. Common peroneal component is piercing through the piriformis muscle. Tibial component is emerging
between piriformis and superior gemelli muscle. Conclusions: Sciatic nerve variation can lead to a Piriformis
muscle syndrome, inadvertent injury during operations in the gluteal region, failure of sciatic nerve block and/or
sciatic neuropathy. The differences in routes of these two nerve components can explain them.
Keywords: Common peroneal nerve, Pyriformis muscle, Piriformis syndrome, Sciatic nerve.
INTRODUCTION
CASE REPORT
The sciatic is the thickest and longest nerve in the

human body. Normally, Sciatic nerve leaves the pelvic
cavity as a single trunk through greater sciatic
foramina to emerge between piriformis and superior
gemelli muscle.1 Variation in the course of sciatic
nerve may or may not be accompanied by a variation
in the piriformis muscle. 2 In this case report, we want
to present a case of the bilateral high division of the
sciatic nerve. The common peroneal component is
piercing the piriformis muscle. The variation has
clinical application in case of non-discogenic sciatica
or piriformis syndrome.3, 4 It is also a cause for
coccgodynia and pain in hip, groin and buttock.4, 5 The
variation can lead to post-operative nerve entrapment
after total hip arthroplasty.6 The same being the cause
of failure of nerve block to relieve the pain.7
During routine undergraduate dissection, at Dept of

Anatomy, Sree Mookambika Institute of Medical
Sciences, Kulasekharam, Tamilnadu the variation was
noticed. A formalin-fixed male cadaver aged 60 years
whose case history and cause of death is not known
was dissected. Exposure of the gluteal region was done
following classical incision and dissection procedures.
After skin incision and removal of panniculus
adipsous, gluteus maximus was resected as directed in
dissection manual to expose the structures under cover
of it. The variation was noticed on both sides. All
arteries and nerves were dissected and identified. The
same procedure was followed on both the sides.
Ethics: The procedures followed were in accordance
with ethical standards of handling of cadaver for
learning and teaching.
In this case the High division of sciatic nerve has
occurred in the pelvis. At the greater sciatic foramina,
451
Rejeena et al.,
tibial component is emerging below the piriformis

where as common peroneal component is noted to
pierce the piriformis as it leave the pelvis to reach
gluteal region. The branches of sciatic did not reunite
in the gluteal or thigh region. The muscular branches
from the tibial component to the hamstring muscles
are seen arising from the tibial nerve. The course,
branches and relations of both nerves in the popliteal
fossa and leg were normal. The piriformis muscle had
a single muscle belly just splitting to allow passage of
common peroneal nerve. (Fig. 1)
Fig. 1: structures under cover of Gluteus Maximus
DISCUSSION AND CONCLUSION

In the anatomy books sciatic nerve is described as a
major nerve from the lumbo-sacral plexus. It is formed
in the pelvis and emerges at the superior border of the
piriformis. It has two components. Its tibial
component supply to the hamstrings and the common
peroneal to the short head of biceps femoris in the
thigh. The nerve normally divides into these two
terminal branches; tibial and common peroneal at the
upper angle of the popliteal fossa. In the popliteal
fossa the common peroneal nerve is lateral to the tibial
nerve. In the upper 1/3rd the tibial nerve is lateral to
popliteal vein and artery.1 Beaton and Anson have
studied 360 specimens and classified relations of
sciatic nerve or its divisions to the piriformis muscle
into six types. 1- Undivided nerve below undivided
muscle; 2- Divisions of nerve between and below
undivided muscle; 3- Divisions above and below
undivided muscle; 4- Undivided nerve between heads;
5- Divisions between and above heads; and 6Undivided nerve above undivided muscle.2, 4 The
present case belongs to Type 2. (Fig. 1)
The variations of sciatic nerve are reported in different
races and populations with a variable frequency.8-12The
relationship between sciatic nerve and the piriformis
muscle explain the anatomical basis of the origin of

signs and symptoms of nerve compression. In this case
it is known as Piriformis muscle syndrome. 3 It is
characterized by sensitivity, motor and trophic
disturbances in the region of distribution of trapped
component of the sciatic nerve.3- 5 The sciatic nerve is
also subject to direct injury, compression, and
ischemia. Total hip arthroplasty may involve excessive
distraction of sciatic nerve, hematoma formation, and
dislocation of bony component and prominence of
implanted unit. Any or all of them can lead to sciatic
nerve injury.6
Sciatic nerve entrapment can lead to pain similar in
distribution and nature like sciatica. Nerve irritation
can be due to contraction or myospasm of piriformis.
Ultrasonography, perineurography by Computerised
Tomography and Magnetic Resonance Imaging can
help to distinguish between two and planning of
intervention.13,14 Resection, division or thinning of
piriformis may help to release entrapped nerve.15, 16
The role of lateral rotation will be managed by
obturator internus, superior and inferior gemelli and
quadrates femoris. Non- surgical management of pain
in Piriformis syndrome includes injecting any one of
these or combination of local anesthetic, steroid,
botulinum toxin and stored in the area of the sciatic
nerve in the gluteal region. A guided procedure under
electromyography (piriformis), nerve stimulator
(sciatic nerve) or other imaging techniques will yield
better results than a blind one.7, 13, 14Other conditions
which mimic the presentation are endometriosis,
myofascial pain syndrome, pelvic tumor, spinal
stenosis, and trochanteric bursitis.
ACKNOWLEDGEMENT
We would like to thank our Institution for the material
support and Mr. Ganeshan for back-up.
REFERENCES:
1. Williams PL, Bannister LH, Berry MM, Collins P,
Dyson M, Dussek JE, et al. Grays Anatomy.
Edinburgh: Churchill Livingstone; 1995, 38th
Ed.:1284.
2. Beaton LE, Anson BJ. The relation of the sciatic
nerve and its subdivisions to the piriformis muscle.
Anat Rec.1937; 70(1): 15.
3. Rich B, McKeag D. When sciatica is not a disc
disease: detecting piriformis syndrome in active
patients. Phys. Sports Med. 1992; 20: 104115.
452
Rejeena et al.,
4. Beaton LE. The sciatic nerve and piriform muscle:

Their
interrelational
possible
cause
of
coccgodynia. J Bone Joint Surgery Am. 1938; 20:
686-88.
5. MMcCrory P, Bell S. Nerve entrapment
syndromes as a cause of pain in the hip, groin and
buttock. Sports Med. 1999; 27: 261-74.
6. Pokorny D, Jahoda D, Veigl D, Pinskerova V,
Sosna A.
Topographic variations of the
relationship of the sciatic nerve and the piriformis
muscle and its relevance to palsy after total hip
arthroplasty. Surgical and Radiologic Anatomy.
2006; 28 (1): 88-91.
7. Benzon HT, Katz JA, Benzon HA, Iqbal MS.
Piriformis syndrome: anatomic considerations, a
new injection technique, and a review of the
literature. Anesthesiology. 2003; 98:1442-48.
8. Patel S, Shah M, Vora R, Zalawadia A, Rathod
SP. A variation in the high division of the sciatic
nerve and its relation with piriformis muscle.
National Journal of medical research. 2011; 1(2):
27-30.
9. Ogengo JA, El-Busaidy H, Mwika PM, Khanbhai
MM, Munguti J. Variant anatomy of sciatic nerve
in a black Kenyan population. Folia Morphol.
2011; 70(3): 175-79.
10. Bardeen CR, Elting AW. A statistical study of the
variations in the formation and position the lumbosacral plexus in man. Anat Anz. 1901; 19: 209-39.
11. Prakash, Bhardwaj AK, Devi MN, Sridevi NS,
Rao PK, Singh G. Sciatic nerve division: a cadaver
study in the Indian population and review of the
literature. Singapore Med J. 2010; 51; 721-23.
12. Guvencer M, Iyem C, Akyer P, Tetik S, Naderi S.
Variations in the high division of the sciatic nerve
and relationship between the sciatic nerve and the
piriformis. Turk Neurosurg. 2009; 19(2):139-44.
13. Gierada DS, Erickson SJ. MR imaging of the
sacral plexus: abnormal findings. Am J
Roentgenol. 1993; 160: 1067-71.
14. Schwemmer U, Markus CK, Greim CA, Brederlau
J, Kredel M, Roewer N. Sonographic imaging of
the sciatic nerve division in the popliteal fossa.
Ultraschall Med. 2005; 26: 496-500.
15. Kosukegawa I, Yoshimoto M, Isogai S, Nonaka S,
Yamashita T. Piriformis syndrome resulting from
a rare anatomic variation. Spine. 2006;
31(18):664-66.
16. Barton PM. Piriformis syndrome. A rational

approach to management . pain.1991;47:345-52
453
Rejeena et al.,
DOI: 10.5958/j.2319-5886.3.2.093

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Accepted: 21st Jan 2014
Case report
DELUSIONAL PARASITOSIS WITH ALCOHOL DEPENDENCE: A CASE REPORT

Nahid Dave1, Austin Fernandes1, Anup Bharati2, *Avinash De Sousa3
1
Resident, 2Assistant Professor, 3Research Associate, Department of Psychiatry, Lokmanya Tilak Municipal
Medical College, Mumbai, Maharashtra, India
*Corresponding author email: avinashdes888@gmail.com
ABSTRACT
Delusional parasitosis is a syndrome with which most psychiatrists are familiar. However, most reports consist of
case reports or small series. We present here a case report of delusional parasitosis of an extremely bizarre nature
in a case of alcohol dependence that responded to pimozide, haloperidol and electroconvulsive therapy (ECT).
Keywords: Delusional parasitosis, Bizzare, Alcohol dependence, ECT.
INTRODUCTION
Delusional parasitosis (DP) is a delusional disorder
characterized by a fixed belief of infestation by
parasites, despite a lack of supporting medical
evidence.1-2 DP may involve tactile hallucinations,
psychosocial functioning may be variably impaired
secondary to the delusion, and the duration of any
concurrent mood disorder must be brief in
comparison to the total duration of the delusion in
order to meet diagnostic criteria.3 Primary DP is not
due to a general medical condition or substance
abuse, while secondary DP is related to a variety of
medical disorders, including stroke, leprosy,
peripheral neuropathy, and loss of visual acuity, as
well as substance abuse and other psychiatric
disorders.4-5 In the present case report, we report a
delusional parasitosis in relation to alcohol
dependence.
CASE REPORT
A 40year old right handed male, Hindu by religion,
matriculate and married since 15years having 2
children, working as a rickshaw driver presented to
the outpatient department of our hospital brought by
his wife with the chief complaints of fearfulness,
suspiciousness, inability to sleep at night, alcohol

consumption, hearing voices inaudible to others and
sensation of worms in the groin region. These
symptoms were present since 5 years prior to
presentation. The patient was apparently alright 10
years prior to presentation when he started alcohol
consumption in the form of country liquor
(haathbatti) for fun and pleasure and then gradually
increased the frequency and quantity of consumption.
He then shifted to daily drinking with a history of an
eye opener drink being present. The patient was also
unable to go to work and his wife who is a
maidservant works to support the family.
The patient had withdrawal symptoms if he did not
get alcohol for a few days in the form of insomnia,
tremors, loss of appetite and irritability while these
symptoms were relieved on taking alcohol. The
patient had a history suggestive of tolerance as the
patient increased the quantity of consumption of
country liquor. He would earlier consume 2-3
quarters a day which gradually increased to 4-5
quarters a day. He had a history of angry, abusive and
aggressive behaviour with family members under
influence of alcohol. 5 years prior to presentation,
454
Nahid et al.,
there was a shortage in the supply of haathbatti and

the patient did not get alcohol for 2-3 days. He started
becoming fearful that someone is following him to do
harm to him and he would hide behind the door and
under the bed. He started removing all his clothes and
walking naked in the house and would even try to run
out of the home in that state but family members
would stop him. He would hit himself at times,
mutter and gesticulate by himself. The fearfulness
and psychotic features persisted despite restarting the
consumption of alcohol.
He was taken to various hospitals for deaddiction.
Each time he would abstain for a few weeks and the
maximum abstinence has been for 6-7 months while
the psychotic features persisted during this time.
The patient describes four men maharaja, papa,
joseph and masterji who are trying to harm him, he
can hear their voices throughout the day but one at a
time. He claims they are watching him 24 hours of
the day, they tell him what to do and what not to.
Patient claims they have a special connection and
only he can hear them. He has never seen any of them
except papa who he claims lives near his house. The
wife denies the presence of any such person. He
claims the voices come from outside of the window
and he has tried finding them on many occasions but
has not found the source. The voices tell him
continually what to do and what not to, if he doesnt
follow their orders, they release worms in the groin
area of his body.
25000 worms suck his blood and semen whenever he
disobeys them. 7000 of them just bite him, and he can
feel the sensation. The worms even crawl up to his
chest and suck his nipples and draw milk. The worms
are given a human like quality of speaking and they
call him pitaji (father). The worms talk to the patient
and say that if they do not follow the instructions
given to them of sucking, they will not get food and
diet. He can feel them walking, biting and sucking
him but as soon as he takes off his pants, they all
vanish. He says he has seen only one worm, on one
occasion which was 4cm long, brownish in colour
and had a hole at one end. The worms also tell him
not not communicate all this to the doctor or they will
punish him more. He believes the 4 men have
performed 14 surgeries on his groin area; they
removed and replaced his genitals with the help of
worms, although the scars of the surgery are not seen.
One of the voices, Joseph tells him that the patients
wife is his wife, this disturbs him a lot, but he is not

suspicious towards his wife.
The patient was started on antipsychotics in the form
of Haloperidol (15mg/day), Trihexyphenydyl
(6mg/day), Olanzapine (15mg/day) and was on an
alcohol withdrawal line of management. He was
admitted in the psychiatry ward and was given
5ECTs in view of the delusions. Patient was
symptomatically better and discharged and asked to
follow up on OPD basis for ECTs but he did not do
so. His auditory hallucinations had stopped, although
the sensations of worms persisted at times during the
day. The patient has abstained from alcohol after
discharge, but non adherent on treatment. Patients
psychotic symptoms increased again a month post
discharge and he restarted alcohol consumption
following the occurrence of psychotic symptoms. The
patient has been counselled regarding abstaining from
alcohol and the medication was changed to
Pimozide4mg per day, which was gradually increased
to 8mg along with Haloperidol and trihexyphenydyl.
The patient is currently being worked up for another
course of ECTs.
DISCUSSION
DP has been known to occur in the presence of
substance abuse and may also be seen with the
presence of tactile hallucinations.6 Patients with DP
may engage in self injurious behaviour and may
scrape or peel their skin when they feel the worms
crawling. They may collect the worms and bring
specimens to show their doctor often called the
match box sign.7 The case we have presented above
is a little different from classic cases of DP as the
delusion here harbours on to or overlaps a delusion of
bizarre quality. He claims that the worms are released
by someone in his groin area and that the number is
2500 or 7000. He also claims that the worms talk to
him and call him names. The bizarre quality is
personified when he says that the worms has operated
on and replaced his genitals. He also claims that the
worms reach his nipples and suck milk. This is one of
the rare cases where we have come across delusional
parasitosis of a highly bizzare nature coupled with
alcohol dependence.
DP is a disorder where the response to medication is
often incomplete and unsatisfactory. No randomized
controlled trials or studies are available due to the
rarity of the condition.8Risperidone, Olanzapine,
455
Nahid et al.,
Haloperidol and Pimozide have all been used

extensively.9 Electroconvulsive therapy may be a
viable option when medicines fail and must be
explored. Combining various forms of treatments
together are often the best options in these cases.10
The patient is often distressed by the symptoms and
needs quick relief from the problem.
9. Reily TM, Batchelor DS. The presentation and

treatment of delusional parasitosis. Int Clin
Psychopharmacol. 1987;1:340-53
10. Szepietowski JC, Salomon J, Hrehorow E, Pacan
P, Zalewska A, Sysa-Jedrzejowska A. Delusional
parasitosis in dermatological practice. J Eur Acad
Dermatol Venereol. 2007;21:46265
CONCLUSION
DP is a disorder with which every dermatologist, and
emergency medicine personnel should become
familiar. To date, however, the only effective
pharmacological
options
are
antipsychotic
medications. A combination of treatments to treat
both DP and the existing comorbid psychiatric
conditions is often warranted.
REFERENCES
1. Trabert W. 100 years of delusional parasitosis.
Meta-analysis
of
1,223
case
reports.
Psychopathology. 1995;28:23846
2. Lepping P, Freudenmann RW. Delusional
parasitosis: a new pathway for diagnosis and
treatment. Clin Exp Dermatol. 2008;33:11317
3. Bhatia MS, Jagawat T, Chaudhary S. Delusional
parasitosis: a clinical profile. Int J Psychiatr Med.
2000;30:83-91
4. Aw DC, Thong JY, Chan HL. Delusional
parasitosis : a case series of 8 patients and review
of literature. Ann Acad Med Singapore.
2004;33:89-94
5. Wenning M, Davy L, Catalano G, Catalano M.
Atypical antipsychotics in the treatment of
delusional parasitosis. Ann Clin Psych.
2003;15:23339
6. Lepping P, Russell I, Freudenmann RW.
Antipsychotic treatment of primary delusional
parasitosis. Br J Psychiatr.2007;191:198205
7. Freudenmann RW, Lepping P. Second-generation
antipsychotics in primary and secondary
delusional parasitosis: outcome and efficacy. J
ClinPsychopharmacol. 2008;28:50008
8. Mercan S, Altunay IK, Taskintuna N, Ogutchen
O, Kayaoglu S. Atypical antipsychotic drugs in
the treatment of delusional parasitosis. Int J
Psych Clin Med. 2007;37:2937
456
Nahid et al.,
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ISSN: 2319-5886
Case report
THYROID METASTASES FROM BREAST ADENOCARCINOMA DIAGNOSED BY FINE NEEDLE

ASPIRATION CYTOLOGY: A CASE REPORT
*
Siddaganga Mangshetty1, Sainath K Andola2
Consultant Pathologist, Medivision Diagnostic Gulbarga, Karnataka, India

Professor and HOD, Dept of Pathology MR Medical College Gulbarga, Karnataka, India
2
*
Corresponding author email: siddagangamangshetty@yahoo.co.in
ABSTRACT
Despite being second only to the adrenal gland in terms of relative vascular perfusion, the thyroid gland is a rare site
of metastatic disease; but when thyroid metastases occur, long term survival has been reported to be dismal.
Metastases to the thyroid are uncommon, but the number of cases seems to have increased in recent years. This
increase may be related to more frequent use of fine needle aspiration biopsy (FNAB) in suspected cases. In clinical
papers, the incidence of metastases to thyroid is low and, according to various sources, amounts to 2-3% of all
malignant tumors of the thyroid. Most commonly the primary tumor is located in the breast, bronchi, GIT (the
colon, esophagus, or stomach) and kidney. Usually metastatic thyroid disease is identified upon autopsy, and only in
sporadic cases. We present a case of breast Adenocarcinoma metastases to thyroid which was diagnosed on FNAC.
Keywords: Adenocarcinoma, Thyroid Metastases, FNAC
INTRODUCTION
The thyroid is a vascular organ and therefore can be
the site of blood borne metastases from other cancer.
The most blood borne metastases are found in the
organs that receives a significant amount of cardiac
output such as the lung, liver, brain and bone marrow.
1-4
Various cancers have a propensity to metastasize to
particular sites such as prostate cancer to the skeleton
and bowel cancer to the liver. Breast cancer is the most
common tumor that metastasizes to the thyroid. They
usually occur when there are metastases elsewhere,
sometimes many years after the diagnosis of the
original tumor.5
There is a wide range from 1.25% in unselected
patients to 24.2% in selected patients with known
metastatic cancer.
How to diagnose metastases to thyroid in patients:
If the patient is known to have non thyroidal cancer
Siddaganga etal.,
with wide spread metastases and has a new thyroid

nodule.
Patient with a known cancer but no evidence of
metastases might develop a nodule that on FNA is
consistent with metastases from the primary cancer.
When a rapidly growing nodule arises in a patient with
a previously diagnosed cancer and no prior thyroid
disease.
In the Mayo clinic series, 12/43 patients developed the
thyroid metastases more than 10 years after the
diagnosis of primary cancer.
Patients can be present with the following symptoms:
Thyroid nodule, Cervical mass, Hoarseness of voice,
Dysponea, Cough, Dysphasia, Asymptomatic
457
CASE REPORT
A 38 year old female presented with history of
swelling over right side of neck from past four months.
She had undergone right sided mastectomy four years
ago for breast cancer.
On examination, she was found to have solitary
swelling in the right thyroid lobe measuring 4x3 cm in
size. The swelling moved with deglutination and was
firm to hard in consistency. Thyroid function tests
were normal.
FNAC of the swelling was done after informed
consent. The aspirate showed scanty hemorrhagic
material.
Processing of specimen: Air dried Methanol fixedGeimsa stain was done. Microscopic examination
revealed highly cellular smear in hemorrhagic and
scant colloid background. There were seen clusters of
malignant breast epithelial cells arranged in cell ball
pattern, these are highly pleomorphic with increased
N:C ratio, vesicular nuclear chromatin with prominent
nucleoli. There was abundant eosinophilic cytoplasm.
Amidst these cells were seen thyroid follicular
epithelial cells and cyst macrophages and a few
inflammatory infiltrate (Fig. 1, 2, 3&4)
Diagnosis of thyroid metastases from breast carcinoma
was done on clinical history and FNAC features.
Fig 3: Few highly pleomorphic malignant epithelial cells

from the breast (marked anisonucleaosis, prominent
nucleoli and abundant cytoplasm) inset also showing few
malignant cells. (400x)
Fig 4: Few clusters of benign follicular epithelial cells

with cyst macrophages.
DISCUSSION
Fig 1: Aspirate shows highly cellular smear (100x)
Fig 2: Few cyst macrophages seen (arrow mark) (400x)
Siddaganga etal.,
Thyroid is a rare site of metastatic disease from other

primary sites, even though this gland is highly
vascular. The commonest primary site for such
metastases to the thyroid is renal cell carcinoma6, lung
carcinoma and breast in order of frequency.
Incidence of metastases to thyroid is reported from
1.2%-24% and usually as a terminal event in
metastases. More than 70% cases have at least one
metastases elsewhere before thyroid metastases.
Thyroid metastases are seen 0.13% of thyroidectomy
specimens and 0.07% of FNAC specimen worldwide.
The usual age of diagnosis is greater than 60 years and
median survival is 10-18 months. In 75% of cases
there is a solitary thyroid nodule, in 25% of cases there
is diffuse thyroid involvement and 81% are metastatic
epithelial tumor.
Various previous studies showed metastatic disease to
thyroid (Table1) Chang et al have showed highest no
of cases of breast carcinoma metastases to thyroid,
458
followed by renal cell carcinoma in study series of

