Ijmrhs Vol 3 Issue 3

DOI: 10.5958/2319-5886.2014.00387.
International Journal of Medical Research

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Received: 28 Feb 2014
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 28 Apr 2014
Accepted: 1st May 2014
Research Article
NUTRITIONAL STATUS, SOCIO-ECONOMIC AND HYGIENIC CONDITION OF SCHOOL AGED

CHILDREN OF A VILLAGE OF PUNE DISTRICT, MAHARASHTRA
*Puranik SS
Assistant Professor, Department of Biotechnology, Modern College of Arts, Science & Commerce, Shivajinagar,
Pune, India.
*Corresponding author email:puranikshubhangi@gmail.com
ABSTRACT
Introduction:The field of anthropometry encompasses a variety of human body measurements, such as weight,
height and size; including skin fold thickness, circumference, lengths, and breadths. Anthropometry is a key
component of nutritional status assessment in children and adults. Anthropometric data for children reflect general
health status, dietary adequacy and growth and development over time. The main objective of the study was to
diagnose and analyze the magnitude and causes of nutritional and health problems of the village.Method:
Anthropometric reference data of 100 children between 7-14 years of age from a small village situated 30 km
from Pune. Using this data BMI i.e. Body Mass Index was calculated which helps in determining whether an
individual is overweight or underweight. Result:The overall study helped us to find out the socioeconomic
condition, hygienic condition as well as nutritional status of children. All the anthropometric measurements of the
girls and boys in 7-14 years age group was found to be significantly normal. Conclusion: The hygienic condition
of the village was good enough and in turn BMI data shows that the socioeconomic condition of the village was
also good.
Keywords: Nutritional status, BMI, Anthropometry, socioeconomic condition.
INTRODUCTION
The work focuses on the health status of the village
children as well as their nutritional status, which
reflects the hygienic condition of the village. The
main aim of this study is to provide anthropometric
data of children.1-3Anthropometry, the measurement
of body size, weight and proportions, is an intrinsic
part of any nutritional survey and can be an indicator
of health, development and growth. Anthropometric
values are closely related to nutrition, genetic
makeup, environmental characteristics, social and
cultural conditions, lifestyle, functional status and
health.4It is frequently used to assess nutritional status
and to study the growth and development of schoolaged children and adolescents. Anthropometric
evaluation is an essential feature of geriatric
nutritional evaluation for determining malnutrition,

being overweight, obesity, muscular mass loss, fat
mass gain and adipose tissue redistribution.
Socioeconomic conditions are consistent correlates of
BMI. Low Body Mass Index and high levels of under
nutrition are the major public health problems,
especially among rural underprivileged adults in
developing countries.Thus, the main objective of this
study was to establish a relationship between
nutritional statuses and the following anthropometric
parameters- weight, height and weight-height ratio.
Camps were arranged for collection of information on
the sex, age, weight and height of children from the
village.Anthropometry provides non-invasive, easy
and cheap, but yet valuable information on nutritional
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Puranik
Int J Med Res Health Sci. 2014;3(3):509-513
status. Anthropometric measures of most significance

in children include: weight and height, weight-height
ratio.1-3.Skin fold thickness at selected sites, 4-6 mid
upper arm.3,6,7 Comparing anthropometric data from
children of different ages is complicated by the fact
that children are still growing (we do not expect the
height of a 5 yr to be the same as height of a 10 yr
old) Thus, height is one of the very important
components in the anthropometric data. Literature
uses height as a marker of health as Deaton (2007)
explains, Height is determined by genetic potential
and by net nutrition, most crucially by net nutrition in
early childhood.8-11 Net nutrition is the difference
between food intake and the losses of activities and to
disease.The most commonly used indices derived
from the measurement of anthropometric data are
stunting (low height for age), wasting (low weight for
height), and underweight (low weight for age) and
overweight (high/ more weight for age). Stunting is
an indicator of chronic under nutrition, the result of
prolonged food deprivation and/or disease or illness;
wasting is an indicator of acute under nutrition, the
result of more recent food deprivation or illness,
underweight is used as a composite indicator to
reflect both acute and chronic under nutrition.12 These
indices reflect distinct biological processes and their
use is necessary for determining appropriate
interventions. However, because they overlap, none is
able to provide a proper result, some children who are
stunted will also have wasting and/or be underweight;
some children who are underweight will also have
wasting and/or be stunted; and some children who
have wasting will also be stunted and/or
underweight.13-15
MATERIAL & METHOD
The numbers of camps were arranged for the
collection of Anthropometric data. The project was
approved by the Institutional Ethics Committee. The
Anthropometric measurements of 50 girls and 50
boys in range of 7-14 years of age were taken by
using standard Anthropometric instruments.Parents
were contacted through schools and signed parental
consent was obtained for children to participatein the
study. The parents were provided with an information
sheet and the study purpose was explained in their
own language by study personnel (Marathi, Hindi,
and English). Participation was entirely voluntary and
patients data was kept confidential. In children the

most common Anthropometric indices used to
measure growth are height-for-ages, weight-for-age
and weight-for-height. Low height-for-age is
considered an indicator of shortness or stunting.
Height-for-age is the recommended indicator that best
reflects the process of failure of a child to reach linear
growth potential. Low weight-for-height for a child is
considered an indicator of thinness or wasting and is
generally associated with recent or ongoing severe
weight loss. Weight loss in children presenting low
weight-for-height is usually due to a recent illness
and/or insufficient calorie intake. Weight-for-age is
primarily a composite of weight-for-height and
height-for-age, and fails to distinguish tall, thin
children from short. Because it is influenced by both
the height of the child and the weight, it is more
difficult to interpret. The inclusion criteria for the
study was school going child, a girl or a boy of a
village, age between 7 and 14 years. Children were
excluded from the study if they were not willing to
participate and above 14 years of age.
Anthropometric measurements: - Children were
measured for height and weight without shoes and in
light clothing. Weight was measured using an
electronic digital scale and height was measured
using a height measuring board.6,7,12 BMI-for-age was
used to assess physical growth and to determine the
prevalence of overweight and underweight of the
children.
Subjects stood with their scapulae, buttocks and
heels resting against a wall, the neck was held in a
natural, non-stretched position, the heels were
touching each other, the toe tips formed a 45 degree
angle and the head was held straight.13-15.
Body Mass Index (BMI): -BMI is generally
considered a good indicator of not only the nutritional
status, but also the socioeconomic condition of a
population, especially adult populations of
developing countries. BMI was estimated by dividing
weight (kg) by square of height (m).16, 17 Individuals
were considered malnourished if their BMI was less
than 18, normal from 18-25 and overweight if more
than 25.
Descriptive statistics for all continuous variables were
presented as the mean SD. Group comparisons were
performed with the independent sample t test.
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Puranik
RESULTS
Table 1: Observed Anthropometric values of male subjects according to age.
Age
years
N
o.
7
9
10
11
12
13
7
3
8
15
8
9
Male subjects
Height
Wt/Ht
(cm)
ratio
( kg/cm)
20.921.64 10412 0.20115
23.501.80 10315 0.22815
23.922.62 11910 0.20100
25.733.90 12807 0.20101
26.182.50 12902 0.20294
30.724.94 13606 0.22588
Weight
(kg)
BMI
N
o
Weight (kg)
19.934.40
22.927.17
16.932.78
15.471.22
15.621.70
16.316.36
13
3
17
8
5
4
20.072.68
17.660.57
20.875.16
26.314.14
33.505.78
37.377.47
Female subjects
Height
Wt/Ht
(cm)
ratio
( kg/cm)
10711 0.1875
10910 0.1620
10614 0.1968
1295
0.2039
1428
0.2359
144 3
0.2595
BMI
17.884.36
15.194.30
19.206.03
15.531.78
16.381.59
17.773.14
Table 2;Standard Anthropometric values of male subjects according to age. (p<0.05)

Male subjects
Femalesubjects
Age
years
Weight
(Kg)
7
9
10
11
12
13
22.9
28.1
31.4
32.2
37
40.9
Height
(cm)
Weight
(Kg)
(kg/cm)
Diff. between
std and observed
Wt/Ht ratios
(p values)
0.18816
-0.0129
0.21255
-0.0155
0.22836
0.02736
0.23
0.02899
0.25170
0.04876
0.26732
0.04144
21.8
28.5
32.5
33.7
38.7
44
Wt/Ht
ratio
121.7
132.2
137.5
140
147
153
Height
(cm)
Wt/Ht
ratio
Diff. between std and

observed Wt/Ht ratios
(p values)
(kg/cm)
Table 3: Levels of malnutrition and obesity

BMI (wt/ht2)
Levels of malnutrition/grades of obesity
Below 16
Severe level of malnutrition.
120.6
132.2
138.3
142
148
150
0.1807
-0.0068
0.2155
0.054
0.2349
0.0381
0.2373
0.0334
0.2614
0.0255
0.2933
0.0338
No. of females
No. of males
Moderate level of malnutrition.
17.1 18.5
Mid level of malnutrition.
18.6 20
Low weight but normal.
12
17
20.1 25
Normal.
18
23
25.1 30
First grade of obesity.
Above 30
Second grade of obesity.
16 17
Comparison of the anthropometric values according

to age and gender participating subjects showed,for
each age group weight were greater in males than
females while height were greater in females.(Table
1,2).BMI was used to determine malnutrition and
overweight (Table 3).17,18Malnutrition was found in
24% of the population (<18.5 BMI); with 15% of
females and 9% males being malnourished. Data
showed that 70% of the population were normal
(BMI >18.5 &<25); with 30% of females and 40% of
males. Obesity/overweight was found in 6% of the
population (BMI >25.1); with 5% of females & 1 %
of males. (Table 3,Fig 1& Fig 2).
Fig 1: Data of female children
511
Puranik
Fig2: Data of male children

DISCUSSION
According to the 2000 Centers for Disease Control17
and Preventiongrowth charts, the majority ofchildren
who were malnourished at 7 years of age remained in
that same weight category at 5 years of age, whereas
the normal weight category was most stable
according to the International Obesity Task Force
(IOTF).13,14,19However, for both the CDC and
International Obesity Task Force references the
underweight category showed the least stability.
While in the case of adults malnourishment can occur
at any age depending on the different conditions in
which the villagers prevail also it can depend on
hygienic condition of the village as well as the
physical work performed by villagers in their day to
day life.
From a public health standpoint, it is clear that
different reference criteria can reveal dramatic
differences in prevalence estimates of pediatric
malnourishment. If a growth reference does not
adequately describe the population in question, public
health concerns may be spuriously increased or
decreased, leading to inappropriate (or lack of)
action. Furthermore, when strategies are designed to
reduce rates of pediatric underweight and
malnourishment, or if studies are planned to examine
changes in growth, the use of different references
may correspond to differences in the ability to detect
changes over time. As a means of addressing the
limitations inherent in the relative BMI
categorizations, it would be prudent to express any
changes over time in both categories (normal weight,
underweight or malnourished) and absolute terms and
not rely on a single indicator. This information would
be useful given that an increase or decrease in
absolute BMI could take place, but not correspond to
a change in the weight category if individuals do not

cross BMI threshold cutoffs.
The study has several strengths. It determined
prevalence estimates from a large sample of young
children representative of the school aged between 7
to 14 years. BMI was calculated from measured
rather than reported heights and weights. But since
the weight-height ratio is independent of age and
taking into consideration weight in relation to height,
it may be considered to have advantages over using
either weight or height singly as an index of growth
or nutritional status. Moreover, because most of the
anthropometric parameters had a close relationship
with this index. There is no internationally acceptable
index to assess childhood malnutrition nor is there an
established cutoff point to define underweight in
children. A consistent and pragmatic definition for
underweight in children and adolescents is required,
BMI may therefore be appropriate. However, other
alternatives may be considered in the future.
CONCLUSION
Almost all the anthropometric measurements of the
girls in each age group were found to be significantly
normal. The weight and weight-height ratio were not
affected to a greater extent. This is true for almost all
girls. However girls showed both overweight and
underweight conditions. 66% girls had normal
weight, 10% girls were overweight and 24% girls
were underweight. This may be due to the lack of
proper food intake or malnutrition. However
malnutrition cannot be the only factor of being
underweight, it may also be due to certain diseases or
illness. Thus the girls aged between 7-13 yrs old
showed the average height 1.15m; average weight
24.02 kg and average BMI 20.23 kg/m2. Almost all
the anthropometric measurements of the of boys were
found to be significantly normal. 86% boys had
normal weight,4% boys were overweight and 10%
boys were underweight. The boys were 7-14 yrs old
and showed the average height 1.23m, average
weight 25.40 kg, average BMI 20.135 kg/m2.
Thus the present data show that hygienic condition of
the village was good enough. And in turn BMI data
shows that the socioeconomic condition of the village
was also good.
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Puranik
ACKNOWLEDGEMENTS
The authors are grateful to thePrincipal, Modern
College of Arts, Science & Commerce, Shvajinagar,
Pune (India) for providing facilities for research. The
author acknowledges the financial support from the
University Grant Commission (UGC), Pune.
Conflict of interest: Nil
REFERENCES
1. Robinson M, Jelliffe DB. Interrelations between
anthropometric variables. A contribution to
nutritional anthropometry of infancy and early
childhood in developing countries. Proceedings
of the VIII International Congress on Nutrition,
Hamburg.1966: 8
2. Samai Mohamed, Samai Hajah H, Bash-Taqi
Donald A, Gage George N and Taqi Ahmed M
The Relationship between Nutritional Status and
Anthropometric Measurements of Preschool
Children in a Sierra Leonean Clay Factory
Displaced Camp. Sierra Leone Journal of
Biomedical Research. August, 2009: 1(1) 21-27
3. Smith DS, Brown ML. Anthropometry in
preschool children in Hawaii. Am J Clin Nutri
1970:23:7.
4. Delarue J, Constans T, Malvy D, Iradignac A,
Couet C, Lamisse F. Anthropometric values in an
elderly French population. Br. J. Nutri. 1994:71 :
295-302
5. Durnin JVGA, De Bruin H, Feunekes GIJ. Skin
folds thickness; Is there a need to be very precise
in their location? Br J Nutri. 1997: 77: 3-7
6. Marilyn D, Johnson, MS, William K, Yamanaka,
Candelaria S, Formacion MS. A comparison of
Anthropometric
methods
for
Assessing
Nutritional Status of Preschool Children. The
Phillippines study. J Trop Pediatr. 1984:30:96104
7. Sharma B, Mitra M, Chakrabarty S and Bharati P.
Nutritional status of Preschool Children of Raj
Gond a Tribal Population in Madha Pradesh,
India. Malaysian J. Nutri. 2006:12: 147-55
8. Deaton, Angus and Jean Dreze. Food and
nutrition in India: Facts and Interpretations
Economic and political Weekly, 2007: 44(7): 4265
9. Angus
Deaton
Height,
health,
and
development. Proceedings of the National
Academy of Sciences. 2007, 104(33): 13232-37
10. BallK, Crawford D. Socio economic status and

weight change in adults: a review. Soc Sci Med.
2005:60:1987-2010
11. Dean Spears.Height and cognitive achievement
among Indian children. Economics department.
Princeton University. Princeton, NJ 08540.
dspears@princeton.edu 609-258-4000 April
2011.
12. Sudesh J,Saroj B and Salil S. Nutritional status of
rural preschool children of Haryana state. Indian
J Pediatr. 2000: 67: 189-96
13. Flegal KM, Ogden CL, Wei R, Kuczmarski RL,
Johnson CL. Prevalence of overweight in US
children: Comparison of US growth charts from
the Centers for disease control and Prevention
with other reference values for body mass
index.Am. J. Clin Nutr.2001;73:1086-93
14. Lavallee C.Anthropometric measurements and
growth charts for Cree children of James Bay,
from 0 to 5 years old. Arctic Med Res. 1988;47
(S1) : 204-08
15. Muntoe M, Shah CP, Badgley R, Bain HW. Birth
weight, length, head circumference and bilirubin
level in Indian newborns in the Sioux Lookout
Zone, north-western Ontario. Can Med Assoc J.
1984;131:453-56
16. Kathleen M. Ziol-Guest, Greg J. Duncan, and
Ariel Kalil. Early Childhood Poverty and Adult
Body Mass Index.Am J. of Public health.March
2009:99:3:527-32.
17. Vidmar S,
Carlin J, Hesketh K, Cole
T.Standarding anthropometric measures in
children and adolscents with new functions for
egen. The Stata Journal. 2004: 4(1:)50-55.
18. World Health Organization. 2006. WHO Child
growth standards and the identification of severe
acute malnutrition in infants and children: A Joint
statement by the World Health Organization and
the
United
Nations
ChildrensFundhttp://www.who.int/childgrowth/s
tandards/weight_for length/en/index.
19. Noreen D. Willows, Melissa S. Johnson, Geoff
D, C Ball. Prevalence Estimates of Overweight
and Obesity in Cree Preschool Children in
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US Reference Criteria. American Journal of
Public Health. February 2007;97(2) : 311-16
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DOI: 10.5958/2319-5886.2014.00388.9

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
th
Revised: 24 Mar 2014
Accepted: 28th Apr 2014
Research Article
EFFECT OF REPETITIVE MCKENZIE LUMBAR SPINE EXERCISES ON CARDIOVASCULAR

SYSTEM
*Agrawal Sonal S
Assistant Professor, Department of Physiotherapy, V.S.P.M.s College of Physiotherapy, Nagpur, Maharashtra, India
*Corresponding author email:sonalagrawal2408@gmail.com

ABSTRACT
Background& Purpose:McKenzie exercises for the lumbar spine, which are done repeatedly, such as flexion in
standing (FIS), extension in standing flexion in lying (FIL) & extension in lying (EIL) have been used in the
management of low back pain for over three decades. The cardiovascular effects of exercises that involve postural
stabilization, arm exercises and of exercises performed in lying are well known, but there are seldom studies
performed to assess the cardiovascular effects of these commonly used McKenzie exercises. Therefore the study
focused on evaluating the effects of 4 commonly used McKenzie exercises on the cardiovascular system.Methods:
80 subjects in the age group of 20-59 years were randomly assigned into 4 groups according to their age, such that
such that each group comprised of an equal number of subjects & equal number of males & females. Each subject
performed all the 4 exercises (FIS, EIS, FIL & EIL) for 10, 15 & 20 repetitions respectively. Heart rate, blood
pressure & rate pressure product were recorded before & after each set of repetitions & after each type of
exercise. Results: Repetitive McKenzie lumbar spine exercises had cardiovascular effects in apparently healthy
subjects (both male & female). Exercises performed in lying were hemodynamically more demanding than that
performed in standing, also exercises involving flexion of the lumbar spine elicited greater cardiovascular demand
as compared to extension exercises i.e. FIL>EIL>FIS>EIS irrespective of the number of repetitions, 10, 15 or 20.
The cardiovascular demand for a given subject increased as the number of repetitions increased, for all the 4
exercises. Conclusion: McKenzie exercises when done repetitively have cardiovascular effects in healthy subjects.
Keywords: McKenzie, low back pain, cardiovascular system
INTRODUCTION
Low back pain is a condition that continues to place a
great deal of stress on the health care system of the
industrialized societies. Low back pain affects
approximately 80% of individuals in community1. It
is the second most common cause for patient visits to
physicians.1 Globally whether viewed in terms of
disability allowances, industrial injury claims, or
frequency of patients visiting physician, low back
pain is the most costly musculoskeletal condition.2
Low back pain can be extremely challenging to
prevent, diagnose and treat since its etiology is
diverse and cause often undetermined.3 Patients
suffering from low back pain as well as health care

providers who treat them are often frustrated by the
lack of progress realized during treatment &
rehabilitation programs. One reason for this may be
that treatment and rehabilitation recommendations for
low back pain vary greatly across health care
providers.4 Additionally, many of the common
treatment interventions prescribed to treat low back
pain patients have little scientific validation of their
efficacy.5
It has been suggested that several factors can
predispose people to the development of low back
514
Agrawal
pain which includes; smoking, obesity, drug abuse,

ageing, genetic predisposition, lack of physical
conditioning, occupation involving excessive
vibrating movements or positions that involve very
little movement (i.e. sedentary occupations),
occupations that involve lifting, bending and twisting.
Also poor posture, frequency of forward bending and
loss of low back extension are predisposing factors
for low back pain.6
Many low back pain treatment and rehabilitation
protocols throughout the mid and late twentieth
century, primarily utilized passive modalities such as
bed rest, ultrasound, electrical stimulation, hot packs
and medication despite their being little validation of
their efficacy. However, one of the current treatment
interventions that utilize a more active approach to
treating and rehabilitating low back pain is McKenzie
therapy.5
Forthe last three decades, McKenzie lumbar spine
exercises are being prescribed for the management of
patients with low back pain. These comprise of
repeated lumbar flexion and extension movements as
a part of routine lumbar spine assessment and
exercise program.6, 7
Moreover,less effort is made to explain about the
cautions for increasing stress on the cardiovascular
system because of these exercises. Thus,
understanding the cardiovascular responses to
McKenzie exercises can be useful for clinicians using
these exercises fordiagnostic purpose and as an
intervention.
Aim: The aim of this study was to examine the
cardiovascular effects of four common McKenzie
exercises lumbar spinal flexion and extension in
standing and lying, when these exercises are repeated
10, 15 and 20 times
Objectives:
To study the cardiovascular effects of 4 common
McKenzie exercises: Flexion in standing (FIS),
extension in standing (EIS), flexion in lying
(FIL)&extension in lying (EIL).
To study the difference in the effects after 10, 15
and 20 repetitions of 4 McKenzie exercises.
To compare the cardiovascular effects between
different exercises i.e. FIS, EIS, FIL&EIL
To compare the cardiovascular effects of these
exercises between males and females
MATERIAL AND METHODS
Study design:The study commenced after obtaining

permission from the head of the institution and the
ethical committee of the college. The study is a cross
sectional design, with the subjects parameters
measured before and after the designed exercise
protocol. The independent variables - 4 types of
McKenzie exercises i.e. FIS, EIS, FIL and EIL; while
the dependent variables - heart rate, blood pressure
(both systolic and diastolic), rate pressure product.
Study setting: Out-patient department V.S.P.M.
College of Physiotherapy
Subjects: Population of 80 subjects in the age group
of 20-59 years was selected as participants for the
study as per the inclusion criteria. Each participant
performed the complete exercise protocol to examine
the cardiovascular effects of 4 common McKenzie
exercises as described earlier.
Sample size: Subjects were equally recruited
maintaining an equal number of males and females.
All the participants were subjected to the complete
exercise protocol.
Inclusion
criteria:Apparently
healthy
and
asymptomatic subjects, age group 20 to 59 years
According to McKenzie this age range represents
individuals at risk for pathology of the spine,
specifically postural syndrome (30 years and
younger), dysfunction syndrome (30 years and older)
and derangement syndrome (20 to 55 years)6.
Exclusion criteria: Cardiovascular conditions,
pulmonary
conditions,
anemia,
recent
musculoskeletal injury, low back pain, intervertebral
or facet joint pathology, metabolic disorders,
smoking, any neurological deficit, cognitive disorders
Outcome measures:The main outcome measures used
were heart rate in beats per minute, blood pressure
both systolic and diastolic in mm of Hg and RPP
Pre-exercise protocol:The study purpose was
informed to all the participants. They were made
aware of the risks and their right to terminate
participation at any time. All subjects acknowledged
their understanding of the study and their willingness
to participate by signing a written consent.
An interview was completed by positioning the
subjects in a relaxed sitting position in a firm
armchair for 5 minutes, which elicited information
about the subjects activity and fitness levels. The
activities of subjects were rated on a 3 point scale to
establish whether the sample was homogenous
concerning activity and fitness level. The resting HR
515
Agrawal
and BP were recorded in a relaxed sitting position in

an armchair.9,10The arterial BP was obtained with an
aneroid sphygmomanometer applied to the left arm in
accordance with the American Heart Association
Standards.10
The resting HR was determined by palpating the left
radial arterial pulse. The pulse was counted for 30
seconds using a stop watch. The value was then
multiplied by 2 to obtain a minute rate.8
Individuals were familiarized with the patterns of the
exercises by verbal instructions, demonstration and
practice. Care was taken to see that the practice
session did not bring about any training effect to
avoid biasing of the study.
Exercise procedure was, according to standard
McKenzie protocol.11
Fig-1: McKenzie Lumbar spine exercises

Each subject performed all 4 types of above
mentioned exercises for 10, 15 and 20 repetitions
respectively in a single sitting. Subject was supposed
to return to the resting position within 30 seconds.8
The HR and BP of the subjects were then recorded.
Care was taken that the parameters were recorded
within 2 minutes.10 The RPP (Rate pressure product)
was calculated by multiplying the product of HR and
Systolic BP by 10-2.
The subjects were instructed to perform the exercises

in a continuous rhythm. The rhythm was dictated by
the therapist such that on average, each subject could
complete 20 repetitions in 1 minute.8 On each
movement, the subject reaches the maximum possible
range for all the movements and maintains the
position for one second before the next
repetition. Breath holding was not allowed during the
exercise. 15 minutes of rest period was allowed after
each set of 10, 15 & 20 repetitions of each of the 4
exercises and also 15 minutes of gap betweenchange
in the type of McKenzie exercise.
Data analysis : Descriptive statistics for the
dependent measures, including means and standard
deviations were calculated for each set of the 4
exercises i.e. Flexion in standing, extension in
standing, flexion in lying and extension in lying and
for each group i.e. 1, 2, 3, and 4.
Statistically the characteristics of the groups and the
results were compared using One- way ANOVA and
Paired and Unpaired t tests.
Statistically the characteristics of the groups and the
results were compared using One- way ANOVA and
Paired and Unpaired t tests.
A one-way analysis of variance (ANOVA) for
repeated measures was used to compare the
dependent measurements after performing all the four
exercises for 10, 15 and 20 repetitions respectively. It
was performed for both male and female subjects.
Paired t- test was used to analyze the difference in the
mean values of RPP within four types of McKenzie
exercises for 10, 15 and 20 repetitions in males.
Unpaired t- test was used to analyze the difference
between the mean RPP values of males and females
after performing four types of McKenzie exercises
for 10, 15 and 20 repetitions.
The level of significance was set at 0.05 for all the
comparisons.
RESULTS
Table 1: Mean & standard deviation for RPP
Male
Female
Exercise
10 Repetition 15 Repetition 20 Repetition
10 Repetition
15 Repetition
20 Repetition
FIL
116.946.90 123.956.10 131.348.45
105.166.48
112.076.22
112.076.22
EIL
109.865.04 116.157.23 123.277.71
98.011.20
102.925.32
102.925.32
FIS
104.535.69 111.556.9
117.147.79
93.327.52
97.466.89
97.466.89
EIS
100.265.50 104.436.43 110.358.25
86.146.24
88.897.57
88.897.57
Flexion in standing (FIS), extension in standing (EIS), flexion in lying (FIL)& extension in lying (EIL).
Table 2: Comparing for the effects of different exercises in males, after applying One-Way ANOVA
516
Agrawal
ANOVA Table for Males

Variable
Source
df
F
p-value
Inference
RPP
after Between Exercise Groups 3
7.74e-16
10
31.1553
Highlysignificant
Within Exercise Groups
156
repetitions
< 2.2e-16
RPP after 15 Between Exercise Groups 3
(34.428)
Highlysignificant
repetitions
37.1464
(156)155
(38.0165)
< 2.2e-16
Highlysignificant
repetitions
(156)154, 41.5182
The above Table shows that p<0.05, i.e. there is significant difference between the effects of different exercises
on the mean values of RPP of males whatever may be the number of repetitions.
Table3: Comparing for the effects of different exercises in females, after applying One-Way ANOVA
ANOVA Table for Females
Variable
Source
df
F
p-value
Inference
RPP
after Between Exercise Groups 3
23.7331
1.044e-12
Highlysignificant
10 repetitions Within Exercise Groups
156
35.4009
< 2.2e-16
Highlysignificant
repetitions
156
45.2708
< 2.2e-16
Highlysignificant
repetitions
156
The above Table shows that p<0.05, i.e. there is significant difference between the effects of different exercises on the mean
values of RPP of females whatever may be the number of repetitions.
Table 4: Comparison between the effects of exercises in females using paired t-test
10 Repetition
15 Repetition
20 Repetition
Exercise
t value
p value
t value
p value
t value
EIS vs EIL
9.49
0.000
9.58
0.000
11.45
EIS vs FIS
5.57
0.000
7.06
0.000
7.74
EIS vs FIL
3.31
0.001
3.97
0.00015
5.44
EIL vs FIS
13.36
0.000
14.95
0.000
17.39
EIL vs FIL
8.90
0.000
9.29
0.000
11.92
FIS vs FIL
7.54
0.000
9.95
0.000
11.66
p value
0.000
0.000
0.000
0.000
0.000
0.000
Flexion in standing (FIS), extension in standing (EIS), flexion in lying (FIL) & extension in lying (EIL).
Table 5: Comparison between the effects of exercises in males using paired t-test
10 Repetition
15 Repetition
20 Repetition
Exercise
t value
p value
t value
p value
t value
p value
EIS vs EIL
8.77
0.000
7.63
0.000
7.23
0.000
EIS vs FIS
6.06
0.000
5.24
0.000
4.46
0.000
EIS vs FIL
11.94
0.000
2.87
0.005
3.54
0.0007
EIL vs FIS
4.44
0.000
13.93
0.000
11.24
0.000
EIL vs FIL
FIS vs FIL
5.23
8.13
0.000
0.000
7.22
8.50
0.000
0.000
6.92
7.82
0.000
0.000
Flexion in standing (FIS), extension in standing (EIS), flexion in lying (FIL) & extension in lying (EIL).
Table 6: Comparison between mean RPP values of

males and females using unpaired t-test
Exercise Repetitions
10
Agrawal
t-value
0.0669
p value
0.47
517
FIS
15
1.3468
0.09
20
1.9517
0.02*
10
1.4104
0.08
15
1.9002
0.03*
EIS
20
2.3787
0.009*
10
0.3629
0.35
15
0.4224
0.33
FIL
20
0.8806
0.19
10
0.4028
0.34
15
0.6745
0.25
EIL
20
0.8833
0.19
The Table shows that p values are significant i.e.
p<0.05 only in 3 cases. Therefore it can be concluded
that mean values of RPP does not differ significantly
between males and females except when EIS is
repeated 15 or 20 times and when FIS is repeated 20
times.
FIL
Increased Mean
Female
EIL
FIS
EIS
40
35
30
25
20
15
10
5
0
10
15
Repetition
20
Fig
2:Mean
RPP
increases
such
that
FIL>EIL>FIS>EIS in females after any number of
repetitions.
FIL
Increased Mean
Male
EIL
FIS
EIS
40
35
30
25
20
15
10
5
0
10
15
Repetition
20
Fig 3: Mean RPP increases such that

FIL>EIL>FIS>EIS in males whatever may be the
number of repetitions.
DISCUSSION
As a result of data analysis repetitive McKenzie

exercises for the lumbar spine elicit significant
hemodynamic stress in healthy subjects both males
and females. [p<0.001] These exercises increase the
work of the heart in people with no known spinal
impairments
and
no
cardiovascular
or
cardiopulmonary insufficiencies. It was found that the
cardiovascular demand increased as the number of
repetitions for a given type of exercise increased.
Richardson D, stated that the magnitude and
frequency of active muscular contractions also affect
the blood flow. The muscle metabolism increases in
response to voluntary contractions, and therefore
blood flow to the active musculature.12
Claire P. Kispert, proposed that RPP has been shown
to be a valid predictor of myocardial VO2 for
measurements performed at rest and during exercise.
The measurements of RPP is useful in clinical
settings because both HR and SBP are easily obtained
as noninvasive measurements.13
Gobel FL, Nordstom LA, et al concluded in their
study that heart rate and rate pressure product, both
are easily measured hemodynamic variables andgood
predictors of mixed venous oxygen saturation
(MVO2) during exercise in ischemic heart disease
patients with normal blood pressure.14
The results strongly support the idea that these
McKenzie exercises performed within 1 minute
represents a risk for a patient with underlying
cardiovascular dysfunction. The degree to which an
increase in RPP is an index of cardiovascular stress,
represents cardiovascular strain depends on the
underlying path physiology. Thus a given absolute
increase of RPP may be inconsequential in a person
without cardiovascular or pulmonary pathology;
however, it may constitute marked hemodynamic
strain in an individual with such pathology.13
It was found that mean RPP values were greater after
20 repetitions of each of the 4 exercises when
compared to mean RPP values after 10 and 15
repetitions. The mean RPP values were also greater
during the exercises which were performed in lying
position than in upright position both in male and
female subjects (FIL>EIL>FIS>EIS) . This finding is
consistent with known physiology.15
Tommy Boonestated that cardiac output increases
when lying down versus standing 16 which is
consistent with the results of the study.
518
Agrawal
The work of a large muscle mass of the upper and

lower extremities, theabdominal muscles, and the
trunk muscles are involved in flexion in lying.11
Christensen EH, Astrand PO, in their work concluded
that volume of oxygen consumed during physical
exercise is necessarily dependent upon the load on the
muscles and also on the mass of the muscles at work.
Work with legs can bring the metabolism to a higher
level than can exercise performed by the arms.17 All
these researches confirm that there is increased
oxygen demand by the contracting muscleswhich in
turn increases the HR, BP, cardiac output and stroke
volume.11
On the other hand, EILis an exercise that involves the
workof upper extremity muscles while raising the
upper trunk against gravity.11
Several studies by Bevgard S, Freyschuss V,
Strandell T, Stenberg J, Astrand P O, Astrand I, Asit
G, John W; in their study concluded that arm exercise
in comparison with leg exercise is accompanied by a
large rise in heart rate, blood pressure, pulmonary
ventilation, and arterial lactate concentration and this
difference are attributed to more dominating
sympathetic vasoconstriction tone during arm
exercise. 18
Flexion in lying, however is additionally associated
with inadvertent holding of breath and increased
intrathoracic pressure, leading to increased resistance
to blood returning to the heart and thus there is a
reflex increase in the HR and BP.11 Thus there is
increased workload on the heart during FIL as
compared to EIL, which is also in accordance with
the results of this study.
The range of motion during back extension is less
than during flexion, therefore there is presumably less
muscle work, and therefore, less work of the heart in
extension compared with flexion, in both standing
and lying positions. This fact was also confirmed by
the results of the current study. (EIS<FIS)
When the mean RPPs of males and females were
compared, it was found that RPP for females were
smaller than their counterpart males except in a few
cases. However, significant differences were found
only when EIS was repeated 15 or 20 times and when
FIS was repeated 20 times.
Bengstsson C19,stated that several studies from
industrialized countries have reported age associated
changes in both systolic (SBP) and diastolic (DBP)
blood pressures. These changes in blood pressures
seem to be different for SBP and DBP and have also

been reported to be different in male and female
subjects.Claire P. Kispert13 in his article stated that, in
general BP is lower for women younger than 40 to 50
years in comparison with men of this age group
which also supports the findings of the present study.
The study indicates that before administering
McKenzie exercises to any patient having spinal
problem cardiovascular status should be examined.
This
study
recommends
that, ruling
out
cardiovascular and pulmonary disease by history
taking alone isnot sufficient and cardiac and
pulmonary risk factor assessment should be done
before prescribing McKenzieexercises. The results of
the study suggest that baseline heart rate and blood
pressure should be recorded routinely. Cardiovascular
monitoringshould also be taught to the patient
themselves so that cardiovascular monitoring can be
performed when repetitive McKenzie exercises for
the lumbar spine are performed as a home exercise
program. Also whenpatients are following McKenzie
protocol as home exercise program care should be
taken those they dont exceed the prescribed number
of repetitions. It is also suggested that when
prescribing FIL which was found to have highest
cardiovascular demand, physical therapist should
closely monitor the patient. Patients should
discourage for breath holding or straining during the
exercise. Patients should be taught to self monitor
their cardiovascular parameters who are knownto
have risk factors for cardiovascular disease.
However till date there are seldom studies
documented on the adverse cardiovascular effects of
McKenzie exercises; therefore awareness of their
effects is important for the judicious prescription of
designed exercise protocol.
CONCLUSION
McKenzie exercises for the lumbar spine i.e. FIS,
EIS, FIL, and EIL performed repetitively i.e. for 10,
15 & 20 repetitions at are routinely used in the
assessment & management of low back pain. This
study found that these exercises have cardiovascular
effects in otherwise healthy individuals & who are
within age group of 20-59 years.FIL>EIL>FIS>EISin
males as well as females and this effect is accentuated
with increasing number of repetitions.Further
research is needed to elucidate factors that increase
the risk for a given patient. Electrocardiographic
519
Agrawal
studies would help establish the effects of these

exercises on cardiac rhythm and provide a guide for
proper prescription of McKenzie exercises.
Limitation:Only non invasive outcome measures
were used for cardiovascular evaluation
REFERENCES
1. Anderson G.Epidemiological features of chronic
Low back pain. Lancet. 1999;354:581-85
2. Videman T, Battie M. A critical review of the
epidemiology of idiopathic low back pain. In:
Weinsterin J, ed. A scientific & clinical
overview. Illinois: American Academy of
orthopedic surgeons, Illinois; 1996;317-32
3. Deyo R A, Cherkin D, Cohrad D, Volinn E. Cost,
controversy Crisis: Low back pain & the health
of the public. Annu. Rev. Public Health. 1991;
12: 141-56
4. Lively MW. Sports Medicine approach to low
back pain. South Med J. 2002; 95: 642-46
5. Polatin P. The functional restoration approach to
chronic low back pain Journal of musculoskeletal
medicine. 1990; 7 : 17-30
6. McKenzie RA. The lumbar Spine: Mechanical
Diagnosis & Therapy. Waikane, New Zealand:
Spinal Publications. 1981; 27-80
7. Stankovic R., Johnell O. 1995; Conservative
treatment of acute low back pain. 5 years follow
up study of two methods of treatment. Spine.
1981; 20: 469-72
8. Astrand PO, Rodahl K. Textbook of Work
Physiology 3rd ed. New York, N Y : McGrawHill Inc.1986
9. Astrand I. Circulatory responses to arm exercise
in different work positions. Scand. J. Clin. Lab
Invest. 1971; 27: 293-97
10. Bevegard S, Freyschuss U, Strandell T.
Circulatory adaptation to arm & leg exercise in
supine & sitting position. J. Appl. Physiol. 1966;
1:37-46
11. Al Obaidi S., Anthony J., Dean E, Al Suwai N.
Cardiovascular
Responses
to
Repetitive
McKenzie lumbar spine exercises; Phys. Ther.
2001; 81: 1524-33
12. Richardson D. Blood Flow responses of human
calf muscle to static contraction at various
percentages of MVC. J. Appl. Physiol: Respirat
Environ Exercise Physiol. 1981; 51: 92933

13. Kispert CP. Clinical Measurements to assess
cardiopulmonary function. Phys. Ther. Dec 1987;
67: 12, 1886-90
14. Gobel FL, Nordstrom LA, Nelson RR. The rate
pressure product as an index of myocardial
oxygen consumption during exercise in patients
with angina pectoris; Circulation. 1978 ; 57: 54956
15. Mc Ardle WD, Katch FI, Katch VL. Essentials of
Exercise Physiology. Philadelphia, Pa: Lea &
Febiger. 1994
16. Ferreira ML, Ferreira PH, Latimer J, Herbest R,
Maher CG. Does Spinal manipulative therapy,
help people with chronic low back pain?
Australian Journal of Physiotherapy. 2003;48:
277-83
17. Astrand PO, Saltin B. Maximal oxygen uptake &
heart rate in various types of muscle activity. J.
Appl. Physiol. 1961; 16: 977-83
18. Astrand I, Asit G, John W. Circulatory responses
to arm exercise with different arm positions. J.
Appl. Physio. 1968;25:525-32
19. Landahl S, Bengtsson C, Sigurdsson JA,
Svanborg A, Svardsudd K. November 1986; Age
Related
Changes
in
Blood
pressure.
Hypertension. 1968; 8(11): 10449
520
Agrawal
DOI: 10.5958/2319-5886.2014.00389.0

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Research Article
VALVULAR HEART DISEASES AND ITS IMPACT: AN ASSESSMENT AMONG PATIENTS

ATTENDING A TERTIARY HOSPITAL IN KOLKATA
*Dey Indira1, Das Bhaskar2, Dey Subrata3
1
Associate Professor, Department of Community Medicine, NRS Medical College, Kolkata, India
Assistant Professor, 3Professor, Department of Cardiothoracic and Vascular Surgery, RGKar Medical College,
Kolkata, India
2
*Corresponding authoremail: indiradeypal@rediffmail.com

ABSTRACT
Background:Valvular heart diseases(VHD) are an important cause of morbidity and mortality worldwide and
rheumatic fever still continues to be a contributing factor to VHD in the developing nations like India. This
enormous disease burden often translates into huge economic and social losses. Aims: This study was undertaken
to identify the sociodemographic characteristics of the patients with VHD, to find the frequency of different types
of valvular diseases and their etiologies and the effect of such diseases on daily living. Materials and Methods:A
hospital based observational study was carried out among the patients with VHD attending Cardiothoracic and
Vascular Surgery OPD from April,2013 to Dec,2013.Data collection was done using a predesigned and pretested
schedule after taking informed consent.Result;Out of the 108 patients majority were males and resided in rural
areas. Their mean age was 36.39 13.88. Mitral stenosis was found to be the commonest single valve lesion and
most of the VHDs were of rheumatic origin. In 32.4% of the cases outdoor activities were completely restricted.
Out of the 62 patients working outside, 40.2% were mostly absent from their workplace.Conclusion:Mitral
stenosis of rheumatic origin was found to be the commonest type of valvular heart disease in this part. This study
reveals that valvular heart disease of rheumatic origin stillexists in our society. So preventive measures, diagnosis
and management of valvular diseases should not be neglected and we need to provide preventive services in cases
of rheumatic fever to reduce the development of VHD.
Keywords: Valvular heart diseases, rheumatic heart disease, impact assessment
INTRODUCTION
The epidemiology of valvular heart disease (VHD)
has changed dramatically over the past 50 years in
developed nations. Valvular heart diseases have a
significant contribution to morbidity and mortality
worldwide.1,2While degenerative valvular diseases
predominates in the developed nations, rheumatic
fever and rheumatic heart disease still continues to be
a major health care concern in the developing
countries among both children and adults.3-6VHD is
still common and often requires intervention. In
India, rheumatic fever is endemic and remains one of
Indira et al.,
the major causes of cardiovascular disease,

accounting for nearly 25-45% of the acquired heart
disease.7,8Moreover, important changes have occurred
regarding the presentation and treatment of the
disease over recent years and there are very few
surveys in the field of VHD as compared with other
heart diseases.9Doubt still persists regarding the
generally perceived decline in the prevalence of RHD
in India.10-12 Inadequacy of hospital admission
statistics and varying individual hospital admission
521
policies greatly influence the prevalence data

obtained from these sources. 7
Furthermore, research concerning the epidemiology,
pathophysiology and clinical management of VHD is
limited.Data regarding the contemporary prevalence
and natural history of VHD are required to the
economists and policy makers responsible for
healthcare planning for allocation of resources to
newer developments, such as percutaneous valve
implantation and repair.13,14
This enormous disease burden translates into huge
economic and social losses.The potential detrimental
effect of valvular heart disease on the activities of
daily living is unknown. These patients continue to
suffer from the illness, their productivity is lost, and
imposes an economical burden on their family and
country. So, this study was undertaken to identify the
socio-demographic characteristics of the patients with
VHD, to find the frequency of different types of
valvular diseases and their etiologies and the effect of
such diseases on daily living.
MATERIALS AND METHODS
A hospital based observational study was carried out
among the patients (n=108), age of the patients varied
from 11 to 65 years of both sex with VHD attending
Cardiothoracic and Vascular Surgery OPD from
April,2013toDec 2013.This is a tertiary medical
college and hospital, catering to population referred
from all over the state of West Bengal. The centre has
cardiac catheterization laboratories and cardiac
surgical facilities as well. The study population
consisted of patients in whom VHD was ascertained
by echocardiography or patients who had undergone
any operation on a cardiac valve (percutaneous
balloon commissureotomy, valve repair, valve
replacement).Ethical clearance was obtained from the
institutional ethics committee. The purpose of the
study was briefed to the patients and their consent for
participation was obtained. A pre-designed and pretested schedule consisting details regarding sociodemographic,
clinical,
echocardiographic
characteristics, and treatment modalitieswas used for
data collection. The effect of the disease was assessed
by finding the difficulties in carrying out daily
activities, participation in out-door activities, number
of days absent from the workplace and monthly
expenditure on the disease.
Indira et al.,
Statistical Analysis: Data were entered in MS Excel

and results are presented as mean and standard
deviation and percentages.
RESULTS
A total of 108 patients with valvular heart disease
attended the Cardio Thoracic and Vascular Surgery
OPD of the tertiary hospital during the period of data
collection. The age of the patients varied from 11 to
65 years with most of the patients lying between 30 to
40 yrs of age. Only 4.6% belonged to geriatric age.
Mean age of the patients was 36.3913.88.
Majority of the patients with VHD were male
(53.7%), belonged to Hinduism (60.2%) and attended
the OPD from rural area (62%). Most of the patients
with VHD completed middle school, but 15.7% were
found to be illiterate. A high proportion of the male
patients were farmers and almost all the females were
engaged in household activities, 7.45 of the patients
were found to be students.(Table1).
The heart valves are responsible for the transport of
blood from one chamber of the heart to another or to
a great vessel. Abnormalities of the valves may be
congenital like malformed leaflets or acquired like
valvular
stenosis(stiff
valves)
or
valvular
insufficiency (leaky valves) leading to regurgitation
of blood. Out of 108 patients attending OPD, 65.7%
were treated medically and the rest had undergone
previous cardiac interventions. Among the patients
undergoing medical treatment, 43.7% suffered from
multiple valvular disease mostly of the left while
right sided lesions were infrequent. Mitral stenosis
was found to be the commonest type of single valve
disease followed by mitral regurgitation. Valve
replacement was done in 67.6% of the operated
patients, whereas the rest underwent conservative
surgery like CMV and TVMC (FIG; 1). The valvular
heart diseases identified were predominantly of
rheumatic origin. Degenerative and congenital causes
were present in only 15% of the cases. The patients of
VHD presented with shortness of breath, weakness or
dizziness to carry out normal activities, chest
discomfort, palpitations and pedal edema.
During the study, 36.1% of the patients were in
NYHA (New York Heart Association)18Cl I, 50.9%
in Cl II and the rest in Cl III. Major co morbidities
present among the cases were cardiovascular
accidents, lower limb ischemia and myocardial
infarction.
522
The impact of VHD on activities of daily living was

also assessed among the patients. All the patients
were able to carry out their daily indoor activities, but
in 32.4% of the cases outdoor activities were
completely restricted and 7.4% perform outdoor
activities occasionally.Whether the disease had any
effect on the occupation of the person was also asked
for. This was not applicable for those engaged only in
household activities. Out of the rest 40.3% mentioned
that they were mostly absent from their workplace
because of the disease.(Table-2)
Table 1: Socio-demographic profile of the valvular
disease patients
Characteristics
Number Percentage
AGE
11 - 20
16
14.81
21 - 30
25
23.14
31 - 40
33
30.65
41 - 50
10
9.35
51 - 60
19
17.61
> 60
5
4.6
SEX
Male
58
53.7
Female
50
46.3
RELIGION
Hindu
65
60.2
Muslim
43
39.8
RESIDENCE
Urban
41
38
Rural
67
62
EDUCATION
Illiterate
17
15.7
Primary
7
6.5
Middle school
36
33.3
Secondary
10
9.3
High secondary
19
17.6
Graduate
19
17.6
OCCUPATION
Farmer
19
17.6
Household
46
42.6
activities
Industrial worker
7
6.5
Student
8
7.4
Skilled worker
4
3.7
Service
7
6.5
Others
17
15.7
Total
108
100
Indira et al.,
Fig1: Distribution of VHD patients attending the

OPD
Table 2: Impact of VHD on daily living
%
Can perform outdoor Number(108)
activities
Yes
65
60.2
No
35
32.4
Occasional
8
7.4
%
Absence from work Number(62)
place
Mostly
25
40.3
Occasionally
7
11.3
No
30
48.4
DISCUSSION
Present study carried out in a tertiary hospital of
Kolkata revealed that most of the valvular heart
disease patients were in their 2nd, 3rd or 4th decade of
life with a mean age of 36.4 years. The Euro Heart
Survey9 carried out in a number of medical centresof
Europe found the mean age for VHD patients to be
64+ 14 yrs. This higher age groupinvolvement in
developed countries is because of the fact that the
valvular diseases are mainly of degenerative origin
while in our place they are commonly of rheumatic
origin affecting the younger age groups. Mitral
stenosis and regurgitation were found to be the
commonest valvular disease in this study,
whereasThe Euro Heart Survey9showed that AS was
the most frequent type of single valvular disease
followed by AR. The multiple valve disease was
significant, whereas right sided lesion was infrequent
in both the studies.
A community based study carried out among the
nonagenarians of Leiden, The Netherlands revealed
that the left sided valvular diseases were in high
523
proportions, mitral and aortic regurgitations being the

commonest valvular disease and no patient had mitral
stenosis. 8 This discrepancy may be due to the fact
that aortic and mitral stenosis are characterized by
poor clinical tolerance and therefore may determine
higher hospital attendance and higher prevalence of
these heart disease in hospital based studies.
Rheumatic fever is still common in developing
countries like India. This is supported by the fact that
in 85% of cases the diseases were of rheumatic
origin, whereas Euro Survey revealed that they were
mostly degenerative.Trends in hospitalization of
cardiac cases in Cuttack16, population survey done in
the villages of Northern India17 and autopsy series
from Mumbai18also revealed that Rheumatic fever &
RHD still contributes to a large number of cardiac
cases in India Diagnosis is done based on history,
clinical features and Echocardiography.
The present study revealed that in 32.4% of the cases
outdoor activities were completely restricted and
7.4% perform outdoor activities occasionally. Out of
those engaged in various employment 40.3%
mentioned that they mostly remain absent from their
workplace because of the disease. However, the
community based study carried out among the
nonagenarians of Leiden; The Netherlands found no
significant difference in daily activities between those
having the disease and others. This may be because of
the fact that they studied the population above 90
years who are engaged in very little daily activities
because of their age.
This study reveals that VHD in India is mostly of
rheumatic origin affecting the productive population
of the country. So we need to continue early detection
and treatment of rheumatic fever in the susceptible
population to reduce the occurrence of valvular heart
diseases.
There is need for carrying out a population based
epidemiological study to derive the actual prevalence
of different types of VHD and their effect on daily
life because the selection of hospital may have
introduced a selection bias.
CONCLUSION
Mitral stenosis of rheumatic origin was found to be
the commonest type of valvular heart disease in this
part. This study reveals that valvular heart disease of
rheumatic origin still exists in our society. So
preventive measures, diagnosis and management of
Indira et al.,
valvular diseases should not be neglected and we

need to provide preventive services in cases of
rheumatic fever to reduce the development of VHD.
ACKNOWLEDGEMENT
We would like to thank the HOD, Dept of CTVS,
RGKar Medical College for allowing us to conduct
the study and all the patients who had answered our
enquiries with patience.
REFERENCES
1. Chambers JB, Shah BN,Prendergast B, Lawford
PV, McCann GP, Newby DE, Ray S et al.
Valvular heart disease: a call for global
collaborative research initiatives. Heart 2013; 99:
1797-99
2. Mohty D, Enriquez-Sarano M, Pislaru S. Valvular
heart disease in elderly adults.www.update.com/
contents/ valvular-heart-disease-in-elderford PV,
ly-adults dt.04.2.2014.
3. Jacob Jose V, Gomathi M. Declining prevalence
of Rheumatic Heart Disease in rural school
children in India: 2001-2002.Indian Heart Journal
2003; 55(2) :158-60
4. Eisenberg MJ. Rheumatic heart disease in the
developing world: prevalence, prevention and
control. European Heart Journal 1993;14(1):12228
5. Periwal KL, Gupta BK, Panwar RB, Khatri PC,
Raja S, Gupta R. Prevalence of Rheumatic Heart
disease in school children in Bikaner: An
echocardiographic study. J Assoc Physicians
India 2006; 54:279-82
6. Nobuyoshi M, Arita T, Shirai S, Hamasaki N,
Yokoi H, Iwabuchi M, Yasumoto H, Nosaka H.
Heart Disease in Asia. Percutaneous Balloon
Mitral Valvuloplasty. A Review. Circulation.
2009; 119: e211-19
7. Vijaylakshmi IB. Acute Rheumatic Fever:
Current
Scenario
in
India:
www.apindia.org/pdf/medicine_update_2012/car
diology- 07.pdf.
8. Parks Text book of Preventive and Social
Medicine. Bhanot publishers, Jabalpur. 2011;21st
ed:350-52
9. Lung B, Baron G, Butchart EG, Delahaye F,
Gohike BC, Levang OW etal. A prospective
survey of patients with valvular heart disease in
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14.
15.
16.
17.
18.
Europe: The Euro Heart Survey on Valvular

Heart Disease. European Heart Journal 2003,
24:1231-43
Krishna Kumar R, Tandon R. Rheumatic fever
and rheumatic heart disease: The last 50 years.
Indian Journal of Medical Research 2013;137
(4):643-58.
Padmavati S. Epidemiology of cardiovascular
disease in India: I. Rheumatic Heart Disease.
Circulation.1962; 25: 703-10.
Faheem, Hafizullah M, Gul A, Jan H, Khan M A.
Pattern of valvular lesions in Rheumatic heart
disease. JPMI. 2007;21(2):99-103
Ramakrishnan, Shyam S Kothari, Rajnish Juneja,
Balram Bhargava, Anita Saxena, Vinay k Bahl.
Prevalence of rheumatic heart disease: Has it
declined in India? The National Medical Journal
of India, 2009;22(2):72-74
Thomas van Bemmel, Victoria Delgado, Jeroen J
Bax, Jacobijn Gussekloo, Gerard J Blauw, Rudi
G Westendorp, Eduard R Holman. Impact of
valvular heart disease on activities of daily living
of nonagenarians: the leiden 85-plus study a
population based study. BMC Geriatrics 2010,10:
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525
DOI: 10.5958/2319-5886.2014.00390.7

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Received: 5 Mar 2014
Coden: IJMRHS
Revised: 6th Apr 2014
Copyright @2014
ISSN: 2319-5886
Accepted: 26thMay 2014
Research Article
ISOLATION AND SPECIATIONOF ENTEROCOCCI FROM VARIOUS CLINICAL SAMPLES AND

THEIR ANTIMICROBIAL SUSCEPTIBILITY PATTERN WITH SPECIAL REFERENCE TO HIGH
LEVEL AMINOGLYCOSIDE RESISTANCE
Saroj Golia1, *Nirmala AR2, Asha S Kamath B2
1
Professor and HOD, 2Post Graduate student, Dr B R Ambedkar Medical College,Bangalore, Karnataka, India
* Corresponding author email:dr.nirmalasri@gmail.com

ABSTRACT
Background and Objectives: Enterococci are important nosocomial agents and strains resistant to penicillin and
other antibiotics occur frequently. Enterococci are intrinsically resistant to cephalosporins and offer low level
resistance to aminoglycosides. In penicillin sensitive strains, synergism occurs with combination treatment with
penicillin and aminoglycoside. Serious infections caused by them are treated with penicillin and aminoglycoside
combination. But the synergistic effect is lost, when the strain develops high level aminoglycoside resistance. The
choice of drug for infections due to such strains is vancomycin. The present study was carried out to isolate and
speciateEnterococci from various clinical samples, to know the susceptibility pattern of the isolates, to determine
the High Level Aminoglycoside Resistance (HLAR) among Enterococcal isolates.Methods: A total of One
hundred Enterococcal species isolated from various clinical samples were identified by various biochemical
reactions.Antimicrobial susceptibilitytesting and HLAR were determined by Kirby- Bauer disc diffusion
method.Results: Out of 100 Enterococcal isolates, 59 were E.faecalis, 38 were E. faecium,3 were other
Enterococcal species. Among these 53 isolates showed High Level Aminoglycoside Resistance. Conclusion:
Present study shows the presence of drug resistance to most of commonly used antibiotics and HLAR is also more
in E.faecium compared to E.fecalis.
Keywords: Enterococci, High level aminoglycoside resistance.
INTRODUCTION
The Genus Enterococcus consists of Gram positive,
aerobic and facultative anaerobic organisms that are
oval in shape and may appear on smears in pairs, as
singles or short chains. E. fecalis is the most common
isolate, being associated with 80-90 % of human
Enterococcal infections.1
Enterococcus species cause urinary tract infections,
bacteremia, endocarditis, intraabdominal and pelvic
infections, wound and soft tissue infections. 2 High
level aminoglycoside resistance,
glycopeptides
resistance and beta lactamase production in
SarojGoliaet al.,
Enterococci causing treatment difficulties in

hospitals.3
Drug resistant Enterococci are due to indiscriminate
use of antibiotics, diabetes mellitus, prolonged
hospital
stay
and
immunocompromised
states.3Enterococci are intrinsically resistant to
cephalosporins and also low level aminoglycoside
resistance. Infections due to Enterococci are treated
with penicillin and aminoglycoside.This synergism is
lost if the strain develops high level aminoglycoside
resistance.4The present study was done to know the
antimicrobial susceptibility including HLAR
detection in various Enterococci species.
526

The present study was done in the department of
Microbiology,
Dr.B.R.Ambedkar
Medical
College,Bangalore, over a period of one year and four
months from September 2012 to December 2013.A
total of 100 Enterococci isolates from various clinical
samples (urine, pus, wound swabs, blood and other
body fluids) from both OPD and IPD
(Medicine,Surgery,OBG,Paediatrics
Departments)
were included in the study. Urine samples were
inoculated on Cysteine Lactose Electrolyte Deficient
(CLED) medium.5 Blood samples were processed in
blood culture bottles containing glucose broth and the
remaining clinical specimens were processed on
blood agar and MacConkeys agar. All plates were
incubated aerobically at 37oC for 24-48 h and
examined for microbial growth. Enterococci were
identified using standard methods.1 Based on colony
morphology, Gram staining, catalase reaction, bile
esculin test, growth in 6.5% NaCl and sugar
fermentation reactions. 1 Isolates were identified by
standard biochemical tests.1
Antimicrobial sensitivity testing was done on MullerHinton agar by standard disc diffusion methods as per
Clinical Laboratory StandardsInstitute (CLSI)
guidelines.6
The antibiotics tested were as follows: Penicillin
(10U), Ampicillin (10ug),Ciprofloxacin (5ug),
Vancomycin
(30ug),Linezolid
(30ug)and
Tetracycline (30ug).
Quality control :E. faecalis ATCC 29212 was used .

All the clinical Isolates were detected for HLAR as
per CLSI guidelines using high content Gentamicin
(120ug) and high content Streptomycin (300ug) discs.
A zone of inhibition <6mm indicated as resistant, 7-9
mm inconclusive, >10mm as sensitive.6
RESULTS
Of the 100 samples, 61 were males and 39 were
females. Various Enterococcal species isolated were
E. faecalis (59), E.faecium (38), E.dispar (02) and
E.durans (01).
E.faecium isolates were more resistant to various
antibiotics-Penicillin(52%),
Ampicillin
(58%),
Ciprofloxacin(82%),
Vancomycin
(05%),Linezolid(03%)
and
Tetracycline(62%).E.faecaliswere
resistant
to
Penicillin (48%), Ampicillin (40%), Ciprofloxacin
(70%), Vancomycin (02%), Linezolid (02%) and
Tetracycline (55%).
HLAR was detected in 53% of isolates. HLAR
among E. faecium isolates (58%) were higher
thanE.fecalis
(48%). High level resistance to
gentamicin and streptomycin among E. fecalis strains
were 56% and 40% respectively. High level
resistance to gentamicin and streptomycin among
E.faecium strains were 68% and 48% respectively.
Combined resistance to both aminoglycosides was
slightly higher in E. faecium (58%) isolates as
compared with E. fecalis (48%).
Table 1: Details of type of specimens from which isolates were obtained
Sr.
no.
1
2
3
4
5
Specimen(n=100)
E. faecalis(%)
E.faecium(%)
Urine
Pus
Sputum
Blood
Total
38
10
06
05
59
22
08
05
03
38
E.dispar
(%)
01
01
02
E.durans
(%)
01
01
Table 2: Resistance pattern ofE.faecium
Sr.
no.
1
2
3
4
5
Specimen(n=38)
Urine
Pus
Sputum
Blood
Total
Penicillin
(%)
34
09
05
04
52
Ampicillin
(%)
40
08
05
05
58
Ciprofloxacin
(%)
65
10
04
03
82
Vancomycin
(%)
03
02
05
Linezolid Tetracycline
(%)
(%)
01
48
01
08
03
01
03
03
62
527
SarojGoliaet al.,
Table 3: Resistance pattern ofE.faecalis
Sr.
no.
1
2
3
4
5
Specimen(n=59)
Urine
Pus
Sputum
Blood
Total
Penicillin
(%)
32
08
04
04
48
Ampicillin
(%)
33
04
02
01
40
Table 4: HLAR pattern

Sr. no. Specimen (n=100)
1
Urine
2
Pus
3
Sputum
4
Blood
5
Total
Ciprofloxacin
(%)
54
11
02
03
70
Vancomycin
(%)
01
01
02
E.faecium(%)
45
08
02
03
58
Linezolid Tetracycline
(%)
(%)
01
44
01
05
03
03
02
55
E.fecalis(%)
38
06
02
02
48
DISCUSSION
Enterococci are the second most common cause of
nosocomial urinary tract and wound infections and
third most common cause of nosocomial bacteremias.
Because of their resistance to penicillin and
cephalosporins of several generations, the acquisition
of high level aminoglycoside resistance and now the
emergency of vancomycin resistance, these
organisms are involved in serious super infections in
patients receiving broad spectrum antimicrobial
therapy.1So it is essential to know the susceptibility
pattern of these organisms.
We isolated E. faecalis more than that of E. faecium.
The same results were obtained by Mendiratta DK et
al.7,Bhat KG et al8and Gupta et al.9High level
aminoglycoside resistance Enterococci were first
reported in France in 1979 and then have been
isolated from all the continents.10Our study showedE.
faecium isolates were more drug resistant compared
to E. faecalis. This is comparable to the results
reported by AnjanaTelkaretal.11
In our study majority of the Enterococcal isolates
were resistant to tetracycline, and ciprofloxacin,
which is comparable to the study conducted by
AnjanaTelkar et al.11
Overall, resistance to penicillin, ampicillin
andciprofloxacin among strains of E. faecium is high.
Linezolid showed a good sensitivity towards
Enterococci species, and this can be used as an
alternative for the vancomycin resistant Enterococci.
In our study E. faecium isolates were multi drug

resistant as compared to E.fecalis, which is
comparable to the results reported by Mendiratta et
al.7 and Bhat KG et al.8Vancomycin resistance
detected in 7% of the isolates. Similar results were
reported by Bhat KG et al.8.
In our study HLGR is more in E. faecium isolates
(68%) compared to E. faecalis (56%) strains. Also
HLSR is more inE.faecium (48%) than in E.faecalis
(40%). The same results were reported by
Mendirattaetal.7 and Gupta V et al.9So high
percentages of HLAR could nullify efficacy of
combination
therapy
of
Beta
lactamase,
aminoglycosides recommended for the treatment of
serious Enterococcal infections.Karmarkaret al12 also
reported greater resistance to vancomycin among E.
faecium.
The higher antimicrobial resistance rates in the
present study may be ascribed to the source of the
isolates being from a tertiary care set up and a wider
usage of broad spectrum antibiotics.
CONCLUSION
In our study multidrug resistant and HLAR is more in
Enterococcal isolates.It is essential to screen for the
multidrug resistant and HLAR in clinical samples.So
proper antibiotic policy and hospital infection control
measures can be initiated to prevent the emergence of
multidrug resistant strains.
528
SarojGoliaet al.,

REFERENCES
1. Winn WC Jr,Allen SD, Jande WH,
KonemanEW,Schreckenberger PC. The gram
positive cocci. Part II: streptococci, Enterococci
and the streptococcus like bacteria. In
Konemanscolor Atlas and Text book of
Diagnostic Microbiology 6th ed. Lippincott,
Philadelphia. 2006;672-764.
2. Parameswarappa J, Basavaraj VP, Basavaraj
CM.Isolation, identification and antibiogram of
Enterococci isolated from patients with urinary
tract infections. Ann Afr Med 2013;12:176-81.
3. LoveenaOberoi, ArunaAggarwal. Multidrug
resistant Enterocci in a rural tertiary care
hospital- A cause of concern.Journal of medical
education and research.2010;12(3):157-58
4. Ananthanarayan and Panikers Text book of
Microbiology.9th edition,2013;208-18.
5. Bailey & Scotts Diagnostic Microbiology, 12th
edition,850-855.
6. Clinical and Laboratory Standards Institute,
Performance
standards
for
antimicrobial
susceptibilitytesting;Twenty-Third Informational
Supplement,
2013;32:M100-S23Wayne,
PA:USA:CLSI
7. Mendiratta DK, Kaur H, DeotaleV, Thamke DC,
Narang R, Narang P. Status pf high level
aminoglycoside resistant Enterococcusfaecium
and Enterococcusfaecalis in a rural hospital of
central India. Indian J Med Microbiol
2008;26:369-71.
8. Bhat KG, Paul C, Ananthakrishna NC. Drug
resistant Enterococci in a south Indian hospital.
Trop Doct 1998;28:106-7
9. Gupta V. Singla N. Antibiotic susceptibility
pattern of Enterococci. Journalof Clin and Diag
Res 2007;5:385
10. Eliopoulos GM, Moellering RC. Antimicrobial
combinations. In: Lorian V, editor. Antibiotics in
laboratory medicine.Mayland : William and
Wilkins;1996p.330-96
11. AnjanaTelkar, Baragundi. Mahesh, Raghavendra
VP, Vishwanath G, Chandrappa NR. Change in
the prevelance and antibiotic resistance of the
Enterococcal species isolated from blood
cultures.Journal of Clinical and Diagnostic
Research 2012;6:405-08
12. Karmarker MG, Gershom ES, Mehta PR.

Enterococcal infection with special reference to
phenotypic characterization & drug resistance.
Indian J Med Res 2004;119:22-25
.
529
SarojGoliaet al.,
DOI: 10.5958/2319-5886.2014.00391.9

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
Accepted: 17th May 2014
Research Article
REAL TIME POLYMERASE CHAIN REACTION (RT-PCR) FOR

TUBERCULOSIS IN SERPIGINOUS CHOROIDITIS- A STUDY OF 29 CASES
MYCOBACTERIUM
*Radha Annamalai1, Jyotirmay Biswas2, S Sudharshan 3, R Gayathri 4,K Lily Therese5, Viswanathan S6, Namitha
Bhuvaneswari7
1
Associate Professor, Department of Ophthalmology, Sri Ramachandra University, Porur, Chennai,India

Director of Uvea & Ocular Pathology Department, Sankara Nethralaya, Chennai,India
3
Consultant- Department of Uvea, Sankara Nethralaya, Chennai,India
4
Postdoctoral fellow, &5Senior Professor and HOD, L & T Microbiology Research Centre, Vision Research
Foundation, KNBIRVO Building 41, College Road, Chennai - 600 006
6
Professor of Ophthalmology, Muthukumaran Medical College, Chennai, India
7
Director and Professor of Ophthalmology, Regional Institute of Ophthalmology, Chennai, India
2
* Corresponding author email: drradhaannamalai@yahoo.co.in

ABSTRACT
Purpose: A study of real time Polymerase Chain Reaction for Mycobacterium tuberculosis (M. tuberculosis)
DNA in 29 cases of active serpiginous choroiditis. Design: Case control study. Methods: DNA extraction from
the aqueous humor was carried out using QIAMP DNA extraction kit. Real- time Polymerase Chain reaction (RTPCR) for MTB was carried out using Genosens Mtb complex quantitative Real time PCR kit. All patients were
also subjected to complete blood count, venereal disease research laboratory test, chest radiograph,
QuantiFERON TB Gold test on the blood and polymerase chain reaction on a sample of aqueous humor. Results:
Aqueous aspirate showed copies of mycobacterium tuberculosis DNA in one out of twenty nine cases of
serpiginous choroiditis. Direct smear and culture for mycobacteria was negative in all cases. Conclusion: RTPCR identifies MTB DNA in suspected latent tuberculosis in serpiginous choroiditis with high specificity.
Serpiginous choroiditis and multifocal choroiditis due to tuberculosis may resemble each other clinically but have
distinct clinical features which can be confirmed by real time polymerase chain reaction performed on the
aqueous humor The association between serpiginous choroiditis and tuberculosis would be a chance association
or if present a rare association.
Keywords: Real-time polymerase chain reaction (RT-PCR), Serpiginous choroiditis, Ampiginous choroiditis,
tuberculosis, QuantiFERON TB Gold test
INTRODUCTION
Serpiginous
choroiditis
is
a
chronicprogressiveinflammatorydisease. It is rare,
usually bilateral but asymmetrical and is seen
between the ages of 30 and 70 years. It begins around
the optic nerve in most eyes, advancing centrifugally
by recurrences to the mid periphery in an irregular
serpentine fashion. Active serpiginous choroiditis
characterized by greyish-yellow, cream-colored

lesions at the level of retinal pigment epithelium
(RPE) with overlying retinal edema.1 In some eyes,
however, the macula is affected initially without
preceding peripapillary activity, a variant known as
macular serpiginous choroiditis.2 In addition,
occasionally patients present with involvement of
530
Radha et al.,
peripheral retina as the primary site of affection. New

recurrent lesions occur at the border of old inactive
lesions and frequently spread to the periphery,
commonly involving a new and contiguous area of
the fundus. Various aetiologies such as
autoimmunity3,
infection4,
degeneration
and
vasculopathy have been assumed to cause serpiginous
choroiditis. Irreversible profound visual loss can
result due to complications such as chorioretinal
atrophy, scarring and choroidal neovascular
membranes. We performed a study on 29 eyes of 27
patients with serpiginous choroiditis with suspected
latent tuberculosis (TB) and found that in one case
Mycobacterium tuberculosis (M .tuberculosis )DNA
was detected in aqueous humor aspirate by real-time
polymerase chain reaction (RT-PCR).
MATERIAL & METHOD
The study was conducted in a tertiary referral hospital
in India. Prior to the study ethics committee clearance
was obtained. Inclusion criteria comprised all patients
with serpiginous choroiditis and multifocal
choroiditis which were suspicious for tuberculosis.
Patients with other causes of posterior uveitis and
those where the serpiginous choroiditis was inactive
or healed were excluded from the study. The aqueous
aspirate was obtained from 29 eyes of 27 patients and
27 controls during cataract surgery. Examination was
performed on all controls using slit lamp and
biomicroscopy. They were healthy patients with no
evidence of intraocular inflammation or uveitis. An
anterior chamber tap was performed under aseptic
precautions using povidone iodine and 0.1ml of
aqueous humor sample was sent immediately to the
microbiology department. Complete blood count,
QuantiFERON TB Gold test and high resolution
chest tomography (HRCT) and polymerase chain
reaction on the aqueous humor sample were
performed in all the cases. DNA extraction from the
aqueous humor was carried out using a QIAMP DNA
extraction kit (QIAGEN, Germany). Real time
Polymerase Chain reaction (RT-PCR) for
M.
tuberculosis was carried out using Genosens MTB
complex (Netherlands) quantitative Real time PCR
kit. RT-PCR for quantitation of MTB DNA was
carried out as a 25 l reaction, using 12 l of MTB
complex super mix R1, 2.5 l of Magnesium solution
R2 and 0.5 l of Internal control IC 1 R3 and 10 l of
aqueous humor DNA. The amplification was carried
out at an initial denaturation at 95 C for 10 minutes,

followed by 45 cycles of 95 C for 15 seconds, 60 C
for 20 seconds, 72 C for 15 seconds. The
quantitation analysis for the internal control and M.
tuberculosis was carried out using JOE (yellow) and
FAM (green) channel. The copy number of M.
tuberculosis was expressed in copies per ml of DNA
RESULTS
Aqueous aspirate showed copies of M. tuberculosis
DNA in one out of twenty nine cases of serpiginous
choroiditis. Direct smear and culture for
mycobacteria was negative in all cases.
RT PCR was positive in one case which is
described below:
A 38 year old Asian Indian male presented to the
uveitis clinic with a history of gradual diminishing
vision for one month. He was being treated with
systemic corticosteroids prescribed elsewhere. Ocular
examination revealed a best-corrected visual acuity of
6/60, N24 in the right eye and 6/6, N6 in the left eye.
Slit lamp examination revealed no aqueous cells or
flare and 1+ vitreous cell in the right eye. The left eye
was normal. Intraocular pressure was 12 mmHg in
both eyes. Fundus examination in the right eye
revealed active choroiditis with geographic borders
and a clinical diagnosis of serpiginous choroiditis was
made (Figure 1). Chest X Ray and ESR were normal.
Tuberculin skin test was negative. An anterior
chamber tap was done in the right eye and the
aspirate was subjected to direct smear, culture,
analysis by polymerase chain reaction (PCR) and RTPCR for M. tuberculosis genome. RT-PCR performed
on his aqueous aspirate showed 14,781 copies of M.
tuberculosis DNA (Figure 2). Direct smear and
culture for M. tuberculosis were negative. He had no
symptoms of systemic tuberculosis (TB) but
QuantiFERON TB Gold test done on his blood
sample was positive. The patient was started on
antituberculous treatment and corticosteroids under
supervision of an infectious diseases specialist.
Follow up after 2 months showed that the lesions had
resolved (Figure 3) and RT-PCR of aqueous was
negative for M. tuberculosis genome (Figure4).
Visual acuity had improved to 6/24, N12 in the right
eye. Control samples from 27 cases of anterior
chamber aspirate of patients without uveitis
undergoing phacoemulsification were subjected to
531
Radha et al.,
RT- PCR.
All
were
tuberculosis(Figure 5).
negative
for
M.
Fig1: Active serpiginous choroiditis
Fig 4:Real time PCR of Aqueous aspirate for M.

tuberculosis DNA-Negative after 2 months
Fig 2: Positive results of real time PCR of Aqueous

aspirate for M. tuberculosis
Fig 5: Real time PCR of Aqueous aspirate on

control sample
DISCUSSION
Fig 3: Resolved serpiginous choroiditis
Tuberculosis is one of the causes of serpiginous

choroiditis but serpiginous choroiditis due to
autoimmune aetiology exists as an independent entity
with distinct clinical characteristics. RT-PCR can
detect active replicating TB bacilli and MTB DNA
and a negative anterior chamber tap result can
indicate the response to treatment. Patients
particularly in tuberculosis endemic areas may have
fundus changes that resemble serpiginous choroiditis
but show evidence of M. tuberculosisDNA in the
532
Radha et al.,
aqueous humor. A substantial contribution may be

from an underlying infection and the likelihood of
this being tuberculosis is high.
Serpiginous choroiditis in the Asian Indian
population is seen in younger individuals with three
distinct presentations that can resemble tubercular
choroiditis.5The ocular morbidity in Indian patients
with active tuberculosis was reported as 1.39% and
the most common ocular finding was bilateral healed
focal choroiditis (50%).6 Patients with evidence of
active or latent tuberculosispresent with serpiginous
like clinical features that can resemble the
autoimmune type. This has been described as
tubercular serpiginous like choroiditis.7, 8. An atypical
picture of serpiginous choroiditis has been reported in
association with toxoplasmosis9 and herpes
virus10suggesting that aetiology of infection is indeed
possible. The advantage of the ease of anterior
chamber paracentesis11 to diagnose posterior segment
inflammation can be of immense help in establishing
the identity of tubercular posterior uveitis. Utility of
QuantiFERON TB Gold test positivity in serpiginous
choroiditis indicating latent tuberculosis has been
reported.12.Apart from ESR, tuberculin skin test and
QuantiFERON TB Gold test a polymerase chain
reaction on anterior chamber aspirate to identify the
genome is recommended.13 We have earlier reported
mycobacterium tuberculosis DNA in aqueous
aspirates from a case of disseminated tuberculosis.14
RT-PCR is a reliable investigation in infectious
posterior uveitis.15 Even in situations where all other
systemic and ocular investigations were negative RTPCR was positive thus providing a diagnosis. We feel
that apart from providing evidence of MTB DNA it
detects the absence of the bacilli in a few months and
thus helps to assess response to treatment at a very
early stage.
CONCLUSION
The utility of RT-PCR to detect M. tuberculosis in
serpiginous choroiditis has never been reported and
our results provide evidence that RT-PCR, on the
aqueous humor can be applied to establish the
diagnosis with certainty. It has the potential to
significantly improve detection by virtue of its
exquisite specificity and follow up for a longer period
of time will help to evaluate progress and the
recurrence pattern. In view of the ease of performing
anterior chamber tap, the ability of RT-PCR to
identify the presence of M. tuberculosis DNA and the

potential of this test to detect the response to
treatment, we recommend the use of this procedure to
determine whether or not tuberculosis is the aetiology
and to provide quantitative assessment of the
bacterial load in the eye.
The presence of confirmatory M. tuberculosis DNA
found by RT-PCR in only one case of 29 patients
points out of the controversy of associating
serpiginous choroiditis with tuberculosis. Our study
indicates that this association could be a chance
association (in an endemic country as India) or if
present, a very rare association. Vitreous aspirate
analysis by RT-PCR may provide more conclusive
evidence by detecting M. tuberculosis DNA in
patients with serpiginous choroiditis.
Conflict of interest: None
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Saptagirish R, Narayana KM, et al. Association
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Rothova A, de Boer JH, Ten Dam-van Loon NH,
Postma G, de Visser L, Zuurveen SJ, Schuller M,
Weersink AJ, van Loon AM, de Groot-Mijnes
JD. Usefulness of aqueous humor analysis for the
diagnosis of posterior uveitis. Ophthalmology.
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DOI: 10.5958/2319-5886.2014.00392.0

&
Health Sciences
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Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Research Article
GALLBLADDER CANCERSURVIVORS AND QUALITY OF LIFE

* Pandey Punam1,Pandey Manoj2, Shukla V.K 1
1
Department of General Surgery, 2Departments of Surgical Oncology, IMS, BHU, Varanasi, UP, India
*Corresponding author email: punampandey38@gmail.com

ABSTRACT
Background: This study was to explore the personal history signs and symptoms, grading and types of
treatmentreceived bygallbladder cancer patients.Association of Quality of life in Gallbladder cancer patients was
assessed with different factors i.e., Socioeconomic status, education, stage and treatment.Quality of life was
reviewed at 0,1, and 3 months in 100 patients attending general surgery and surgical oncology OPD.Method:
Information was collected by quality of life questionnaire containing five parameters, physicalwell being, social
wellbeing, emotional wellbeing, functional, well being, and disease specific wellbeing which was obtained from
facit.org. FACT Hep Hindi(version4) was used by the permission of copy write owner. Self developed
questionnaire related to symptoms, sign, stage and treatment ofpatientswere also included.Association of QOL in
Gallbladder cancer patients with different factors i.e. socioeconomic status, education, stage and treatment of
patient have been assessed at the time of admission.The association was assessed by dividing the patients into
three groups according to their score of mean SD range poor, moderate and good QOL. Result:Mean age is 53
years; range is (25-80). Male/female ratio is 1:2.8, 65% patients were literate. Diet veg. & Non-veg. were 55%
and 45% respectively.96% patients were married.Mean score of 100 patients in PWB, SWB, EWB, FWB, HCS,
FACT-Hep score is 16.6, 19.6, 14.19, 12.88, 41.96, 103.76 respectively, which is found to be average,Most of the
patients found to be in late stage with poor QOL.
Keywords: Functional assessment of cancer therapy, Quality of life, Gastrointestinal tract
INTRODUCTION
The process of assessing quality of life is to measure
the extent of happiness which is although not
sufficient but necessary for wellbeing of gallbladder
patient.1,2 Particularly at time when healing seems to
be unrealistic, quality of life becomes the focus of
care and treatment in patients with carcinoma of the
gallbladder. The gallbladder cancer is insidious and
when it is diagnosed suddenly it is shocking for the
patients as well as the relatives, and its treatment has
significant impact on the person's physical
functioning, mental healthwell-being, social and
functional well being, and thereby causes disruption
inthe quality of life in these patient. 3,4Some
important factors like patient education, spousal
support and work status, financial stability etc., have

been found to influence Quality of life (QOL) in the
gallbladder cancer patient.5 The quality of life QOL is
a central concern in any evaluative research. To
improved quality of life in gallbladder cancer patient
is probably the most desirable outcome of this
research study.2 QOL is defined as degree of
satisfaction or dissatisfaction felt by people on
various aspects of their life and experience of their
life.2,3 Quality of life is a frequently used phrase, but
it lacks a precise and consistent definition. According
to World Health Organization (WHO) describes
manycomplexities in an individual life. A person
perceives a position in life according to his goal,
535
Punam et al.,
expectation of his beloved one, family, and his own

acceptation, standard of workhe can do, his strength
his weakness in the context of the culture and value.
It is a concept which have no limitation and it affects
in complex way by the person's physical health,
psychological state, level of independence, social
relationships, and also complexity arises with
gallbladder cancer.4,6
Carcinoma of the gallbladder is a common health
problem in Western Bihar eastern Utter Pradesh and
regions of India constitutes 4.44% of all types of
cancer and 0.3% of all admissions in our hospital. 7In
this study QOL in cancer gallbladder patient, have
been assessed to know the basic needs and problems,
and accordingly implement treatment modalities in
cancer of gallbladder patients to improve their QOL.
METHODOLOGY
This study was conducted among 100consecutive
patients who attended general surgery and surgical
oncology outpatient department of the University
Hospital, Varanasi, India.This study was approved by
ethical committee of Institute of Medical sciences
BHU. In the present study 100 patients of both sex
and all new cases with biopsy proven carcinoma of
the gallbladder, 18 years of age or older was
included. Current psychosis, and health too poor to
complete questionnaire was excluded from the study.
The participants were mostly from eastern UP and Bihar. A
quality of life questionnaire containing five
parameters(physical wellbeing, social wellbeing,

emotional wellbeing, functional wellbeing and
disease specific wellbeing) was obtained from
facit.org. FACT Hep Hindi(version4)8,9was used by
the permission of copyright owner. FACT-Hep
(version4) is a sensitive tool in measuring the QOL in
the patients with carcinoma of the gallbladder. 8
The study and questionnaire were explained to all the
participants. While collecting the data the questions
were read to the participants and the answers were
recorded. Question related to the variables
wereanswered using a fivepoint scale 1-completely
disagree to 5-completely agree (totally agree).10After
the patients clear understanding has been confirmed,
the patient is encouraged to complete every item in
order without skipping any. Some patients may feel
that a given question is not applicable to them and
they, therefore skip the item altogether.11,12The
response
is
circled,
which
is
most
applicable.Frequency table was prepared for each and

every important variable. QOL is classified into three
groups according to their mean range poor, moderate
and good. Socioeconomic status is computed by
modified B.G.Prasad scale.13-16 The information from
coded schedule was transferred in to a computer
using Statistical software for performing various
statistical calculations. Data analysis is done
according to fact Hep guidelines.17-18Subscale are
Physical wellbeing (PWB) score range was 0-28,
Social wellbeing (SWB) score range was 0-28,
Emotional wellbeing (EWB) score range was 0-24,
Functional wellbeing (FWB) score range is 0-28,
Hepatobiliary cancer subscale (HCS) score range is
0-72.16
RESULTS
Table 1: Scoring is done according to FACT-Hep
guidelines16 of 100 patients and their reviewFACTHep total score, range is 0-180. Mean score of 70
patient in PWB, SWB, EWB, FWB, HCS, FACTHep score were16.7, 19.6, 13.6, 12.6, 41.6, 103.76
respectively, which is found to be average. Mean age
was 53 years (range 25-80). Male/female ratio is
1:2.8.Total 65% patients were literate (Table 2).Diet
veg. & Non-veg. were 55% and45% respectively
(Table 4). Total 96% patients were married. In this
study, 15 cases have been expired within0- 1 month,
85 cases were alive. And at review of 3months 46
Patients were remaining in mostly having poor QOL
these patients found to be in late stage. Correlation
among the parameter score and sub score is found to
be significant.
Descriptive analysis of 100 Ca Gallbladder
patients.In the clinical manifestation, most of the
patients had symptoms of pain, fever, jaundice,
abdominal distension, nausea and vomiting, loss of
appetite, weight loss (Table 3). In history of
addiction, most of the patients were tobacco chewer.
Family history was not significant, Examination,
grade, types of intervention treatment patient is
getting is descried. (Table 6,7)
Association of QOL in Gallbladder cancer patients
with different factors(Table 8) Shows that
medium34% and upper medium22% group of people
are affected. Table3b: shows 55% literacy rate and
45% illiterate, having 32% moderate QOL and
37%educated having moderate QOL Illiterate having
better QOL than literates.(Table 9,10)
536
Punam et al.,
Table 1:Scoring 100 patients and their review: Scoring is done according to FACT-Hep guidelines15
Mean score
Mean score after Mean
score Score range P Value
Subscale
On the
beginning(100
cases)
PhysicalWellBeing
16.7score
SocialWellBeing
19.6
EmotionalWellBeing
14.19
Functional WellBeing 12.88
HepatoCellularScore
41.96
FACTHep
103.76
Significantlevel PValue 0.00 level
1month85(cases)
3month
(46 Cases)
16.88
17.87
13.54
13.92
46.74
104
17.84
19.62
14.92
14
48
105
Table 2:Descriptive analysis of 100Carcinoma of

Gallbladder patients:
Age group
1- 30
31 60
Above 60
24
75
Total
Male
Female
100
23
77
Table 3: Clinical manifestations

FACTORS
N=100
Pain(Mild)
97.6
Pain(Severe)
40
Fever
31
Jaundice
32
Abdominal distention
39.2
Nausea and vomiting
48
Loss of appetite
68.8
Palpable gallbladder
68.80%
Icterus jaundice
42.4%
Left Supraclavicular node
25.6%
Lump
50.4%
Ascitis
17.6%
Table 4: History of addiction
History of tobacco N=100
chewing
History of Smoking
10
Last 6years
History of alcoholism 6
Last 10 years
Dietary habit
N=100
Vegetarian
55
55%
No vegetarian
45
45%
Table 5: Histology report
Histological type
Adenocarcinoma,
squamous cell carcinoma
insitu carcinoma
%
98.4
.8
.8
0.00
0.00
0.00
0.00
0.00
0.00
Table 6: Gradeof patient

1st Grade
2nd Grade
3rd Grade
4th Grade
Table 7: type of treatment
Intervention
Surgical resection
Chemotherapy
Radiotherapy
Adjuvant therapy
N= 100
9
13
45
33
%
8.8
12
44.8
33.6
N=100
37
56
4
46
%
29.6%
84.67%
3-2%
36.8
Table 8: Socioeconomic Status and literacy

Economic
Status
Good
QOL1
Moderate
QOL1
Poor
3
3
Lower medium
3
3
Medium
3
27
Upper medium
2
17
High
0
0
2
Chi square -9.537, df-6, p--0.146
Illiterate
10
32
Primary
4
25
High school
4
4
Inter
1
4
Graduate
0
4
Post graduate
0
0
2
Chi square -23.01,df-6,
p-.003
Poor
QOL1
Total
1
1
4
3
0
7
7
34
22
0
3
0
5
2
2
0
45
29
13
7
6
0
Table 9: Association of treatment and QOL

Treatment
N=100
98
1
1
0-28
0-28
0-24
0-28
0-72
0-180
Surgery
Good
QOL3
3
4
Radiotherapy 0
Adjacent
4
Total
14
2
Chi square -.581a
Chemotherapy
Moderate
QOL3
Poor
QOL3
20
11
34
31
13
48
2
1
3
6
5
15
59
30
100
rd
df.-4 p0.04 (3 month)
537
Punam et al.,
Table 10: Association of Stage and QOL of patients

Stage
Stage-1
Stage-2
Stage-3
Stage-4
Good
QOL0
Moderate
QOL0
Poor
QOL0
1
2
4
8
8
17
24
19
0
10
5
2
9
29
33
29
Chi square 2 14.24, df-6, P-0.027
Good
QOL1
Moderate
Poor
QOL1
QOL1
0
1
2
4
7
15
19
12
2
10
5
8
9
26
26
24
Chisquare26.85,p-0.033
Good
QOL3
Moderate
QOL3
0
1
0
3
1
9
3
6
2 -11.84 df-6
Poor
QOL3
3
10
4
5
p0.077
4
13
14
14
QOL0= Beginning, QOL1= 1month, QOL3= 3rd month

DISCUSSION
QOL in a person is not stable it changes with
perception of wellbeing, we can observe
differentiation of QOL with time duration between
first visit and investigation,second visit with
treatment modalities, their waiting time and also
impact of treatment process whether regression or
progression of their health. Table 1 indicates that in
starting 100 patients with gallbladder cancer were
observed within one month 15 cases were expired.
Within0- 1 month 85 cases were remaining. And ina
review of 3months46 Patients were remaining
patientswas having average QOL,and these patients
were found to be in late stage.Correlation
issignificant in QOL parameter score and sub scores.
During the reviewwe saw that when a patient comes
to the hospital for treatment, overall QOL of the
patients were average. In the first month, the patients
QOL was declined because they have to go through
many investigations and psychologically patient is
very upset of his diagnosis and treatment is unable to
accept the reality. During third month, patient accepts
the reality that he is suffering with cancer and cope
with his treatment procedures although it is invasive
and painful having so many side effects of the
chemotherapeutic drugs he bargains with God for
better health and promises himself not to continue his
smoking,
chew
tobacco
and
alcohol
consumption,their quality of life was slightly
improved with the treatment.6,8
Table2shows the descriptive analysis of 100 patients.
The age groupsinto 3 range. Less than30, 30 to 60,
more than 60 they were found 1, 75, 24 percent
respectively. The male female ratio is 1:3.3,
vegetarian, non vegetarian is 55% 45% respectively,20
in clinical manifestation, most of the patients had
symptoms of pain, fever, jaundice, abdominal
distension, nausea and vomiting, loss of appetite,
weight loss. On examination of the patient, the

important factors are palpable gallbladder, icterus
jaundice, left supraclavicular node, lump, ascitis. the
patients came for the treatment is in advanced stage 3
and 4. 90% of cases with largegallstones were found
to be the most significant risk factor for developing
gallbladder cancer. Larger gallstones and chronic
inflammation of the gallbladder from infection also
increases the risk for gallbladder cancer. The most
common symptom is pain in the upper right portion
of the abdomen, Patients with gallbladder cancer
may also report symptoms such as nausea, vomiting,
weakness, jaundice, skin itching, fever, chills, poor
appetite, and weight loss.20-22
According to IA Malik(2003) (77%)patients were
women Mean age was 55 years (+/-11 year) The
majority of patients hada history of symptomatic
gallbladder disease. The commonest presenting
symptom was pain, followed by nausea and vomiting,
weight loss, and jaundice. 25% of patients had a
palpable abdominal mass.22-24History of addiction
was found to be associated with gallbladder cancer
48% of patients were addicted with tobacco, smoking
and alcohol since 5to 15 years. In history of addiction
32% patients were tobacco chewer. Family history
was not significant.25
In table3 Association of QOL in gallbladder cancer
patients with different factor was assessed. Patient of
medium and upper medium socioeconomic family
status were 34% and22% came for the treatment. No
higher incomegroup was found in the study as they
may prefer private nursing homes, and poor people
were less as they were too poor to afford the surgical,
chemotherapeutic treatment and as they came to
know they are suffering from cancer they never come
for treatment in hospital and have symptomatic
management in their locality, because of poverty
538
Punam et al.,
theyare unable to afford the treatment.Education

shows 55% literacy rate and 45% illiterate. The
illiterate patient having 10% good and32% moderate,
3% has poor QOLas they dont understand the
severity of disease as educated people having 9%
good, 37% moderate and 9% patients having poor
QOL. The educated patient found to be emotionally
upset and worry about the disease, treatment
modalities and rehabilitation.
An association of QOL with a stage was assessed at
0months, 1month and 3month. At the time of
admission0month, 9%. 29%, 33%, and 29% patients
were found in stage 1, 2, 3, 4 simultaneously total
patients were 100.26 After one month 4,26,26,24 in
stage 1,2,3,4 simultaneously total number of patients
were 85 , After 3month gallbladder cancer patients
were found 4,13,14,14 in stage 1,2,3,4 simultaneously
total number of patients were 47,gallbladder cancer
cannot be discovered in early stage we can found
maximum patient in 3rd and 4th stage.26 Staging can be
estimated by spread of cancer from its origin organ,
treatment is ineffective and prognosis is poor when
patient comes in advance stage and grade.24,27,28
Gallbladder cancer patients in present study receiving
treatment in which Surgery patients were 34% ,
chemotherapy patients were 48%, radiotherapy were
3%, adjuvant therapy were 15%. Thesepatients were
having good, moderate, and poor QOL, in Surgical
intervention was 3, 20, 11, in chemotherapy treatment
4, 31, 13, inradiotherapy 0,2,1 and in adjuvant
therapy is 4, 6.5, simultaneously.22,23As we can see in
literature QOL in gallbladder cancer can be assessed
by physical, psychological and social condition of the
patient.27 Patient have adverse effect on their QOL
due to metabolic effects of cancer.25 The deteriorating
effects of chemotherapy on cancer patients are well
documented, so there is the need and impact of
psychological, behavioral, or educative interventions
in improving quality of life, in those patients.27-28 In
the developing countries, cancer centers have a very
high patient load and providing quality treatment and
achieving good survival is still the first priority.
However, in the pursuit of quality of survival, the
quality of life is often ignored. Psychological and/or
behavioral interventions that could enable the patient
to cope better, be independent and well informed
about the treatment which might improve quality of
life of remaining years.20-22These factors enables the
health care provider to design and individualized

treatment plan.
CONCLUSION
This study gave tentative exploration in predictors of
health related quality of life. Mean score of QOL in
100 patients was found to be average,Most of the
patients found to be in late stage. The QOL is
associated withdifferent factors i.e. socio economic
status, education, stage and treatment.The presence of
chronic illness is associated with deteriorating
QOL.Further follow up work is needed to assess
QOL in different perspectives and its effect on
patientsimprovementandsurvival.
ACKNOWLEDGEMENTS
We would like to thank the patients willingly
participated in the study.
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DOI: 10.5958/2319-5886.2014.00393.2

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Received: 11 Mar2014
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 6 May 2014
Research Article
ASSESSMENT OF PARENTAL UNDERSTANDING OF PAEDIATRIC MEDICAL PRESCRIPTIONS

DrSadiqua Anjum1, *DrMohdNasir Mohiuddin2,DrNarayan Reddy U3,DrNarsingRao J4, DrSana Afreen2, DrMir
S Adil2, DrJaveedullah M2
1
Asst. Professor, 3Professor &HOD, 4Professor, Dept. of Pediatrics, Deccan College of Medical Sciences (DCMS)
- Princess EsraHospital, Hyderabad
2
PharmD,Clinical Pharmacist, Dept. of Pediatrics, Princess Esra Hospital, Hyderabad
*Corresponding author email: muhammed_nasser7788@yahoo.com
ABSTRACT
Introduction:Medical prescriptions are bound to be misinterpreted by patients and pharmacists if not properly
conveyed. Pediatric prescriptions differ from adult prescriptions having wide variation in doses and
formulations.There is a need to evaluate the lacunae in the parental understanding of pediatric prescriptions.Aims
and objective: To evaluate the parental understanding ofpediatric prescription and to evaluate the adequacy of
communication with the physician and pharmacist regarding the same.Material and methods: 550 parents were
enrolled and their literacy level was noted.They were subjected to modify MUSE questionnaire.Physicians
prescription was analyzed in terms of ease of understanding by parents. These parents were followed up till the
pharmaciesand the pharmacist understanding of prescription was analyzed and their communication with parents
regarding drug usage was noted. Finally, ease of usage of drugs by parents was noted. Results:MUSE scale was
modified to suit pediatric prescription understanding by parents and also additional questions were asked to
include complete parental understanding of doctors prescription. Majority of parents failed to completely
understand the written prescription. Though around 80% of pharmacist could understand the prescription, their
communication with parents was poor resulting in difficulty for parents to even enquire about medicines from
them. Parental overall understanding of prescription increased with their literacy levels. Conclusion:Not all
prescriptions are completely understood by parents as well as a pharmacist. This can lead to misuse of drugs.
Efforts to explain the drug usage are not adequate enough from the doctor or the pharmacist. While
communicating literacy levels of parents is not being considered which may further worsen the understanding
ability.
Keywords: Pediatric medical prescription,pediatric physicians, pharmacists, parents, communication.
INTRODUCTION
Medical prescription is meant to offer respite to
human suffering due to ill health.Central to this is to
understand that which is written in the prescription
which If not properly conveyed will remain as
medical jargon not only for the patient, but also the
pharmacist which can result in usage of incorrect
drug, inadequate dose and may be associated with
potentially harmful medication errors.Unfortunately

various problems in understanding, interpreting and
communicating have been documented across the
health care.1Patients often misunderstand the proper
dosage of the medication as well as the warnings
associated with the medication.Medicines designed
for the betterment of patients health can actually
541
M NasirMohiuddin etal.,
prove detrimental when misused. Therefore the

medicines side effects, dosage and usage must be
properly communicated. While most doctors can see
the importance of patients knowledge of prescription
when dealing with medicines, most of them hardly
make appropriate efforts to communicate the same to
them.1-3Pharmacists can contribute to positive
outcomes by educating and counselling patients to
prepare and motivate them to follow their
pharmacotherapeutic regimens and monitoring plans.4
Physiological factors like age, weight and surface
area should be considered. The following age groups
should be used for drug use in children: neonate
(birth to 1 month), infant (1 month to 2 years), child
(2 to 12 years) and adolescent (12-18 years). Errors in
drug administration are among the commonest
medical errors. Children are particularly at risk for
such errors because of the need to calculate doses
individually. Doses that are ten times the correct
amount (1000% of the correct dose) are occasionally
given and can be life-threatening.5
Alteration in the amount of drug used or
reconstitution of powdered formulations may not only
alter the drug response, but also carries the risk of
giving rise to drug resistance. As antibiotic resistance
is already on the rise, causing a heavy toll on health
care in developing countries like India; proper
prescription, dosing, dispensing and usage of drugs
specifically antibiotics may become an important
contribution towards our attempt in reducing drug
resistance thus facilitating the achievement of a
hurdle free dispensing of health care in our country.
The ability to read and understand prescription label
instructions may appear to be a simple task, yet van
den Broek& Kremer describesthe various sources of
failure in comprehension that are particularly
applicable for the abbreviated text on container
labels.
These
include
readers
cognitive
characteristics, constraints on the reading situation,
and the nature of the presented health information.6
Pediatric prescription differs from adult prescription
as drugs are supposed to be prescribed as per the
body weight of child unlike adult prescription where
the dosage is uniform for most of them.Thus, it
makes pediatric prescription more complex as it
demands clarity from the prescription in terms of
dosage, formulation, timing, frequency, and duration,
as well as clarity from the pharmacists when they
dispense drugs to the parents. Thus the assessment of
parental knowledge of pediatric prescription is very

important in determining the extent of understanding
of prescription by them, which acts as a vehicle in
implementing technical care.
Evidence shows that although health literacy
interventions might help to improve the overall
outcome in the patient, it may not eliminate health
disparities.2
Various scales were designed in the past to assess the
patients understanding of medical prescription as
well as the ease with which medications can be used
by them. Of all the scales, MUSE (medication use
and self-efficacy) scale was found to be more
reflective of the patients understanding and use of
prescribed drugs, but even this scale did not cover all
areas of patient understanding. 7-12
None such studies were done in India especially on
pediatric prescriptions. As there is an increasing need
to understand the grey areas in parental understanding
of pediatric prescription, this study was devised.
Our study aims to assess the inadequacies in
understanding pediatric prescriptions written by
pediatric consultants, inability of the pharmacist to
interpret the prescribed prescription as well as
incapability of the parent to understand the doctors
prescription or to understand the method of usage of
drugs in the right manner.
This would help us to understand the cause of
misinterpretation of the prescription and also help us
devise newer methods of overcoming these problems.
This study aims at evaluation of adequacy of parental
understanding of medical prescription written by
pediatric practitioner,assessing the drug dispensing at
the level of pharmacist and the parental
understanding of the usage of the prescribed drugs by
using modified MUSE (medication understanding
and use self-efficacy) scale13along with additional
questions added to it.
Prior permission from the ethics committee of our
hospital was taken for the present study. This is a
cross sectional study conducted in the out-patient
department of Princess EsraHospital, Hyderabad and
the pharmacies attached to it. It is a 1000 bedded
teaching hospital providing tertiary level health care
services to all strata of people.Pediatricoutpatientturn
over varies from 150 to 250 patients with 3 to 5
attending pediatric consultants.
542
A total of 550 participants were enrolled in the study,

ofunderstanding of prescription details by the parent
out of which 500could be followed up at the
or the pharmacist, we have adequately modified it to
pharmacy for evaluating drug dispensing.
suit the parents response to their kids medication
Parents/guardians who came to the pediatric
needs and also added four questions to the scale to
outpatient department of the Princess Esra Hospital
assess parents understanding of the details of the
were included irrespective of their literacy or their
medical prescription and two questions to assess the
childs age or sex. Those who came for immunization
pharmacists understanding of the same. Thus, our
of their children, those who were referred to other
scale included a total of 14 items taken as an
departments for further management and those who
extended and modified MUSE scale.
were admitted as inpatients from the outpatient
The prescriptions given to parents/guardians by the
department were excluded.
pediatric consultants were assessed and their details
The parents/guardians of the children who came to
in terms of formulation, dosing, frequency and
the out-patient department of the Princess Esra
duration of the use of drugs prescribed were noted in
Hospital were enrolled after explaining the study
the preformed questionnaire. Parental understanding
process and taking an informed consent. Parents or
of the prescription was noted after receiving it from
guardians were subjected to a preformed
the doctor. The education level of parents varied from
questionnaire which included eight MUSE scale
illiteracy to graduation. These parents were followed
questions along with additional questions added to
up till the pharmacy. Here the understanding of
the scale to cover the understanding of the complete
prescription by the pharmacist was assessed. After the
prescription details by the parent as well as a
drugs were dispensed to the parents, their
pharmacist. Among the six additional questions, four
understanding of the usage of drugs was noted and
were asked to the patients representative and the
the ease with which they can use the prescribed drugs
remaining two for the pharmacist.
was enquired through the questionnaire. Response to
The original MUSE scale was designed for adult
the questionnaire was recorded in terms of yes or no
patients and included eight items of which four were
replies.
associated with taking medication and remaining four
Statistical analysis: Statistical analysis was done
were associated with learning about medication. As
using epi info 7.
the
scale
does
not consider
assessment
Table 1: Components of the questionnaire asked to parents and pharmacist
Modified Patient medication understanding questionnaire
Questions asked to parent in addition to MUSE scale.
It is easy for me to understand strength of medications from the prescription
1
It is easy for me to understand dose of medications from the prescription
2
It is easy for me to understand frequency of medications from the prescription
3
It is easy for me to understand duration of medications from the prescription
4
Questions asked to parent from original MUSE scale.
It is easy for me to give medicine to my child on time
5
It is easy for me to ask my pharmacist questions about my childs medicine
6
It is easy for me to understand my pharmacists Instructions for my childs medicine
7
It is easy for me to understand Instructions on medicine bottles
8
It is easy for me to get all the information I need about my childs medicine
9
10 It is easy to remember to give all my child all the medicines
11 It is easy for me to set a schedule to give my childs medicines each day
12 It is easy for me to give my childs medicines every day
Questions asked to pharmacist.
13 It is easy for the pharmacist to interpret overall prescription as lucid.
14 It is easy for the pharmacist to interpret the individual drug details
543
YES %
RESULTS
When the overall response to modifiedMUSE scale
As the modified MUSE scale was analyzed in
was analyzed, the following results were obtained. Of
accordance to the literacy level of parent/guardian, it
the 4 questions added to assess the parents
revealed that as the education level increases from
understanding of the doctors prescription,it
illiteracy to graduation there was a gradual increase in
wasrevealed that most difficult area to understand
understanding the doctors prescription and also a
from the prescription was the strength of
gradual increment in attempting to learn about their
medication(only16.36% could understand) and the
medication as well as increased ease in taking the
easiest was to understand the duration of medication
medications properly (fig 2). This increase was
from prescription(80% could understand)
statistically significant leading to increased ability to
When the two questions posed to the pharmacist were
complete the medication schedule as per the
assessed, it was revealed that, for 83% of times the
recommended format as shown in table 2 .There was
overall prescription was lucid to pharmacist and in
no statistical significance in the increase in the
76.6% of the total prescriptions it was easy for the
understanding of strength of medication or ease with
pharmacist to clearly interpret the individual drug
which they give their childs medicines on time and
details.
each day.
Analysis of the eight questions of original muse scale,
120
pertaining to learningabout the parents knowledge of
100
medication revealed thatgetting all the information
needed about the medication was the most difficult
80
task with just 39.63% participants giving positive
60
response. Whereas, the participants reported that the
easiest parthas been to give the medicine to their
40
child regularly (97.27%) and on time (97.07%).
Around 86% of participants believed that it is easy
20
for them to set a schedule to give their child the
0
medicines prescribed and to remember giving all the
Q1Q2Q3Q4Q5
Q4Q5Q6Q7Q8Q9Q10Q11Q12Q13Q14
medicines required. About 68% of the participants
Yes % 1 7 6 8 9 4 4 6 4 8 8 9 8 7
reported that understanding the instructions on the
container was easy for them.However, only 48.72%
positive replies to the questions asked to
found understanding pharmacists instructions for
parents and pharmacist.
their medicines easy and only 42.27% found asking
Fig 1: Percentage of positive replies obtained to
questions to a pharmacist about medications easy.
questions 1 to 14
(Table 1, Fig 1)
Table 1: Questions 1to 12 versus the literacy levels of parents {No of yes responses (%)}
Question
1
2
3
4
5
6
7
8
9
10
11
12
Illiterate
Total : 52
7(13.4)
23(44.2)
24(46.1)
33(63.1)
50(96.1)
11(21.1)
15(28.8)
17(32.6)
4(07.6)
45(86.5)
41(78.8)
50(96.1)
1 to 6th
Total : 54
6(11.1)
33(61.1)
29(53.7)
36(66.6)
52(96.2)
19(35.1)
26(48.1)
26(48.1)
9(16.6)
45(83.3)
43(79.6)
47(87.1)
7-10th
Total : 267
39(14.6)
188(70.4)
177(66.3)
213(79.7)
257(96.2)
130(48.6)
119(44.5)
180(67.4)
98(36.7)
227(85.0)
233(87.2)
265(99.2)
Inter
Total : 80
15(18.7)
65(81.2)
64(80.0)
69(86.2)
78(97.5)
40(50.0)
43(53.7)
59(73.7)
37(46.2)
64(80.0)
69(86.2)
76(95.0)
Graduate
Total: 97
23(23.7)
88(90.7)
85(87.6)
89(91.7)
97(100)
60(61.8)
65(67.0)
92(94.8)
70(72.1)
90(92.7)
90(92.7)
97(100)
P value
>0.05
<0.001
<0.001
<0.001
>0.05
<0.001
<0.001
<0.001
<0.001
<0.001
<0.05
>0.05
544
100
80
60
40
20
0
Fig 2: Overall understanding of parents (% of positive

replies) as derived from the modified MUSE scale
DISCUSSION
The study reveals that the prescription written by the
physician is not completely understood in terms of
strength, dose, frequency and duration of the
medication. This may be because either it is not
properly communicated with the doctor or the
pharmacist, illegibly written prescription or parents
literacy level is not adequate enough for them to
understand the doctors instruction either written or
verbal.
Though pharmacist understand most of the
prescriptions, their interaction with the parents is not
adequate enough to make them understand the
complete prescription.
Moreover,as the education level increases, their
ability to understand the physicians prescription,
ability to enquire about the prescriptions from the
pharmacist, ability to understand the usage of
prescribed drugs increases, leading to increased
ability to complete their childs medication as
recommended.However, there was almost uniformly
decreased understanding of drug strength and the
equal ease in giving their child drugs on time and
each day for both uneducated and educated parents.
(table 2)
Inference from table 2 reveals it is relatively difficult
for parents with lower education levels to understand
the strength, dose and frequency of medication to be
used, it is difficult to interact with pharmacist and
also difficult to understand instructions on medicine
bottles.
Pediatric formulation, especially antibiotics are
unique and different from the adult formulation as
most common dosage forms are powdered
formulation which is supposed to be reconstituted
with water.14The dose of antibiotic and other
medications are supposed to be prescribed as per the

weight of the child. Hence, the dose of syrup
formulation/number of drops may vary in amounts
significantly from patient to patient, unlike adult
prescriptions where fixed dose tablet formulations are
prescribed.15
Under-dosing, overdosing, abnormal frequency or
duration of antibiotics can be the most important
contributing factor for developing antibiotic
resistance.16Illegible handwriting in prescription can
be the source for misinterpretation of the drug
strength or drug as a whole by the pharmacist and
inadequate counseling regarding the drug use by the
doctor or the pharmacist may lead to gross errors by
the patient in using the drugs.
If patients literacy is not evaluated, it will be difficult
to judge the amount of effort needed to make the
patients understand the prescription.
CONCLUSION
Pediatric physicians prescriptions are not being
completely understood by parents. Pharmacists are
unable to follow all the physicians prescriptions and
are too busy to communicate either with the doctor or
the patient for the same. Parents are unable to get all
the information needed either from the physician or
the pharmacist and this varies with their education
levels. No attempt is made to understand the parents
ability to follow what is conveyed through
prescription. Though parents are dedicated enough to
use the drugs as prescribed, but unfortunately the
lacunae in communicating the prescription properly is
still strong enough to affect the health care delivery
system.
RECOMMENDATIONS
1. Ideally prescription should be typed and checked
by the doctors for completeness.
2. In case typing is not possible, care should be
taken to ensure that specifically the strength of
the antibiotics prescribed is written legibly or
there should be an ease of communication
between the doctor and the pharmacist dispensing
the drugs in case of any discrepancy in
understanding the prescription.
3. The patient should be properly counseled based
on their literacy level. This can be done by a
personspecifically appointed for counseling in
case the doctor or the pharmacist is too busy to
communicate. Special stress should be made on
545
dose and frequency of drug intake in counseling

parents with lower education levels
4. There should be a system for taking feedback
from the parent at the end of consultation as well
as at the end of collecting the drugs in order to
analyze difficulties faced and device methods to
overcome the difficulties.
5. Pharmacist should be instructed to explain the
reconstitution of the powdered formulation
adequately.
6. It would be ideal to devise a uniform calibrated
drug dispensing container for all oral liquid
formulations to measure each ml of the drug to be
used.
Limitations: Our study could not evaluate the actual
usage of drugs by parents.Studies evaluating the
outcome with typed prescriptions and a counselor to
explain the usage of drugs should be done in order to
confirm inadequacies of the current system of the
drug prescription and delivery especially in hospitals
with large patient turnover in the outpatient
departments.
ACKNOWLEDGEMENT
We are thankful to the medical staff of outpatient
pediatrics department at Princess Esra Hospital for
co-operating with us during the study.
Conflict of interest: None declared
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DOI: 10.5958/2319-5886.2014.00394.4

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Research Article
EFFECTS OF SCIRPUSIN B, A POLYPHENOL IN PASSION FRUIT SEEDS, ON THE CORONARY

CIRCULATION OF THE ISOLATED PERFUSED RAT HEART
Yutaka Matsumoto1, Nozomi Gotoh1, Shoko Sano2, Kenkichi Sugiyama2, Tatsuhiko Ito2, Yohei Abe3, Yumi
Katano1, *Akira Ishihata1
1
Division of Theoretical Nursing and Pathophysiology, Yamagata University School of Medicine, Japan
Research Institute, Morinaga & Co.,Ltd.
3
Department of Pharmacy, Yamagata University School of Medicine, Japan
2
*Corresponding author email:comedic2013@gmail.com

ABSTRACT
Objective:Piceatannol, a polyphenol which is contained in passion fruits seed, is a derivative of resveratrol and is
known to have antioxidant, anti-inflammatory and vasorelaxing activities. Passion fruits seed also contains a
dimer of Piceatannol, Scirpusin B. The aim of this study was to investigate the effect of Scirpusin B on the
coronary circulation of the isolated rat heart. Methods: Hearts were isolated from male Fischer 344 rats (5 - 6
months old), and perfused with modified Krebs-Henseleit solution aerated with 95% O2 and 5% CO2 (37 C) at
constant pressure (75 cmH2O) by Langendorff's method. Piceatannol or Scirpusin B (10, 30 and 100 M)was
injected as a bolus into the aortic cannula and coronary flow (CF) was continuously measured by the
electromagnetic flow meter. In some experiments, rat hearts were pretreated with L-NAME (an inhibitor of nitric
oxide synthase) or Diclofenac (an inhibitor of cyclooxygenase) to reveal the possible involvement of nitric oxide
(NO) and vasodilating prostanoids in the effect of Scirpusin B. Results:Scirpusin B increased CF up to 108.2 %
of the initial value, while Piceatannol did not increase CF. In addition;Scirpusin B increased CF concentrationdependently. Pretreatment with L-NAME or Diclofenac significantly attenuated the Scirpusin B-induced coronary
vasodilatation. Scirpusin B did not change the heart rate either left ventricular pressure. Conclusion:This study
shows that Scirpusin B could increase CF via production of NO and vasodilating prostanoids.
Key words: Scirpusin B, Piceatannol, coronary flow, NO, Perfused heart
INTRODUCTION
Over the past few decades, patients suffering from
arteriosclerosis have been increasing in many
countries. Arteriosclerosis causes a wide variety of
complications such as coronary heart disease (CHD),
heart failure, cerebral infarction and arteriosclerosis.
Mortality in CHD in France is about 25% of that in
Britain, although the major risk factors are similar.1In
spite of a high intake of saturated fats commonly
found in the French diet, the low rate of CHD in
France compared with other developed countries with
Matsumoto et al.,
comparable diets, has been called the French

Paradox.2 In this epidemiological paradox, it has
been speculated that a higher intake of red wine with
Resveratrol(3,5,4-trihydroxy-trans-stilbene) may be
correlated with the incidence of myocardial infarction
in France, which is about 40 percent lower than that
in other European countries.2 It has been reported that
Resveratrol is converted in vivo to Piceatannol
(3,4,3,5-tetrahydroxy-trans-stilbene)
via
the
3
cytochrome P450 enzyme CYP1B1. The only
547
difference between Resveratrol and Piceatannol is the

presence of an extra hydroxyl group in one of the
aromatic rings of Piceatannol. Piceatannol and
Resveratrol are phenolic compounds produced
naturally in grapes and red wine. 4 In general,
phenolic compounds have been recognized as
important natural anti-oxidants found in many kinds
of foods and plants. Resveratrol has strong antioxidative,5,6
anti-inflammatory,7
anti-cancer,8,9
5,10
melanogenesis inhibitory,
and collagen synthesis
activating effects10. Passion fruits (Passiflora edulis),
especially the seeds of passion fruits contain
Piceatannol in a natural state, which is nearly 50
times larger than that found in grapes.10,11 Actually,
88% of the total polyphenols are contained in the
seeds.10 In addition, the extract of passion fruit seeds
contains another polyphenol named Scirpusin B,
which is a dimmer of Piceatannol (Fig. 1).Previous
studies reported that Scirpusin B also shows the
strong vasorelaxant effect in the rat thoracic aorta
probably due to nitric oxide generation, 12 superoxide
anion scavenging activity13 as well as DPPH radical
scavenging activity. 12 It is very interesting that
scirpsin B was demonstrated to be more potent in the
aortic vasorelaxing effect and in radical scavenging
effect than Piceatannol. 12 In addition, it has been
reported that Scirpusin B could improve glucose
metabolism to prevent the postprandial elevation of
blood glucose. 14 These properties strongly suggest
that Scirpusin B could have vasodilatating effect and
anti-arteriosclerotic effect, those are clinically
important especially in maintaining blood supply to
myocardium. Therefore, the aim of this paper is to
investigate the effect of Scirpusin B isolated from
passion fruit seeds on the coronary circulation of the
perfused rat heart.
Animals and Ethics; Experiments were performed in
accordance with the Guide for Care and Use of
Laboratory Animals by US National Institute of
Health and in accordance with the Regulation OF
Animal Experiment in Yamagata University15 under
the regulation of the Animal Care Committee of
Yamagata
University School of Medicine
(Identification number 25072). In this study, 5 - 6
months old (340 - 370 g) male Fischer rats (27
animals in total) obtained from Charles River Japan
(Atsugi, Japan) were used. Each rat was used for the
Matsumoto et al.,
experiment of the isolated heart during the ages

between 20 to 26 weeks-old to avoid ageing effects.
Female rats were not used because of the possible
effects of changes in sex hormone levels (i.e. estrogen
and progesterone). Rats were bred in the Laboratory
Animal Center, Yamagata University School of
Medicine. They were maintained on standard rat
chow with water ad libitum. Scirpusin B was
extracted from passion fruit seeds and purified by
high-performance liquid chromatography (HPLC). 12
In brief, the extracts of passion fruit seeds were
fractionated by reverse-phase HPLC. Each fraction
was collected by an Inertsil ODS-3 column (GL
Sciences Inc., Tokyo, Japan) with conditions of a (A)
water and/or (B) acetonitrile mobile phase at a flow
rate of 5 mL/min. A gradient elution of 0 80% (B)
at 0 90 min was used for fractionation. The
fractionated samples were analyzed by using ODS-3
column. The analytical HPLC was carried out with
(A) water and/or (B) acetonitrile mobile phase at a
flow rate of 0.75 mL/min. A gradient elution of 0
45% (B) at 0 25 min was used for this analysis.
Fig 1: Chemical structures of Piceatannol and

Scirpusin B
Measurement of the coronary flow in isolated
perfused hearts
Fischer-344 rats were deeply anesthetized with
diethyl ether and sacrificed; then the hearts were
quickly excised by performing thoracotomies and
placed in an ice-cold solution of modified KrebsHenseleit (118 mM NaCl, 4.7 mM KCl, 24.9 mM
NaHCO3, 1.18 mM MgSO4, 1.18 mM KH2PO4, 1.8
mM CaCl2, 5.0 mM glucose, 2.0 mM pyruvic acid,
0.057 mM ascorbic acid). The isolated hearts were
immediately perfused by Langendorffs method
under constant pressure (75 cm H2O) with modified
Krebs-Henseleit solution. The buffer solution was
548
continuously aerated with 95% O2 - 5% CO2 mixture

(pH 7.4), and its temperature was kept constant at 37
0.1C with a water-jacketed column.
Piceatannol (10, 30 and 100 M; n = 7) and the
Scirpusin B (10, 30 and 100 M; n = 10) were
injected into the coronary artery as a bolus for 10
seconds. The changes in the coronary flow were
continuously recorded and expressed as a percentage
of the basal flow just before the injection of the
Scirpusin B and Peceatannol. The coronary flow
(ml/min) was measured with an electromagnetic flow
meter (MFV 1100, Nihon Kohden, Tokyo, Japan).
The left ventricular pressure was recorded with a
pressure transducer (Statham P-50, Gould). The heart
rate was detected with a heart rate counter (AT-601G,
Nihon Kohden, Tokyo, Japan).
Effects of L-NAME and Diclofenac on the Scirpusin
B-induced coronary vasodilatation NG-nitro-Larginine methyl ester hydrochloride (L-NAME) or
Diclofenac were applied by continuous infusion via
the rubber tubing connected to the aortic cannula. The
concentrations of L-NAME (final concentration: 100
mM) and Diclofenac (final concentration: 10 mM)
were sufficient to inhibit the synthesis of nitric oxide
(NO) and prostaglandins, respectively.16,17 In the
groups receiving pretreatment with either L-NAME
or Diclofenac, L-NAME or Diclofenac were
continuously infused through a micro syringe pump
(IC3200, KD Scientific Inc., Holliston, MS, USA) for
10 minutes prior to and during the application of the
Scirpusin B. The response to the Scirpusin B in the
presence and absence of L-NAME or Diclofenac was
recorded in each experiment by using different hearts.
Statistical analysis : All data were expressed as means
standard error of the mean (SEM). Differences
between two groups were compared for statistical
significance using unpaired Students t-test.
Differences between the three groups were compared
using ANOVA (analysis of variance), followed by
Tukeys post-hoc tests for multiple comparisons.
Differences were considered significant at p < 0.05.
Materials used: Chemicals used in these experiments
were
3,4,3,5-tetrahydroxy-trans-stilbene
(Piceatannol, Cayman Chemical Co., Ann Arbor, MI,
USA),NG-Nitro-L-arginine
methyl
ester
hydrochloride (L-NAME, Sigma-Aldrich Co., St.
Louis, MO, USA) and sodium Diclofenac (SigmaAldrich). The Scirpusin B (purity > 96%) derived
from passion fruit (Passiflora edulis) seeds was
Matsumoto et al.,
purified and provided by Morinaga & Co., Ltd.

(Kanagawa, Japan). Piceatannol and the Scirpusin B
were dissolved in DMSO. The vehicle used for
dissolving
L-NAME
and
Diclofenac
was
physiological saline. Each solution was prepared
freshly on the day of experiment.
RESULTS
Effects of Piceatannol and Scirpusin B on the
coronary flow; Fig. 2 shows the effect of the
Scirpusin B (100 M) and Piceatannol (100 M) on
the coronary flow in the perfused rat heart. Each drug
was infused into the rubber tubing connected to the
aortic cannula. The Scirpusin B increased coronary
flow up to 108.2% of the initial value within 15
seconds, then it gradually decreased and returned to
the basal level after 2 minutes. Scirpusin B did not
change heart rate and cardiac contractility. In
contrast, Piceatannol did not significantly increase the
coronary flow. The Scirpusin B-increased the
increase in coronary flow was concentrationdependent (Fig. 3).
Effects of L-NAME and Diclofenac on the Scirpusin
B-induced coronary vasodilatation in an isolated
perfused heart.
For revealing the role of NO and vasorelaxing
prostanoids on coronary vasodilatation induced by
Scirpusin B, rat hearts were pretreated with their
inhibitors. In order to determine whether NO was
involved in the Scirpusin B-induced vasodilatation,
NG-Nitro-L-arginine methyl ester hydrochloride (LNAME) was used as an inhibitor of NO synthase. In
the rats pretreated with L-NAME (100 M), the
Scirpusin B-induced coronary vasodilatation was
significantly attenuated compared with administration
of the Scirpusin B alone (Fig. 4). In order to elucidate
whether vasorelaxing prostanoids (for example,
prostacyclin and PGE2) were involved in the
Scirpusin B-induced coronary vasodilatation,
Diclofenac was used as an inhibitor of
cyclooxygenase. In the rats pretreated with
Diclofenac (10 M), the Scirpusin B-induced
coronary vasodilatation was also significantly
attenuated (Fig. 4). Although coronary flow was
slightly diminished by treatment with L-NAME
alone, treatment with Diclofenac alone did not change
coronary flow at all.
549
Continuous infusion of each inhibitor through a

syringe pump began 10 minutes before and continued
during the application of the scirpusin B. Results are
expressed as mean SEM. *P< 0.05, **P< 0.01 vs.
scirpusin B alone.
DISCUSSION
Fig 2: Comparison of the effects of Scirpusin B and

Piceatannol on the coronary flow in perfused rat
hearts.
Each drug was infused into the aortic cannula.

Results are expressed as mean SEM. *P< 0.05 vs.
Piceatannol, **P< 0.01 vs. Piceatannol.
Fig 3: Effect of scirpusin B on the coronary flow of the

Langendorff-perfused rat hearts.
Scirpusin B was infused into the aortic cannula.

Scirpusin B increased coronary flow in a
concentration-dependent manner. Results are
expressed as mean SEM. *P< 0.05, **P< 0.01 vs.
basal value.
Fig4: Effects of nitric oxide synthase inhibitor LNAME and of cyclooxygenase inhibitor diclofenac on
the scirpusin B-induced coronary vasodilatation in
Langendorff-perfused rat hearts
Matsumoto et al.,
It is widely known that moderate red wine

consumption is associated with reducing the risk of
coronary heart diseases (CHDs). Polyphenolic
antioxidants found in red wine, includingResveratrol
and piceatannol, are thought to be responsible for the
cardiovascular benefits associated with moderate red
wine consumption.18 Oxidative stress can cause
endothelial dysfunction and is associated with the
development of cardiovascular diseases such as
hypertension and atherosclerosis.19 In general,
polyphenol exhibit various biological activities such
as the decrease of LDL oxidation, inhibition of
platelet aggregation20 and improvement of endothelial
function.21 These biological activities indicate that
polyphenol possess cardioprotective properties.
The phytoalexin Resveratrol is produced naturally by
some spermatophytes in response to fungal attack or
injury. Resveratrol is commonly found in food and
drinks, including red wine, grapes, mulberries,
passion fruit10 and peanuts.22 Many studies have
revealed that Resveratrol has anti-inflammatory
properties, suppression of ICAM-1 gene expression23
and health benefits to prevent CHD.
On the other hand, piceatannol is an analogue of
Resveratrol, which also has a wide variety of
bioactivities, such as anti-oxidative effects,5,6 antiinflammatory effects,7,24,25 inhibition of vascular
smooth muscle cell proliferation, 26 anti-arrhythmic
activity.27 Taken together, both Resveratrol and
piceatannol could have preventative properties for
atherosclerosis, which in turn can help prevent CHD.
The genus Passiflora, comprising about 500 species,
is the largest in the family Passifloraceae.
Passifloraceae were introduced into medicine in
1840, and have been widely used as medical herbs in
many countries. For instance, Passifloraceae have
been used as hypnotic,25 anxiolytic,29,30 sedative, anticonvulsant,31 anti-tussive, analgesic, wormicidal, and
against inflammatory skin diseases. In addition, antiinflammatory effects7 and the acceleration of the
healing of incisions32 have been reported on the
550
experimental basis. Passion fruit (Passiflora edulis) is

rich in piceatannol.10, 11 Besides, in passion fruit seeds
contain a much larger amount of polyphenol
compared to its rind and pulp.10 Thus, we took notice
of passion fruit seed extract. Passion fruit (Passiflora
edulis) seed polyphenol is mainly comprised of
piceatannol and another polyphenol, scirpusin B. In
the present study, we have evaluated the effects of
scirpusin B and piceatannol in the coronary
vasodilatation effect observed for passion fruit seed
extract.
The effects of scirpusin B and piceatannol on the
coronary flow of the perfused rat heart was compared
(Fig. 2). Although coronary flow was not
significantly increased by piceatannol, scirpusin B
(purity > 96%) increased coronary flow up to 108.2%
of the initial value within 15 seconds, then it
gradually decreased and returned to the basal level
after 2 minutes. These results would indicate that
scirpusin B itself has the vasodilating effect on
coronary arteries of the rat. In addition, scirpusin B
increased coronary flow in a concentration-dependent
manner (Fig. 3). Scirpusin B (10, 30 and 100 M)
increased coronary flow up to 101.4%, 102.8%,
108.2% on percentage of the initial value within 15
seconds, respectively.
In order to elucidate the coronary vasorelaxant
pathway, the perfused rat hearts were pretreated with
two different inhibitors. For the following reason, we
used L-NAME as an inhibitor of NO synthase and
diclofenac as an inhibitor of cyclooxygenase. The
endothelium is the monolayer of endothelial cells and
plays a critical role in regulating vascular tone and in
maintaining the cardiovascular function. Two of the
well-known factors involved in vasodilatation are
endothelium derived NO and vasorelaxing
prostanoids (i.e., prostacyclin and prostaglandin E2).
They may be released not only in the basal condition
but also in response to various vasodilatating
substances such as bradykinin, and to the
intravascular shear stress.33,34 Atrial natriuretic
peptide (ANP) also plays an important role in
regulating coronary circulation in vivo.35 In the rat
heart pretreated with L-NAME, the scirpusin Binduced coronary vasodilatation was significantly
attenuated compared with that of scirpusin B alone
(Fig. 4). Also, in the rat heart pretreated with
diclofenac, the scirpusin B-induced coronary
vasodilatation was significantly attenuated (Fig. 4).
Matsumoto et al.,
These results suggest that the vasodilating effect of

scirpusin B depends, at least in part, on the release of
NO and vasodilating prostanoids.
PGI2 is the major prostaglandin released under basal
conditions of perfused heart. However, the basal
release of prostaglandins are known to be less than
100-300 pg/ml. 33,36 The functional significance of the
small amount of basal PGI2varies among species. For
example, coronary vascular tone was increased by
inhibition of PG synthesis in guinea-pig heart,37 while
not affected in rat and rabbit heart38,39 probably
depending on the level of basal PG release. In our
present study, inhibition of the basal release of PGs
by diclofenac could not significantly affect the basal
coronary flow probably because the level of basal
PGI2 was low. On the other hand, the PGI2 release
could be stimulated to be functionally sufficient
amounts by scirpusin B, so the CF was inhibited by
diclofenac.
Although scirpusin B significantly increased coronary
flow, it did not influence HR, LVP. These results
suggest that scirpusin B may have a protective effect
on an ischemic heart by increasing coronary flow
without affecting the cardiac function. Chronic
ischemia is caused by a mismatch of the oxygen
supply and demand, where significant fixed coronary
stenosis and/or excess myocardial oxygen demand
could result in ischemia. As to oxygen demand, the
coronary blood flow increases as the metabolic
activity of the heart. Although normal PaO2 levels
range from 80 to 100 mmHg, the coronary sinus
blood has a PO2 of about 20 mmHg. Therefore
oxygen extraction is very high in coronary
circulation. An increase in oxygen demand elicits an
increase in coronary blood flow as a result of
vasodilatation of the coronary vessels. Thus, we
speculated that scirpusin B might have a protective
effect on an ischemic heart.
In the present study, we found that scirpusin B has a
coronary vasodilating effect via production of both
NO and some prostanoids. It is known that these
vasodilator substances (NO and prostacyclin) have
anti-aggregatory effects on platelets. An intact
endothelium shows an anti-thrombotic, anticoagulatory and fibrinolytic properties.40 In contrast,
endothelial dysfunction is associated with
cardiovascular events.41 Therefore, scirpusin B would
exert the beneficial effect on coronary circulation of
551
the intact endothelium

arteriosclerosis.
and
on
preventing
CONCLUSION
This study shows that scirpusin B increases rat
coronary flow via production of NO and vasodilating
prostanoids. It is implicated that scirpusin B may
have beneficial effects on preventing cardiac events
and atherosclerosis by increasing these vasodilating
substances.
9.
10.
ACKNOWLEDGEMENTS
This study was supported partly by the Grants-in-Aid
for Scientific Research (C) No.24500846 (A.I.). We
wish to thank Erin MacNamara and Robert Jones for
correcting English editing of the manuscript.
11.
Conflicts of interest: Declare no conflict of interest.