Chen et al2
Few authors studied the frequency of thyroid
metastases in autopsy series (Table 2). Silverberg and
Vidone reported highest frequency of thyroid
metastases, which constitute 24% and lowest
frequency of 1.25% was found in Berge and
Lundeberg study series.
Some evidence points to the metastases being more
common in patients with underlying thyroid diseases
like hurthle cell carcinoma and follicular cell
carcinoma in to which renal cell carcinoma, breast
carcinoma, and GI Carcinoma can metastasize.
Metastatic renal cell carcinoma and mammary
carcinomas can be distinguished from follicular and
papillary carcinoma without knowledge of clinical
history.7
All metastatic carcinomas of thyroid are negative for
thyroglobulin, so organ specific antigens are useful.
The diagnosis of thyroid metastases can be made with

prior history of cancer. Most common age at the time
of diagnosis is above 50yrs with equal gender
distribution (Micheow et al from Mayo clinic). Tissue
diagnosis by FNAC should be obtained. Other
diagnostic modalities like thyroid scintigraphy will
show cold area and the USG is not so useful because
in all metastases it shows heterogeneous and hypo
echoic areas.
So FNAC is the best diagnostic modality prior to
surgery. The role of surgery in metastatic disease
remains controversial. Surgery is the most frequently
utilized of all the treatment for metastases of thyroid
cancer. In some instances, only the portion of the
thyroid where the tumor resides will be removed. In
other cases an extraction of the entire thyroid gland
may be called for.
Table: 1. Few previous studies show cases metastases to the thyroid

Reference
No of pts Kidney Breast Lungs GI tract
2
Chen et al
10
50
10
20
chung et al
9
67
Haugen et al
56
12
11
12
Nikhi avniet al 43
33
16
16
9
8
Schorder et al 25
38
20
28
9
Wood et al
10
27
7
7
7
Melanoma
3
7
Others
20
33
6
26
40
Table: 2. Frequency of metastases to the thyroid gland in autopsy series

Study year No of patients % of thyroid involvement
Author
Willis11
1931
170
5.2
Rice
1933
89
10.1
12
Shimoaka et al
1955-60
1980
8.6
13
Abrams et al
1943-1947 1000
1.9
Mortensen et al
1951-1953 467
3.9
Thorpe
1954
200
2
14
Silverberg and Vidone
1964-65
62
24.2
Berge and Lundeberg
1958-1969 16,294
1.25
Berge and Lundeberg
1958-1969 7732
2.8
CONCLUSION
We have described the case of a 38yrs old female
patient presenting with thyroid nodule 4years after
mastectomy done for breast cancer. We should always
rise the suspicious of thyroid metastases when there is
a new thyroid nodule. Although thyroid metastases is
considered rare occurrence, an increasing number of
patients with metastases to thyroid are being reported8.
Siddaganga etal.,
TAKE HOME MESSAGE

The occurrence of new thyroid nodule in a patient with
a known history of cancer has to be considered as
metastatic until proved otherwise
US guided FNAC is the best diagnostic procedure
used in the work up of new thyroid nodules occurring
during the follow up of cancer patients
459
Thyroidectomy should be considered with potentially

curative intention in all patients where the thyroid is
the only site of known metastasis.
REFERENCES
1. Kim TY, Kim WB, Gong G, Hong SJ, Shong
YK. Metastases to the thyroid diagnosed bt fine
needle aspiration biopsy. Clin Endocrinol.
2005;62(2):236-41.
2. Chen H, Nicol TL, Udelsman R. Clinically
significant, isolated metastatic disease to the
thyroid gland. World J surg.1999;23(2):177-81
3. Arrangoiz R, Papavasilious P, Dushkin H, Farma
Jm. Case reportand literature review: metastatic
lobular carcinoma of the breast an unusual
presentation. Int J Surg Case Rep. 2011;2(8):
301-05
4. Lacka k, Breborowicz D, Uliasz A, Teresiak A,
Teresiak M. Thyroid metastases from breast
carcinoma diagnosed by fine needle spiration
biopsy. Case report and review of the literature.
Exp Oncol.2012 Jul;34(2):129-33
5. Kihara M,Yokomise H,Yamauchi A- Metsastases
of renal cell carcinoma to the thyroid 19 year
after nephrectomy: a case report. Auris Naus
Larynx. 2004 Mar;31(1):95-100
6. Benoit L, Favoulet P, Arnould L, Margarot A,
Franceschini C, Collin F, Fraisse J, Cuisenier J,
Cougard P. Metastatic renal cell carcinoma to the
thyroid gland: report of seven cases and review of
the literature. Ann chair. 2004;129(4):218-23
7. Schrouder S, Burk CG, De Hee K. Metastases to
the thyroid gland. Langenberks Arch. Chair.
1987; 370(1):25-35
8. Wood K, Vini L, Harmer C. Metastases to the
thyroid gland: the Royal Masden experience. Eur
J Surg Oncol. 2004;30(6):583-8
9. Schmid. Clinicopathological management of
tumors of thyroid gland in an endemic area.
Combined use of pre operative fine needle
aspiration biopsy and intra operative frozen
section.. Acta cytology. 1991;35:27-30
10. Shih YC, Wayne Huey, Herng S, Ming CC, Kam
TT, Tin- I L, Hog Da L: Diagnosis of thyroid
metastasis in cancer patients with thyroid mass by
FNAC and USG . Chin Med J (Taipei).2002;
65:101-105
Siddaganga etal.,
11. Willis RA. Metastatic tumors in the thyroid

gland. Am.J Pathol. 1931;7:187-208
12. Shimoka K, Sokal JE, Pickren JW. Metastatic
neoplasm in the thyroid gland, pathological and
clinical findings. Cancer .1961;15:557-565
13. Abrams HL, Spiro R, Goldstein N. Metastases in
carcinoma: analysis of 1000 autopsied cases.
Cancer.1950;3:74-85
14. Silverberg SG, Vidone RA. Metastatic tumors in
thyroid. Pacific Med Surg. 1966;74:175-180
460
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Case report
FETAL DIPROSOPUS (DOUBLE FACE): A CASE REPORT

*Onankpa BO1, Ukwu E2, Singh S2, Adoke AU2, Tahir A1
1
Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital, PMB 2370, Sokoto, Sokoto State,
Nigeria.
2
Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, PMB 2370,
Sokoto, Sokoto State, Nigeria.
*Corresponding author email: benonankpa@yahoo.com
ABSTRACT
Diprosopus is an extremely rare form of congenital anomaly that results in partial or total duplication of the face.
Most cases of diprosopus are delivered as stillborn or die few moments after delivery. The aim of this report is to
alert clinicians that the antenatal finding of polyhydramnious may be strongly associated with fetal diprosopus,
this routine high resolution anomaly scans should be recommended to help detect such anomaly early in
pregnancy. We report a case of a female neonate with partial duplication of the face (diprosopus) delivered by a
39 year old booked multipara. Babys condition deteriorated within 24hrs with worsening respiratory distress and
died on the 2nd day of life.
Key words: Facial diprosopus
INTRODUCTION
Diprosopus, is a Greek word for two-faced.1 This
congenital anomaly is often referred to as craniofacial
duplication in which there is partial or total
duplication of the face. However, the fetus has a
single trunk with normal limbs. In a typical
presentation the fetus has a duplicated nose with eyes
spaced far apart, but, in extreme cases, the baby has
the entire face duplicated (i.e. diprosopus). It is an
extremely rare condition with a reported incidence of
1 case in 180,000-15 million births.2 Cases of fetal
diprosopus have been reported in Italy3, Germany4,
Spain5, Saudi Arabia6, Turkey7 and India.8 To our
knowledge this is the second case reported in Nigeria,
after the case reported by Ibrahim et al9
Several attempts have been made by several
researchers to explain the mechanisms that leads to
craniofacial duplication. In the presence of two
completely formed, but identical faces, the babies are

often referred to as a rare variant of conjoined twins.
This mechanism resulting in two faces is considered
to have occurred as a result of cranial bifurcation
during neurulation of the notochord. 10 Two vertebral
axes develop alongside the neural plates as a result of
the bifurcation including neural crest derivatives.
Facts from the literature also revealed that 0.4 percent
of diprosopus is seen in conjoined twins.10 Another
possibility is that there could be an increased
production of sonic hedgehog (SHH), a protein which
is essential for craniofacial patterning during fetal
development; this has already been demonstrated in
chicks by researchers in an experimental studies.11
These studies showed that the chicks were born with
anomalies including double beaks with their eyes
spaced far apart. In contrast, the researchers also
461
Onankpa etal.,
found that too little SHH led to abnormal midline

facial features resulting in cyclopia.11
Prenatal diagnosis is possible for diprosopus using in
utero technics including ultrasound and computer
tomography (CT) scanning. The presence of
polyhdromnios is considered as a strong indication of
craniofacial duplication. Presently, there is no
treatment for diprosopus however, termination of
pregnancy is sometimes considered an option,
especially if diagnosed is made early in pregnancy.
Children with this defect are normally stillborn, but a
young girl, Lali Singh, born in 2008 survived for 2
full months before dying of a heart attack. 12 Partial
facial duplication, as in our case, is associated with
fewer anomalies, and the prognosis is better with
symmetry and an excess of tissue, rather than a
deficiency, favoring a positive result. 13 Most of the
cases reported were females (4 males/11 females). 5
To our knowledge, there have been less than 150
reports of diprosopus in the world medical literature. 9
CASE REPORT
Baby AM, a female was delivered to a 39- year old
booked multipara. The mother had regular antenatal
visits. The mother was admitted on account of
polyhydramnious at 36 weeks gestation. She had
abruptio placenta while on admission and, she was
delivered of the baby by emergency Caesarean
section. Baby required minimal resuscitation, had
Apgar scores of 7 & 9 at 1st and 5th minutes
respectively. The birth weight was 2800grams, length
was 47centimeters and the occipito-frontal
circumference was 35centimeters. Baby was
uniformly pink, in mild respiratory distress with
SPO2 of 98%. The major findings were on the head
and neck.
Baby had one cranium with 2 faces fused at the
midline, with a pair of mouth for each face. The left
face had an intact nose with the right face having a
trunk like organ with a single opening for a nose.
There were 2 intact ears. The left face had a well
formed left eye; the other incomplete eye appeared to
fuse in a transverse groove across the faces. Each
head had an anterior fontanelle. Baby had normal
female external genitalia. Babys condition
deteriorated within 24hrs with worsening respiratory
distress and died on the 2nd day of life. The parents
declined autopsy. However, we got an ethical
clearance from UDUTH ethical committee and an

informed consent from the parents to report the case.
Fig 1: Female neonate with diprosopus

DISCUSSION
Craniofacial duplication remains a rare entity with
only 27 cases reported since 1900.14 Polyhydramnios,
a condition that is considered as an indication for
craniofacial duplication was detected in this patient.
The risk factor for congenital anomaly includes
familial tendencies, advance maternal age, previous
history and polyhydramnious. The patient was of
advance age and developed polyhydramnious during
the third trimester. However, repeated ultrasound
scan done could not reveal other findings apart from
polyhydramnious. Perhaps a high resolution 4D scan
would have detected these congenital anomaly and
also highlight others if any. Other investigations,
including CT-scan, MRI may have helped in the
diagnosis, but the cost of this investigation is beyond
the reach of most patients in our environment.
Congenital anomalies are associated with myths and
beliefs, particularly in Africa and sub-Saharan Africa.
Thus, such babies are abandoned and poorly cared for
by their parents. Probably because diprosopus is
rare, few management options including corrective
surgeries have been documented.15 The prognosis and
fetal outcome has remained unfortunately poor in all
cases reported.
CONCLUSION
Diagnosis may be quite elusive during pregnancy
with many cases undetected before delivery. High
index of suspicion, full evaluation of cases of
polyhydromnious and high resolution scan may help
in the early diagnosis and prompt intervention.
462
Onankpa etal.,
Conflict of interest: None

REFERENCES
1. Al Muti Zaitoun A. Chang J, booker M.
Doprosopus
(Partially
duplicated
shead)
associated with anencephaly. A case report.
Pathology Research and Practice. 1999;195:45-50
2. DArmiento, Massimo, Jessica Falleti, Maria
Marilotti, Pasquale Mertinelli. Diprosopus
Conjoined Twins: Radiologic, Autopic, and
Histological Study of a Case. Fetal and Pediatric
Pathology. 2010;29:43138
3. Pavone L, Camera G, Grasso S, Gambini C,
Barberis M, Garaffo S etal., Diprosopus with
associated malformations: report of two cases.
Am J Med Genet. 1987;1:85-88
4. Stefan Hhnel, Peter Schramm, Stefan Hassfeld,
Hans H Steiner, Angelika Seitz. Craniofacial
duplication (diprosopus): CT, MR imaging, and
MR angiography findings case report. Radiology.
2003;1:210-3.
5. Mara Luisa Martnez-Fras, Eva Bermejo,
Jacobo Mendioroz, Elvira Rodrguez-Pinilla,
Manuel Blanco, Javier Egs, Valentn Flix.
Epidemiological and clinical analysis of a
consecutive series of conjoined twins in Spain.
Journal of Pediatric Surgery. 2009; 44(4):811-20
6. Amr SS, Hammouri MF. Craniofacial duplication
(diprosopus): report of a case with a review of the
literature. Eur J Obstet Gynecol Reprod Biol.
1995;1:77-80
7. Kutsi Koseoglu, Cantay Gok, Yelda Dayanir. CT
and MR imaging findings of a rare craniofacial
malformation: diprosopus. Am J Roentgenol.
2003;3:863-64
8. Suhil A Choh, Bakshi Jehangir, Naseer A Choh,
Omar Kirmani, Roomi Yousuf. Imaging findings
in diprosopus tetraophthalmos: a case report.
Pediatr Int. 2010;1:54-6
9. Ibrahim A, Mshelbwala PM, Ajike SO, Asuku
ME, Ameh EA. Diprosopus (double mouth) in a
Nigerian child: Case report and literature review.
Nigerian Journal of Plastic Surgery 2012;8(2)
10. Dhaliwal Harjit, Paul Adinkra, Diane Ennis, and
Pauline Green. Monocephalus Diprosopus
(Complete Craniofacial Duplication) Associated
with Hydrancephaly and Other Congenital
Anomalies. Priory Lodge Education Limited,
11.
12.
13.
14.
15.
2007.
http://priory.com/medicine/Birth_
Abnormality.htm (Accessed November, 16,
2010).
Hannel, Stefan, Peter Schramm, Stefan Hassfeld,
Hans Steiner, and Angelika Seitz. Craniofacial
Duplication (Diprosopus): CT, MR Imaging, and
MR Angiography Findings. Radiology.2003;226:
21013
Jamie Frater Top 10 Bizarre Medical Anomalies.
LISTVERSE. January 8, 2009.
June Wu, David A Staffenberg, John B Mulliken,
Alan L Shanske. Diprosopus: a unique case and
review of the literature. Teratology. 2002;6:28287
Turpin IM, Furnas DW, Amlie RN. Craniofacial
duplication (diprosopus). Plast Reconstr Surg.
1981;67: 139e-42
Okazaki, Joel, James Wilson, Stephen Holmes,
Linda Vandermark. Diprosopus: Diagnosis in
Utero. American Journal of Roentgenology.
1987;149:14748.
463
Onankpa etal.,
DOI: 10.5958/j.2319-5886.3.2.096

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th
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ISSN: 2319-5886
Case report
ACUTE METHEAMOGLOBINEMIA DUE TO NITROBENZENE POISONING: CASE SERIES

*Harish Kumar S1, Ujjawal Kumar2, Raghavendra Prasad B N3, Kiran BJ2, Anil Kumar M2
1
Assistant Professor, 2Resident, 3Professor and Head, Department of Medicine, Sri Devaraj Urs Medical College,
Kolar, Karnataka, India
*Corresponding author email:drharish21@yahoo.co.in
ABSTRACT
Nitrobenzene is a nitrite compound; its toxic effects are due to its ability to convert hemoglobin to
methaemoglobin by oxidizing iron. The clinical features of nitrobenzene poisoning vary based on the
concentration of methaemoglobin in blood. Immediate identification based on clinical features, odour of the
compound with supporting evidence of increased methaemoglobin levels will help in a timely intervention thus
preventing fatal outcome. Early haemodynamic and ventilator support along with administration of methylene
blue as an antidote has been proved crucial in saving some lives. An acute nitrobenzene poisoning presenting with
methaemoglobinemia is becoming quite common in this part of the country. Here authorsreport a series of cases
of nitrobenzene poisoning where immediate clinical evaluation, with repeated intravenous methylene blue saved
three patients, but two patients presenting late and with heavy exposure could not be saved.
Keywords: Acute methaemoglobinaemia, Nitrobenzene poisoning, Ascorbic acid, Mechanical ventilator
INTRODUCTION
CASE REPORT
Nitrobenzene is a synthetic organic yellow oily liquid

with an odour resembling bitter almonds. It is widely
used in agriculture in this part of the country as a
plant energizer, flowering stimulant and yield booster
in variable percentages for the crops like tomato,
brinjal, paddy, chilies, fruits, pulses and flowering
crops. It is also used in manufacturing of dyes, inks
and shoe polishes.1,2 The toxic effects of nitrobenzene
is due to its ability to
convert haemoglobin to
methaemoglobin by oxidizing iron.3 The fatal dose of
undiluted nitrobenzene is said to be about fifteen
drops. Death usually occurs within six to seven hours
of ingestion. Nitrobenzene poisoning is on the rise,
due to easy access to products containing
nitrobenzene.
Case report 1: A 65 year old female came with

history of consumption of about 30 ml of 20%
nitrobenzene [Brand name: Boom Plus(micronutrient
for plants)] two hours prior to admission. She had a
history of four episodes of vomiting after
consumption. On examination, she was conscious and
oriented; cyanosis was present, pulse rate- 80 b/m, BP
-140/80 mm Hg, SpO2 on pulse oximeter-85% on
100% oxygen. Stomach wash was given with
activated charcoal in the casualty. Investigation
showed
Hb-12.2gm/dl,
TLC-26.900cells/mm3,
3
platelets-3.18 lakhs/mm and her RFT, LFT, chest X
ray, ECG were all normal. ABG at admission showed
pH 7.33, PaCo2 27, PaO2 60, HCO316.3, O2Sa 80%.Methaemoglobin level -17%, she had respiratory
distress and saturation started falling still further, so
she was intubated and put on a mechanical ventilator.
We had to wait for six hours to give IV methylene
464
Harish et al.,
blue as it was not readily available in our hospital, but

meanwhile IV vitamin C 500mg was given. She was
administered IV methylene blue 50 mg as a 1%
solution over five minutes after six hoursof admission
and immediatelyher SpO2 improved to 92%, which
dropped later, when 30 mg IV methylene blue was
repeated. With fluctuating symptoms, IV methylene
blue (50 mg TID) and IV ascorbic acid (500 mg OD)
was continued for four days. The patient was
extubated on the fourth day and was discharged after
10 days.
Case report 2: A 58 year old male presented with h/o
consumption of 20 ml of a compound named
AMRUTH which contained nitrobenzene as 50% of
its constituents around two hours prior to admission.
O/E: patient was restless, tachyapneic, central
cyanosis was present, pulse rate 94- b/m, BP- 140/90
mmHg, SpO2-85% with high flow O2. Investigations
showed
Hb-14.3gm/dl,
TLC-9,300cells/mm3,
platelets-1.96lacs/mm3, ABG showed pH 7.44, PaO2
60, PaCO2 28, HCO3 20, methaemoglobin levels 25%, RFT, LFT, chest X ray, ECG were all normal.
He was given IV methylene blue 50 mg as a 1%
solution over five minutes and 50 mg IV TID for 2
days. His symptoms and Sp02 improved immediately
after giving the first dose of methylene blue. He was
also supplemented with IV ascorbic acid 500mg OD;
patient improved symptomatically and got discharged
5 days later.
Case report 3: A 22 year lady was referred from a
primary health centre to our casualty with history of
consumption of around 150 ml of 20% nitrobenzene
(Boom plus) sixhours prior to admission with
complaints of ten episodes of vomiting, drowsiness
and breathlessness. O/E she was unconscious,
gasping for breath,pupils were semi dilated and
sluggishly reacting to light, had central and peripheral
cyanosis, pulse rate -120b/min, BP-90mmHg systole,
SPO2 -74% with 10 liters of oxygen, she was
immediately intubated and connected to mechanical
ventilator. Investigations Hb 9gm%, TLC12000cells/mm3, platelet count- 2.5lakhs/mm3,
methaemoglobin level was 70%. ABG pH- 7.12,
HCO3-12,PaO2 -76,PaCO2- 38,ECG showed sinus
tachycardia, RFT, LFT and chest X ray were all
normal. Inj methylene blue IV 50mg as 1% solution
was given, after one hour repeat ABG showed pH
7.10,
PaO2
80mmHg,
PaCO2
50mmHg,
HCO38,suggesting persistent metabolic acidosis, so

Inj methylene blue IV 50mg was repeated. Over next
two dayspatient didnt regain her consciousness, inj
methylene blue 50 mg IV TID was continued and she
expired on third day of admission.
Case report 4: A 35 year old female patient
presented with history of ten episodes of vomiting
and breathlessnessshe was referred from local
hospital after gastric lavage. She had consumed
around 200 ml of 20% nitrobenzene (brand name:
Ranger used as plant nutrient) for suicidal purpose
sevenhours prior to admission. O/E she was
conscious, restless, irritable, central and peripheral
cyanosis, extremities were cold, pupils dilated and
sluggishly reacting to light, pulse rate 110/min, BP
80/60mmHg, SpO2 on pulse oximetry: 74% with 10
liters of oxygen. Investigations Hb -11.5 gm%, TLC15, 600cells/mm3, platelet count- 2.61 lakhs/mm3,
methaemoglobin level-56%. ABG showed pH 7.06,
PaO270, PaCO2 24, HCO316, O2Sa -80 %.ECG
showed sinus tachycardia, global ST segment
depression, T wave inversion and LFT, RFT, chest Xray was normal. There was no improvement in
cyanosis even with high flow oxygen. Inj methylene
blue IV 50mg as a 1 % solution was given and
dopamine infusion was started. After one hour repeat
ABG showed pH: 7.02, PaO280, PaCO2 50, HCO310,
suggestive of persistent metabolic acidosis, so Inj
methylene blue IV 50mg was repeated .As oxygen
saturation did not improveandtachycardia persisted
the
patient was intubated and connected to
mechanical ventilator. Twenty four hours later she
developed sinus bradycardia, had cardiac arrest and
succumbed to death.
Case report 5: A 25 year old lady came with history
of consumption of 20% nitrobenzene substance
(brand name-BOOMFLOWER-N used as plant
nutrient) of unknown quantity, four hours prior to
admission. O/E she was restless and in altered
sensorium, pulse rate 120 /min, BP 94/60mmHg,
SpO2 on pulse oximetry 85% with 4 liters of
oxygen.Investigations showed Hb% -8.3gm% ,TLC12,400cells/mm3,platelets-2.95lakhs/mm3 .Her RFT,
LFT, Chest X ray and ECG were all normal, ABG
showed pH 7.02, PaO2 36, PaCO2 36, HCO3 18.7,
O2Sa -80 %, methaemoglobin level-28%. She had
respiratory distress and saturation started falling still
further, so she had to be intubated and put on a
465
Harish et al.,
mechanical ventilator. Inj methylene blue IV 50mg as

a 1 % solution was given, later repeated after one
hour and continued tid for 2 days, she was also
supplemented with IV ascorbic C 500mg every 12
hrs.Her consciousness improved over a few hours, the
patient improved symptomatically and was extubated
on the second day and discharged a week later.
DISCUSSION
Nitrobenzene is oxidizing nitrite compound.
Nitrobenzene ingestion converts haemoglobin to
methaemoglobin by oxidizing iron.Normally around
1% of methaemoglobin is present in the blood and if
it exceeds more than 1% it is termed
methaemoglobinemia. There are two mechanisms
HMP shunt pathway and diaphorase pathway which
maintain low levels of methaemoglobin in blood. 4
These two enzyme systems require NADH and
NADPH, to reduce methaemoglobin to its original
ferrous state. In a condition where there is excessive
oxidative stress like in nitrobenzene passing it will
result in an increased methaemoglobin level, which is
more than the capacity of the body to reduce it
through the above two enzyme systems. The lethal
dose in adults is about
2 to 6 gm.5 A normal
individual will be symptomatic only when the
methemoglobin level is more than 10% and present
with symptoms of headache, fatigue and nausea. At
methaemoglobin level of 30 -40 % patient will have
symptoms of dyspnoea on exertion, palpitation and
lethargy. At methaemogloin level of 40% to 70%
patient will have seizures, coma, lactate acidosis,
respiratory distress and arrhythmias. Levels greater
than 70% will lead to death.5, 6Clues for diagnosis are
history of consumption of chemical compound,
characteristic smell of bitter almonds, persisting
cyanosis even while on oxygen therapy and normal
oxygen saturation on ABG (calculated). Blood
collected in syringe will be dark brown in appearance
and will turn chocolate red colour after drying on a
blotting paper.
Treatment:
Decontamination,
haemodynamic
support and ventilator management. Methylene blue
is the specific antidote for methaemoglobinemia
induced by nitrobenzene poisoning. Methylene blue
is administered if methemoglobin levels are more
than 20%5and it is infused intravenously at a dose of
1 2 mg/kg (max up to 50 mg/ dose in adults) as a
1% solution over five minutes. Injection methylene

blue should be repeated after one hour if
methaemoglobin levels are high and the patient is still
symptomatic.Maximum dose of 7 mg/kg over 24
hours can be used, in doses of more than 7 mg/kg
methylene
blue
itself
may
induce
7,8
methaemoglobinemia. Ascorbic acid, an antioxidant
can also be administered when methemoglobin levels
are more than 20%.7
In the first three patients we have observed that the
quantity consumed was less and also admission to
hospital after consumption was early, but in
thelattertwo patient amount consumed was more and
hospitalization was delayed that could have been the
probable reason for death.It was observed that
ingestion of nitrobenzene causes very high oxidative
stress as shown by increased methaemoglobin levels.
In severe poisoning administration of methylene blue
will slightly decrease the level of methaemoglobin on
first day, but the levels will rise again high on second
day due to release of nitrobenzene from
gastrointestinal tract and adipose tissue stores which
may be responsible for the deteriorationof patients.4
CONCLUSION
The authors here wish to point out that nitrobenzene
poisoning can be managed successfully with
intravenous methylene blue and ascorbic acid with
intensive hemodynamic and cardiopulmonary
support, but patients presenting late and with heavy
exposure, the chances of survival are less.
Patient consent: Patient/guardian consent was
obtained
Competing interests: None.
REFERENCES:
1. DuttaR,DubeSK,Mishra LD, Singh AP. Acute
methemglobinemia. Internet J EmergIntensive
Care Med. 2008; 11:10924051.
2. Subrahmanyam
BV.
Modis
Medical
Jurisprudence and Toxicology. New Delhi:
Butterworth India. 1999; 22nded: 375-377.
3. Wright RO, LewanderWJ, Woolf AD.
Methemoglobinemia: etiology, pharmacology
andclinical management. Ann Emerg Med 1999;
34:64656
466
Harish et al.,
4. Patel A, Dewan A, Upadhyay K, Patel S, Patel J.

Chemically Induced MethemoglobinemiaFrom
Acute Nitrobenzene Poisoning. The Internet
Journal of Laboratory Medicine. 2008;3:2.
5. Chongtham DS, Phurailatpam, Singh MM, Singh
TR.
Methemglobinemia
in
nitrobenzene
poisoning. J Postgrad Med. 1997; 43:734
6. Alok Gupta, Nirdesh Jain, AvinashAgrawal. A
fatal case of severe methaemoglobinemia due to
nitrobenzene poisoning. Emerg Med J 2012 29:
70-71
7. Verive M, Kumar M. Methemglobinemia:
Treatment and Medication, e medicine from web
med. Available from: http://www.emedicine.
medscape.com/article/956528-treatment
8. Whitwan JG, Taylor AR,White JM. Potential
hazard of methylene blue.Anaesthesia 1979;
34:18182
467
Harish et al.,
DOI: 10.5958/j.2319-5886.3.2.097

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ISSN: 2319-5886
Case report
SIGNET RING CELL ADENOCARCINOMA IN A URACHAL CYST-A RARE CASE

*KalpanaKumari MK1, Nagaraj HK2, Sulata Kamath3, Rashmi K4,Vijaya V Mysorekar
1
Associate Professor,3Professor, 4Assistant Professor, 5Senior Professor,Department of Pathology, M.S.Ramaiah

Medical College and Teaching Hospital, Bangalore, India
2
Senior Professor, Department of Urology, M.S. Ramaiah Medical College and Teaching Hospital, Bangalore, India
*Corresponding Author email:kalpank@gmail.com
ABSTRACT
Adenocarcinoma arising in anurachal cyst is extremely rare. This paper describes a patient who came with chief
complaints of hematuria, was treated with partial cystectomy for urachal cyst, and the pathologic examination
revealed urachal adenocarcinoma of signet ring cell type in the urachal cyst.
Keywords: Urachus, adenocarcinoma, signet ring cells
INTRODUCTION
The urachus is a remnant of the primitive bladder
dome and extends from the anterior dome of bladder
towards the umbilicus. It exists as vestigial part of the
two embryonic structures, the cloaca, from urogenital
sinus and allantois, which is derivative of yolk sac 1.
Many anomalies of the urachus remnants have been
reported like urachal cyst, urachal fistula, umbilical
urachal sinus, vesicourachal diverticulum and very
rarely adenocarcinoma of urachus.2.We hereby report a
case of signet ring cell adenocarcinoma in aurachal
cyst with fewer than 300 cases reported in literature.
CASE REPORT
A 57yrs old female patient was admitted in November
2013with chief complaints of hematuria and clots
since 20 days. There was no evidence of abdominal
pain or distension. Laboratory investigations revealed
normal renal function tests and serum electrolytes.
Urine cytology was normal. The patient underwent
ultrasound
scan
which
suggested
complex
diverticulum and raised a doubt of urachal cyst. On CT
scan a complex cystic lesion was noted anterior to the
dome of bladder with thin lateral septations and foci of

calcification. The diagnosis was confirmed by
cystoscopy and partial cystectomy with resection of
urachal cyst and umbilicus. The gross examination
revealed a single globular cystic mass with an attached
flap of urinary bladder with fragment of skin covered
tissue (umbilicus).There was no communication seen
between the bladder and the attached cystic mass. Cut
section showed multiloculated cyst filled by gelatinous
material (Fig l). Microscopic studies showed
malignant epithelial tumour withtumour cellsarranged
in glandular pattern, lakes of mucin and signet ring
cells (Fig2). The tumour was confined to urachal cyst
with surgical margins free from tumour. Clinically and
histopatholgically the disease was proposed as stage II.
Chest x ray andultrasound scan did not reveal any
evidence of distant metastasis. Postoperative period
was uneventful and tumour markers such as CEA and
CA19 levels were normal.
468
Kalpana et al.,
Fig 1: Urachal cyst filled with gelatinous material
Fig 2: Signet ring cells floating in mucinous lake
DISCUSSION
Urachal cyst is also known as a median umbilical
ligament. Urachal cysts are sequale of remnants of
vestigial structure connecting allantois to the bladder
apex. Urachal adenocarcinoma is extremely rare.
Adenocarcinomatous change in such cystic remnants
accounts for 0.17-0.34% of bladder cancers3and 2030%
of
primary
adenocarcinoma
of
the
4
bladder. Seventy five percent of the urachal
adenocarcinomas are seen in men.4 In our case it was a
female patient aged 57 yrs. These cases have been
reported in patients aged 4months to more than 80yrs4.
Common symptoms are irrita tive voiding, discharge
of mucous like material and gross hematuria. In our
case patient came with chief complaints of hematuria
with blood clots. Urachal adenocarcinomas have poor
prognosis when compared to bladder cancer because
the lesion arises outside the bladder, where it does not
cause any symptoms.5
Gore et al 6 described the clinicopathological criteria to
distinguish urachal adenocarcinoma from bladder
cancer or metastasis:
1) Sharp demarcation between tumour and intact
urothelium.
2) Cystitis cystica or glandularis is absent.

3) Growth in the bladder with extension to bladder
dome or anterior wall.
Urachal malignant epithelial tumours have a glandular
pattern, but Paner. GP et al7 have described urachal
carcinoma of the nonglandular type in their study with
rare histologic types as squamous cell and other
carcinomas. However the criteria for diagnosing
urachal adenocarcinoma cannot be applied to non
glandular tumours.
Urachaladenocarcinomas
have
several
morphologicalpatterns, including enteric, mucinous,
signet ring cell types and not otherwise specified, the
clinical significance of these morphological types are
not known. Bissonnetteetal8 have suggested larger
studies, to know the clinical implications of the
different morphological types of urachal carcinoma.
Several staging systems are proposed. The most
commonly used ones are Sheldon and the Mayo
staging system .Sheldon staging is as follows Stage Ino invasion beyond the urachal mucosa; Stage IIinvasion confined to the urachus; StageIII- local
extension to the bladder, abdominal wall, and viscera
other than the bladder; and Stage IV- metastasis to
regional lymph nodes and distant sites. The Mayo and
Sheldon staging systems were highly correlated (p
value<.001) in a study done by Ashley et al 5.
Pigay F et al stated that these tumors can recur and
most commonly metastasize to lymphnodes,
retroperitoneum lungs, liver and bone.9
Ceylan et al 10 concluded in their study that the roles of
radiotherapy and chemotherapy in the treatment of
urachal carcinoma are not clear. Usually, patients with
nodal involvement, positive surgical margin and
metastasis are treated with adjuvant chemotherapy.
CONCLUSION
Signet ring cell adenocarcinoma of urachal cyst is
extremely rare. These tumors have worst prognosis
because of late presentation. The 5 yr survival depends
mainly on the clearance of surgical margins.
Source(s) of support: NIL
Conflicting Interest: NIL
469
Kalpana et al.,
REFERENCES
1. Choi YJ, Kim JM, Ahn SY, Oh JT, Han SW, Lee
JS.Urachal anomalies in children: a single centre
experience.Yonsei Med J2006;31:47:782-86
2. NimmonratA, Na ChiangMai W, Muttarak M.
Urachalabnormalities: clinical and imaging
features. Singapore Med J2008 ;49:930-35
3. Khalid
K,
Ahmed
MS,
Malik
MS.
Adenocarcinoma of urachal cyst associated with
pseudomyxomaperitonei
masquerading
as
abdominal tuberculosis: A case report and review
of literature. Indian J Urol. 2008; 24: 25860
4. KorishettiSI, InamadarAC, Patil SB, PatilGS. Case
report: Ultrasound demonstration of urachal cyst
cancer - a rare case. Indian J radiol and
imaging2006;16: 883-84
5. Ashley RA, Inman BA, Sebo TJ, Leibovich BC,
Blute ML, Kwon ED,etal. Urachal carcinoma:
clinicopathologic features and long-term outcomes
of an aggressive malignancy. Cancer.2006;
107:712-20
6. Gore DM, Bloch S, Waller W, Cohen P. Peritoneal
mucinous cystadenocarcinoma of probable urachal
origin: a challenging diagnosis. J ClinPathol2006;
59:1091-93
7. Paner GP, Barkan GA, Mehta V, Sirintrapun SJ,
Tsuzuki T, Sebo TJ etal. Urachal carcinomas of
the nonglandular type: salient features and
considerations in pathologic diagnosis. Am J
SurgPathol 2012; 36:432-42
8. Bissonnette ML, Kocherginsky M, Tretiakova M,
Jimenez RE, Barkan GA, Mehta Vetal.The
different morphologies of urachal adenocarcinoma
do not discriminate genomically by micro-RNA
expression profiling. Hum Pathol2013; 44:160511.
9. Pigay F, Mornex JF. Combined modalities
treatment of pulmonary metastasis from an
urachaladenocarcinoma. Rare Tumors. 2013; 20:
5:e32
10. Ceylan C, Baytok. O, Keklik TT, Doluoglu OG.
Urachal Cancer in a 47-Year-Old Patient:A Case
Report and Literature Review. Br J Med Med
Res 2012 ;2: 693-700
470
Kalpana et al.,
DOI: 10.5958/j.2319-5886.3.2.098

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www.ijmrhs.com
Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Case report
MUCOEPIDERMOID CARCINOMA OF EYELID - AN UNUSUAL SITE: A CASE REPORT

*Hemalatha AL1, Sadaf Bashir2, Ashok KP2, Amitha K3, Vijay Shankar S3
1
Professor, 2PG Student, 3Associate Professor, Department of Pathology, Adichuncahanagiri Institute of

Medical Sciences, BG Nagara, Karnataka, India
*Corresponding author email: halingappa@gmail.com
ABSTRACT
Mucoepidermoid carcinoma is predominantly a malignancy of the major salivary glands (10-30%) and minor
salivary glands (15%).These tumours are also reported in lacrimal glands, conjunctiva, and nasopharynx, though
rarely. The average age at presentation is between 20 to 60 years with a female preponderance. Owing to the
rarity, it mandates an early diagnosis to facilitate appropriate patient management. This case report highlights the
unusual occurrence of primary mucoepidermoid carcinoma of the eyelid in a 33 year old male patient.
Keywords: Mucoepidermoid carcinoma, Eyelid, Low grade
INTRODUCTION
Mucoepidermoid carcinoma is a tumour composed of
neoplastic mucin producing cells and epidermoid
cells. This tumour predominantly involves salivary
glands, but literature provides evidence of its
occurrence in the conjunctiva, lacrimal glands and
nasopharynx.1 Eyelid is a specialised tissue consisting
of epidermis, dermis, sebaceous glands and sweat
glands. Malignant tumours arising from the eyelid are
rare. Basal cell carcinoma and squamous cell
carcinoma are the most common malignant tumours
arising from the eyelid.3But mucoepidermoid
carcinoma of the eyelid is a rarely encountered
malignancy.
CASE REPORT
A 33 year old male patient presented with a swelling
over the left upper eyelid which was present since
two years. There was no history of pain.
Local examination revealed a solitary, irregular, nontender, indurated nodule over the left upper eyelid,
measuring 2 2 mm. It showed restricted mobility in
all directions. There was no surface ulceration. The
borders were ill-defined. A clinical diagnosis of

hidradenoma was offered by the clinician. The patient
underwent triangular excision and the resected
specimen was submitted for histopathological
examination.
Microscopic examination: The overlying stratified
squamous epithelium was thinned out. The
subepithelium showed a well- circumscribed tumour,
which was seen to arise from the epithelium at one
focus. (Figure 1) The tumour was composed of
pleomorphic cells arranged in sheets, clusters and
tubulo-glandular patterns. (Figure2) The individual
cells were predominantly squamoid in nature and
were interspersed with mucin secreting cells. (Figure
3) The glands were lined by flat cuboidal epithelium
which exhibited focal snouting. (Figure 4) Also seen
were intra-glandular mucin and focal islands of
mucin within the stroma. (Figure 5)
With these findings, a histopathologic diagnosis of a
low grade muco-epidermoid carcinoma (MEC) was
arrived at.
471
Hemalatha et al.,
Fig 1: Section from the tumour depicting the origin

from the epithelium at one focus. (H&E,40)
Fig 5: Section from the tumour intra-glandular mucin

and focal islands of mucin within the stroma.
(H&E,400)
DISCUSSION
Fig 2: Section from the tumour depicting the squamoid

component. ( H&E,400)
Fig 3: Section from the tumour showing squamoid

tumour cells with interspersed mucin secreting cells.
(H&E,400)
Fig 4: Section from the tumour showing glandular

component with cells exhibiting focal snouting.
(H&E,400)
Though the salivary gland is the commonest site of

occurrence for mucoepidermoid carcinoma (MEC), it
has occasionally been reported in the upper
respiratory tract, oesophagus, nasal mucosa, maxilla,
mandible, liver, cervix, penis and the anus.2 But,
ocular involvement by this tumour has rarely been
reported. Clinically, the tumour can present as a
plaque like lesion, papillomatous or a pedunculated
nodule.3 In contrast, the tumour in the present case,
presented as a sessile, painless nodule. Intra-ocular
extension has been reported in a few cases.4A detailed
examination excluded intra-ocular extension of the
tumour in this case.
The eyelid is a specialized tissue, which is covered
by epidermis and dermis with hair follicles,
sebaceous glands and sweat glands. The interior layer
of the eyelid is a mucous membrane containing
scattered mucin secreting goblet cells.5 Therefore,
any tumour arising from the eyelid can show
differentiation towards mucin secreting cells as well
as squamous cells. This can eventually give rise to a
mixed pattern within the tumour, as seen in this case
of ocular MEC.3
The tumour may be graded based on the three-grade
scheme point system as proposed by Armed Forces
institute of Pathology6as, 2 points for intra-cystic
component greater than 20%-, 2 points for neural
invasion, 3 points for necrosis, 3 points for four or
more mitoses per 10 HPF and 4 points for anaplasia.
The total score is calculated to grade the tumour.5
Low grade tumours have a score between 04.intermediate grade tumours have a score between 5
-6 and higher grade tumours have a score of 7 or
more.6
472
Hemalatha et al.,
Based on the above mentioned grading scores, the

tumour in the present case was graded as a low- grade
tumour.
Various studies have reported 98% survival rate for
patients with low grade MEC and 42% for those with
high grade tumours.
CONCLUSION
MEC of eyelid mandates an early recognition since
the chances of missing it are high owing to its rarity.
REFERENCES
1. Blake J, Mullaney J, Gillan J. Lacrimal sac
mucoepidermoid carcinoma. British Journal of
ophthalmology. 1986;70:681-85
2. Hemalatha AL, Sharath Kumar HK, Geetanjali S,
Giripunja M, Shashikumar S D. Nasopharyngeal
mucoepidermoid carcinoma-A common entity at
an uncommon location. Journal of Clinical and
Diagnostic Research. 2014;8(1):164-165
3. Jyothirmay
B,
Manoj
D,
Nirmala
S.Mucoepidermoid carcinoma of the lower lidreport of a case. Indian Journal of
ophthalmology.1996;44(4):231-33
4. Brownstein S. Mucoepidermoid carcinoma of the
conjunctiva
with
intraocular
invasion.
Ophthalmology. 1981;88:1226-30
5. Victor P Eroschenko. di Fiores-Atlas of
histopathology with functional correlations. 12th
edition.
6. Juan Rosai MD. Rosai and Ackerman Surgical
Pathology. 10th edition;26(2):247.
473
Hemalatha et al.,
DOI: 10.5958/j.2319-5886.3.2.099