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DOI: 10.5958/2319-5886.2014.00395.6

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
rd
Received: 3 Apr 2014
Coden: IJMRHS
Revised: 6thMay 2014
Copyright @2014 ISSN: 2319-5886

Accepted: 23rd May 2014
Research Article
EVALUATION OF SURFACE CONTAMINATION OF BACTERIA IN VARIOUS DENTAL CLINICS WITH

SPECIAL REFERENCE TO OBLIGATE AND FACULTATIVE ANAEROBIC SPORE BEARING BACILLI
*Kannan I, Jessica Yolanda Jeevitha, Sambandam Cecilia, Jayalakshmi M, Premavathy RK, Shantha S
Department of Microbiology, Tagore Dental College and Hospital, Rathinamangalam, Chennai, Tamil Nadu,
India
*Corresponding author email:kannan_iyan@hotmail.com
ABSTRACT
Introduction: The occupational health and safety is an important prerequisite in dental clinic setup for well being
of both the doctor and patient. Both the patient and dentist are always at the risk of infections. Aim and
objectives: There is no proper literature on the survey of bacterial spores, especially of Clostridium species in
dental clinics. Hence an attempt has been made in the present pilot study to evaluate the surface contamination
with special reference to bacterial spores. Materials and methods: Various dental clinics from Chennai city,
India were selected for the present study. Samples were collected from two clinics each from endodontic,
prosthodontic, orthodontic, and periodontic. In each clinic important places were selected for sampling. The
samples were collected in the form of swabs. The swabs thus obtained were inoculated into Robertson Cooked
Meat Medium and was incubated in anaerobic condition at 370C for 7 days. Each day the tubes were examined for
turbidity and colour change and were noted. At the end of 7th day the smear was prepared from each tube and
gram staining was performed. The gram stained slides were examined microscopically for the presence of spore
bearing bacilli especially with special reference to terminal spore bearing bacilli. Results and conclusion: From
the present study it is clear that the dental clinics invariably posses a lot of aerobic and anaerobic spores
irrespective of stringent disinfection procedures. Hence it is mandatory for the dental clinics to undergo
periodical microbiological surveillance and to take proper steps in the control of bacterial spores.
Keywords: Surface contamination, dental clinics, anaerobic spores, Clostridium tetani
INTRODUCTION
The occupational health and safety is an important
prerequisite in dental clinic setup for well being of
both the doctor and patient. Both the patient and
dentist are always at the risk of infections. A lot of
research has been conducted to estimate the microbial
contamination of dental units. It has been proved that
infections spread through blood and saliva through
direct or indirect contact, droplets, aerosols, or
contaminated instruments and equipment.1 The
researchers are much concerned with the
microorganisms arises from the mouth of the
patients.2, 3 Most of the works are concerned with the

identification of microorganisms in aerosol or surface
with special reference to contamination due to dental
procedures.4, 5 There are also lot of works concerned
with the waterline contamination in the dental units.6,7
The infection control practice in dentistry in mainly
concerned with the microorganisms arises from the
patient or from the water source.8 Hence the approach
towards the infection control mainly relies on use of
disinfection methods.
554
Kannan et al.,
The global incidence of tetanus is still estimated at

one million cases annually, with a case fatality ratio
ranging from 6% to 72%.9 Hence the infection control
methods should help to remove the anaerobic spores
also. However the infection control methods are
helpful mostly in the control of microorganism arises
due to various dental procedures. There are no
evidences to prove that they manage to remove the
surface contamination occurred by external sources
especially the spores. The spore bearing
microorganisms in a hospital environmentare always
a problem and they arise mainly due to the
contamination from the external environment. The
personnel who enter into the dental clinic may bring
the microorganisms and spores from the outside
environment. The bacterial spores may not be
removed completely by the disinfection process
normally adopted in dental clinics.
There is no proper literature on the survey of bacterial
spores, especially of Clostridium species in dental
clinics. Hence an attempt has been made in the
present pilot study to evaluate the surface
contamination with special reference to bacterial
spores.
Dental clinics:Various dental clinics from Chennai
city were selected for the present study. Samples
were collected from two clinics each from
endodontic,
prosthodontic,
orthodontic,
and
periodontic. In each clinic important sites (Table 1)
were selected for sampling.
Table 1: Sites of sample collection from different
clinics
Dental chair, Side tray, Light
Endodontic
handle, Floor, Suction tip, Mouth
clinic
mirror, Tap, Spit out, Triple
syringe, Waiting area , Operators
chair
Prosthodontic Mask, Dental chair, Side tray
Spit out, Floor, Dust bin, Light
clinic
handle, Suction tip, Triple syringe,
Waiting area floor, Waiting area
chair, Operators chair
Dental chair, Side tray, Light
Periodontic
handle, Floor Scaler tip, Tap, Spit
clinic
out ,Triple syringe
Dental chair, Side tray, Floor, Tap,
Orthodontic
Spit out, Triple syringe, Waiting
clinic
area, Operators chair, Floor,
Booster bottle, Trolley, Window
Sample collection: The samples (N=43) were

collected in the form of swabs. The sterile swabs
were dipped in sterile saline prior to the collection of
surface samples. The moist swab was rubbed against
the surface with the swirling movement for 30
seconds. Then collected swabs were placed in sterile
test tubes and were transported to the lab immediately
for further analysis.
Isolation and identification: The swabs thus
obtained were inoculated into Robertson Cooked
Meat Medium (HiMedia) and was incubated in
anaerobic condition at 370C for 7 days. Each day the
tubes were examined for turbidity and colour change
and were noted. At the end of 7th day the smear was
prepared from each tube and gram staining was
performed. The gram stained slides were examined
microscopically for the presence of spore bearing
bacilli especially with special reference to terminal
spore bearing bacilli.
RESULTS
At the end of 7th day tubes were finally checked for
the turbidity and colour change. Some of the tubes
showed turbidity and black indicating the growth of
anaerobic bacteria (Figure 1).
Fig 1: Robertson cooked meat medium showing the

turbidity and black colour
Fig 2: Gram stained smear showing the bacilli with

terminal bulged spore along with facultative anaerobic
bacilli
555
Kannan et al.,
A smear was prepared from the broth of all tubes

irrespective of turbidity and gram staining is
performed to visualize the spore bearing bacteria.
Some of the smears showed the presence of aerobic
spore bearing bacteria (Facultative anaerobic

bacteria). Some smears showed the gram positive
bacilli with terminal bulged spore whose morphology
resembled that of Clostridium tetani (Fig 2).
Table 2: Results obtained from Endodontic clinic

Site
Clinic 1
Culture result
Smear
Dental chair
Turbidity and Bacteria
morphologically
blackening
resembling C. tetani
Side tray
morphologically
blackening
Light handle
No
turbidity No bacteria
and no colour
Floor
No
and no colour
Suction tip
No
and no colour
Mouth mirror No
and no colour
Tap
morphologically
blackening
Spit out
Clear
No bacteria
Triple
Clear
Few aerobic spore bearers
syringe
Waiting area
Clear
No bacteria
Operators
Turbid
Lot of aerobic spore bearers
chair
Table 3: Results obtained from Prosthodontic clinic
Site
Clinic 1
Culture result
Smear
Mask
No turbidity
No bacteria
and no colour
Dental chair
No turbidity
No bacteria
and no colour
Side tray
Turbidity and
Aerobic spore bearers
no colour
Spit out
Floor
Dust bin
Light handle
Suction tip
Triple syringe
Waiting area
floor
Waiting area
chair
Operators chair
Clinic 2
Culture result
Turbid
Smear
Aerobic spore bearer
No turbidity
no colour
No turbidity
no colour
No turbidity
no colour
No turbidity
no colour
No turbidity
no colour
No turbidity
no colour
and
No bacteria
and
No bacteria
and
No bacteria
and
No bacteria
and
No bacteria
and
No bacteria
Clear
Clear
No bacteria
No bacteria
Clear
Turbid
No bacteria
Lot of aerobic spore
bearers
Clinic 2
Culture result
No turbidity and
no colour
Turbid
Smear
No bacteria
Turbidity and
blackening
Turbidity and
blackening
Turbidity and
blackening
No turbidity
and no colour
No turbidity
and no colour
No turbidity
and no colour
Turbid
Turbid
Morphology resembling C.
tetani
tetani along with lot of aerobic
spore bearers
Bacteria morphologically
No bacteria
Turbid
Turbidity and
blackening
Turbid
resembling Clostridium tetani
No bacteria
No turbidity and
no colour
No turbidity and
no colour
Turbid
No bacteria
Turbid

bearers
bearers
Turbid
Turbid
Turbid
Turbid and
black
No bacteria
No bacteria
556
Kannan et al.,
Table 4: Results obtained from Periodontic clinic

Site
Clinic 1
Culture result
Smear
Dental chair
No turbidity
No bacteria
and no colour
Clinic 2
Culture result
Turbid
Smear
Turbid and
black
Turbid
Turbid
tetani
tetani
tetani

bearers
No bacteria
Turbid
Turbid
No bacteria
No bacteria
Clear
No bacteria
Side tray
Turbid
Light handle
Turbid
Floor
Turbid
Scaler tip
No turbidity
and no colour
Turbid
Morphology resembling
C. tetani
C. tetani
No bacteria
Tap
Spit out
Triple syringe
No turbidity
and no colour
Clear
Table 5: Results obtained from orthodontic clinic

Site
Clinic 1
Culture result
Smear
Dental chair
Turbid and
black
C. tetani along with lot of
aerobic spore bearers
Side tray
Turbid
bearers
Floor
Turbid
bearers
Tap
Spit out
Triple syringe
Waiting area
Operators chair
Floor
Booster bottle
Trolley
Window
Turbid and
black
Turbid
Turbid
Turbid and
black
Turbid and
black
Turbid and
black
Turbid and
black
Turbid

bearers
bearers
bearers
C. tetani.
C. tetani
C. tetani
Turbid and
black
C. tetani
The Table 2 depicts the results obtained from two

endodontic clinics. The first clinic showed the
presence of bacterial resembling Clostridium tetani in
the dental chair, side tray and tap. The second clinic
showed some aerobic spore bearers
The Table 3 gives the results obtained prosodontic
clinic. The first clinic showed the presence of bacteria
Turbid
Clinic 2
Culture result
Turbid
Smear
Turbid
Turbid
Turbid
Turbid
Lot of aerobic spore bearer
Turbid
Turbid

Turbid and
black
Turbid and
black
Turbid and
black
Turbid and
black
Turbid and
black
tetani
tetani
tetani
tetani
resembling C. tetani in floor and dust bin. The second

clinic showed the presence of bacteria resembling C.
tetani in dental chair, side tray and dust bin. Both the
clinics showed the presence of lot of aerobic spore
bearers.
The Table 4 shows the results obtained from
periodontic clinics. The first clinic showed the
557
Kannan et al.,
presence of bacteria morphologically resembling C.

tetani in light handle and floor. The second clinic
showed the presence of bacteria morphologically
resembling C. tetani in side tray, light handle and
floor. Both the clinics also showed the presence of lot
of aerobic spore bearers.
The Table 5 shows the results obtained from
orthodontic clinics. The first clinic showed the
presence of bacteria morphologically resembling C.
tetani in dental chair, operators chair, floor, booster
bottle and window. The second clinic showed the
presence of bacteria in morphologically resembling
C. tetani in operators chair, floor, booster bottle and
window. Both the clinics also showed the presence of
lot of aerobic spore bearers.
bacterial spores. Dental clinics should undergo a

sterilization process which should also include
fumigation followed by screening for the bacterial
spores. Lack of spores is the indication of thorough
sterilization of the dental clinics and hence the safety
of patients.
ACKNOWLEDGEMENTS
We thank Prof. J. Mala, Chairperson, Tagore group of
Colleges, for providing necessary facilities for the
present study. We are thankful to Dr. T. N.
Swaminathan, Advisor and Dr. Chitraa R. Chandran,
Principal, Tagore Dental College and Hospital for
their kind support and encouragement.
Conflict of interest: No
DISCUSSION
The results obtained from the present study clearly
shows that anaerobic spores are prevalent in various
dental clinics irrespective the disinfection procedures
adopted. Almost all the clinics showed the presence
of bacteria morphologically resembling C. tetani.
Certain clinics even showed their presence in the side
tray where the instruments are kept for invasive
dental procedures.
Eventhough vaccine is available for tetanus; still the
disease remains a threat throughout the world in
health care units.10 Tetanus still occurs sporadically
especially in developing countries and can affect even
fully immunized persons who fail to develop or
maintain adequate immunity with the booster doses
of vaccine.11, 12C. tetani predominantly present in soil
and can enter into the dental clinic through various
routes. The C. tetani spore can enter into the body of
human undergoing various dental procedures thus can
pose the danger of tetanus infection. Tetanus
management is very difficult both in terms of
materials and manpower.13, 14Overall mortality is
approximately 10-50%, however, in certain age
groups like neonates it is as high as 90-95%.15
CONCLUSION
From the present study it is clear that the dental
clinics invariably posses a lot of aerobic and
anaerobic spores irrespective of stringent disinfection
procedures. Hence it is mandatory for the dental
clinics to undergo periodical microbiological
surveillance and to take proper steps in the control of
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1. Merchant VA. Herpesvirus and other microorganisms of concern in dentistry. Dent Clin
North Am 1991; 35:28398
2. Grenier D. Quantitative analysis of bacterial
aerosols in two different dental clinic
environments. Appl Environ Microbiol 1995;
61:316568
3. Osorio R, Toledano M, Liebana J, Rosales JI,
Lozano
JA.
Environmental
microbial
contamination. Pilot study in a dental surgery. Int
Dent J 1995; 45:35257
4. Piazza M, Guadagnino V, Picciotto L, Borgia G,
Nappa S. Contamination by hepatitis B surface
antigen in dental surgeries. BMJ 1987; 295:47374
5. Legnani P, Checchi L, Pelliccioni GA, D'Achille
C. Atmospheric contamination during dental
procedures. Quintessence International 1994;
25:43539
6. Atlas RM, Williams JF, Huntington MK.
Legionella contamination of dental-unit waters.
Appl Environ Microbiol 1995; 61: 120813
7. Pankhurst CL, Philpott-Howard JN. The
microbiological quality of water in dental chair
units. J Hosp Infect 1993; 23: 16774
8. Centre for Disease Control and Prevention.
Recommended infection-control practices for
dentistry. MMWR Morbid Mortal Wkly Rep
1993; 42:112
9. Oladiran I, Meier DE, Ojelade AA, Olaolorun
DA, Adeniran A, Tarpley JL: Tetanus continuing
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10.
11.
12.
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14.
15.
problem in the developing world. World J Surg

2002, 26(10):1282-85
Oladiran I, Meier DE, Ojelade AA, Olaolorun
DA, Adeniran A, Tarpley JL: Tetanus continuing
problem in the developing world. World J Surg
2002; 26(10):1282-85
Lau LG, Kong KO, Chew PH: A ten-year
retrospective study of tetanus at a general hospital
in Malaysia. Singapore Med J 2001; 42(8):346-50
Joshi S, Agarwal B, Malla G, Karmacharya B:
Complete elimination of tetanus is still elusive in
developing countries: a review of adult tetanus
cases from referral hospital in Eastern Nepal.
Kathmandu Univ Med J. 2007; 5(3):378-81
Mchembe MD, Mwafongo V: Tetanus and its
treatment outcome in Dares Salaam: need for
male vaccination. East African Journal of Public
Health 2005; 2: 22-23
Edlich RF, Hill LG, Mahler CA, Cox MJ, Becker
DG, Horowitz JH: Management and prevention
of tetanus. J Long Term Eff Med Implants 2003;
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Bhatia R, Parbharkar S, Grover VK: Tetanus.
Neurol India 2002; 50:398-407
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DOI: 10.5958/2319-5886.2014.00396.8

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
nd
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Research Article
A STUDY TO ASSESS THE DOMESTIC VIOLENCE IN MENTAL ILLNESS & NORMAL MARRIED
WOMEN
*Jyoti Srivastava1, Indira Sharma2, Anuradha Khanna3
1
Ph.D Scholar, College of Nursing, 2Professor, Department of Psychiatry, 3Professor, Department of Obstetrics &
Gynaecology, IMS, Banaras Hindu University Varanasi, UP, India
*Corresponding author email: jyotichoithram@rediffmail.com
ABSTRACT
Background: Domestic violence against women is the most pervasive human rights violation in the world today.
According to UNiTE to End Violence against Women (2009) by UN Women, In the United States, one-third of
women murdered each year are killed by intimate partners. In South Africa, a woman is killed every 6 hours by an
intimate partner. The Objective: To assess the magnitude and causes of domestic violence with mental illness &
normal women. Material & Methods: The sample of study comprised of 50 women with mental illness and 50
normal women. Mental illness patients diagnosed according to with Axis one psychiatric Disorder DSM IV-TR,
who were selected from the Psychiatry OPD and ward of the S.S. Hospital, BHU and normal women were be
selected from the accompany with patients of Sir Sunder Lal Hospital. The patients were assessed on the
structured questionnaire on Domestic Violence. Results The domestic violence present in married women with
mental illness was 72% and normal women were 36%. Perceived causes of domestic violence in married women
with mental illness were more compared to those with normal women. The health care personnel should be given
an opportunity to update their knowledge regarding domestic violence and there is need education for domestic
violence and cessation, so that they can help the women to protect/prevent domestic violence.
Key words: Domestic violence, Married women, Normal women, domestic abuse, Family Violence.
INTRODUCTION
Violence against women is perhaps the most
shameful human rights violation, and it is perhaps the
most pervasive. It knows no boundaries of
geography, culture or wealth. As long as it continues,
we cannot claim to be making real progress towards
equality, development, and peace.1
Domestic violence is a critical public health problem
that has devastating physical, psychological effects
on human beings across all societies and classes in
the world.2, 3
Definitions and Key Concepts: The United Nations
Declaration on the Elimination of Violence against
Women (1993) defines violence against women as
"any act of gender-based violence that results in, or is

likely to result in, physical, sexual or psychological
harm or suffering to women, including threats of such
acts, coercion or arbitrary deprivation of liberty,
whether occurring in public or in private life.4
Violence against women in a well recognized public
health problem and human right violence of
worldwide significance5. The Declaration defines
violence against women as encompassing, but not
limited to, three areas: violence occurring in the
family, within the general community, and violence
perpetrated or condoned by the State. Acts of
560
Jyoti et al.,
omission are also included as a form of violence

The causes of domestic violence in the women with
against women and girls (UNICEF, 2000).5
mental illness and normal women have not been
Domestic violence refers to acts of violence that
studied well in the Indian population especially in
occur between people who have, or have had, an
Northern India. As women with mental illness are
intimate relationship in domestic settings. These acts
more likely to be abused than normal women, there is
include physical, sexual, emotional and economic
need to study and compare domestic violence in these
abuse, Defining forms of violence, its perpetrators
populations. There is limited work in this area.
and their victims, is complicated by the many
different kinds of intimate and family relationship
6.
and living arrangements present in communities
This was a descriptive study, using a quantitative
Globally, it has been estimated that 1 woman in 3 has
approach performed. The sample comprised of 50
been beaten, forced into sex, or otherwise abused in
women with mental illness and 50 normal women at a
her lifetime.7 Mental health sequelae to spousal/
selected from Psychiatry OPD and ward of Sir Sunder
intimate partner violence are significant and have
Lal Hospital, Banaras Hindu University, Varanasi,
long-term health implications. Battered women were
Uttar Pradesh over a period of three months. A
found to have more depressive symptoms than other
convenience sample of 100 women with mental
women.8. Sexual violence was associated with a
illness and normal women was selected. Inclusion
higher severity of depressive symptoms and a higher
criteria for the present study includes: Age group
incidence
of
suicide
attempts
in
the
between 16 to 40 years, Subjects who were ready to
physically/psychologically abused group9. There has
participate for the interview, All the Participant were
been much debate regarding the most appropriate
attending the Psychiatry OPD/Ward of SSH, BHU &
terminology to use for violence between spouses and
Married female. The data was collected through face
partners. Objections have been raised to both
to face interview, after taking written informed
domestic Violence and family violence as well as
consent. The study protocol was approved by the
use of terms such as victims of domestic violence 10.
Ethical Committee of Institute of Medical sciences.
Tamil Nadu shows the highest prevalence with 41
The study sample was assessed using the following
percent of the women reporting domestic violence
instruments: i) Socio-demographic Performa. ii)
incidents since the age of 15 years. Andhra Pradesh,
Domestic violence questionnaire13. iii) Global
Karnataka, Meghalaya, Arunachal Pradesh, Mizoram,
disability scale for assessment of psychiatric
Orissa, Bihar and Jammu and Kashmir have
disability (IDEAS) 14, iv) Burden of care: Burden
prevalence rates higher than 20 percent. Himachal
assessment scale15. v) Questionnaire for perceived
Pradesh shows the lowest prevalence of 5.8 percent,
cause of domestic violence
followed by Kerala (10.1 percent) and Gujarat (10.2
Descriptive and inferential statistics were used in
percent) 11.
order to analyze the data using SPSS version 16.
Not only is the body scarred by such violence.
Statistical analysis: The data was analyzed with the
Consequences also included depression, anxiety,
help of parametric and non-parametric tests.
phobias and substance abuse, confirming that the
Categorical data was analyzed by the chi square test
effects of violence can last long after the brutality has
with yates correction or fishers test wherever
ended. Women who had been physically or sexually
applicable. Numerical data was analyzed byt test
abused were three times likelier to have had suicidal
and f test.
thoughts, and four times likelier to have attempted at
least once to take their own lives.12
RESULTS
Table 1a: Socio-demographic characteristic of the sample
Mental Illness (N=50) Normal (N=50)
Variable
Mean SD Range Mean SD Range
Age at the time of Marriage of women (years) 18.8 4.1
Age at the time of interview of women (years) 30.6 5.9
10-29 19.73.7
21-40 31.7 5.7
12-29
19-40
Df-1, f=1.35, P<0.05

Df-1, f=5.52 P<0.05
Jyoti et al.,
561
Table 1b: Socio-demographic characteristic of the sample

Mental Illness (N=50)
Variable
N
%
Religion
Hindu
50
100
Husbands Family Type
Nuclear family
18
36.0
Joint family
32
64.0
Womens natal family Domicile
Rural
26
52.0
Urban
24
48.0
Normal (N=50)
N
%
50
100
14
36
28.0
72.0
21
29
42.0
58.0
X2
Df-1
X2= 0.73
P>0.05
Df-1
X2= 1.00
P>0.05
Table 1c: Socio-demographic characteristic of the sample

Normal (N=50)
N
%
N
%
X2
Variable
Womens Education
Illiterate
06
12.0
06
12.0
Df-6 X2=9.35
Primary
10
20.0
02
04.0
NS
Middle
08
16.0
10
20.0
High school
05
10.0
07
14.0
Intermediate/Diploma
09
18.0
06
12.0
Graduation/Post graduation
12
24.0
17
34.0
Profession or honours
00
00.0
02
04.0
Husbands Occupation
Professional / Semi professional
05
10.0
08
16.0
Df-5 X2=2.89
Clerical/shop owner
23
46.0
19
38.0
NS
Skilled worker
05
10.0
06
12.0
Semi-Skilled Worker
10
20.0
07
14.0
Unskilled Worker
06
12.0
07
14.0
Unemployed
01
02.0
03
06.0
Husbands Education
Illiterate
01
02.0
01
02.0
Primary
01
02.0
00
00.0
Df-6 X2=4.57
Middle
05
10.0
06
12.0
NS
High school
09
18.0
09
18.0
Intermediate/Diploma
14
28.0
07
14.0
Graduation/Post graduation
19
38.0
25
50.0
Profession or honours
01
02.0
02
04.0
Table 2: Assessment of Domestic violence in women with Mental illness & Normal women
Mental Illness (N=50) Normal women (N=50)
N
%
N
%
Present
36
72.0
21
42.0
Absent
14
28.0
29
58.0
Table 3: Type of Domestic violence in women with Mental illness & Normal women
Normal women (N=50)
Present
Absent
Present
Absent
N (%)
N (%)
N (%)
N (%)
Variable
Emotional /Verbal violence 36 (72%)
14 (28%)
21 (42%)
29 (58%)
Physical violence
31 (62%)
19 (18%)
17 (34%)
33 (66%)
Economical violence
20 (40%)
30 (60%)
05 (10%)
45 (90%)
Sexual violence
14 (28%)
36 (72%)
10 (20%)
40 (80%)
562
Jyoti et al.,
Table 4: Distribution of sample according to diagnostic breakup (Clinical characteristics of women with
mental illness)
Variables
N=50
N
Diagnosis
%
Schizophrenia
13
26.3
Bipolar I disorder, most recent episode manic
15
30.0
MDD with psychotic features
03
06.0
Mania
02
04.0
Generalized Anxiety disorders
03
06.0
Depression without psychotic symptoms
09
18.0
Obsessive Compulsive Disorder
03
06.0
Conversion disorders
02
04.0
Table 5: Correlations between Domestic violence and Total duration of marriage, Husbands income, total
family member, duration of illness, total disability and burden assessment.
(Mental illness Group N=50)
Total Score
Pearson R Value
Approximate Significant
Domestic violence and Total Duration of marriage
-.219
.126
Domestic violence and Husbands Income
.069
.632
Domestic violence and Husbands Total family member
-.077
.596
Domestic violence and duration of illness (month)
.004
.980
Domestic violence and Total disability
-.056
.701
Domestic violence and Burden Assessment
.093
.519
Table 6: Correlations between Domestic violence and duration of marriage, Total family member &
husbands income.
(Normal women Group N=50)
Total Score
Pearson R Value Approximate Significant
Domestic Violence and Total duration of marriage
.037
.800
Domestic Violence and total family member (husbands homes)
.078
.590
Domestic Violence and Husbands income
.074
.609
Table 7: Perceived Causes of domestic violence against women with mental and normal women
Mental Illness
Normal women
(N=36)
(N=21)
S.no Variable
N
%
N
%
1.
2.
3.
4.
5.
6.
7.
1
2
3
4
5
6
7
8. 8
9. 9
10
11
Unable to perform domestic chores
30
14
Other family members complain about her behavior
14
Husband is not find time to know the truth & starts scolding
13
Remain mentally sick, so husband does not like you
13
Not good sex partner which cause for domestic violence
12
Husband has got approved by the family to do anything wrong or 12
Dowry is one of the cause which creates violence in the family
right against you

Husband does not like you and creates problem
Poverty, which is cause violence
Husband is greedy and demands money
Male child is preferred over the female child
11
11
10
03
83.3
38.9
38.9
36.1
36.1
33.3
33.3
3
3
1
6
0
10
2
14.2
14.2
04.7
28.5
00.0
47.6
09.5
30.6
30.6
27.8
8.3
0
4
4
6
00.0
19.0
19.0
28.8
563
Jyoti et al.,
Table 2. Data represented in Table 3 showed the

distribution of domestic violence among women with
mental and normal women. The domestic violence
present in married women with mental illness was
72% and normal women were 42%. There was a
significant association between present of domestic
violence and mental and normal women.
The above table depicts that majority of domestic
violence against women was as follows:
emotional/verbal violence 72% and physical violence
was 62% in mental illness. Conversely
emotional/verbal violence was 42% in normal women
(Table.3).
Tables 4 showed that majority of 30% women with
mental illness were suffered from bipolar disorder.
Table 5: Showed that the there was no correlations
between Domestic violence with mental illness and
Total duration of marriage, Husbands income, Total
family member, duration of illness, total disability
and burden assessment.
Table 6: Showed that the there was no correlations
between Domestic violence with normal women and
Total duration of marriage, Total family member of
husbands home and husbands income.
The majority of causes of domestic violence showed
that 83.3% women with mental illness & 14.2%
normal women though that she was unable to perform
domestic chores. 38.9% women with mental illness
and 14.2% normal women told that Dowry was one
of the causes which created violence in the family.
38.9% women with mental illness and 4.7% normal
women complaint about her behaviour. 36.1%
women with mental illness & 28.5% normal women
told that husband is not find time to know the truth &
starts scolding. 36.1% remain mentally sick, so
husband did not like &33.3% women with mental
illness was not good sex partner which cause for
domestic violence. 33.3% % & 9.5% husband had got
approved by the family. 30.6% women with mental
illness that husbands did not like and creates problem.
Poverty, money and Male child was also the causes of
domestic violence (Table-7).
violence in married women with mental illness and

normal women.
The finding of the study showed that the assessment
of domestic violence married women with mental
illness and normal women score among 100 subjects
of the women, total distribution among given
population 72% women with mental illness & 42%
normal women. Domestic violence in the married
women with mental illness is largely due to the stigma
of mental illness. There is an association between
domestic violence with mental and normal women &
selected demographic variable like husbands family
domicile, womens natal family type, womens
occupation and socioeconomic status. The findings
provide robust evidence for a greater degree of
domestic violence in women with mental illness and
less so in women with normal women.
In mental illness, there is no correlation between
Domestic violence and Total duration of marriage,
Husbands income, and total family member, duration
of illness, total disability and burden assessment. And
also in normal women, there is no correlation
between Domestic violence and total duration of
marriage, total family member of husbands home
and husbands income. Perceived causes of domestic
violence were reported more in the married women
with Mental Illness compared to normal women.
DISCUSSION
We thank the Dr.G.P Singh, Dept.of Community

Medicine & DST-CIMS, IMS, BHU & DST centre
BHU for analysis through SPSS.
The present study was aimed to assess the Domestic

violence in married women with mental illness and
normal women. It should be emphasized that no
studies were found that the assessment of domestic
CONCLUSION
According to the result obtained from the research,
the domestic violence in women was quite high
whereas domestic violence in women with mental
illness were more than women with normal women.
Domestic Violence in the married women with
mental illness was largely due to the stigma of mental
illness.
The study findings imply that there is a need for
health education programmed to be carried out to
create awareness among the women regarding
domestic violence and their risk.
ACKNOWLEDGMENTS
Conflicts of interest: No competing interests.
564
Jyoti et al.,
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2. Veena A Satyanarayana, Prabha Chandra. World
report on violence. Indian journal of medical
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3. Shipway Lyn.(2004). Domestic violence: A hand
book for Health Professional. British library
cataloguing. 1st.1
4. United Nations. Declarations on the elimination of
violence against women. United nations General
Assembly New York. 1993. http://www.un.org/
documents/ga/res/48/a48r104.htm.
5. UNICEF. Domestic violence against women and
girl innocent digest. 2000;6:6
6. Morgan. Masculine general roles associated with
increased sexual risk and intimate partner
violence perpetrators among young adult men.
Journal of urban health: Bulletin of the New York
Academy of medicine. 2010; 123:737-46
7. Bachman R,Saltzman L. Violence against
women: Estimates from the redesigned survey.
Bureau of Justice Statistics special report.
Washington, D.C.: U.S. Department of Justice,
Office of Justice Programs, Bureau of Justice
Statistics. 1995; (Publication NCJ-154348).
http://www.bjs.gov/content/pub/pdf/FEMVIED.P
DF.
8. Counts DA, Brown J, Campbell J. Sanctions and
Sanctuary: Cultural Perspectives on the Beating
of Wives. Boulder, CO: Westview Press.1992;
9. Pico-Alfonso MA, Garcia-Linares MI, CeldaNavarro N, Blasco-Ros C, Echebura E, Martinez
M. The impact of physical, psychological and
sexual intimate male partner violence on women's
mental
health:
depressive
symptoms,
posttraumatic stress disorder, state anxiety, and
suicide. J Women Health. Larchmt. 2006;15(5),
599-611.
10. Fehlberg B, Behrens J. Australian family law: the
contemporary context, Oxford University Press,
South Melbourne. 2008;(1). 177-79.
11. IRIN UN. Pakistan: Domestic violence endemic,
but awareness slowly rising. Humanitarian news
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March 11. http://www.irinnews.org/ Report.aspx?

ReportId=77226.
12.The Hindu news. Working women face more
domestic violence in India: Study. Oct 2009
13. Indu PV. Development and validation of the
Domestic Violence Questionnaire in married
women aged 1855 years. Indian J Psychiatry.
2011;53(3): 21823
15. Thara RS, Rajkumar, Valecha V. Schizophrenia
Research Foundation. (SCARF, India). Burden
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Domestic Violence Questionnaire in married
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DOI: 10.5958/2319-5886.2014.00397.X

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Volume 3 Issue 3
th
Coden: IJMRHS
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ISSN: 2319-5886
th
Revised: 5 May 2014
Accepted: 3rd Jun 2014
Research Article
CORRELATION OF INTRAOCULAR PRESSURE WITH BLOOD PRESSURE AND BODY MASS

INDEX IN OFFSPRINGS OF DIABETIC PATIENTS: A CROSS SECTIONAL STUDY
*Shailaja Patil1, Anita Herur2, Shashikala GV1, Surekharani Chinagudi2, Manjula R3, Roopa Ankad1, Sukanya
Badami1, Brid SV4
1
Assistant Professor, 2Associate Professor, 4Professor and Head, Department of Physiology, S. Nijalingappa
Medical College, Navanagar, Bagalkot, Karnataka, India
3
Assistant Professor, Department of Community Medicine, S. Nijalingappa Medical College, Navanagar,
Bagalkot, Karnataka, India
*Corresponding author email: drshailajapatil@gmail.com
ABSTRACT
Background: Raised intraocular pressure (IOP) has been associated with risk factors like hypertension, diabetes
mellitus (DM), obesity, body mass index (BMI) and sex, increasing the risk of glaucoma causing visual
impairment and blindness. Since familial inheritance is known with glaucoma and DM, the aim was to study the
IOP and its correlation with BMI and blood pressure (BP) in offsprings of DM and also to predict the future/early
onset of glaucoma in them. Methods: This was an observational study done in medical undergraduate students.
25 students were included in the study group (offsprings of diabetic parents-cases) and 23 students in the control
group (offsprings without diabetic history in parents). Height, weight, blood pressure and intraocular pressure
were recorded in both the groups and these were compared. Statistical analysis was done by students t test and
Pearsons correlation. Results: Cases exhibited a lower IOP, BMI, mean arterial pressure (MAP) and diastolic
blood pressure (DBP), but not SBP, as compared to controls. These differences, however, were not statistically
significant except DBP. There was a negative correlation found between IOP and BMI and also between IOP and
MAP in cases, whereas in controls, there was a positive correlation found between BMI and IOP and no
correlation between IOP and MAP. Conclusion: Offsprings of diabetic patients may be less prone for primary
open angle glaucoma. Limitations: The limitations of the present study include a smaller sample size, study of
the results in relation to paternal or maternal diabetic status and also of grandparents, so that the inheritance of
diabetes and also of IOP can be studied.
Keywords: Intraocular pressure; Diabetes mellitus; Body mass index; blood pressure; glaucoma
INTRODUCTION
Glaucoma is one of the leading causes of acquired
blindness and is common in females after thirty five
years and in those with a family history of glaucoma1.
Glaucomatous optic nerve damage is more likely to
be associated with high intraocular pressure (IOP).
Although IOP is not the only risk factor for optic
Shailaja et al.,
nerve damage, but is one of the main risk factors for

emergence of glaucoma and is the only amendable
risk factor.
Raised IOP (Normal IOP:10-20mmHg) has been
associated with risk factors like hypertension2,
diabetes3, obesity, body mass index (BMI)4, sex5 and
566
age6, increasing the risk of glaucoma causing visual

impairment and blindness. Among the diabetics, IOP
is high as compared to non-diabetics and also an
increase in IOP is seen with increasing BMI and there
is a positive correlation between this variable and IOP
in diabetics. It indicates that the increase in BMI
appears to be a positive additive determinant of
raising IOP in diabetics3 and also few studies show
minimal or no association between diabetes mellitus
(DM) and primary open angle glaucoma (POAG) 5,6.
Familial inheritance is known with glaucoma and
DM, and an interesting point about glaucoma is that
most of the times it goes unnoticed in the initial stage
where progression to blindness can be prevented.
There is a paucity of literature involving studies on
IOP in offsprings of DM. Hence, the aim was to study
the IOP and its correlation with BMI and blood
pressure (BP) in offsprings of DM and also to predict
the future/early onset of glaucoma in them.
who consented to the study, twenty five students were

included in the study group and twenty three students
in the control group.
Ethical clearance was obtained from the institution.
Informed consent was taken from all the subjects.
Height was recorded by stadiometer, weight by a
standard weighing machine, blood pressure by
sphygmomanometer and IOP by non-contact
tonometer in both cases and controls. BMI and Mean
arterial pressure (MAP) were calculated. The
recorded parameters were compared in both the
groups. Statistical analysis was done by students
(unpaired) t test and Pearsons correlation using SPSS
package 11 version.
RESULTS
Forty eight subjects (25 cases and 23 controls) were

included, age ranging from 17 to 20 years. Mean age
of cases and controls was 18.28years and 18.43years.
The mean weight of cases and controls was 59.92 Kg
and 58.3 Kg. The mean height of cases and controls
was 163.76 cm and 164.86 cm.
This was an observational study done in first year
Mean IOP of 14.8 mmHg and a mean MAP of 88.2
medical undergraduates of Bagalkot. Students (Male
mmHg was recorded in cases and a mean IOP of
& Female) whose at least one parent had a diabetic
15.15 mmHg and a mean MAP of 91.1 mmHg was
history were included in the study (Cases). Age
recorded in controls. Selected characteristics of the
matched students without parental diabetic history
study are shown in Table 1.
was included in the control group (Controls). Subjects
It was found that cases (offsprings of diabetic
with any systemic illness/endocrine disorders and
parents) exhibited a lower IOP, BMI, MAP and DBP,
subjects with a history of ocular injury/ surgery were
but not SBP, as compared to controls (offsprings
excluded from the study.
without diabetic history in parents). These
Twenty seven students were found to be having a
differences, however, were not statistically
parental diabetic history, of these two students did not
significant.
cooperate for data collection. Among the students
Table 1:Comparison of IOP, BMI and BP in cases and controls
Intraocular pressure (mm Hg)

Mean Arterial Pressure (mm Hg)
BMI (Kg/m2)
Systolic BP (mm Hg)
Mean SD
cases
25
14.802.62
controls
cases
controls
cases
controls
cases
23
25
23
25
23
25
15.152.94
88.297.99
91.715.91
22.244.04
21.294.18
118.487.62
controls
23
116.349.43
cases
25
73.209.03
controls
23
79.395.67
Diastolic BP (mm Hg)
-1.001
0.322
-1.661
0.104
1.728
0.091
0.865
0.392
-2.814
0.007*
*Significant P<0.05
Shailaja et al.,
567
There was a negative correlation between IOP and

BMI; and also between IOP and MAP in cases (Fig
1& 2).
In controls, there was a positive correlation found
between BMI and IOP and no correlation between
IOP and MAP (Figure 3 and 4).
DISCUSSION
Fig 1: Correlation between IOP and Mean arterial

pressure (MAP) in cases
Fig 2: Correlation between IOP and body mass

index (BMI) in cases
Fig3. Correlation between IOP and MAP in

controls
Fig 4: Correlation between IOP and BMI in

controls.
Shailaja et al.,
The results of the present study showed a negative

correlation of BMI with IOP which however was not
statistically significant.
There are studies which have shown increased IOP
and BMI in diabetic patients, but there are no studies
done in offsprings of diabetic parents.
Reports of Armaly and Baloglour7 observed low IOP
in diabetics compared to non-diabetics. A few early
studies found no evidence of increased intraocular
pressure in diabetes8-10.
In contrast to the above findings, another study
revealed that diabetics seem to have higher
intraocular pressures and may have a higher rate of
glaucoma than those without diabetes4. The mean
intraocular pressure in maturity onset diabetes was
19.26 mm of Hg which was higher than the normal
mean intraocular pressure reported in the general
population, which was 16.1 mm of Hg11,12 and others
5, 7,12,13,14
have observed a slightly higher mean IOP
among the diabetic participants than the non-diabetic
participants. Etiologic links between IOP and
diabetes remain unclear.
When BMI was evaluated, it was found that the mean
BMI (in Kg/m2) in cases was 22.24 and the mean
BMI was 21.29 in controls. The BMI was higher in
cases than those in controls. A trend of decreasing
IOP with increasing BMI was observed in cases
whereas, in controls there was an increasing IOP with
increasing BMI.
We also compared blood pressure variations both in
cases and controls and found less MAP, DBP but
high SBP in cases, which was not statistically
significant. A similar finding of high SBP was
observed in a study done in offsprings of diabetic
mothers 15.
The findings of the present study indicate a lower
IOP in cases as compared to the controls and persons
prone to diabetes may be less prone (?) to develop
primary open angle glaucoma in future, but further
studies in this regard with large sample size and
prospective cohort studies may be helpful.
568
CONCLUSION
It can be concluded from the above study that
offsprings of diabetic patients may be less prone (?)
for primary open angle glaucoma in future.
Limitations of the study: The limitations of the
present study include a smaller sample size, study of
the results in relation to paternal or maternal diabetic
status and also of grandparents, so that the inheritance
of diabetes and also of IOP can be studied.
ACKNOWLEDGEMENT
Authors are thankful to the students for their
cooperation and involvement in the study
REFERENCES
1. Riordan-Eva P, Whitcher JP. Vaughan and
Asburys General Ophthalmology. 16th edition.
United States of America: Mc Graw Hill
Companies, 2004. p. 212.
2. Mitchell P, Smith W, Chey T, Healey PR. Openangle glaucoma and diabetes: the Blue Mountains
eye study, Australia. Ophthalmology 1997;
104(4):712-18
3. Klein BEK, Klein R, Moss SE. Intraocular
pressure in diabetic persons. Ophthalmology
1984; 91:1356-60
4. Mori K, Ando F, Nomura H, Sato Y, Shimokata
H. Relationship between intraocular pressure and
obesity in Japan. Int J Epidemiol 2000;29:661-66
5. Tielsch JM, Katz J, Quigley HA, Javitt JC,
Sommer A. Diabetes, intra-ocular pressure, and
primary open-angle glaucoma in the Baltimore
eye survey. Ophthalmology 1995; 102:48-53
6. Weih LM, Mukesh BN, McCarty CA, Taylor HR.
Association of demographic, familial, medical,
and ocular factors with intraocular pressure. Arch
Ophthalmol 2001;119(6):875-80
7. Armaly MF, Baloglou JP. Diabetes mellitus and
the eye. II Intraocular pressure and aqueous
outflow facility. Arch Ophthalmol 1967;77:493502
8. Bouzas AG, Gragoudas ES, Balodimos MC,
Brinegar CH, Aiello LM. Intraocular pressure in
diabetes. Relationship to retinopathy and blood
glucose level. Arch Ophthalmol. 1971;85(4):423
27
Shailaja et al.,
9. Bankes JLK. Ocular tension and diabetes

mellitus. Br J Ophthalmol 1967; 51:557-61
10. Waite JH, Beetham WP. Visual mechanisms in
diabetes mellitus; a comparative study of 2002
diabetics, and 457 non diabetics for control. N
Engl J Med 1935; 212:367-429
11. Becker B. Diabetes mellitus and primary angle
glaucoma. The XXVII Edward Jackson Memorial
Lecture. Am J ophthalmol 1971; 71:1-16
12. Klein BEK, Klein R, Linton KL. Intraocular
pressure in an American community: The Beaver
Dam Eye Study. Invest Ophthalmol Vis Sci 1992;
33:2224-28
13. Leske MC, Wu SY, Hennis A, Honkanen R,
Nemesure B. Risk Factors for Incident Openangle Glaucoma. The Barbados Eye Studies.
Ophthalmology 2008; 115:85-93
14. Oh SW, Lee S, Park C, Kim DJ. Elevated
intraocular pressure is associated with insulin
resistance and metabolic syndrome. Diabetes
Metab. Res. Rev 2005; 21:43440
15. Aceti A, Santhakumaran S, Logan KM, Philipps
LH, Prior E, Gale C, Hyde MJ, Modi N. The
diabetic pregnancy and offspring blood pressure
in childhood: a systematic review and metaanalysis. Diabetologia. 2012;55(11):3114-27
569
DOI: 10.5958/2319-5886.2014.00398.1

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Research Article
A STUDY ON ASSOCIATION OF SMOKING AND GASTRIC CARCINOMA IN THE RESIDENTS OF

WEST BENGAL
Ashis Kumar Saha1, Goutam Chatterjee1, Subhas Chandra Hazra2
1
Assistant Professor, 2Professor & Head, Department of General Medicine, K P C Medical College, Jadavpur,
Kolkata
*Corresponding author email: asissaha2008@gmail.com
ABSTRACT
Objectives: The aim of the study is to know the association of tobacco intake in the form of smoking and
chewing with gastric carcinoma in West Bengal. Materials and methods: Total 28860 patients (smokers and
tobacco chewer 17240, nonsmokers 11620) were interrogated before performing upper gastrointestinal
endoscopy. Among the smokers and tobacco chewers, isolated bidi and cigarette smokers were 5067, 9323 and
2850 respectively. Among 542 gastric cancer cases, smokers were 301 (165 cigarette and 136 bidi smokers) and
tobacco chewers 82 respectively. Then comparisons were done: 1. to know the incidence of smokers and
nonsmokers in total number of patients, the influence of bidi and cigarette smoking on gastric carcinoma, 3]
Effects of the early starters and number of cigarettes/bidi per day on gastric carcinogenesis. Again, comparisons
were done to know influence of bidi and cigarettes on the sites of gastric carcinoma. Results: Bidi smokers,
earlier starters of smoking and significantly (P<0.0001) suffered from gastric carcinoma. Heavy drinkers were
mostly affected (P<0.0001). Conclusions: Bidi smokers, young heavy smokers were mostly affected. So there
were strong associations between bidi smoking and gastric carcinoma in the residents of West Bengal.
Keywords: Tobacco smoking, tobacco chewing, gastric carcinoma, residents, West Bengal
INTRODUCTION
Stomach cancer is the second most common cause of
death due to cancer only throughout the world1
following lung cancer.2 It is the 2nd and 4th most
common cancer in males and females respectively. 3, 4
Case fatality ratio is higher than other malignancies,
like, colon, breast and prostate cancers 5. Tobacco
smoking has been identified as recognized risk factor
as observed in different epidemiological studies6, but
some studies failed to identify tobacco smoking as
risk factor 7,8 .Risk factors for gastric cancer include
high intake of alcohol, tobacco smoking and tobacco
chewing, high intake of prickled and salted food 9.
Complex interaction between genetic factors and
environmental factors are responsible for the genesis
Ashis et al.,
of gastric cancer. Genetic factors include

polymorphism in inflammatory cytokine genes,
xenobiotic metabolic genes these factors play a
major role.10, 11. Whereas major environmental factors
are alcohol, tobacco smoking, tobacco chewing,
Helicobacter pylori infection, low intake of fruits and
green vegetables and a high intake of salted and
prickled food. The association between smoking and
gastric carcinogenesis has been studied for several
years, since, first cohort studies conducted by Khan 12
and Hammond 13. The risk of gastric cancer among
young adult and adult smokers, higher than in nonsmokers was shown in a meta-analysis published in
1997. 14 .The blood group of the patients suffering
570
Int J Med Res health Sci. 2014;3(3):570-574
from gastric cancer is A. Our present study was to

demonstrate the association of tobacco smoking (in
the form of bidi and cigarette) and chewing in the
genesis of gastric cancer in the Gangetic areas of
West Bengal and to update with the systemic review
of the available epidemiological evidences on the
relationship between tobacco smoking and chewing
and gastric carcinogenesis.
smoking. UGIE were performed using 15% xylocaine

as local anesthesia. From the suspected lesion in the
stomach, eight bits of tissues were taken and were
sent in 10% formalin at room temperature for
histopathological examinations.
Statistics: All the analyses were done at 95%
confidence interval and probability values (p-values)
were observed to identify the significance of the
results. Mean values with standard deviation were
used to detect the age at which the smoking was
started and the number of bidi or cigarette per day.
1. P value indicates the maximum probability for a
given level of significance.
2. 95% CI for difference of percentage:
(p1- p2) 1.96SE (p1- p2), where SE (p1-p2) = [{
p1 (1-p1) n 1} + { p2 ( 1- p2 ) n 2 }]
Calculations were done by using Graphic pad
software.
After the IEC approval and inform consent from the

patients, the present study was conducted in the
department of Medicine in K P C Medical College
from the year 2007 to 2013.
Inclusion criteria: The patients undergone upper
gastrointestinal endoscopy for evaluation of
symptoms (pain abdomen, vomiting, indigestion,
hematemesis with/or without melena, dysphagia,
weight loss, anorexia) in the age-group of 18 to 85
RESULTS
years and in both sexes were included in our study.
Among 28860 patients underwent endoscopy, 17240
Exclusion criteria: Obviously, who were not willing
patients were smokers and tobacco chewers and
to give consent for endoscopy excluded from the
11620 patients were non-smokers and non-chewers.
study. In our study, no patient suffered from HIV
Total 542 patients were diagnosed as gastric
disease or active tuberculosis.
carcinoma, some tumors were well differentiated, and
We started our extensive study the influence of
some were poorly differentiated (fig 1, 2 and 3).
tobacco smoking and tobacco chewing on the genesis
Smokers and tobacco chewers were significantly
of gastric cancer. During the last six years, total
affected than non-smokers and non-chewers (383 vs.
28860 patients from different districts of West Bengal
159, p<0.0001) [Table 1]. Smokers were
(involving Malda, Murshidabad, Nadia, Howrah,
significantly affected than tobacco chewers (301
Hoogly, North and South twenty-four Parganas,
among 14390 vs. 82 among 2850 patients, p<0.005).
Midnapore and Kolkata) were sent for upper
[Table 2].Again, bidi smokers were significantly
gastrointestinal endoscopy (UGIE) to evaluate the
affected than cigarette smokers (165 in 9323 patients
different presenting symptoms. Before performing
vs. 136 in 5067 patients, p<0.0001) [Table 3]. Early
UGIE, informed written consent were taken from
starters as well as, heavy smokers were significantly
patients parties followed by taking a proper history
affected (23.25.8 vs. 12.35.1 in case of early
in the form of a structured questionnaire. This
starters, p<0.0001, and 13.17.5 vs. 20.59.2,
included demographic data (age, sex and religion)
p<0.0001) [Table 4]. Again, antral and incisural
and substance use (tobacco smoking and chewing)
mucosa were significantly involved in smokers and
data. Under the heading of substance use data,
non-smokers respectively (214 in 383 vs. 58 in 159
following histories were included 1. Age at which
patients, p<0.002 and 39 in 383 and 37 in 159
smoking and chewing have been started. 2. Number
patients, p<0.01 respectively) [Table 5].
of bidi or cigarette per day was taken. 3. The form of
tobacco used tobacco chewing, bidi or cigarette
Table: 1 Incidence of gastric carcinoma in smokers and nonsmokers (n=28860)
Smoker and tobacco chewers
patients undergone endoscopy
persons affected
% affected
Smoker & tobacco chewer

Non smoker
17240
11620
383
159
2.221
1.368
571
Ashis et al.,
Table: 2 Relation between isolated smoking and tobacco chewing with gastric carcinoma (n=383):
Smokers+ Tobacco chewer (17240)
UGIE performed
Cases (383)
%
Smoking
14390
301
2.09
Tobacco chewer
2850
82
2.87
Table: 3 Relationship of bidi & cigar with gastric carcinoma (smokers =301):
Smoker (cigar + bidi)
(14390)
pts performed
Cases (420)
95% CI
Cigarette smoker
9323
165
1.76
-0.01, 0.004 <0.001
Bidi smoker
5067
136
2.68
Table: 4. Among the smokers (MeanSD)14390

Criteria of smoking
Subjects
not Subjects
affected (14089)
affected (301)
Age at which smoking 23.2 5.8
12.3 5.1
started
No. of cigars/day
13.1 7.5
20.51 9.2
P value
95% CI
t- test
P value
10.24, 11.56
32.33
<0.001
-8.27, -6.55
-16.87
<0.0001
Table: 5 Among the affected persons (542) relation of smoking and tobacco chewing with site of gastric
carcinoma
Type of Fundus
persons
95%
CI
P
value
Body
95%
CI
Smokers
&
tobacco
chewer
(383)
59
(15.4)
-0.11,
0.03
0.42
66
(18.53)
-0.09,
0.05
Non
smokers
(159)
31
(19.4)
Antrum
P
value
95%
CI
P
value
219
(55.8)
0.04,
0.22
0.01
Incisura
95%
CI
39
(10.18)
-0.19,
-0.06
0.37
34
(21.3)
P
value
0.01
58
(36.4)
37
(22.64)
NS*= Not significant, S**= Significant
Fig 1: Stomach GEJ (bx): Moderately differentiated

adenocarcinoma
Fig 2: Stomach (bx) : Well differentiated

adenocarcinoma.
572
Ashis et al.,
Fig 3: Stomach (GEJ) (bx): Signet ring cell carcinoma.
DISCUSSION
The molecular genetics and the pathogenesis
responsible for the development of gastric
carcinogenesis are poorly understood. The
relationship between gastric carcinogenesis and
tobacco smoking and chewing is poorly evaluated.
Recent review by Tredaniel et al 14 containing metaanalysis of the 40 studies demoed quantitative
estimation of association between tobacco smoking
and genesis of gastric cancer. In this review, all
categories of smoking, e.g. current smoker and nonsmoker, smoker and non-smoker and smoking dose
relationship (ODDS RATIO=1.49 for smokers up to
20 cigarettes per day and ODDS RATIO=1.67 for
heavy smokers) had been properly evaluated. Lauren
system classifies gastric cancer into two types: type I
is intestinal type (expansive and epidemic type of
gastric cancer) and type II is diffuse type (infiltrative
and endemic type). This study demonstrated that rise
in gastric cancer was higher in current smokers than
ever smokers indicating decreasing trends in the
risk after quitting smoking. Similarly, increased risk
of gastric cancer in smokers and tobacco chewers
were demonstrated by Phukon et al 15 as well as
studies performed in South India 16 Gajalakshmi et al
17
Our study similarly demonstrated the higher
incidence of gastric cancer in smokers. Sung et al
demonstrated a weak association between tobacco
smoking and gastric cancer.18 Symptoms of gastric
carcinoma are anorexia, anemia, asthenia, vomiting,
pain abdomen, weight loss. Again, Laroiya I et al
demonstrated that tobacco smoking and chewing
were frequently seen in case than the controls, but
these differences were not significant.19 Moreover,
case-control study demoed reduced risk (OD=0.52,
95% CI: 0.3 0.89) in current smokers as compared
Ashis et al.,
to non-smokers.19 The study led by E.C. Smith of

Memorial Sloan-Kettering Cancer Centre and
Colleagues found men and women who had ever used
hundred cigarettes per day in their life time were 1.45
times as likely as non tobacco users to die from
gastric cancer even after curative operation. But after
operation vitamin B12 lack is responsible for lowering
of the quality of life in the patients survived. On the
other hand, vitamin D is responsible for blocking the
growth of the tumor, lowering the blood supply to the
tumor and preventing its spread.
Again, Mizoram study 14 showed higher incidence of
gastric cancer in tobacco chewers than tobacco
smokers, which was similar to our study, where
tobacco smokers were significantly affected.
Our study demonstrated that distal parts of the
stomach like antrum, incisura were significantly
affected in smokers and non-smokers respectively,
which was similar to the study done by Chao et al.20
Studies in India showed a strong association between
bidi smokers and cancer in pharynx, larynx, oral
cavity and esophagus 21 Again, Gajalakshmi et al
showed threefold increase in incidence of gastric
carcinogenesis in bidi smokers as compared to
cigarette smokers. It is true that amount of tobacco in
bidi (0-0.3 gm.) is less as compared to cigarette (1
gm.)22 but rise in gastric carcinogenesis is higher in
bidi smokers, which may be attributed to poor
combustibility as a result of low porosity of the
negligee (Tendu leaf), which causes accumulation of
higher concentration of volatile phenol (neoplasm
provocating agents), tar, carcinogenic hydrocarbon
benz (a), anthracene and benzo (a) pyrene.
Our study demonstrated the significant increase in the
incidence of gastric cancer in early starters and
chronic heavy smokers as compared to late starters
and occasional smokers. Similar findings were shown
in the study done by Gajalakshmi et al17 i.e. The risk
of gastric (diagnosed by endoscopic biopsies and
histopathological examinations) cancer was decreased
with a higher age of onset of smoking. Here, in that
study, this trend was shown in case of bidi smokers,
and incidence was increased with an increase in the
quantity of bidi smoking during their life time.
CONCLUSION
Smokers were significantly affected than nonsmokers. Again, bidi smoking was revealed as a
significant risk factor for the development of gastric
573
carcinogenesis. Early starters and chronic heavy

smokers were susceptible to gastric cancer. The lower
part of the stomach was significantly affected in
smokers.
REFERENCES
1. Peter Boyle, Bernard Levin (eds.) World Cancer
Report, IARC. Lyon .2008.
2. Pisters P, Kelson D, Powell S, Tepper J. Cancer
of the stomach. In: Devita VT, HellmanS,
Rosenberg SA, editor. Cancer: Principles and
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DOI: 10.5958/2319-5886.2014.00399.3

&
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Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
Research Article
A STUDY ON STUDENTS FEEDBACK ON THE FOUNDATION COURSE IN FIRST YEAR MBBS
CURRICULUM
*Srimathi T
Department Of Anatomy, Sri Ramachandra University, Chennai, Tamil Nadu, India
*Corresponding author email: drtsanatsrmc@yahoo.in, arima_tamil@yahoo.co.in
ABSTRACT
Aim of the Study: To study the students feedback on the short orientation course in first year MBBS curriculum,
which was introduced in the institution as per the recommendations of Medical Council of India for the
Foundation course. Methodology: 250 First year MBBS students were divided into 7 small groups of 35 to 36
each. They attended a short orientation course over a period of 8 days on a rotation basis. The skills taught include
Stress and Time Management, language, communication, use of information technology, National health policies,
Biohazard safety, Introduction to the preclinical subjects, Medical literature search, First Aid and Basic life
support, Medical ethics and professionalism. The results were analyzed on the 8th day by students feedback and
debate sessions. Results: Positive feedback of 88.5 to 98.5% was recorded regarding the objectives of the course,
contents, presentation, future value of the course in the students career by a Questionnaire issued to the students.
Remedial measures undertaken for negative Feedback. The course enabled self directed learning of the subjects.
Conclusion: The Foundation Course at the beginning of the First phase of the course enables the First year
students to acquire the basic knowledge and skills required for all the subsequent phases in MBBS course and
later on their medical practice and career.
Key words: Foundation course, orientation course, MBBS curriculum
INTRODUCTION
The short orientation course was introduced at the
entry level for 250 first year MBBS students in the
institution as per the recommendations of Medical
Council of India for the Foundation course.
Foundation course will be of 2 months duration after
admission to prepare a student to study Medicine
effectively. This aims to orient student to national
health scenarios, medical ethics, health economics,
learning skills& communication, life support,
computer learning, sociology& demographics,
biohazard safety, environmental issues and
community orientation. This also provides an
overview in the preclinical subjects.1
Srimathi .,
AIM: To study the student feedback on the short

orientation course in first year MBBS curriculum.
MATERIAL & METHOD
The Study was conducted by the Medical Education
Unit, Sri Ramachandra Medical College and
Research Institute after the approval of the
Institutional Ethics committee. The classes were
taken by the respective preclinical, paraclinical and
clinical teachers. 250 First year MBBS students were
divided into 7 small groups with 35-36 in each. They
were made to attend a short orientation course over a
period of 8 days on a rotation basis. The skills taught
include Stress and Time Management, Language,
575
Communication, Use of information technology,

National health policies, Biohazard safety,
Introduction to the preclinical subjects, Medical
literature search, First Aid and Basic life support etc.
The results were analyzed on the 8th day from
students feedback through following questionnaire
8
parameters). The parameters (questionnaire no)
included were:1. Whether the objectives of the session were
clearly stated.
2. Whether the objectives of the session were met
adequately
3. Whether the content was tailored to meet the
objectives
4. Whether the presentation was clear and
informative
5. Whether the audiovisual aids were appropriate
6. Whether adequate time was provided for the
program components
7. Whether the student is encouraged to use what
was learned in this program.
All the students were asked to tick YES or NO as
their response to above questionnaire.
The response rate for the feedback was 79%. Students
were explained about the parameters included in the
feedback which may be used for future studies.
RESULTS
group sessions. The response rate was 79%. The

expected response was either yes or no for the given
parameters in the questionnaire.
The feedback percentage for the introduction to
orientation, medical terminologies and the preclinical
sessions was positive from 94.5% to a maximum of
99%. (Table.1) The percentage of positive feedback
from the students for the large group sessions for the
introduction to the paraclinical subjects was ranging
from 84% for genetics session to a maximum of
100% for the Universal precautions and vaccinations
session (Table.1).
The percentage of positive feedback from the
students for the large group sessions in Introduction
to Clinical subjects which included Basic life support,
medical ethics and patient safety sessions was a
maximum of 98.5%. (Table.2).
The percentage of positive feedback from the
students for another large group session like
information technology, alternate health systems and
the debate was a maximum of 98% for information
technology and a minimum of 84.5% of students
debate (Table.3). 0.5% students felt the alternate
health systems should not be made a compulsory
session. The percentage of positive feedback from
the students for the small group sessions which
included hospital tour, stress management,
meditation, communication skill and language
training were Hospital tour (maximum 96%),
physical fitness (maximum 96.5%), Language
training (maximum 100%), Communication skill
(98.5%), Basic Life support lab visit (98.5%) and
stress management (95% ) (Table.3 & Table.4).All
the other comments both positive and negative from
the students were also recorded (Table.5).
250 students participated in the study. They were

divided into 7 small groups of 35 to 36 each. Using
the Predesigned questionnaire, feedback was obtained
from them, for preclinical, paraclinical, clinical
orientation sessions, and other sessions like
debate. Feedback was also obtained for the small
Table 1: Large group sessions- Percentage of positive feedback from the students
Introduction to Basics and pre and paraclinical subjects
Parameter for Session (Yes %)
Questionnaire Orientation
serial no*
Bio
Anatomy
chemistry
Physiology Medical
Community National Universal
Genetics
terminology medicine
health
precautions &
Policies vaccination
1
98%
97.5% 96.5% 99%
96.5%
2
96%
96%
96.5% 99%
97.5%
3
96%
96%
95%
98.5%
96.5%
4
97.5%
97.5% 98%
98%
97.5%
5
96%
94.5% 96.5% 98.5%
97%
6
97%
97%
97.5% 98%
97%
7
96%
98.5% 98%
98%
97.5%
*The parameters 1-7 refer to those mentioned in methodology.
97.5%
96.5%
97.5%
98%
93%
98.5%
97.5%
95%
89%
86%
88%
88%
91%
92%
96%
95%
93%
95%
96%
95%
97%
88.5%
85%
84.5%
86.5%
89.5%
89%
90%
576
Srimathi .,
Table 2: Large group sessions - Percentage positive feedback from the students Introduction to Clinical
subjects
Parameter for Session (Yes)
Patient safety
Basic Life support
Medical Ethics
1.
98.5%
98.5%
97.5%
2.
97.5%
98.5%
98%
3.
98%
98%
97.5%
4.
96.5%
97.5%
98%
5.
95%
98.5%
96.5%
6.
96%
98.5%
97.5%
7.
98%
98.5%
98%
Table 3: 0ther large and Small group sessions- Percentage of positive feedback from the students
Physical
Parameter
IT/Medical Alternate Short film
BLS
Hospital Stress/
Student
fitness
for Session literature
health
And student
skill
tour
time
debate
(Yes/No)
search
systems
debate
lab
management
1
97.5%
94.5%
94%
90.5%
99%
94.5%
61%
72%
2.
98%
92%
93.5%
89.5%
96%
93%
60%
65%
3.
97.5%
93.5%
93%
88.5%
98%
89.5%
61%
68%
4
965
89.5%
93%
88%
97%
84.5%
63%
66%
5.
93.5%
95%
92%
84.5%
98%
82%
66%
63%
6.
97.5%
94%
93.5%
88%
98%
86%
74%
76%
7.
97.5%
90.5%
91%
83.5%
100%
96%
63%
70%
BLS: Basic Life support
Table 4: Small group sessions - Percentage of positive feedback from the students
Meditation
Communication skill Language training
Questionnaire serial no for Session (Yes)
1
95%
98.5%
98.5%
2
95%
96.5%
100%
3
91%
96%
99.5%
4
94%
96%
100%
5
94%
94.5%
96.5%
6
96%
96%
99%
7
96.5%
98.5%
98%
Table 5: Students comments on other parameter
Students comments
Percentage of students
Duration of sessions to be reduced
0.5 %
Hospital exposure was short
1%
Usefulness and knowledge giving
5%
Audiovisual aids were not appropriate
Planning and organisation was effective
Sessions (Alternate health system, stress management) to be made optional
Language training should be more
Helpful to adapt to new environment
Support for future use and continuation of the programme
Genetics to be made more interactive
Teachers are very interactive
0.5 %
0.5 %
0.5 %
0.5 %
2%
2%
1.5%
0.5 %
DISCUSSION
According to Medical Council of India Vision 2015,
Foundation course will be of 2 months duration after
admission to prepare a student to study Medicine
effectively. This period aims to orient students to

national health scenarios, medical ethics, health
economics, learning skills& communication, life
577
Srimathi .,
support,
computer
learning,
sociology&
demographics, biohazard safety, environmental issues
and community orientation. In addition, this would
include overview in the three core subjects of
Anatomy, Physiology and Biochemistry to be taught
in first MBBS. The total duration of the course will
be five and half years with 14 months for the first
year, including the 2 months of the Foundation
course. The second year will be of 12 months
duration, the final year, including the electives (for 2
months) will be of 28 months duration and the
internship will be for 1 year. 1
The admission process of medical students varies
from state to state in India but mostly based on their
merit list in their school final and in their entrance
exam. The students may be from different boards of
education with different syllabus. For getting adapted
to the new college environment from their school
environment they may need some time. They may
also belong to different regions, socioeconomic strata
and have different languages. In order to facilitate the
adaptation to the Institution and also to provide some
knowledge and essential skills required for the
medical curriculum, it was planned prior to the
student's admission to implement the foundation
course of Medical Council of India as a short
orientation course in the First year MBBS curriculum
and analyze its results and the student feedback.
Based on the results from their feedback it was
decided to take remedial measures and follow the
suitable orientation programme in the subsequent
academic years. The schedule was designed after
discussion with the faculty in Medical education Unit,
the Preclinical Departments.
Table.1 shows the feedback percentage for the
introduction to orientation, medical terminologies and
the preclinical sessions. The positive feedback was
from 94.5% to a maximum of 99%. Though the
sessions were found to be very useful, as their
preexisting knowledge was not tested in this study a
comparison could not be made as to their gain in the
knowledge. The feedback questionnaire included the
level of prior knowledge of the students as a
parameter and tested the gain in knowledge after the
sessions. The majority of the students did not have
prior knowledge except for language, internet skills
and time management.2
The basic science teaching should be conceptualized,
and provoke student curiosity. It should teach them
the skills of applying basic sciences in clinical
medicine. Students would be more interested to learn

basic sciences if they feel it is the basic to clinical
practice and is important to their future role as a
doctor. 3 Our orientation programme was found to be
more informative and helped the students acquire the
skills necessary in their paraclinical and clinical
phases of the curriculum also.
Table.1 shows the percentage of positive feedback
from the students for the large group sessions for the
Introduction to the paraclinical subjects. A positive
feedback of 84% for genetics was the minimum to a
maximum of 100% for the Universal precautions and
vaccinations. 83 out of 97 respondents benefited by
the community health care sessions and genetics
session was not included in the orientation course.2
from the students for the large group sessions in
Introduction to Clinical subjects. This included Basic
life support and medical ethics and patient safety
sessions. The maximum positive feedback was
98.5%. Lecture sessions were conducted on medical
ethics in different medical schools in Saudi Arabia
and the student assessment was done by a paper
based examination at the end of the lectures. This was
followed by case studies, PBL sessions, seminars, and
student presentations. It was found the formal
evaluation of ethics teaching existing in 73% of the
schools in the country. Problem based learning was
found to be more effective than the lectures on
medical ethics.4 Our Study has integrated the stress
management, medical ethics programme with other
sessions and the assessment was done only based on
the students feedback on the sessions.
from the students for another large group session like
debate. 0.5% students felt the alternate health systems
should not be made as a compulsory session (table.
5).
Table.3 and Table.4 shows the percentage of positive
feedback from the students for the small group
sessions which included hospital tour, stress
management, meditation, communication skill and
language training. Hospital tour (maximum 96%) and
physical fitness (maximum 96.5%) had relatively less
positive feedback, whereas Language training
(maximum 100%), Communication skill (98.5%),
Basic Life support lab visit (98.5%), had more
positive feedback. Our stress management session got
a maximum 95% positive feedback. A seven-week
578
Srimathi .,
course in mindfulness training was founded to reduce

mental distress in students and also helped their wellbeing. 5
The institutes of international medical education
(IIME), New York, defined global minimum essential
requirements (GMER), which are grouped into 7
broad educational domains. 6
1. Professional values, attitudes, behavior and ethics.
2. Scientific foundation of medicine
3. Clinical skills
4. Communication skills
5. Health scheme
6. Management of information
7. Critical thinking and research
The Orientation course implemented by us also gave
an introduction to most of these aspects except
critical thinking and research. Teaching of scientific
research competencies should start early in
undergraduate medical education and continue
throughout the pre-clinical and clinical years. This
will also help in their research oriented career in their
future.7
Table.5 shows the students' comments on other
parameters. All the negative comments were recorded
and appropriate remedial measures were undertaken.
The questionnaire used in this study was modified
based on the reference from Medical students view
about the integrated MBBS course: a questionnaire
based cross-sectional survey8 to suit our study.
CONCLUSION
This study makes it evident that the foundation course
is very much needed for the students entering MBBS
and its implementation will help to acquire the basic
skills necessary for their paraclinical and clinical
phases of the course and in their medical practice
also.
REFERENCES
1. Medical Council of India (homepage on the
internet). Vision 2015. Available from
http://www.mciindia.org/tools/announcement/M
CI_booklet.pdf.
2. Singh Suman. Foundation course for MBBS at
entry level: Experience at an Indian medical
school. South East Asian journal of Medical
education. 2007;1(1):33-37
3. Ravi Shankar P. Medical Student Attitudes
Towards and Perception of the Basic Sciences in
a Medical College in Western Nepal: Journal of
the International Association of Medical Science
Educators; 2005;www.MedicalScienceEducator.
4. AlKabba. Teaching and evaluation methods of
medical ethics in the Saudi public medical

colleges: cross-sectional questionnaire study.
BMC Medical Education 2013;13:122
5. De Vibe. Mindfulness training for stress
management: a randomised controlled study

of medical and psychology students. BMC
Medical Education 2013,13:107
6. Core Committee, Institute for International
Medical Education (Global minimum essential
requirements in medical education. Medical
Teacher 2002;24(2) 130 -135.
7. Ahmed Abu-Zaid and Khaled Alkattan.
Integration of scientific research training into
undergraduate medical
education: a reminder call .Med Educ Online
2013, 18: 228-32 .
8. Indrajit Banerjee. Medical Students View about
the Integrated MBBS Course: A Questionnaire
Based Cross-sectional Survey: Nepal Journal of
Epidemiology . 2011;1(3): 95-100.
ACKNOWLEGEMENTS
The Dean of Education Dr. P. V. Vijayaraghavan, Sri
Ramachandra University, The Head of the
Department, Dept. of Anatomy, Dr. V. S.
Anandarani, Professor, Dept. of Anatomy, Mr. V.
Manikanta Reddy, Dept. of Anatomy Sri
Ramachandra University, The staff of Medical
Education Unit, Sri Ramachandra University.
579
Srimathi .,
DOI: 10.5958/2319-5886.2014.00400.7

&
Health Sciences
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Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Research Article
CLINICAL EFFECTS OF PRANAYAMA ON PERFORMANCE OF RIFLE SHOOTERS

*Amte Snehal Shekhar1, Mistry Hetal M2
Department of Physiotherapy, Topiwala National Medical College, Mumbai, Maharashtra, India
*Corresponding author email: snehalamte2@gmail.com
ABSTRACT
Background: Yoga has an enormous scientifically proven effect on man's physical and psychological
functioning. Pranayama constitute the most vital aspects of yoga. Various methods of pranayama have a sound
scientific basis and are traditionally believed to produce equilibrium between psychic and somatic aspects of
bodily functions. The link between body and mind is obligatory for the better performance of sports persons.
Aim: The aim of the study is to find out the effect of pranayama on the performance of Rifle shooters by
measuring the parameters like-breath holding time, lung functional capacity and shooting performance. Method:
52 state level shooters subjects were chosen from 2 centres between the age group of 15-30years. Out of them, 26
shooters were given training in the techniques of pranayama for 3weeks.The other 26 subjects served as control
i.e. with out Pranayama training. Variables like shooting performance, breath holding time (BHT), peak
expiratory flow rate (PEFR), respiratory rate (RR) and pulse rate (PR) were measured in both the groups.
Results: The study showed highly significant improvement in all the five variables shooting performance (in
mm), BHT, PEFR, RR and PR with p value of 3.62E-05, 2.78E-07, 1.31E-09, 0.013, 3.40E-04respectively.
Conclusion: So it can be concluded that pranayama is efficacious for better performance of Rifle shooters and
should be included in their training practice.
Keywords: Yoga, Pranayama, Rifle shooting, Breathing exercise, Peak expiratory flow rate.
INTRODUCTION
Shooting is a sport which requires supreme precision,
striking control and close coordination between eye,
nervous system and the musculoskeletal system. This
sport is based mainly on positioning the body and
stability of themind.1 Shooter has to aim at the target
while breathing; with the natural inspiration and
expiration movements of the chest wall, the rifle too
move upanddown.2 Due to the movement created by
breathing it is impossible to release an accurate
shot without holding the breath.
However, as soon as breathing is suspended the
bodys functions begin to depreciate as oxygen
starvation sets in. The eyes ability to function is the
Amte et al.,
first to go followed by the muscles, which begin to

contract. The breath hold should not be prolonged, so
that the unnatural feeling sets in. If it is too long, the
body suffers from oxygen deprivation which will
cause a fatiguing sensation with muscle tremors and
blurred vision and So there is a physiological urge
that I must breathe, I must breath as the body
attempts to protect itself it begins to send out
indications to resume breathing. These indications
produce involuntary movements of the diaphragm,
which interfere with the shooters attentiveness and
chest wall starts to move. All of which are not
favorable to firing a meticulous shot. Shooters have to
implement breathing control during the shooting
580
process. They have to achieve eye sight alignment

while breathing and finish aiming and shooting while
holding breath. Shooters do this by inhaling and
exhaling naturally and stop at the very point of
physiological exhale, starting this respiratory hold,
firing the shot and begin to inhale again. Breath hold
should not be prolonged. If firing is not done within7
second so faiming then the shooter will relax, and
will not take that shot. He will lower the rifle, and
start again because if the position is held too long
then the shooter may lose the equilibrium and
concentration which is needed to take the shot.
Fig14: Breathing and their relationship to correct

sighting
Proper breathing is an often overlooked aspect of
Rifle shootings first principles, even though
controlled breathing helps store uceun wanted rifle
movements and also induce a calming effect.
Breathing links physical, mental, and emotional
status. The three primary blocks to positive emotional
energy flowanger, sorrow, and fear are each
characterized by an imbalance in breathing. Anger
often produces weak inhalation with strong and
forceful exhalation. Sorrow manifests very weak
exhalation coupled with fitful, spasmodic inhalation.
Fear causes tension in the body and often causes
breathing to be reduced to almost nothing or to stop
completely for a few moments. All these emotions are
faced by the sports person during competition.
Recognizing these breathing patterns allows the sports
person to stop and take corrective action using
comfortably slow and deep belly breathing. This will
actually take some control over the emotions,
conscious mind and will relax the body. Because we
have much more control over our body than the mind,
breathing in this way, has profound an effect on our
ability to indirectly control and calm emotional and
mental activity. Even when positive emotional energy
Amte et al.,
is flowing, the same breathing technique still has

mental and physical benefits with calmness of mind
and relaxation of the body. So, by using breathing
control rifle shooters can learn to recognize and break
this Cycleoftension.5 This breathing control can be
taught in the powerful form of Pranayama.
When the Breath wanders, the mind is unsteady, but
when the Breath is still, so is the mind still." Hatha
Yoga Pradipika. Now, one will think, what is
Pranayama? What are its effects? How it is helpful
to a sports person? According to the Oxford
dictionary Pranayama is defined as the regulation of
the breath through certain techniques and exercises.
The word, Prana is both the breath and the life
force. Second part of the word yama means to
control, which is the key feature of Pranayama, deep
and prolonged breath which can be hold voluntarily
called as Kumbhaka in Pranayama. This deep and
prolonged breathing not only increases the uptake of
oxygen at the cellular level throughout the body,
but also gives both physiological and psychological
benefits. There is substantiating information that is
practicing Pranayama significantly improves
cardiovascular efficiency along with the respiratory
functions. Pranayama produces decrease in systolic,
diastolic and mean blood pressure and this can be
used as the prophylactic measure to combat the rise
in blood pressure associated with everyday stress
and strains of life, and also the competitive anxiety.
Conscious, deep and regular breathing can
harmonize and strengthen intrinsic cardiovascular
rhythms and modify baroreflex sensitivity.7
Pranayama also helps in controlling autonomic
function and results in alteration of autonomic
equilibrium. It also works at the cerebral level,
causing deep, psychosomatic relaxation. 6 For
example; breathing via left and right nostril has an
effect of decreased or increased sympathetic activity,
respectively.25 Calmness, which is a result of
practicing Pranayama is helpful for the individuals
with hypertension and others with cardiovascular
conditions. Because of the main emphasis on
breathing Pranayama aids in clearing the lung field
and passage simultaneously increases the strength
of the main respiratory muscle diaphragm.
Pranayama is a very well-ordered, so the phases of
breathing, inhalation, breath hold and exhalation is
always done in a fixed ratio. Only sometimes the set
of ratio can vary between 1:2:2 or 1:4:2
581
depending on the comfort and level of practice.

Yogic Asana and Pranayama have been shown to
reduce the resting respiratory rate and increase
vital capacity, timed vital capacity, maximum
voluntary ventilation, breath holding time and
maximal inspiratory and expiratory pressures, which
produces favourable conditions for improving any
sports performance.
Studies show that Pranayama decrease the reaction
time. It indicates that Pranayama impacts the
central nervous system, and decrease in reaction
time can be brought into effect by enhancing
processing ability and sensory, motor functions.
These effects of Pranayama
training on
the
central
nervous system could be due to better
concentration power and the ability to ignore and/or
inhibit extraneous stimuli resulting in less
distractibility. Which collectively leads to decreased
mental fatigability and an increase in performance
quotient.8 Hence, there is a need to study the effects
of Pranayama on the performance of the shooters, so
that if there is any improvement, then an organized
breathing exercise protocol can be assimilated into
their existing training program and can be used as
another powerful tool in the shooters toolkit.
Aim: The aim of the study is to find out the effect of
Pranayama on the performance of Rifle shooters.
Objectives: To find that the practice of Pranayama
enhances Breath-Holding Time [BHT], Peak
Expiratory Flow Rate [PEFR], basal pulse rate these
factors lead to improved shooting performance.
MATERIALS AND METHODOLOGY
Research Design: Experimental, Casecontrol study
Population: 52 state level shooters
Sample: Group A26shootersbothmaleand female
doing Pranayama (experimental group) Group B 26
shooters both male and female not was doing
Pranayama (control group).
Type of sampling: Random sampling
Source of sample: subjects were recruited from the
Air rifle shooting club and research centre approved
by guide and college.
Duration of Study: 12months.
Inclusion Criteria: Male and female shooters of age
between 1530years, State level performers
Exclusion Criteria: Respiratory or cardiac disorder,
Neurological disorder, Eye problems, Psychological
Amte et al.,
problem, sleeping disorders

Materials: To carry out the study following materials
were used:
I) For Evaluating shooting Performance: Air rifle,
Target Paper, 15 cm measuring ruler
II) For recording Breath-Holding Time: Digital
stop watch10
III) For recording lung-function: Mini-Wright Peak
flow meter used to measure Peak Expiratory Flow
Rate [PEFR].
Fig2: Mini Wright Peak Flow Meter

Mini-Wright Peak Flow Meter Procedure for Data
Collection: All the subjects coming to the Air rifle
shooting club were divided into 2 groups by
convenience sampling Experimental (n=26) and
control (n=26. All subjects consent was taken to
participate in the study. Each participant shooter was
given a Performa which asked information relevant to
the study, such as name, age, sex, smoking and
drinking habits and sleeping quality and duration.
Subject information sheet was given, which gave an
idea about the study to the subjects. Main tests:
Subjects were in standing position when breath
holding time (BHT) was measured with the help of
stop watch. Subjects were asked to pinch their nose
closed at the end of inhalation and BHT (breath
holding time) was counted in seconds; nose was
closed until they experience the first desire to breathe.
Peak Expiratory Flow Rate (PEFR) was recorded
with peak expiratory flow meter.
To take a peak flow reading:
1. Check that the pointer is at zero.
2. Subjects were taken in standing position.
3. Subjects were asked to hold the peak flow
582
meter level (horizontally) and keep your fingers

away from the pointer.
4. Asked to take a deep breath and close your lips
firmly around the mouthpiece.
5. Then blow as hard as you can.
6. Pointer reading was checked.
7. The pointer was reset back to zero.
8. This was done three times and the highest
reading was recorded
For Shooting-performance based data, each
participant was asked to best of their ability shoot
five rounds (each round consisting of five shots) in
the shooting rangeof10minstanding position. Target
paper was collected and the distance between the two
far most hits was measured. Scoring was done as per
the Firing Standard
Specified by A.M.U. (Armed marksmanship unit)
which is as follows: Excellent- 12.5mm (in),
Good-2.5cm (1in), Fair-3cm(1 in)
Fig 3: Performing Rifle shooting
Kapalabhati Pranayama: To perform the

kapalabhati pranayama technique, sit in a
comfortable position crossing your legs. Perform
two to three deep inhales and exhales. Now
inhale deeply and exhale forcefully drawing all
the air out. Your belly should be drawn in, as you
exhale. When you inhale, let it happen passively
without you making any effort to inhale as the

belly goes back to normal position. Exhale
forcefully again and continue doing this for about
20 to 30 times.
Anulomvilom: Hold your right nasal with
thumb, breathe in from the left. Now open right
nasal and close left nasal with middle and ring
finger and breathe out from right nasal. Now
breathe in from right nasal. Now close right nasal
and open left and breathe out and in from left
nasal and so on.
Duration: 10 minutes
Bhramari: One should close their eyes with both
hands by four fingers and thumb on the ear. Now
inhale and exhale forcibly with a humming or
buzzing sound. Inhalation and exhalation should
be from both nostrils and mouth should be
closed. One should start slowly and then
accelerate.
While performing bhramari pranayama one
should take care that inhalation and exhalation
should be from the lungs and abdominal
movements should be minimal.
Shitali Pranayama: Sheetal also means cool,
and this pranayama technique will help you
achieve the same. To perform shitali pranayama
be seated in a comfortable position. Cross your
legs and take five to six deep breaths to get
yourself prepared. Now open your mouth in an
"o" shape and start to inhale through the mouth.
When you exhale, do so with your nose. This can
be repeated five to ten times. A session of 30
Min. was carried out each day in the evening for
3 weeks, instructions for which were delivered
verbally. On the other hand, the subjects in the
Group B (control Group) were not given any
training during the same time span. On the 22nd
day of training, again the parameters were
measured for both Group A and Group B.
RESULTS
The data was collected and analyzed with unrelated and relatedt test.
Table1: Comparison of Shooting performance(mm)'before and after among study group:
Shooting
performance N
Mean
Std.
Median
IQR
(mm)
Unpaired T test
Deviation
Experiment
26
-2.65
2.727
-2.50
4
4.535
difference
Control
26
*p valuesignificant at 1.31E-09
Amte et al.,
1.00
3.072
0.50
p value
*3.62E-05
Difference is significant
583
Table 2: Comparison of PEFR (L/min)'before' and 'after' among study group:

PEFR (L/min)
N
Mean SD
Median
IQR
Unpaired T
difference
test
p value
Experiment
26
31.1512.108
30.00
20
-7.424
*1.31E-09
Control
26
-3.0820.153
0.00
30
*p value significant at 2.78E-07
Table 3: Comparison of BHT(Sec) 'before' and 'after' among study group:
N
Mean
Std. Deviation
Median
IQR
BHT(Sec) difference
Unpaired T test p value
Experiment
26 5.00
3.150
5.00
5
-5.934
*2.78E-07
Control
26 -0.62
3.656
0.00
4
*p significant at3.62E-05
Table 4: Comparison of respiratory rate(per min) 'before' and'after' among studygroup:
DifferenceRR (per
N
Mean
Std.
Median
IQR
Unpaired T
min)
Deviation
Test
p
value
Experiment
26
-2.50
1.838
-2.00
3
2.582
*0.013
Control
26
0.19
4.988
0.00
6
*p value is significant at0.013
Table 5: Comparison of Pulserate (per min)'before' and 'after' among study group:
Pulse ratedifference
N
Mean
Std.
Median
IQR
Unpaired T
(Beats/min)
Deviation
Test
p
value
Experiment
26 -3.23
2.997
-3.00
3
3.847
*3.40E-04
Control
26 0.85
4.496
1.00
6
*p value is significant at3.40E-04
DISCUSSION
The result of the present study indicates that the
shooting performance of the experimental group
improved significantly. The credit for this significant
result can be given to many parts of the training along
with the Anulom Vilom (Alternate nostril breathing).
Left nostril breathing draws Ida energy and right
nostril breathing draws Pingla energy. In medical
terms these energies can be compared with
sympathetic and parasympathetic systems. So with
the help of the alternate nostril breathing the
equilibrium can be achieved between the energies
which in turn results in mental balance, which is
consistent with the study of Telles S et al 1994 and
leads to improved quality of the performance. Also,
improved agility of the tasks and the speed of the
mental processing are the results
of
Yogic
breathing through single nostril12 can be the reason
for this result.
Similarly, like Alternate nostril breathing, recurrent
chanting of Om by shooters during research also
proved to be beneficial in improving their
performance, indicating the earlier findings that
Amte et al.,
Pranayama or Om Pranayama leads to autonomic

changes in the body resulting in increased mental
alertness.13 These results accord with those of Smriti
Kapoor1
PEFR by definition is maximum expiratory peak
flow i.e. the greatest rate of airflow that can be
obtained during forced exhalation which can be
easily calculated by Minis Wright peak flow meter
and these calculations are highly alveolar pores of
Kohn, in total resulting in increased lung volume.
The increase in PEFR can be seen along with
FEV114,15 (forced expiratory volume in 1 sec.) after
continuous practice
of
Pranayama
Shivesh
16
Prakash. Yogis had significantly better PEFR as
compared to sedentary workers and athletes.16
In Pranayama, the phase Kumbhaka plays an
important role in achieving this result. As it is
known that during breath holding (Kumbhaka) the
heat is generated in the body and blood supply to the
brain is increased because of the temporary mild
anoxia to the brain. Anoxia is caused due to build-up
of CO2 and depletion of Oxygen in the body, which
584
is why there is urging to breath. But with the regular

practice of Kumbhaka the individuals central and
peripheral chemoreceptors gets adapted to the
anoxia, this result is achieved by the body by
causing hypo metabolism. Thus, reflecting as
prolonged breath hold and decreased urge to breathe
while doing so. In addition to this, the training of
the stretch receptors in the respiratory muscles,
chest wall and also walls of the alveoli support the
breath holding. The autonomic or the reflex
mechanism of the respiration is far more powerful
than the control from the higher centres.17 That is
why after a particular stage it is not possible to hold
the breath further .W. A. Whitelaw, B. McBride and
G. T. Ford (1987) supports the study, they did the
analysis of the pressure waves made by diaphragm
contractions during breath holds at various lung
volumes. Which shows large lung volume lessens
the discomfort of breath holding18-20 reliable, means
that it can be reproduced easily. Maximum
expiratory flow depends on the initial lung volume,
which is increased by practicing pranayama, because
during normal breathing the alveolis are not fully
open. During pranayama and prolongs breath-hold
time.
Decrease in respiratory rate (RR) is because of over
all reduction in the consumption of oxygen by the
body for any activity after regular practice of
Pranayama, supported by the finding deep inspiration
opens all the alveolis and also kaviraja alveolis and
also of Kaviraja udup21, Madanmohan2 2 and the
breath holding phase (Kumbhaka) helps in opening
the interbronchiolar channels of Martin, bronchiolealveolar channels of Lambert and Raju et al.
Decrease in Pulse rate (PR) is because of
modulation of both right and left heart ventricular
performance
by
increasing
parasympathetic
activity
and
decreasing sympathetic activity
Ravinder Jerath et al and also decrease in QT/QS2
and this indicates a decrease in cardiac sympathetic
activity Udupa et al. all results are after prolonged
practice of Prnayama.
Shooting highly depends on the posture of the
individual. Accurate and targeted shooting require
firm and steady posture. All the respiratory muscles,
being a part of the trunk participates as an accessory
supporter of the trunk stability. This accessory
activity of respiratory muscles can have a hindering
Amte et al.,
effect on the respiration. Thats why it is very crucial

to improve the strength and coordination of the
respiratory muscles. Pranayama is the great way to
get this effect. The study done in the past put forward
the fact that intercostal and accessory respiratory
muscles stabilize the arms and torso, obstructing the
chest-wall movement and there is shift of respiratory
load from these muscles to the diaphragm.23
This collective effect of improved mental stability,
focus, concentration, improved breath holding time,
decrease heart rate and respiratory rate is brought
about by the modulation of sympathetic and
parasympathetic activity and improved strength of the
respiratory muscles.
Limitations: 1.Thesample size was small. 2. The Age
range was limited. 3. Only Air Rifle shooters were
included in the study.4. Shooting performance was
recorded for standing position only.
CONCLUSION
This study concludes that the practice of Pranayama
enhances breath-holding time (BHT) which gives
shooters enough time to take the targeted shot without
urging for oxygen in between the shooting rounds. In
addition, steady practice of these breathing can
result in improved respiratory muscle strength and
adaptation at the cellular levels in alveoli, leading
to improved peak expiratory flow rate (PEFR) and
harmonization
of
the
sympathetic
and
parasympathetic causing decrease in the physiological
parameter like respiratory rate and pulse rate; all
these desirable factors work towards end result,
improved shooting performance. So because of this
lucrative end result practice of Pranayama should be
included in the training regimen of shooters.
ACKNOWLEDGEMENT
My sincere gratitude and thanks to H.O.D. and Guide,
Assistant Professor, Department of Physiotherapy
department, T.N. Medical college for inspiring and
guiding me throughout this project.
I do also thank our Dean, whose permission for the
study did it occurred. I do thank all the members of
the Rifle shooting Centre, Shivaji Park, Mumbai for
their timely help. The cooperation and willingness
of my subjects leave me deeply in their debt.
585
REFERENCES
1. Kapoor
S, Paul M. Clinical Effect of
Combination of Pranayama and Kriya on the
Performance of Shooters. Indian Journal of
Physiotherapy and Occupational Therapy
2008;2(2):34-37
2. Fundamentals of Marksmanship with a scoped
rifle.
http://shadowspear.com/vb/threads/akafundamentals-of-marksmanship-with-a-scopedrifle.2806/
3. Andy Fink , Introduction and breathing.
http://www.juniorshooters.net/2009/04/20/tipshints-of-the-week-1-introduction-breathing
4. Melbourne International Shooting Club, The
beginners guide to small-bore Rifle shooting
http://melbourneinternational.org.au/index.php/do
wnloads/cat_view/8-coaching
5. Body, Mind Mastery by Dan Millman. New
World Library, revised
edition
of The
InnerAthlete(\1994.
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6. Telles S, Nagratana R, Nagendra HR. Breathing
through a particular nostril can alter the
metabolism and autonomic activities. IndianJ
Physiol Pharmacol 1994;38:133-7.
7. Bhavanani AB, Madanmohan, Udupa K. Acute
Effect of Mukh Bhastrika (A Yogic Bellows
TypeBreathingon Reaction Time. Indian Journal
of Physiology and Pharmacology.2003; 47(3):
297-300.
8. Borker AS, Pednekar JR. Effect of pranayam on
visual and auditory reaction time.Indian J Physiol
Pharmacol 2003;47 (2) : 229230
9. Whitelaw WA, McBride B, Ford GT. Effect of
lung volume on breath holding, Journal of
Applied Physiology. 1987;62(5);1962-69
10. Razia Nagarwala, Prarthana Dhotre, Isha Gelani.
Correlation between core strength and breath
holding time in normal young adults. Journal of
Orthopaedic and Rehabilitation2011;1(1):75-78.
11. Sivananda Sri Swami. The Science of Pranayama.
A Divine Life Society Publication, Distt. TehriGarhwal, Uttar Pradesh, Web edition2000,
66.http://www.dlshq.org/download/pranayama.ht
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exercises(pranayama)inpatientswith
bronchialasthmaofmildtomoderateseverity.
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Autonomic changes during OM meditation.
Indian Journal of Physiology and Pharmacology.
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14. Joshi LN, Joshi VD. Effect of forced breathing on
ventilator functions of the lung. J Postgrad Med
1998; 44:67
15. Saxena T, Saxena M. The effect of various
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bronchial asthma of mild to moderate severity. Int
J Yoga2009;2:22-25
16. Shivesh Prakash, Meshram S, Ramtekkar U.
Athletes, yogis and individuals with sedentary
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Physiol Pharmacol 2007;51 (1): 7680
17. JouliaF, Sternberg JG. Faucher M, Jamin T,
Ulmer C, Kipson N, JammesY. Breathhold
training of humans reduces oxidative stress and
blood acidosis after static and dynamic apnea.
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19. Joshi LN, Joshi VD, Gokhale LV. Effect of short
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the effect of some yogic breathing exercises
(pranayams) in normal persons. Indian J Med Res
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22. Mandanmohan LJ, Udupa K, Bhavanani AB.
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DOI: 10.5958/2319-5886.2014.00401.9

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
Research Article
A STUDY OF FUNDUS STATUS IN MYOPIA

*Christina Samuel1, Sundararajan D2
1
Postgraduate student, 2Professor & HOD,

Kanchipuram, TamilNadu, India
Department Of Ophthalmology, Meenakshi Medical College,
*Corresponding author email: tinachandar@gmail.com

ABSTRACT
Background: The most important sensory organ for a human is the eye. Any damage to the retina can cause
diminution or loss of vision. One of the most important refractive errors of the eye is Myopia apart from
hypermetropia and astigmatism. It is one of the commonest conditions seen in everyday practice. Myopic
degeneration is one of the common causes of decreased visual acuity. Aim: The aim of this clinical study is to
observe the fundus changes associated with Myopia. Methods: A prospective study of 100 cases of myopia were
included in this study. Detailed anterior segment and good posterior segment examination after achieving
mydriasis was done with a direct ophthalmoscope and indirect ophthalmoscope with 20D lens. Result: In our
study, we found that males were more commonly affected than females with myopia (54%). 50% of the cases
affected belonged to the student community. 53.68% had positive changes in the retina suggestive of degenerative
changes in the fundus. Conclusion: Degenerative changes of fundus are most commonly seen in myopic patients
of which Tessellated fundus was about 90.20%. Vitreous degenerative changes for 70.59%. Crescent formation
was 87.25%. Dull foveal reflex in 82.35% and lattice degeneration accounted for 40%.
Keywords: Myopia, Vitreous degeneration, Lattice degeneration, White with and without pressure, tessellated
fundus, Foveal reflex.
INTRODUCTION
The Greek word Myopia means to close or contract
the eye. Myopia (Ancient Greek: , mupia,
from myein "to shut" ops (gen. opos) "eye".1
Myopia is one of the most common type of refractive
errors and one of the commonest conditions seen by
an Ophthalmologist. When the accommodation is at
rest, parallel rays of light from beyond are focused at
the sensitive layer of the retina, then the eye is in
Emmetropic state (optically normal eye).2,3
Myopia or short sightedness is a type of refractive
error, when the accommodation is at rest the parallel
rays of light from infinity falls in front of the retina.
The image thus formed is a blurred image. For a
person to see clearly the object should be brought

close to the eye. A divergent lens which is placed in
front of the eye can bring the parallel rays of light to
be focused on the retina.1-3
It is said that as the Intelligent quotient of a person
increases, myopia steadily increases and there has
been many studies to support it.4-6 The incidence of
Myopia is more in the Asian population when
compared to European, United States and least in
Africans.4,7-9
Etiology of Myopia can be hereditary, chromosomal,
congenital, environmental, drug induced and ocular
disorders. The clinical variants of myopia are
587
Samuel et al.,
Congenital myopia, Simple or developmental

myopia, Pathological or degenerative myopia and
Acquired Myopia. Simple myopia is very common. It
stabilizes by the age of 21years and usually the
prognosis is good.2,3,10,11
Various degenerative changes are seen in a myopic
fundus, these changes are associated with the grade of
myopia, age, gender. Peripheral retinal degenerations,
lattice degenerations, white with and without
pressure, Foster Fuchs spots, Lacquer cracks and
optic disc changes are some of the common findings
in the retina. Older patients are at risk of developing
macular hole and later retinal detachment.
MATERIALS AND METHOD
The present study was carried out in the Department.
of Ophthalmology at Meenakshi Medical College and
Hospital, Kanchipuram. In this study a total of 100
patients were taken, 54 males and 46 females of the
age group 8years to 70 years. All degrees of myopias
were included. Prior to the study an informed consent
form from the patients and ethical clearance was
obtained from the Institutional Ethics Committee.
Exclusion Criteria: Age group less than 8 years and
more than 70 years were not included. Emmetropes
(non myopes) were not taken into this study. Patients
with Ocular conditions like Glaucoma and Corneal
degenerations, Patients with history of Diabetes and
Hypertension were excluded.
Type of study: A cross sectional descriptive study for
a period of 12 months.
Procedure: A detailed case history was taken, in
view of heredity contribution in myopias. Visual
acuity was noted with the help of Snellens chart.12
Best corrected visual acuity was given using streak
retinoscope.12Adetailed slit lamp examination of the
anterior segment was done. Intra ocular pressure was
recorded
with
the
help
of
Schiotz
12
Tonometer. Mydriasis achieved with the help of
tropicamide and phenylephrine combination. Fundus
examined in detail with a help of Direct
Ophthalmoscope
and
Binocular
Indirect
Ophthalmoscope with 20D lens. The media, disc,
vessels, cup disc ratio, macula and peripheral retina
were examined with a help of scleral indentation
method.
RESULTS
The distribution of Myopia was higher in the age
group of 11-20years. The distribution of Myopia was
more in Males. The distribution of Myopia was more
in the student community. 8% of the cases had a
positive family history of Myopia. 90% showed
bilateral Myopia (180 eyes) and 10% showed
unilateral myopia (10 eyes). 53.68% (102 eyes)
showed fundus changes while 46.32% (88 eyes) were
normal. Tesselated fundus (90.2%) with Crescent
formation (87.25%) and Abnormalfoveal reflex
(82.35%) was seen in most myopic eyes. Vitreous
degeneration, lattice degeneration, White with and
without pressure and Retinal detachment was more in
the range of 4-8Dioptres. 30.77% showed
chorioretinal degeneration in the range of 812Dioptres and was more in the older age group.
Fig 1: Distribution of various types of Fundus

changes
*Series 1: No of eyes, Series2: distribution of vitreous haemorrhage
Fig 2: Distribution of Vitreous Degeneration in

Myopia
588
Samuel et al.,
Fig 3: Distribution on occupation
First number indicates the no of eyes and the second number represents
the % of diustribution of lattice degeneration
Fig 4: Distributionof Lattice degeneration in Myopia
Fig 5: Distributionof white with and without

presuure and the range of Myopia
DISCUSSION
Our finding of 53% of bilateral lattice degeneration
was similar to the results of SubediS.11 (45.8%) and
Karlinet al (40%). Most of the lattice lesions in our
study were found to be in the superior temporal
quadrant, although other quadrants were involved.
This is probably due to the excessive stretching and
increased vascularity of this area.3,11 Similar results
of higher distribution of lattice degeneration was

observed by others too, in the myopic range of 48Dioptres. Our study further showed the tendency of
decreasing lattice with increasing myopia of > 15Dioptres. It can be explained, on the basis of
Yaras finding, that in high myopic eyes with
posterior staphyloma, the lattice is significantly less
than the entire elongated eyes.3,11Patients aged 3040years were most frequently affected by lattice
degeneration which was similar to the finding by
Subedi S.11
On the edge of the lattice, vitreous adhesions are
commonly seen and this accounts for the association
of retinal detachment with lattice. This is more
commonly seen in patients with moderate myopia.13
The distribution of Myopia was high among the
student community. This may be because they were
symptomatically aware of the refractive error.
Intelligence and myopia are directly proportional to
each other. When a child reads more the chances of
elongation of the growing eyeball is also increased. In
case of children with more outdoor activities and
sports the chances of myopia are decreased. However
Genetics have a very important role to play in
myopia.14-17
Our study also showed that myopic crescent was
seen in eyes with all grades of myopia. Enlargement
of optic disc was seen in moderate to higher grades of
myopia.
Tessellated funds accounts for nearly 90.20% in our
study. This is mainly due to atrophy of the retinal
pigment epithelium wherein the underlying choroidal
vessels are clearly seen18.
Vitreous floaters were seen in 70.59% of eyes. This is
due to the vitreous degeneration in myopes3. The
various studies done showed that the onset of vitreous
degeneration and degree of myopia has a close
association. In this study young patients with a higher
degree of myopia had vitreous degeneration and an
increased chance of retinal breaks13.
Retinal breaks accounted for 9.80% in our study. It is
essential to find retinal breaks as it is very difficult to
visualize. It acts as a predisposing factor for retinal
detachment to occur3. Retinal detachment was 8.82%
in our study and most of it occurred in young
patients.19 3 out of 9 patients, who came, presented
with Total Retinal Detachment. The distribution was
more in myopes with 4-8D.
589
Samuel et al.,
Therefore, it is essential to diagnose retinal holes;

retinal breaks in the early stages. A good peripheral
examination of the fundus is required as these
conditions are more common in the periphery. Young
adults are more commonly affected.20Eyes with
posterior staphyloma are more commonly affected
with macular hole retinal detachment.21 Treatment is
mostly surgical even though the success rates are less.
Scleral buckling and Pars planavitrectomy are the
options to be considered.22,23
6.3% of patients had lenticular opacity. Common type
seen was posterior polar cataract.24
CONCLUSION
It should be mandatory that fundus of all myopic
patients must be examined as a routine in the Out
Patient Department with good mydriasis as many
degenerative conditions can be overlooked.
Tessellated fundus accounts for 90.20% and
abnormal foveal reflex for 82.35%. These were the
most common conditions observed apart from the
degenerative changes. In case of hazy view due to
Lens changes in elderly people a B mode
ultrasonogram should be done to rule out Posterior
vitreous detachment and Retinal detachment.
Effective reduction of visual impairment is available
with optical correction by spectacles, contact lenses,
and refractive surgery.
Limitations of the study: To identify the genetic
variants through genome-wide association studies and
exome sequencing of rare alleles, as well as more
intensive
investigation
of
gene-environment
interactions, may assist in the identification of highrisk children who could benefit from interventions to
prevent progression to high myopia.
ACKNOWLEDGEMENT
It is with the sense of accomplishment and deep
gratitude that I dedicate the work to all those who
have been instrumental in its completion.
I am greatly thankful to the Department of
Ophthalmology, Meenakshi Medical College,
Hospital and Research Institute, Kanchipuram. To my
HOD, Associate Professors, Assistant Professors,
Colleagues and Staffs of my Department.
I sincerely acknowledge the invaluable help rendered
by R. Balasubramanian MSc, MPhil. Statistician cum
Lecturer.

REFERENCES
1. Harper, Douglas. Myopia. Online Etymology
Dictionary.www.etymonline.com/index.php?term
=mmyopia
2. Khurana AK. Errors of Refraction and Binocular
Optical Defects. Theory and Practice of Optics
and Refraction. Elsevier; 2012;2nd Ed 61-79.
3. Parsons. Refractive Errors of the Eye.
ParsonsDiseases
of
the
Eye.
th
Elsevier;2007;20 ed:72-73,307.
4. Sperduto RD, Seigel D, Roberts J, Rowland M.
Prevalence of myopia in the United States. Arch.
Ophthalmol. 1983;101(3): 40507
5. Mavracanas TA, Mandalos A, Peios D.
Prevalence of myopia in a sample of Greek
students. ActaOphthalmol Scand. 2000;78 (6):
65659
6. Rosenfield, Mark and Gilmartin, Bernard.
Myopia and nearwork. Elsevier Health Sciences.
1998;P23.
7. Verma A, Singh D. Myopia, Phakic IOL.
www.eMedicine.com. 19 August 2005.
8. Fredrick DR. Myopia. BMJ.2002;324 (7347):
119599.
9. Wu HM, Seet B, Yap EP, Saw SM, Lim TH,
Chia KS. Does education explain ethnic
differences in myopia prevalence? A populationbased study of young adult males in Singapore.
Optom Vis Sci. 2001; 78: 23439.
10. Vukojevi, N; Siki J, Curkovi T, Juratovac Z,
Katusic D, Saric B. Axial eye length after retinal
detachment
surgery.
Collegium
antropologicum.2005;29 (S1): 2527
11. Subedi S. Prevalence of lateral degeneration in
axial myopia. Journal of Nepal Medical
Association 2004; 43:187-90
12. Orthoptists and Prescribing in NSW, VIC and
SA. The Royal Australian and New Zealand
College of Ophthalmologists. Retrieved 29 July
2010.
13. Myron Yanoff, Jay. S Duker. Peripheral Retinal
Lesions and Retinal Breaks. Ophthalmology.
Elsevier; 2014;4th ed:641-42
14. Angle, John, and David A. Wissman.
Epidemiology of Myopia. American Journal of
Epidemiology.1980;111: 220-28
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15. Lieberman, Daniel E. The Story of the Human

Body: Evolution, Health, and Disease. New
York: Pantheon Books, 2013;1sted: 43
16. Shaw, Seang-Mei. Nearwork in early-onset
myopia. Investigative Ophthalmology and Visual
Science.2001;43: 332-339.
17. NadellMC, Hirsch MJ. The relationship between
intelligence and the refractive state in a selected
high school sample. American Journal of
Optometry and Archives of AMerican Academy
of Optometry.1958;35: 321-326.
18. JackKanski and Brad Bowling. Acquired Macular
Disorders. Clinical Ophthalmology: A Systemic
Approach. Elsevier;2011;7thed: 637-38
19. Lemrini F, Dafrallah L, KabbajA.Retinal
detachment
in
children
J.Fr.Ophthalmol.1993;16(3):159-64.
20. Algvere PV, Jahnberg P, Textorius O. The
Swedish Retinal Detachment Register. I. A
database for epidemiological and clinical studies.
Graefes Arch ClinExpOphthalmol 1999; 237:
137-44.
21. Baba T, Ohno-Matsui K, Futagami S. Prevalence
and characteristics of foveal retinal detachment
without macular hole in high myopia. Am J
Ophthalmol 2003; 135: 338-42
22. Nishimura A, Kimura M, Saito Y, Sugiyama K.
Efficacy of primary silicone oil tamponade for
the treatment of retinal detachment caused by
macular hole in high myopia. Am JOphthalmol
2011;151:148-155
23. Suda K, Hangai M, Yoshimura N. Axial length
and outcomes of macular hole surgery assessed
by
spectral-domain
optical
coherence
tomography. Am J Ophthalmol 2011;151: 118-27
24. Leske MC, Chylack LT, Wu SY. The lens
opacities case-control study. Risk factors for
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DOI: 10.5958/2319-5886.2014.00402.0

&
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Volume 3 Issue 3
th
Coden: IJMRHS
rd
Revised: 3 Jun 2014
Copyright @2014
ISSN: 2319-5886
Accepted: 14th Jun 2014
Research Article
EFFECT OF AMLODIPINE AND INDOMETHACIN IN ELECTRICAL AND PICROTOXIN INDUCED

CONVULSIONS IN MICE
*Jagathi Devi N1, Prasanna V2
1
Assistant Professor, 2Professor and Head, Department of Pharmacology, Osmania Medical College, Hyderabad
*Corresponding author email: jagathinagari@gmail.com

ABSTRACT
Background and Objectives: Antiepileptic drugs (AEDs) are the drugs used in the treatment of epilepsy. Many
AEDs have been developed, but the ideal AED which can not only prevent but also abolish seizures by correcting
the underlying pathophysiology is still not in sight. Calcium channel blockers (CCBs) may form such a group, as
the initiation of epileptogenic activity in the neuron is connected with a phenomenon known as intrinsic burst
firing which is activated by inward calcium current. In this study, Amlodipine, a CCB of the dihydropyridine
class was evaluated for its anticonvulsant activity in mice. It was compared with Phenytoin sodium, one of the
oldest anti epileptic drugs. Amlodipine was also combined with Indomethacin, a conventional NSAID, to look for
any potentiating effect of this prostaglandin-synthesis inhibitor. Materials and Methods: A total of 48 adult
Swiss albino mice of either sex weighing 20-30 G were used for this study; 48 were divided into 8 groups, each
group containing 6 mice. Group 1-4 MES (50 m Amp for 0.1 secs) induced convulsion method, Group 5-8
evaluated by using the chemo-convulsant, picrotoxin (0.7 mg / kg). Group 1, 5 are controls of MES, Picrotoxin
(without treatment). Group 2 &6 administered standard drug phenytoin (0.5mg/100mg i.p), Group 3 & 7:
Amlodipine group (8 mg / kg i.p) and Group 4 & 8: Amlodipine (8 mg/kg) and Indomethacin group (20 mg / kg).
In MES method Duration of tonic hind limb extension, Clonic convulsions, Recovery period were studied. In
Picrotoxin method Latent period before onset of convulsions, severity of convulsions assessed. Results: In
electrically induced seizures, the 3 parameters compared are duration of tonic hind limb extension, THLE,
(P<0.05); duration of clonic seizures (P>0.05); duration of recovery phase (P<0.0001) and in picrotoxin-induced
seizures, the 2 parameters are onset of seizures (P<0.05) and severity of seizures (P<0.05). Conclusion: The
combination of Amlodipine and Indomethacin showed a superior anticonvulsant effect than the use of
Amlodipine alone, in both electrically-induced seizures and picrotoxin-induced seizures in mice.
Key words: Anti epileptic drug, Ca+2 channel blocker, Maximal electroshock, Picrotoxin-induced seizures, Tonic
hind-limb extension (THLE).
INTRODUCTION
Antiepileptic drugs (AEDs) are the drugs used in the
treatment of epilepsy. Many anti epileptic drugs have
been developed, but the ideal AED is still not in sight.
The ideal AED should not only prevent & abolish
seizures,
but
also
correct
the
aberrant
pathophysiology
of
epileptogenesis,
without
interfering with the normal neural transmission.
Therapy is symptomatic in that available drugs inhibit

seizures, but neither effective prophylaxis nor total
cure is available. Compliance is a major problem
because of the need for long term therapy together
with the unwanted effects of many drugs. Overall
drugs introduced after 1990 like gabapentin,
topiramate, tiagibine, levetiracetam and zonisamide
592
Jagathidevi et al.,
present fewer problems with respect to drug

interactions, but have insufficient evidence as
monotherapy and are mainly useful as add on
drugs1.As a general rule, complete control of seizures
can be achieved in up to 50% of patients while
another 25% can be improved significantly.1 It has
been observed that the presently available
antiepileptic drugs are unable to control seizures
effectively in as many as 25% of the patients.2 The
mounting number of drugs, the additional adverse
effects, drug interactions and other limitations
contribute to cause decreased patient compliance,
especially if epilepsy is co-existent with other chronic
diseases like hypertension.
A new group of drugs with antiepileptic activity,
without sedative properties is an interesting prospect.
The results from experimental animal models of
epilepsy & theoretical considerations suggest that
calcium (Ca2+) antagonists may form such a group.
The initiation of epileptogenic activity in the neuron
is connected with a phenomenon known as intrinsic
burst firing which is activated by an inward Ca2+
current.3 Ca2+ is described as the primary mediator of
excitotoxic neuronal damage during seizure activity.
There is a decrease in the extracellular calcium
concentration prior to the onset of seizure activity
followed by an increase in the intracellular calcium
concentration.4 Considering the crucial role played by
calcium, Calcium Channel Blockers (CCBs) can be
used in the treatment of epilepsy.
In this study, Amlodipine, a Calcium channel blocker
of the dihydropyridine class is evaluated for its
anticonvulsant property in mice. Amlodipine has
unique pharmacokinetic and dynamic properties
among all the CCBs. It has a prolonged half life
varying between 36-50 hours. It has slow, sustained
action and is suited for chronic therapy. Amlodipine
is also an antagonist of the N and P/Q type of calcium
channels unlike the other CCBs, Verapamil &
Diltiazem which are mainly L-type calcium channel
antagonists.5 Experimental evidence indicates that Ntype calcium channels are responsible for glutamate
release in the cerebral cortex and hippocampus.
Glutamate is the major excitatory neurotransmitter in
the brain and is crucial for epileptogenesis. It is also
noted that calcium current through the N-type
calcium channel accounts for 20% of the total inward
calcium current in isolated cortical neurons obtained
from epileptic patients.5

Hence the effect of
Amlodipine has been evaluated.
Studies have indicated that some prostaglandins
especially PGF2 (have pro-convulsant properties.6
Subsequently prostaglandin synthesis inhibitors or
Cyclooxygenase
inhibitors
like
Aspirin,
Indomethacin, Naproxen, Nimesulide and Rofecoxib
have been tried and proven to have an adjuvant role
in the treatment of epilepsy in animal models.7 In this
study, Indomethacin has been combined with
Amlodipine to potentiate the latters effect on
experimentally induced seizures. The combination of
Amlodipine with Indomethacin, two drugs with two
different mechanisms of action could result in an
additive or synergistic effect.
The present study was conducted in the Department
of Pharmacology. The approval for the study was
taken from the Institutional Animal Ethics
Committee.
In the present study, anticonvulsant activity of
Amlodipine and combined effect of Amlodipine and
Indomethacin is evaluated using electrically induced
and picrotoxin-induced convulsions in mice.
Grouping: The mice were divided into 8 groups,
each group contained 6 mice. (N=48), Groups 1-4
were MES method and Group 5-8 were picrotoxin
induced seizures
Group 1: MES Control Group (without any treatment,
administered normal saline 0.1 ml. i.p.)
Group 2: Phenytoin Group (administered Phenytoin
sodium 0.5mg/100mg i.p)8,9
Group 3: Amlodipine Group (administered
Amlodipine 8 mg / kg i.p. 10
Group
4:
Amlodipine
and
Indomethacin
(administered Amlodipine 8 mg/kg and Indomethacin
20 mg/kg, i.p.,11
Group 5: Picrotoxin Control Group (without any
treatment, administered normal saline 0.1 ml. i.p)
Group 6: Phenytoin Group administered Phenytoin
Sodium 0.5mg/100g i.p
Group 7: Amlodipine Group administered
Amlodipine 8 mg/kg i.p.
Group 8: Amlodipine & Indomethacin (administered
Amlodipine 8 mg/kg i.p. and Indomethacin 20 mg/kg
i.p.)
I. Supra maximal Electroshock or Maximal
Electro Shock (MES test): 24 mice were subjected
593
Jagathidevi et al.,
to maximal electroshock through ear electrodes with

an intensity of 50 m Amp of alternating current for
0.1 secs 60 minutes after the intra peritoneal
injections in mice.8,9
using Techno
Electroconvulsometer. This resulted in almost
immediate onset of convulsions, preceded by tonic
hind limb extension (THLE) and followed by post
ictal depression and recovery. The following 3
parameters were recorded.
A. Duration of THLE, B. Duration of clonic
convulsions, C. Recovery period.
II. Picrotoxin Induced Seizures : 60 minutes after
the above injections to induce convulsions
(intraperitoneal injection of picrotoxin 0.7 mg / kg
body weight)12,13 and the resultant seizures with its
various phases recorded.
The following parameters were considered with
picrotoxin induced seizures.
1. Latent period before onset of convulsions. 2.
Severity of convulsions-as assessed by a scoring
system
The convulsions severity scoring system 1-7 is as
follows: 12
Hyper locomotion & Pilo erection=1, Catatonia,
stunning = 2, Clonic body tremors =3, Prolonged
Clonic tremors = 4
Tonic forelimb convulsions followed by clonus = 5,
Repetitive fore limb convulsions followed by clonus
= 6, Tonic extension of both fore limbs and hind
limbs = 7, followed by clonus
RESULTS
The onset of convulsions or their inhibition, nature of
convulsions, duration of the tonic hind limb extension
(THLE), a period of post ictal depression (when
present) and recovery were observed and noted in all
groups of animals and compared with the control
group administered normal saline 0.1 ml. i.p. and
Phenytoin group administered Phenytoin sodium
0.5mg/100mg i.p).8
Data were analysed and all descriptive statistics are
expressed as Mean, Standard Deviation.. The results
obtained from the study were analysed by ANOVA
test and Student t test. P value <0.05* was considered
to be statistically significant.
Table 1: The duration of THLE is 20 seconds in the
Control group mice. It is one second in the Phenytoin
group. In the Amlodipine group it decreases to 12
seconds and with the addition of Indomethacin further
decreased to 10 seconds.
The observed difference between the 4 groups as
calculated by ANOVA is statistically significant at
95% confidence intervals P<0.001***.
The mean duration of clonic phase in the control
group is 60 seconds. It is shortened to 35 seconds in
the Phenytoin group, 40 seconds in the Amlodipine
group and to 35 seconds in the combined group. The
observed difference between the 4 groups as
calculated by ANOVA test is statistically highly
significant P<0.00001***
Table 1: Duration of THLE, Clonic Phase, and recovery period (in seconds) by MES Method
Group
Tonic hind limb extension
Clonic Phase
Recovery Period
Group
Mean SD P value$
Mean SD P value$
Mean SD
P value$
Group 1
20 1.68
600.63
401.41
Group 2
10.58
<0.0001***
350.63
<0.0001***
100.89
<0.0001***
Group 3
Group 4
121.09
100.89
<0.0001***
<0.0001***
400.89
350.63
<0.0001***
<0.0001***
300.89
401.41
<0.0001***
1 (ns)
* Significant, ** Very Significant, *** Extremely significant Ns: Non significant

$
P value comparison with Group 1

Table 2: Onset of Seizures, Convulsion score by Picrotoxin method
Onset of Seizures
Convulsions Score12
Group
Mean SD (in minutes)
P value
Mean SD
P value
Group 6
121.41
70.89
<0.001***
Group 7
180.89
<0.0001***
50.63
<0.001***
Group 8
200.44
<0.0001***
41.41
<0.0001***
Group 9
300.89
<0.0001***
20.63
<0.001***
* Significant, ** Very Significant, *** Extremely significant
On the convulsions severity scoring scale (1-7), control has 7, followed by phenytoin group with 5 and then Amlodipine
group with 4. The combined use of Amlodipine with Indomethacin is highly effective, decreasing the severity to 2. The
observed difference between the 4 groups as calculated by ANOVA test is statistically significant (P<0.05)*(table 2)
594
Jagathidevi et al.,
DISCUSSION
A large body of evidence supports the role of L-type
calcium channels in epileptogenesis.Nifedepine was
demonstrated to inhibit picrotoxin-induced seizure
activity
in
adult
Sprague-Dawley
rats13
Intraperitoneal injection of Nifedepine at doses of
10-20 mg/kg body weight significantly decreased the
severity of seizures after i.p injection of 4mg/kg
picrotoxin in rats.13 Other CCBs have been used for
various experiments. Nifedipine 5mg/kg and
Flunarizine 4mg/kg were found to have promising
effects in both MES and audiogenic seizures9. Effect
of Cinnarazine has been evaluated as a calcium
channel blocker on antiepileptic activity of Maximal
electroshock seizures in mice. 2
In the experiment carried out by Kaminski et al,
Amlodipine (up to 10mg/kg) reduced Pentylene
tetrazole-induced clonic and tonic convulsions in
mice.14 Many other experiments have been carried out
by combining amlodipine and other CCBs with
antiepileptic drugs like carbamezepine, valproate.
Lamotrigine and Topiramate. 15
The mouse MES model has been universally accepted
as the standard for generalized tonic-clonic seizures.
MES and Pentylene tetrazole are the standard
methods against GTCS and petitmal epilepsy. The
aim of this study is to assess the anticonvulsant effect
of Amlodipine alone and in combination with
Indomethacin in experimentally induced seizure
models in mice.. The above drugs are compared with
both the Control (normal saline) and the standard
(Phenytoin Sodium).
In electrically induced seizures, the 3 parameters
compared are duration of tonic hind limb extension,
THLE, (P<0.05); duration of clonic seizures
(P>0.05); duration of recovery phase (P<0.0001) and
in picrotoxin-induced seizures, the 2 parameters are
onset of seizures (P<0.05) and severity of seizures
(P<0.05).
The efficacy of CCBs to change the parameters in
MES model correlates well with the ability to prevent
partial and generalized tonic-clonic seizures and thus
its capacity to prevent seizure spread..
Role of prostaglandin synthesis inhibitors on
chemically induced seizures have been evaluated in
albino mice.11 Based on the findings that the levels of
prostaglandins (PGs), the cyclooxygenase metabolites
of arachidonic acid are increased in the brain during
experimentally-induced seizures in mice, a role for

NSAIDs have been suggested. In our study efficacy
of Amlodipine in combination with Indomethacin
was evaluated and found to be comparable to
Phenytoin in MES seizures and more than phenytoin
in picrotoxin-induced seizures.
CONCLUSION
The combination of Amlodipine and Indomethacin
showed a superior anticonvulsant effect than the use
of Amlodipine alone, in both electrically and
chemically induced seizures with picrotoxin, in mice.
In MES seizures, the combined anticonvulsant effect
was comparable to that of the standard drug,
phenytoin.
In picrotoxin induced seizures, the combined
anticonvulsant effect was superior to that of
phenytoin both in delaying the onset of seizures and
decreasing the severity of seizures.
Hence the anticonvulsant potential of this
combination is seen in both seizure models which are
equivalent to generalized tonic clonic seizures and
partial seizures. Further clinical investigation of these
drugs is needed in the context of their being
established drugs with no sedation, minor side effects
and fewer drug interactions.
Epilepsy being a chronic disease may be coexistent
with other chronic diseases like hypertension and
osteoarthritis. In these clinical settings, the
potentiating effect of calcium channel blockers like
Amlodipine and Nonsteroidal anti-inflammatory
drugs like Indomethacin may prove to be useful.
Limitation of study
There is a definite limitation of this study as the
number of animals, i.e. Mice studied are small
groups (N=6). This preliminary study was to
substantiate the mechanism of anti-epileptic action of
both CCBs & NSAIDs. Further clinical studies are
however needed to prove this action in humans.
ACKNOWLEDGEMENT
I am thankful to the Department of Pharmacology,
Osmania Medical College, Hyderabad, and Central
Animal House of Osmania Medical College for
support in the successful completion of this study.
595
Jagathidevi et al.,

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DOI: 10.5958/2319-5886.2014.00403.2

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Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
th
ISSN: 2319-5886
Research Article
AN ASSESSMENT OF NUTRITIONAL STATUS OF CHILDREN LESS THAN 3 YEARS IN RURAL

AREAS OF MAHOTTARI DISTRICT OF NEPAL
*Yadav DK1, 2, Gupta N1, Shrestha N3
1
Faculty of Health Sciences, Sam Higginbottom Institute of Agriculture, Technology and Sciences, Allahabad,
India
2
School of Health and Allied Sciences, Pokhara University, Nepal
3
Valley College of Technical Sciences, Mahrajgunj, Kathmandu, Nepal
*Corresponding author email: dipendrayadavph@gmail.com
ABSTRACT
Background: More than one-fourth of under five children (about 150 million) are underweight while about onethird (182 million) are stunted. Geographically more than 70% of protein energy malnutrition children live in
Asia, 26% in Africa and 4% in Latin America and the Caribbean2. Malnutrition among children is a public health
problem in Nepal. Nepal Demography and Health Survey (NDHS, 2011) reported that 29 % children are
underweight, 41% stunted and 11% wasted. Material and Methods: A base-line data were analyzed and
prepared this article with objective was prevalence and its associated factors of stunting, underweight and wasting
among children less than 3 years old from the study that was conducted a pre-post with controlled design
conducted in Mahottari district of Nepal in 2012. Results: In this study, Prevalence of wasting, stunting and
underweight was 31.1%, 42.3% and 45% of children less than 3 years respectively. The study found that the
prevalence of severe wasted and wasted were 18.2 % and 12.9 % respectively, while the prevalence of stunting
and severe stunting status of children were 20.7% and 21.7% and the prevalence of underweight and severely
underweight children were 20.2% and 24.9%. Conclusions: Present study shows that the prevalence of
malnutrition (underweight, stunting, and wasting) is still major health problems among children less than 3 years,
particularly in the Central Terai region.
Keywords: Stunting, Wasting, Underweight, Children
INTRODUCTION
Malnutrition in all its forms, either directly or
indirectly, is responsible for approximately half of all
deaths worldwide. This applies to perinatal and
infectious diseases as well as chronic diseases.
Malnutrition accounts for 11% of the global burden
of disease, leading to long-term poor health and
disability and poor educational and developmental
outcomes1.
Yadav DK et al.,
Good nutrition is a prerequisite for the national

development of countries and for the well-being of
individuals. Although problems related to poor
nutrition affect the entire population, women and
children are especially vulnerable because of their
unique physiology and socioeconomic characteristics.
Adequate nutrition is critical to childrens growth and
development. The period from birth to age two is
especially important for optimal physical, mental, and
597
cognitive growth, health, and development.

Unfortunately, this period is often marked by proteinenergy and micronutrient deficiencies that interfere
with optimal growth. Childhood illnesses such as
diarrhea and acute respiratory infections (ARIs) also
are common2.
More than one-fourth of under five children (about
150 million) are underweight while about one-third
(182 million) are stunted. Geographically more than
70% of protein energy malnutrition children live in
Asia, 26% in Africa and 4% in Latin America and the
Caribbean2. Malnutrition among children is a public
health problem in Nepal. Nepal Demography and
Health Survey (NDHS-2011) reported that 29 %
children are underweight, 41% stunted and 11%
wasted.
NDHS 2011 reported nationally, 41 percent of
children under age 5 are stunted, and 16 percent are
severely stunted. More than half of children whose
size at birth was very small or small are stunted.
Children in rural areas are more likely to be stunted
(42 percent) than those in urban areas (27 percent),
and a similar pattern is noted for severe stunting (17
percent in rural areas and 6 percent in urban areas).
Also reported overall, 11 percent of children are
wasted and 3 percent are severely wasted. Analysis
by age group shows that wasting is highest (25
percent) in children age 9-11 months and lowest (7
percent) in children age 36-47 months. Male children
are more likely to be wasted (12 percent) than female
children (10 percent). The study reported that 29
percent of children under age 5 are underweight (low
weight-for-age), and 8 percent are severely
underweight.
Maternal and child mortality have declined
significantly in Nepal to the extent that Nepal is on
track to meet the Millennium Development Goals for
maternal and child mortality. Similar improvements
have not been seen in general nutrition status of
them5.
A base-line data were analyzed and prepared this
article with objective was prevalence and its
associated factors of stunting, underweight and
wasting among children less than 3 years old from the
study that was conducted a pre-post with controlled
design conducted in Mahottari district of Nepal in
Yadav DK et al.,
2012. Study population was under 3 year's children

and their mother.
Sample Size: Desired numbers of participants were
selected by using the formula as following:
n = D [(Z1 + Z2)2 * (P1 (1 - P1) + P2 (1 - P2)) /(P2 P1)2]
A total of 615 sample size was selected for the study.
Ethical approval was taken from ethical committee
for biomedical research, faculty of health sciences,
SHIATS, Allahabad, India and Nepal Health
Research Council, Kathmandu, Nepal. Verbal consent
was taken from every participant mother and
permission was taken from District Health Office,
Mahottari to carry out this study.
This study adopted stratified sampling. Unit of study
will be selected by applying following stages. First
Stage: Mahotarri district was selected purposively
and the district (76 VDCs) was divided into three
stratums according to geographical location (North,
Middle & South Part) in terms of caste, food taboos
and health behavior and practices. Second Stage:
Names of all Village Development Committee VDCs
were recorded alphabetically in separate stratum. 4
VDCs from each stratum were selected randomly. 12
VDCs were selected for study. In the final stage:
Each VDC consists of nine wards. Five wards were
selected randomly from each VDC and at least 10
respondents were selected from each ward by
Expanded Programme on Immunization (EPI)
method of households selection sampling technique.
Base-line data collection was collected from February
1, 2012 to May 13, 2012., Excluding 1 municipality
because this research was conducted in rural areas
only. Only one child aged less than 3 years (0 to 35
months completed age) was recruited for the study
from each selected household through randomly if
more one children. If in the selected house, there was
no child, then the house was skipped and the next
house was selected for the study. If for any reason,
one selected house could not be surveyed (refusal of
the house occupants) then the house was not
substituted by another one.
Interview schedule focused on socio-demographic
conditions, nutrition and feeding behaviours and child
seeking practices were collected from mothers.
Anthropometric measurements: Anthropometric
measurements were carried out to assess the degree of
malnutrition in children under 3 years of age from all
598
the study groups from intervention and control areas.

Height for weight, weight for age, height for age and
Mid-Upper Arm Circumference MUAC were
calculated for children. Height was measured using a
standard height measuring scale (board) for children
under 3 years. Children up to 2 years (23 months or
85 cm) of age are measured on a horizontal
measuring board. Shoes should be removed. The
child is placed gently onto the board, the soles of the
feet flat against the fixed vertical part, the head near
the cursor or moving part. The child should lie
straight in the middle of the board, looking directly
up. The assistant holds the feet firmly against the
footboard and places one hand on the knees of the
child, while the measurer gently holds the childs
head, places the cursor against the crown of the head
and reads out the length to the nearest 0.1 cm.
Children over 2 years of age (or over 85 cm) are
usually measured standing on a horizontal surface
against a vertical measuring device. The assistant
makes sure that the child stands straight, with the
heels, knees, and shoulders against the wall, while the
cursor is lowered onto the crown of the head,
compressing the hair. The height is read out as
before, to the nearest 0.1 cm. Weight of children was
measured using a lightweight electronic SECA digital
scale (UNICEF Electronic Scale). MUAC of children
was measured with UNICEF MUAC tape.
Data were coded and entered in Epi Data 3.1 version
software. Anthropometric analysis, such as Z-score
value was calculated in Epi Info 3.3.2 version. EpiInfo software was produced tables of frequencies for
Z-score classes of 0.5 Z-score intervals and graphs of
frequency distributions. All the data from Epidata and
EpiInfo were exported to IBM SPSS Statistics 20
software and then analyzed it. Appropriate statistical
test was applied wherever required. The result was
interpreted in the light of the objectives.
RESULTS
Indicators of the nutritional status of children were
calculated using new growth standards published by
the World Health Organization (WHO) in 2006. On
the following classifications of nutritional status of
children are used in the study description. Stunted:
Children having the index value for height for age
below two standard deviation units (<-2SD), Wasted:
Children having the index value for weight for height
Yadav DK et al.,
below two standard deviation units (<-2SD).