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Health Sciences
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Coden: IJMRHS
st
Revised:10th Feb 2014
Copyright @2014
ISSN: 2319-5886
Case report
ANAESTETIC MANAGEMENT OF CAESAREAN SECTION FOR CONJOINT-TWINS: A CASE

REPORT
*Deogaonkar Shrikrishna G1, Aditya Prakash2
1
Associate Professor, 2Resident, Dept. of Anaesthesiology and Critical Care, Rural Medical College, Pravara
Institute of Medical Sciences (DU), Loni, Ahmednagar, Maharashtra.
*Corresponding author email: deogaonkarshrikrishna@gmail.com
ABSTRACT
At Pravara Rural Hospital a 29 year old patient was admitted for delivery. Patient had conjoint-twins diagnosed
after sonography and was posted for elective caesarean section. Patient was managed under general anaesthesia
after thorough preparation and under multi-disciplinary involvement. Both the twins females were living and were
further managed by neonatologists. Though conjoint-twins are rare and patients coming for delivery with
conjoint-twins are still rarer because of early diagnosis and termination, anaesthesiologists working in developing
countries and working in remote areas may face such patients. There are very few publications for management of
delivery in such patients, hence this case report.
Keywords: Conjoint-twins; Ceaserian section; General anaesthesia

INTRODUCTION
Conjoint-twins as human malformation have

been documented as early as 1100 from England
and later from African countries1. Most popular
have been the Siamese-twins in years 1811 to
18741. Today, with the advent and routine use of
prenatal diagnostic techniques such as
sonography, these cases are diagnosed early and
subsequently termination of pregnancy is done
routinely. History though, tells about the
existence of conjoint-twins, there is limited
knowledge about the mode and method of
delivery, as well as care of the mother and fetus
at the time of and after the delivery.
There are not much literature regarding delivery
of conjoined twins, normally or by caesarean
section, and hence managing such patients is a
challenge. There is some literature available
regarding anaesthesia for separation of conjoined

twins, but regarding anaesthesia for caesarean
section literature is minimal.1 Even today a day
comes when Obstetrician and Anaesthesiologist
may face such a patient. We have managed such
patient at a Rural Hospital.
So we thought to report a case of conjoined
twins, being managed for caesarean section at
Rural Medical College, Loni, Ahmednagar,
Maharashtra State
CASE REPORT
A female aged 29 years was admitted for delivery on
7th May 2013 at Pravara Rural Hospital, Loni with 9
months of amenorrhea (34 weeks), History of- one
Full Term Normal Delivery, home delivery and then
one 4 months spontaneous abortion. Patient had no
474
Deogaonkar etal.,
other medical problem. Patient was investigated for

routine examinations of blood and urine. Hb 11.2gm% and Blood group was O Positive
USG showed appearance of conjoined twins joined
mainly in area of Thorax and Abdomen, single heart
and polyhydramnios.
Patient was planned for caesarean section on 16th
May 2013.
During pre-operative check-up patient was
thoroughly examined with special considerations on
a) Respiratory physiology, which may be disturbed
due to over distended abdomen.
b) Cardio-vascular system for congenital or acquired
changes secondary to over distension and/ or
overload.
c) Anxiousness and reactions after knowing about the
condition of the fetus.
Routine as well as special investigations like Liver
Function tests (LFTs), Renal function tests (RFTs),
Sonography were studied. LFT and RFTs were within
normal limits. Fetal condition was judged with Fetal
Heart Sounds (FHS) & Fetoscopy.
Pravara Rural Hospital being a Medical College
Hospital, all concerned specialties like additional
team of Obstetricians, General surgeon, two teams of
Neonatologists, and an additional team of
anaesthesiologist were ready at the time of surgery.
Adequate amount of blood was kept ready.
General Anaesthesia had been the choice of attending
Anaesthesiologist. Premedication inj. Fentanyl 20g
was given and patient was shifted to OT.
After preoxygenation with 100% O2 for 5 minutes,
patient was induced with Thiopentone (Sodium
thiopental) 250 mg and Scoline (Suxamethonium
chloride) 100 mg. Intubated with cuffed ETT no.8
and ventilated with O2:N2O and Isoflurane with
assisted ventilation. There had been difficulty while
delivering baby and inverted T incision was taken
which eased delivery of Conjoint-twins. Once the
baby was delivered Pitocin 10 units added to drip.
Additional inj. Ergometrine was given to facilitate
contraction of uterus. Twins, Thoracophagus were
handed to Neonatologist for further management as
both were living and with APGAR score2 at 1, 5 and
10 minutes respectively4,5&6.
Patient was
maintained on Nitrous Oxide Oxygen, Isoflurane
and Vecuronium with controlled ventilation. All vital
parameters remained in the normal range during the
procedure. At the end of surgery patient was reversed
Deogaonkar etal.,
with inj. Neostigmine and Glycopyrolate. Recovery

was uneventful. The total surgery took 45 minutes.
The twins delivered were well resuscitated by
concerned pediatricians both females with APGAR
score 4,5,6.
Post surgery patient was haemodynamically stable
with pulse 82/ min and BP 132/82 mm of Hg.
DISCUSSION
The issue of Conjoined twins has always been
looking at from various angles as like religious,
cultural and legal angles. The worldwide incidence of
conjoined twins ranges from 1 in 50,000 to 1 in
200,000, more in Africa & South West Asia. Large
number of infants die, either in utero (28%) or
immediately after birth (54%), only around 20%
survive.3
With advent of newer diagnostic tools like
Sonography, it is possible to diagnose conjoined
twins as early as 9-12 wks of gestation4 and if
diagnosed it is advised to get it terminated to avoid
maternal and social trauma to patient. Confirmation
can be done with echocardiography and fetal MRI.1
Two types of conjoined twins are describedsymmetrical & asymmetrical. Some researchers also
classified it on the basis of site of union like
Craniophagus, Thoracophagus etc.
In Rural areas where USG facility is not available or
due to illiteracy and ignorance of importance of ANC
check- up, patients come at later stages of pregnancy.
If parturient attends hospital after 32 weeks of
pregnancy termination is not possible and attending
obstetrician has to decide about mode of delivery.
Usually planned caesarean section delivery is
preffered.3
Even with all precautions and expertise available, the
rate of stillbirth is very high. Similarly, high maternal
mortality during labour is also reported.4
475
Once planned ceaserian section delivery is decided

Anaesthesiologist comes in picture. He has to
examine patient, see for all investigations done and
decide for safe technique of anaesthesia for both
mother and twins. It is to be considered only in the
Institute where a team of medical professionals with
expertise in related specialties is available.
Choice of Anaesthesia: For caesarean section patient
can be managed by Nuraxial anaesthesia5 or with
General Anaesthesia.6 But as described by Drake et al
when giving nuraxial anaesthesia one should be
always ready to support with General anaesthesia.
We preferred General Anaesthesia because of
following reasons: anxiousness of patient,
overdistended abdomen, likely hood of extension of
uterine incision, chances of atonicity of uterus and
easy to manage complications, if occurs.
Thorough preoperative visit for routine as well as
specific problems like lung function changes due to
over distended abdomen and haemodynamic changes
were taken care of.
Induction had been routine with Thiopentone &
suxamethonium with Endotracheal Tube (ETT) and
assisted ventilation till delivery of twins .There was
no extension of uterine incision. Tone of uterus was
also maintained with Pitocin 10 units/500ml drip and
methyl ergometrine.
Once delivered, the conjoined twins were handed
over to pediatricians & both twins with
Thoracophagus have been living and needed marginal
resuscitation. Both were females with an APGAR
score at 1, 5 and 10 minutes of 4,5,6 respectively.
Furuya et al has mentioned that survival of fetus after
caesarean section is rare and most of the times twins
were still born.6 But in our case both conjoined twins
were living & with good prospectus of survival.
Mother also had an uneventful recovery.
during surgery and atonicity of uterus, and may

sometimes need further emergency management.
REFERENCES
1. Cheryl D. Norris, BS, Harris J. Finberg, William
Peoples, Mary L. Nielsen, George R. Tiller.
Twins
conjoined,
thoraco-omphalopagus.
www.thefetus.net
1994-08-1211. http://sonoworld.com/The
Fetus/page.aspx?id=315
2. Apgar, Virginia.The Newborn (Apgar) Scoring
System: Reflections and Advice. Pediatric clinics
of North America. 1966;13: 64550.
3. Khalid kamal. Conjoined Twins Treatment &
Management.
http://emedicine.medscape.com/
article/934680-treatment#a1132
4. Alastair JW, Millar, Heinz Rode, Jenny Thomas,
John Hewitson. Thoracophagus Conjoined twins.
Pediatric Thoracic Surgery 9th ed: Springer
Publications 2009;557-69
5. Drake E, Burym C, Money D, Pugash D, Gunka
V. Anaesthetic management of a craniopagus
conjoined twin delivery. Int J Obstet Anesth.
2008;17(2):174-76
6. Furuya A, Okawa I, Matsukawa T, Kumazawa T.
Anesthetic management of cesarean section for
conjoined twins. Masui 1999;48(2):195-7
CONCLUSION
Though rare, an anaesthetist may have to manage a
case of delivery of conjoint twins any day. Such
patients should be managed at an institute level where
multidisciplinary specialists and facilities are
available. Anaesthesiologist should also be prepared
for associated complications which may due to over
distended abdomen, increased chances of bleeding
476
Deogaonkar etal.,
DOI: 10.5958/j.2319-5886.3.2.100

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Accepted: 23rd Feb 2014
Case report
LEPTOSPIROSIS COMPLICATED WITH MENINGOENCEPHALITIS AND PANCREATITIS - A

CASE REPORT
*Sumantro Mondal1, Tony Ete1, Debanjali Sinha1, Soumik Sarkar1, Atanu Chakraborty1, Arijit Nag1, Jyotirmoy
Pal2, Alakendu Ghosh3
1
Post graduate trainee, 2Associate Professor, 3Professor, Department of Medicine, Institute of Post Graduate
Medical Education And Research, Kolkata, India
*Corresponding author email: drmsumantro@gmail.com
ABSTRACT
In severe leptospirosis multi organ involvement is common. Pancreatitis and meningo encephalitis are two
uncommon manifestations of leptospirosis. Our patient presented with fever, jaundice, altered sensorium and
subsequently developed severe pain abdomen. He was finally diagnosed as having icteic leptospirosis
complicated with pancreatitis and meningoencephalitis. Simultaneous presence of these two complications in a
patient of leptospirosis probably not been documented before.
Key words: Leptospirosis, Pancreatitis, Meningo encephalitis.
INTRODUCTION
Leptospirosis is a zoonosis, and is considered as a
major public health problem. The clinical phenotypes
of leptospirosis are diverse, ranging from mild, flulike illness to a severe disease form known as Weils
syndrome. Severe disease is characterized by hepatic,
renal and pulmonary involvement, which can lead to
death. The disease may also present with some
uncommon manifestations. Ascending progressive
leg weakness, acalculous cholecystitis, hemorrhagic
pneumonitis have been documented as atypical
manifestations
of
leptospirosis
in
various
literatures.1,2,3 Pancreatitis and meningoencephalitis
are uncommon manifestations of leptospirosis. There
are few case reports concerning leptospirosis
complicated
with
either
pancreatitis
or
meningoencephalitis. However presence of both
pancreatitis and meningoencephalitis in a patient of
leptospirosis is extremely rare. The case reported
herein describes the concomitant presence of
pancreatitis and meningoencephalitis in a patient of

complicated leptospirosis.
CASE REPORT
A 32 year male, admitted with a history of moderate
grade, intermittent fever for 10 days associated with
mild cough. Fever was associated with redness of
eyes and pain in muscles, especially calf regions. The
patient developed yellowish discolouration of sclera 3
days prior to admission, repeated vomiting,
drowsiness and diminution of urine volume since last
1 day. On the day of admission the patient developed
intense pain in his upper abdomen. There was no
history of any rash or convulsion. Examination
revealed a confused patient (Glasgow coma scale:
11), severe pallor, icterus, neck rigidity, positive
kernigs sign, pulse rate 114/minute and a blood
pressure of 112/74 mm of Hg. Abdominal
examination was inconclusive apart from sluggish
peristaltic sound and hepatic enlargement. Other
477
Sumantro et al.,
systems were normal. Routine blood investigations

showed anemia (Hb 9.4GM/dl) with leucocytosis
(15600/ cu.mm.) with neutrophilic predominance.
Liver function was dearranged with a total bilirubin
11.7 mg/dl (conjugated 7.6 and unconjugated 4.1
mg/dl), SGOT 168 IU/L and SGPT 71 IU/L.
Prothrombin time was normal. Serum urea 110 mg/dl,
creatinine 4.1 mg/dl. CSF study showed cell count
36/cu.mm (70% lymphocyte), protein 76 mg/dl and
sugar 48 mg/dl. CSF for Herpes simplex virus (HSV)
and arbovirus were negative. Serum amylase (750
U/L) and lipase (3720 U/L) were elevated. CT scan of
abdomen showed bulky pancreas with peri pancreatic
fat stranding, suggestive of acute pancreatitis (Figure
1). Test for malaria parasite, vivax and falciperum
antigen and IgM antibody for dengue were also
negative. As there was a high index of suspicion of
leptospirosis in this clinical setting serum Creatine
phosphokinase (CPK) was sent and the value was 968
U/L (normal: 52-336 U/L). Later on leptospirosis was
confirmed by a positive IgM anti leptospira antibody.
The patient was treated with injection Ceftriaxone (1
GM/day i.v BD) and showed good clinical
improvement over next 10 days. Follow up after 1
month showed normalization of liver function test
parameters, CPK value with a normal CT scan of
abdomen.
Fig 1: CT scan of abdomen at the level of pancreas

showing bulky pancreas with mild peri pancreatic fat
stranding suggestive of acute pancreatitis.
DISCUSSION
Leptospirosis is a zoonoses and this disease entity is
frequently found in India. The first recognized
leptospiral disease was described by Weil in 1886.
Causative agent of Weils disease was isolated in
1915 and named Leptospira icterohaemorrhagiae.
Leptospirosis has two clinically recognizable
phenotype the anicteric leptospirosis (80-90% of all

cases) and icteric leptospirosis.
Apart from hepatic and renal involvement, various
other organs are frequently affected in leptospirosis.
Pancreatitis is an unusual manifestation of
leptospirosis affecting approximately 25% of patients.
There are some case reports regarding pancreatitis in
leptospirosis.4,5 In our patient pancreatitis was
confirmed by both laboratory investigation and
imaging and there was no other common cause of
pancreatitis like gall stone, alcoholism or drug intake.
Though the exact mechanism of acute pancreatitis in
leptospirosis has not been clearly established,
vasculitis of small vessels with ischemic injury
leading to activation of proteolytic enzymes and
pancreatic auto-digestion is the possible mechanism.6
Features of meningo encephalitis, as seen in our
patient are also uncommon in leptospirosis. Currently
there are not enough published data about
neurological features in Leptospirosis. In one study it
was found that only 5.9% patient can present with
signs of meningism. 7 Another prospective study
conducted in France among 62 cases of leptospirosis
meningo encephalitis was documented in only 2
patients, signifying rarity of this feature. 8 In a study
by Matiash VI, et al. on 120 patients with fatal
icterohemorrhagic leptospirosis, neurotoxicosis was
evident in almost all patients along with
microcirculatory disturbances. Meningitis was found
in 29.2%, meningoencephalitis in 5% of patients.
Morphologic studies showed that focal serous
meningitides and meningoencephalitides were
significantly more common that they are diagnosed in
clinical settings. They tend to develop during the
second and third weeks of the course of the illness.9
Seizures and altered sensorium are most common
neurological manifestation of leptospirosis.10
Alteration of sensorium and signs of meningeal
irritation were present in our patient along with
lymphocytic pleocytosis in CSF study, establishing a
diagnosis of meningoencephalitis.
Concomitant presence of encephalitis and pancreatitis
in a patient with leptospirosis is very rare and
probably not reported before. It should be emphasized
that neuroleptospirosis is an important differential
diagnosis of cerebral malaria, dengue and other viral
encephalitis, especially in the Indian subcontinent.
478
Sumantro et al.,
REFERENCES
1. Silva AP, Burg LB, Locatelli JF, Manes J,
Crispim M. Leptospirosis presenting as ascending
progressive leg weakness and complicating with
acute pancreatitis. Braz J Infect Dis. 2011; 15(5):
493-97
2. Peter G, Narasimha H. Acalculous cholecystitis:
a rare presentation ofleptospirosis progressing to
Weil's disease. Asian Pac J Trop Med.
2011;4(12):1007-08
3. Pai
ND,
Adhikari
PM.
Haemorrhagic
pneumonitis: A rare presentation of leptospirosis.
J Postgrad Med. 2001;47(1):35-36
4. Baburaj P, Antony T, Louis F, Harikrishnan BL.
Acute abdomen due to acute pancreatitis--a rare
presentation of leptospirosis. J Assoc Physicians
India. 2008; 56:911-12
5. Kaya E, Dervisoglu A, Eroglu C, Polat C, Sunbul
M, Ozkan K. Acute pancreatitiscaused by
leptospirosis: report of two cases. World J
Gastroenterol. 2005; 11(28):4447-49
6. A Desai, D Hattanga. Leptospirosis As A Rare
Cause Of Acute Pancreatitis. The internet journal
of surgery. 2008;20(1):DOI
7. Datta S, Sarkar RN, Biswas A, Mitra S.
Leptospirosis: an institutional experience. J
Indian Med Assoc. 2011; 109(10):737-78
8. Abgueguen P, Delbos V, Blanvillain J,
Chennebault JM, Cottin J, Fanello S, et al.
Clinical aspects and prognostic factors of
leptospirosis in adults. Retrospective study in
France. J Infect. 2008;57(3):171-78
9. Matiash VI, Anisimova IuN. The clinicomorphological characteristics of the nervous
system lesions in icterohemorrhagic leptospirosis.
Lik Sprava. 1997;( 3):94-99
10. Mathew T, Satishchandra P, Mahadevan A,
Nagarathna S, Yasha TC, Chandramukhi A, et al.
Neuroleptospirosis-revisited: experience from a
tertiary care neurological centre from south India.
Indian J Med Res 2006; 124: 155-62.
479
Sumantro et al.,
DOI: 10.5958/j.2319-5886.3.2.101

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Health Sciences
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th
Copyright @2014
ISSN: 2319-5886
Case report
GASTROSCHISIS: RECENT TRENDS, EMBRYOLOGY, MATERNAL AND INFANT RISK FACTORS

*Shivaleela C1, Vinay kumar K1, Suresh NM2
1
Assistant Professor, 2Professor, Department of Anatomy, Sri Siddhartha Medical College, Tumkur, Karnataka,
India
*Corresponding author email: drshivaleela83@yahoo.co.in
ABSTRACT
The term gastroschisis is derived from the Greek word laproschisis, meaning bellycleft. It was used in the 19th
and early 20th centuries by teratologists to designate all abdominal wall defects. Gastroschisis occurs in
approximately 1 in 2,300 live births, and mortality for gastroschisis may approach 10 percent. Several maternal
risk factors suspected to be associated with gastroschisis have been investigated, and there is a consistent
association with young maternal age. The association of low birth weight also could be attributed to the fact that
data demonstrate that the birth weights of babies with gastroschisis are significantly lower than those of the
general population and are similar in different populations. Recently, Stevenson et al. proposed that gastroschisis
is caused by the failure of the sac and yolk duct, as well as of the vitelline vessels, to initially incorporate to the
allantois and later to the body stem. The specific role of the genetic component in the etiology of gastroschisis is
unclear. Although there are reports of familial cases, gastroschisis occurs mostly as a sporadic event. It was
observed that 4.7% of cases have at least one affected relative and the risk of recurrence is 3.5% among siblings.
Definitive treatment is surgical. The timing and technique for surgical closure depends on the degree of intestinal
inflammation, size of the defect and the newborns general condition. In general, the prognosis is good with a
survival 90%, but in developing countries the risk of death may be as high as 60%.
Keywords: Gastroschisis, Yolk duct, Vitelline vessels
INTRODUCTION
The term gastroschisis is derived from the Greek
word laproschisis, meaning bellycleft. It was used
in the 19th and early 20th centuries by teratologists to
designate all abdominal wall defects.
Gastroschisis is a congenital defect of the abdominal
wall in which the babys intestines, and sometimes
other abdominal organs, protrude from the belly
through a small hole. Gastroschisis occurs in
approximately 1 in 2,300 live births1, and mortality
for gastroschisis may approach 10 percent. Rates of
gastroschisis have been increasing in many developed
and developing countries with no tenable explanation
or specific known causes for this trend. In 1994, the
prevalence rate was 2.78 per 10,000 live births, and

increased to 3.54 per 10,000 live births in 2011. Rates
of gastroschisis are particularly high among younger
mothers, including teen moms.
In most cases gastroschisis is an isolated birth defect;
however, it also can be associated with other defects,
particularly those with possible vascular mechanisms
of origin. Reported overall incidence of concurrent
anomalies is 7 to 30 percent, which may include
anencephaly, cleft lip and palate, ectopia cordis, atrial
septal defect, diaphragmatic hernia, scoliosis,
syndactyly and amniotic band syndrome. Although
480
Shivaleela et al.,
these anomalies are not related directly to the

gastroschisis defect, they contribute to the morbidity.2
CASE REPORT
A term male baby was delivered by emergency
cesarean section to a 24yr old primigravida mother
due to fetal distress. Mother did not had regular
antenatal check ups and was not a registered case.
Birth weight was 2.6 kgs. Baby had severe respiratory
distress at the time of birth and gradually deteriorated
and did not respond to the resuscitatory measures and
succumbed about one hour after birth (figure -1). On
examination baby had right sided anterior abdominal
wall defect measuring about 3.5 x 4 cm. There was
evisceration of stomach, small and large bowel loops
which were thickened and edematous. No membrane
was covering the eviscerated bowel loops. The
umbilical cord had two arteries and one vein. No
other obvious external congenital anomalies were
detected.
Fig1: Male baby born with gastroschisis.
Table 1: Risk factors associated with Gastroschisis

Parental occupation (eg, printer/computer
manufacturing factories)
Young maternal age
Hispanic race
Poor maternal education
Low socioeconomic status
Lack of prenatal care
Nulliparity
More than one elective abortion
Table 2: Potential Teratogens associated with

Gastroschisis
Organic chemicals/solvents
Cyclooxygenase inhibitors (Aspirin, Ibuprofen)
Decongestants
Acetaminophen
Oral contraceptives
Maternal smoking
Alcohol
Illicit drugs (cocaine, amphetamine)
X-ray irradiation in early pregnancy
DISCUSSION
Several maternal risk factors (Table -1 & 2) suspected
to be associated with gastroschisis have been
investigated, and there is a consistent association with
young maternal age (< 20 years of age). Torfs et al.
reported a tenfold increased risk of gastroschisis
occurrence where maternal age was between 15 and
19 years of age. Body mass index (BMI) and nutrient
deficiencies in maternal dietary intake also are being
considered as possible risk factors for gastroschisis.3
Low alpha-carotene and low total glutathione and
high nitrosamine intake during the trimester prior to
conception have been associated with gastroschisis.
This led to the hypothesis that younger age of
mothers may lead to maternal fetal competition for
nutrients with the result being maternal dietary
inadequacy. 3, 4 Lam et al. found a higher risk of
gastroschisis for underweight mothers and a lower
risk for overweight mothers, and the California Birth
Defects Monitoring Program revealed that
underweight young mothers who presented with a
Body Mass Index less than 18.1 had a greater risk of
having a child with gastroschisis.5 The association of
low birth weight also could be attributed to the fact
that data demonstrate that the birth weights of babies
with gastroschisis are significantly lower than those
of the general population and are similar in different
populations. These findings support the notion that a
normally functioning intestinal tract is essential for
normal fetal growth.6
Short interval between menarche and first Pregnancy
Chorionic villus sampling

Residence surrounding landfill sites
Maternal diet (low alpha-carotene, low total
glutathione, high nitrosamines)
Low pregnancy body mass index
481
Shivaleela et al.,
Table 3: Theories
Gastroschisis
Author
Duhamel7 (1963)
Shaw 8 (1975)
DeVries 9 (1980)
Van Allen10
(1981)
11
Hoyme (1983)
Regarding
Embryogenesis
of
Theory
Teratogenic insult resulting in
defective differentiation of
the somatopleural
mesenchyme
Rupture of a hernia of the
umbilical cord at the site of
involution of the right
umbilical vein
Abnormal right umbilical
vein atrophy resulting in
weakness and defect of
abdominal wall, with failure
of epidermal differentiation
Vascular disruption theory
Omphalomesenteric artery
insult with disruption of
umbilical ring
Over the years, various authors proposed different

hypotheses for the development of gastroschisis
(Table -3). Recently, Stevenson et al. proposed that
gastroschisis is caused by the failure of the sac and
yolk duct, as well as of the vitelline vessels, to
initially incorporate to the allantois and later to the
body stem. It has been determined that there is a
second perforation in the abdominal wall, as well as
that of the umbilical ring, through which the midpoint
of the intestine (Meckel point) is connected to the
externalized vitelline structures. These are attached to
the bowel abnormally, separating it from the body
stem, which causes a failure in the incorporation of
the umbilical stalk. As a result, the gut is extruded
into the amniotic cavity without remnants of yolk sac
or amnion so that the midpoint of the intestine is
always externalized and there is an absence of
vitelline remnants in the umbilical cord.12 The
location on the right of the defect can be explained by
the tendency of the yolk stalk to move to this side due
to the presence of the heart and more rapid growth of
the left lateral wall.12, 13.
The specific role of the genetic component in the
etiology of gastroschisis is unclear. Although there
are reports of familial cases, gastroschisis occurs
mostly as a sporadic event. It was observed that 4.7%
of cases have at least one affected relative and the
Shivaleela et al.,
risk of recurrence is 3.5% among siblings.14

Gastroschisis is usually detected by ultrasound after
18 weeks gestation because before week 14, the
process of physiological herniation of the midintestine has not been completed.15-18 Measurement of
AFP (-fetoprotein) in maternal serum between 16-18
weeks of gestation is useful for the detection of
abdominal wall defects and the acetylcholinesterase/
pseudocholinesterase index to distinguish wall
defects such as gastroschisis with neural tube
defects.14 When maternal alpha-fetoprotein (AFP)
levels are elevated, obstetricians look for defects by
having the expectant mother undergo a detailed
prenatal ultrasound. With gastroschisis, this test will
show loops of bowel (intestines) floating freely in
amniotic fluid. More frequent ultrasounds are
generally recommended to continue monitoring the
fetus.
Multidisciplinary pre and postnatal management is
required. Controversy remains today regarding the
timing and route by which delivery should be
performed. It is known that elective termination via
cesarean section after 36-37 weeks gestation and
before the onset of labor prevents passage through the
birth canal, which decreases the risk of contamination
with bacterial flora and mechanical damage in the
viscera. However, a significant difference has not
been shown in terms of complications or survival.19
Definitive treatment is surgical. The timing and
technique for surgical closure depends on the degree
of intestinal inflammation, size of the defect and the
newborns general condition.20-23
Primary surgical closure within 24 hours after birth is
preferred, but if there is viscero-abdominal
disproportion (present in 20-49% of cases), gradual
reduction with silo is necessary to avoid
complications. Surgical repair should be performed
between 6 and 10 days of extrauterine life. In general,
the prognosis is good with a survival 90%, but in
developing countries the risk of death may be as high
as 50-60%. The leading causes of mortality are
related to prematurity, neonatal sepsis, intestinal
complications related to intestinal ischemia, acute
renal failure or multiple organ failure.24
CONCLUSION
Epidemiologic studies from the United States and
other developed countries around the globe have
reported an increased prevalence of gastroschisis over
482
a
wide
geographic
distribution.
Although
environmental and maternal factors have been
suspected, the cause of gastroschisis remains unclear,
and no single cause has yet been implicated.
Universally, there is a significant association of
gastroschisis with young maternal age along with
smoking, leading to speculations of a teratogen
related to modern lifestyle that remains to be
identified. Also, it is possible that gastroschisis may
be related to a combination of factors working
synergistically, rather than an isolated single event or
exposure. This rising prevalence of gastroschisis has
been described as an epidemic, emphasizing the
importance of continued monitoring and evaluation of
patho-genetic factors. The potential association of
gastroschisis with medications, diet, and other
maternal factors could have implications for
pregnancy planning similar to neural tube defects.
Thus, it is an important public health issue,
highlighting the need for a more complete multicenter
epidemiologic study.
REFERENCES
1. Parker SE, Mai CT, Canfield MA, Rickard R,
Wang Y, Meyer RE, et.al; for the National Birth
Defects Prevention Network. Updated national
birth prevalence estimates for selected birth
defects in the United States, 2004-2006. Birth
Defects Research (Part A): Clinical and
Molecular Teratology. 2010; 88(12): 1008-16
2. Laughon M, Meyer R, Bose C, Wall A, Otero E.,
Heerens A., Clark R. Rising birth prevalence of
gastroschisis. Journal of Perinatology. 2003;
23:291-93
3. Torfs CP, Velie EM, Oechsli FW, Bateson TF,
Curry CJ.1994. A population-based study of
gastroschisis: demographic, pregnancy, and
lifestyle risk factors. Teratology. 1994; 50(1):4453
4. Torfs CP, Lam PK, Schaffer DM, Brand RJ.
Association between mothers nutrient intake and
their offsprings risk of gastroschisis. Teratology.
1998; 58(6):241-50
5. Lam PK, Torfs CP, Brand RJ. A low pregnancy
body mass index is a risk factor for an offspring
with gastroschisis. Epidemiology. 1999; 10(6):
717-21
6. Emusa D, Salihu HM, Aliyu ZY, Pierre-Louis BJ,
Druschel CM, Kirby RS. Gastroschisis, low
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
maternal age, and fetal morbidity outcomes. Birth

Defects Research (Part A): Clinical and
Molecular Teratology. 2005; 73:649-54.
Duhamel B. Embryology of exomphalos and
allied malformations. Arch Dis Child. 1963; 38:
142-47
Shaw A. The myth of gastroschisis. J Pediatr
Surg 1975; 10: 235-44
DeVries PA. The pathogenesis of gastroschisis
and omphalocele. J Pediatr Surg 1980; 15: 245251.
Van allen MI. Fetal vascular disruptions:
mechanisms and some resulting birth defects.
Paediatric Annzales.1981;10: pp 219-233.
Hoyme HE, Jones MC, Jones KL. Gastroschisis:
abdominal wall disruption secondary to early
gestational interruption of the omphalomesentenc
artery. Semin Perinatol l983; 7: 294-98.
Stevenson RE, Rogers RC, Chandler JC,
Gauderer MW, Hunter AG. Escape of the yolk
sac:a hypothesis to explain the embryogenesis of
gastroschisis. Clin Genet 2009; 75:326-33.
Jones KL, Benirschke K, Chambers CD.
Gastroschisis: etiology and developmental
pathogenesis. Clin Genet 2009; 75:322- 25.
Stevenson RE, Hall JG, Goodman RM. Human
Malformations and Related Anomalies. New
York: Oxford University Press; 1993. 882-85.
Nyberg DA, McGahan JP, Pretorius DH, Pilu G.
Diagnostic Imaging of Fetal Anomalies.
Philadelphia PA: Lippincott Williams & Wilkins;
2002. 511-19.
Weir E. Congenital abdominal wall defects.
CMAJ 2003; 169:809-10
Badillo AT, Hedrick HL, Wilson RD, Danzer E,
Bebbington MW, Johnson MP, et al. Prenatal
ultrasonographic gastrointestinal abnormalities in
fetuses with gastroschisis do not correlate with
postnatal outcomes. J Pediatr Surg 2008; 43:64753
David AL, Tan A, Curry J. Gastroschisis:
sonographic diagnosis, associations, management
and outcome. Prenat Diagn 2008; 28:633-44
Santiago-Munoz PC, McIntire DD, Barber RG,
Megison SM, Twickler DM, Dashe JS. Outcomes
of pregnancies with fetal gastroschisis. Obstet
Gynecol 2007; 110:663-68
Duncan ND, Brown B, Dundas SE, Wierenga K,
Kulkarni S, Pinnock-Ramsaran C, et al. Minimal
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21.
22.
23.
24.
intervention management for gastroschisis: a

preliminary report. West Indian Med J 2005;
54:152-54
Lund CH, Bauer K, Berrios M. Gastroschisis:
incidence,
complications,
and
clinical
management in the neonatal intensive care unit. J
Perinat Neonatal Nurs 2007; 21:63-68
Weinsheimer RL, Yanchar NL, Bouchard SB,
Kim PK, Laberge JM, Skarsgard ED, et al.
Gastroschisis closuredoes method really
matter? J Pediatr Surg 2008; 43:874-78
Walter-Nicolet E, Rousseau V, Kieffer F, Fusaro
F, Bourdaud N, Oucherif S, et al. Neonatal
outcome of gastroschisis is mainly influenced by
nutritional management. J Pediatr Gastroenterol
Nutr 2009; 48:612-17.
Garca H, Franco-Gutirrez M, Chvez-Aguilar
R, Villegas- Silva R, Xequ-Alamilla J.
Morbilidad y mortalidad en recin nacidos con
defectos
de
pared
abdominal
anterior
(onfaloceley gastrosquisis). Gac Md Mx 2002;
138:519-26.
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DOI: 10.5958/j.2319-5886.3.2.102

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Health Sciences
www.ijmrhs.com
Coden: IJMRHS
st
Copyright @2014
ISSN: 2319-5886
Case report
FACIAL DERMATITIS ARTEFACTA: A RARE PRESENTATION

Ramtanu Bandyopadhyay1, *Rudrajit Paul2, Seshadri Sekhar Chatterjee3, Kaberi Bhattacharya4, Dilip Mondal5
1
Associate Professor, 2Assistant Professor, Department of Medicine, Medical College Kolkata, West Bengal,
India
3
Senior Resident, 4Assistant Professor, 5Professor, Department of Psychiatry, Medical College Kolkata, West
Bengal, India
*Corresponding author email: docr89@gmail.com
ABSTRACT
Dermatitis artefacta (DA) is a rare psycho-cutaneous disorder where bizarre skin lesions are seen in accessible
parts of the body. It is common in young females with mental stress. We here report a case of DA from West
Bengal. A 16 years old female with depression presented with mainly facial lesions. She responded to
psychotherapy. The relevant literature regarding DA and other similar disorders has been also discussed at length.
Keywords: Dermatitis artefacta, Depression, Depigmentation, Face
INTRODUCTION
Dermatitis artefacta is a rare psychiatric disorder
where patients deliberately create skin lesions to
satisfy an inner psychological urge.1 Its diagnosis and
treatment is often very difficult and frustrating and
close association between patient and psychiatrist is
needed for a long time.1 It follows a waxing and
waning course. The lesions are usually found in
accessible parts of the body and they do not follow
any known disease pattern. Often, prolonged
diagnostic testing and follow up is done before the
disease is actually suspected. We here present a case
of facial dermatitis artefacta in a young female. As far
as we searched, this is probably the first such case to
be reported from West Bengal.
CASE REPORT
A 16 years old unmarried girl, diagnosed as major
depressive disorder and on no therapy presently, was
brought by her father to the psychiatry outdoors with
complaints of multiple, well-demarcated skin lesions
on the whole of face, dorsum of bilateral hands and
legs (Fig 1). According to her, the lesions initially

appeared on her legs and healed by themselves after a
few days. Later, similar lesions started appearing on
her face. But she could not specify the time.
Cutaneous examination revealed multiple linear fresh
lesions with tapering ends on her face involving the
bridge of the nose, malar eminences, chin, and also
forehead. Skin between the lesions was absolutely
normal. Most of the lesions were linear or oval in
shape, in various stages of healing. Some of the
lesions
were
healed
with
scarring
and
depigmentation. The lesions were asymptomatic with
no pruritus or photosensitivity, except for a few fresh
lesions that were tender to the touch. This
presentation could not be explained by any known
dermatological condition, according to our
dermatology colleagues, which made us suspicious.
She got admitted in our indoor department. On
detailed dermatological survey, these lesions were
noted to be located on the easily approachable aspect
of bilateral upper limbs and legs, with sparing of the
485
Ramtanu et al.,
usually covered and unapproachable areas of limbs,

trunk, and genitalia. She denied any knowledge of the
origin, cause, or circumstances in which these skin
lesions appeared or progressed, of course she did not
admit their self-infliction. There was no scalp lesion
or loss of hair. Ear lobe, natal cleft, umbilicus and
nails were also normal.
Routine blood tests, including complete haemogram,
urea/creatinine and liver function test were normal.
Blood for anti-nuclear factor (ANF) was positive in
1:40 dilution only. A biopsy from the skin lesion
(fresh) revealed only non-specific inflammation
without any immune deposits. The biopsy specimen
was also negative for AFB.
On psychiatric analysis, it was found that she had
depressed mood, loss of interest and enjoyment,
reduced concentration, pessimistic views about
future, reduced self esteem and self-confidence with
occasional suicidal ideation. According to her father,
these were continuing for last six months. The patient
was the youngest of four siblings, having disturbed
interpersonal relationships. MSE revealed alert,
cooperative patient having poor eye contact, stooped
posture, semi-abstract thinking and with depressed,
constricted affect which was decreased in range and
reactivity. There was slow, soft, monotonous speech
with increased reaction time. Preoccupied thought
and suicidal ideation were present, but there was a
normal cognitive function and grade 4 insights.
After multiple sessions of the interview, the
interviewer was able to establish rapport. The patient
confessed having significant stress due to the
prevailing family situation and that she had inflicted
the wounds with her nails. During her stay in the
wards, she was once observed unawares by a nurse
scratching her face vigorously.
Fig 1: Facial lesions over cheek and forehead
She was prescribed Fluoxetine 20 mg OD and also

associated supportive psychotherapy. After two
weeks the old lesions crusted with minimal
inflammation and some hypopigmentation (Fig 2).
After one month of medication and intense supportive
psychotherapy appearance of new lesions stopped
completely. She is now on regular following up under
both psychiatry and dermatology consultants. The
depressed mood has now improved to some extent
Fig 2: partially healed facial lesions after starting

of treatment
DISCUSSION
Dermatitis artefacta (DA) is an under diagnosed skin
condition.1, 2 These patients may have various
psychiatric disorders with long history of hospital
attendance or they may report absolutely normal
health with no underlying stress factors.2 History of
substance abuse or family history of psychiatric
illness must be enquired in suspected cases of DA.
Our patient did not have any substance abuse, but she
later reported personal conflicts. However, the main
obstacle for diagnosis is the low index of suspicion
among clinicians. Since these patients may present to
any speciality, all clinicians must be aware of this
entity. In our case, the patient first visited a general
physician where she was prescribed antibiotics and
local steroids for one week. Females are reported to
be more affected by this disorder with highest
incidence in the second decade of life.1 In some cases,
borderline personality disorder is found to be the
underlying psychiatric comorbidity.1 Other disorders
reported to be associated with DA include post
traumatic stress disorder, multiple personality
disorder and anorexia nervosa.3 Especially in eating
disorders, the prevalence of DA was found to be as
high as 33% in one study.3
486
Ramtanu et al.,
The lesions of DA are usually present in accessible

parts of the body like face, distal upper and lower
limbs or front of chest.2 The lesions may vary from
superficial erosions to deep ulcers, necrosis, scars and
even crusted linear lesions or ecchymoses. Post
inflammatory hypopigmentation, like our case, is
very common. Two other common associations with
DA are monalisa smile and hollow history.3 Hollow
history means the patient will deny any knowledge of
temporal profile or evolution of the lesions, as in our
case. Mona lisa smile means the patient will have an
indifferent attitude towards the seemingly serious
skin lesions although the relatives will be highly
agitated.4 The diagnosis often comes as a shock and
patients and relatives will often vigorously deny the
etiology.4 The patients do not do this for economic
gain or some other ulterior motive but just as an
outlet to pent up stress.4 Thus, only treatment of the
skin lesions will not help the situation, proper
sympathetic understanding and rapport is needed.
DA falls in the broad group of psychocutaneous
disorders.
This
includes
disorders
like
trichotillomania, delusion of parasitosis or neurotic
excoriations.5 Often, differentiation can be very
difficult. Especially neurotic excoriations (NE) may
often be confused with DA. But in NE, there is
usually a benign skin lesion which is repeatedly
picked with crusting. Scrotum or perianal regions are
often preferred.5
The skin lesions in DA may be caused by nail
scratching, as in our case, or with more harmful
substances like cigarette butt, caustic chemicals or by
binding elastic rubber bands.6 Hence, meticulous
examination of the skin lesions is needed. Also, the
wounds may get secondarily infected even with
organisms like pseudomonas.4 Thus, proper
counselling of the patients is needed and patients may
often need admission for a period to avoid selfharm.1, 4 Sometimes, skin vasculitic lesions may
closely mimic DA. Both occur commonly in females
of roughly the same age.6 Thus, in equivocal cases,
skin biopsy must be done. Persons with Munchausen
syndrome also inflict same type of skin lesions.6 But
proper psychoanalysis will reveal the underlying
deliberate motive of some gain. While DA is a
psychiatric disease and needs compassionate therapy,
Munchausen syndrome is basically a criminal
behaviour.6
DA has been rarely reported from India. However, as

the general awareness among clinicians is rising, this
disease is being diagnosed with more frequency.7 The
social or familial factors leading to DA are unique to
India and thus, needs individualised approach.
Finally, it should be remembered that DA is not just a
psychiatric disorder. It is often a subtle cry for help.
This diagnosis may be an opportunity to address the
underlying mental conflicts of a person and resolve
the issues. Thus we can avoid future catastrophe like
suicide. But cases must be handled with extreme care
as patients often react violently when confronted with
the diagnosis. We present this case to sensitize the
clinicians to this diagnosis.
CONCLUSION
Dermatitis artefacta is a rare psychiatric disorder
which may present to any speciality. Proper diagnosis
and sympathetic counselling are the cornerstones of
management. One should always try to address the
underlying psychological problems.
Conflict of interest: none
Consent of patient: taken
REFERENCES
1. Koblenzer CS. Dermatitis artefacta. Clinical
features and approaches to treatment. Am J Clin
Dermatol. 2000;1:47-55
2. Koo JY. Dermatitis Artefacta. Medscape.
Available
online
from
http://emedicine.
medscape.com/article/ 1121933-overview
3. Gattu S, Rashid RM, Khachemoune A. Selfinduced Skin Lesions: A Review of Dermatitis
Artefacta Cutis. 2009;84:247-51
4. Obasi OE, Naguib M. Dermatitis artefacta: a
review of 14 cases. Annals of Saudi Medicine
1999; 19:223-26
5. Jafferany M. Psychodermatology: A Guide to
Understanding
Common
Psychocutaneous
Disorders. Prim Care Companion J Clin
Psychiatry. 2007; 9 :20313
6. Wong JW, Nguyen TV, Koo JYM. Primary
Psychiatric Conditions: Dermatitis Artefacta,
Trichotillomania and Neurotic Excoriations.
Indian J Dermatol. 2013; 58: 4448
7. Kumaresan M, Rai R, Raj A. Dermatitis artefacta.
Indian Dermatol Online J. 2012; 3: 141-43.
487
Ramtanu et al.,
DOI: 10.5958/j.2319-5886.3.2.103