Underweight: Children having the index value for
weight for height below two standard deviation units
(<-2SD), Severely stunted: Children having the
index value for height for age below two standard
deviation units (<-3SD), Severely wasted: Children
having the index value for weight for height below
two standard deviation units (<-3SD) and Severely
underweight: Children having the index value for
weight for height below two standard deviation units
(<-3SD).
Table 1: Prevalence of wasting, stunting and
underweight among children.
Measurement
Weight For
Height
Height For
Age
Weight for
Age
Nutritional
Status
Severe Wasted
Frequency
112
18.2
Wasted
79
12.9
Normal
424
68.9
Total
615
100.0
Severe stunted
133
21.6
Stunted
127
20.7
Normal
355
57.7
Total
Severely
Underweight
Underweight
Normal
615
153
100.0
24.9
124
338
20.1
55.0
Total
615
100.0
A total 615 participants were selected for the study of

them 284 (46.2%) were female and 331 (53.8%) were
male. The mothers mean age was 25.21 for with
4.15 SD and children mean weight was 9.05 for with
2.76 SD.
Study found that the prevalence of severe wasted and
wasted were 18.2 % and 12.9 % respectively while
prevalence of stunting and severe stunting status of
children were 20.7% and 21.7% and prevalence of
underweight and severely underweight children were
20.1% and 24.9%.
Study shows the highest number of children were notstunted that those sources of family income were job
26 (78.8%) and Business 25 (65.8%) that the
significant association between stunted and notstunted children to source of family income and p
value is 0.01. There were direct relationship between
highest family income and not-stunted children and
significant association between family income and
not-stunted children and p value is 0.02.
599
Table 2: Comparison between normal (Non-Stunted) and Stunted children based on characteristics
p-value
Characteristics
Normal
Stunted
OR
95% CI
based
on 2
Children Sex
Female
158 (55.6)
126 (44.4)
Male
197 (57.7)
134 (40.5)
Family Type
Nuclear
145 (60.7)
94 (39.3)
Joint
210 (55.9)
166 (44.1)
Educational Status of mother
Illiterate
274 (57.2)
205 (42.8)
Literate
81 (59.6)
55 (40.4)
Children had Diarrhoea
Yes
246 (56.7)
188 (43.3)
No
109 (60.2)
72 (39.8)
Sources of income
Agriculture
175 (58.1)
126 (41.9)
Animal husbandry
8 (38.1)
13 (61.9)
Casual wages of labour
41 (46.6)
47 (53.4)
Foreign employee
80 (59.7)
54 (40.3)
Business
25 (65.8)
13 (34.2)
Government employee
26 (78.8)
7 (21.2)
Family Income Nepali Rupees (Monthly)
Less than 4999
26 (44.8)
32 (55.2)
5000 9999
276 (57.6)
203 (42.4)
10000 & above
53 (67.9)
25 (32.1)
Table 3: Comparison between normal (Non-Underweight)
characteristics
Characteristics
Normal
Underweight
Children Sex
Female
155 (54.6)
Male
183 (55.3)
Family Type
Nuclear
132 (55.2)
Joint
206 (54.8)
Illiterate
259 (54.1)
Literate
79 (58.1)
Children had diarrhea
Yes
235 (54.1)
No
103 (56.9)
Less than 4999
28 (48.3)
5000 9999
263 (54.9)
10000 & above
47 (60.3)
Yadav DK et al.,
0.33
0.853
0.619 - 1.176
0.23
1.219
0.877 - 1.696
0.62
0.908
0.616 - 1.337
0.41
0.864
0.607 - 1.230
0.01
0.026
and Underweight children based on
p-value
based on 2
OR
95% CI
129 (45.4)
148 (44.7)
0.86
0.972
0.707 - 1.336
107 (44.8)
170 (45.2)
0.914
1.018
0.735 - 1.410
220 (45.9)
57 (41.9)
0.406
0.849
0.578 - 1.248
199 (45.9)
78 (43.1)
0.531
0.899
0.630 - 1.268
30 (51.7)
216 (45.1)
31 (39.7)
0.381
600
Table 4: Comparison between normal (Non-Wasted) and Wasted children based on characteristics
Characteristics
Normal
Children Sex
Female
196 (69.0)
Male
228 (68.9)
Family Type
Nuclear
162 (67.8)
Joint
262(69.7)
Illiterate
328 (68.5)
Literate
96 (70.6)
Children had diarrhea
Yes
296 (68.2)
No
128 (70.7)
Less than 4999
43 (74.1)
5000 9999
328 (68.5)
10000 & above
53 (67.9)
Female children were at an increased risk of stunting
and underweight compared to male children probably
due to the feeding and caring more focused on male
children. Female and male children were at same
increased risk of wasting compared to gender. There
was no association between the level of stunting,
wasting and underweight and sex of the children all p
value of > 0.05.
DISCUSSION
Health and nutritional status are two crucial and
interlinked aspects of human development, which in
turn interact with demographic variables in important
ways. In children, the three most commonly used
anthropometric indices are weight-for-height, heightfor-age, and weight-for-age. Deficit in height-for-age
is called stunting and indicates chronic malnutrition.
Deficit in weight-for-height is called wasting and
indicates acute malnutrition. Deficit in weight-for-age
is often referred to as underweight and reflects low
weight-for-height, low height-for-age, or both (global
malnutrition). Weight-for-age is thus not a good
indication of recent nutritional stress in the
population8.
In this study, Prevalence of wasting, stunting and
underweight was 31.1%, 42.3% and 45% of children
less than 3 years respectively. According to Nepal
Yadav DK et al.,
Wasted
p-value
based
on 2
OR
95% CI
88 (31.0)
103 (31.1)
0.97
1.00
0.71 - 1.34
77 (32.2)
114 (30.3)
0.62
0.91
0.64- 1.29
151 (31.5)
40 (29.4)
0.63
0.90
0.59 - 1.37
138 (31.8)
53 (29.3)
0.53
0.88
0.60 - 1.29
15 (25.9)
151 (31.5)
25 (32.1)
0.66
NDHS 2011 report, Prevalence of wasting, stunting

and underweight were 11%, 41% and 29%
respectively children below five years, which is lesser
as compared to this study. This difference could be
due to a smaller sample size of our study.
Study found that the prevalence of severe wasted and
wasted were 18.2 % and 12.9 % respectively which
are higher prevalence than the Central Terai that
severely wasted and wasted among the children are
10.4% and 3.2% respectively reported in NDHS,
2011.
Present study revealed that prevalence of stunting and
severe stunting status of children were 20.7% and
21.7% which are lesser and greater the prevalence of
stunting, severe among the children in Central Terai
that are 40.5% and 19.5% respectively reported in
NDHS, 2011.
Study found prevalence of underweight and severely
underweight children were 20.1% and 24.9% which
are higher prevalence than the Central Terai that
underweight, severely and underweight among the
children are 32% and 10.7% respectively reported in
NDHS, 2011.
Female children were at an increased risk of stunting
and underweight compared to male children probably
due to the feeding and caring more focused on male
children. Female and male children were at same
601
increased risk of wasting compared to gender. There

was no association between the level of stunting,
wasting and underweight and sex of the children all p
value of > 0.05. A nutritional assessment study done
by Bloss, E.et al, 6 they found that Male children were
at an increased risk of stunting and underweight
compared to female children. Female children were at
an increased risk of wasting compared to male
children. This difference could be due to regional
differences.
Study shows the highest number of children were notstunted that those sources of family income were job
26 (78.8%) and Business 25 (65.8%) that the
significant association between stunted and notstunted children to source of family income and p
value is 0.01.
There were direct relationship between highest family
income and not-stunted children and significant
association between family income and not-stunted
children and p value is 0.02. A similar study done by
Sapkota, V. and C. Gurung 7 and reported the
economic status is a strong predictor of the
underweight and stunting status of children.
Comparatively, the risk of being underweight in the
children from the poor economic status of family is
almost four times as much as in the children from the
rich economic status. Similarly, in the poor economic
group, the risk of getting stunted is three times as
much as in rich economic group.
CONCLUSION
From the findings of the study: It shows that
prevalence of malnutrition (underweight, stunting,
and wasting) is still major health problems among
children less than 3 years, particularly in Central
Terai region. Effective strategies such as communitybased regular growth monitoring, nutritional
counseling and referral mechanism will adopt by
health workers to control these problems.
Literate mothers had less number of Stunted, wasted
and underweight children in comparison with
illiterate mothers. Basis of present findings, the idea
that educating the primary child-caretakers (mothers)
that improving womens awareness of appropriate
feeding practices can improve the nutritional status of
children.
Yadav DK et al.,
ACKNOWLEGEMENT
We wish to express our sincere thanks to the
Mahottari District Health Office for providing
permission to conduct this study, the Ethical
Committee for ethical approval and FCHVs for their
willingness to take on the extra workload involved in
the interventions. We are also indebted to all the
participants for their actively participation in this
study.
REFERENCES
1. World Health Organization, Turning the tide of
malnutrition responding to the challenge of the
21st century. 2000, Nutrition for Health and
Development
(NHD): CH-1211 Geneva,
Switzerland.http://apps.who.int/iris/bitstream/106
65/66505/1/WHO_NHD_00.7.pdf
2. Ministry of Health and Population, Nepal
Demographic and Health Survey. 2011.
http://www.mohp.gov.np/english/publication/ND
HS%202011%20Full%20version.pdf
3. WHO, Global Database on Child Growth and
Malnutrition,
2011.
http://www.who.int/nutgrowthdb/en/
4. Black RE. Maternal and child undernutrition:
global and regional exposures and health
consequences. Lancet, 2008; 371(9608):243-60
5. Codling K. Accelerating Progress in Reducing
Maternal and Child Undernutrition in Nepal.
2011,
World
Bank.
https://www.k4health.org/sites/default/files/Nepal
_Nutrition_Evidence_Review_for_peer_review_
Oct_2011.pdf
6. Bloss E, Wainaina F, Bailey RC. Prevalence and
predictors of underweight, stunting, and wasting
among children aged 5 and under in western
Kenya. J Trop Pediatr, 2004;50(5): 260-70
7. Sapkota V, Gurung C. Prevalence and predictors
of underweight, stunting and wasting in underfive Children. Nepal Health Res Counc, 2009;
7(15): 120-26
8. Thapa M. Nutritional status of children in two
districts of the mountain region of Nepal. J Nepal
Health Res Counc 2013;11(25): 235-39
9. Sukhdas G. Nutritional status of tribal children in
Andhra pradesh. Int J Med Res Health Sci.
2014.3(1):76-79
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10. M P, EGA, MGM. Factors associated with the

prevalence of under-nutrition in pre-school
children in matisi peri-urban location, trans-nzoia
district, kenya. Journal of Biology, Agriculture
and Healthcare. 2013; 3(2): 61-68
11. Gareth Jones. How many child deaths can we
prevent this year? The Lancet, 2003;362; 65-71.
12. Kilaru, A., et al., Community-based nutrition
education for improving infant growth in rural
Karnataka. Indian Pediatr, 2005. 42(5): p. 425-32.
13. Shrestha BP. Community interventions to reduce
child mortality in Dhanusha, Nepal: study
protocol for a cluster randomized controlled trial.
Trials Journal, 2011. 12(136): 1-14
14. Central Bureau of Statistics. Census report.
Central
Bureau
of
Statistics,
2011.Kathmandu,Nepal. http://cbs.gov.np/
15. Malekafzali H. Community-based nutritional
intervention for reducing malnutrition among
children under 5 years of age in the Islamic
Republic of Iran. East Mediterr Health J, 2000.
6(2): 238-45
16. Horodynski MA, Stommel M. Nutrition
education aimed at toddlers: an intervention
study. Pediatr Nurs, 2005. 31(5):364, 367-72
17. District Health Office. District Annual Report.
Mahottari District Health Office, 2013.
Jaleshwar, Nepal. http://mdho.gov.np/
18. Kabahenda MK. Developing an intervention to
improve the child-feeding behaviors of rural
mothers in western uganda., in Graduate Faculty
2002., university of Georgia: Athens, Georgia.
http://spock.fcs.uga.edu/ss/docs/kabahenda_marg
aret_k_200205_ms.pdf
Yadav DK et al.,
603
DOI: 10.5958/2319-5886.2014.00404.4

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
rd
Revised: 23 May 2014
ISSN: 2319-5886
Accepted: 9thJun 2014
Research Article
POLYCYSTIC OVARY SYNDROME, BLOOD GROUP & DIET: A CORRELATIVE STUDY IN

SOUTH INDIAN FEMALES
Rahul Pal1, *Pratik Kumar Chatterjee2, Poulomi Chatterjee3, Vinodini NA2, Prasanna Mithra4, Sourjya Banerjee5,
Suman VB2, Sheila R. Pai2
1
MBBS student, 2Department of Physiology, 4Department of Community Medicine, 5Department of RadiationOncology, Kasturba Medical College (KMC), Mangalore, Manipal University (MU), Karnataka, India.
3
Dietician - formerly attached to Manipal Ecron Acu-Nova KH Clinical Research Centre, Manipal, Karnataka,
India.
*Corresponding author email: pratikchatterjee68@rediffmail.com
ABSTRACT
Aim: To find out the co-relation between polycystic ovary syndrome (PCOS) with blood group & diet in South
Indian females, between the age-group of (20-30) years. Objectives: Correlative analysis of ABO & Rh system,
dietary habits & alcohol consumption with PCOS. Materials & Methods: 100 patients between (20-30) years,
diagnosed with PCOS were selected. A standard PCOS questionnaire was given. Blood group & dietary status
data were collected. Patients were grouped according to ABO & Rh system considering their diet & alcohol
intake (p0.05 significant). Result: Our data revealed that the highest risk of PCOS was observed in females with
blood group O positive followed by B positive who were on mixed diet & used to consume alcohol. Our study
also suggests that Rh negative individuals didnt show any association with PCOS. Conclusion: The results of
our study suggest that O positive females, are more prone to PCOS. Though the relative frequency of B positive
individuals are more in India, females with blood group O positive are more susceptible to PCOS, contributing
factors being mixed diet & alcohol intake. So, early screening of O positive &B positive females of
reproductive age-group in South-India, could be used as a measure for timely diagnosis of PCOS, better
management &also prevention of complications. However, further research should be done to investigate the
multifaceted mechanisms triggering these effects.
Keywords: Polycystic ovary syndrome, Blood group, Diet, Alcohol.
INTRODUCTION
The first description of the human blood group
system was published by Karl Landsteiner in 1900,
working to understand the unpredictability of
haemolytic reaction resulting from early attempts at
transfusion.1International society of blood transfusion
(ISBT) currently recognizes 285 blood group
antigens.2In Humans, among these, ABO system is
the most important blood group system & Rh is the
second most significant. Anthropologists use ABO
Rahul et al.,
blood types extensively as a guide to the development

of early diseases, especially digestive disorders,
cardiovascular diseases, cancer & infection.3-7Some
blood types are associated with inheritance of other
diseases; for e.g., the Kell antigen is sometimes
associated with Mc. Leod syndrome.8 Certain blood
types may affect susceptibility to infections, an
example being the reduced susceptibility to vivax
malaria in individuals lacking duffy antigen.9Positive
604
correlation has been seen with group A & ischemic

heart disease.
Polycystic ovary syndrome (PCOS) is one of the most
common syndromes in the modern world in women
during their reproductive age. Polycystic ovary
syndrome is a complex metabolic, endocrine &
reproductive disorder affecting approximately (5-10)
% of the female population in India.10PCOS, a
complex syndrome of unclear etio-pathogenesis,
appears to involve genetic & environmental
components.11 It has also been associated with
coronary heart disease, diabetes & other metabolic
syndromes & hence the estimation of high PCOS
prevalence rates appear in the countries where obesity
& type 2 diabetes are more common.12Even though
women with PCOS vary in degree of overweight,
(30-75%) of the cases contend with being
overweight/obese.13 In the past two decades,
developing countries began relying on westernized
diets &lifestyles. It is predicted that they may see up
to 6 fold increase in the obesity prevalence in the next
10 years, especially from India who already has the
highest rates of diabetes in the world.14 Though
genetic predisposition plays an important role, many
studies also show that dietary habits & exercise can
also
influence
the
causation
of
the
disease.15Treatment of PCOS is mainly aimed at
lowering insulin resistance levels, restoration of
fertility & regular menstruation, treatment of
hirsutism/ acne & prevention of endometrial
hyperplasia & endometrial cancer though the optimal
treatment is still doubtful.16,17
Polycystic Ovary Syndrome
Polycystic ovary syndrome (PCOS) is a complex
heterogeneous disorder, with a strong evidence of it
being classified as a genetic disease.18 PCOS is the
most common cause of anovulation in women with
normal serum FSH and estradiol levels.19 This
condition was first described in the year 1935 by
American gynaecologists Irving F.Stein, Sr. &
Michael L. Leventhal from whom the original name
of Stein-Leventhal Syndrome is taken.20PCOS
includes signs & symptoms with varying degree of
mildness & severity in affecting the reproductive,
endocrine and metabolic functions.21PCOS is the
commonest cause of an ovulatory subfertility. The
symptoms are usually excessive weight gain,
oligomenorrhea/amenorrhea,
high
triglyceride
&insulin levels in the blood, etc., It is also associated
with other types of menstrual disorders& infertility

which
generally
results
from
chronic
22
anovulation. The most common signs are acne,
hirsutism, hypermenorrhea,23 etc., Though the exact
cause of PCOS is yet unknown, there is strong
evidence that it is a genetic disease. Such evidence
includes the familial clusters of cases, greater
concordance in monozygotic compared with
dizygotic twins and heritability of endocrine and
metabolic features.24
In India, nowadays the adolescents &teenagers are
more attracted towards the western food habits. The
intake exceeds the burning of calories, thus resulting
in the accumulation of fats in the adipose tissue.
There is in general agreement that, obese women with
PCOS are insulin resistant.23There are some long
term health complications of PCOS like, those with
hyper-insulinemia are at a greater risk of developing
type-II diabetes & gestational diabetes, hyperandrogenic individuals are more prone towards
developing arterial diseases, etc.,16For a PCOS
patient, it is always advised to have a proper diet rich
in fibers, vitamins& a low glycemic index (GI) diet in
which a significant part of total carbohydrates are
obtained from fruit, vegetables & whole grain
sources.25It is well known that Vitamin D deficiency
may play a significant role in exacerbating PCOS &
so, vitamin D supplementation is found to be
effective in the management of this syndrome.26As
we all know, regular exercise is required to keep us
healthy, it has been seen that, low-carbohydrate
diets& sustained regular exercise may help practically
to improve every parameter of PCOS, e.g., in obese,
an ovulating PCOS women, weight loss restores
ovulation & pregnancy rates.
Blood Group & Diseases
A study has shown that about 39% of the Indian
population belongs to blood group B, followed by
blood group O (31%) & A (21%). Only about 9.0%
of the Indian population belongs to blood group AB.
About 95% of these people are Rh+&5% are Rh- 27.
Relationship between blood group O & peptic ulcer is
well established.2A study of association between
ABO blood groups, peptic ulcer & gastric cancer
showed that there is an increased risk of gastric
cancer in A & AB blood groups & a low risk of
stomach ulcers in all the non O groups relative to
blood group O.A longitudinal study of the association
between ABO phenotype & the total serum
605
Rahul et al.,
cholesterol levels in a Japanese cohort showed that

the total cholesterol levels are elevated on an average
by about 4mg/dl in phenotype A as compared to non
A groups, thus indicating that phenotype individual
may be more predisposed to the cardiovascular
diseases through one of its major risk factors7.
Common health complications of PCOS include
endometrial cancer, heart disease, diabetes, metabolic
syndrome, etc.,16
Till date, no relevant study has been conducted to
show whether any association exists between blood
groups & PCOS. So, the present study was designed
to find out the relationship of blood group & diet with
polycystic ovary syndrome (PCOS) in females of
reproductive group.
RESULTS
Fig. 1 represents that females with blood group O
positive have the highest risk of developing PCOS
(p 0.05 ), followed by women of blood group B
positive. Also, Rh negative individuals didnt show
any association with PCOS.
MATERIALS & METHODS

Study design & setting: this is a hospital based cross
sectional study which included patients between the
age-group of (20-30) years, diagnosed with PCOS,
from Kasturba Medical College Hospitals &
Government Lady Goshen Hospital, Mangalore,
Karnataka, India. The study protocol was approved
by the Institutional Ethics Committee. At orientation,
each patient was explained the purpose, procedures &
confidentiality of this study prior to their written
informed consent. The duration of the study was one
year.
Inclusion criteria: patients between the age group of
(20-30) years, diagnosed of PCOS, were taken into
the study.
Exclusion criteria: patients diagnosed of suffering
from any chronic illnesses (except diabetes mellitus)
were not included in the study.
Method of study
The study involved 100 patients between the age
group of (20-30) years, diagnosed with PCOS, in our
hospitals. A PCOS questionnaire was handed over to
the patients included in the study & data was
recorded in the proforma for each patient.28,29Patients
were grouped according to their blood groups& food
habits including alcohol consumption. A correlative
analysis of the data was then be made accordingly.
Statistical analysis: parameters were analyzed using
one way ANOVA(Tukeys Multiple Comparison
Test). p 0.05 was considered as significant.
Fig 1: Co-relation between blood group & PCOS

(Values are represented as Mean SD, p 0.05
significant)
The data in Fig 2 show that females on the mixed diet
were found to have a significant risk of developing
PCOS as compared to those on vegetarian diet only.
Alcohol intake was an additive factor to that.
Fig 2: Co-relation of PCOS with blood group & food

habits. (Values are represented as Mean SD, p
0.05 significant)
606
Rahul et al.,
DISCUSSION
There is increasing evidence that blood group
substances play a major role in the causation of a
disease/in the protective mechanism against it. A
study conducted showed a significant positive
association with blood group A & negative
association with blood group O in myocardial
infarction, a significant positive association with all
the blood groups except for blood group O in
valvulo-pathic (rheumatic) diseases, a positive
association with A phenotype & negative with B in
arterial hypertension, in males only & no association
of ABO blood groups & congenital heart
diseases.1Differential diagnosis of PCOS includes,
hypothyroidism, congenital adrenal hyperplasia,
Cushing's syndrome, hyper-prolactinemia, androgen
secreting neoplasms, other pituitary/adrenal disorders,
etc.,29
The most commonly used blood group systems in
humans are ABO & Rh systems due to their
importance in blood transfusion & association with
various diseases.29Polycystic ovary syndrome affects
approximately (5-10) % of the female population in
India10.It is well known that the prevalence rates of
PCOS are rising in countries, where obesity & type 2
diabetes are more common.12It is known that in
PCOS individuals serum levels of insulin may be
elevated. Around 40% of females with PCOS have
some degree of glucose intolerance. So, blood
glucose level testing for diabetes is usually
recommended. Studies have shown that anti-diabetic
medications like, metformin, etc., have shown
encouraging results, particularly in obese patients
who are suffering from chronic anovulation.16India
having the highest rates of diabetes in the world with
an increasing trend towards obesity in this modern
era, is expected to have a high prevalence of PCOS in
the next few years.14Literature surveys shows that
blood group substances have significant association
with the causation of disease, e.g., blood group A
with arterial hypertension & myocardial infarction,
blood group O& peptic ulcer, etc.,1The present study
showed that females with blood group O positive
have the highest risk of developing PCOS, followed
by women of blood group B positive. Though the
relative frequency of B positive individuals are more
in India, females with blood group O positive are
more susceptible to PCOS. Standard diagnostic
assessments for PCOS include, history taking, signs

& symptoms, various laboratory tests, but pelvic
ultrasound still remain the major diagnostic tool.16.A
previous study conducted on blood group &breast
cancer showed no relation exists with the Rh factor
&breast cancer.30,31Similarly, our findings also reveal
that, Rh negative individuals didnt show any
association with PCOS. Researches have shown that
dietary habits can influence the causation of the
disease.15The present findings are in accordance with
previous studies which shows that mixed diet &
alcohol are contributing factors for the development
of the disease.
CONCLUSION
Early screening of O positive & B positive females of
reproductive age-group in South-India especially
those on mixed diet & alcohol could be used as a
measure for early diagnosis of PCOS, better
management & also prevention of complications.
LIMITATIONS OF THE STUDY
Though the present study showed that females with
blood group O positive have the highest risk of
developing PCOS, followed by women of blood
group B positive & Rh negative individuals didnt
have any association with PCOS, further research
should be done to investigate the multifaceted
mechanisms triggering these effects.
Generalization of the obtained findings would not be
possible till replication of the same is carried out on
the patient population in other parts of the country.
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26. ThomsonRL, Simon Spedding, Jonathan D.
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Khattak T, Ali A. Frequency of ABO and Rhesus
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AyubMedical College. 2008;20(4):127-29
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DOI: 10.5958/2319-5886.2014.00405.6

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Accepted: 5thJun2014
Research Article
MRI STUDY ON SPINAL CANAL CONTENT IN WESTERN MAHARASHTRIAN POPULATION

*Khanapurkar SV1, Kulkarni DO2, Bahetee BH1, Vahane MI3
1
Department of Anatomy, 3Department of Radiology, B.J. Govt Medical College, Pune, Maharashtra, India
Department of Anatomy, SKN Medical College, Pune, Maharashtra, India
*Corresponding author email: sonalikhanapurkar@gmail.com

ABSTRACT
The morphology of the spinal canal content has been studied since the invention of myelography. However, most
studies have measured the diameters of the spinal cord only, not the size of the subarachnoid space. The present
study complements the current data on the morphology of the spinal contents, and in particular, the spinal
subarachnoid space, by analyzing MRI images. Objective: To study morphology of the dural sac, spinal cord &
subarachnoid space using MRI. To define the inner geometrical dimensions of spinal canal content that confine
the maneuver of an endoscope inserted in cervical spine. 3. To have comprehensive knowledge of the anatomy of
cervical spinal canal. Method: Based on MRI images of the spine from 60 normal patients of age between 25-60
years, the dimensions of spinal cord, dural sac & subarachnoid space were measured at mid-vertebral &
intervertebral level from C1-C7 vertebrae. The parameters measured were transverse, sagittal diameter of spinal
cord & dural sac. The subarachnoid space was measured as anterior, posterior, right, left distance between spinal
cord and dura mater. Results: It was found that at each selected transverse level, the subarachnoid space tends to
be symmetrical on the right and left sides of the cord, and measures 3.38 mm on an average. However, the
anterior and posterior segment, measured on the mid-sagittal plane are generally asymmetric & varies greatly in
size ranging 1mm to 6mm with mean 2.57 of anterior & 2.59 of posterior. These measurements match those found
in previous studies. The coefficient of variance for the dimensions of the subarachnoid space is as high as 36.16%,
while that for the dimensions of the spinal cord (transverse & sagittal) are11.08%&13.28%respectively.
Conclusion: The findings presented here, expand our knowledge of morphology of spinal canal and show that a
thecaloscope must be smaller than 3.38 mm in diameter.
Keywords: Subarachnoid space, Dural sac, Spinal canal, MRI
INTRODUCTION
The morphology of the spinal canal content has been
studied since the invention of myelography.
However, most studies have measured the diameters
of the spinal cord only, not the size of the
subarachnoid space. 1- 3 The aim of this investigation
is to detail the dimensions of the subarachnoid space
as a prerequisite for development of an intradural
endoscope for the cervical subarachnoid space. Also a
detailed anatomy of the spinal canal content is of
much importance as it may form a developmental

basis for spinal canal stenosis. Researchers found a
significant correlation between the morphometry of
cervical spinal canal content and the pathological
changes seen in cervical spine. 2-5
So the study is designed to have a composite
knowledge of cervical spinal canal content. The
present study complements the current data on the
morphology of the spinal contents, and in particular,
Khanapurkar et al.,
610
the spinal subarachnoid space, by analyzing MRI

images taken from normal examinations.
Present study is guided by the need to develop
subarachnoid endoscope for its visualization &
treatment. When the review of the literatures has been
taken, we found out that no study has been conducted
on Indian population and also available data was
discreet. So the present study was carried out.
Objective: To study morphology of the dural sac,
spinal cord & subarachnoid space using MRI. To
define the inner geometrical dimensions of spinal
canal content that confine the maneuver of an
endoscope inserted in cervical spine. 3. To have
comprehensive knowledge of the anatomy of cervical
spinal canal.
MATERIALS & METHOD
A study was conducted in Dept of Radiology,
BJGMC. Pune. The data was obtained retrospectively
from normal MRI of 60 patients. A study was carried
on normal MRI images of 60 adult patients, 30 males
and 30 females belonging to a Western Maharashtrian
population. The images have been studied
retrospectively. The patients were ranged in age from
25 to 60 years. The geometrical dimensions of the
dural sac and the subarachnoid space, from the first
cervical vertebra (C1) to the 7th cervical vertebra
(C7), have been measured. Normal vertebral and
intervertebral discs were included, degenerative cases
have been omitted.
The following parameters are studied:
Dimensions of dural sac: Transverse diameter (mm)
of dural sac (DS tra), Sagittal diameter (mm) of dural
sac (DS sag).
Dimensions of spinal cord: Transverse diameter
(mm) of spinal cord (SC tra), Sagittal diameter (mm)
of spinal cord (SC sag).
Dimensions of subarachnoid space (SAS):
Measured from pia mater to arachnoid mater on its
anterior, posterior, right & left lateral region.
Measurements are denoted as: SAS anterior, SAS
posterior, SAS Rt lateral, SAS Lt lat
For each segment, the dimensions have been obtained
at the mid-height of the vertebra and at the level of
the adjacent disc (for example: at the mid-height of
the 4th cervical vertebra C4 and the adjacent
intervertebral disc C4/C5).
MRI imaging, using a 1.5 T Elscint system was
performed on the axial and sagittal planes for each
patient. The dimensions of the spinal cord and the

subarachnoid space were measured on the axial
image. The measurements have been taken at the
mid-sagittal and mid-coronal virtual lines on the
transversal image and they were based on the T2
weighted images, which better delineate the borders
of both the spinal cord and the dural sac.
Mean and range are calculated for each parameter.
Any difference between male and female parameters
is found by applying unpaired t-test.
RESULTS
Table 1: Transverse & sagittal diameter of dural
sac, spinal cord and subarachnoid space (in mm)
(N=60)
Mean SD RANGE
Dural Sac
Sag
13.83 1.65 10.46-18.59
Trans 19.231.76 13.52-24.58
Spinal Cord
Sag
6.9790.92 04.16-10.24
Trans 11.891.31 06.06-15.36
Subarachnoid Ant
2.5780.82 01.07-05.67
Space
Post
2.5980.93 01.12-06.10
Rt lat 3.3820.79 01.47-06.06
Lt lat 3.3810.79 01.47-06.16
Sag: Sagital, Trans: Transverse, Ant: Anterior, post:
Posterior, Rt lat: Right lateral, Lt lat: Left lateral
Table 1 demonstrates the mean, standard deviation of
Transverse &sagittal diameter of dural sac spinal cord
and subarachnoid space.
When the dimensions of subarachnoid space at a
given level are considered we found that there is wide
variation between ant & post diameter ranging
between 1 to 6 mm while the diameters of right & left
side are almost equal.
Fig 1: Showing the dimensions of subarachnoid

space (SAS anterior -4.18mm, SAS posterior
3.05mm, SAS Rt lat-4.55mm SAS Lt lat-4.54mm)
611
Khanapurkar et al.,
Table 2: Dimensions of spinal cord to show

cervical enlargement (in mm)
Level
c1
c2
c2-3
c3
C3-4
C4
C4-5
C5
C5-6
C6
C6-7
C7
Spinal canal sagittal Spinal

canal
diameter
transverse diameter
7.815
11.33
7.685
11.41
7.651
11.46
7.338
11.66
7.222
12.31
7.064
12.73
7.022
12.9
6.908
13.04
6.623
12.67
6.434
11.93
6.102
11.16
5.799
10.29
The sagittal diameter of spinal cord decreases monotonically. The

Transeverse diameter is largest at C5 level & the site of cervical
enlargement is C4-5 to C5.
Table 3: Showing Mean values for subarachnoid spaces

(in mm)
level
c1
c2
c2-3
c3
C3-4
C4
C4-5
C5
C5-6
C6
C6-7
C7
Anterior
2.711
2.929
2.639
2.652
2.278
2.249
2.197
2.332
2.318
2.739
2.652
3.247
Posterior
3.744
3.353
2.584
2.208
2.406
2.42
2.376
2.493
2.338
2.387
2.273
2.681
Rt lat
4.439
4.111
3.767
3.464
3.116
3.001
2.984
3.144
2.833
3.166
3.005
3.555
Lt lat
4.448
4.102
3.762
3.461
3.114
3.002
2.981
3.147
2.833
3.164
3.006
3.556
From the Table-3 it is clear that the right & left lateral
subarachnoid spaces are almost equal, while the
anterior & posterior spaces are asymmetrical.
Dimensions of dural sac: To determine the accuracy
of the measurements of the spinal cord and
subarachnoid space, the dimensions of the dural sac
as a whole were measured. Table 4; illustrates the
transverse and sagittal diameters of the dural sac. The
bulge noted in the cervical spinal cord can be
observed also in the dural sac. But the correlation
between changes in the diameter of spinal cord with
the changes in the diameter of dural sac, is
statistically non-significant (p>0.05).
Table 4: Showing mean values for dural sac
(values in mm)
level
C1
C2
C2-3
C3
C3-4
C4
C4-5
C5
C5-6
C6
C6-7
C7
Sagittal
14.39
13.82
12.58
12
11.51
11.54
11.29
11.45
11.15
11.37
11.14
11.7
Transverse
20.8
20.19
19.7
19.25
18.97
19.31
19.01
19.64
18.97
18.95
17.95
18.06
Table 5: Transverse &sagittal diameter of dural sac, spinal cord and subarachnoid space (in mm) (MALE)
Male
Female
MEAN SD
RANGE
MEAN SD
RANGE
Dural Sac(DS)
Sag
13.671.806
10.460-18.59
12.891.474
9.080-16.68
Trans
19.451.662
15.50-24.58
19.011.833
13.52-23.13
Spinal Cord(SC)
Sag
7.0871.054
4.160-10.24
6.8710.7650
4.930-8.730
Trans
12.071.328
6.060-15.07
11.711.284
7.140-15.36
Subarachnoid
Ant
2.5550.8207
1.070-5.670
2.5520.9458
1.120-5.80
Space(SAS)
Post
2.6430.9318
1.190-6.100
2.6020.8225
1.130-5.140
Rt lat
3.3950.8123
2.270-6.060
3.3690.7801
1.470-5.820
Lt lat
3.3940.8114
2.270-6.160
3.3680.7795
1.470-5.820
When we compared the values for male & female we found out that the values for female are slightly smaller as
compared to males but the difference is statistically insignificant.
612
Khanapurkar et al.,
DISCUSSION
Endoscopic visualization of various anatomical areas
for diagnostic as well as therapeutic purposes is an
everyday expanding field in modern medicine. But
endoscopic visualization of the spinal canal contents
is still limited, partly because of the technical
problems associated with developing a miniature
device that fits into and which can be safely steered
inside the delicate and hazardous area of the spinal
canal and the subarachnoid space in cervical region.
Meeting these challenges requires a thorough
understanding of the spinal canal morphology for
which accurate measurement of its different
compartments is very important.
There have been several studies on the dimensions of
the dural sac, the subarachnoid space, and the spinal
cord. These studies have either been carried out on
cadavers, or have used radiological methods such as
myelography, CT-myelography, and MRI1- 7
The present study complements the current data on
the morphology of the spinal contents, and in
particular, the spinal subarachnoid space, by
analyzing MRI images taken from normal
examinations. These data are essential for designing
intradural instruments such as intradural endoscope
(thecaloscope) and intradural robotic instruments, as
well as for understanding the normal spinal anatomy.
Thijssen et al1 studied morphology of the cervical
spinal cord on computed Myelography, sample size
was 20. They evaluated the subjects for transverse &
sagittal diameter of spinal cord. Thijseen et al study is
correlating well with present study. The decreasing
diameter pattern is identical. The slightly higher side
in Thijssen study may be due to different
methodology and also because of racial differences.
Table
6:
Showing
comparison
between
H.O.M.Thijssen et al1 & present study
Level H.O.M.Thijssen
Present study
Transverse
C1
C2
C3
C4
C5
C6
C7
10.4
10.9
11.3
11.7
11.8
10.5
9.3
Sagittal
Transverse Sagittal
7.2
6.5
6.2
6.0
6.2
6.4
6.8
11.33
11.41
11.66
12.73
13.04
11.93
10.29
7.815
7.685
7.338
7.064
6.908
6.434
5.799
Comparison between the studies demonstrated that

the transverse diameter increases towards the middle
cervical spine and is likewise maximum at C4 and C5
level.
Table 7: Showing comparison between sagittal &
transverse diameters of spinal cord from the study
done by Y.U.Yu et al2 and present study
level Sagittal
Transverse
Ratio
diameter
diameter
(sag/tr)
C2-3
C3-4
C4-5
C5-6
C6-7
C7T1
Yu
Present
et al2 study
Yu present
et al2 study
Yu Present
et al2 study
7.8
7.5
7.1
6.9
6.8
7.0
12.8
13.4
13.8
13.4
12.6
10.9
0.62
0.56
0.52
0.52
0.54
0.66
7.651
7.222
7.022
6.623
6.102
-
11.77
12.48
12.93
12.9
11.24
0.68
0.59
0.54
0.52
0.53
-
Y.U.Yu et al2 studied 36 normal individuals on CAM

for four parameters that is sagittal diameter.
Transverse diameter, area & circularity of spinal
cord.
The pattern of values is identical, the ratio is quite
comparable. Maximum transverse diameter in both
the studies is at C4-5 level.
One can also evaluate the dimensions of the spinal
cord by finding the ratio between the transverse
diameter of the spinal cord and that of the dural
sac8.in our study we found that the ratio(Trans
SC/DS) is 0.65.
Table 8: Showing the comparison between Zaroor
et al6 and present study
Range
Mean
Zaroor etal6
0.44-0.72
0.66
Present study
0.44-0.62
0.65
From the table it is quite evident that the present
study is correlated with Zarror et al study.
Lee et al9 reported that the average sagittal cervical
canal diameter (C3-C7) in 469 cadaver specimen was
14.15+1.6mm, but in the current study, we found that
average sagittal canal diameter (DS) from C1-C7to be
13.83+1.6mm, lesser value in our study is because we
have not taken extradural space measurements. So we
strongly believe that our study correlates with Lee et
al study.
613
Khanapurkar et al.,
Zaroor et al6 stated that the mean of transverse

subarachnoid space is 2.5mm while in our study it is
3.38mm. The observed difference may be attributed
to racial, geographical difference; also inter-observer
error may be the reason.
CONCLUSION
We carefully measured all the parameters from
normal 60 MRI. We found out that the subarachnoid
space in right and left lateral region is symmetrical.
The mean value is 3.38mm. The mean of transverse
and sagittal diameter of dural sac is 19.23mm and
13.83mm resp. also the mean of transverse and
sagittal diameter of spinal cord is 11.89mm and
6.97mm resp.
From the point of view of developing a thecaloscope
or intradural robotic device care should be taken so as
its diameter should not be exceeding that of 3.38mm.
6. Menashe Zaaroor, Gbor Ksa.morphological

study of the spinal canal content for subarachnoid
endoscopy
Minim
Invasive
Neurosurg. 2006;49(4):220-26
7. Okada Y, Ikata T, Katoh Sh, Yamda H.
Morphologic analysis of the cervical spinal cord,
dural sac and spinal canal by magnetic resonance
imaging in normal adults and patients with
cervical
spondylotic
myelopathy.
Spine
.1994;19:2331-35
8. Shapiro R, Myelography. Chicago: Year Book
.Medical Publisher, 1975. 3rd ed 602
9. Yuichiro
Morishita, Masatoshi
Naito.
Relationship between cervical spinal canal
diameter and the pathological changes in the
cervical spine,. Eur Spine J. 2009 ; 18(6): 87783
ACKNOWLEDGEMENT
I sincerely acknowledge my gratitude towards my
colleagues, staff and friends from department of
Anatomy and Radiology.
REFERENCES
1. Thijssen HOM., Keyser A, Horstink MWM,
Meijer E. Morphology of the cervical spinal cord
on computed myelography. Neuroradiology
1979;18:57-62
2. Yu YL, du Boulay GH, Stevens JM, Kendall BE.
Morphology and measurements of the cervical
spinal cord in computer-assisted myelography.
Neuroradiology. 1985;27:399-402
3. Yone K, Sakou T, Yanase M, Ijiri K.
Preoperative and postoperative magnetic
resonance image evaluation of the spinal cord in
cervical myelopathy. Spine, 1992;17:S388-92
4. Inoue H, Ohmori K, Takatsu T, Teramoto T,
Ishida Y, Suzuki K. Morphological analysis of
the cervical spinal canal, dural sac and spinal
cord in normal individuals using CT
myelography. Neuroradiology 1996;38:148-51
5. Fujiwara K, Yonenobu K., Hiroshima K., Ebara
S, Yamashita K, Ono K. Morphometry of the
cervical spinal cord and its relation to pathology
in cases with compression myelopathy. Spine
1988;13:1212-16
614
Khanapurkar et al.,
DOI: 10.5958/2319-5886.2014.00406.8

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Health Sciences
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Volume 3 Issue 3
th
Research Article
Coden: IJMRHS
Copyright @2014
ISSN:2319-5886
th
Accepted: 23rd Apr 2014
A STUDY ON PREVALENCE AND ETIOLOGY OF HEART FAILURE IN QATARI RESIDENTS:

DATA ANALYSIS FROM A TERTIARY HOSPITAL
Barman M, Djamel B.
Department of Cardiology, Al Ahli Hospital, PO Box 6401, Doha, Qatar.
*Corresponding author email: drbarman@yahoo.com
ABSTRACT
Objective: Heart failure is a multi-faceted syndrome with diverse etiologies. Knowledge of the cause can be
crucial to therapy and management including long term strategy planning. The aim of this study is to analyze the
prevalence and etiology of heart failure present in Qatari residents, which is a mix of multiple ethnicities. Qatar is
today one of the leading growing economies of the world and witnessing a population boom. It is currently
undergoing major lifestyle changes, which comes with aplenty due to recently discovered vast natural resources.
Enhanced knowledge of disease incidence/prevalence in the Qatari environment can have a prospect of
developing and evaluating novel and more effective approaches for disease prevention, diagnosis and treatment in
the future. Methods: Our study was conducted in a total of 50 patients over a period of 21 months in a tertiary
care institute. Detailed clinical history, followed by examination and laboratory tests were performed to identify
the etiology and data analyzed to study the prevalence. Results: Our study revealed that in all cases of HF
admitted in our hospital, 52% were males and 48% were females. The occurrence of Congestive Heart Failure
(CHF) was highest between 50 and 80 years in both males and females. The relation of CHF to various etiologies
has been discussed. The data has also been compared with select international studies and the variations
discussed. Conclusion: Major etiology of CHF was a combination of lifestyle disease, Hypertension, Diabetes
Mellitus and Ischemic heart disease. Minor causes included Valvular heart disease, chronic arrhythmias, and
myocarditis and conduction system disease.
Keywords: Heart failure, prevalence, Qatar.
INTRODUCTION
Heart failure can be dened as an abnormality of
cardiac structure or function leading to failure of the
heart to deliver oxygen at a rate commensurate with
the requirements of the metabolizing tissues, despite
normal lling pressures (or only at the expense of
increased lling pressures). Heart Failure is dened,
clinically, as a syndrome in which patients have
typical symptoms (e.g. breathlessness, ankle swelling,
and fatigue) and signs (e.g. elevated jugular venous
pressure, pulmonary crackles, and displaced apex
beat) resulting from an abnormality of cardiac
structure or function.1 Heart failure is a common and

major health problem worldwide that continues to
increase in both prevalence and incidence. It is a
frequent cause for hospitalization. It is a multi-faceted
syndrome with diverse etiologies.2 Knowledge of the
cause can be crucial to therapy. Improving the
reliability of diagnosis has been essential since
determining the etiology and the stage of heart failure
leads to different management choices to improve
symptoms, quality of life and disease prognosis.
Barman et al.,
Int J Med Res Health Sci. 2014;3(3): 615-620
615
The overall incidence of heart failure is likely to

increase in the future, because of both an aging
population and therapeutic advances in the
management of acute myocardial infarction leading to
improved survival in patients with impaired cardiac
function. The epidemiology of heart failure has been
extensively investigated, but the etiology of heart
failure in a contemporary population remains
incompletely described.3, 4
Aims and objectives
To systematically analyze the predisposing,
determining and precipitating causes exacerbating
Congestive Heart Failure (CHF).
1. To identify the most common etiology of CHF on
the basis of clinical assessment, non-invasive
investigations and coronary angiography.
All cases of CHF satisfying the European Society of
Cardiology's (ESC) diagnostic criteria for heart
failure admitted in the Intensive Coronary Care Unit
(ICCU) unit of a tertiary hospital & research center in
Qatar were included in the study.
The present study was undertaken from October 2011
to June 2013. A total of 50 patients >16 years of age
were selected for this study. Detailed clinical history
of patients was recorded. This was followed by a
detailed clinical examination and laboratory tests.
A master chart was prepared with the requisite
variables to analyze the etiology of CHF.
Laboratory testing (Done in all patients): Complete
Blood Picture (CBP), Erythrocyte Sedimentation Rate
(ESR),
Blood Sugar, Serum Urea, Serum Creatinine,
Electrolytes, Protein, Liver Function Tests (LFT),
Lipid and Thyroid Profile, Cardiac Biomarkers, B
natriuretic peptide BNP/Pro BNP, Chest X-ray (PA
view),
ECG
(12-lead
multi-channel),
2D
Echocardiograph,
The following definitions were used in the study:
Heart failure can be dened as an abnormality of
cardiac structure or function leading to failure of the
heart to deliver oxygen at a rate commensurate with
the requirements of the metabolizing tissues, despite
normal lling pressures (or only at the expense of
increased lling pressures). HF is dened, clinically,
as a syndrome in which patients have typical
symptoms (e.g. breathlessness, ankle swelling, and
fatigue) and signs (e.g. elevated jugular venous
pressure, pulmonary crackles, and displaced apex

beat) resulting from an abnormality of cardiac
structure or function.1
Coronary artery disease (CAD): Clinical history of
myocardial infarction (anterior/lateral/inferior/right
ventricular), ECG Abnormalities, Echo evidence of
Regional Wall Motion Abnormality (RWMA) or
angiographic confirmation of CAD.
Hypertension (HTN) - ESC and ESH Guidelines
(23)
Diabetes Mellitus (DM), ESC and EASD Guidelines
(24)
Smoking: The subject was considered to be a smoker
if he/she gave a history of tobacco smoking within
the past 20 years. Subjects who had quit smoking
completely before 20 years were not considered as
smokers.
Alcohol Consumption: Only patients who were
heavy drinkers were considered. > 15 drinks/week in
men or > 8 drinks/week in women
Dyslipidemia: Criteria may include documentation
of the following Total cholesterol > 5.2 mmol/l,
LDL >3.3mmol/l, HDL <1.03mmol/l, Triglycerides
>1.5 mmol/l or use of lipid-lowering therapy.
Family History: Included those who exhibited the
following family history of sudden cardiac death,
myocardial infarction/angina/HF, premature CAD
(<55 years for male relatives and <65years for female
relatives), cardiomyopathy (Dilated Cardiomyopathy
DCM)
/
(Hypertrophic
Obstructive
Cardiomyopathy HOCM) or pacemaker
insertion/conduction system disease.
Valvular heart disease: History of Rheumatic Heart
Disease (RHD) with echocardiographic evidence of
valvular abnormalities or history of congenital and
degenerative valvular disease.
Arrhythmias: Patients who had clinical and ECG
evidence of arrhythmias such as atrial fibrillation,
paroxysmal supraventricular tachycardia, ventricular
tachycardia or ventricular fibrillation.
Anemia: Defined as blood hemoglobin level <12 g%
for men or 11 g% for women.
Drug related: On treatment with -blockers, calcium
channel blockers, NSAIDS, steroids, anti-arrhythmic,
tricyclic antidepressants, chemotherapeutic agents.
Obesity: Body Mass Index (BMI) of 30 or greater
was considered clinically obese.
616
Barman et al.,
RESULTS
Agesex distribution of CHF
Of the total study population of 50; 26 [52%] were
males and 24 [48%] were females. The study
population was divided into 7 age intervals ranging
from 21 to 90 years. The occurrence of CHF was
highest between 50 and 70 years in both males and
females. 64% patients were between 50 and 80 years
and nearly 22% were between 20 and 50 years. 14%
were above 80 years.
Acute/chronic distribution of heart failure with
age distribution
33 (66%) i.e. nearly 2/3 presented with acute heart
failure and 17 (34%); i.e. rest of the 1/3rd had chronic
heart failure. Of the 33 patients with acute heart
failure, acute coronary syndrome was seen in 4 (12%)
patients, CAD causing acute LVF was in 7 (21%) and
acute on chronic HF was seen in 8 (24%) patients.
Out of the 17 patients with chronic heart failure, 9
[53%) were females and 8 (47%) were males.
Majority of the males, nearly 78% with acute heart
failure were between 50 and 80 years. Majority of the
females, nearly 75% with acute heart failure were
also between 50 and 80 years. In the 7190 age
interval, the distribution of acute and chronic heart
failure were nearly equal in both males and females.
Major etiologies of CHF
Among this study population of 50, major etiology of
CHF was a combination of IHD, HTN and DM
accounting for nearly 90% of cases. There was
presence of significant overlap between HTN, CAD
and DM. The etiologies have been sub grouped into
three groups according to prevalence. Group 1 being
the most prevalent and Group 3 the least. [Figure1]
The etiology wise distribution has been given below
in Table 1.
Table 1: Etiology wise distribution of congestive

heart failure patients.
Group
No.
Etiology
Group 1
a
b
c
a
b
HTN
CAD
DM
ValvularHeart Disease
Conductive
disorder[LBBB/IVCD]
Dilated
Cardiomyopathy
Corpulmonale
Others, Myocarditis
Group 2
c
Group 3
a
b
No. of
patients
32
27
19
4
2
1
1
2
2
64
54
38
8
4
Multi factorial etiology of CHF

There was significant overlap of patients having
CAD, HTN and DM. Patients having
multifactorial etiologies were commoner than
single etiology patients Table 2 and Fig 2
Table 2: Prevalence of multifactorial etiology in
CHF patients
Etiology
DM + HTN + CAD
HTN + CAD
DM + HTN
DM + CAD
Isolated CAD
Isolated HTN
Isolated DM
No. of patients
21
16
15
12
0
12
0
Percent [n=50]
42
32
30
24
0
24
0
Fig 2: Multifactorial etiology of heart failure.
Fig 1 : Etiology wise distribution of congestive heart

failure patients (Overlap exists).
Other causes of CHF form a large number in our

study. Among them were
a) Valvular Heart disease 4 patients
b) Arrhythmias [AF] 3 patients
Barman et al.,
617
Heart failure is a multi-faceted syndrome with

multiple etiologies.2 In some cases, the etiology
remains hypothetical or undefined. The diseases that
can lead to HF are very different and their detection is
of great importance as this can modify the diagnostic,
therapeutic and preventive approach as well as
determine prognosis.
Data from the Framingham study indicate that the
incidence of congestive heart failure increases with
age and is higher in men than in women as also seen
above in this study.6 Galasko et al in his study found
that the final primary etiology for definite Left
Ventricular Systolic Dysfunction (LVSD) was CAD
in 68% which is close to 54% seen in the present
study.7,8
The most interesting feature of this study was that
multifactorial cause was the commonest etiology for
CHF with HTN being the single commonest etiology,

contributing to 64% of cases of heart failure.
In the Framingham study, CAD and HTN (either
alone or in combination) were implicated as the cause
in over 90% of cases of HF.6 In the Hillingdon heart
failure study, in which etiology has been allocated on
the basis of non-invasive investigations, coronary
artery disease was identified as the primary etiology
in 36% cases of HF.9 In a study based upon 31 reports
on heart failure, Teerlink et al reported 50.3% of the
cases to be due to CAD.10 Eriksson et al found 54%
to have sustained MI or have angina pectoris.11 In a
prospective study of 730 consecutive patients in a
Chinese population of Hong Kong by Sanderson et al,
the main identifiable risk factors were HTN (37%),
IHD (31%), Valvular Heart Disease (15%),
Corpulmonale (27%), Idiopathic DCM (4%) and
miscellaneous (10%).12 In a study by Mair et al, the
principal etiology was CAD in 45.1%; HTN in
18.0%; Valvular heart disease in 9%; Corpulmonale
in 6.6%; cardiomyopathy in 2.3%; metabolic in 1.9%
and unknown etiology in 16.9% of patients.13
In a population-based study by Cowie et al, the single
most common etiology was coronary artery disease
(36%); but this frequently co-existed with
hypertension (44%).7 Valvular heart disease was
present in 7% of cases. In 34% of cases, no etiology
could be allocated on the basis of clinical and
echocardiographic evidences. In a study of etiology
of heart failure in Arab population by Agarwal et al,
the common causes of heart failure were Ischemic
Heart Disease (51.7%), Hypertensive Heart disease
(24.9%) and idiopathic dilated cardiomyopathy
(8.3%). Valvular heart disease and Corpulmonale
were less common.14
In the Framingham study, CAD accounted for only
46% of heart failure in men and 27% of chronic heart
failure cases in women.6 In a population-based
surveillance study from Eastern Finland by Remes
et al, CAD was found in 68% men and 32% of
women.15
The concept of multiple risk factors well established
for CAD is increasingly being applied for CHF. The
present study found that following HTN, IHD was the
leading factor accounting for 54%, while 38% of the
population were diabetic. However, they are not
mutually exclusive.
The Framingham study, which defined the major risk
factors found that coronary risk factors such as
Barman et al.,
c) Conduction disorder , LBBB/IVCD 2

patients
d) Myocarditis 1 patient
e) Cardiomyopathy 4 patients
Co morbid factors for CHF: Our study
revealed a few Co morbid factors which were not
direct causes of CHF but were additional risk
factors (table 3)
Table 3: Co morbid risk factors for CHF.
Risk factor
Obesity
(BMI > 30)
Family History
Smoking
Dyslipidemia
Value
33
Percent [n = 50]
66
12
14
17
24
28
34
Acute precipitants of CHF

In this study population, the major acute
precipitant of CHF was acute Myocardial
Infraction (MI). The remaining causes are as
detailed in table 4. In many patients, more than
one precipitating cause was implicated
Table 4: Distribution of acute precipitants of
heart failure in study population.
Precipitants
ACS
Uncontrolled
HTN
Infection
Arrhythmias
Value in population (n = 50)

Value
4
12
Percentage%
8
24
9
3
18
6
DISCUSSION
618
smoking, DM, body weight and a high ratio of total

cholesterol concentration of high-density lipoproteins
are independent risk factors for HF.6 The
INTERHEART study showed potentially modifiable
risk factors accounting for over 90% of the risk of an
initial acute MI.16 In a study by Wilhelm Sen et al, it
was reported that the strong resemblance between the
risk factor pattern in heart failure& CAD seems to be
due to the high percentage with coronary heart
disease.17 The findings in our study that high blood
pressure, tobacco smoking, DM and a higher BMI
were risk factors are well in accordance with previous
results in other populations.
In this study, among the 33 patients who were
obese (BMI > 30) 16 were males and 17 were females
and the majority were was between 51 and 70 years.
Various studies have recognized obesity to be a risk
factor for heart failure. It is unclear whether
overweight individuals are at risk of heart failure. The
Framingham study identified a greater predictive
value of obesity in women.6 In a large communitybased study by Kenchaiah et al, increased BMI was
associated with an increased risk of heart failure.18
Increased BMI is a risk factor for HTN, DM and
dyslipidemia, all of which augment the risk of MI, an
important antecedent of heart failure.
In the present study, 64% of the patients had
hypertension; among them 61% were males and 39%
were females. In the Framingham heart study,
hypertension was reported as the cause of heart
failure either alone or in association with other factors
in over 70% cases.6 In the SOLVD trials, women
were more likely to have concomitant hypertension
than men.19 The MRFIT trial supports the idea that
the presence of hypertension indicated by systolic
BP > 140 mm Hg increases the risk of CAD by about
2.5 times.20
In the present study, 38% were diabetics. Among
them, 20% were males and 18% were females.
Majority of them were between 51 and 70 years.
Sanderson et al reported 21% diabetes in a study
population of 730 patients.12 Data from the
Framingham study have shown an increased
incidence of congestive heart failure in diabetic
subjects irrespective of CAD and hypertension.6 In
the SOLVD study, diabetes was an independent
predictor of morbidity and mortality in heart failure.19
This relationship was confirmed by the RESOLVD
trials. In the DIGAMI study, diabetes with heart
failure was the most common reason for morbidity

and mortality.21 Recent Italian cross sectional data
shows 30% prevalence of diabetes in an elderly heart
failure population.22
In the present study, valvular heart disease accounted
for 8% of which (50%) were females. The SOLVD,
Framingham and hospital-based studies report a
predominance of women with valvular heart disease.6,
19
However, the incidence of valvular disease has
been steadily decreasing over the past 30 years. In the
Framingham study, RHD accounted for heart failure
in 2% of men and 3% of women.6 In a study by Mair
et al, valve disease was an etiology in 9% of cases.13
Sanderson et al reported 15% of valvular heart
disease in a prospective study of 730 patients.12 In a
study by Fox et al, valvular disease was reported in
9.6 %.3
In the present study, all patients were assigned
etiology on the basis of clinical data, laboratory data,
ECG, Echo and coronary angiography.
Barman et al.,
CONCLUSION
Multiple risk factors such as Hypertension, Ischemic
Heart Disease and Diabetes Mellitus are the leading
causes of Heart Failure in this study. The concept of
multiple risk factors, well established for coronary
artery disease should be increasingly applied to
primary and secondary heart failure prevention. HTN
causing heart failure was the major etiology
amounting to 64%. In patients where etiology is
unknown and who have multiple risk factors, the
probability of CAD is high; hence coronary
angiography needs to be done. Our study also
provides enough research databases, for a
comprehensive array of laboratory-based research
aimed at an improved understanding of disease
mechanisms, treatment initiation and implementation.
Funding- None.
Competing interests None
REFERENCES
1. ESC Guidelines for the diagnosis and treatment
of acute and chronic heart failure 2012. European
Heart Journal. 2012;33, 17871847
2. Tavazzi L. Towards a more precise definition of
heart failure aetiology. Eur Heart J. 2012;22;19295
619
3. Fox KF, Cowie MR, Wood DA. Coronary artery

disease as the cause of incident heart failure in
the population. Eur Heart J.2001;22:22836
4. Klatsky AL,Sharon RN, Udaltsova Natalia. Heart
failure etiology is usually pluricausal whether or
not
there
is
associated
coronary
disease. Permanente J. 2007;11:1318
5. Kenchaiah S, Narula J, Vasan RS. Risk factors
for
heart
failure. Med
Clin
North
Am. 2004;88(5):114572
6. McKee PA,
Castelli WP,
McNamara PM,
Kannel WB. The natural history of congestive
heart failure; the Framingham study. N Engl J
Med. 1971;285:144146
7. Cowie MR, Wood DA, Coats AJ. Incidence and
etiology of heart failure: a population study. Eur
Heart J. 1999;20:42128
8. Galasko GIW,
Senior R,
Lahiri A. Ethnic
differences in the prevalence and etiology of left
ventricular systolic dysfunction in the
community:
the
Harrow
heart
failure
watch. Heart. 2005;91:595600
9. Lip GYH, Gibbs CR, Beevers DG. Abc of heart
failure:
history,
epidemilogy,
aetiology. BMJ. 2000;320:10407
10. Teerlink JR, Goldhaber SZ, Pfeffer MA. An
overview of contemporary etiologies of
congestive
heart
failure. Am
Heart
J.1991;121:185253
11. Eriksson H, Svarsudd K, Larsson B. Risk factors
for heart failure in the general population: the
study of men born in 1913. Eur Heart
J. 1989;10:64756
12. Sanderson JE, Chan SK, Chan WW, Hung YT,
Woo KS. The aetiology of heart failure in the
Chinese population of Hong Kong a
prospective study of 730 consecutive patients. Int
J Cardiol. 1995;51(1):2935
13. Mair FS, Crowley TS, Bundred PE. Prevalence
aetiology and management of heart failure in
general practice. Br J Gen Pract. 1996;46:7779
14. Agarwal AK,
Venugopalan P,
de
Bono D. Prevalence and aetiology of heart
failure in an Arab population. Eur J Heart
Fail.2001;3(3):30105
15. Remes J,
Reunanen A,
Aromaa A,
Pyorala K. Incidence of heart failure in Eastern
Finland; A population-based surveillance study.
Eur Heart J. 1992;13:58893
16. Cleland JGF. Heart failure: a Systematic Guide to
Clinical Practice. London: Science Press; 1997;123
17. Wilhelmsen ,
Rosengren A,
Eriksson H,
Lappas G. Heart Failure in the general population
of men; morbidity, risk factors and prognosis. J
Intern Med. 2001;249:25361
18. Kenchaiah S, Evans JC, Levy D. Obesity and the
risk
of
heart
failure. N
Engl
J
Med. 2002;347;305-13
19. Limacher M,Rousseau M. Clinical characteristics
of patients in studies of ventricular dysfunction
(SOLVD). Am J Cardiol. 1992;70:894900
20. Fonseca C. Diagnosis of heart failure. Heart Fail
Rev. June, 2006;11(2): 95-107.
21. Solang L,
Malmberg K,
Ryden L. Diabetes
mellitus and congestive heart failure further
knowledge needed. Eur Heart J. 1999;20:78979
22. The SEOSI Investigators. Survey on heart failure
in Italian hospital cardiology units. Eur Heart
J. 1997;18:1457-64
23. Mancia G, De Backer G, Dominiczak A, Cifkova
R, Fagard R, Germano G. 2007 Guidelines for the
management of arterial hypertension: The Task
Force for the Management of Arterial
Hypertension of the European Society of
Hypertension (ESH) and of the European Society
of Cardiology (ESC). European Heart Journal
2007;28:1462-1536
24. Guidelines on diabetes, pre-diabetes, and
cardiovascular diseases: executive summary. The
Task Force on Diabetes and Cardiovascular
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Study of Diabetes (EASD): European Heart
Journal. 2007;28:88-136
Barman et al.,
620
DOI: 10.5958/2319-5886.2014.00407.X

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 13 Jun 2014
Research Article
ROLE OF EARLY CLEAVAGE IN PREDICTING SUCCESS OF INTRA CYTOPLASMIC SPERM

INJECTION IN ASSISTED REPRODUCTIVE TECHNOLOGIES
*Manjula Gopalakrishnan1, Sanjeeva Reddy Nellapalli2, Muthiah sinvaniah surulimuthu3
1
Embryologist, 2Professor & Head, Department of Reproductive Medicine, Sri Ramachandra University, Chennai
3
Embryologist, Kanmani Fertility clinic, Chennai
*Corresponding author email: manjuladaniel2000@yahoo.co.in, manjula2000srmc@gmail.com
ABSTRACT
Aim and Objective: The present study is aimed to carry out the impact of early cleavage over late cleavage in
assessing the pregnancy outcome using of Intra Cytoplasmic Sperm Injection (ICSI) in assisted reproductive
technologies. Materials and Methods A total of 154 patients enrolled for Intra Cytoplasmic Sperm Injection
(ICSI) fulfilling the selection criteria were recruited for the study at a tertiary care assisted reproductive centre.
ICSI was performed 35 h after oocyte aspiration with the prepared sperm. All embryos were checked for early
cleavage at 27 hours post intra cytoplasmic sperm injection. They were divided into two groups. Group IEmbryos which cleaved before 27 hours after Intra Cytoplasmic Sperm Injection (ICSI). Group II- Embryos
which cleaved after 27 hours. The pregnancy rates were compared between the two groups. Results: All the 154
patients were analysed. There was no difference in the mean age, duration of ovarian stimulation, number of
oocytes retrieved, fertilization, cleavage rates and embryo quality between the two groups. Early cleavage was
observed in 98 patients (63.64 %). Late cleavage was observed in 56 patients (36.36%). The clinical pregnancy
was confirmed in 59 patients (60.20%) in Group I and 20 patients (35.71%) in Group II which was statistically
significant P <0.001. Conclusion: Early cleavage is a strong predictor of embryo quality and can predict ICSI
outcome.
Keywords: Clinical pregnancy, Early cleavage, Embryo quality, Intracytoplasmic sperm injection, Ovarian
stimulation.
INTRODUCTION
Assisted reproductive technology (ART) is a general
term referring to methods used to achieve pregnancy
by artificial or partially artificial means. All
treatments or procedures that include the in vitro
handling of both human oocytes and sperms or of
embryos for the purpose of establishing a pregnancy.
It is a reproductive technology used primarily in
infertility treatments. Different methods of embryo
transfer have been followed in this treatment are fresh
embryo transfer and frozen embryo transfer.
Manjula et al.,
The success of assisted reproductive technologies

(ART) depends primarily on the quality of the
embryos transferred and endometrial receptivity.
Routinely the selection of embryos for transfer is
based on embryo morphology and developmental
stage. Sometimes, implantation may not occur after
transferring good quality embryos to a receptive
endometrium.1 Other methods of selection of
embryos include pronuclear morphology, oocyte and
pronuclear polarity, blastomere symmetry and
blastocyst culture.2 Pronuclear zygote morphology
621
may vary during the dynamic process of syngamy.3

According to previous studies, selection of embryos
on the basis of cell number and quality at the time of
transfer is of more significant benefit.4 Other
morphological features such as variation in zona
thickness and the presence of multinucleated
blastomeres have also been affect the implantation
and pregnancy.5 Some authors scored blastocyst on
the basis of inner cell mass and trophectodermal cells
and selecting high quality blastocyst, which leads to
higher pregnancy and implantation rates.6 Several
biochemical methods have been used to assess the
human embryo quality, such as O2 consumption,
pyruvate uptake, glucose uptake, lactate production
and secretion of platelet-activating factor production
or amino acid turnover.7 These procedures are all
more complex and time-consuming and it is very
difficult to follow in routine practice. There is still a
need for an easy, simple, and more efficient method
of viable embryo selection. A recent study showed
that assessment of the time of cleavage to the two cell
stage was a reliable parameter for the selection of
embryos with the highest capability of implantation
and successful pregnancy after transfer.8 The aim of
the present study was done to evaluate the impact of
early cleavage over late cleavage in assessing
pregnancy outcome using Intra Cytoplasmic sperm
injection.
It was a prospective observational study conducted in
the Department of Reproductive Medicine, at a
tertiary care centre from Oct 2010-May 2012. A total
of 154 patients who underwent Intra Cytoplasmic
Sperm Injection (ICSI) were included in the study in
the age group of 21-45 years. Inclusion criteria: All
patients enrolled for ICSI during this study period
were included in the study. The patient has only early
cleavage embryos and the patient having only late
cleavage embryos for transfer were included in the
study. Exclusion criteria: Patient having both early
and late cleavage embryos for transfer was excluded
from the study. Informed consent was taken before
the enrollment of each participant and the
Institutional ethical committee approval was obtained
(IEC/10/JULY/83/29).
Two stimulation protocols were used in this study;
The A gonadotropin-releasing hormone (GnRH)
agonist protocol- A gonodotropin releasing hormone
agonist is an analogue that activates the receptors

resulting in increased secretion of Follicle stimulating
hormone (FSH), Luteinizing hormone (LH). The
GnRH antagonist protocol -A gonadotropin-releasing
hormone antagonist is an analogue that blocks the
GnRH receptor resulting in an immediate drop in
gonadotropin (FSH, LH). In the GnRH agonist
protocol, pituitary down regulation was done with
GnRH agonists. Once the patient was down regulated
completely (had menses, E2 <30 pg/ml) gonadotropin
injections
(recombinant
follicle
stimulating
hormone/human menopausal gonadotropin) were
given until the day of hCG administration. The doses
were adjusted according to the patient's ovarian
response. In the GnRH antagonist protocol, without
down regulation gonadotropin injections were
administrated daily from the second day of the
menstrual cycle. The doses were adjusted according
to the patient's individual ovarian response. Once the
dominant follicle reached 14 mm in mean diameter,
GnRH antagonist was administered subcutaneously at
a dose of 0.25 mg daily until the day of hCG
administration. In both groups, ovulation was induced
by the administration of either recombinant h CG or
urinary h CG when at least two follicles reached 18
mm in diameter, and oocyte retrieval was performed
3436 hours later. Oocytes were retrieved
transvaginally under ultrasound- guidance. Motile
sperms were isolated by a swim-up or gradient
centrifugation.
Ejaculated,
testicular
biopsy;
cryopreserved ejaculated and cryopreserved testicular
biopsy semen specimens were all included in the
study. Intra Cytoplasmic Sperm Injection (ICSI) was
performed 35 h after oocyte aspiration with the
prepared sperm. Normal fertilization was confirmed
by the presence of two pronuclei and two polar
bodies 1620 h (day1) after Intra Cytoplasmic Sperm
Injection (ICSI). Normally fertilized oocytes
(Zygotes) were spherical and had two polar bodies
and two PNs. PNs had approximately the same size,
centrally positioned in the cytoplasm with two
distinctly clear, visible membranes. The presence of
nucleolar precursor bodies, their number and size
aligned at the PN junction were assessed. On the
same day, early cleavage examination was performed
on the zygotes within 27 hours after Intra
Cytoplasmic Sperm Injection
(ICSI). Embryos displaying two cells at inspection
were designated as 'early cleavage'. The embryos that
622
Manjula et al.,
had not yet cleaved to the 2-cell stage after 27 hours

were designated as 'late cleavage'. Two or three
embryos were transferred on Day2 depending on the
patients age and embryo quality. The embryos that
were not transferred were cryopreserved. The luteal
phase was supported by vaginal supplementation of
progesterone or intramuscular injection of
progesterone.
Pregnancy was determined by a serum human
Chorionic Gonodotropin ( h CG) test 14 days post
transfer. The clinical pregnancy was confirmed by the
presence of an intrauterine gestational sac with fetal
cardiac activity by ultrasound examination at 4 weeks
after embryo transfer. Patients were divided into two
groups. Group I- Embryos which cleaved to two cells
before 27 hours after injection. Group II- Embryos
which cleaved to two cells after 27 hours. The
pregnancy rates were compared between the two
groups.
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. For the numerical data nonparametric
MannWhitney U test was used to find the
significance. To find the significance in categorical
data Chi - Square test was used. In all the statistical
tools, the probability value of p<0.05 was considered
as significant level.
RESULTS
A total of 154 patients were analyzed. The baseline
characteristics were shown in (Table1). About 65% of
the patients were in the age group of 26-35 years.
Early cleavage was observed in 98 patients (63.64 %)
and late cleavage was observed in 56 patients
(36.36%) (Table 1). In our study 71.78% of MII
oocytes retrieved in the early cleavage and 28.22% in
the late cleavage group (P<0.0001) (Fig 1). The
results showed that the good quality embryos were
significantly higher in the early cleavage group than
in the late cleavage group (78.30% vs. 21.70%)
(P<0.0001) (Fig 2). The transfer of early cleavage
embryos resulted in a significantly higher pregnancy
rate than those with late cleavage embryos. (66.33%
vs. 39.29%) (p<0.001) (Fig 3) The clinical pregnancy
was confirmed in 60.20% in the early cleavage group
and 35.71% in the late cleavage group which was
statistically significant p <0.001. (Fig 4)
Table 1: Baseline Characteristics

Parameters
Mean Age
(years)
Mean Duration of
Infertility (years)
No of oocytes
retrieved
No of MII
Oocytes retrieved
No of Grade I
Embryos
No of patients
Early Cleavage Late Cleavage

(Group I)
(Group II)
31 4
32 5
7 4
8 5
15 8
11 8
12 7
8 7
7 5
98 (63.64 %)
4 4
56 (36.36%)
Fig 1: Comparison of early cleavage and late

cleavage with No. of MII oocytes retieved
Fig 2: Comparison of early cleavage and late

cleavage with good quality embryo
623
Manjula et al.,
Fig 3: Pregnancy rate in early cleavage and late

cleavage group.
Fig 4: The clinical pregnancy rate in early

cleavage and late cleavage group.
DISCUSSION
In the present study , the effect of the early cleavage
of transferred embryos were evaluated aiming to
increase the pregnancy rate and prevent multiple
pregnancies.In the previous studies, transfer of more
embryos has been the approach to increase pregnancy
rates. However, this also increases the multiple
pregnancy with increased medical risks, cost to the
patient and society1. Some authors they found that the
selection of embryos at the time of transfer based on
cell number and quality was more benefit.4- 6 Good
quality embryos must exhibit appropriate kinetics and
synchrony of cell division10. In normal-developing
embryos, cell division occurs in every 1820 h. If
we observed a group of four cell embryos at the time
of transfer, it was not possible to distinguish which
has just cleaved to the four cells or which has been at
the four cells for several hours. Hence, selection of
the more advanced embryo was difficult to assess.4- 6
Cleavage stage embryos range from the 2-cell to the
compacted morula composed of 816 cells.10
The types of cleavage on day 3 embryos were

classified according to blastomere number as rapid
cleavage (>9 cells), normal cleavage (7-8 cells), or
slow cleavage (<6 cells). On the basis of quality of
embryos on day 3 were classified as good embryos
(<20 % fragmentation and an even blastomere) or
poor embryos (>20% fragmentation and an uneven
blastomere).15 Embryos which are dividing either too
slow or too fast may have metabolic and/or
chromosomal defects.10 Recent time-lapse studies
found that not only the timing of cleavage, but also
the time between each cell division is also important.
In cleavage stage embryos if all blastomeres divide in
exact synchrony, only 2-, 4- or 8-cell embryos would
be observed. However, we frequently observed 3-, 5-,
6-, 7- or 9-cell embryos, which is an indication of
asynchronous development of embryos.10 Some
authors found that implantation increased fourfold in
embryos with low glycolytic activity.1 Selection of
embryos by pronuclear assessment has some
drawbacks. Accurate pronuclear assessment needs
considerable manipulation of zygotes outside the
incubator8. According to some studies the blastocyst
transfer has been successfully used as a means of
embryo selection. It is not in routine use because of
lack of experience in prolonged embryo culture, as
well as anxieties about those patients whose embryos
arrest before blastocyst formation8. Although several
factors influence the result of an assisted reproductive
technology (e.g. stimulation response, endometrial
receptivity, oocyte maturity, culture conditions),
embryo quality is also one of the most important
factors9. More recently they showed the assessment
of the time of cleavage to the two cell stage was a
reliable parameter for the selection of viable embryos
with the highest capability of implantation and
successful pregnancy after transfer8. The early
cleaving embryos give rise to better embryo quality
due to intrinsic, unknown factor within the oocyte.
This unknown factor improves the viability of
embryos.1,4,7 One of the possible important
mechanisms of delaying cleavage may be delayed
fertilization. Oocyte immaturity is the most important
factor responsible for delayed fertilization. Since only
metaphase II oocytes were injected in Intra
Cytoplasmic Sperm Injection (ICSI) procedure, the
possibility of oocyte immaturity was eliminated in the
present study. Although there may a difference in
fertilization time between In vitro fertilization (IVF)
624
Manjula et al.,
and Intra Cytoplasmic Sperm Injection (ICSI), there

seems to be no correlation between the time of
fertilization and cleavage1. Semen parameters may
also affect fertilization and cleavage time.1 Different
morphological abnormalities of the oocytes caused by
the reduced blood supply of the follicle during
stimulation resulting in oxygen deficiency leads to
reduced viability.3 In our present study, we observed
that a significantly higher number of early cleaving
embryos became good quality embryos (Fig 2) and
indicating an indirect way of selecting the best quality
viable embryos. Several other studies have also
strongly supported this approach and showed the
value of early cleavage as a marker of embryo
viability.5,7,11 In the recent study they found
significantly more embryos in the best category
showing signs of early cleavage (51.1%) compared
with the Non-early cleavage (38.7%) .13 A number of
reports have been published and found that the
transfer of an early cleavage embryo resulted in a
significantly higher pregnancy rate.5, 11, 12 The results
from our study were similar to these reported studies
(Fig 3). We did not transfer mixed early cleavage
embryos and late cleavage embryos together in order
to evaluate the outcome of early cleavage clearly.
One of the recent studies supported this approach15.
Many articles in the literature deal with the
importance of early cleavage to improve embryo
selection before transfer and help to reduce multiple
pregnancies13. In the previous study, they found the
clinical pregnancy rate was significantly higher in the
early cleavage group than in late cleavage group14. In
the present study, we investigated that a significantly
higher pregnancy rate and the clinical pregnancy rates
when early cleaved embryos were transferred
compared with late cleavage embryos. (66.33 versus
39.29% and 60.20 versus 35.71% respectively). (Fig
3 and Fig 4).Our data strongly support the previously
published studies dealing with early cleavage.5, 11, 14
So from our study the assessment of early cleavage
seems to be a simple, easy, non invasive, effective
and valuable method of assessing the embryo
viability with higher clinical pregnancy rate.
CONCLUSION
In conclusion the assessment of early cleavage is a
strong predictor of embryo quality and can predict
ICSI outcome. Therefore, early cleavage criteria can
be included for selecting embryos with a higher
potential of implantation and successful pregnancy

while avoiding multiple pregnancies.
ACKNOWLEDGEMENTS
Sincere thanks to the Faculty and staffs of the Dept of
Reproductive Medicine, Sri Ramachandra University,
Chennai, India. Special thanks to Dr. P.
Venkatachalam, Dept of Human Genetics, Sri
Ramachandra University.
REFERENCES
1. IsiklarA, MercanR, Balaban B, Alatas C.Aksoy
S, and Urman B. Early cleavage of human
embryos to the two-cell stage. A simple effective
indicator of implantation and pregnancy in
intracytoplasmic sperm injection. J Reprod Med
2002; 47: 540
2. Windt ML, Kruger TF, Coetzee K, Lombard CJ.
Comparative analysis of pregnancy rates after the
transfer of early dividing embryos versus slower
dividing embryos. Hum Reprod 2004; 19:115562
3. Ebner T, Moser M, Sommergruber M, Tews G.
Selection based on morphological assessment of
oocytes and embryos at different stages of
preimplantation development: a review. Human
reproduction update. 2003;9:251
4. Denny Sakkas D, Youssef shoukir, Didier
Chardonnens, Patrizia Grace Bianchi, and Aldo
Campana. Early cleavage of human embryos to
the two-cell stage after intracytoplasmic sperm
injection as an indicator of embryo viability.
Hum Reprod1998; 13: 182-87
5. Andres Salumets, Christel Hyden-Granskog,
Sirpa Makinen, Anne-Maria Suikkari,Aila
Tiitinen and Timo Tuuri. Early cleavage predicts
the viability of human embryos in elective single
embryo
transfer
procedures,
Human
Reproduction2003; 4: 821
6. Sakkas D. Assessment of early cleaving in vitro
fertilized human embryos at the 2-cell stage
before transfer improves embryo selection. Fertil
Steril 2001;76: 1150
7. Shoukir Y, Campana A, Farley T, Sakkas D.
Early cleavage of in-vitro fertilized human
embryos to the 2-cell stage: a novel indicator of
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embryo quality and viability. Hum Reprod

1997;12:153136
8. Bos-Mikich, ALG Mattos, Ferrari AN. Early
cleavage of human embryos: an effective
method for predicting successful IVF/ICSI
outcome. Human reproduction 2001;12:2658-61
9. Jing Fu & Xian-Jing Wang & Yong-Wei Wang
& Jian Sun &Kristina Gemzell-Danielsson &
Xiao-Xi Sun. The influence of early cleavage
on embryo developmental potential and
IVF/ICSI outcome J Assist Reprod Genet
2009;26:43741
10. Fernando J. Prados, Sophie Debrock, Josephine
G. Lemmen,and Inge AgerholmThe cleavage
stage
embryo
Human
Reproduction,
2012;No.S1:. i50i71
11. K. Lundin ,C. Bergh and T.Hardarson Early
cleavage is a strong indicator of embryo quality
in human IVF Human reproduction 2001;12:
2652
12. Fancsovits.P, Toth .L, Takacs.F, Murber.A,
Papp.Z and Urbancsek.J.Early pronuclear
breakdown is a good indicator of embryo
quality and viability.Fertility and sterility
2005;4:881
13. Maria Jos e de los Santos, Gemma Arroyo, Ana
Busquet, Gloria Calder_on ,Jorge Cuadros
Maria Victoria Hurtado de Mendoza, Marta
Moragas,Raquel Herrer, Agueda Ortiz, Carme
Pons, Jorge Ten, Miguel Angel Vilches,and Jos
e Figueroa .A multicenter prospective study to
assess the effect of early cleavage on embryo
quality, implantation, and live-birth rate
Fertility and Sterility 2014 ;4: 0015-0282
14. Lian WL,Xin ZM,Jin HX, Song WY, Peng ZF,
Sun YP, Effect of early cleavage embryo
transfer on Invitro fertilization-embryo transfer
pregnancy outcome, Clinical and experimental
Obstetrics and Gynecology 2013;40:319-22
15. Meng-Ju Leem, Robert Kuo-Kuang Lee, MingHuei Lin, Yuh-Ming Hwu .Cleavage speed and
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DOI: 10.5958/2319-5886.2014.00408.1

&
Health Sciences
www.ijmrhs.com
Received: 19th Apr 2014
Volume 3 Issue 3
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
rd
Revised: 3 Jun 2014
Research Article
IS LOW SELF-ESTEEM A RISK FACTOR FOR DEPRESSION AMONG ADOLESCENTS? AN

ANALYTICAL STUDY WITH INTERVENTIONAL COMPONENT
*
JayanthiP1, Rajamanickam Rajkumar2
Research Scholar, SRM University, Chennai, India

Professor, Dept. of Community Medicine, Meenakshi Medical College Hospital & Research Institute, Enathur,
Kanchipuram, Tamil Nadu, India
2
*Corresponding authoremail: jayanthiarul2011@gmail.com

ABSTRACT
Background: Self - esteem is an important factor for helping persons deal with life stressors. It is an important
determinant of psychological well-being that is particularly problematic during an adolescent life stage. Low selfesteem might contribute to depression through both interpersonal and intrapersonal pathways. Many theories of
depression postulate that low self esteem is a defining feature of depression.Aims: Self-esteem in adolescents has
been associated with a number of risk and protective factors in previous studies. This study examined the
relationship between low self esteem and depression among adolescents.Methods: This study used a case control
(retrospective) design. Samples of 1120 adolescents, aged 14-17 years were selected for the study. Screening was
done by using MINI-KID and the level of depression was assessed by using Beck depression inventory. Self
esteem was measured by Rosenberg self esteem scale. Odds Ratio and Multivariate logistic regression were used
to examine the relation between self-esteem and socio-demographic variables.Results: The odds ratio analysis
revealed that adolescents who had low self esteem found to have 3.7 times (95% CI=1.9-6.9 and p- value 0.001)
more risk of developing depression than the adolescents who had high self esteem.Conclusions: The findings
implied that low self-esteem is a risk factor for depression among adolescents. Adolescents with low self esteem
have to be identified earlier and prompt interventions will prevent future psychiatric illnesses. As an intervention
towards the educational component pamphlet was distributed to the adolescents, parents and teachers.A concept
programme called Self Esteem Education & Development SEEDprogramme, is planned for, from High
school level.
Keywords: Self esteem; Depression; Adolescents, SEED Programme
INTRODUCTION
Self - esteem is defined as a persons feeling of self
worth.1Self- esteem is an important factor for helping
persons deal with life stressors.2 It is an important
determinant of psychological well-being that is
particularly problematic during adolescent life stage.1
Adolescence as a time of increasingly heightened
self-scrutiny
and
greatly
fluctuating
selfesteem.Adolescents have varying levels of self-
esteem, which appears to be influenced by such

factors as gender, ethnicity, and social class. It can
also vary within an individual- an adolescent may
have different levels of self esteem in different
domains such as social, scholastics, athletics,
appearance, and general conduct and actions.3
Self-esteem changes significantly during adolescence,
which provides important insight into the dynamics
627
Jayanthi et al.,
of adolescent self-esteem.4Environmental issues such

as socioeconomic status, family relations and
language barriers may be factors contribute to the
difference in the self-esteem level.5
Studies have found that one-third to one-half of
adolescents struggle with low self-esteem, especially
in early adolescence.6,7 The results of low self-esteem
can be temporary, but in serious cases can lead to
various problems including depression, anorexia
nervosa, delinquency, self-inflicted injuries and even
suicide.Adolescence with low self-esteem is more
likely to do poorly in school, to become pregnant, or
to impregnate a partner.
Gender has been reported to have an influence on
developing self-esteem during adolescence. Boys are
more likely to have high self-esteem at this stage of
life than girls. Adolescent girls have greater
dissatisfaction with physical appearance that can lead
to low self-esteem6. Adolescent boys self-esteem can
be affected by contradictory societal messages.8
Middle-class and upper-class adolescents have higher
self - esteem than less affluent adolescents.3
Ethnic differences were found to be predictors of selfesteem in a study conducted in Los Angeles, where
self-esteem was found to be significantly lower in
Asians than Caucasians adolescents.4 In the United
States, Black adolescents have higher self-esteem
than biracial adolescents followed by Asian
adolescents. 9
Quality of family relations has a strong influence on
self-esteem.10Family environment is one of the most
fundamental and central environments in adolescent
life.11 Family cohesion has significant effects on
changes in adolescent self-esteem. Self-esteem and
family functioning are positively correlated with
relatively greater effect in girls compared to boys.12
Relationships with parents and relationships with
peers are two important sources of support that
contribute to adolescents self-esteem.6,13
Adolescence is a period of increased vulnerability to
stressful life events such as depression.The
contributory factors to depression are many and
varied. This study examined the important
contributory factor to depression such as low self
esteem.14
There is a correlation between low self-esteem and
depression, and the resulting risk of suicide, increased
unmarried sexual intercourse, teen pregnancy and
alcoholism among todays adolescents.2,15
Studies conducted in the 1990s reveal that depressed

mood
and
low
self-esteem
occur
with
disproportionately
high
prevalence
among
16
adolescents. Also recently emerging studies suggests
that low self-esteem contributes to the development
of depression.17
Documented studies on gender differences in both
self-esteem18and depression19 reveal that during early
adolescence, more girls are affected than boys from
depression. For instance, although boys experience a
similar or even higher rate of depressive symptoms
than do girls prior to adolescence, roughly twice as
many as boys become depressed once they reach
adolescence.19
Many theories of depression postulate that low self
esteem is a defining feature of depression.20 Indeed
numerous studies have documented strong concurrent
relations between low self esteem and depression.
The vulnerability model hypothesizes that low self
esteem serves as a risk factor for depression,
especially
in
the
face
of
major
life
stressors.21According to Becks (1967) cognitive
theory of depression, negative beliefs about the self
one of three central components of depressive
disorders-are not just symptomatic of depression but
play a critical causal role in its etiology.22
Low self-esteem might contribute to depression
through both interpersonal and intrapersonal
pathways. One interpersonal pathway is that some
individuals with low self-esteem excessively seek
reassurance about their personal worth from friends
and relationship partners, increasing the risk of being
rejected by their support partners and thereby
increasing the risk of depression.23,24
A second interpersonal pathway is that some
individuals with low self-esteem seek negative
feedback from their relationship partners to verify
their negative self-concept, which may further
degrade their self-concept.25
A third interpersonal pathway is that low self-esteem
motivates social avoidance, thereby impeding social
support, which has been linked to depression26and
individuals with low self-esteem are more sensitive to
rejection and tend to perceive their relationship
partners behaviour more negatively, thereby
undermining attachment and satisfaction in close
relationships.27,28
A fourth interpersonal pathway is that individuals
with low self-esteem engage in antisocial behaviours,
628
Jayanthi et al.,
such as aggression and substance abuse that might

contribute to their feeling excluded and alienated
from others.29
An intrapersonal pathway explaining how self-esteem
contributes to depression might operate through
rumination. The tendency to ruminate about negative
aspects of the self is closely linked to depression.30,31
Suicide is the third leading cause of death among
adolescents. The major reason for suicide is
unrevealed depression and the contributing factor is
low self-esteem. This study aimed to explore the
relationship between depression and low self-esteem.
METHODS
Participants: The sample for this study was recruited
from the total enrollment of three private and one
government, higher secondary schools (grades 9-12)
from a school district in Puzhal block, Tiruvallur
district that agreed to participate in the study. The
community in which the schools are located is a small
urban community. The parents of all eligible children
(N=1120) in the higher secondary schools were asked
to provide informed consent for their children to
participate. Parents who did not return consent forms
were excluded from the study. Assent was obtained
from the adolescents prior to data collection. Ethical
clearance certificate was obtained from International
Centre for Collaborative research, OmayalAchi
College of nursing, Chennai.
Sample size calculation
Anticipated values of the population proportions
=P1& P2
Level of significance 100 (1-) %
Power of test= 100 (1-) %
Medically meaningful difference =d
n=
[P1 (100-P1) + P2 ((100 P2)] (Z+ Z)2
(P1-P2) 2
P1 =65 %, P2=53 %, =2.58, =1.28,d=12%
n=[65 X 35) + (53 X 47] (2.58 + 1.28) 2
122
n=493 per group
There were two groups of samples taken. School
going adolescents with depression consisted of
560(cases) and school going adolescents without
depression
consisted
of
560(control)
who
wereattending the school in Puzhal block. The
samples were matched based on their age, gender,
education, medium of study and type of school.
Jayanthi et al.,
MEASURES
MINI-KID32:The MINI Kid was used to screen
depression among adolescents. The tool consists of 9
questions. If five or more answers coded Yes, then
the adolescent likely to have Major Depressive
Episode.
Beck depression Inventory33: The Beck Depression
Inventory is a self-report questionnaire used in the
evaluation of the existence and severity of depression
symptoms. It consists of 21 questions related to
possible depression symptoms. Each question is
answered on a 4-point scale, ranging from 0 to 3.This
inventory generally has high reliability and in the
present study reliability score was 0.85.
Rosenberg self esteemScale1:Rosenberg Self esteem
scale is a ten- item uni-dimensional scale designed to
measure an individuals level of self-esteem. The
items answered on a four point scale ranging from
strongly agree to strongly disagree. Scores range from
10 to 40, higher scores indicating a higher level of
self-esteem. The Cronbachs alphacoefficient of the
scale in the present study was 0.86.
Data analyses: Data was analyzed using the
Statistical Package for Social Sciences Programme
(SPSS) version 17.0. Descriptive statistics was used
to describe the demographic variables. Students
independent t-test was used to compare the self
esteem score between case and control group. Karl
Pearson correlation coefficient was used to examine
the relationship between level of depression and self
esteem. Chi square test was used to find the
association between self esteem and the demographic
variables. Odds Ratio and Multivariate logistic
regression was used to examine the strength of
association between the level of depression and selfesteem.
RESULTS
A total of 2432 school going adolescents were
screened. 640 students got the highest score in Minikid and 612 students (cases) were confirmed by the
certified Medical Practitioner. To improve the
efficacy of the study the samples were matched and a
total of 1120 school going adolescents from four
schools (three private and one government) were
finally included for analysis. Of these 50% (n=560)
were boys and 50% (n=560) were girls. The students
ranged in age from 14-17 years. Students from class
IX, X, XI and XII standard chosen equal numbers
629
(n=280).The majority of the adolescents in case

(n=414) lived in a nuclear family.
group, 77.5% (n=434) and in control group 74.9
Table 1: Percentage of Self Esteem Score N=1120
Strongly
Disagree
Disagree
Agree
statement
Cases Control Cases Control Cases Control
On the whole, I am satisfied with
33.8% 1.1%
41.1% 2.7%
17.3% 38.4%
myself
At times, I think I am no good at all
62.3% 1.6%
31.3% 4.3%
2.9% 41.8%
I feel that I have a number of good
58.8% 2.1%
21.6% 15.5% 13.2% 44.5%
qualities
I am able to do things as well as most
64.6% .5%
18.9% 15.2% 7.9% 32.7%
other people
I feel I do not have much to be proud
48.8% 3.2%
28.8% 19.3% 13.9% 37.9%
of
I certainly feel useless at times
40.5% 1.1%
28.0% 16.1% 23.9% 31.6%
I feel that I am a person of worth, at
43.0% 1.6%
33.4% 13.4% 16.3% 39.1%
least on an equal plane with others
I wish I could have more respect for
54.6% 1.6%
26.3% 10.9% 13.4% 43.8%
myself
All in all, I am inclined to feel that I am
60.5% .5%
26.1% 15.0% 8.8% 32.7%
a failure
I take a positive attitude toward myself 58.8% 2.1%
30.7% 15.5% 6.4% 25.4%
Table 2: Level of self esteem in case and control group
Group
Cases
Level of self-esteem
n
%
Low
436
77.9%
Moderate
124
22.1%
High
0
0.0%
Total
560
100.0%
*** Extreme significant at P0.001
Majority of the adolescents in case group 60.4%
(n=338) and in control group 54.3% (n=304) were
resided in urban region. 60% (n=336) of adolescents
in case group and 55.2% (n=309) of them in control
group had one sibling. Majority of the adolescents in
case group 53.3% (n=297) and in control group
55.2% (n=309) were the first born child.
Of the 560 adolescents who completed the BDI, 52
(9.3%) presented with minimal depression. Mild
depression was found in 142 (25.4%) adolescents.
The number of adolescents who reported moderate
depression was 256 (45.7%) and severe depression
was 110 (19.6%). Thus a total of 336 (65.3%)
adolescents presented with moderate to severe
depression.
Strongly Agree
Cases Control
7.9%
57.9%
3.6%
52.3%
6.4%
37.9%
8.6%
51.6%
8.6%
39.6%
7.5%
51.3%
7.3%
45.9%
5.7%
43.8%
4.6%
51.8%
4.1%
57.0%
Control
Chi square test
n
%
0
0.0%
2=896.0
102 18.2%
p=0.001***
458 81.8%
560 100.0%
Considering the
overall score in case group
adolescents mean score is 17.27 with SD of 3.24
where as among control group adolescents mean
score is 33.30 with SD of 2.56, so the difference is
16.13, this difference is large and it is statistically
significant at p<0.001 level.
The Pearsons correlation test results showed a
statistically
significant,
negative,
moderate
relationship betweendepression andself esteem.The r
value is - 0.43at P<0.001level, which means when the
level of depression increases their self esteem score
decreases moderately.
The odds ratio analysis revealed that adolescents who
had low self esteem found to have 3.7 times (95%
CI=1.9-6.9 and p- value 0.001) more risk of
630
Jayanthi et al.,
developing depression than the adolescents who had

high self esteem. The adjusted odds ratio using
multivariate logistic regression identifies low self
esteem among adolescents were associated with more
depression.
DISCUSSION
Low self esteem emerged as a risk factor for
depression in adolescence. This finding demands a
closer examination of this factor in the Indian cultural
context.
In case group boys had a statistically significant low
self esteem score than girls. In control group girls had
a statistically significant high self esteem score than
boys.
This study found that in case group early adolescence
had a low self esteem score than the late adolescence
and in control group middle adolescence had a high
self esteem score. This finding is consistent with the
study conducted by Harter6, Hirsch7 (1991) and
results revealed that one-third to one-half of
adolescents struggle with low self-esteem, especially
in early adolescence.
In the case group government school students had
low self esteem than the private school students and it
was statistically significant. Self esteem is lower
among adolescents of low socioeconomic status and
the majority of the students studying in a government
schoolbelongs to low socioeconomic status. This
findings consistent with the study conducted by
Sadhukishore(2013)34 andParthia PM (2013)35.
Prathiba PM(2013)35conducted a study to assess the
self esteem among 60 adolescents studying in private
schools in Chennai. The findings revealed that in
experimental group 6 (20%) and in control group 17
(56.66%) had low self esteem.
The study found that case group adolescents who had
more than three siblings had low self esteem and
control group adolescents who had one sibling had
high self-esteem. This findings consistent with the
study conducted by Sadhukishore (2013)34 and
Herman (2003)36.
The overall mean self-esteem score difference
between case and control group adolescents in Puzhal
Block was 16.13. There were statistically significant
associations between self-esteem and gender, medium
of study, type of school, number of siblings, family
monthly income, mothers education, involvement in
religious activity and recreational activity in case
Jayanthi et al.,
group. There
were
statistically
significant
associations between self-esteem and age, gender,
family monthly income and distance from home to
school in control group.
Depression among adolescents was associated with
low self-esteem. The findings implied that low selfesteem is a risk factor for depression among
adolescents. Internal emotional deficiency may
function as a personal vulnerability factor to
depression, and significantly impinge on the
wellbeing of the adolescents. Therefore, greater
importance should be given to the presence of low
self-esteem during adolescence with the aim of
increasing the possibility for adolescents to grow and
function encouragingly across their life span.
Adolescents with low self esteem have to be
identified earlier and prompt interventions will
prevent future psychiatric illnesses.As an intervention
towards the educational component pamphlets was
distributed to the adolescents, parents and
teachers.The researcher intended to generate evidence
and recommended school authorities to strengthen the
mental health component in the school health
programme and appoint a school counsellor.
A model program called Self Esteem Education &
Development SEEDprogram, is planned, for
introducing in the high school level. This is an
educational intervention programme at regular
intervals, to be developed by the authors. This is
based on building from what they have and teaching
from what they know. The concept is that,
everybody has a talent and everybody has a basic
knowledge and desire to do something for the benefit
of the society. This will be brought out, for
recognition, by the peers, teachers, parents and the
society. Self recognition and self realisation, of ones
potentials, and their usefulness to the society, will
lead to the building up of self dignity and self esteem.
The National programs like National Social Service
Scheme NSS, implemented in schools and colleges
can be made use for piloting the Self Esteem
Education & Development SEED programme.
CONCLUSION
The findings implied that low self-esteem is a risk
factor for depression among adolescents. Adolescents
with low self esteem have to be identified earlier and
prompt interventions will prevent future psychiatric
illnesses. As an intervention towards the educational
631
component pamphlets was distributed to the

adolescents, parents and teachers.A concept
programme called Self Esteem Education &
Development SEED programme, is planned for,
from High school level.
ACKNOWLEDGEMENT
We would like to thank The Chief Educational
Officer, Thiruvallur District for granting permission
to carry out this study in the schools.
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DOI: 10.5958/2319-5886.2014.00409.3

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Coden: IJMRHS
Copyright@2014
ISSN: 2319-5886
th
Revised: 5 May 2014
Accepted: 3rd Jun 2014
Research Article
VARIATIONS IN ANATOMICAL FEATURES OF THE SACRAL HIATUS IN INDIAN DRY SACRA

*Desai Rajeev R1, Jadhav Surekha D2, Doshi Medha A1, Ambali Manoj P1, Desai Ashwini R1
1
Department of Anatomy, Krishna Institutes of Medical Sciences Deemed University, Karad, Maharashtra, India.
Department of Anatomy, Padamashree Dr. Vithalrao Vikhe Patil Foundation Medical College, Ahmednagar,
Maharashtra, India
2
*Corresponding author email: polodesai2012@gmail.com

ABSTRACT
Objective: An opening present at the caudal end of sacral canal is known as sacral hiatus, which is clinically
important to give caudal epidural block in orthopedics and obstetric practice. The success of caudal epidural block
depends upon the anatomical variations of sacral hiatus. Aim: Aim of our study was to determine the anatomical
variations of sacral hiatus in Indian dry human sacra. Material and methods: We used 271 Indian dry human
sacra of unknown sex, to observe various shapes of the hiatus, which includes inverted U- shape (42.12%),
inverted V-shape (35.43%), irregular (12.99%). The mean length of sacral hiatus was 21.70 mm. The mean
anteroposterior diameter of sacral canal at the apex of sacral hiatus was 5.50 mm. Conclusion: In conclusion, the
sacral hiatus has anatomical variations and understanding of these variations may improve reliability of caudal
epidural block.
Keywords: sacral hiatus, dry human sacra, Indian, variation.
INTRODUCTION
Sacral hiatus (SH) is an opening which is located
inferior to the 4th or 3rd fused sacral spines or lower
end of median sacral crest. It contains lower sacral
and coccygeal nerve roots, filum terminale externa
and fibrofatty tissue and covered by superficial
posterior sacrococcygeal ligament which is attached
to the margins of the hiatus and the deep posterior
sacrococcygeal ligament attached to the floor of SH.1
Epidural space is approached through SH for giving
analgesia and anesthesia for various operations,
treatment of lumbar spinal disorders and for management of chronic back pain. The success rate of caudal
epidural block (CEB) depends upon accurate
localization of SH. Therefore, precise knowledge of
the anatomical variations in SH is essential.2
According to Dalens, 3 the SH provides easy access to

the sacral epidural space at a level where most of the
roots of the cauda equina are no longer inside the
sacral canal, below the termination of the dural sac.
One of the most important reasons for failure of CEB
is anatomic variations in the SH.4 Anatomical
abnormalities of the sacrum include upward and
downward displacement of the SH, narrowing or
partial obliteration of the sacral canal, ossification of
the sacrococcygeal membrane, absence of bony
posterior wall of the sacral canal and variation in
shape of the SH.5
SH has been utilized for administration of epidural
anesthesia in obstetrics,6 orthopedic practice for
treatment and diagnosis,4 also used to provide peri
and post - operative analgesia in adults and children
634
Rajeev et al.,
or it may be combined with general anesthesia.7 For

successful caloscopy it is important that we must be
familiar with the common possible variations of the
SH.8
According to Brailsford9, the variation in the
development of the SH can cause decrease area for
the attachment of extensor muscle at back causing
painful conditions. SH with guide wire assistance is
an accessible conduit for uncomplicated entry into the
subarachnoid and basal cisternal space without
damaging the surrounding structures.10 Considering
the clinical importance of anatomical variations of the
SH this study was done by us which will provide
additional knowledge to anesthetists and researchers
to locate the sacral hiatus and to know the possible
causes for the failure of caudal epidural block.
Fig1a: Showing inverted U shaped sacral hiatus (1b):

Showing V shaped sacral hiatus (1c): Showing
irregular sacral hiatus

Present study was carried in the department of
anatomy KIMS on 271 adult human dry sacra of
unknown sex. Sacra showing wear and tear, fracture
any erosion, damage or any pathology were not used
for study. All measurements were taken with the help
of digital Vernier caliper accuracy up to 0.01mm.
Each sacrum was studied for following parameters
and the results were tabulated and discussed.
1. Shape of the hiatus was noted by appearance,
2. Level of apex of SH with respect to sacral
vertebra.
3. Level of base of SH
4. Length of SH- measured from the apex to
midpoint of the base.
5. Anteroposterior diameter or depth at its apex,
6. Transverse width of SH at the base which is
measured between inner aspects of inferior limit
of sacral cornu.
7. Sacral composition
RESULTS
We observed complete agenesis of the dorsal bony
wall of the sacral canal in 11 (4.05%) and in 6 (2.21
%) sacra there was a complete absence of SH. So
these 17 sacra were excluded from the measurements
as typical SH was not present in them. Total 254
sacra were used for taking above mentioned
measurements.
Fig 2a: Showing elongated sacral hiatus, (2b): Showing

dumbbell shaped sacral hiatus
Table 1: Shape of sacral hiatus (n=254)

Shape
Number of Percentage
Sacra
(%)
Inverted U (Fig. 1a)
107
42.12
Inverted V (Fig.1b)
90
35.43
Irregular (Fig. 1c)
33
12.99
Elongated (Fig. 2a)
10
4.00
Dumbbell (Fig.2b)
14
5.51
Total
254
100
Table 2: Location of apex of hiatus in relation to
the level of sacral vertebra (n=254)
Location of apex
Sacra
(%)
5th sacral vertebra
42
16.53
4th sacral vertebra
153
60.23
3rd sacral vertebra
45
17.71
2nd sacral vertebra
14
5.60
Total
254
100
635
Rajeev et al.,
Table 3: Location of the base of hiatus in relation

to sacral /coccygeal vertebrae (n=254).
Location of apex
Sacra
(%)
4th sacral vertebra
11
4.33
5th sacral vertebra
191
75.19
Coccyx
54
21.25
Table 4: Length of sacral hiatus from apex to the
midpoint of base (n=254)
Length (mm) Number of Sacra Percentage (%)
00 10
28
11.02
11 20
79
31.10
21 30
101
39.76
31 40
32
12.6
41 50
14
5.51
Table 5: Anteroposterior diameter or depth of
sacral canal at the level of apex (n=254)
Diameter (mm)
Number of Sacra
Percentage (%)
0 3 mm
4 6 mm
7 9 mm
10-12mm
27
201
25
01
10.62
79.13
9.84
0.40
Table 6: Transverse width at the base of hiatus

(n=254)
Diameter (mm)
Number of Sacra
Percentage (%)
00 05 mm
06 10 mm
11 15 mm
16 20 mm
39
97
92
26
15.35
38.20
36.22
10.23
Table 7: Sacral composition (n=254)

Sacral composition
Number
of Sacra
4 Segments
16
5 Segments
186
6Segments
Partial
or 10
complete sacralisation of 5th
lumbar vertebra
Coccygeal ankylosis
42
Total
254
Percentage
(%)
6.30
73.22
3.93
16.53
100
DISCUSSION
Anatomical variations of SH are one of the most
important factors for unsuccessful CEB. While
performing CEB needle passes through skin,
subcutaneous tissue and sacrococcygeal ligament and
needle enters into caudal epidural space.4 When CEB

is done under the guidance of USG of fluoroscopy
then the success rate is 100% but it is not always
possible due to various reasons such as availability of
instrument, cost etc. Therefore, knowing the
variations in anatomical features of the SH will
facilitate the procedure. 11 Routinely, during CEB the
SH is identified by palpating sacral Cornu. 12
Our study has shown that the shapes of SH are
variable as shown by other authors. The most
common shape was noted inverted U (Fig. 1a),
followed by V (Table 1; Fig 1b). This was in line
with the study conducted by Nagar,13 Aggarwal et al2,
Seema et al.14 But Vinod et al15 noted that the most
common shape of the SH is the inverted V-shape in
46.55% and 76.23% respectively which was not in
line with the present study and other authors. Nagar13
observed dumbbell shaped SH in 13.3% and Vinod et
al15 in 7.43% sacra but we obtained low percentage
compared to these authors.
Standard textbooks of Anatomy describe that, the
apex of sacral hiatus is at the level of 4th vertebra.
Present study observed it in 60.23% sacra [Table 2].
Kumar et al16 found it in 76.23%, Sekiguchi et al4 in
64% and Njihia et al.17 We noted that location of apex
of SH can vary from upper S2 to S5. Duncan et al 18
stated that, distance from the apex of the sacral hiatus
to the lower lumbar spinous processes is important to
develop the techniques to prevent the neurological
injury associated with the neuraxial injections.
Present study reported base of the SH (Table 3) was
most commonly located at S5 (75.19%). Our findings
are in line with other researchers, but the percentage
is variable.
Length of hiatus (Table 4) ranged from 6 mm to 49.7
mm. (mean 21.70 mm) in our study which was
similar to the previous work done by various authors
(Table 8). The anteroposterior diameter of sacral
canal at apex of sacral hiatus is clinically important
because it should be adequately large to put a needle.
Variations in measurements lead to subcutaneous
deposition of anesthetic drug. The anteroposterior
diameter [Table 5] was ranged between 2.3 to 10.9
mm (Mean 5.28mm). Various researchers reported
almost similar values for mean anteroposterior
diameters.
Transverse width at the base of hiatus [Table 6]
ranged between 2.8 mm and 20 mm (mean
16.67mm). In 75% cases, it was between 0.6 -15 mm.
636
Rajeev et al.,
The width at the base was noted by Trotter and

Letterman19 from 7-26 mm with a mean of 17 mm,
Lanier et al. 19.30.3 mm,20 Kumar et al 5-20 mm
(1.3 in mean)16, Aggarwal et al2 11.95+2.78 mm and
Sekiguchi et al 10.20.35 mm 4 Present study
reported, 73.22% sacra were made up of 5 segments,
6.30% sacrum made up of only 4 segments and 16.53
% sacra had cocygeal ankylosis (Table7). Our
observations and previous workers observations are
almost same.
Normally, sacrum is made up of five sacral
vertebrae..2 Increase in length of the SH is influenced
by the defect of nonunion of 2nd and 3rd pair of sacral
laminae and also by coccygeal ankylosis.2 Our study

reported that, 73.22 % sacra were made up of 5
segments, whereas 6.30 % sacra showed 4 segments.
Vinod Kumar et al15 observed 5 segmented and 4
segmented sacra in 69.80% and 1.48% respectively.
However, But Trotter and Lanier19 observed 4
segments in 0.7% sacra. Our findings are in line with
those of Vinod kumar et al.15 We observed partial or
complete sacralisation of 5th lumbar vertebra in
3.93% and coccygeal ankylosis was observed in
16.53 % sacra. Trotter and Lanier19 observed
sacralisation of 5th lumbar vertebra in 12.6% and
coccygeal ankylosis in 39.3% sacra.
Table 8: Comparison between the findings of different authors in different regions

Author
Shape
Level of
Level of
Length(mm) Anteroposterior
Apex
Base
diameter at the
apex (mm)
13
Nagar et al.
Inverted U S4
S5 (72.6%)
11-20
4-6
(2004)
(41.51%)
2
Aggarwal et al. Inverted U S4
4 .30-38.60
1.90-10.4
(2009)
(40.35%)
Njihia et al. 17
Inverted V S4
6.4=3.1
(2011)
(32.1%)
Seema et al. 14 Inverted U S4
S5 (70.45%) 11-20
4-6
(2013)
(42.95%)
Present study
Inverted U S4
S5 (75.19%) 5- 49.5
2-11.2
(2014)
(42.12 %)
Base (mm)
10-15
11.952.78
11-1
4-19.4
CONCLUSION
Variations in anatomical features of the sacral hiatus
have implications in the clinical practice because it
is used for caudal epidural block, in orthopedic
therapeutic and diagnostic procedures in the
treatment of sciatica to give corticosteroids
injections.21 Therefore, precise knowledge of these
variations is mandatory and it may help to improve
both the reliability and safety of caudal epidural
anesthesia and also prevent the iatrogenic injury of
dural sac during caudal epidural anesthesia. It is
important to have knowledge of different shapes of
hiatus and defects in dorsal wall of sacral canal
should be taken into consideration before
undertaking caudal epidural block so as to avoid its
failure and injury to dural sac. Present study data
may be helpful while performing various
procedures.
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sacra. J. Anat. Soc. India. 2004; 53(2):18-21
Seema, Singh M, Mahajan, A. An anatomical
study of variations of sacral hiatus in sacra of
north Indian origin and its clinical significance.
Int. J. Morphol. 2013; 31(1):110-14
Vinod K, Pandey SN, Bajpai RN, Jain PN,
Longia GS. Morphometrical study of sacral
hiatus. Journal of Anatomical Society of India.
1992; 41(1): 7-13.
Kumar V, Panday SN, Bajpai RN, Srivastava
RK, Longia GS. Termination level of dural sac
in the sacral canal. J. Anat. Soc. India.1994;
43(2):137-142.
Njihia BN, Awori KO, Gikenye G. Morphology
of the sacral hiatus in an African PopulationImplications for Caudal Epidural Injections.
Ann. Afr. Surg. 2011; 7:20-3
Duncan MA, Sherriff M, OKeeffe D,
Dangerfield PH. A radiographic assessment of
the distances from the sacral hiatus to the lower
lumbar spinous processes. Eur. J. Anat.2009;

13(10):19- 22
19. Trotter M, Letterman GS. Variations of the
female sacrum; their significance in continuous
caudal analgesia. Surg. Gynaecol. Obstet. 1944;
78(4):419-24
20. Lanier VS, Mcknight HE, Trotter M. Caudal
analgesia: An experimental and anatomical
study. Am. J. Obstet. Gynecol 1944; 47(5):63341
21. Czarski Z. Treatment of sciatica with
hydrocortisone and novocaine injection into the
sacral hiatus. Przegl Lek. 1965; 21(7): 511-13
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DOI: 10.5958/2319-5886.2014.00410.X

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Health Sciences
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Volume 3 Issue 3
rd
Received: 3 May 2014
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Research Article
EPIDEMIOLOGICAL STUDY OF DILATED CARDIOMYOPATHY FROM EASTERN INDIA WITH

SPECIAL REFERENCE TO LEFT ATRIAL SIZE
*
Rudrajit Paul1, Saumen Nandi2, Pradip K Sinha3
Assistant Professor, Department of Medicine, Medical College, Kolkata88, College Street, Kolkata
RMO, Department of Chest Medicine, Malda Medical College, Malda, West Bengal
3
Professor and HOD, Department of Medicine, Malda Medical College, Malda, West Bengal
2
*Corresponding author email:docr89@gmail.com

ABSTRACT
Background: Dilated cardiomyopathy (DCM) is a common cause of emergency visit in our country. The disease
is often misdiagnosed and mistreated. There are very few studies on DCM from India. We undertook a small
study on DCM patients from Eastern India to find the demographic and echocardiographic characteristics.
Patients and methods: We undertook this study in a tertiary care Medical College of Eastern India. All patients
coming to the emergency with dyspnea were evaluated for cardiac dysfunction. Emergency echocardiography was
done to diagnose dilated cardiomyopathy. Patients with DCM were then evaluated as per protocol. After
stabilization, echocardiography was repeated to note the study parameters like left atrial diameter. Standard
statistical tests were used. Results: we had a total of 70 patients in our study with a male: female ratio of 43:27.
Most patients were aged over 40 years. Patients with COPD, history of radiation, malignancy or drug abuse were
excluded. Most patients (47%) were on NYHA stage 3 at the time of presentation. In our patient cohort, 24%
were alcoholic and 46% were smokers. Atrial fibrillation was present in 15.7% of the patients and right and left
bundle branch block had been present in 8 and 15 patients respectively. In echocardiography, increased left atrial
(LA) size (>40 mm) was found in 45 patients. Many patients had valvular regurgitation, mitral, aortic or tricuspid.
LA size was positively correlated with left ventricular systolic diameter (r=0.403) and negatively correlated with
ejection fraction (r= -0.23). Analysis and conclusion: different ECG abnormalities like bundle branch block and
arrhythmias like atrial fibrillation are quite common in DCM. In echocardiography, left atrial size is an important
prognostic marker and correlates with left ventricular function.
Keywords: Dilated cardiomyopathy, left atrial size, LVIDS, male preponderance, NYHA staging
INTRODUCTION
Dilated cardiomyopathy (DCM) is an important cause
for emergency room visits in our country. This
disease is often misdiagnosed as COPD or asthma
and patients often receive wrong treatment for a long
time. Exact prevalence of DCM in India is not
known. In a study from Europe, the incidence of
DCM was found to be 6.95/100 000/year.1Diabetes,
alcoholism, neurological disorders and congenital

cardiac diseases were the main associated
comorbidities in DCM patients in this study.1But in
many cases, the cause remained unknown. The
patients were also found to have different types of
arrhythmia.
639
Rudrajit et al.,
Studies regarding DCM are very rare from India. A

study on paediatric patients with DCM found a very
high incidence of different viral infections like CMV
and Coxsackie.2 However, similar risk factors for
Indian adults are largely unknown. One study
evaluated the role of inheritance in Indian DCM
patients.3 However, there were no definite
conclusions and DCM in India was found to be a
heterogeneous disease. Diet, especially pure
vegetarian diet with no animal protein, was found to
be an important factor in causation of DCM in India.3
DCM is a very common problem in daily practice,
but we hardly know the epidemiological features in
Indian setting. We, therefore, undertook this small
pilot study from Eastern India to characterise the
different demographic variables in DCM patients.
The
Electrocardiographic
(ECG)
and
echocardiographic characteristics of these patients
were also studied for any association.
PATIENTS AND METHODS
This was a hospital based cross sectional
observational study. Adult patients coming to the
emergency of a tertiary care medical college with
dyspnea and/or chest pain were evaluated.
Emergency chest X ray, Electrocardiography (ECG)
and echocardiography were done and a trained
cardiologist examined the patients clinically. Those
who were found to have dilated cardiomyopathy
(DCM) were then evaluated after stabilization.
Informed written consent was taken from each study
subject or next of kin, also obtained permission of an
institutional ethical committee of the medical
collegeDemographic data like alcoholism history and
smoking history were taken from the patient or next
of kin. Exclusion criteria: Patients with coexisting
COPD (chronic obstructive pulmonary disease), any
malignancy, rheumatological disorder, drug abuse,
history of radiation to the thorax or those with
congenital cardiac diseases were excluded from the
study.
ECG (electrocardiography) was done using a standard
BPL machine (model number: CMECG-04) at paper
speed of 25 mm/second. All ECGs were interpreted
by the same person.
Echocardiography was done using a Philips Envisor
machine version C.1.3 model number M2540A. All
the echocardiographic observations were made by the
same observer to avoid inter-observer variations.

Echocardiography was done in emergency to
diagnose DCM. But for the chamber dimensions and
other study parameters, the test was repeated after the
patient was stabilized. Left atrial size was measured
as the anterio-posterior diameter in parasternal long
axis view (PLAX). In the same view, ejection fraction
and fractional shortening were also measured.
Valvular regurgitation was measured by continuous
wave Doppler (CWD) in apical four chamber view as
per the European Association of Echocardiography
recommendations, 2010.
There were a total of 70 patients in our study. Initially
88 patients were chosen, but some did not consent to
the study and some others were found to have one or
more of exclusion criteria. The data was entered into
Microsoft excel worksheet before analysis.
Continuous data is here expressed as mean S.D. and
discrete data is expressed as number/percentage. Chisquare test with Yates correction has been used to
calculate p-value (2-tailed) of 22 contingency tables.
For continuous data, Pearsons correlation coefficient
was calculated. For discrete data like NYHA class,
Spearmans Rho coefficient was used. To compare
means of continuous data, students T test has been
used. P value of less than 0.05 was considered
significant.
RESULTS
We had a total of 70 patients in our study. The male:
female ratio was 43:27 (table 1). Most of the patients
(n=60) were aged over 40 years. 50% of the patients
were 60 years or older. As table 1 show, 24% of the
patients had a history of regular intake of alcoholic
drinks and 46% of the patients were smokers. Of the
smoker subset, 15 patients (46.9%) had a smoking
history of more than 20 pack-years. The chief
presenting complaint of DCM was dyspnea. Majority
of the patients were in New York heart association
(NYHA) class 3 (figure 1). Palpitation and chest pain
were found in minority of study population (n=4 and
n=6 respectively).
Table 2 shows the different electrocardiographic
(ECG) characteristics of our patients. Tachycardia
(heart
rate>100/minute)
waspresentin48patients.However,
rate>120/minute
was present in only 8 patients. Atrial fibrillation
(figure 2) was found in 11 patients and ectopic beats
640
Rudrajit et al.,
were found in 15 patients. Of these 15 patients, 11

had ventricular ectopics. Right bundle branch block
(figure 3) was found in 8 (11.4%) patients.
Table
1:
Table
showing
the
demographic
characteristics of the study subjects (N=70)
Parameter
Table 3: Table showing the echocardiographic

findings of our study subjects
Parameter
Number (%)
Ejection
<20%
3 (4.3)
Fraction
20-30%
27 (38.6)
>3040%
30 (42.9)
>4050%
10 (14.3)
>50%
Number
[percentage]
Age
in <20
years
2 [2.8]
20<40
8 [11.4]
Left
41<60
25 [35.7]
size
61
atrial 3 cm
3.1-4 cm
25 (35.7)
35 [50]
4.1-5 cm
39 (55.7)
Male
43 [61.4]
>5 cm
6 (8.6)
Female
27 [38.6]
6 cm
Alcohol
No
39 [55.7]
6.17 cm
29 (41.4)
intake
Occasional
7.18 cm
35 (50)
>8 cm
6 (8.6)
4 cm
6 (8.6)
4.15 cm
32 (45.7)
Sex
(1-2
times/week)
Frequent
times/week)
Smoking
(>2
4 [5.7]
LVIDs
17 [24.3]
None
38 [54.3]
5.16 cm
29 (41.4)
20 pack year
17 [24.3]
>6 cm
3 (4.3)
>20 pack year
15 [21.4]
Regurgitatio
Mitral
11 (15.7)
Aortic
1 (1.4)
Combined
12 (17.1)
Table 2: Table showing the ECG findings in our

study (n=70)
Parameter
Number/
%
Rate
100
22/31.4%
(/minute)
101-110
27/38.6%
111-120
13/18.6%
121-130
7/10%
131
1/1.4%
Rhythm
Regular
44/62.9%
Irregular Ectopics
15/21.4%
Atrial
11/15.7%
fibrillation
Bundle
Rt-BBB
8/11.4%
branch block Lt BBB
15/21.4%
(BBB)
Ectopics
LVIDd
Atrial
Ventricular
4/5.7%
11/15.7%
mitral and aortic

Tricuspid
20 (28.6)
Table 4: showing the age group wise parameters

Parameter
50 years
>50 years
pvalue
Gender ratio M:F
Ejection fraction (%)
Heart rate
17:11
26:16
0.92
32 9.2
33.1 6.2
0.54
108.1 16.8 102.7 12.6
0.12
Atrial fibrillation
3 (10.7%)
8 (19%)
0.50
Left
43.4 4.6
42.6 4.7
0.46
50 7.4
49.5 5.6
0.76
atrial
size
(mm)
LVIDs (mm)
The p-values show that there was no significant

statistical difference between the two age groups.
641
Rudrajit et al.,
CLINICAL FEATURES OF PATIENTS

0, 0%
13, 19%
24, 34%
NYHA 1
NYHA 2
NYHA 3
33, 47%
NYHA 4
Fig 1: Pie diagram showing the presentation

according to NYHA classification. 13:
NYHA 1:angina, dyspnea, syncope or palpitation
(ADSP) at more than usual physical activity
NYHA2:ADSP at usual/ordinary physical activity
NYHA3:ADSP at less than usual physical activity
NYHA 4:ADSP at rest or with minimal activity.
Bedbound Patients
Fig 2: ECG showing atrial fibrillation
Fig3: ECG showing right bundle branch block (RBBB)
Table 3 shows the echocardiographic characters of

the study subjects. It is seen that 57 of the patients
had an ejection fraction between 20 and 40%. None
of the patients in our study had an ejection fraction
above 50%. Left atrial diameter above 4 cm was
found in 45 (64.3%) of the patients. Left ventricular
systolic and diastolic internal diameters were also
elevated in most of the patients. Systolic internal
diameter was more than 4 cm in 64 out of the 70
subjects and diastolic diameter was more than 6 cm in
all the subjects. Due to the left ventricular
enlargement, Valvular regurgitation was quite
common. It is seen that combined mitral and aortic
regurgitation was present in 17% of the patients.

Tricuspid regurgitation was present in 20 patients.
As seen in table 4, there was no significant difference
in the parameters based on age. In those aged over 50
years, atrial fibrillation was present in 19% cases.
It was seen that left ventricular systolic diameter
(LVIDs) was positively correlated with left atrial
(LA) size (r=0.403; p=0.0005). Thus, more the left
ventricular systolic dimensions (LVIDs), more the
left atrial size.No such positive correlation was found
with diastolic dimensions of left ventricle (LVIDD).
The ejection fraction was negatively correlated with
the left atrial size (r= -0.2306; p=0.055). Similar
relations were found with fractional shortening (FS)
of left ventricle (r=-0.279; p=0.019). The LA size
showed a negative correlation with heart rates of the
patient (r= -0.2342) although this was not statistically
significant. LVIDs showed a weak correlation with
the presenting NYHA stage of the patient (r=0.253,
p<0.05 by Spearmans rho coefficient).
DISCUSSION
In our study, we found a male preponderance (1.59:1)
in our DCM patient cohort. Also, most of the patients
were elderly. Similar finding has been reported from
U.P., India, where the male: female ratio was 1.5:1
and 48% of the patients were above 60 years of
age.4In our study, 50% of the patients were 60 years
or older. In the aforementioned study, DCM in less
than 40 years, females was mainly due to peripartum
cardiomyopathy4. However, in our study, there were
11 females in the under-40 age group. But only 3 of
them (27.3%) had postpartum cardiomyopathy. For
the rest, no specific cause was identified. Similar
male preponderance in DCM has also been reported
from other European studies.1, 5The exact cause for
this is not known. But some authors think that the
male hormones and lifestyle related changes may
predispose to cardiac muscle dysfunction and
alteration
of
cardiomyocyte
membrane
functions.3However, there are also a few studies
where this male predominance has not been found. In
one study comparing DCM in blacks and whites in
USA, they have found that in the black subset, the
male: female ratio was almost equal.6
With age, comorbidities like hypertension, diabetes,
malignancy or renal failure increase. These may
cause DCM and heart failure. In the European study,
642
Rudrajit et al.,
in autopsy proven DCM cases, the mean age of

patients was 63 13.3 years.1In our study, the mean
age was 54.416.2 years.
Alcohol and smoking are two risk factors for different
types of heart disease, including DCM. In an Indian
study from Hyderabad, smokers and alcoholics
comprised almost 18 and 16% of DCM cases
respectively.3In our study, 1 in 4 patients were
alcoholic. However, it is said that only alcohol is not
enough to cause DCM in most cases; alcoholic
cardiomyopathy is more common in those with
genetic predisposition to heart diseases, in contrast to
those without.7But we did not do genetic testing in
alcoholic DCM cases due to financial reasons. Once
DCM develops in alcoholics or smokers, the
prognosis is uniformly poor.7
Different ECG and echocardiographicfindings are
found in DCM patients. In one Indian study, they
found ST-T changes in 90% cases, Left bundle
branch block (LBBB) in 30% and atrial fibrillation in
5% of the cases.4In our study, LBBB was found in
21% cases and atrial fibrillation (AF) in 15.7% (table
2). ST-T changes were found in 51% of the cases.
Atrial fibrillation and other arrhythmias are potential
risk factors for sudden cardiac death in DCM
patients. AF may occur spontaneously or may be
related to changes in geometry of the heart. In a study
from Romania, they found presence of increased
LVIDD and mitral regurgitation as risk factors for
occurrence of AF.8Also, they found that higher the
NYHA class, the more the chance of having
permanent AF.8In our study, 45.5% of patients with
AF had mitral regurgitation (MR). Overall prevalence
of AF was 15.7%, but among patients with MR, AF
was present in 21.7%. Also, as figure 1 shows,
overall 46 patients in our study had NYHA class 3 or
4 symptoms (65.7%). But among patients with AF in
our study, 72.7% had NYHA 3 or 4 symptoms.
Prominent echocardiographic findings in our study
included valvular regurgitation and increased
dimensions of left sided chambers (table 3).
Especially we found left atrial (LA) diameter >4 cm
in 45 patients. Left atrial diameter has important
prognostic implications.9 It is a good indicator of left
ventricular end diastolic pressure.9In a study from
Kosovo, the authors have found a significant
correlation between LVIDD and different left atrial
dimensions like diameter, volume and LA area
withdifferent views in heart failure patients.10Large

LA size is also a risk factor for thrombotic episodes,
which may lead to sudden death. Not only cardiac
events, but cerebrovascular stroke is also increased in
patients with large LA.10In another study from
Turkey, the authors have found significantly
increased LA size in those with large LV systolic
dimensions in DCM.11This was also linked to
increased chance of AF and LA thrombus. Thus,
systolic dysfunction in DCM, as evidenced by
increased LVIDS, is a risk factor for these
comorbidities. LA size may act as a surrogate marker
for severity of systolic dysfunction. Appropriate
prophylactic therapy may be needed in some cases to
prevent potential catastrophe.
In our study, the LV ejection fraction was negatively
correlated with LA size of the patients. This
correlation between left atrial size and left ventricular
function has been found in some other studies too. In
one study, the sensitivity of left atrial dimensions in
predicting abnormal ejection fraction was found to be
71%12. LA size>40 mm was a marker of reduced
ejection fraction in that study.12,13
Limitation of the study; our study is limited by the
small number of patients. Also, further
echocardiographic studies are needed with newer
parameters like LA volume, LV mass and tissue
Doppler imaging to characterise the cardiomyopathic
changes in DCM. We also could not do transesophageal echocardiography in our patients due to
logistic reasons. This is a better technique in
assessing left atrial abnormalities.
CONCLUSION
This small observational study depicts the high
prevalence of DCM in elderly population, especially
males. These patients are more likely to have
arrhythmia and embolic episodes. Certain
echocardiographic parameters like left atrial size were
found to correlate with left ventricular parameters and
thus may be useful in predicting prognosis in DCM.
However, further multicentric studies are needed in
order to find the associated features in DCM patients
in India and to better elucidate the significance of
different chamber dimensions.
643
Rudrajit et al.,
ACKNOWLEDGMENT
Principal and M.S.V.P of the institution for allowing
us to conduct the study in the institution and guiding
us throughout.
REFERENCES
1. RakarS, SinagraG, Di LenardaA, PolettiA,
BussaniR,SilvestriFet al. Epidemiology of dilated
cardiomyopathy: A prospective post-mortem
study of 5252 necropsies. European Heart Journal
1997; 18: 117-23
2. Khalil A, Chawla K, Chakravarti A. Dilated
Cardiomyopathy: Clinical Profile and Treatment.
Indian Pediatrics 2000;37: 1242-6
3. Ushasree B, Shivani V, Venkateshwari A, Jain
RK, Narsimhan C, NallariP.Epidemiology and
genetics of dilated cardiomyopathy in the Indian
context.Indian J Med Sci. 2009;63:288-96
4. Deshmukh A, Deshmukh A, Deshmukh G, Garg
PK. A pilot study of dilated cardiomyopathy
(DCM) in western Uttar Pradesh, India: A four
year review. Medico-Legal update 2011; 11:
available
online
from
http://www.indianjournals.com/ijor.aspx?target=i
jor:mlu&volume=11&issue=1&article=001
5. OlbrichHG.Epidemiology-etiology of dilated
cardiomyopathy. Z Kardiol. 2001;90 Suppl 1:2-9
6. CoughlinSS,
GottdienerJS,
BaughmanKL,
WassermanA, MarxES, TefftMCet al. Blackwhite differences in mortality in idiopathic
dilated cardiomyopathy: the Washington, DC,
dilated cardiomyopathy study.JNatl Med Assoc.
1994; 86: 58391
7. Dancy M, Maxwell JD.Alcohol and dilated
cardiomyopathy. Alcohol Alcohol. 1986;21:18598
8. Predictive factors for atrial fibrillation appearance
in dilated cardiomyopathy. Romanian journal of
cardiology.
Available
online
from
http://www.romanianjournalcardiology.ro/en/pre
dictive-factors-for-atrial-fibrillation-appearancein-dilated-cardiomyopathy-31.html
9. Modena MG, Muia N, Sgura FA, Molinari R,
Castella A, Rossi R.Left atrial size is the major
predictor of cardiac death and overall clinical
outcome in patients with dilated cardiomyopathy:
a long-term follow-up study.ClinCardiol.
1997;20:553-60
10. Bakalli A, Georgievska-Ismail L,Musliu N,

Koinaj D, GashiZ,Zeqiri N. Relationship of left
ventricular size to left atrial and left atrial
appendage size in sinus rhythm patients with
dilated cardiomyopathy. Acta Inform Med. 2012;
20: 99102
11. Bakalli A, Kamberi L, Pllana E, Zahiti B,
Dragusha G, Brovina A. The influence of left
ventricular diameter on left atrial appendage size
and thrombus formation in patients with dilated
cardiomyopathy. TrkKardiyolDernAr - Arch
Turk SocCardiol 2010; 38:90-94
12. Hamby RI, Zeldis SM, Hoffman I, SarliP.Left
atrial size and left ventricular function in
coronary artery disease: an echocardiographicangiographic
correlative
study.CathetCardiovascDiagn. 1982;8:173-83
13. The Criteria Committee of the New York Heart
Association. (1994). Nomenclature and Criteria
for Diagnosis of Diseases of the Heart and Great
Vessels. (9th ed.). Boston: Little, Brown & Co.
pp. 2536
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DOI: 10.5958/2319-5886.2014.00411.1

&
Health Sciences
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th
Volume 3 Issue 3
Coden: IJMRHS
Copyright @2014
th
Revised: 5 Jun 2014
ISSN: 2319-5886
Research Article
A STUDY TO ASSESS INJECTION PRACTICES IN CIVIL DISPENSARIES

Bhargo Leena1, *Tiwari Ranjana2, Chouksey Mahendra3, Bhatia Manohar1, Jain Swapnil1, Tiwari Sakshi4
1
PG Student, 2Professor, 3Asst. Professor, Department of Community Medicine, G.R. Medical College, Gwalior
(M.P.) India,
4
M.B.B.S. Student, G.M.C.Bhopal (M.P.) India.
*Corresponding author email: drranjana.tiwari50@gmail.com
ABSTRACT
Background: About 16 billion injections are administered each year worldwide, and at least half of them are
unsafe. India contributes 25-30% of the global injection load. A majority of curative injections are unnecessary.
Estimates suggest that at least 50% of the worlds injections administered each year are unsafe particularly in
developing countries. Methods and materials: The Present study was a cross-sectional study done for 3 months
in all the Civil Dispensaries to Assess the Knowledge, Skill and Practices of Health Care Providers working at
Civil Dispensaries regarding Safe Injection Practices and also to compare the differences between the
knowledge and actual practices among Health Care providers of District Gwalior. Result: A total of 35 Health
Care Providers were taken in the study. All of them knew that the gloves should be worn during injection
procedure but only 4 (11.43%) actually worked during the process. 10 (28.57%) knew that the gloves should be
worn for both personal and patient safety. 5(14.29%) did not knew anything about blood borne viral diseases i.e.
Human Immuno Deficiency Virus, Hepatitis B and Hepatitis C which could be transmitted to the Health Care
Providers. Conclusion: There was a great disparity between knowledge and practices of Health Care Providers
regarding injection practices. Efforts are to be needed to be done in this regard for the benefit of both Health Care
Providers and the patients.
Key words: Blood Borne Infections, Gloves, Injection practices, Safe injection, Waste disposal.
INTRODUCTION
Injections are among the most commonly used
medical procedure with an estimated 16 billion
administrations each year worldwide.
An
overwhelming majority (90%-95%) of these
injections are administered for curative purposes.1
Immunization accounts for around 3% of all
injections.2
According to Indian Programme
Evaluation Network Study, 03-06 billion injections
are administered annually in India.3 Estimates
suggest that at least 50% of the worlds injections
administered each year are unsafe, particularly in
developing countries. Most of the curative injections
are unnecessary, ineffective or inappropriate.4
According to WHOA safe injection does no harm to

the recipient, does not expose the healthcare worker
to any risk, and does not result in waste that puts the
community at risk.5 Hence, safe injection practices
involves administration of rational injection by a
qualified and well trained person using a sterile
device (syringe, needle etc), adopting sterile
techniques, and discarding the used devices in a
puncture-proof specially designed container for
appropriate disposal. Any breach in the process
makes the injections extremely unsafe and hazardous
to Health Care Providers as well.6 More than 90% of
645
Leena et al.,
these infections are occurring in developing

countries, and most of them are preventable.7
Today injections are one of the most common health
care procedures in both formal & informal health care
sectors. Though in some developing countries &
especially in tertiary health facilities 8,9 patients prefer
injections because they believe them to be more
effective. They also believe that doctors regard
injections to be the best form of treatment. In turn
doctors over- prescribes injections because they
believe that this satisfies patient best, even though
patients are often open to alternatives.10 Additionally,
knowledge regarding injection safety among injection
prescribers, providers and consumers is often
suboptimal.11-13 Poor injection technique can cause
abscess, nerve palsy, subcutaneous nodule,
subcutaneous atrophy, hyper pigmentation, muscle
contracture and fibrosis
The present study was a cross sectional Qualitative
study consisted of assessing the knowledge of Health
Care Providers and observation during injection
procedure (Subcutaneous or Intramuscular or Intra
dermal but not intra articular), took place for a 3
months period from August 2013 to October 2013 in
all the Civil Dispensaries of District Gwalior. Ethical
Approval: The study was approved by the Ethical
Committee of the College.
A list of all the Civil Dispensaries was taken from
the Office of Chief Medical Health Officer, District
Gwalior and also the details of Health Care Providers
working in injection room and immunization room
were also taken. There was a total of 15 Civil
Dispensaries in the City of Gwalior providing
primary Health Care Facility to the people. Among
these three are working as a maternity home
providing both primary Health Care and Maternal
Care. Form each Civil Dispensary (In 11 Civil
Dispensaries 2 Health Care Providers (11x2=22) are
posted while in 2 Civil Dispensaries which are
working as maternity home 5 are posted so 5x2 =10
while in 1 Civil Dispensary there is only 1 Health
Care Provider posted while in 1 Civil Dispensary
which is working as maternity home 2 Health Care
Providers are posted ) (22+10+1+2=35).Health Care
Providers were interviewed depending on their work
place so a total of 35 Health Care Providers were
taken for the study.
Data Collection: Injections practices are very

common in all the Civil Dispensaries in Gwalior City.
The data collection method comprises of two
components. First components were observational in
which the field researcher observed the complete
injection technique starting from patients entering to
the injection room or immunization room and leaving
either of the rooms. The researcher was given
primary training of how ideal injection practice
should commence and was also given both theoretical
and practical knowledge about the safe injection
practices (WHO tool regarding safe injection
practices were used). Maximum patients were tried to
be observed as possible so that the final data comes to
be as near to the reality as possible. The data is not
entered then and there with the pen so that it was felt
that this may cause unnecessary anxiety to the Health
Care Provider.
In the Civil Dispensaries the injection room and the
immunization room runs in the same room, but for
the immunization days that is Tuesday and Friday
vaccination was also given along with the routine
injection practices. If any patient comes for any
injection he is also given injections if required. The
Health Care Providers participated in pre-structured
in depth interviews regarding their views and
experiences related to injection safety, awareness
about the different blood borne diseases spread by
faulty injection techniques and risk to the Hospital
Staff associated with these faulty injection
techniques. After observing the injection session of
the Health Care Provider who were involved in the
injection procedure were also interviewed. The
interviews were conducted at private room using
pretested questionnaire. The questionnaire was based
on the research objective, review of literature and
direction of discussion with the Health Care Provider.
After the complete formation of methodology of
research, pilot testing was conducted in 02 randomly
selected Civil Dispensaries of the city. After
collection of the data both observational and
interview components further literature review was
conducted and appropriate and suitable changes were
made to the questionnaire and also after the complete
process to each Health Care Providers of each Civil
Dispensaries corrective measures in a supportive
supervision style was done so that these measures
could be followed in future for the safe injection
practices for the benefit of both Health Care
646
Leena et al.,
Providers and the patients. The data was collected,

analyzed and interpreted.
Statistics: The statistics used in this study are
percentages and chi square.
RESULTS
A total of 35 Health Care Providers of Civil
Dispensaries was involved in the present study. All of
them were cooperative throughout the study. The
maximum % of the Health Care Providers were of
more than 50 years of age that is 10 (28.57%) and
were having more than 10 years work experience i.e.
22 (62.86%) as shown in Table No.1.
Table 1: Showing the Age and Duration of experience
of Health Care Providers working at Civil Dispensaries.
Age
in No. of participants (n=35)
Years
No.
%
20-25
02
5.71
25-30
05
14.28
30-35
08
22.86
35-40
01
2.86
40-45
04
11.43
45-50
05
14.29
>50
10
28.57
Total
35
100.00
work experience in years
1-5
6
17.14
5-10
7
20.00
>10
22
62.86
All the Health Care Providers working in these Civil
Dispensaries were females and all of them did not
had any formal training for safe injection practices.
As shown in Fig.1, 5(14.29%) did not knew regarding
blood borne viral infections.
X2= 43.6, df= 3,p-value= 0.00

Fig 1: Bar showing the knowledge of Health Care
Providers regarding blood borne viral infections due to
injectable practices at Civil Dispensaries.
X2= 11.4, df=2, p value= 0.003 Significant

Fig.2: Pie Showing Awareness of Knowledge regarding
Reasons of Wearing Gloves before giving injection by
Health Care Providers working at Civil Dispensaries.
Table 2: Showing the knowledge of Health Care

Providers regarding use of personal safety
measures for giving Injections and disposal of
Injection waste generated after giving injection.
Knowledge regarding
Injection
Practices
and
(n=35)
Disposal of Injection related Yes (%)
waste
by
Health
Care
No.(%)
Providers
Wash hands before giving the 35
00
injection
(100%)
Wear gloves during Procedure 35(100%)
00
Check expiry date before 35(100%)
00
giving the injection
Use cutter to open the 35(100%)
00
Ampoule
Use syringe from unopened 35(100%)
00
packet
Clean the site before giving 35(100%)
00
the injection
Recapped needle after giving 00
35(100%)
injection
Bent the needle after giving 00
35(100%)
the injection
Use hub cutter
35(100%)
00
Immediately after the
35(100%)
00
procedure, disposed sharps
waste
Table 2, all the Health Care Providers had the 100%
knowledge regarding use of personal safety measures
for giving injections and also regarding disposal of
injection waste generated after giving injections.
647
Leena et al.,
packed and also cleaned the site by the spirit swab

before giving the injection. These swabs were already
prepared and kept in a plastic box which is used
consecutively for two or three days till the box is
emptied.
Fig.3: Showing the different Skills used regarding use

of safety measures for giving Injections by Health Care
Providers at Civil Dispensaries.
As shown in Fig. 3, there was a great disparity

between their knowledge and actual practices of
Health Care Providers regarding injection practices.
The positive part of the skill in the injection practice
was that 35(100%) used syringe from unopened
X2= 36.5, df=3,p-value=0.000

Fig. 4: Bar Showing the different Skills used for
disposal of waste generated after giving injections
Table: 3 Showing the Details of Waste Disposal of Safe Injection Practices.