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Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Case report
HEPATIC ADENOMA IN AN ELDERLY MALE PATIENT: A RARE CASE REPORT
*Ravi Swami, Nimbargi RC, Karandikar MN, Jagdale KA

Department of Pathology, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
*Corresponding author email: ravimswami@rediffmail.com
ABSTRACT
Hepatocellular adenomas are usually affect females in their 3rd and 4th decades of life. Uses of oral
contraceptives use or anabolic steroids have been blamed for this. This is rare in old age and in an elderly male
presented with hepatic adenoma. Such cases are difficult to diagnose on fine needle aspiration cytology and
can cause under or over diagnosis. Here we present a rare case of hepatic adenoma in an elderly male with
both cytological as well as histopathology features of adenoma.
Keywords: Adenoma, Liver
INTRODUCTION
Liver cell adenomas usually affect females in
their 3rd and 4th decades of life. 1 H o w e v e r
a d e n o m a s may be seen in males. Hepatic
adenomas are benign tumours of the liver.
Estrogeneic hormones may favour their growth.
The medical literature documents hepatic
adenomas in male who have been taking steroids.
They are also documented in caeses of glycogen
storage disorders type I and type III, but hepatic
adenomas do occur in absence of any of these risk
factors. However, it is now clear that hepatic
adenomas may also affect men without these risk
factors.2 Here we report a rare case of
hepatocellular a d e n o m a in 62 year old male
without any history of steroid exposure and with
normal AFP levels.
CASE REPORT
A 62 year male initially presented with right
inguinal swelling. There was h/o Pain in right
scrotum. He was an op e r a t e d case of gluteal
a b s c e s s . He was a known c h r o n i c alcoholic,

tobacco chewer since 16 years of age. The Clinical
Impression was right orchitis w i t h bilateral
bulbourethrocele with Grade II prostatomegaly.
Ultrasond (USG) scrotum showed right acute
epididymitis with abscess with mild hydrocele
while USG abdomen and pelvis showed
prostatomegaly, liver abscess (4 x3.7 cm) with
Cholelithiasis (7 cm calculus) and right inguinal
hernia. X- Ray chest was normal. Colonoscopy
was Normal. X ray abdomen erect posture is
normal. Tumour markers showed, Serum PSA
16.72 (N- less than 4 ng/ml) A.F.P. levels- 0.04
(N-less than 5ng) CA 19.9 43.0 (< 37 u/ml). On
CT abdomen a well defined solitary m a s s was
seen in VI s e g m e n t of liver. The central p a r t
showed delayed enhancement than surrounding
area. Gall bladder showed a calculus of 6 x 4
mm. Provisional diagnosis of hepatoma was made
and histopathological correlation was advised.
Fine needle aspiration was done under USG
guidance.
488
Ravi Swami et al.,
Fig1 : Endoscopy of colon
Fig 2: CT abdomen showing a well defined mass

in liver.
The cytology showed cellular smears in which

cells were arranged in groups, acinar and glandular
pattern. The cells were having round monomorphic
nuclei with prominent nucleoli. No sinusoidal
pattern was seen but cytoplasmic bile pigment was
present. Occasional intranuclear inclusions were
noted. The cytological diagnosis of hepatocellular
carcinoma. Biopsy and clinical correlation was
advised in view of normal AFP levels and sos IHC
evaluation.
Following this patient underwent partial resection of
lobe of liver along with cholecystectomy. The tissue
was sent for histopathological evaluation. We
received a partially resected lobe of liver totally
measuring 1 0 X 9 X 4 cm, and weighing 1 8 0 gm.
External surface was smooth while cut surface
showed single well circumscribed tumor mass
measuring 4.3 X 3.5 X 3 cm. C/s greenish. We also
received a gall bladder measuring 10 x 8 cm which
showed gall stones.
On histopathological examination of the solid
mass, a well circumscribed tumour was seen
composed of many hepatocytes arranged in acinar,
glandular and cord like pattern. The hepatocytes
were separated by fibrous septae. Individual tumour
cells were round to polygonal with vesicular nuclei,
prominent nucleoli, and moderate amount of
eosinophilic cytoplasm. The nuclei showed mild
anisonucleosis, minimal periportal and parenchymal
chronic inflammation. Many hepatocytes showed
presence of cytoplasmic bile pigment. Final
diagnosis was hepatocellular adenoma. The gall
bladder showed chronic cholecystitis
Fig 3: Gross photographshowing well circumscribed

mass M 4.3 X 3.5 X 3 cm . C/s green
Fig 4: FNAC of liver showing nests and acini of

hepatocytes(10X), hepatocytes showing stain cytoplasmic
bile pigment (40X)
Fig 5: S howing hepatocytes arranged in nests and

cords (10X), Glandular, acinar arrangement and
bile pigment (arrow, 40x)
489
Ravi Swami et al.,
DISCUSSION
Hepatic adenomas are thought to be affecting only
premenopausal women, but they do occur in men
even in the absence of various risk factors that is use
of anabolic steroids or presence of a glycogen
disorder.16-20% of hepatic adenomas develop in
males. Most of these cases single adenomas and the
liver are non cirrhotic 2. Tumour rupture and
malignant
transformation
are
the
major
complications of a hepatic adenomas occurring either
in males or females. Intra abdominal hemorrhage is
reported in 50 -60% of cases3. The risk for males is
not exactly known, but Fostar and Burman reported a
20% incidence of malignant transformation 4.
Molecular biological studies disclosed three
variants of HCAs, i.e., I) with mutation of HNF 1alpha gene, II) with mutation of beta-catenin
gene, and III) no mutation of the two genes 5.
In our case, the cytohistopathological correlation
was not correct because of difficult cytological
features of adenoma. In cytology invasion can not
be assessed resulting into over or underdiagnosis.
The old age of the patient also favored diagnosis of
carcinoma over adenoma. In their series of 5 cases
studied by Foster and Burman it is of at most
importance to diagnose hepatic masses accurately
as the treatment may vary from just palliative care
to hepatic lobectomy. Radiological imaging a n d
serological markers h e l p in the differential
diagnosis.
Although serum AFP level is a marker its sensitivity
is less for the diagnosis of hepatocellular carcinoma
(HCC). The cytological appearance of HCC varies a
lot with the degree of differentiation 6. A well
differentiated hepatocellular carcinoma closely
resembles benign adenoma or reactive conditions
like a regenerative nodule, a dysplastic nodule,
chronic hepatitis or cirrhosis. On the other hand,
cytology of benign lesions may show significant
reactive atypia or even dysplasia to create a
picture like well differentiated hepatocellular
carcinoma. The points that favour the diagnosis of
highly WD-HCC are hypercellularity of the smears,
cohesive broad trabeculae (>2-cell-thick), small
monotonous hepatocytes with nuclear crowding,
high N: C ratio, cytoplasmic hyaline inclusions
(mallorys hyaline), atypical naked nuclei,

macronucleoli, tumor giant cells, and a transgressing
or peripheral endothelium. Billliary epithelium is
not seen in HCC 6,7. In our case, on FNAC
hepatocytes showed mild atypia. The cell cords
were >2-cell-thick and subtle increases in the N/C
ratio. Reactive atypia or dysplasia in an adenoma is
likely to create confusion between an adenoma or
hepatocellular carcinoma.
CONCLUSION
Tissue diagnosis is recommended for focal hepatic
lesions as the risk of aggressive therapy is greater
than the risk of a minimally invasive diagnostic
procedure. Ultrasound or CT scan-guided FNAC is
a useful diagnostic procedure for evaluating hepatic
masses as the procedure is rapid, simple, costeffective and safe. FNAC is more accurate for
diagnosis of malignant than benign lesions.
REFERENCES
1. Craig JR, Peters RL, Edmonson HA. Tumors of
the liver and intrahepatic bile ducts, 2nd series.
Washington DC: AFIP; 1989
2. Ronald M, Woodfield J, M c C a l l J, and
Koea J Hepatic adenomas in male patients.
HPB (Oxford). 2004; 6(1): 2527
3. Terkivatan T, de Wilt J, de Man R, van Rijn R,
Tilanus H, Ijzermans J. Treatment of ruptured
hepatocellular
adenoma.
BrJ
Surg.
2001;88:20709
4. Foster J, Berman M. The malignant
transformation of liver cell adenomas. Arch
Surg. 1994;129:71217
5. Sornmayura P, Siripornpitak S, Leela-udomlipi
S, Bunyaratvej S. Hepatocellular adenoma: a
case
report.
J Med Assoc Thai.
2010;93(3):393-97
6. Jitendra GN, Patel V, Parikh B, Shah M,
Davara K. Fine-needle aspiration cytology and
biopsy in hepatic masses: A minimally invasive
diagnostic approach. CCIJ.2013;2(2):132-42
7. Asghar F, Riaz S. Diagnostic accuracy of
percutaneous cytodiagnosis of hepatic masses,
by ultrasound guided fine needle aspiration
cytology. Annals kemu 2010;16:184-88
490
Ravi Swami et al.,
DOI: 10.5958/j.2319-5886.3.2.104

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th
Copyright @2014
ISSN: 2319-5886
Accepted: 4thMar 2014
Case report
SMALL BOWEL OBSTRUCTION CAUSED BY A CARCINOID TUMOUR

*Ganesan M1, Nirankumar Samuel2, Karthikeyan.D2, Ajay Raja2
1
Professor,2MS Postgraduates, Department of General Surgery, Meenakshi Medical College Hospital and
Research Institute, Enathur, Kanchipuram, Tamil Nadu, India
*Corresponding author email: drganeshsanjeevini@gmail.com
ABSTRACT
Carcinoid tumours are rare neuroendocrine tumours causing a spectrum of symptoms ranging from chronic
intestinal obstruction to systemic symptoms like sweating, diarrhoea and right side heart failure. We present here
the case history of a male patient aged forty with a carcinoid tumour in the distal small intestine presenting with
chronic intermittent intestinal obstruction and no systemic symptoms and metastasis. This case is presented for its
rarity.
Keywords: Carcinoid Tumors, Intestinal Obstruction, Metastasis
INTRODUCTION
The carcinoid tumors are well differentiated tumors
of the neuroendocrine cells.1Though rare, these
tumorsare mostly found in the terminal ileum.1,2They
are also the most common tumor of the
appendix.1Those that are found in the jejunum and
ileum are multicentric in 26-30% of the cases2. As
metastasis from these tumours are late, mostpatients
presents with hepatic metastasis.3
CASE REPORT
A male patient aged forty presented to us at
Meenakshi Medical College Hospital & Research
Institute, Kanchipuram with complaints of lower
abdominal pain with episodes of vomiting and nausea
and a mass in the right iliac fossa.The patient had
repeated episodes of vomiting and intermittent
abdominal pain with the appearance - disappearance
of the abdominal mass over a period of three months
before presenting to us. Primary examination
revealed a right iliac fossa mass with visible intestinal
peristalsis and active bowel sounds. The patient
underwent a sonography, which showed peristaltic
dilated jejunal and ileal bowel loops. An abdominal

CT was done, which identified the same and rolled up
thickened mesentery. A provisional diagnosis of
ileocecal tuberculosis abdomen was made and the
patient was managed initially by nil per oral,
intravenous fluids and antibiotics and Ryles tube
aspiration. The patient underwent an emergency
laparotomy when the abdomen was silent and
abdominal X-ray showed features of intestinal
obstruction.
During laparotomy, we found the presence of
unhealthy thickened fibrotic and bunched together
loops of small bowel about twenty centimeters
proximal to the ileocecal junction. The mesentery was
thickened and rolled up and a few lymph nodeswere
also found in the mesentery. The team resected the
unhealthy bowel and performed an end to end
anastomosis. Histopathology revealed a small bowel
carcinoid(Fig 1) with clear margins with no
mesenteric nodal metastasis. The post operative
period of the patient was devoid of complications and
an evaluation for metastasis was done by estimation
491
Ganesan et al.,
of 5-HIAA in 24 hour urinary sample which was

negative.
Fig 1: Histopathology of carcinoid tumour showing

cells arranged in clusters.
DISCUSSION
Oberndorfer coined the term carcinoid in 1907 to
describe hormonally active tumors.4 They originate
from the gut wall stem cells and are classified
depending on the location.5 They constitute more than
two thirds of all carcinoids and 1.5% of all GI
tumors.8.4% are found at autopsies.6 Various sites of
origin of this neoplasm are extra gastrointestinal
33%,small intestine 30%,rectum 11% ,colon
10%,appendix 8%,stomach 4-8%, duodenum/
pancreas < 2%, esophagus <1%.6 The tumors are
often diagnosed late as most tumors are
silent.7Clinical presentation ranges from obstructive
symptoms, secondary to small bowel obstruction due
to peritumoral fibrosis or desmoplastic reactions
leading to ischemic changes, to vasoactive symptoms
of a functioning tumor like secretory diarrhoea,
cutaneous flushing and heart valve fibrosis.8
The term 'carcinoid tumor' reserved for classical
midgut carcinoid secreting serotonin.9The syndrome
occurs due to vasoactive in the systemic
circulation.The
demonstration
of
rising
concentrations of 5-HIAA in 24 hour urine samples
biochemically diagnoses carcinoidtumour.
The
primary midgut carcinoids are generally too small to
be
diagnosed
with
conventional
contrast
10,11
studies. The presence of
a circumscribed
mesenteric mass with radiating densities in CT is very
suspicious of a midgut carcinoid mesenteric
metastasis.11Segmental occlusions and tortuosity of
mesenteric vessels are seen in mesenteric
angiography.11The presence of hepatic metastases is
detected by Ultrasonography. PET with the serotonin
precursor 5-hydroxytryptophan labeled with C11 are

highly sensitive in identifying small bowel
carcinoids.12
Surgical resection remains the primary management
of carcinoid tumours.Lesions less than 1 cm requires
local resection, but lesions more than 1.5 cm requires
extensivesegmental resection owing to its high risk of
recurrence.1
Surgery
proves
beneficial
in
symptomatic relief, prevention of metastasis and
improves the prognosis.3Somatostatin analogues are
proven not only to be useful in relieving the patients
of symptoms secondary to amines in the circulation in
70-80% of patients, but also stabilizes the tumour
growth.3
There has been a significant change in the
management of carcinoid tumours with hepatic
metastases. A 90% symptomatic relief was reported
by Que et al. with liver resection.13However, studies
have shown similar benefits using Hepatic
ArteryEmbolization as an alternative to surgery.14
CONCLUSION
Carcinoid tumours are rare and have a good prognosis
if treated early. Often they are diagnosed
postoperatively by the pathologist. Hence a suspicion
of a carcinoid tumour is a must in the evaluation of a
patient with chronic intermittent intestinal
obstruction. A thorough surveillance of the abdomen
per operatively for mesenteric lymph nodal metastasis
and a regular postoperative biochemical follow up
with 24 hour urinary 5-HIAA improves the survival
of the patient.
REFERENCES
1. Singhal
H,
Carcinoidtumor,
Intestinal.
http://www.emedicine.com
2. Burke AP, Thomas RM, Elsayed AM, Sobin LH.
Carcinoids of the jejunum and ileum: an
immunohistochemicaland clinicopathologic study
of 167 cases. Cancer 1997; 79:1086-93
3. Eriksson B, Klopel G, Krenning E.Consensus
guidelines for the management of patients with
digestive
neuroendocrine
tumourswelldifferentiated
jejuno-ilealtumor/carcinoma
Neuroendocrinology 2008, 87:8-19
4. Oberndorfer S.Karzinoidetumorendesdnndarms.
FrankfurtZietschrif fur Pathologie1907, 1:426-29
492
Ganesan et al.,
5. Broaddus RR, Herzog CE, Hicks MJ.

Neuroendocrine
tumors(carcinoid
and
neuroendocrine carcinoma) presenting atnextraappendiceal sites in childhood and adolescence.
ArchPathol Lab Med 2003, 127(9):1200-03
6. ModlinIM,Lye K, KiddM. Carcinoid tumors.
In:SchwartzAE,Persemilidis D, Gagner M(eds)
Endocrine surgery,Chap. 51,New York: Marcel
Dekker,2004; pp.613-41.
7. Strodel WE, Vinik AI, Thompson NW.Small
bowel carcinoid tumors and the carcinoid
syndrome. In Endocrine Surgery UpdateEdited
by: Thompson NW, Vinik AI. New York, NY:
Grune and Stratton; 1983:277-91.
8. Levy AD, Sobin LH. Gastrointestinal Carcinoids:
Imaging
features
with
clinicopathologic
comparison. Radiographics2007, 27(1):237-57
9. Basson MD, Ahlman H, Wangberg B. Biology
and management of the midgut carcinoid. Am J
Surgery 1993, 165:288-97
10. Oberg
K.
Carcinoid
tumors:
current
conceptsindiagnosisand treatment. Oncologist
1998;3:339-45
11. AkerstormG,HellmanP,Ohrvall U. Midgut and
hindgut carcinoid tumors; how aggressive should
we be? J gastrointestSurg 2001;5:588-93
12. Westberg G, Wangberg B, Ahlman H. Prediction
and prognosis by echocardiography in patients
with midgut carcinoid syndrome. Br. J surg
2001;88:865-72
13. Chen H, Hardacre JM. Isolated liver metastases
from neuroendocrine tumors: does resection
prolong survival? Journal of the American
College of Surgeons 1998, 187:88-92
14. Chamberlain
RS,
Canes
D.Hepatic
neuroendocrine metastases: does intervention
alter outcomes? Journal of the American College
of Surgeons 2000, 4:432-45
493
Ganesan et al.,
DOI: 10.5958/j.2319-5886.3.2.105

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Health Sciences
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Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Case report
BASAL CELL CARCINOMA OF ALA OF NOSE A CASE REPORT

*Sonawane SR, Bhavthankar TD, Syed AA, Singh P, Kotalwar SB, Sahu Ankit, Baviskar PK
Department of Oncology, Pravara Institute of Medical Sciences, Loni, Ahemdnagar, Maharashtra, India
*Corresponding author email: satishujjwal@yahoo.com
ABSTRACT
Skin cancers contribute very less to the total number of carcinomas. Especially when on the face or exposed parts
affect cosmetically more than functionally. One of that is Basal Cell Carcinoma over face; which rarely
metastasize. Case is reported in an adult male in a rural setup who came for cosmetic purpose. Who was treated
with best modality available in setup, wide local excision with local naso-labial flap reconstruction with follow up
for oncotherapy.
Keywords: Skin Cancer, Basal cell carcinoma, Flap Reconstruction, Metastasize.
INTRODUCTION
Basal cell carcinoma is cancer of skin, especially of
non-melanocytic origin may be of an epithelial tumor
that arises from basal cells;1 which are small, round
cells found in the lower layer of the epidermis.2,3
Most common sites for BCC are face; head mainly
scalp, neck and hand. BCC is the commonest skin
cancer in human beings, which accounts for less than
0.1% of deaths in cancer. These tumors are
predominant in sun-exposed skin with its slow
growing nature it metastasizes rarely (less than
0.55%).4,5 On appearance BCC is a small in size,
raised above skin, pink or red, translucent, shiny or
waxy lesion and the area may bleed with minor
trauma. 65 - 70% of BCCs occurred on the head
(most frequently on the face), 20-25% on the trunk,
and 5% on the penis, vulva or peri-anal skin.
Unusually other organs may get affected.
CASE REPORT
Presenting a case of 90 years normotensive non
diabetic male, farmer by occupation resident of
Sangamner with complaints of Nodular friable
growth over Right Lateral aspect of Ala of Nose of