Details of Waste Disposal
Yes
A
No.
%
No.
Depiction of
Written Guidelines 9
25.71
26
regarding Waste Disposal
Availability of Colour Coded Boxes
27
77.14
8
Details of Colour Coded Boxes (n=27)
B
Original Colour Coded Boxes
8
29.62
19
Iron bucket/ Plastic bucket/ Iron dustbin 19
70.38
8
used for Waste Disposal
Knowledge regarding use of Colour 8
22.86
27
C
Coded Boxes for immediate disposal of
injection related waste (n=35)
Skill of using different Colour Coded 3
D
37.5
5
Boxes for the waste generated during
injection practices (n=8)
NO
%
74.29
p -Value
22.86
70.38
29.62
X2 =8.96, df=
1,
p-Value= 0.003
77.14
62.5
DISCUSSION
The present study regarding use of safe injection
practices done in all the Civil Dispensaries of
Gwalior showed that all the Health Care Providers
were females, which was dissimilar from the study of
A.A. Mahfouz et al12 in which only 35.5% were
females.
In the present study, none of the Health Care Provider
had taken training in safe injection practices which is
quite similar to the study done by Choudhary et al14
in which 73% of the providers were not trained, but
in the study of M.C. Shill et al13 only 5 (16.7%) of the
Health Care Provider were trained. The knowledge of

blood borne viral diseases of HIV, Hepatitis B,
Hepatitis C was only seen in 5 (14.29%) of Health
Care Providers and also 5 (14.29%) of the Health
Care Providers were not knowing regarding the
transmission of blood borne viral diseases. In the
study of Shill M C et al13) who expressed that 78.3%
had knowledge of Hepatitis B vaccine, 62.09% of
Hepatitis C vaccine and 69.02% of HIV. The
knowledge of blood borne viral diseases was quite
low in comparison to the other studies.2, 10, 15
648
Leena et al.,
The knowledge regarding the injection procedure was

100 % in this study which was similar to the study of
Ashish Naik et al15 Also in his study 15] 65% of
provider had the knowledge not to recapped the
needle while in this study it was 100 %. The
cutaneous nerves with close proximity with injection
in the dorsogluteal site are the branches of the
subcostal nerve (T12), dorsal rami of lumbar nerve,
dorsal rami of sacral nerve, Inferior cluneal nerve,
and posterior femoral cutaneous nerve.
The reasons of wearing the gloves for personal safety
against infection as seen in Ashish Naik et al15 was
60% for personal safety, 25% for patients safety and
15% for personal and patients safety but in this
study it was quite low.i.e. 54%, 17% and 29%
respectively. Oladimeji Akeem et al 16 stated that
20% provider washed their hands before and after
giving the injections, Omorogbe Vincent E 17 stated
78.07%. But in this study it was only 07 (20%) which
was quite low.
In the present study only 4 (11.3%) wore gloves
during the procedure while in the study of Ashish
Naik 15 35.0% wore gloves during the procedure 31
(88.57%) did not wear gloves which was almost 50%
in comparison to the study done by Varun Agarwal18.
In a study of Rehan H.S. et al 19 who stated 61.6% of
the providers did not wore gloves and 44.7% by
Muralidhar et al.20 Who did not were gloves during
the injection procedure. The upper outer quadrant of
gluteal region is to be chosen while dorsal gluteal
region is to be avoided as it lies in close contact with
sciatic nerve and superior gluteal artery.
In the study, 25 (71.43%) of the Health Care
Providers checked the expiry date of the injection
while 10 (28.57%) did not checked assuming that if
the injections has been supplied it has been taken for
granted that it would not have been expired. In the
study of Choudhary A et al.14 Who stated that 84.5%
providers used new syringe for giving the injections
while in another study A.A. Mahfouz et al 12 and
M.C. Shill13 which stated that 100.00% providers
used new syringe for giving the injections which was
similar to this study also.
In the present study 31(88.57%) did not used cutter to
open the Vial/ ampoule which was a negative aspect
but Rehan H.S. et al.19 study quoted that 44.4%
providers opened the ampoule with the solid object.
In the present study 30 (85.72%) of Health Care
Providers did not recapped the needle after the
injection while only 5 (14.28%) recapped it. Review

on this aspect by Ashish Naik 15 . Rehan H.S19,
Omoragbe Vincent E.17 Muralidhar et al 20, Oladimeji
et al16 all stated that 50. 12.2%, 23%, 66.3%, 86.7%,
respectively providers recapped the needle.
Subcutaneous injection goes into the fatty tissue
below the skin and require a smaller shorter needle.
The needle i.e. 1/2" to 5/8 of an inch long with a
gauze of 25to 30 is usually sufficient. Intramuscular
goes into the muscle below the subcutaneous layer so
the needle must be thicker and longer to ensure that
the medicine is being injected into proper tissue,. 20
or 22 gauze, needle that is an inch or one and half
inch long are usually appropriate.
In the present study 21 (60%) of the Health Care
Providers were bending the needle after the injection
which was quite high while in the study of A.A.
Mahfouz et al12 only 11.3% provider were bending it.
The use of hub cutter was not done in 26 (74.39)
cases, while only 09 (25.71%) used it.
In the present study 8 (32.0%) Health Care Providers
immediately disposed the injection waste in the
provided dustbin and the use of color coded was quite
low but in the study of Oladimeji et al 16 who stated
that 95.2% provider used color coded boxes for
immediately disposing the injection waste.
CONCLUSION
There was a great difference between the theoretical
knowledge and the practical knowledge of health care
providers during injection practices. Enough efforts
are required in this regard for training for Safe
Injection Practices for the benefit of both health care
providers and the patients.
ACKNOWLEDGMENT
The Authors acknowledge the contribution of Health
Care Providers who participated in the study very
truthfully and accepted the fact when they were
rectified in supportive supervision style after the
whole process.
REFERENCES
1.
World Bank, Safe Injection Global Network

(SIGN). Injection Safety. http://siteresources.
worldbank.org/INTPHAAG/Resources/AAGInje
ctionSafety9-03.Pdf accessed on 15 July 2013.
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2. Pandit N B,Choudhary S K, Unsafe injection

practices
in
Gujarat,
India.
Singapore
Med.J.2008; 49(11): 936.
3. India Programme Evaluation Network (IPEN)
Study report. New Delhi AIIMS 2004.
Assessment of Injection Practices in India.
www.crosearo.who.int/publication/journal/--/whoseajphvli2p/189.pdf
4. Simonsen L, Kane A, Lloyd J, Zaffran M, Kane
M. Unsafe injections in the developing world and
transmission of blood-borne pathogens: a review.
Bull WHO. 1999;77:789-800
5. World Health Organization. Safe Injection Global
Network (SIGN) initial meeting report, October
4-5, 1999, WHO headquarters, Geneva,
Switzerland.
Geneva:
WHO,
2000.
http://www.who.int/iris/handle/10665/66232
6. Mantel C, Khamassi S, Baradel K, Nasri H,
Mohsni E, Duclos P: Improved safety after
targeted interventions in the Syrian Arab
Republic. Trop Med Int Health 2007;12:422-30
7. Medubi SA, Akande TM, Osagbemi GK.
Awareness and pattern of needlestick injury
among health workers at University Teaching
Hospital Ilorin, Nigeria. AJCEM. 2006; 7(3):18388
8. Odeyemi KA, Onifade KA, Onifade EU. Needle
Stick/Sharp injuries among Doctors and Nurses at
the Lagos University Teaching Hospital. NQJHM
2005; 15 (2):50-54
9. Pandit NB, Choudhary SK. Unsafe injection
practices
in
Gujarat,
India.
Singapore
Med.J.2008; 49(11):936
10. Kotwal Atul, Priya R, Thakur R, Gupta V,
Kotwal J, Seth T, Injection practices in a
metropolis of North India: Perceptions,
determinants and issues of safety. Indian J Med
Sci 2004;58:334-44.
11. Anand K, Pandav CS, Kapoor SK. Injection use
in a village in North India. Natl. Med. J. India
2001; 14: 143-4.
12. Mahfouz AA, Abdelmoneim I, Khan MY,
Daffalla AA. Diab MM, Shaban H, et al.,
Injection safety at primary health care level in
South-Western
Saudi
Arabia
Eastern
Mediterranean Health Journal 2009 ;15 (2): 443.
13. Shill MC, Fahad MB, Sarker Sarmistha, Dev
Shrabanti, Rufaka HK., Ashish KD. Injection
Practices at Primary Healthcare Units in
14.
15.
16.
17.
18.
19.
20.
Bangladesh: Experience at Six Upazilla Health

Complexes. Australia Med J. 2011; 4(1): 2642.
Choudhary AK, Roy T, Faroque AB, Bachar SC,
Asaduzzaman M, Nasrin N, et al. A
comprehensive situation assessment of injection
practices in primary health care hospitals in
Bangladesh. BMC Public Health 2011,11:779
Naik Ashish, Gharat Vaibhav, Bansal RK. An
Assessment of Injection Practices in Urban
Health Centres of Surat City: Are the Health Care
Workers safe? NJCM. 2012; 3 (1): 125-28
Oladimeji Akeem Bolarinwa, Adekunle Ganiyu
Salaudeen, Sunday Adedeji Aderibigbe, Omotoso
Ibraheem Musa, Tanimola Makanjuola Akande,
James Olusegun Bamidele Injection safety
practices among primary health care workers in
Ilorin, Kwara State of Nigeria Health Science
Journal 2012; 6 (3): 496-508.
Omorogbe Vincent E, Omuemu Vivian O, Isara
Alphonsus R Injection safety practices among
nursing staff of mission hospitals in Benin City,
Nigeria
Annals of African Medicine.2012;
11(1):36-41
Varun Agarwal, Anju Seth, Jagdish Chandra,
Rohini Gupta, Praveen Kumar, Ashok Kumar
Dutta
Occupational exposure to human
immunodeficiency virus in health care providers:
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HS, Chopra
D, Sah
RK, Chawla
T, Agarwal A, Sharma GK Injection practices of
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Muralidhar S, Singh PK, Jain RK, Malhotra M,
Bala M. Needle stick injuries among health care
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DOI: 10.5958/2319-5886.2014.00412.3

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Research Article
EFFECT OF SIMULATION BASED EDUCATION ON KNOWLEDGE OF MEDICAL STUDENTS IN

CONTEXT OF COMMUNITY MEDICINE
*Bogam Rahul R
Assistant Lecturer, Department of Community Medicine, Bharati Vidyapeeth University Medical College,
Maharashtra, Pune, India
*Corresponding Author email: rhl_bogam@yahoo.co.in
ABSTRACT
Simulations are being increasingly used to train medical students in diverse clinical skills. Simulation is arguably
the most prominent innovation in medical education over the past 15 years. Role play is a simulation technique
which can potentially strengthen knowledge that will lead to improved expertise. The present study was
undertaken to assess an effectiveness of simple intervention, in the form of Role Play Simulation on the
knowledge of undergraduate MBBS medical students of one of randomly selected medical colleges in
Maharashtra is regarding Epidemics Investigations. Methods: A cross-sectional study consisting of pre and post
test intervention was conducted at one of the randomly selected medical colleges in Western Maharashtra. A
structured pretested self administered questionnaire consisting of 15 close ended questions was distributed to all
144 participants. The present study attempted to incorporate simulation based role play which was based on
epidemic/outbreak investigations for food poisoning. Immediately after this intervention, same questionnaire was
distributed to participants as a post test and responses were collected. Paired t-test was used to assess pre and
post intervention knowledge of participants. Results: Present study revealed significant improvement in
knowledge of participants about epidemic investigations from pre to post intervention as a result of Role Play
Simulation Based Education (t = 42.87, p < 0.001).Statistically significant difference was observed for all fifteen
questions. Conclusion: A simple simulation form like role play can make significant change in knowledge of
medical students about very important topic i.e. Epidemic Investigation in Community Medicine subject.
Key words: Simulations, Community Medicine, Knowledge, Medical students, Role play
INTRODUCTION
There have been burgeoning developments and
changes in medical education.1 The information and
communication technology has revolutionized the
teaching and learning process.1 various new teaching
methodologies are being used to impart medical
education to the students in a more effective way. The
basic reason to look for these methodologies is the
dis-satisfaction with conventional mode of education,
which is losing its relevance in this era of information

explosion.1
Simulations are being increasingly used to train
medical students in diverse clinical skills. Simulation
is arguably the most prominent innovation in medical
education over the past 15 years.2 They help us to
replicate situations which may not possible to get into
real settings or where it may be logistically difficult
to work on real patients. 1 Role play is a simulation
651
Rahul.,
technique which can potentially strengthen

knowledge that will lead to improved expertise.
Despite of an effectiveness of role play in providing
medical education, its use in educating medical
students is limited. 3-5
Epidemic Investigation is not only an essential
aspect in Community Medicine subject but also it has
public health relevance. Even though very few studies
have been conducted so far in India to evaluate the
knowledge of medical students pertaining to
investigations of epidemic, some evidences have
shown that Simulation Based Education can be an
effective teaching tool to educate medical students
about emergency situation like epidemics. Clinical
situations for teaching and learning purposes are
created using various forms of simulation like
mannequins, part-task trainers, simulated patients or
computer-generated simulations.
Multiple studies have demonstrated the effectiveness
of simulation in the teaching of basic science and
clinical knowledge, procedural skills, teamwork, and
communication as well as assessment at the
undergraduate and graduate medical education
levels.4
The present study was undertaken to assess an
effectiveness of simple intervention, in the form of
Role Play Simulation on the knowledge of
undergraduate MBBS medical students of one of
randomly selected medical colleges in Maharashtra is
regarding Epidemics Investigations.
Objective: To assess an effectiveness of Role Play
Simulation on knowledge of undergraduate MBBS
medical students about Epidemics Investigations
A cross-sectional study consisting of pre and post test
intervention was conducted at one of the randomly
selected medical colleges in Western Maharashtra.
The inclusion criteria were all 144 undergraduate
medical students from 7th semester who were present
on the day of an intervention. Those who did not
attend the class on the day of an intervention were

excluded from the study. Written permission was also
obtained from participants after explaining the
purpose of study to them. Since the study did not
involve any invasive intervention or procedure and it
was related to only educational intervention.
A structured pretested self administered questionnaire
consisting of 15 close ended questions was
distributed to all participants. They were allowed 15
minutes to complete questionnaire under strict
supervision. A questionnaire consisted of questions
based on various aspects of epidemic investigations
like essential criteria for confirmation of existence of
an epidemic, spot map, epidemiological case sheet
etc.
The present study attempted to incorporate simulation
based role play which was based on epidemic/
outbreak investigations for food poisoning. Few
volunteer medical students were selected and trained
to participate in simulation based role play. They
were asked to focus on ten important steps in
investigation of an epidemic i.e. verification of
diagnosis, confirmation of an existence of an
epidemic, defining the population at risk, rapid search
for all cases and their characteristics, data analysis,
formulation of hypothesis, testing of hypothesis,
evaluation of ecological factors, further investigation
of population at risk and writing the report (Table 1).
Remaining students were asked to watch this
simulation based role play. Total duration of role play
was about 20 minutes. Immediately after this
intervention, same questionnaire was distributed to
participants as a post test and responses were
collected.
Data Analysis: The scoring system for each
complete question was assigned for pre and post
intervention. Statistical analysis was done using
Microsoft Office Excel Sheet. Paired t-test was used
to assess pre and post intervention knowledge of
participants.
652
Rahul.,
Table 1: Pre and Post intervention questions with correct response (n = 144)
Question
Correct Response
In case of an epidemic, epidemiological investigations should be False
delayed until the laboratory results are available.
First step in investigation of an epidemic is
Verification of diagnosis
What is the basic and essential criterion for confirmation of existence of Observed frequency is in excess of
an Epidemic?
the expected frequency of disease
During epidemic investigation, till how long search for new cases to be Period twice the incubation period of
done?
suspected
disease
since
the
occurrence of last case.
The document used to collect the data from cases and exposed persons Epidemiological case sheet
during epidemic investigations is
During epidemics investigation, there is no need to conduct medical False
survey for those people who are exposed to disease but do not develop
disease. It is applicable only for cases (those who develop disease).
Epidemiological case sheet can be administered by trained lay health True
workers for collecting data during epidemic
Control measures is not a part of investigation of an epidemic
False
If large numbers of people are affected at same time with similar True
manifestations and common source, it can be an epidemic
Ideally how many steps are there for investigation of an epidemic?
Ten
During epidemic situations, geographical information is best displayed Spot Map
by
What will be the ideal step after defining the population at risk during Rapid search for all cases and their
investigation of an epidemic?
characteristics
Epidemic/Outbreak is confined to only communicable diseases.
False
Data analysis should be in preference to time, place and person
True
In case of food poisoning epidemic, there is no need of comparison of True
observed frequency and expected frequency
RESULTS
In the present study, of 144 participants 78 (54.16%)
were males and 66 (45.83%) were females. All
(100%) participants were in the age bracket of 20-23
years. Simulation method like role play is a cost
effective educational intervention which can create
maximum impact on learning abilities of medical
students.
Table 2: Mean marks of participants (n = 144)
Mean Score SD t value
P value
(out of 15)
Pre test 5.16 2.06
42.87
<0.001**
Post test 12.01 1.18
**highly significant
The P value or calculated probability is the estimated
probability of rejecting the null hypothesis (H0) of a
study question when that hypothesis is true. A p value

of less than 0.05 was considered significant. A t-test
tells the probability that two sets of values come from
different groups.
DISCUSSION
In contemporary medical education, there is strong
emphasis on the use of innovative teaching methods
like Problem Based Learning, One Minute Preceptor
(OMP), Computer Assisted Learning, Flipped
Teaching etc. Uses of these types of methods help
students to learn various clinical skills in a more
effective way.
The present study attempted to impart knowledge to
undergraduate medical students about investigations
of an epidemic by using Role Play Method rather
than using traditional teaching methods.
653
Rahul.,
The present study showed that simple simulation

form like role play made improvement in the
knowledge of participants about Epidemic
Investigation. The major objectives of epidemic
investigations are to define the magnitude of the
epidemic outbreak in terms of time, place and person
and to determine the particular conditions and factors
responsible for the occurrence of an epidemic.7
Similarly, other Studies also reported that the use of
simulations as a teaching tool increases students
comprehension of complex theoretical concepts in
relation to modules that are taught solely with the
traditional lecture/seminar format. 7 Jennifer M
Weller et al. 8 also recommended that Simulation
Based Education needs to be integrated into medical
curricula at the development stage, with careful
attention paid to transfer of skills learnt to the real
clinical environment. In a Malaysian medical school,
role plays have been used to teach communication
skills in primary care medicine. 9 Simulation has a
vital role in strengthening clinical reasoning skills,
communication skills as well as formative and
summative assessment of medical students.
Present study revealed significant improvement in
knowledge of participants about epidemic
investigations from pre to post intervention as a result
of Role Play Simulation Based Education (t =
42.87, p < 0.001) (Table 2). Statistically significant
difference was observed for all fifteen questions.
However prior to an intervention, poor level of
knowledge was found amongst participants regarding
certain aspects of epidemic investigations like Spot
Map, criteria for confirmation of epidemic, period of
investigation of an epidemic etc.( Table 2).
The present study reiterates the need for
incorporation of innovative methodologies like
simulations along with traditional methods for better
learning of students. At some places, methodology
like Role Play has been regular teaching method in
medical colleges.10 At the University of Heidelberg,
Germany, introducing role plays augmented the
realism of technical training and improved doctorpatient communication and to teach students to obtain
a sexual history and discuss sexual health issues.11
Role-play is simple form of simulation which can be
a valuable teaching tool for medical education,
requiring few resources and allowing students to look
at the material they are learning in a new light.
CONCLUSIONS
Present study reported significant improvement in
knowledge of undergraduate medical students
pertaining to epidemic investigation from pre to postintervention as a result of role play method. It shows
that even a simple simulation form like role play can
make significant change in knowledge of medical
students about very important topic i.e. Epidemic
Investigation in Community Medicine subject.
ACKNOWLEDGEMENT
We heartily acknowledge the cooperation and support
of Dr. Shekhar M. Kumbhar for conduction of this
study.
Declaration of interest: The author reports no
conflicts of interest. The author alone is responsible
for the content and writing of the article.
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of Simulations as a Teaching Tool in Higher
Education 2005,4(5):1-25.
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Marshall, Peter M Brooks, Jennifer J Conn.
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learning.MJA.2012; 196 (9):1-5.
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students perspective about role plays as a
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Pakistan. 2012; 22(4): 22225
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Zipfel S, Herzogi W et al.: Integration of roleplaying into technical skills training: a
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DOI: 10.5958/2319-5886.2014.00413.5

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Health Sciences
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Volume 3 Issue 3
th

Research Article
Coden: IJMRHS
nd
Revised: 2 Jun 2014
Copyright @2014
ISSN: 2319-5886
th
Accepted: 16 Jun 2014
SOME INTERESTING MORPHOLOGICAL FEATURES OF LIVER LOBES IN MUMBAI POPULATION
*Khedekar Deepak N1 & Hattangdi Shanta S2

1
Assistant professor, 2Head & Professor, Department of Anatomy, Lokmanya Tilak Municipal Medical College &
GH, Sion, Mumbai, Maharashtra, India
*Corresponding Author email: drdeepak2025@yahoo.co.in
ABSTRACT
Introduction: Liver is the largest gland in the body mainly situated in the right upper quadrant of the abdomen.
Abnormalities of liver are rare. Common abnormalities are irregularities in form, occurrence of one or more
accessory lobes, fissures or abnormal ligaments. Rare abnormalities include atrophy, or complete absence of one
of the lobes. Although the segmental anatomy of the liver has been extensively researched, very few studies have
dealt with the surface variations of the liver. Accessory lobe may be confused with tumour. Accessory fissure may
mimic internal trauma at the time of the post-mortem study. Aim: Present study was carried to find out the
morphological variations of liver lobes occurring in Mumbai population. Methods & Materials: The materials
used for present study comprised of formalin fixed 50 adult livers. Results & conclusion: In the present study we
found accessory liver lobes in 3 cadavers i.e. 6 %, atrophy of left lobe in 15 cadavers i.e. 30 %, accessory fissures
in 21 cases i.e.42%.There is also abnormal connection between left lobe and quadrate lobe in 14% cases. The
findings of study may be helpful to radiologist and surgeons respectively, to avoid possible errors in
interpretations and subsequent misdiagnosis, and for planning appropriate surgical approaches.
Keywords: liver lobes, accessory lobes, accessory fissures, atrophy of left lobe, morphology, variations.
INTRODUCTION
Liver is the largest gland in the body mainly situated
in the right upper quadrant of the abdomen. Here it is
protected by the thoracic cage and diaphragm. It
occupies most of the right hypochondrium and upper
epigastrium and extends into the left hypochondrium.
The liver has diaphragmatic surface (anterior,
superior and some posterior) and relatively flat or
even concave visceral surface which are separated by
the sharp inferior boarder which follows right costal
margin inferior to diaphragm. Diaphragmatic surface
is smooth, dome shaped and covered with visceral
peritoneum, except posteriorly in the bare area of the
liver. Anteriorly left lobe and right lobe are separated
by falciform ligament which extends from liver to
anterior abdominal wall lies essentially in midline
Deepak et al.,
plane. Right lobe is 4-5 times larger than left lobe. On

the slanted visceral surface, the right and left sagittal
fissures course on each side of transverse porta
hepatis separating two accessory lobes (part of
anatomic right lobe).The quadrate lobe anteriorly and
inferiorly and the caudate lobe posteriorly and
superiorly. Right sagittal fissure is continuous groove
formed anteriorly by the fossa of the gall bladder and
posteriorly by the groove for vena cava. Left sagittal
fissure continuous groove formed anteriorly by
ligamentum teres hepatis and posteriorly by the
ligamentum venosum. Two sagittally oriented fissures
linked centrally by tranverse porta hepatis forming H
shaped groove on visceral surface. Porta hepatis
contain portal triad i.e. portal vein, hepatic artery, bile
656
duct. Normally there is no communication between

quadrate lobe and left lobe.1
Abnormalities of liver are rare inspite of its complex
development in the ventral mesogastrium; common
abnormalities are irregularities in form, occurrence of
one or more accessory lobe, fissure or abnormal
ligament. According to Champetier J.et al hepatic
anomalies can be divided into two categories, i.e.
anomalies due to defective development and
anomalies due to excessive development of the liver.
The liver tissue in the communicating with the main
mass of liver is termed as accessory lobe while the
liver tissue lying in the vicinity of the liver termed as
ectopic liver.1-3
This study was undertaken to find out the
morphological variations of liver lobes occurring in
Mumbai population. The congenital abnormalities of
liver can cause diagnostic confusion for physicians,
surgeons, radiologist and anatomist.
cases i.e. 30% (fig: 3,6), Accessory fissures ( ranging

from 1-5) in 21 cases 42% (fig: 4, 5). Elongated right
lobe in 6 cases i.e. 12 % (fig: 6), interconnected left
lobe and Quadrate lobe with absence of fissure for
ligamentum teres in 7 cases i.e. 14 % (figure: 2). One
case with absent quadrate lobe (fig 1.).
Fig 1: Absence of quadrate lobe

This study was conducted in the department of
Anatomy, Lokmanya Tilak Municipal Medical
College & General Hospital, Mumbai, India. The
materials used for present study comprised of 50
formalin fixed adult livers which were dissected
during routine dissection classes for medical
undergraduate students over a period of 6 years. The
embalmed livers were carefully studied for the
abnormality in various lobes of liver, presence of
accessory lobes, accessory fissures. Specimens were
photographed the findings were appropriately
documented. The procedures followed were in
accordance with the ethical standards of
experimentation (institutional) and with the Helsinki
Declaration of 1975, as revised in 2000.
Inclusion criteria: age between 20-72 years, weight
between 1.2kg -1.8kg, intact specimens with normal
anatomical features.
Exclusion criteria: age below 20 years, specimens
with cirrhotic liver, damaged liver, liver with gross
changes in size and shape.
Fig 2: Interconnected left lobe and quadrate lobe
RESULTS
In our study we found morphological variations of
liver lobes out of 50 livers occurring in Mumbai
population. We found Accessory liver lobes in 3 cases
i.e. 6 % (fig: 4). Atrophy of left lobe of liver in 15
Deepak et al.,
Fig 3: Atrophy of left lobe
657
Fig 4: Accessory fissure (arrow) and accessory lobe on

posterior and inferior surface of liver
Fig 5: Accessory fissures on anterior surface of liver
Fig 6: Atrophy of left lobe and and elongation of

right lobe.
DISCUSSION
In this world of the modern imaging techniques it
becomes utmost important to radiologist and
diagnosing clinician to have thorough knowledge of
anatomy and commonly occurring variations in organ
like liver which is largest gland of the body and the
main metabolic centre of the body. Externally liver
has been divided into two anatomical lobes and two
accessory lobes by the reflections of peritoneum from
its surface. Internally on the basis of the blood supply
Deepak et al.,
and biliary drainage, there are four main hepatic

division. These hepatic divisions can be subdivided
into eight surgically resectable hepatic segments, each
served independently by secondary or tertiary branch
of portal triad, respectively.1
Accessory lobe of the liver is very rare variation
which may remain silent in many subjects. In our
study we found accessory lobes in 3 cadavers. There
was no evidence of ectopic liver tissue. Sato el found
incidence of ectopic liver lobe and accessory liver
lobe 0.7%. 4 Accessory lobes are most commonly
found on the undersurface of the liver, but also have
been seen on the gall bladder surface 5 , hepatogastric ligament, near the umbilicus, adrenal gland 6 ,
pancreas and the thoracic cavity accessory
intrathoracic liver lobe was first reported by
Hansborough and Lipin in 1975.7 Riedel in 1888
described the occasional tongue-like projection of the
right lobe of the liver, extending to or below the
umbilicus.8 Madhur gupta et al related liver size to
body surface area.9
Multiple accessory fissures may mimic pathologic
liver nodules on CT and may be associated with
diaphragmatic scalloping or eventration on the chest
film. When only parts of these fissures are seen
sonographically, they may be mistaken for echogenic
liver lesions.10 We got quite higher incidence of
accessory fissures i.e.42%.Shailaja et al in her study
revealed accessory lobes (6%) and accessory fissures
(24%) associated with gallbladder mesentery (4%)
amongst the liver specimens studied.11 A liver was
observed with duplicated caudate lobe and
hypoplastic left lobe of the liver.12 Hussein Muktyaz
et al found accessory liver lobes in 6 cadavers 14.6%,
atrophy of left lobe in 2 cadavers 4.8%, accessory
fissures in 5 cases 12.1%.13
Lobar atrophy of the liver due to causes other than
liver tumor or liver cirrhosis is a relatively rare
pathological condition, and there are only a few
reports in the literature.14 We got 15 cases of left
lobar atrophy during our study. Hepatic lobar atrophy
usually occurs in the setting of combined biliary and
portal vein obstruction. A significant correlation
exists between hepatic lobar atrophy and ipsilateral
portal vein obstruction.15
Joshi SD et al utilised 90 livers for their studies. In
that study, the quadrate lobe was absent in 2 cases and
in two other cases, the quadrate lobe was not seen on
the inferior surface, but after retracting the two lips of
658
the fissure for ligamentum teres, it was seen lying

deeply.16 In our study incidence of absent quadrate
lobe is 2%.There was no incidence of deeply seated
quadrate lobe.
CONCLUSION
In this study we have described morphological
variations of the liver lobes. This could be a cause of
medical interventions because of unexpected
presence of the variant accessory lobe of liver
resembling. Atrophy, agenesis, presence of accessory
fissure or lobe, absence of normal fissure or lobe of
liver can cause diagnostic confusion for surgeons
during surgery and for physicians, radiologist and
anatomist. Therefore it becomes necessary for
clinicians to have up to date knowledge of the
morphological variations of liver.
7.
8.
9.
10.
11.
ACKNOWLEDGEMENTS
All authors are thankful to Department of Anatomy,
LTMMC &GH, Mumbai. Authors of this study also
acknowledged to authors, editors, and publishers of
all those articles, journals and books from where
literature for this article has been reviewed and
discussed.
Conflict of interest : Nil
REFERENCES
1. Kieth LM, Arthur FD, Anne MR. Clinically
Oriented Anatomy. 6th ed. Lippincott Williams
&Wilkins.2010:268-76
2. Champetier J, Yver R, Letoublon C.A general
review of anomalies of hepatic morphology and
their clinical implications. Anat Clin.1985; 7:
285-99
3. Collan Y, Hakkiluoto A, Hastbacka J. Ectopic
Liver. Ann Chir. Gynaecol.1978; 67: 27-29
4. Sato S, Watanabe M, Nagasawa S, Niigaki M,
Sakai S, Akagi S, et al. Laproscopic observations
of congenital anomalies of the liver. Gastrointest
Endosc.1998; 47:136-140
5. Cullen TS. Accessory lobes of the liver: an
accessory hepatic lobe springing from the surface
of the gall bladder. Arch Surg.1925; 11:718-64
6. Rendina E,Venuta F, Pescarmona E. Intrathoracic
lobe of the liver: Case report and review of
Deepak et al.,
12.
13.
14.
15.
16.
literature. Eur J Cardio thoracic Surg.1989; 3:7578

Hansborough ET, Lipin RJ. Intrathoracic
accessory lobe of the liver. Ann Surg.1975; 145:
564-67
Riedel BM. Uber den zungenformigen Fortsatz
des
rechten
Leberlappens
und
seine
pathognostische Bedeutung fur die Erkrankung
der Gallenblase nebst Bemerkungen uber
Gallensteinoperationen. Berlin Klin Wschr. 1888;
25:577
Madhur G, Lavina S, Yadav T. Morphology of
liver. India Journal of Surgery 2008; 70 (1): 3-7
Auh YH, Rubenstein WA, Zirinsky K, Kneeland
JB, Pardes JC, Engel IA,et al. Accessory fissures
of the liver: CT and sonographic appearance. AJR
Am J Roentgenol.1984 Sep; 143(3):565-72
Shailaja S, Lakshmi K, Jayanthi V, Sheshgiri C.
A Study of variant external features on cadaveric
livers. Anatomica Karnataka.2011; 5(3): 12-16
Singh R, Singh K, Man S. Duplicate caudate lobe
of liver with oblique fissure and hypoplastic left
lobe of liver J. Morphol. Sci., 2013; 30(4): 309311
Hussein M, Usman N, Gupta R, Sharma Kr.
Morphological variations of liver lobes and its
clinical significance in north Indian population
G.J M.M.S. 2013; 1(1):1-5
Ishida H, Naganuma H, Konno K, Komatsuda
T, Hamashima Y, Ishioka T, et al .Lobar atrophy
of the liver. Abdom Imaging. 1998; 23(2):150-3
Hann LE, Getrajdman GI, Brown KT, Bach
AM, Teitcher JB, Fong Y, et al. Hepatic lobar
atrophy: association with ipsilateral portal vein
obstruction.Am J Roentgenol. 1996;167(4):101721
Joshi SD, Joshi SS, Athavale SA. Some
interesting observations on the surface features of
the liver and their clinical implications. Singapore
Med J 2009; 50(7): 715
659
DOI: 10.5958/2319-5886.2014.00414.7

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Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Research Article
CLINICAL OUTCOMES OF END STAGE RENAL DISEASE AND ADEQUACY OF ADULT

MAINTENANCE HEMODIALYSIS PATIENTS
*Ismail Mahmud Ali1, Amirthalingam R2
1
Hospital Director, Head, Assistant Professor, Department of Surgery, Ibn Sina Teaching Hospital, Sirt
University, Libya.
2
Specialist, Department of Molecular biology, Ibn Sina Teaching Hospital, Sirt University, Libya. P.O. Box 705
*Corresponding author email: amrithrgenes@yahoo.co.in
ABSTRACT
Background & Aim: End stage renal disease (ESRD) is an irreversible loss of kidney function caused by various
risk factors and affected persons of lives mainly depending on the technology of renal replacement therapy (RRT)
or renal transplantation (RT) to sustain the life. Aim of this study is to overview the clinical outcomes of ESRD
and adequacy of maintenance hemodialysis among the patients. Materials & Methods: Currently, there are sixty
two end stage renal disease patients clinical datas were collected and included in the study. For all patients, pre
and post hemodialysis samples were collected and processed through biochemical and hematology auto analyzer.
The hemodialysis modalities 4008 H/S and high-flux & low flux ultra filter dialyzers had utilized to three dialysis
sessions per week, 4 hrs per session for each individuals. Blood flow rates differed from 150 to 350ml min-1
depending on conditions and standard dialysate flow was 500ml/ min-1. Results: Of total sixty two patients,
51.62% females and 48.38% males with mean age of 47.76 (18-72) years; gradually increased at the ages of 55 to
72 years then adult age. Concerning overall risk factors in ESRD, 61.30% of hypertension as a leading risk factor
followed by 21% NIDDM, 11.30% other kidney diseases and 6.40% cardiac related diseases. Although, there are
others clinical signs such as hypothyroidisms; extra-pulmonary infection, retinitis pigmentosa and infertility have
been diagnosed. In addition, nearly 33.87%% of HCV, 6.45% HBV and 3.22% of co-infection have been
prevalence in ESRD hemodialysis population. Relating to hepatitis C, B and co-infection during dialysis exposure
were 29.41%, 2.94% and 2.94% in that order. In relation to overall adequacy of maintenance hemodialysis in this
study nearly 75.80% ( 1.3 to 2.5 Kt/V) and 24.20% (1.05 to 1.3 Kt/V) were been analyzed through Kt/V formula
for wastage clearance. Conclusion: The present study highlighted that the co morbidity of ESRD, current
adequacy of adult maintenance hemodialysis, and suggesting to boost better by 90% (1.2Kt/V) of adequacy in
all dialysis patients. In addition to that, exposure of hepatitis B and C virus during dialysis and advocating to
implement current medical strategic to prevent ongoing clinical phenomenon within the patients.
Key words: Maintenance hemodialysis, End Stage Renal Disease, Co-morbidity, GFR
INTRODUCTION
The chronic kidney disease (CKD) is characterized to
be an end stage renal disease (ESRD) with
irreversible loss of kidney function needed of dialysis
and renal transplantation (short term) to carry over
Ismail et al.,
life. The glomerular filtration rate (GFR) is one part

of excretory function and if deficiency of GFR less
than 60ml/min/1.73m2 it is considered as CKD so it
wont be cured permanently. Even if the disease is
660
curable, it must be a coincidence. The normal GFR in

adult population is nearly 125ml/min/1.73m2 but in
ESRD individual is nearly <15ml/min/1.73m2.The
GFR deficiency might be quantifiable by recent
formula for GFR based on serum creatinine and
cystatin C radios but not a single marker. According
to KDOQI practical guideline, general physiologic
age-related changes in kidney function often lower
GFRs to ~ 60-90 ml/min/1.73m2.Hence,the age
related deficiency in GFR is~ 1 ml/min/1.73m2/year,
starting after 30-40 years1. In addition and
inconsistently, the decrease of muscle mass linked
with aging may overestimate the GFR and potentially
mislead the healthcare provider. Currently in
type1&2 diabetes, the new biomarkers like serum
tissue necrosis factors 1 and 2 (sTNFR1&2) having
significant role to predict the kidney disease by ten
years advance2-3 and it is the best clinical marker than
creatinine and cystatin C radios in kidney injury. The
signs of chronic kidney diseases may not be
noticeable for a year; hence the loss of kidney
function may be slow down without symptoms until
kidney stopped working. The symptoms might be loss
of appetite, bone pain, common ill feeling with
fatigue, excessive thirst, headaches, pruritus, nausea,
numbness, breath odor, sleep and vomiting problem
and weight loss4.
There are different types of clinical laboratory
markers available in current medical practice to
identify the co morbidity of ESRD in maintenance
hemodialysis patients. Albumin is one of the plasma
protein occur in urine if there is kidney diseases. The
significance of albumin creatinine radios (ACR>
30mg/g); and albumin excretion radios (AER) in
subsequent clinical risk factors such as CKD
progression, cardiovascular and diabetic kidney
disease in both types of diabetes with background of
ESRD5.The main causes of ESRD among prevalent
individuals
were;
diabetic
nephropathy,
glomerulonephritis,
hypertensive
nephropathy,
congeneital hereditary diseases and polycystic kidney
diseases and others6. Also, higher albumineuria is
significantly linked with severity of hypertension and
insignificant lipid indication like elevated total
cholesterol, triglycerides, lipoprotein-a, decline of
HDL-c levels and malformation of coagulation7.
Besides that, micro-albuminuria is sensitive early
marker for detection of ESRD with diabetes-2 and an
irregularity of systolic blood pressure is an
Ismail et al.,
independent risk factor for elevation of albuminuria8.

The association of cardiac biomarkers such as brain
natriuretic peptide (BNP), C-reactive protein (CRP),
IL-6, IL-10 (interleukin), cardiac troponin T and
asymmetric dimethyl arginine (ADMA) for
inflammation,
oxidative
stress,
endothelial
dysfunction, myocardiopathy, renal insufficiency and
atherosclerosis in ESRD patients with pre and post
maintenance
dialysis9-10.The
creatininekinase
isoenzymess MB, and myoglobin are usual
biomarkers for myocardial necrosis in patients with
end stage renal failure11 .The ischemia modified
albumin (IMA) is sensitive marker for identifying
ischemia and higher in ESRD, also significantly
linked with larger left ventricular size, decline
systolic function and higher estimated left ventricular
filling pressures with life time treatment12. For
diagnosis of anemia and management of ESRD
patients, there are several parameters like target
hemoglobin (11-12g/dl), ferritin (100-200ng/ml),
transferring saturation (TSAT) (20%), HYPO<10%
(hypo chromic percentage) and mean reticulocyte
hemoglobin content (CHret->29pg) 13-14.
Renal osteodystrophy is caused by high turnover
bone disease (HTBD) due to elevation of iPTH (intact
parathyroid hormone) and low turnover bone disease
(LTBD) due to deficiency of iPTH caused by
hyperglycemic and hyper-insulinemia in ESRD with
type-2 diabetes in maintenance hemodialysis
population15-16. In ESRD MHD patients (maintenance
haemodialysis), elevated levels of VLDL, IDL and
LDL (very low density lipoprotein) cholesterol are
considered uremic dyslipidemias and in same time
decline of HDL (high density lipoprotein) as well as
lipid and lipoprotein abnormality have been
observed17.These are all markers had significant roles
to identifying several risk factors in co-morbidity of
end stage renal disease and in fact needed of these
marker to well-known of patho-physiological
phenomenon of kidney damages. In present study
primarily focused on clinical outcomes of end stage
renal disease and adequacy of maintenance adult
hemodialysis as a first scientific research work
among hemodialysis individuals and also suggesting
these biomarkers to be introduced in near feature.
Patient and study blueprint: The study subjects
incorporated both males and females of 62 ESRD
661
patients in the ages of 18-72 years with clinical

history, receiving maintenance hemodialysis as free
of charge from government healthcare sector. All the
ESRD patients were admitted in the hospital with
consultation of nephrologists and epidemiologist for
the purpose of maintenance hemodialysis and it is
running since establishment. The patients samples
were collected from the maintenance adult
hemodialysis units at the department of hemodialysis
in Ibn Sina Teaching Hospital. The ethics panel and
internal review board of the organization approved
the procedure. Informed consent was obtained from
individual patients. The datas were included the age,
gender, types of ultra filtration, dry weight, blood
groups, hemodialysis doses, blood pressure, urea and
creatinine (before & after hemodialysis), other
laboraty datas and co morbidity of end stage renal
diseases as inclusion criteria and others clinical sign
were considered as exclusion criteria.
Patients clinical status analysis: Datas were
collected from patients data registry in a month
period in the years of 2014 at the department of
hemodialysis. Co morbidity of ESRD among
hemodialysis patients were comprised anemia,
hypertension, NIDDM (Non-insulin dependence
diabetes mellitus), dilated cardiac myopathy (DCM),
coronary artery diseases (CAD), renal atrophy, renal
transplantation, diabetic nephropathy, myocardial
infarction,
polycystic
kidney
diseases,
hypothyroidisms, HCV, HBV and hepatitis B&C
virus co-infections were predicted meticulously
through proper investigation. Biostatical analyses
were performed by using Minitab (v16) and
Microsoft ware Excel-2007.
Hemodialysis modalities (4008S/H) : All the
patients have been on regular maintenance
hemodialysis using ultra filtration membrane
(GFS17,GFS14 &GF6); 4 hours per episode and 3
times per week, within permitted dialysis fluid
concentration. Concerning about hemodialysis
vascular access in ESRD, most of the patients had
arteriovenous fistulas access (AVF). Blood flow rates
varied from 150 to 350ml and standard dialysate
500ml/ min-1. Heparin doses were differed according
to the condition of patients and the heparin doses like
free, priming, 2500, 5000, 7500 and 10000 IU. The
minimum dialysis dose was set free at the dialysis
unit Kt/V, according to the manufacture guideline.
Online clearance monitor (OCM) is an extra option
intended for use with these modality systems. This

option permits resolve of the estimated efficient urea
clearance (K), the dialysis dose Kt/V and the plasma
sodium concentration during dialysis. All patients
were dialyzed with high/low-flux ultra filtration
membranes. The dialysate used was identical for all
management and consisted of sodium 138mmol/l,
potassium 2mmol/l,calcium1.75mmol/l, magnesium
0.50mmol/l,
chloride
109.50mmol/l,
acetate
3.0mmol/l and bicarbonate 32mmol/l. Dialot and
citrosterile were been applied for clean-up instrument
(4008S/H Fresenius Medicare Germany) after
dialysis and new dialyzer have been used to treat
patients for each treatment of hemodialysis. All
patients laboratory parameter were screened in the
beginning of month through the regular practice for
adult maintenance hemodialysis and it is not
difficulty even if it is sound because of technical
advances.
Clinical Lab analysis: ESDRD patients blood
samples (5ml) were drawn correctly from overnight
fasting pre-and post maintenance hemodialysis in
serum and plasma vacationer. This sample used for
quantification of complete blood count profile, serum
creatinine, blood urea nitrogen (before/after
hemodialysis),
sodium,
potassium,
calcium,
phosphorus, total protein, and liver enzymes. Fasting
blood glucose was measured within this sample for
diabetic patients. All patients samples were
immediately centrifuged and stored at 2-8C until
analysis for the others biochemical parameters. All
the biochemical and hematology parameters were
measured by using AU480 and ACT5 Diff-Beckman
clinical laboratory auto analyzer.
RESULTS
11.30%
21.00%
HTN
6.40%
NIDDM
61.30%
OKD
CAD
Fig 1: Co morbidity of ESRD

Generally, the prevalence of ESRD was higher
among females 51.62% while in males 48.38% but it
was very low in young patients. It has steadily
increased between the ages of 55 to 72 years in both
662
Ismail et al.,
genders and the mean age was 47.76 (18-72 years) in

of them had pulmonary hypertension, 11.30% had
this region. Concerning blood groups, 54.84% O type
other kidney diseases (1n renal atrophy, 2n renal
(n-34), 37.10% A type (n-23), 4.84% B type (n-3)
rejection, 2n poly cystic kidney diseases and 2n
and 3.22% AB type (n-2) respectively, were observed
glomerular nephritides) and 6.40% had cardiac
in dialysis population. As sown in figure 1, about
related diseases (1n coronary artery diseases, 2n
61.30 % of patients (n-38) were clinically diagnosed
dilated cardiac myopathy and 1n myocardial
as hypertension, 21%(n-13) type 2 diabetes with few
infarction).
Table.1: Clinical outcomes of End Stage Renal Diseases and Biochemicals profiles with adequacy of
maintenance hemodialysis
Biochemicals
Hypertension NIDDM
Cardiac
Other
HCV
HBV
profiles - n62
n38
n13
Diseases n4
Nephropathy Infection
infection
(95% CI)
(95% CI)
(95% CI)
(95% CI) n7 (95% CI) n21 (95% CI) n4
Blood Glucose
108.80
156.70
91.495
92.33
106.11
127.00
(mg/dl)
134.24
285.50
370.00
132.53
134.85
129.00
Haemoglobulin
9.361
7.38
7.536
7.916
9.491
5.404
(g/dl)
10.379
9.75
12.864
10.426
10.861
14.596
Urea (mg/dl)
139.91
157.6
172.522
129.3
134.64
67.164
before dialysis
160.97
220.0
263.473
205.5
164.59
226.227
Urea(mg/dl)
45.46
55.78
70.738
33.1
43.18
18.341
after dialysis
55.84
84.52
112.62
102.9
60.82
77.159
CREA(mg/dl) before
9.761
7.51
9.703
7.85
9.286
5.312
dialysis
11.239
13.19
19.497
13.72
10.922
15.78
CREA(mg/dl)
3.713
2.98
3.611
2.621
3.646
1.805
after dialysis
4.575
4.00
8.539
6.607
4.762
6.095
Sodium (Na)
134.490
129.13
130.763
133.687
133.748
136.62
(mmol/l)
136.510
134.56
137.237
136.597
137.014
137.37
Potassium(K)
4.773
4.445
4.696
4.354
4.89
2.845
(mmol/l)
5.167
5.447
6.354
5.830
5.29
7.135
Calcium(Ca)
9.273
8.522
8.459
9.198
9.182
5.893
(mg/dl)
9.867
10.062
9.941
10.602
10.188
15.30
Phosphorus
4.844
4.204
6.051
4.06
4.771
3.69
(mg/dl)
5.878
6.100
8.369
6.024
6.355
9.20
Total Proteins (g/dl)
7.118
6.851
6.824
6.504
7.139
4.099
7.466
7.655
7.685
7.666
7.651
11.01
ALT (U/L)
13.82
7.32
6.451
20.045
15.41
12.09
29.60
15.91
19.549
46.045
31.25
139.91
AST (U/L)
16.71
9.90
6.372
3.833
18.95
21.141
25.07
21.02
20.628
23.666
31.15
87.859
ALP (U/L)
98.80
83.0
42.620
113.533
138.7
27.327
254.00
161.1
421.88
269.533
418.5
207.17
31.60
69.30
75.00
42.90
Overall: 1.05-1.3 (24.20%)
Kt/V( 1.4 to 1.5) %
68.40
30.70
25.00
57.10
1.3-2.4 (75.80%)
65
to
65%
URR
44.80
69.30
57.15
Overall: 40 to 64 (51.60%)
(Ureareduction radio)
55.20
30.70
100 (65%)
42.85
65 to 85(48.4 0%)
Along with this population, there are two more cases
were diagnosed as hypothyroidisms, retinitis
pigmentosa, one infertility and one extra-pulmonary
tuberculosis with background of renal rejection. In
addition, 33.87% of hepatitis C (n-21), 6.45% of
Ismail et al.,
hepatitis B (n-4) and 3.22% co-infection (n-2) cases

were been identified as infective agents in ESRD
patients. These are infection had before and during
dialysis. As well, there are more than 54.85% of
patients (n-34) had multiples blood transfusions
663
during hemodialysis and 45.15% of (n-28) patients

were under the treatment of erythropoiesis
stimulating agent (ESA) after dialysis. Among the
blood transfusion patients, there are 29.41% (n-10) of
patients were hepatitis C virus infected through blood
transfusion during hemodialysis and rest of them had
pre exposure. Concerning hepatitis B virus infection,
2 .94%(n-2) of patients and , 2.94% (n-2) of patients
co-infected with hepatitis C& B viruses in the course
of transfusion therapy and rest of them had had pre
exposure.
Relating to the current clinical studies, 61.30% of
patients had hypertension as many dialysis patients
receiving antihypertensive drugs, only 38.70% have
best controlled blood pressure with or without
treatment of hypertension during study period. The
overall systolic blood pressure for defined
hypertension (>140-182mmHg) were 37.09% in pre
and 35.48% in post dialysis (>140-188mmHg). As
well as in overall diastolic blood pressure for defined
hypertension (>91-103 mmHg) were 12.90% in pre
and 12.90% in post dialysis (91-103 mmHg). Hence,
hypertensive stage1&2 cases were few more observed
in type 2 diabetes, others kidney diseases and cardiac
related diseases.
As shown in Table 1, regarding anemia the statics
data were reported as 95% confidential intervals (CI):
9.361 - 10.379 in hypertensive cases; 7.38- 9.75 in
type 2 diabetes; 7.536 - 12.864; in cardiac related
diseases; in other nephropathies 7.916 - 10.426; 9.491
- 10.861 in HCV and in hepatitis B&C virus coinfections (5.404 -14.596) respectively. It is clearly
understood that the most of the ESRD patients in
hemodialyis having deficiency of hemoglobulin
because of regular maintenance dialysis and they
have been under several medications but needed more
care in cardiac related cases than others.
Hemodialysis carried out at home with self
management for better quality of life but every one
cannot be afford. In current study relating to the
adequacy of hemodialysis in ESRD population, the
serum blood glucose has been raised in type 2
diabetes (95% CI: 156.70 - 285.50) and in cardiac
related diseases than others co morbidity. Thus, there
was an elevation of serum glucose (95% CI 91.495 370) in cardiac diseases as history of type 2 diabetes
and small sample size in estimation. Concerning
about urea and creatinine intensity before dialysis the
estimated values were reported as 95% CI:139.91-
160.97; 9.761-11.239 in hypertensive patients; but

after post dialysis its levels were 45.46-55.84; 3.714 4.574, respectively ; in type 2 diabetes pre and post
dialysis its levels were 157.6 - 216.91; 7.51 - 13.90;
55.78 - 84.52; 2.98 - 4.007, respectively; in cardiac
diseases before dialysis its levels were 172.522 263.473; 9.703 - 19.497 though after dialysis it
quantity were 70.738 - 112.62; 3.611 - 8.539,
respectively and in others nephropathies, before
dialysis it quantity were 129.3 -205.5; 7.85 -13.72
while after dialysis the levels were 33.1 -102.9; 2.621
- 6.607, respectively. It seems that average wastages
(urea/creatinine) have been removed through
hemodialysis and medical consultant must
concentrate more on cardiac and diabetes individuals
to reduce the further wastage for better life and
control the mortality. Hence, overall adequacy in this
study close to 75.80% ( 1.3 to 2.5 Kt/V) and 24.20%
(1.05 to 1.3 Kt/V) were been analyzed and the Kt/V
formula has been used for wastage clearance
estimation. For this imbalanced clearance, an
organizations need to implement an international
standard practice (above 90% of 1.2 Kt/V
clearance), proper training of hemodialysis staffs and
an updated technology to improve the better life of
ESRD individuals.
Other biochemical molecules like sodium and
calcium are within the expected limit in co morbidity
of ESRD. Potassium was somewhat elevated in
cardiac diseases and co-infection of hepatitis B& C
viruses than expected values and others co morbidity
were within the predicted ranges. Like total protein,
the ALT and AST are within normal limit in co
morbidity. However, ALT was merely elevated in coinfection and AST was very low in other
nephropathies. Also, other important biomarker such
as alkaline phosphates (ALP) was highly increased
and decreased in all ESRD population. The
quantification values were reported as 95% CI; 98.80254.0 in hypertension; 83.0 -161.1 in type 2 diabetes;
42.620 - 421.880 in cardiac related diseases; 113.533
- 269.533 in other nephropathies; 138.7 - 418.5 in
HCV infection and 27.327 - 207.12 in co-infection of
hepatitis B&C viruses, respectively. It showed that
ALP is important marker in ESRD but need to
differentiate weather vascular calcification or bone
degeneration or hepatitis infections. Concerning
hyperphosphatemia, most percentages have been
observed in males individuals than females especially
664
Ismail et al.,
in other nephropathies and cardiac related diseases

but there was no cases found as a deficiency of
phosphorus in the study.
DISCUSSION
An end-stage renal disease (ESRD) is usually
prevalent in Libya like developed nation. To maintain
this problem till date there are more than 40
maintenance dialysis centers established by
government health care sector. The prevalence will
increase at the rate of 8% yearly from 2417 to
7667(2009-2024)18 and it was higher when compared
with Middle East and North Africa regions (MENA).
The overall clinical outcomes of ESRD in Libya were
26.5% of diabetic nephropathy, 21.2% of
glomerulonephritis,
14.6%
of
hypertensive
nephropathy, 12.3% of congenital and hereditary
disease; 7.3% of unknown cases, 6.3% of polycystic
kidney disease, 5% of obstructive nephritis, 2.9% of
others, 2% of chronic pyelonephritis, 1.2% of
interstitial nephritis, and 0.7% of auto immune
disease19. Whereas, in present study showed that the
clinical outcomes of ESRD in hemodialysis patients
were 61.30% of hypertension, 21% of type 2
diabetes, 11.30% of other kidney diseases and 6.40%
of cardiac related diseases and totally differed from
earlier study. In addition, there were 29.41% of HCV
infection, 2.94%of HBV infection and 2.94% of
hepatitis B&C viruses co-infection of both viruses
infected through the exposure of hemodialysis.
Anemia is a usual deficiency in Sirt hemodialysis
individuals were observed with conditions of chronic
renal failure. Rectification of this deficiency might
progress
the
dialysis
individuals
activity,
cardiovascular function, lower mortality and better
life. To correct this burden among individuals after
dialysis, 45.15% of dependable dialysis patients were
treated often with aid of erythropoiesis stimulating
agent (ESA) to reach the target between 11.0 and
12.0 g/dl and if it is reach more than 5000 unit per
month ESA medication might cause pruritus20 (itchy
skin) so proper clinical diagnosis and research work
must be done on each ESA receiving individuals in
maintenance dialysis. On the basic of estimated
glomerular filtration rate after kidney disorder, the
chronic kidney diseases are classified according to
the modification of diet in renal diseases (MDRD)
into five stages proposed by the US National Kidney
Foundation. With this term to classify the patients;
eGFR between 45-60ml/min/1.73m2 (3A), eGFR

between 30-45ml/min/1.73m2 (3B), eGFR between
15-30ml/min/1.73m2(stage4); GFR<15ml/min/1.73m2
(stage5) and eGFR>90ml/min/1.73m2 considered as
stage 1&2.21
Hypertension is caused by an augment of extracellular volume duo to renal failure and it is one of
the leading risk factor in these ESRD dialysis
populations. National Kidney Foundation Kidney
Diseases Outcomes Quality Initiative (NKF-K/DOQI)
procedure advocate that pre and post dialysis BPs
must be <140/90 and 130/80mmHg as well22.
Moreover in the study, nearly 37.09% patients had
systolic hypertension in pre dialysis (>140-182
mmHg) and 35.48% had post hemodialysis (>140188mmHg) but most of them under the control of
antihypertensive drug management. Likewise, >91109 mmHg as diastolic hypertension in pre and post
dialysis it was 91-103 mmHg. Certainly, perfect dry
weight estimation and ultra filtration of wastage have
significant role in hypertension management. The
average dry weights in these hemodialysis individuals
were between 41-90 kg and wastage filtration was 0.5
to 4kg after dialysis; it is depending on the dosage
and body weight during dialysis period. Indeed
require to maintain hypertension through restricting
sodium dietary intake as a best practice in
maintenance hemodialysis.
Type 2 diabetic is the second foremost cause of end
stage renal disease after the hypertension and serum
glucose was increased totally in all type 2 diabetes
patients. Proteinuria elevation in urine is sign of
disease but not predictors of kidney disease.
Generally, in normal metabolisms more than 2400
metabolic molecules produced and released in plasma
and among this only 16 uremic solute were
considerable role in progressive stage of end stage
renal disease. Thus, tissue necrosis factor receptors
(TNFR1&2) are significant role to predict the loss of
renal function in early stage without proteinuria in
diabetes and ESRD individuals23. In upcoming year,
it is necessary to do broad research work on
metabolite which is relative to the clinical disorder in
ESRD for early diagnosis and prevention of disease.
Blood group A, AB and Rh having significant link
with type-2 diabetes and hypertension than blood
group B and O24-25. In current analysis, frequency of
blood group O is higher in Libyan hemodialysis
ESRD patients followed by groups A, B and AB.
665
Ismail et al.,
This genetics factors and blood groups system needed

to investigate thoroughly in hemodialysis population
to get quality of life and control the sudden death
rate. Imbalanced condition of serum potassium is
known as hypokalemia (<3.5 mEq/L) and
hyperkalemia (> 5.0mEq/L) in ESRD26 patients, while
in current analysis revealed that hypokalemia was
very unusual event and hyperkalemia had (4.69-6.35
mmol/L) excessive levels in several hemodialysis
patients. So many biomarkers (BNP and cardiac
troponin) and imagine methods (cardiac MRI, PET
and cardiac CT) are introduced in current medical
practice to diagnosis and distinguish the diseases
condition. Current study also advised to follow the
current medical practice and to concentrate further
research works very deeply on cardiac related
diseases and others nephropathy disorder in aspect.
Concerning about adequacy of hemodialysis,
sufficient quantity of wastage elimination using often
maintenance hemodialysis doses from body is
described as outcomes of maintenance dialysis. There
are so many aspects are allied for outcomes of
hemodialysis such as exclusion of middle particles
(high-flux dialyzers), phosphate over load, uremic
toxins, fortification of retention of renal function (23ml/min-urea clearance), vascular access, quality of
life with care and better clinical practice with
acceptance of international standard27. In present
study relating to vascular access, 51.60% of branchiocephalic arteriovenous fistulas access (AVF), 38.70%
of radiao-cephalic arteriovenous fistulas access and
others 9.70% of were unknown data but the radial
AVF access is primary option for best outcomes of
hemodialysis and it was recommended by American
society of nephrology.
Also, the overall estimation of urea levels in pre and
post hemodialysis of ESRD patients were 67 to
263mg/dl but after dialysis 18-112mg/dl. Concerning
serum creatinine, most of the patients had values
between 5-19mg/dl before dialysis, whereas after
dialysis patients had values 1.8 to 8.5mg/dl. In
addition to that, hemoglobin (Hb) levels were
between 5.4 to 14.5 g/dl and most of them under
anemic condition even after treatment. So many
factors concerned for anemic such as blood omitted in
the dialysis route nearly 2-3g28 in a year per patient,
recurrent blood drawn for investigation, vascular
access procedures and genetics factors. Adequacy of
hemodialysis is termed the total amount of uremic
toxin removal as well as phosphorus but 4 hrs

duration hemodialysis (3times per week), it purge
near 900 mg of phosphorus every time29. Thus, the
ranges in present analysis were 3.69 to 10.68 mg/dl of
phosphorus estimated during study period and need to
assess the phosphorus removal in each time of
dialysis. Raised amounts of serum alkaline
phosphatase are significant role with ESRD
maintenance dialysis patients; especially in coronary
artery calcification30 but current study were observed
in overall between 17.94-421.88 U/L and need to
investigate about vascular calcification disorder very
sincerely. Also others aspects regarding adequacy of
dialysis required to investigate thoroughly in
forthcoming years. Relating to overall adequacy
amount of wastage removal (urea/creatinine) was
75.80% ( 1.3 to 2.5 Kt/V) and 24.20% (1.05to1.3
Kt/V) been analyzed. The goal of Kt/V is 1.2 in adult
hemodialysis individuals and this measurement was
guided by KDOQI. So need to update the better
service according to the global clinical society
acceptance.
Finally, the current study advised to introduce
vaccines against some of viruses and bacteria such as
hepatitis A & B, Influenza type A&B,
Staphylococcus aureus and Streptococcus pneumonia
through the global vaccination guideline programs
before receiving a renal replacement therapy among
ESRD patients in this locality. The immunization
against hepatitis B might be control the hepatitis C
virus infection which is infecting through
hemodialysis
modality31-32.
Therefore,
an
organization ought to implement vaccination
programme mainly against hepatitis B virus and make
compulsory nucleic acid test screening before blood
transfusion or avoid frequent of blood transfusion.
The transfusion medicine has major role for infection
of hepatitis in hemodialysis patients because of
improper performance of global health practice in this
locality. Feature goal of adequacy are concerned with
different roles in this region such as implementing
new adequacy panel, assess monthly lab data with
data manager, patients specific care chart, better
training to staffs and patients, early referral and
evaluate current process.
666
Ismail et al.,
CONCLUSION
Present study highlighted that the risk factors of
ESRD and current study adequacy of adult
maintenance hemodialysis. In addition, an improving
over 90% of adequacy in dialysis patients is an
important goal in this local ethnicity similarly to the
population of chronic kidney diseases in developed
countries and its co-morbidity literally differing from
inhabitants and geography so this study were revealed
both function with supervision and forwarding it to
the national hemodialysis society in Libya to renew
further scenario.
7.
8.
9.
ACKNOWLEDGEMENT
We would like to convey our honest gratitude to Mr.
Al Seddik Husain, Dr. Mohammed and Dr. Masouda
for the contributions of the data from the department
of hemodialysis. Also, we would like to express our
cordial thanks to Mr. Khalil Mohammed for helping
in lab investigation.
10.
11.
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DOI: 10.5958/2319-5886.2014.00415.9