Right nostril since 2 years, gradually progressive to
current size, associated with itching and bleeding on
touch. It is not associated with difficulty in breathing,
difficulty in swallowing with no discharge from
growth. No history of preceding trauma. No history
loss of appetite and weight. There was no history of
similar lesion over other body parts, no past surgical
history, and no alteration of bowel and bladder habits,
sleep and diet. No history of backache, cough, fever,
headache, vision abnormalities. No history of
treatment taken for same. On general examination
patient was averagely built with stable vitals. No
evidence of pallor cyanosis icterus, clubbing pedal
edema and lymphadenopathy. On local examination
the lesion was 31 cm nodular firm growth over
lateral edge of right ala of nose which was roughly
oval black in color, slightly tender, bled on touch
with minimal surrounding induration. No palpable
lymph nodes on clinical examination. Patient was
evaluated investigated for same to detect Basal Cell
Carcinoma of Right ala of nose. Patient and relatives
counseled about the nature of disease and after
494
Sonawane et al.,
written and verbal informed consent, patient

underwent wide local excision with Naso- Labial flap
cover over the area, postoperative period was
uneventful successful acceptance of naso-labial flap.
Histopathology reports suggestive of basal cell

carcinoma. Patient was counseled and discharged for
further oncological adjuvant therapy.
DISCUSSION
Table 1: Clinico-pathologic types of BCC, each of which has a distinct biologic behavior. 3,5
Type
Nodular
Infiltrative
Micro-nodular
Morpheaform
Superficial
Features
The most common type of BCC. Cystic, pigmented, keratotic and flesh colored
with telangiectases.
Margins not defined as tumor infiltrates the dermis in between the fibrous
collagen
Non ulcerative. Well defined margins.
Firm in consistency. Sclerotic plaques. Rarely ulcerates
Erythematous, well circumscribed lesion. Most commonly over trunk and
proximal extremities.
Table 2: Histologically, BCC is divided into the following 2 categories. 3,5
Type
Undifferentiated
Differentiated
Features
Solid BCC. Includes superficial, Sclerosing and Infiltrative.
Differentiated BCC often has slight differentiation toward hair (keratotic BCC),
sebaceous glands (BCC with sebaceous differentiation), and tubular glands
(adenoid BCC); noduloulcerative (nodular)
Table 3: 5-Year Recurrence Rates for Primary (Previously Untreated) BCCs With Respect To Various Treatments6
Treatment Modality
Surgical excision
Radiation therapy
Curettage and electro desiccation
Cryotherapy
All non-Mohs modalities
Mohs micrographic surgery
Primary aim of treatment is elimination of the tumor
with maximal preservation of function and physical
appearance. In all cases of BCC, surgery is the
recommended treatment modality. Techniques used
include Electro desiccation and curettage, Excisional
surgery, Cryosurgery, Mohs micrographically
controlled surgery. Recurrence in these cases shows
that the distance to the closest resection margin is an
important predictor.6,7
Photodynamic therapy (PDT) as an adjunct is a
reasonable choice in the following cases:8
1. Tumor recurrence with tissue atrophy and scar
formation.
2. Elderly patients or patients with medical
conditions preventing extensive oncoplastic
reconstructive surgery.
Recurrence Rate
10.1%
8.7%
7.7%
7.5%
8.71%
1%
3. Tumor with poorly defined borders based on
clinical examination.
4. Tumor requiring difficult or extensive oncoplastic
surgery.
Radiation therapy: BCCs are usually radiosensitive;
radiation therapy (RT) is used in patients with
advanced and extended lesions, as well as in those for
whom surgery is not suitable. Postoperative radiation
can also be a useful adjunct when patients have
aggressive tumors that were treated surgically or
when surgery has failed to clear the margins of the
tumor.
Pharmacologic therapy: Topical 5-Fluorouracil 5%,
Imiquimod, Tazarotene. The Oral Agent Vismodegib
are topical agents used in the treatment of superficial
BCC.
495
Sonawane et al.,
The prognosis for patients with BCC is 100%

survival rate for cases that have not spread to other
sites.9 If BCC is allowed to progress, it can result in
significant morbidity, and cosmetic disfigurement
may occur. Though BCC is a malignant neoplasm,
metastasize is rare. The incidence of metastatic BCC
is estimated to be less than 0.1%. After treatment
BCC may develop in new sites after primary curative
treatment.6
On follow up, regular skin screenings are
recommended as chances of developing another
tumor is as high as 35% in 3 years while 50% in next
5 years if etiology not cured.10
Patient and relatives are counseled for further
prevention of recurrence and spread of basal cell
carcinoma.
Patients should avoid possible
potentiating factors like sun exposure, ionizing
radiation, arsenic ingestion, tanning beds. The regular
use of sun-protecting clothing with wide-brimmed
hat, long-sleeved shirts and sunglasses with ultraviolet [UV] protection is advised.11
CONCLUSION
Wide local excision with naso- labial flap cover can
be considered for local basal cell carcinoma over
nasal ala which gives excellent cosmetic results
which can be further given topical agents.
REFERENCES
6.
7.
8.
9.
10.
11.
cancer in psoralen and ultraviolet A-treated

patients. J Invest Dermatol. 2005;124(3):505-13
Walling HW, Fosko SW, Geraminejad PA,
Whitaker DC, Arpey CJ. Aggressive basal cell
carcinoma: presentation, pathogenesis, and
management. Cancer Metastasis Rev. 2004;23(34):389-402
National Comprehensive Cancer Network.
NCCN Clinical Practice Guidelines in Oncology.
Basal Cell and Squamous Cell Skin Cancers.
2011;1: Accessed June 3 2011. Available at
http://www
nccn.org/
professionals/physiciangls/pdf/nmsc.pdf.
Zhang H, Ping XL, Lee PK, Wu XL, Yao YJ,
Zhang MJ, et al. Role of PTCH and p53 genes in
early-onset basal cell carcinoma. Am J Pathol.
2001;158(2):381-85
Dandurand M, Petit T, Martel P, Guillot B.
Management of basal cell carcinoma in adults
Clinical practice guidelines. Eur J Dermatol.
2006;16(4):394-401
National Center for Biotechnical Information.
Tumor Protein p53; TP53. Available at
http://www.ncbi.
nlm.nih.gov/omim/191170.
Accessed November 7, 2007.
Centers for Disease Control and Prevention
(CDC). Sunburn prevalence among adults-United States, 1999, 2003, and 2004. MMWR
Morb Mortal Wkly Rep. 2007;56(21):524-28
1. Newman JC, Leffell DJ. Correlation of

embryonic fusion planes with the anatomical
distribution of basal cell carcinoma. Dermatol
Surg. 2007;33(8):957-64
2. Kumar N, Saxena YK. Two cases of rare
presentation of basal cell and squamous cell
carcinoma on the hand. Indian J Dermatol
Venereol Leprol. 2002;68(6):349-51
3. Young LC, Listgarten J, Trotter MJ, Andrew SE,
Tron VA. Evidence that dysregulated DNA
mismatch
repair
characterizes
human
nonmelanoma skin cancer. Br J Dermatol.
2008;158(1):59-69
4. Barry J, Oon SF, Watson R, Barnes L. The
management of basal cell carcinomas. Ir Med J.
2006;99(6):179-81
5. Lim JL, Stern RS. High levels of ultraviolet B
exposure increase the risk of non-melanoma skin
496
Sonawane et al.,
DOI: 10.5958/j.2319-5886.3.2.106

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Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Copyright @2014
ISSN: 2319-5886
Case report
MUCINOUS CARCINOMA OF BREAST: A DIAGNOSTIC PITFALL

Magdalene KF*, Sapna M, Jeevaraj TR
Sree Narayana Institute of Medical Sciences, Chalaka, Kerala, India
*Corresponding author email: magdalenekf@gmail.com
ABSTRACT
Mucinous carcinoma is also known as mucoid carcinoma, colloid carcinoma, gelatinous carcinoma and mucin
producing carcinoma. They are uncommon neoplasms of the breast and the reported incidence varies from 1-4%.
Most of the mucinous carcinomas occur in older age group. FNAC can aid in diagnosis of mucinous carcinoma
with only a few FNAC studies documented in literature. We present here a 56year old lady with a huge ulcerated
breast mass clinically diagnosed as Malignant Phyllodes tumor. An FNAC was done which showed epithelial cell
clusters with mild atypia in a background of both bluish violet and pink extracellular material. Spindle shaped
cells were noted in the ground substance which led to a diagnosis of a phyllodes tumor with extensive myxoid
change. Mastectomy was performed and the histopathological features confirmed a diagnosis of mucinous
carcinoma. The tumor had areas showing thick collagenized fibrous septae separating tumor cell clusters and also
areas of fibrosis. The pitfall in FNAC diagnosis may be due to the sampling from such an area.
Keywords: Mucin, Phyllodes tumor, Spindle cells
INTRODUCTION
Carcinomas having at least 90% of the structure with
pure mucin are designated as Mucinous carcinoma.1, 2
They have glistening cut surface and soft consistency.
The size of tumor is usually between 1- 4cm in
diameter. The prognosis of mucinous carcinoma is
better than ductal carcinoma and hence it is important
to diagnose this category of breast carcinomas. The
incidence of pure mucinous carcinoma with nodal
metastasis is low, accounting for 24%.3-5 Since there
are reports of deaths even 12 years or more after
therapy, long term follow up of patients is suggested.6
FNAC can aid as an important
pre-operative
diagnostic tool in many breast carcinomas. A few
FNAC studies regarding mucinous carcinomas are
reported in literature. 7-10
CASE REPORT
A 56 year old lady presented with myalgia and
swelling of left breast. On clinical examination, the
whole breast was swollen with a breast mass

measuring 12x10x6cm, involving all the quadrants of
the left breast. There were a few palpable small
lymph nodes in the axilla. A clinical diagnosis of
malignant phyllodes tumor was considered because of
the huge size of the tumor. An FNAC was performed.
The smears showed clusters of epithelial cells with
mild atypia and a background material with spindle
shaped cells (Fig.1a, 1b). A bluish violet to pink
background material was noted which showed spindle
shaped cells (Fig 2). No mitotic figures and areas of
necrosis were noted. Even though a differential
diagnosis of mucinous carcinoma was considered, a
final diagnosis of phyllodes tumor with extensive
myxoid change was given because of the myxoid
staining quality of the background substance, the
presence of the spindle shaped cells and the huge size
of tumor.
497
Magdalene et al.,
A mastectomy with axillary clearance was performed

and specimen was received in the histopathology lab.
The skin surface showed bosselated appearance and
areas of ulceration from which jelly like material
was extruding out (Fig 3a).Cut surface showed a
tumor measuring 12x10x6cm cm with gelatinous
and jelly like appearance. (Fig 3b). Areas of
haemorrhage and focal cystic changes were noted.
The histopathology sections showed tumor cells
floating in pools of extracellular mucin which
constituted more than 90% of the tumor area ( Fig
4a). There were also areas of fibrosis and thick
collagenized fibrous sepatae within the tumor (Fig
4b). No mitotic figures and atypia were noted in the
areas with the spindle shaped cells. 7/7 axillary
lymph nodes were free of tumor. A diagnosis of
Mucinous carcinoma, Modified Nottingham Grade 1
with pathological tumor stage p T4b and N0 was
given. The tumor cells were ER and PR positive. The
superior and posterior margins were involved by
tumor. The patient was referred to an oncology center
for further treatment and was lost for follow up.
Fig 3a: Mastectomy specimen with bosselated

appearance. Jelly- like material extruding from
ulcerated areas. 3b: Cut surface of tumor with jellylike appearance and areas of hemorrhage.
Fig 4a: Microscopy showing islands and clusters of

tumor cells floating in pools of extracellular mucin
((H&E X 100), 4b: Microscopy of mucinous
carcinoma with collagenized thick walled fibrous
septae and clusters of tumor cells floating in
extracellular mucin pools (H&E X 100)
DICUSSION
Fig 1a: Islands and clusters of epithelial cell with
background material showing a few spindle shaped cells.
(PAP X 100), 1b: Epithelial cell clusters with mild atypia
and background substance having spindle shaped cells.
(MGG X 100)
Fig 2: Bluish violet to pink background material with

scattered spindle shaped cells. (MGG X 400)
FNAC helps in the rapid, noninvasive pre-operative

diagnosis of lesions in many parts of the body. There
are certain specific cytological features which help in
rapid diagnosis of malignant as well as benign
tumors. Some authors have documented FNAC
studies on mucinous carcinoma of the breast and have
found it as an important diagnostic tool. 7- 10
Features that favor a diagnosis of mucinous
carcinoma in the FNAC smears are abundant mucin
which stains bluish violet in MGG stain.11 Epithelial
cells floating in pools of mucin with mild to moderate
nuclear atypia can be seen in small clusters,
aggregates and singles. Chicken wire blood vessels
may also be seen.
Sometimes the epithelial mucin as in mucinous
carcinomas may be mistaken for the myxoid stromal
ground substance of phyllodes tumor and
498
Magdalene et al.,
fibroadenoma in FNAC smears. MGG helps to

differentiate these two. Epithelial mucin stains bluish
violet, whereas myxoid ground substance stains
pink/violet.11 Another feature is that epithelial mucin
is homogeneous and structureless. Myxoid ground
substance may be slightly fibrillar and often may
show a few fibroblastic spindle cells.
In the present case study the background material
showed both the staining qualities by imparting
bluish violet as well as pink color. Also there were
spindle cells in the ground substance. Probably
FNAC from a site with collagenized stroma would
have led to the pink staining quality of the
background material.
Mucicarmine stains epithelial mucin. FNAC smears
of mucinous carcinoma of the breast may show pools
of mucicarcmine-positive material. Benign cystic
changes, normal lobules and ducts may show
mucicarmine-positive mucin. Hence it does not help
to exclusively confirm a diagnosis of mucinous
carcinoma.
False diagnosis of epithelial neoplasm is possible if
there is significant epithelial proliferation in
Phyllodes tumor. This can cause an important
diagnostic pitfall in Phyllodes tumor. The epithelial
cells in this case report showed only mild atypia.
Since epithelial proliferations can occur in Phyllodes
tumor it could not be totally excluded.
Pure mucinous carcinoma show usually ill-defined
lobulated sonographic and mammographic margins.
In the majority of cases mammographic calcifications
are absent (82%).12 Imaging of Phyllodes tumor may
show rounded usually sharply defined mass
containing clefts , cysts and sometimes coarse
calcification. Since mammography was not done in
this patient, the findings could not be correlated.
2.
3.
4.
5.
6.
7.
8.
9.
10.
CONCLUSION
11.
We would like to conclude that the cytological

diagnosis of mucinous carcinoma may have pitfalls.
Hence it may be also be included in the differential
diagnosis and the issue may be resolved after a
histopathological assessment of the tumor.
12.
histopathology of the breast. London: WB

Saunders; 1987:193235
Komaki K, Sakamoto G, Sugano H. Mucinous
carcinoma of the breast in Japan. A prognostic
analysis based on morphologic features. Cancer
1988; 61: 98996
Diab SG, Clark GM, Osborne CK, Libby A,
Allred DC, Elledge RM. Tumor characteristics
and clinical outcome of tubular and mucinous
breast carcinomas. J Clin Oncol 1999; 17:144248
Norris HJ, Taylor HB: Prognosis of mucinous
(gelatinous) carcinoma of the breast. Cancer
1965;18:879-85
Rasmussen BB, Rose C, Christensen IB:
Prognostic factors in primary mucinous breast
carcinoma. Am J Clin Pathol 1987;87:155-60
Clayton F. Pure mucinous carcinomas of breast.
Morphologic features and prognostic correlates.
Hum Pathol 1986;17:34-38
Eli Avisa, Muhammad Akram Khan, Deborah
Axelrod, Krishna Oza: Pure Mucinous
Carcinoma of the Breast. Annals of Surgical
Oncology 1998; 5(5):447-51
Ruchita Tyagi, Mahendra Kumar, Pranay
Tanwar, Pranab Dey. Mucinous carcinoma of
breast: FNAC as effective diagnostic modality.
Asian Journal of Medical Science 2012;3:32-35
Cyrta J, Andreiuolo F, Azoulay S, Balleyguier
C, Bourgier C, Mazouni C et al. Pure and mixed
mucinous carcinoma of the breast: fine needle
aspiration cytology findings and review of the
literature. Cytopathology. 2013;24(6):377-84
Sangeeta
Sharma, Rani
Bansal, Anjali
Khare, Nivesh Agrawal. Mucinous carcinoma of
breast:
Cytodiagnosis
of
a
case
J
Cytol. 2011;28(1): 4244
Orell SR, Sterrett GF, Whitaker D. Fine needle
aspiration cytology. 4th ed. Elsevier Churchill
Livingstone; 2005.pp190-191
Tan JZ, Waugh J, Kumar B. Mucinous
carcinomas of the breast: Imaging features and
potential of misdiagnosis. J Med Imaging Radiat
Oncol. 2013; 57(1):25-31
REFERENCES
1. Page DL, Anderson TJ, Sakamoto G. Infiltrating
carcinoma: major histological types. In: Page
DL, Anderson TJ, editors.
Diagnostic
499
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DOI: 10.5958/j.2319-5886.3.2.107

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Case report
A RARE CASE OF MALIGNANT PERIPHERAL NERVE SHEATH TUMOUR

*Anita Harry1, Nirankumar Samuel2, Vigil TD3
1
Professor, 2,3 MS Postgraduates, Department of General Surgery, Meenakshi Medical College, Hospital and
Research Institute, Enathur, Kanchipuram, Tamil Nadu
*Corresponding author email: omnarayana05@yahoo.com
ABSTRACT
Malignant Peripheral Nerve Sheath Tumours are tumours of ectomesenchymal origin often originating from
major nerves or their nerve sheaths, they are commonly found in patients with neurofibromatosis-1 though
sporadic cases have been reported. We report a rare sporadic case of MPNST in a 20 year old patient arising from
the spinal accessory nerve.
Keywords: Peripheral nerve sheath tumour, malignant, neurofibromatosis.
INTRODUCTION
Malignant Peripheral Nerve Sheath Tumours are
tumours of ectomesenchymal origin.1, 2 MPNSTs, a
term coined by the World Health Organisation
represents collective tumours including malignant
schwannoma,
malignant
neurilemmoma,
neurofibrosarcoma and other neurogenic tumours that
have the same biological behaviour.3,4 They arise
from major and minor nerves5 or their nerve sheaths.6,
7
As they are aggressive, surgery remains the primary
line of management of MPNSTs.8-10 They may arise
as a sporadic variant or in patients with
neurofibromatosis. The symptomology varies from a
swelling to compressive symptoms and neurological
deficits based on its size, location and tumour
extension. We report a rare case of a sporadic
Malignant Peripheral Nerve Sheath Tumour arising
from a nerve twig of the spinal accessory nerve.
CASE REPORT
A 20 year old lady, with no history of NF-1,
presented to the outpatient unit at Meenakshi Medical
College Hospital and Research Institue, Kanchipuram
with a rapidly growing non painful swelling in the
left supraclavicular fossa with no history of pain

radiating to her left arm (Fig. 1). The swelling was
firm, lobular with well-defined margins and did not
involve the skin. On putting the trapezius into
contraction, the swelling became less prominent. A
neck magnetic resonance imaging showed a welldefined intermuscular soft tissue intensity swelling
with multiple axillary lymphadenopathies (Fig 2).
FNAC of the swelling showed features of
benignschwannoma and FNAC of the lymph nodes,
done
with
ultrasound
guidance
showed
granulomatous changes. Patient underwent a wide
local excision during which it was found that the
swelling was arising from a nerve twig supplying the
trapezius (Fig.3). Histopathological examination
showed pleomorphic spindle shaped cells arranged in
intersecting fascicles with mitotic figures (Fig 4).
Immunohistochemistry revealed positivity for S-100
and confirmed the diagnosis of MPNST with clear
margins. A post-operative MRI showed no evidence
of residual tumour or neurovascular infiltration.
500
Anita et al.,
DISCUSSION
Fig1. Swelling in the left supraclavicular fossa
Fig 2: MRI of the left supraclavicular region showing a

well defined lesion in the intermuscular plane
MPNSTs of the head and neck are rare tumours and

70% of them arise in patients with von
Recklinghausen disease, or neurofibromatosis.1, 8, 11 It
constitutes about one tenth of the soft tissue sarcomas
and often considered a subgroup of the latter.1, 2
Ducatman et al., 8 in his work declared that patients
with von Recklinghausen disease had 4600 times risk
of getting MPNST than those without VRHD.
MPNSTs of the spinal accessory nerve are extremely
rare. The diagnosis of MPNSTs usually requires a
combination
of
microscopic
and
immunohistochemical
studies.8
Histologically,
MPNSTs have a classic fascicular pattern of spindle
cells displaying pleomorphism, mitotic figures and
undifferentiation.12 Immunohistochemical markers
like vimentin, S-100 are used to confirm the
diagnosis of MPNSTs12. Radical dissection with a
clear margin is compulsory in the management of
MPNSTs. The
oncology consensus
group
recommends the use of post-operative radiotherapy
despite achieving a clear margin. 10 Though these
tumours have the highest rate of recurrence among
soft tissue sarcomas, 13 an adequate and a proper
initial management improves the prognosis of the
disease. 14
CONCLUSION
Fig 3: Tumour arising from the neural twig supplying

the trapezius.
Malignant Peripheral Nerve Sheath tumours are

aggressive tumours of neurogenic origin. It requires a
combination
of
microscopic
and
immune
histochemical analysis for the diagnosis of MPNSTs.
Surgery is the first line of management of MPNST
and it is often important to achieve a clear margin in
the initial surgery as it improves the prognosis. This
case highlights the fact that a high suspicion of a
sporadic MPNST should be kept in mind in dealing
with patients with solitary cervical swellings.
REFERENCES
Fig 4: Showing spindle shaped cells with serpentine

quality proving the neural origin with mitotic figures
(40X)
1. Hruban RH, Shiu MH, Senie RT, Woodruff

JM: Malignant peripheral nerve sheath
tumours of the buttock and lower extremity A
study of 43 cases. Cancer 1990, 66:1253-65
2. Angelov L, Guha A: Peripheral Nerve
Tumours. In Neuro oncology Essentials 1st
edition. Edited by: Berstein M, Berger MS.
New York Theme Publishers; 2000:434-44
501
Anita et al.,
3. Wanebo JE, Malik JM, VandenBerg SR,

Wanebo JH, Driesen N, Persing JA:
Malignant peripheral nerve sheath tumours.
A clinicopathologic study of 28 cases. Cancer
1993, 71:1247-53
4. Dasgupta TK, Choudhuri PK: Tumours of
soft tissue 2nd edition. Connecticut Appleton
& Lange; 1998:127-395
5. D'Agostino AN, Soule EH, Miller RH:
Sarcoma of the peripheral nerves & somatic
soft tissues associated with multiple
neurofibromatosis (Von Recklinghausen's
disease). Cancer 1963, 16:1015-27.
6. Cashen DV, Parisien RC, Raskin K,
Hornicek FJ, Gebhardt MC, Mankin HJ:
Survival data for patients with malignant
schwannoma. Clin Orthop Relat Res 2004,
426:69-73
7. Hirose T, Scheithauer BW, Sano T.
Perineural malignant peripheral nerve sheath
Tumour (MPNST) A clinicopathologic,
immunohistochemical and ultrastructural
study of seven cases. Am J Surg Pathol 1998,
22:1368-78
8. Ducatman SB, Bernd WS, David GP, Herbert
MR, Duane MI: Malignant peripheral nerve
sheath tumours. A clinicopathologic study of
120 cases. Cancer 1986, 57:2006-21
9. Nambisan RN, Rao U, Moore R, Karakousis
CP. Malignant soft tissue tumours of nerve
sheath origin. J Surg Oncol 1984, 25:268-72
10. Ferner RE, Gutmann DH: International
consensus statement on malignant peripheral
nerve sheath tumours in neurofibromatosis.
Cancer Res 2002, 62:1573-77
11. Kourea HP, Bilsky MH, Leung DH, Lewis
JJ, WoodruffJM. Subdiaphragmatic and
intrathoracicparaspinal malignant peripheral
nerve sheath tumours: aclinicopathologic
study of 25 patients and 26 tumours.Cancer
1998;82:2191-03
12. Strauss M, Grey L. Malignant tumours of the
peripheral nerves. In: Weiss SW, Goldblum
JR, editors. Enzinger and Weiss's soft tissue
tumours. 4th ed. St. Louis: Mosby;2001.
p.903-44
13. Collin C, Godbold J, Hajdu S, Brennan M.
Localized extremity soft tissue sarcomas an
analysis of factors affecting survival. J Clin
Oncol 1987, 5:601-12
14. Ghosh BC, Ghosh L, Huvos AG, Fortner JG.

Malignant schwannoma A clinicopathologic
study. Cancer 1973, 31:184-90
502
Anita et al.,
DOI: 10.5958/j.2319-5886.3.2.108

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Case report
GARENOXACIN IN SKIN & SKIN STRUCTURE INFECTIONS COMPLICATED BY BEAR BITE

Pukar M1, *Hajare A2, Krishnaprasad K2, Bhargava A2
1
Professor, Department of General Surgery, SBKS Medical Institute and Research Centre, Vadodara
Medical Services, Glenmark Pharmaceuticals Ltd., Mumbai, Maharashtra
*Corresponding author email: maheshpukar@yahoo.com, anoophajare@gmail.com

ABSTRACT
Animal bites have always been a common problem to humans. The incidence of resistant organisms is also
increasing in the community. Garenoxacin a novel oral des-fluoroquinolone with potent antimicrobial activity
against common pathogens causing skin and soft tissue infections, including resistant strains offers the benefit of
broad spectrum of coverage including gram positive, gram negative and anaerobic organisms. The result of the
case study indicates that garenoxacin is very effective in treating skin and soft tissue infections caused by animal
bites.
Keywords: Garenoxacin, Wound infection, Animal bite
INTRODUCTION
Animal and human bites are a common problem1.
Proper care requires wound inspection for injury to
deeper structures; meticulous wound care at the initial
encounter; and decisions regarding primary closure,
the provision of prophylactic antibiotics for wounds
at high risk for infection, and prophylaxis for tetanus
and rabies as indicated. In case of inadequate or
undertreated cases, Extensive morbidity, including
disability and cosmetic damage is expected to be a
foregone conclusion due to underlying infection
For wounds that appear infected at the time of initial
assessment, antibiotic therapy is usually started after
Gram stain and/orculture reports are made available.2
There is a lack of controlled studies evaluating the
use of different antibiotics in infected bite wounds.
Empirical treatment should be directed toward the
most common infecting organisms. The predominant
pathogens in animal bite wounds are the oral flora of
the biting animal and human skin flora. Infection
usually results from a mixture of organisms. Common
Pukar et al.,
pathogens include Pasteurella species, staphylococci,

streptococci, and anaerobic bacteria.
Circumstances when the use of prophylactic
antibiotics may be used include
Table 1: Prophylactic use of antibiotics
Dog bites more than 8-12 hours old
Moderate to severe dog bite less than 8-12 hours
(Oedema, Crush injuries)
Puncture wounds, particularly if bone or joints were
penetrated
Severe facial wounds
All hand bites
Wounds in the genital area
Wounds in immunocompromised or asplenic patients
Moderate to severe cat or human bites
CASE STUDY
A female aged 68 years weighing 52kgs was
presented to a Doctor in a tertiary care setting. The
patient presented with facial trauma due to bear attack
leading to disfigurement of the face. This event
occurred a day prior to presentation when she
wandered into the outskirts of her village for
503
household chores. Patient was conscious, averagely

built and had vital parameters including temperature,
pulse and respiratory rate within normal limits. She
had no history of any chronic illnesses, including
diabetes mellitus or tuberculosis in the past. Similarly
no icterus or generalized lymphadenopathy was
observed.The patient was stabilized and wounds were
cleaned and dressed for further action. A
reconstructive surgery was performed on the face on
the same day with excision sample was sent for
further analysis and culture. The culture report
showed P. aeruginosa & S. aureus on the third day.
As
Surgical
prophylaxis,
patient
received
Amoxicillin-clavulanate injection 1.2 g every 8 hours
with Metronidazole 500 mg every 8 hours for three
days. The patient accepted oral feeds on the third day
and shifted to Garenoxacin tablets (400 mg OD) for
10 days. Clinical inflammatory response around the
surgical flaps subsided within five days. There was
no graft rejection, discharge, dehiscence or infection
nidus around the sutures. The sutures were removed
after 15 days
Fig 2: Before and after treatment pictures of

facial disfigurement in patient who sustained
trauma due to Bear attack
DISCUSSION
Facial laceration or injury remains an important cause
of cosmetic disfigurement unless closed. Infection of
these wounds is common, perhaps due to the
excellent blood supply to the face and scalp.
Provision of proper wound care is essential for good
outcomes and to reducing infection risk in patients
who undergo wound closure. When bite wounds are
sutured, extensive irrigation, debridement, avoidance
of deep sutures (if possible), institution of
prophylactic antibiotic therapy, and close follow-up
are indicated. A common approach involves initial IV
Pukar et al.,
therapy until infection is resolving followed by oral

therapy to complete a course of 10 to 14 days.
Aggressive wound management of animal bite
wounds is thought to decrease the infection rate2.
Cleansing of the wound with a few hundred mL of
high pressure saline is usually effective. Removal of
devitalized tissues is also important to prevent a nidus
of infection.
Despite the lack of prospective studies, primary
wound closure is not typically performed on bite
wounds. In general, bite wounds are left open,
reevaluated within 2 to 3 days, and managed by
secondary intention or delayed primary closure. Some
retrospective studies have also suggested primary
closure of puncture wounds, crush injuries, wounds
that are more than 24 hours old, wounds over the
hands, wrists, feet and joints, wounds in
immunocompromised individuals, and wounds
inflicted by cats or humans3. Once the wound has
been observed for a few days and there are no signs
of infection delayed closure can be attempted. Noninfected facial wounds less than 24 hours old can
probably be repaired4. Facial wounds can be closed
with high rates of success, probably due to high
vascularity and absence of dependent edema.
For wounds that appear infected at the time of initial
assessment, antibiotic therapy should be started after
a Gram stain and aerobic and anaerobic cultures have
been obtained. There is a lack of controlled studies
evaluating the use of different antibiotics in infected
bite wounds. Empiric treatment should be directed
toward the most common infecting organisms.
Garenoxacin,
a
recently
introduced
desfluoro(6)quinolone in India offers broad yet potent
spectrum of activity against Gram positive, Gram
negative and Anaerobic pathogens5,6The excellent
clinical response observed with Garenoxacin during
the post-operative period probably highlights its
clinical utility as a useful switch therapy while
preventing post-surgical infections
CONCLUSION
Garenoxacin offers a broad spectrum of activity
against various pathogens involved in skin and soft
tissue infections including gram positive, gram
negative and anaerobic organisms. Garenoxacin
appears to be a suitable option for the resistant or
difficult to treat infections and add to the
armamentarium of the clinicians.
504
Conflict of interest: Nil

REFERENCES
1. Goldstein EJC. Bite wounds and infection. Clin
Infect Dis 1992;14:633-40
2. Abrahamian FM, Goldstein EJ. Microbiology of
animal bite wound infections. Clinical
microbiology reviews. 2011;24(2):231-46.
3. Edwards MS. Animal bites. In: Feigin RD,
Cherry JD, Demmler GJ, Kaplan SL (eds):
Textbook of Pediatric Infectious Diseases, fifth
edition. Saunders, 2004, pp3267
4. Goodson A, Simmons J. Suturing Part 3: Suturing
traumatic facial wounds; special areas and tips for
tricky closures. Face Mouth & Jaw Surgery.
2012;2(1).
5. Krishna G, Gotfried MH, Rolston K, Wang Z.
Penetration of garenoxacin into lung tissues and
bone in subjects undergoing lung biopsy or
resection. Current Medical Research and
Opinion. 2007;23(8):1841-7
6. Fung-Tomc JC, Minassian B, Kolek B, Huczko
E, Aleksunes L, Stickle T, et al. Antibacterial
spectrum of a novel des-fluoro (6) quinolone,
BMS-284756. Antimicrobial Agents and
Chemotherapy. 2000;44(12):3351-56
Pukar et al.,
505
DOI: 10.5958/j.2319-5886.3.2.109

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Coden: IJMRHS
th
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ISSN: 2319-5886
Accepted: 22nd Mar 2014
Case report
DUCHENNE MUSCULAR DYSTROPHY DIAGNOSED BY DYSTROPHIN GENE DELETION TEST:

A CASE REPORT
*Rathod Kishor G1, Dawre Rahul M1 , Kamble Milind B1,Tambe Saleem H1
1
Department of Pediatrics, Dr. Shankarrao Chavan Government Medical College, Nanded, Maharashtra, India
*Corresponding author email: kishorgrathod@gmail.com

ABSTRACT
Duchenne muscular dystrophy (DMD) is an X-linked recessive disease affecting 1 in 36006000 live male
births. A muscle biopsy is not necessary if a genetic diagnosis is secured first, particularly as some families might
view the procedure as traumatic. DMD occurs as a result of mutations (mainly deletions) in the dystrophin gene
(DMD; locus Xp21.2). Mutations lead to an absence of or defect in the protein dystrophin, which results in
progressive muscle degeneration leading to loss of independent ambulation. Ninety percent of out frame
mutations result in DMD, while 90% of in-frame mutations result in BMD. Electron microscopy is not required to
confirm DMD. Genetic testing is mandatory irrespective of biopsy results. But the muscle biopsy is not required if
the diagnosis is secured first by genetic testing.
Keywords: Duchenne Muscular Dystrophy, dystrophin gene deletion test.
INTRODUCTION
DMD is an X-linked disease that affects 1 in 36006000 live male births.1 Affected individuals are
unable to run and jump properly due to proximal
muscle weakness, which also results in the use of the
classic Gowers' manoeuvre when arising from the
floor. Most patients are diagnosed at approximately 5
years of age, when their physical ability differs
markedly from their peers. Respiratory and cardiac
complications emerge, and without intervention, the
mean age at death is around 19 years. Nonprogressive cognitive dysfunction might also be
present.2 DMD occurs as a result of mutations
(mainly deletions) in the dystrophin gene. Mutations
lead to an absence of or defect in the protein
dystrophin, which results in progressive muscle
degeneration and loss of ambulation by the age of 13
years.3
CASE REPORT
A 7 years old male child, second by order of birth,
born of non consanguineous marriage, brought with
complaints of frequent falls while walking since 2
years. And difficulty in standing from sitting position
since 1 year. Birth history was uneventful. Milestones
were achieved as per age till 5 years of age.
On admission general condition was good, speech
normal, no mental retardation; calf hypertrophy was
present, Gowers sign positive, and tone normal.
Power grades in various muscle groups of the lower
limbs were as shown in Table 1.
Truncal weakness was present. Neck flexors were
weak as compared to extensors.
Investigation: Hb 11.4 gm%, total leukocyte count 6600/cmm platelets- 3.55 lac/cmm.CPK-12600
IU/Lit.
506
Rathod et al.,
Table 1: Grading of power in various muscle groups

of lower limb.
Region
Muscle group Right side Left side
Hip
Flexors
4
4
Extensors
3
3
Abductors
3
3
Knee
Extensors
4
4
Flexors
4
4
Ankle
Dorsi-flexion
4
4
Plantar flexion 5
5
Reflexes Knee reflex
Absent
Absent
Ankle reflex
+
+
Muscle biopsy was not done because relatives were
not ready. Molecular test for deletion of dystrophin
gene showed Deletion has seen of exons 45, 46, 47,
48, 49and 50. These deletions indicating out frame
mutations. This is along with the age of the patient is
consistent with DMD. (90% of out frame mutations
result in DMD, while 90% of in-frame mutations
result in BMD).
Clinical manifestations: Infants rarely symptomatic,
though some manifest by mild hypotonia. Early gross
motor milestones are usually achieved at the proper
ages or may be mildly delayed. Poor head, holding in
infancy may be the earliest sign of weakness. In
toddlers lordotic posture is to compensate for gluteal
weakness. A Gowers sign and Trendelenburg gait is
often evident by age 5 or 6 yr.
Some are confined to a wheelchair by 7 yr of age;
most patients normal till 10 yr of age. With orthotic
prostheses, physiotherapy, and sometimes minor
surgery (Achilles tendon lengthening), most are able
to walk until age 12 yr. Apart from postponing the
psychological depression ambulation even for as little
as 1 hour per day prevents scoliosis.
The weakness progresses continuously into the 2nd
decade. The distal muscles are relatively well
preserved. Respiratory involvement like weak and
ineffective cough, frequent respiratory infections, and
decreasing respiratory reserve, with pharyngeal
weakness leading to aspiration, nasal regurgitation of
liquids, and nasal voice quality.
Contractures involving the ankles, knees, hips, and
elbows are common. Pseudohypertrophy of the calves
and wasting of thigh muscles are classic features of
DMD. It is due to hypertrophy of some muscle fibers,
infiltration of muscle by fat, and proliferation of
collagen. After the calves, the next most common site
Rathod et al.,
of muscular hypertrophy is the tongue, followed by

muscles of the forearm. The voluntary sphincter
muscles rarely become involved.
Unless ankle contractures are severe deep tendon
reflexes remain well preserved. The knee deep tendon
reflexes may be present until about 6 yr of age, but
are less brisk than the ankle jerks and are eventually
lost. In the upper extremities, the brachioradialis
reflex is usually stronger than the biceps or triceps
brachii reflexes.
Cardiomyopathy is seen in 5080% of patients and its
severity of cardiac involvement does not necessarily
correlate with the degree of skeletal muscle
weakness. Some patients die early of severe
cardiomyopathy while still ambulatory; others in
terminal stages of the disease have well-compensated
cardiac function. Smooth muscle dysfunction,
particularly of the gastrointestinal tract, is a minor,
but often overlooked, feature.
Mental retardation is common, although only 20
30% have an IQ <70. The majority has learning
disabilities that still allow them to function in a
regular classroom, particularly with remedial help. A
few patients are profoundly mentally retarded, but
there is no correlation with the severity of the
myopathy. Epilepsy is slightly more common than in
the general pediatric population. Dystrophin is
expressed in brain and retina, as well as in striated
and cardiac muscle, though the level is lower in brain
than in muscle. This distribution may explain some of
the CNS manifestations. Abnormalities in cortical
architecture and of dendritic arborization may be
detected neuropathologically; cerebral atrophy is
demonstrated by MRI late in the clinical course. The
degenerative changes and fibrosis of muscle
constitute a painless process. Myalgias and muscle
spasms do not occur. Calcinosis of muscle is rare.
Death occurs usually at about 1820 yr of age. The
common causes of death are respiratory failure in
sleep, intractable heart failure, pneumonia, or
occasionally aspiration and airway obstruction.4
DIAGNOSIS
An open muscle biopsy is necessary if the differential
diagnosis includes DMD among other types of
muscular dystrophy, so that adequate tissue will be
available for further analysis. A needle biopsy may be
appropriate if testing is only for DMD. The key tests
done on biopsy are immunocytochemistry and
507
immunoblotting for dystrophin.3 Electron microscopy

is not required to confirm DMD. Genetic testing is
mandatory after a positive biopsy. However, if
genetic testing is negative for mutation, but creatine
kinase concentrations are increased and signs or
symptoms consistent with DMD are present, then the
next necessary diagnostic step is to do a muscle
biopsy. This is also the case if there is a family
history of DMD and a suspicion of the diagnosis, but
no family mutation is known.5
Stanton, editors. Nelson Textbook of Pediatrics.

Elsivier. 2007;18th ed: 2540-41
5. Muntoni F, Torelli S, Ferlini A. Dystrophin and
mutations: one gene, several proteins, multiple
phenotypes. Lancet Neurol.2003; 2: 731-740.
6. Katharine B, Richard F, David JB, Laura EC,
Paula RC, Linda C. Diagnosis and management
of Duchenne muscular dystrophy. The Lancet
Neurology. 2010;9:77-93
Treatment: Gluco-corticoids slow the decline in

muscle strength and function in DMD. The goal is to
preserve ambulation and decrease in later respiratory,
cardiac, and orthopaedic complications. Other dietary
supplements, such as coenzyme Q10, carnitine,
aminoacids (glutamine, arginine), anti-oxidants (fish
oil, vitamin E, green-tea extract), and others, are
being used. Expert doesnt recommend the use of
these supplements due to lack of supportive data.6
CONCLUSION
A muscle biopsy is not necessary if a genetic
diagnosis is secured first, particularly as some
families might view the procedure as traumatic.
Electron microscopy is not required to confirm DMD.
However, if genetic testing has been done and no
mutation
identified,
but
creatine
kinase
concentrations are increased and signs or symptoms
consistent with DMD are present, then the next
necessary diagnostic step is to do a muscle biopsy.
REFERENCES
1. Drousiotou A, Ioannou P, Georgiou T. Neonatal
screening for Duchenne muscular dystrophy: a
novel semi quantitative application of the
bioluminescence test for creatine kinase in a pilot
national
program
in
Cyprus. Genet
Test. 1998; 2: 55-60
2. Poysky J. Behavior patterns in Duchenne
muscular dystrophy: report on the Parent Project
Muscular Dystrophy behavior workshop 89 of
December2006, Philadelphia, USA. Neuromuscul
Disord .2007; 17: 986-94
3. Hoffman EP, Brown RH, Kunkel LM. Dystrophi
n: the protein product of the Duchenne muscular
dystrophy locus. Cell. 1987; 51:919-28
4. Harvey B Sarnat. Duchenne and Becker Muscular
Dystrophies. In: Kligman, Behrman, Jenson,
508
Rathod et al.,

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DOI: 10.5958/j.2319-5886.3.2.

International Journal of Medical Research

Volume 3 Issue 2 (April - Jun)

Received: 10th Oct 2013

Revised: 22nd Dec 2013

Accepted: 4th Jan 2014

EFFECT OF AGE ON TEST PERFORMANCE IN COMMUNITY DWELLING ELDERLY PEOPLE:

muscle power and exercise capacity. Therefore,

Int J Med Res Health Sci. 2014;3(2):228-232

functional impairments such as in walking and stair

included in the present study and they were divided

Int J Med Res Health Sci. 2014;3(2):228-232

Table.2: Table showing comparison in between the groups in 6MWD

Group B vs. Group C

Table.4: Table showing comparison in between the groups in TST time

All Pair wise Multiple Comparison Procedures (Tukey Test)

Results showed that there was a progressive

increasing age. 8 6 MWT also depends on

Int J Med Res Health Sci. 2014;3(2):228-232

complete TST with increasing age. The test also

elderly people and provides a criterion related

From the results it can be concluded that there is

Int J Med Res Health Sci. 2014;3(2):228-232

performance tests on elderly people in the

I sincerely thank my H.O.D. and Guide for

1. Szucs TD. Future disease burden in the

8. Teresa S, Timothy A H, Louise M. Age and

Int J Med Res Health Sci. 2014;3(2):228-232

International Journal of Medical Research

ROLE OF COLOUR DOPPLER SONOGRAPHY IN ADNEXAL MASSES

*Corresponding author email: shaziashrafkhan@rediffmail.com

presentations) to critically evaluate the likelihood of

Doppler visually reflects the state of blood flow to the

Table 1: Vascularity of Masses

Int J Med Res Health Sci. 2014;3(2):233-236

Table 2: Mean RI and Mean PI in Benign and Malignant Adnexal Masses

index (PI). Mean RI and PI were significantly lower in

was 84.2%, 96.3% , 84.2% and 96.3% respectively.

pulsatility index in benign and malignant diseases.

Int J Med Res Health Sci. 2014;3(2):233-236

International Journal of Medical Research

GONIOSCOPIC CHANGES IN CONVENTIONAL ECCE VS MANUAL SICS: A COMPARATIVE

Senior Resident, 2Associate Professor, 3Postgraduate,4Professor, 5Senior resident Dept of Ophthalmology,

The current surgical trend for the majority of

Small Incision Cataract Surgery with PCIOL. An

The Scheies method of grading TM pigmentation

MATERIALS AND METHOD

Fig 1: Age-sex wise group distribution graph

Fig 2: Incidence of peripheral anterior synechiae in

PAS formation was observed in 28 eyes of 50 cases,

Fig 3: As overlying the lens haptics pigment dispersion

20 eyes showed PAS overlying the Haptics of PC

Fig 4: Incidence of pigment dispersion

observed by R Blair Evans PAS overlying the

International Journal of Medical Research

HISTOLOGICAL AND HISTOMETRIC STUDY OF TESTIS IN ALBINO RATS TREATED WITH

histometrically, and therefore it has been planned to

of the experimental period, the testis were removed,

Fig 2: Testis control and test (Massons trichrome stain

Fig 3: Sections of testis from control and test (Van

Fig 4: Sections of seminiferous tubules from control , test

Arrow (test) shows early fatty degeneration of

Fig 1: Sections of testis Control and test rats (H &E 100X)

Fig 6: Seminiferous tubules from control, test (Massons