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
st
Received: 1 Jun 2014
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Research Article
DIFFERENCES IN BLOOD PRESSURE MEASUREMENTS IN THE FOREARM AND UPPER ARM

OF OBESE OTHERWISE HEALTHY FIRST YEAR MEDICAL STUDENTS
Suganthi V1, * Navin Rajaratnam2, Suzanne Maria Dcruz3
1
Department of Physiology, Vinayaka Missions Kirupananda Variyar Medical College & Hospital, Salem,
Tamil Nadu, India
2
Department of Physiology, Meenakshi Medical College Hospital and Research Institute, Kanchipuram,
Tamil Nadu, India
3
Department of Physiology, Sri Muthukumaran Medical College Hospital and Research Institute, Chennai,
Tamil Nadu, India
*Corresponding author email: drnavin@ymail.com
ABSTRACT
Background: The prevalence of obesity is increasing in Indian youth and obesity is associated with
complications like systemic hypertension. Often, due to the non-availability of appropriate sized cuffs, standard
cuff bladders are used to measure blood pressure in the forearms of obese young adults. Aim: To compare the
upper arm arterial blood pressure measured using an appropriate cuff with the forearm arterial blood pressure
measured using a standard cuff and conventional sphygmomanometry in obese otherwise healthy first year
medical students. Materials and Methods: Blood pressure was measured in 27 obese otherwise healthy first year
medical students after five minutes of rest using a mercury sphygmomanometer with the subjects seated and the
arm and forearm at heart level, using an appropriate sized cuff for the upper arm according to American Heart
Association standards and a standard cuff for the fore arm. Results: A statistically significant difference in both
systolic [t-test (paired) = -6.921; df = 26; sig = .000 (2- tailed)] and diastolic blood pressure [t-test (paired) = 8.508; df = 26; sig = .000 (2- tailed)] was found, with the blood pressure readings being higher in the forearm.
The correlations between upper arm and forearm systolic and diastolic blood pressure were 0.785 (p = .000) and
0.870 (p = .000). Conclusion: Both systolic and diastolic blood pressure measurements were significantly higher
in the forearm. Further studies with larger sample size should be conducted to confirm that forearm blood
pressure measurements using standard cuff bladders cannot be considered equal to upper arm measurements made
using an appropriate sized cuff in all young obese individuals
Keywords: Blood pressure measurements; cuff bladders; forearm; obese; upper arm.
INTRODUCTION
The prevalence of obesity is increasing globally.
Chopra et al note that the prevalence of obesity is
increasing in Indian youth, with studies from different
regions of India revealing a high prevalence of
childhood obesity; especially in urban school going
girls.1 Obesity is associated with complications like
Suganthi V et al.,
systemic hypertension which is the most common

risk factor for cardiovascular disease. While attempts
are being made to diagnose systemic hypertension in
obese young adults early, failure to sufficiently
follow guidelines on the correct methodology of
blood
pressure
measurement
can
be
669
counterproductive and contribute to confusion and

wrong diagnosis instead.
Parati et al recognize that despite growing awareness
on the impact of hypertension on health and rapid
progress in the field of blood pressure measurement,
many methodological issues still needed to be
addressed.2 Arterial blood pressure can be measured
non-invasively by manually operated and automated
devices. Tholl et al point out that the quality of blood
pressure monitoring depends not only on the
technical limitations of the devices used, but more
commonly on correct handling by the user.3 This is
especially applicable while measuring blood pressure
in obese patients. Prineas states that choosing the
correct cuff width-arm circumference (CW/AC) ratio
is very important in the obese.4 Obese individuals and
individuals with muscular arms require a longer and
wider cuff to adequately compress the brachial
artery.5 The use of small cuff bladders can lead to
overestimation of blood pressure while over-cuffing
can cause underestimation of blood pressure. 6,7
Often, in routine clinical practice, due to the nonavailability of appropriate sized cuffs, standard cuff
bladders are used to measure blood pressure in the
forearms of obese patients. Schell et al, in 2005,
compared automatic noninvasive measurements of
blood pressures in the upper arm and forearm in 204
stable patients attending the emergency department
and concluded that forearm and upper arm values
were not interchangeable despite strict attention to
correct cuff size and placement of the upper arm or
forearm at heart level. 8 Earlier, Tachovsky had in
1985 compared indirect auscultatory blood pressure
values measured at the forearm with the upper arm in
98 female non-obese subjects aged 18 to 25 years,
and found lower systolic values and higher diastolic
values at the forearm site.9 Latman et al who had in
1996 evaluated the performance of an automatic,
noninvasive BP monitoring instrument concluded that
the forearm was an acceptable site for clinically
useful systemic blood pressure measurement.10 Singer
et al had in 1999 found that the correlations between
forearm and upper arm systolic and diastolic BPs
measured using an automated device were 0.75 and
0.72 respectively in a study involving 151 patients,
40% of whom were female and suggested that the
forearm may be used when measurement of blood
pressure in the upper arm was not feasible.11 Emerick
proved that non-invasive blood pressure measured at
Suganthi V et al.,
the wrist consistently overestimated mean arterial,

systolic and diastolic pressure by approximately 10
mmHg when compared to the upper arm.12
Pierin et al used an automatic oscillometric device to
compare upper arm blood pressure readings recorded
using an appropriate cuff bladder and forearm values
recorded using a standard cuff bladder in obese
patients.13 They found that the forearm measurements
in obese patients could not replace upper arm
measurements as the fore arm blood pressure values
were higher.13 Domiano et al too found that forearm
blood pressure was higher than the upper arm-they
however also found that this site difference was
greatest for men, obese adults and middle aged
adults.14 Fonseca-Reyes et al not only confirmed that
usage of a standard cuff in obese patients
overestimates blood pressure, also found a high
prevalence of patients with arms of large
circumference among hypertensive patients and
normo-tensive subjects and therefore stressed the
need for using cuffs of different size.15 Watson et al
found that both forearm blood pressure and the use of
an extra-long blood pressure cuff on the upper arm
lead to a significant overestimation of the upper arm
blood pressure measured using a recommended cuff
in post anaesthesia patients with large upper arm
circumferences.16 Another study done by Schell et al
to determine the effects of anatomical structures like
limb subcutaneous tissue and vessels on the
differences between forearm and upper arm
oscillometric
noninvasive
blood
pressure
measurements revealed that forearm and upper arm
vessel depth, forearm vessel diameter, and upper arm
circumference explained a statistically significant
portion of the difference between forearm and upper
arm blood pressures.17 While Palatini et al found that
forearm blood pressure overestimated upper arm
blood pressure, they also found a significant
relationship between the systolic difference in blood
pressure and both BMI and skin fold thickness in
males for whom the systolic blood pressure
difference was greater. 18
While other researchers studied differences in blood
pressure measurements in the general population,
hospitalized patients, or in obese patients, in 2006,
Schell and Waterhouse studied young healthy college
students, recognizing the increasing prevalence of
obesity and hypertension in young adults in the
United States and the tendency of health care workers
670
to measure blood pressure in the forearm during

routine screening when the standard size cuff did not
fit the upper arm. They found statistically significant
differences between upper arm and forearm diastolic
blood pressures while differences between systolic
blood pressure readings were not significant and
concluded that upper arm and forearm automatic,
noninvasive
blood
pressures
were
not
19
interchangeable.
Recognizing that such readings
were used interchangeably in nursing practice,
Fortune et al studied 100 healthy undergraduate
nursing students using an automatic blood pressure
device and found that both systolic and diastolic
blood pressure measurements were significantly
higher in the forearm when compared to the upper
arm.20
Researchers have thus compared upper arm and
forearm blood pressure readings in subjects belonging
to a varied age group, in obese subjects and in young
healthy non-obese/non-overweight young adult
students. Given the increasing prevalence of obesity
in Indian youth and the tendency to use forearm
blood pressure readings as an alternative to upper arm
readings due to non-availability or lack of easy access
to appropriate size cuff bladders, we were interested
in studying whether there were any differences in
blood pressure measurements in forearm and upper
arm in our obese otherwise healthy first year medical
students. We however chose to use conventional
sphygmomanometry
unlike
the
automatic
noninvasive measurements of blood pressures done
by many other researchers.
AIM: The aim of this study was to compare the upper
arm arterial blood pressure measured using an
appropriate cuff with the forearm arterial blood
pressure measured using a standard cuff and
conventional sphygmomanometry in obese otherwise
healthy first year medical students.
This study was done in the Department of Physiology
of VMKVMCH in Salem, South India, after
obtaining clearance from the institutions ethical
committee.
Sample size: Out of the 100 first year medical
students in the age group 18-19 years, 27 obese
students with a BMI 30 ( 9 = male, 18 = female)
Suganthi V et al.,
were selected for the study on the basis of the

following inclusion and exclusion criteria:
Inclusion criteria: First year medical students with a
BMI 30, in the age group 18-19 years, with an arm
circumference of 32 cm were studied.
Exclusion criteria: Individuals with history of any
diseases
like
diabetes
mellitus,
systemic
hypertension, heart disease, bronchial asthma and
medical problems that could influence blood pressure
or any surgical problems, were excluded from the
study. Individuals with history of smoking, alcohol or
nicotine intake and individuals with history of current
intake of any medication were also excluded.
The purpose of doing the study was explained and
written consent was obtained after a detailed history
and physical examination. The subjects blood
pressure was measured using a conventional manual
mercury sphygmomanometer after five minutes of
rest with the subjects seated and the arm and forearm
at heart level. For the arm blood pressure
measurement, an appropriate sized cuff was used for
each subject according to American Heart
Association standards 5, while a standard cuff was
used for the forearm blood pressure. The blood
pressures measurements were done for each site with
a two minute resting period in between, the order of
sites being selected at random and alternated.
Statistical analysis: The systolic and diastolic blood
pressure values obtained for the arm and forearm of
the 27 subjects were compared using the paired
Students t test. A 'p' value of < 0.05 was considered
to be significant. Pearson product-moment correlation
coefficient was determined to find the relationship
between the upper and forearm arterial blood
pressure. SPSS 17 was used for statistical analysis.
RESULTS
This study done to compare the upper arm arterial
blood pressure measured using an appropriate cuff
with the forearm arterial blood pressure measured
using a standard cuff in obese otherwise healthy first
year medical students. The sample included 27 obese
otherwise healthy first year medical students in the
age group 18-19 years (9 = male and 18 = female)
with an arm circumference of 32 cm and a BMI
30. It was found that there was a statistically
significant difference in both systolic blood pressure
[t-test (paired) = -6.921; df = 26; sig = .000 (2tailed)] and diastolic blood pressure [t-test (paired) =
671
-8.508; df = 26; sig = .000 (2- tailed)] with the blood

pressure readings being higher in the forearm than in
the upper arm (Table 1).
The Pearson product-moment correlation coefficients

between upper arm and forearm systolic and diastolic
BPs were 0.785 (p = .000) and 0.870 (p = .000)
respectively.
Table 1: Comparison of the upper arm and forearm blood pressure values of obese otherwise healthy
young adults.
Upper Arm Forearm
Difference
t
df
p value
Mean SD
Mean SD
Mean SD
Systolic Blood Pressure (mm Hg) 109.411.6
119.311.2
-9.97.5
-6.921
26
.000*
83.29.6
-7.84.8
-8.508
26
.000*
Diastolic Blood Pressure (mm Hg) 75.4 8.7
Systolic and Diastolic blood pressure in mmHg expressed as mean and standard deviation, being measured in the upper arm
of 27 obese otherwise healthy young adults using an appropriate cuff and in the forearm using a standard cuff, with
corresponding t values and degrees of freedom; *p value of <0.05 being taken as significant.
DISCUSSION
Our study done to compare the upper arm arterial
using a standard cuff in 27 obese otherwise healthy
first year Indian medical students revealed that both
systolic and diastolic blood pressure measurements
were significantly higher in the forearm. Although
Schell et al too concluded that forearm and upper arm
values were not interchangeable, the mean age of
their subjects 52% of whom were male was 36.5
years.8 Our findings do not agree with those of
Tachovsky who found lower systolic values and
higher diastolic values at the forearm in 98 female
non-obese subjects aged 18 to 25 years,9 as both
systolic and diastolic blood pressure measurements
were found to be significantly higher in the forearm
in our study which however included both male and
female obese subjects. While the correlations
between upper arm and forearm systolic and diastolic
BPs were 0.785 (p = .000) and 0.870 (p = .000) in our
study, Singer et al found that the correlations between
forearm and upper arm systolic and diastolic BPs
were 0.75 and 0.72 respectively. 11 Only 40% of their
subjects were female, whereas in our study, 67%
were female. Latman et al however found that
systolic blood pressure and heart rate correlated more
closely than diastolic blood pressure with the
standard. 10 While Emerick proved that blood
pressure measured at the wrist consistently
overestimated mean arterial, systolic and diastolic
pressure by approximately 10 mmHg,12 the difference
in systolic and diastolic blood pressure in our study
was 9.9 and 7.8 mmHg respectively. Obese
Suganthi V et al.,
individuals require a longer and wider cuff to

adequately compress the brachial artery and hence the
upper arm blood pressure measurements that we
obtained using an appropriate cuff were measured as
per recommendations. 5 Schell et al determined the
effects of anatomical structures like limb
subcutaneous tissue and vessels on the differences
between forearm and upper arm forearm and
suggested that upper arm vessel depth, forearm vessel
diameter, and upper arm circumference explained a
statistically significant portion of the difference
between forearm and upper arm blood pressures. 17
This could be the reason for the differences obtained.
Our findings are in agreement with those of other
researchers who specifically studied obese
individuals and found that the forearm blood pressure
was significantly higher, 13-16, 18 and other researchers
who found the same while studying young healthy
college students. 19,20 In the study by Pierin et al, 13
116 out of 129 patients were women, in the study by
Domiano et al 64% of their participants were
female,14 and 90 out of 100 subjects were female in
the study by Fortune et al,20 while in our study 67%
of the participants were female. The findings of our
study assume relevance in view of the observation of
Chopra et al of a high prevalence of childhood
obesity in India, especially in urban school going
girls. 1 Forearm blood pressure measurements made
using standard cuff bladders in such young obese
individuals cannot be considered equal to upper arm
measurements made using an appropriate sized cuff.
Awareness on the need to use cuffs of appropriate
sizes as per guidelines, 5 should be created in health
care providers.
672
Limitations: Limitations of the study include the

sampling of only first year medical students in one
medical college, less sample size, study population
consisting more of females, ethnic similarity and nonrepresentativeness of the participants and failure to
use Bland Altman plots. All the subjects of this study
were first year medical students of a medical college
in South India and hence may not be representative of
young adults in general. Further studies can be done
to overcome these limitations using random diverse
samples of larger sizes, the effect of different
variables can be analyzed and the data can be used to
create awareness on the need to use cuffs of
appropriate sizes as per guidelines while measuring
upper arm blood pressure, instead of considering
forearm measurements made using a standard cuff.
This is especially relevant in view of the increasing
prevalence of obesity in the young. The possibility of
obtaining an equation to correct forearm blood
pressure measurements could also be explored after
further studies.
CONCLUSION
Our study done to compare the upper arm arterial
using a standard cuff in 27 obese otherwise healthy
first year medical students revealed that both systolic
and diastolic blood pressure measurements were
significantly higher in the forearm. Further studies
with larger sample size should be conducted to
confirm that forearm blood pressure measurements
using standard cuff bladders cannot be considered
equal to upper arm measurements made using an
appropriate sized cuff in all young obese individuals.
REFERENCES
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Overweight,
obesity
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related
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6. Russell AE, Wing LM, Smith SA, Aylward PE,
McRitchie RJ, Hassam RM, West MJ, Chalmers
JP. Optimal size of cuff bladder for indirect
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9. Tachovsky BJ. Indirect auscultatory blood
pressure measurement at two sites in the arm. Res
Nurs Health. 1985; 8(2):125-29
10. Latman NS, Coker N, Teague C. Evaluation of an
instrument for noninvasive blood pressure
monitoring in the forearm. Biomed Instrum
Technol. 1996;30(2):160-63
11. Singer AJ, Kahn SR, Thode HC Jr, Hollander JE.
Comparison of forearm and upper arm blood
pressures. Prehosp Emerg Care. 1999;3(2):12326
12. Emerick DR. An evaluation of non-invasive
blood pressure (NIBP) monitoring on the wrist:
comparison with upper arm NIBP measurement.
Anaesth Intensive Care. 2002; 30(1):43-47
13. Pierin AM, Alavarce DC, Gusmo JL, Halpern A,
Mion D Jr. Blood pressure measurement in obese
patients: comparison between upper arm and
forearm measurements. Blood Press Monit.
2004; 9(3):101-05
14. Domiano KL, Hinck SM, Savinske DL, Hope
KL. Comparison of upper arm and forearm blood
pressure. Clin Nurs Res.2008 ; 17(4):241-50.
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15. Fonseca-Reyes S, de Alba-Garca JG, ParraCarrillo JZ, Paczka-Zapata JA. Effect of standard
cuff on blood pressure readings in patients with
obese arms. How frequent are arms of a 'large
circumference'? Blood Press Monit. 2003;
8(3):101-06
16. Watson S, Aguas M, Bienapfl T. Postanesthesia
patients with large upper arm circumference: is
use of an extra-long adult cuff or forearm cuff
placement accurate? J Perianesth Nurs. 2011;
26:13542
17. Schell KA, Richards JG, Farquhar WB. The
effects of anatomical structures on adult forearm
and upper arm noninvasive blood pressures.
Blood Press Monit. 2007; 12(1):17-22
18. Palatini P, Longo D, Toffanin G, Bertolo O,
Zaetta V, Pessina A. Wrist blood pressure
overestimates blood pressure measured at the
upper Arm. Blood Pressure Monitoring 2004;
9(2):77-81.
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and Upper Arm: Automatic, Noninvasive Blood
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20. Fortune M, Jeselnik K, Johnson S. A
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674
DOI: 10.5958/2319-5886.2014.00416.0

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
st
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Research Article
PREVALENCE OF EMOTIONAL DISTRESS IN CAREGIVERS OF CANCER PATIENTS

*Santre Manjeet S1, Rathod Jyoti2, Maidapwad Sainath 3
1
Department of Psychiatry, Dr.SC Government Medical College, Nanded, Maharashtra, India

Department of Psychology, INHS Asvini, Colaba, Mumbai, Maharashtra, India
3
Department of Statistics, Dr.SC Government Medical College, Nanded, Maharashtra, India
2
*Correspondence of Author email: drmanjitsantre@rediffmail.com

ABSTRACT
Background: A diagnosis of cancer is an intensely stressful experience for patients. How much it affects the
caregivers is not apparent as it leads to hidden Co morbidity in the persons involved in the care giving process.
Cancer can not only affect the patients, but can equally evoke emotional distress in the caregivers. Aims: We
carried out a study to evaluate the prevalence of anxiety and depression as well as effects of socio demographic &
cancer characteristics on emotions of caregivers. Methods and Material: This is a cross sectional study of 100
consecutive consenting caregivers of diagnosed cancer patients attending an oncology department of a tertiary
care hospital. Caregivers are those who have willfully taken the responsibility of care giving to the ailing cancer
patients. Hospital Anxiety, Depression Scale (HADS) a well validated questionnaire based scale to evaluate the
prevalence of anxiety, depression and emotional distress. It has 14 items 07 related to anxiety & 07 related
depressions. Results: 100 caregivers were studied to assess the anxiety and depression levels during their care
giving task. The mean anxiety & depression score of subjects were 8.28 (SD-3.45) & 8.79 (SD-3.94) respectively.
34% caregivers were having score between moderate to severe category with a cutoff of (>10) on both the
subscales of HADS. 53% of the subjects showed emotional distress as seen in high score above cutoff of (>15) on
total HADS score. The data was compiled, tabulated and analyzed by using SPSS 16 .0 v. P < 0.05 is taken as
statistically significant in our study. Conclusion: There are multiple factors involved in the emotional distress of
the caregivers. A holistic treatment approach that encompasses both medical and psychological measures for
reducing the hidden morbidity in co sufferers of cancer patients to be adapted in treatment of cancer patients.
Keywords: Anxiety, Cancer, Caregivers, Depression, Cancer, Emotional distress.
INTRODUCTION
Cancer is perceived as a serious and chronic disease.
The diagnosis of cancer still remains the disease
equated with hopelessness, pain, fear, dependency
and disfigurement, disruption of key relationships,
depression and death in spite of recent advances in
management of cancer. Psychological disturbance is
not only produced by the diagnosis and treatment of
disease but the patients knowledge of the disease,
perception and stigma pertaining to disease.1-2
Cancer diagnosis is not only an individual experience

but also brings certain changes in the life of
caregivers of the patients. Caregivers who witness
the pain, sufferings and hopelessness of their beloved
ones become tired and unhappy. They have to fulfill
the roles of patient in addition to their own role. The
individual who takes care of the patients might
develop physical, psychological difficulties and
675
Manjeet et al.,
physical diseases due to deterioration of the immune

system. 3
Emotional distress extends in a continuum ranging
from common normal feeling of vulnerability,
sadness and fear to problems that can become
disabling anxiety, panic, social isolation and
depression. Many authors stated that because of
social isolation, role conflicts, tiredness, fatigue,
financial burden and the attachment of the caregiver
to the patients sometimes brings more emotional
distress in caregivers as compared to the patients.4
Family members are the first line of emotional
support to the cancer patient. Care giving is highly
satisfying but the caregivers are likely to feel under
stress when the psychological, physical or both
demands of the care giving task exceed the capacity
to cope, hence they are called as co sufferers in the
treatment of cancer.5-7
Caregivers can be categorized in formal and
informal caregivers. Formal caregivers are part of
the health care sector and being paid for the care
giving services e.g. institutionalized care workers.
Informal caregivers are those who have assumed the
task of care giving either willfully or who are highly
motivated by a commitment to patients. These
informal caregivers usually are the family members
related to the patient who are emotionally attached to
them compared to other relatives.8
These caregivers when assume the main
responsibility of care giving are called as Primary
caregivers and they can seek help of Secondary
caregivers in times when care demands exceeds the
carrying capacities of primary caregivers. A recent
trend in shift of cancer management from inpatient
hospitalization to home settings & longer survival of
patients has increased the number of informal
caregivers. 9-11
Care giving burden is dependent on caregivers as
well as care recipients characteristics. Socio
demographic characteristics like age,12-13 gender,14-16
socioeconomic status and type of relationship with
the care recipient17-18 of caregivers cause emotional
distress in caregivers. The care recipients
characteristics such as type of disease, staging of
disease, treatment,19-21 physical and psychological
symptoms and dependency feeling has negative
impact on care giving.22-23 Quality, intensity and
different types of care provided24, availability of
health resources, preparedness of caregivers in care
Manjeet et al.,
providing process and the period for which the care

giving is to be done too have significant impact on
the care giving.25
Care giving is demanding and overwhelming and can
be a very stressful experience affecting all aspects of
caregivers leading to risk of developing
psychological problems which includes anxiety,
depression, reduced self esteem and somatic health
problems and thus adversely affecting the treatment
outcome.26-29
Literature review has shown that majority of studies
are done in western settings and very few in Indian
setting. Considering this geographical differences we
conducted the present study to evaluate the
prevalence of anxiety and depression in caregivers
and to study the socio demographic and cancer
variable factors leading to emotional distress.
METHODS AND MATERIAL
The study a cross sectional & carried out at a large
urban tertiary care centre. We undertook the study
after an approval from institutional ethical committee.
The center provides medical, surgical and radiotherapeutic treatment. Cases included in the study
were Caregivers who were providing care to cancer
patients, who were either admitted or attending to
oncology department for treatment or follow up. A
total 100 caregivers of cancer patients who had taken
the responsibility of care giving willfully were
selected by random sampling for the questionnaire
based study.
The purpose of the study and questionnaire were
explained & verbal consent was obtained from each
subject. The subject underwent the following
assessments. Socio demographic variables such as
age, sex, education, occupation, income, residence,
marital status and family type were collected. The age
range was 19-60 yrs. Maximum caregivers were in
the age group of 42-49 yrs. In our study male and
female subjects were equal in number.
Mental status evaluation by a psychiatrist was carried
out. HADS (Hospital Anxiety, Depression Scale) was
given to the subjects. HADS scale is designed for
assessment of anxiety and depression of the subjects.
HADS is originally developed by Zigmond AS and
Snaith RP. It has two subscales each consisting seven
questions related to anxiety and depression
respectively. HADS is brief, easily understandable
and acceptable scale and it generates ordinal data.30
676
Because of these properties it can be used for non

cancer patient also.31
HADS (A) subscale of Hospital Anxiety &
Depression Scale mainly elicit the responses
pertaining to frightened feelings, fearfulness, worries
and panic attacks while the HADS (D) mainly elicits
the responses in regards to subjects feeling of
slowness in the activities, inability to enjoy or derive
pleasure from pleasurable activities or feeling
pessimistic about future course of the life.32
The subjects were asked to express their responses
on a Likert scale ranging from 0 (not at all) to 3 (very
often needed / most of the time). Responses are based
on the relative frequency of symptoms over the past
week. Responses are summed to provide separate
scores for anxiety and depression. Subscales score
range from 0-21 for anxiety and depression on
HADS.
Mykletun A et al studied the factor structure, item
analyses, and internal consistency in a large
population of HADS.33
Caregivers who after explaining the nature of the
study and the time the questionnaire will take for
them to be replied and willfully agreed were taken in
the study. Those who could not understand the
questions were not included in the study. All subjects
were interviewed by same set of examiners for
maintaining the uniformity in the scoring while
obtaining the data. Data was compiled, tabulated in
Microsoft excel sheet and analyzed with help of
statistical software SPSS 16.0 version with help of
institutional statistician. The significance level was
set at P <0.05.
In cancer variable 49% of patients were in stage I of

diagnosis and only 1% were in stage IV. 75% of
cancer patient were diagnosed more than 6 months
prior to their inclusion in the study. 49% patients had
received chemotherapy or their cycles of treatment
were in process & 8% received radiotherapy. 28%
patients were operated cases and were considered for
radiotherapy or chemotherapy treatment. Relationship
frequency of the caregivers to the care recipients is
shown in Fig 2.
On hospital anxiety, depression scale the mean
anxiety scores on HADS (A) were 8.28 (S.D.-3.45).
Anxiety score was in range from 3-17 on the scale.
32% cases were having an anxiety score in moderate
to severe category. Mean score on HADS (D) was
8.79 (S.D.-3.94). 34% care giver were scored
between moderate to severe grade with a cutoff of
(>10) on HADS. The range of HADS (Total Score)
was 6-33. 53% of the subjects were having emotional
distress on cutoff of (>15) on total HADS score. The
Correlation of socio demographic, cancer &
relationship status variables with HADS (A) & (D)
scores were shown in Tables 1, 2 & 3 respectively.
RESULTS
Fig 1: Cancer site
We did a study of 100 subjects. The mean ages of

subjects were 40.4 yrs (SD-9.637). Mean years of
schooling of the caregivers was 9.3 yrs of schooling
(SD 2.37). 27% subjects studied beyond 12th standard
which includes graduation and post graduation. Out
of 100 subjects 92 were married. 47% subjects were
from rural background while 67% subjects live in
nuclear family. Maximum subjects were home maker
by occupation. 4% were unemployed and dependent
on the family or patients for their financial needs.
13% of the caregivers were retired. In cancer
variable the frequency of cancer according to the site
is shown in Fig 1.
Fig 2: Relationship Frequency of Care Givers
677
Manjeet et al.,
Table 1: Socio Demographic Variables with HADS Score of Cancer Caregivers

Variables
18-25
26-33
34-41
42-49
50-57
>58
Male
Gender
Female
Married
Marital
Unmarried
Education 0-5
6-11
>12
Residence Rural
Urban
Joint
Family
Nuclear
Up to 8000
Income
(Rs.)
8001-10000
10001-12000
12001-14000
>140001
Occupation Dependent
Employed
Homemaker
Retired
Age
HADS (A) Score

Moderate
Mild
01(14.3) 00(0)
04(23.5) 04(23.5)
04(15.4) 07(26.9)
09(27.3) 13(39.4)
03(25)
03(25)
00(0)
01(20)
07(14)
11(22)
14(28)
17(34)
20(21.7) 28(30.4)
1(12.5)
00(0)
3(37.5)
3(37.5)
12(18.5) 22(33.8)
6(22.2)
3(11.1)
9(19.1)
17(36.2)
12(22.6) 11(20.8)
6(18.2)
9(27.3)
15(22.4) 19(28.4)
0(0)
3(42.9)
11(26.2) 14(33.3)
7(28
5(20)
1(9.1)
2(18.2)
2(13.3)
4(26.7)
1(100)
0(0)
5(13.9)
8(22.2)
13(27.7) 16(34)
2(15.4)
4(30.8)
Severe
01(14.3)
00(0)
00(0)
02(6.1)
01(8.3)
00(0)
01(2)
03(6)
3(3.3)
1(12.5)
0(0)
3(4.6)
1(3.7)
2(4.3)
2(3.8)
1(3.0)
3(4.5)
0(0)
4(9.5)
0(0)
0(0)
0(0)
0(0)
1(2.8)
3(6.4)
0(0)
X2
X2=16.42
p-0.35
X2=9.40
P=0.024
X2=5.75
P=0.24
X2=7.94
P=0.24
X2=3.089
P=9.37
X2=0.525
P=0.91
X2=15.89
P=0.19
X2=15.52
P=0.214
HADS(D)Score
Moderate
Mild
02(28.6) 00(0)
03(17.6) 03(17.6)
04(15.4) 04(15.4)
07(21.2) 11(33.3)
01(8.3)
03(25)
02(40)
00(0)
10(20)
9(18)
9(18)
12(24)
17(18.5) 21(22.8)
2(25)
0(0)
3(37.5)
2(25)
9(13.8)
13(20)
7(25.9)
6(22.2)
11(23.4) 9(19.1)
8(15.7)
12(22.6)
8(24.2)
5(15.2)
11(16.4) 16(23.9)
1(14.3)
0(0)
10(23.8) 7(16.7)
3(12)
7(28)
1(9.1)
2(18.2)
4(26.7)
5(33.3)
2(50)
0(0)
7(19.4)
8(22.2)
7(14.9)
12(25.5)
3(23.1)
1(7.7)
Severe
01(14.3)
02(11.8)
02(7.2)
05(15.2)
03(25)
00(0)
3(6)
10(20)
12(13)
1(12.5)
1(12.5)
11(16.9)
1(3.7)
7(14.9)
6(11.3)
5(15.2)
8(11.9)
1(14.3)
10(23.8)
1(4)
1(9.1)
0(0)
0(0)
2(5.6)
9(19.1)
2(15.4)
X2
X2=14.32
p-0.501
X2=5.97
P=0.11
X2=2.43
P=0.48
X2=6.60
P=0.35
X2=1.66
P=0.64
X2=1.71
P=0.63
X2=16.51
P=0.16
X2=11.74
P=0.46
(*Read the number in parentheses as percentages)

Table 2: Cancer Variables and HADS Score of Cancer Caregivers
Diagnosis
Duration
Staging
Treatment
X2
HADS
Cancer
Variables
Breast
Genitourinary
Gastrointestinal
Lung Cancer
Head,Neck &
Face
Leukemia
Sarcoma
Lymphoma
< 6Months
>6Months
I
II
III
IV
Chemotherapy
Mild
Moderate
Severe
0(0)
11(42.3)
3(13.6)
4(40)
1(6.7)
6(23.1)
8(36.4)
3(30)
0(0)
0(0)
2(9.1)
0(0)
1(11.3)
3(33.3)
0(0)
1(14.3)
0(0)
1(16.7)
8(32)
13(17.3)
11(22.4)
8(22.9)
2(13.3)
0(0)
2(28.6)
3(60)
2(33.3)
6(24)
22(29.3)
11(22.4)
9(25.7)
8(53.3)
0(0)
0(0)
1(20)
1(16.7)
3(12)
1(1.3)
0(0)
3(8.6)
1(6.7)
0(0)
9(18.4)
13(26.5)
02(4.1)
X2=37.44
P=0.015
X2=9.040
P=0.029
X2=11.88
P=0.220
X2=14.29
P=0.282
X2=8.911
P=0.446
HADS
Mild
2(13.3)
5(19.2)
2(9.1)
3(30)
X2
1(6.7)
9(34.6)
5(22.7)
1(10)
Severe
0(0)
0(0)
6(27.3)
1(10)
2(22.2)
1(11.1)
2(22.2)
1(14.3)
2(40)
2(33.3)
3(12)
16(21.3)
10(20.4)
8(22.9)
0(0)
1(100)
2(28.6)
1(20)
1(16.7)
5(20)
16(21.3)
4(8.2)
11(31.4)
6(40)
0(0)
1(14.3)
2(40)
1(16.7)
5(20)
8(10.7)
3(6.1)
5(14.3)
5(33.3)
0(0)
7(14.3)
Moderate
11(22.4)
5(10.2)
X2=27.61
P=0.151
X2=2.13
P=0.544
X2=28.89
P=0.001
X2=17.81
P=0.037
X2=17.81
P=0.037

678
Manjeet et al.,
Table 3: Relationship & HADS Score of caregivers

Relationship
Spouse
Husband
Wife
Daughter in law
Daughter
Mother
Son
HADS (A) Score

Mild
Moderate
04(13.8)
08(27.6)
07(29.2)
09(37.5)
03(23.1)
04(30.8)
04(36.4)
03(27.3)
00(0)
01(33.3)
03(15)
03(15)
X2
Severe
00(0)
01(4.2)
00(0)
00(0)
02(66.7)
01(5)
x2=42.90
p-0.000
HADS (D) Score

Mild
Moderate
6(20.7) 5(17.2)
4(16.7) 7(29.2)
2(15.4) 0(0)
3(27.3) 3(27.3)
0(0)
2(66.7)
4(20)
4(20)
X2
Severe
1(3.4)
4(16.7)
4(30.8)
1(9.1)
1(33.3)
2(10)
X2=17.8
P=0.270

DISCUSSION
Recent shifts in care of cancer patients from a
hospital setting to home care environment has
increased the enrollment of informal caregivers in the
care giving process. Caregivers have to cater for the
different needs of the patients. These can be in the
form of emotional support, financial management,
assistance in activities of daily living, maintaining the
appointment schedule with oncologist, helping in
choosing the treatment option offered by the treating
oncologist and even monitoring the schedule &
administration of the treatment.
In providing optimum & quality care, caregivers must
maintain equilibrium between the previous and
current role they are playing so that care giving
should not affect their already established roles and
turn give rise to conflicts in the process of care
giving. Even the caregivers positive and negative
attitude towards diagnosis and progression of the
disease has a significant impact on care giving
process.34
In our study the possible cases of anxiety and
depression were 32% & 34% respectively. These
findings are in keeping with those from the previous
studies. Michal Braun et al35 in a study of 101 spouse
caregiver of mixed cancer patients found to have
significant symptoms of depression (BDI-II >15) in
38.9% of cases which is in agreement with our study.
On gender variable scores are statistically significant
(p<0.024) and in agreement with prior studies.36-38
These studies show that females suffer more care
giving burden. This may be due to the dual role of
maintaining the home and also caring of the patient.
Females as such are more prone to depression in
general population.
Caregivers who are unmarried suffer from increased
psychological distress39 as they perceive less of social
support. In our study sample unmarried cases were

very less hence could not be commented upon.
On educational status the results of our study show
that there were proportionately increased number of
patients with anxiety and depression with education
between 6-11 standard of schooling. Lower level of
education is likely to increase distress due to lack of
knowledge of the disease and feeling of ill
preparedness for the complex task of care giving.40-42
The relation to residence and family were not
statistically significant with emotional distress but
those belonging to the rural background has
substantiate proportionate of anxiety and depression
as they have to travel frequently from far flung areas
to the places where the specialist treatment of cancer
is available and eventually exhaust themselves
physically, financially and emotionally. Living in
nuclear family has increased proportion of anxiety
and depression as they have to perform all the tasks
and feels a lack of support being alone.
Prior studies have shown that there was an increased
emotional distress in people from lower
socioeconomic status.40, 43 Even though our study did
not show any significant score on socioeconomic
status of the cases may be the caregivers do not feel
the burden of finances for treatment on them as their
relatives who were suffering from cancer got
treatment free of cost from the hospital.
Care giving in itself is a full time job. Apart from the
personal occupation in which the caregivers were
involved they have to perform this task also.
Caregivers experience adverse impact of care giving
task on their occupation. Different types of
occupation have different impact on emotions of the
caregivers.44-46 In our study caregivers involved in
the occupation of the homemaking experiences
679
Manjeet et al.,
proportionately more distress as compared to others,

this may be due to the bias of sample.
Zabora et al47 studied 4496 cancer patients with 14
different diagnoses. He found that while pancreatic
cancer produced highest mean scores on anxiety and
depression, while Hodgkins lymphoma exhibited
highest mean score on hostility criteria in patients.
Thus the cancer site affected influence quality of life
and psychological well being differently of the
patients. Similarly there are changes in the emotional
distress level of the caregivers with different types of
cancer. Thus in our study on HADS (A) subscale the
scores were statistically significant in caregivers
caring for patients with variable cancer site. Our
study results were consistent with prior studies in
which the distress varies according to the greater
illness severity.48-49
As the duration of time period increases in the care
giving the emotional fatigue also increases in the
caregivers. Our study result on anxiety subscale is in
concurrence to prior study done by Baral et al.50
With advanced disease staging there are changes in
the physical symptoms of the patients. Dependency
feelings & preoccupation of the thoughts of nearing
death of the care recipients also increases during
advanced staging. Our study results on HADS (D)
subscale were in concurrence to prior studies.51-53
Patients type of treatment, schedule of treatment,
side effect of treatment, anxiety regarding the
intervention procedures, cost of treatment and final
outcome of the treatment all leads to distress in
caregivers as they are the ones who would actively
be there with the patient through all this process and
also a part of decision making in choosing the
treatment option for the patient. Our study in the
treatment category found to have statistically
significant results (p-0.037) were in agreement with
prior studies.54-56 Eva Grunfeld et al57 in a study of 89
caregivers of women with advanced breast cancer
found to have mean scores of 8.8 & 5.2 on anxiety
and depression scale respectively at the start of
palliative period and the score on depression
increased in terminal period insignificantly this is
again in concurrence to our findings.
Caregivers relationship to the care recipient is
another important factor to the emotional distress
they suffer. The level of emotional distress varies
with the degree of emotional attachment and the
relationship of the caregiver to the care recipient. In
Manjeet et al.,
case of spouses who stay with patient, experience

more emotional distress as compared to other kinship.
Spouses in particular become restricted in their
activities and socially isolated in their care giving
task. Problems of communication, sexual difficulties,
neglect of their children and significant others and
also absenteeism in their professional work all
leading to emotional stress.58-59 This is in agreement
to our study in which the spouses suffered
significantly. In a study done by Young RF et al60 on
care giving of heart patients in 183 caregivers found
significant strain on non spousal caregivers mainly
daughters. In our study also daughters have
proportionately more emotional stress than mother,
daughter in law and son.
We acknowledge limitations of our study, the studied
sample size was small. This study was questionnaire
based study and the diagnostic research criteria for
psychiatric diagnosis were not applied at the time of
categorizing cases as emotionally distressed.
Caregivers emotional distress is influenced by many
factors. This factors be related to care recipient or to
the caregivers. Aspects of internal resources playing
a role in care giving were not studied.61 The
psychological symptoms, personality traits and traits
of dependency of patients were not considered here
which too influence the care giving burden. Apart
from these there are many more factors which can
influence the emotional status of the caregivers
which needs a longitudinal study in a larger sample
with consideration of all the factors which affect the
caregivers levels of anxiety and depression.
CONCLUSION
The diagnosis of cancer carries with it a significant
amount of emotional distress not only in cancer
patients but their caregivers as well. Optimum care
for cancer patients depends largely on optimum care
of caregivers so as to sustain them in the challenging
task of care giving. Early evaluation is warranted for
management of emotional distress in caregivers.
Results of the study showed that both anxiety and
depression were significantly higher in caregivers.
Their emotional distress level changes with the age,
gender, education, economic status, types of cancer,
stage of cancer and with different treatment
modalities. The relationship status of the caregiver to
the cancer survivor also has an impact on the
emotional stress experienced by the caregivers.
680
There is a need to assist, support and motivate

caregivers in their new and demanding role. In
addition to these there is a need to acknowledge the
importance of relationships from the point view of
caregivers and patients involved in the cancer
treatment.
A psychiatrist can play a very important role in an
integrated oncology treatment team, by providing
specialized treatment at the earliest which will not
only reduce the emotional distress in cancer survivors
but also their caregivers to continue their care
giving. This will result in reducing the hidden
psychological morbidity of caregivers and bringing
overall improvement in quality of life of cancer
patients and their caregivers as well.
ACKNOWLWDGEMENT
I would like to acknowledge support extended by Dr.
Vijay Kumar Domple, Assistant Professor,
Department of Preventive & Social Medicine, Dr.SC
Government Medical College, Nanded, Maharashtra.
Conflict of Interest None
Financial sponsorships - None
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DOI: 10.5958/2319-5886.2014.00417.2

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 5 May 2014
Short communication
PREVALENCE OF PRADER-WILLI SYNDROME IN WESTERN INDIA
*Pankaj K. Gadhia, Salil N. Vaniawala
Molecular Cytogenetic Unit, S N. Gene Laboratory and Research Centre, President Plaza A, Near RTO circle,
Surat, India
* Corresponding author email: pankajkgadhia@gmail.com
ABSTRACT
The prevalence of Prader-Willi Syndrome (PWS) was studied using both classic cytogenetic and FISH techniques
in referred cases of microdeletion 15q11-13 to our laboratory from Western India. A total of 53 cases were
registered, of which 08(15%) were found positive for Prader-Willi Syndrome i.e. 15q11-13 microdeletion
syndrome. FISH technique found to be suitable and sensitive to confirm clinically diagnosed PWS.
Keywords: Prader-Willi syndrome, Western India, FISH, 15q11-13
INTRODUCTION
Prader-Willi syndrome (PWS) is a complex
multisystem disorder due to the absent expression of
the paternally active genes in PWS region on
chromosome 15.1 In 75 to 80% of affected individuals
there is a microdeletion of paternal chromosome
15q11-13.2 PWS is a complex genetic disorder
attributed to genomic imprinting. It is relatively
common prevalence of 1/15,000 30,000. Despite
genetic cause it appears to be sporadic, sex-ratio
equals and occurs in all races.3,4 The differential
diagnosis includes obesity, cryptorchidism, short
stature, mental retardation, sleep apnoea and squint
myopia.
The microdeletion syndrome is characterised by
hemizygous microdeletion less than 5 mb of
chromosome in which one or group of genes are lost.5
G-banded karyotyping is approach to detect genomic
resolution more than 5 mb. This resolution has been
overcome by FISH. It is possible to detect cryptic
chromosomal rearrangement such as microdeletion by
conventional FISH technique.

The study was conducted at S. N. Gene Laboratory
and Research Centre, Surat, India between August
2010 and February 2014. A total of 53 suspected
cases were refereed to us from different parts of
Western India and inform consent form was taken
from all the subjects. From all patients EDTA and
heparinised blood sample (1 2 ml.) were collected
and were cultured for 72-hours by standard method
developed by Moorehead et al.6 The karyotypes were
examined using GTG banding and the automatic
scanning system (Axioimager Z2Carl-Zeiss) and
karyotyping software (IKAROS, Germany) was used
to make karyotype.
Fluorescence in situ
hybridization (FISH) was carried out in both
interphase cells and metaphases by using Vysis
probes of LSI SNRPN and D15S10 PraderWilli/Angelman. The LSI D15S10 probes identify
deletion of the locus D15S10 and UBE3A gene
located within 15q11-13 region of chromosome 15.
The procedure was performed as per instruction given
by manufacturer. From each patient minimum of 25
684
Pankaj et al.,
interphase cells and 25 metaphases or 50 metaphases

were scored and analysed for presence or absence of
15q11-13 microdeletion.
RESULTS AND DISCUSSION
A total of 53 patients clinically diagnosed as PraderWilli syndrome (PWS) were referred to us for
chromosome study and FISH analysis. Out of 53
patients, 30 were males and 23 females ranging in age
from 8 days to 41 years. G-banded karyotypes of all
patients did not show any deletion on chromosome #

15. Only 08 (15%) patients (Table-1) confirmed
positive with microdeletion (Figs. 2,3) of 15q11-13
by FISH analysis. Prader-Willisyndrome is single
most commonly known genetic cause of obesity. It
has been estimated to have a population prevalence
about 1:10,000 to 1:52,000 as reported by
Whittington et al.,7.In large database population study
was carried out by Grugni et al.,4on the Italian
National survey for Prader-Willi syndrome.
Table: 1 shows age and sex distribution among confirmed Prader-Willi syndrome
Patients no.
Age
Sex
FISH result
1
4 Years M
20 metaphases and 20 interphase cells with microdeletion
2
1 year
M
3
8 years
M
50 metaphases with microdeletion
4
7 years
M
5
6 years M
6
2 years M
7
3 years M
8
2 years F
Fig 1: G-banded karyotype of male patient shows

no deletion in chromosome # 15
Fig 2: Metaphase showing 2 green and one orange

signals confirming micro deletion of 15q11-13
Deletion
15q11-13
15q11-13
15q11-13
15q11-13
15q11-13
15q11-13
15q11-13
15q11-13
Fig 3: Interphase cell showing 2 green and 1

orange confirming micro deletion of 15q11-13
The study revealed; out of 425 subjects del 15 was
found in 238 cases. It is generally known that PWS
patients developed morbid obesity.8
The complications associated with obesity are the
main risk factor for the death in PWS9.
In the present study, we found only one older person
with age of 41 years. Rest of all patients were under
age of 12 years. In addition, it is interesting to note
that out of 08 affected patients, 07 were males and
only one female (Table-1). On the contrary, few
published studies have reported that PWS affects
males and females equally,10,11. In another study from
India, Halder et al.,5 has reported 4 positive cases (2
pure and 2 mosaic) out of 38 patients studied for
685
Pankaj et al.,
suspected Prader-Willi/Angelman syndrome. They

have further suggested that whole genome screening
may be used as a first line of test and FISH may be
used for confirmation of screening results.
8.
CONCLUSION
In conclusion, we propose that routine use of FISH
for diagnosis of microdeletion of 15q11-13 is
considered to be a gold standard technique which
confirm accurately done diagnosis of microdeletion in
general and Prader-Willi syndrome in particular.
9.
10.
ACKNOWLEDGEMENTS
The authors wish to thank Mr. Jori and Mr. Urvish
Dalal for their help and Ms. Parita, Tanvi, Nitisha and
Rachna for their technical assistance.
11.
the people with Prader-Willi syndrome in one UK

health region. J. Med. Genet. 2001; 38:792-98
Gunay-Aygun M, Schwartz S, Heeger S,
ORiodran MA, Classidy SB. The changing
purpose of PWS clinical diagnostic criteria and
proposed
revised
criteria.
Pediatrics.
2001;108:92-95
Einfeld SF, Kavanagh SJ, Smith A, Evans EJ,
Tonge BJ, Taffe J. Mortality in Prader-Willi
syndrome. Am. J. Ment. Retard. 2006; 111:19398
Classidy SB.Prader-Willi syndrome. J. Med.
Genet. 1997; 34: 917-23
Watterndorf DJ, Muenke M.
Prader-Willi
syndrome. Am. Fam. Physician2005; 72: 827-30
Conflict of interest: declare no conflict of interest

Financial support: Nil
REFERENCES
1. Bittle DC, Butler MG. Prader-Willi syndrome:
Clinical Genet. Cytogenet. And Mol. Biol. Exert
Rev. Mol. Med. 2005; 7:1-20.
2. Buiting K, Horsthemke A. Molecular genetic
finding in Prader-Willi syndrome:In: Butler MG,
Lee PDK, Whitman BY, 3rd Edition.2006;N.Y.p.
58-73
3. Classidy SB, Driscoll DJ.
Prader-Willi
syndrome. Euro. J. Humn. Genet. 2009;17(1):313
4. Grungi G, Crino A, Bosio L, Carrias A, Cuttini
M, Toni DT, et al. The ItalianNational survey for
Prader-Willi syndrome: An epidemiological
study. Am. J.Med. Genet. 2008; 146A: 861-72
5. Halder A, Jain M, Chaudhry I, Gupta N, Kabra,
M. Fluorescence in situ hybridization (FISH)
using non-commercial probes in the diagnosis of
clinically suspected microdeletion syndrome. Ind.
J. Med. Res. 2013; 138: 135-42
6. Moorehead PS, Nowell PC, Mellman WJ, Battips
DM, Hungerford DA. Chromosome preparations
of leukocytes cultured from human peripheral
blood. Exptl, Cell Res. 1960; 20:613-616
7. Whittington JE, Holland AJ, Webb T, Butler J,
Clarke D, Boer H. Population prevalence and
estimated birth incidence and mortality rate for
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DOI: 10.5958/2319-5886.2014.00418.4

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Review article
ELECTRODERMAL ACTIVITY: APPLICATIONS IN PERIOPERATIVE CARE

*Aslanidis Theodoros
Intensive Care Unit, Department of anesthesia and intensive care medicine, A.H.E.P.A Univ. Hospital,
Thessaloniki, Greece.
*Correspondence author email: thaslan@hotmail.com
ABSTRACT
Background: Electrodermal activity is originated from the activation of sweat glands in the skin in response to
stress or other stimuli and thought to reflect the activity of the sympathetic nervous system, or physiological
arousal. Though it has been studied since the late 19th century, it still does not make the transition into everyday
clinical application. Improvement of recording and analyzing measurement data has recently increased the
interest for possible applications in various clinical settings- operation room, recovery and intensive care unitwhere monitoring of autonomous nervous system activity is vital. Aims: This paper presents the applications of
electrodermal activity measurements, in both adult and pediatric patients. Materials-methods: It especially
reviews the results of studies carried out in perioperative setting and reviews their results. Conclusion: Although
no final conclusion can be drawn safely, it seems that in adult populations electrodermal activity monitoring has
the role of stress detector, while in pediatric populations it works more efficiently as algesimeter. Possible future
applications in intensive care are also discussed.
Key words: Electrodermal activity, Stress, Perioperative care
INTRODUCTION
Sensing technologies in physiology gain a lot of
importance for the assessment of the human
functional state. Electric, mechanical or chemical
signals of biological origin delivered by living things
can always be of interest for diagnosis, patient
monitoring, and biomedical research. The registered
biomedical signalsreferred to as biosignals here
can be defined as a description of a physiological
phenomenon, irrespective of the nature of this
description. Since there are a nearly unlimited
number of physiological mechanisms of interest, the
number of possible biosignals is very large.1
Bioelectromagnetism is the discipline that examines
the electric, electromagnetic, and magnetic
phenomena which arise in biological tissues. The
main reason of its ever growing importance is that
bioelectric phenomena of the cell membrane are vital
Aslanidis T.,
functions of the living organism. Applications of

bioelectromagnetism include electrocardiography,
electroencephalography, surface electromyography
and many other widely used diagnostic and
therapeutic methods.2 This paper focuses on a
particular application of bioelectromagnetism
discipline in clinical medicine, the measurement of
skins electrical properties (electrodermal activity) in
the perioperative setting.
ORIGIN OF ELECTRODERMAL ACTIVITY
Sweat glands are considered to be exocrine glands, as
they secrete directly onto the skins surface. There are
average 2.6 million (1.6-4 million) sweat glands in
the human body with their density (per cm2) varying
in different areas: 233 on the palms, 620 on the soles,
360 on the forehand, 120 on the thighs and zero on
the lips, inner ear channel, glans penis, clitoris, labia
687
Int J Med Res Health Sci.2014;3(3):687-695
minora and on the inner surface of the prepuce. Their

density decreases from fetal stage (3000/cm2 in the
24th week of pregnancy) to adulthood. They are
further divided into eccrine, which means that their
secretion do not contain a noticeable amount of
cytoplasm from the glandular cells and apocrine
(mainly in the areola region of the breast and the
genitals). However, the latter doesnt play a
considerable role in the total amount of sweating.
The eccrine sweat gland is composed by the secretory
segment and the duct. The first is located in the
hypodermis and the dermis and it consists of a tube
which is coiled into a rounded mass (0.4m in
diameter).The duct (5-10m in diameter) follows an
undulating course through the dermis and then a
spiral course through the epidermis.3, 4
Innervation of sweat glands comes from a dense net
of nerve terminals, both cholinergic and adrenergic.
In particular, the secretion of the apocrine glands is
stimulated by circulating adrenaline, whereas
innervation of secretory part of the eccrine sweat
glands is solely via the sympathetic branch of the
autonomic nervous system (ANS), which also reaches
the dermal part. It is well known that for these glands
the postganglionic synapse is cholinergic, having
acetylcholine as synaptic transmitter.4
When the secretory part of the sweat glands are
stimulated by nerve endings, the clear cells secrete a
fluid (by filtering the plasma), called primary
secretion (or precursor sweat), that is similar to
plasma but without the proteins and fatty acids. It
contains prevalently water and ions (high
concentration of Na+ and Cl-, low concentration of K+
and is hypertonic with respect to blood. This fluid
contains approximately: Na+ at concentration about
147-151 mM, Cl- at about 123-124 mM, k+ at about 5
mM, bicarbonate at 10-15 mM, and also lactic anion
at 15-20 mM, as well as small amounts of other ions,
urea and vitamins. The precursor sweat moves from
the secretory part of the duct towards the skin surface,
under the combined effects of intraductal hydrostatic
pressures and rhythmic contractions (at frequencies of
about 12-21 Hz) of the myoepitelial layer
surrounding the sweat gland duct. These contractions
are induced by the action of the sympathetic
cholinergic nervous fibers.
When the fluid reaches the dermal part of the duct, it
is subjected to various modifications in composition,
depending mainly from the rate of perspiration.5,6
Although the major function of sweating is the

regulation of the body temperature, it is known that
sweating on the palm is independent of the ambient
temperature (under normal condition), and is elicited
by emotional (fear, pleasure, agitation), physiological
(inspiratory gasp, tactile stimulation, movements) and
stressful (mental exercises) stimuli. All findings
concerning the central innervations of sweat glands
activity point to several centers, located at different
levels of the CNS, and partly independent of one
another.7 Hence, the activity from the sympathetic
nervous system (SNS) regulates the secretory part of
the sweat glands, which in turn changes the electrical
properties of the skin due to the filling of electrolytecontaining sweat in the ducts. Measurement of the
output of the sweat glands, which electrodermal
activity is thought to do, provides a simple gauge of
the level and extent of sympathetic activity. This is
the simple and basic concept underlying
electrodermal activity and its applications.
TERMINOLOGY, MEASUREMENT SITES
AND CHARECTERISTIC SIGNALS
Electrodermal Activity (EDA) is a general term, first
introduced by Jonhson and Lubin (1996), that
includes all electrical properties (conductance (SC),
resistance (SR), potentials (SP), impedance (SZ),
admittance (SY)) which can be traced back to the
skin and its appendages. Electrodermal recordings are
called endosomatic, when they are not using an
external current and only the skin potentials (in
micro-volts (V)) originating in the skin itself are
measured and exosomatic when either direct (DC) or
alternating (AC) current is applied to the skin.
Especially in DC measurements, if voltage if kept
constant (known as qausi-constant voltage method),
EDA is recorded directly in SC units (micro-Siemens
(S)); while SR (Ohms ()), units are used when
current is kept constant (quasi-constant current
method) (figure1). Accordingly, in AC measurements
if effective voltage is kept constant, EDA is recorded
as SZ, while SY results when the effective current is
kept constant.
688
Aslanidis T.,
Fig 1: Schematic representation of the methods used to

measure skin resistance and skin conductance
Quasi-constant current method to measure skin

resistance (left) and qausi-constant voltage method to
measure skin conductance (right) In the first case
Vout = SR and in the second one Vout = SC. 3,7
EDA is also divided into tonic or baseline level at any
given moment (slow changing component or the
background signal) abbreviated with L (e.g. SCL
=skin conductance level) and a phasic, fast changing
component arising from a response signal to a
stimulation (abbreviated with the letter R, e.g. SCR =
skin conductance response). Yet, there are often
phasic parts of EDA that cannot relate to any specific
stimulation. Thus, they are called nonspecific or
spontaneous (NS.SCR).3,8
In the literature various suffixes may be added to
describe features of the component of interest:
frequency (the number of Electrodermal responses
(EDR) in a given time frame; amplitude, which refer
to the height of a single response; latency, which is
the time interval between stimulus and onset of the
response; rise time, which refers to time interval
between onset and maximum of the response; and
recovery time, which indicates the time needed to
recover either to 50% or 63% of the amplitude. Some
monitoring devices includes more specific parameter
like average peak, which is the difference in
conductance value between the identified maximum
and minimum of one peak is its peak value (
calculated from all peaks in the time window); area
huge peaks and area small peaks. Area huge peaks are
calculated by establishing a horizontal base line from
the first peak minimum in the time window. The area
that is calculated is the accumulated difference
between the conductance values at the registration
curve and the established baseline when they are
larger than the baseline. Finally, the area small peaks

measure is calculated by establishing a line between
two adjacent peak minimum points. The area is the
accumulated difference between the line and the skin
conductance registration curve values when they are
larger than the line (fig 2).3,8,9
The best recording sites for electrodermal measures
are found on the palms of the hands or the soles of the
feet (although the latter are less practical), where the
sweat glands are numerous and much more
responsive to psycho-physiological stimuli than to
thermal stimuli. In the hand, the preferred active sites
are the thenar and hypothenar eminences and the
medial and distal phalanges of the index and middle
fingers. Two or 3-electrodes are usually used. The 3electrode system consists of a measuring electrode
(M), a countercurrent electrode (C), and a reference
voltage electrode (R), which ensured a constant
applied voltage across the stratum corneum beneath
the M electrode. (Fig 3).
Fig 2: Area huge peaks (a), area small peaks (b) and
example of other EDA measurements (c).9
Fig 3: Suggested measurement sites a) 3-electrode

2,3,7,8
system b) 2-electrode systems c) foot sites.
There are various types of commercially available

electrodes for EDA measurements. Yet, they all
follow the same basic principles. In general, the
electrodes used are of the Ag/AgCl type which are
689
Aslanidis T.,
recessed from the skin and require the use of a

suitable electrode paste. Since this is a reversible type
of electrode, polarization and bias potentials are
minimized. Sodium chloride is the preferred material
of the electrode gel, because it is a main component
of sweat. Since the conductance/resistance of the skin
is affected by its water content, the contact medium
should be isotonic with sweat.
Historical Frame and Applications: Autonomic
electrical recordings, obtained for the first time at the
end of the nineteenth century.10, 11 The psychometer,
an instrument allowing recording of autonomic
measures, became extremely popular as a way of
revealing aspects of mental life and constituted a
surprising belief in machines for reading thoughts. 12
Fifty years later, the activation arousal theory,13
describing continuity between central mechanisms
and peripheral autonomic responses, assumed that
any organ influenced by the autonomic nervous
system (ANS) could be a potential index of mind
activity. In line with these premises, the use of the
autonomic responses as markers of emotion,
attention, decision making, motor preparation, reward
or punishment anticipation, unconscious detection,
has been strongly developed since the 80s.14
Along with that, EDA measurements have been used
as a prognostic index in epilepsy15 and after brain
trauma injury, 16 as an efficiency index of therapy in
schizophrenia 17, as a diagnostic tool for subclinical
epileptic seizure18, in sleep research19, in early
diagnosis of skin malignancies20 and in therapeutic
hypnosis21 and acupuncture. 22
Applications in perioperative care:
The most
important studies about electrodermal activity in
perioperative setting are displayed in tables 1 and 2.
Adult population: In 2002, there is the first report
of correlation between both the number and
amplitude of SC fluctuations (NFSC) with blood
pressure, heart rate, bispectral index (BIS),
norepinephrine and epinephrine levels in 11 patients
during laparoscopic cholecystectomy under general
anesthesia with propofol and remifentanil along.23
Three years later Storm et al. measured mean level of
SC and NFSC along with BIS and five-point clinical
stress score CSS) (systolic blood pressure >130
mmHg, cough, tears, EMG in the forehead >50 or
movements) in patients during surgical stimulation.
The NFSC was sensitive to clinical stress during
surgical stimulation and the combined use of SC and
NFSC may have a potential to differentiate between

situations of stress due to inadequate hypnotic effect
vs. inadequate analgesic effect.24
Ledowski et al. (2006) compared NFSC and BIS in
patients waking from general anesthesia, 25 under
propofol and remifentanil and 25 under sevoflurane
and remifentanil. In the case of total intravenous
anesthesia BIS was found to predict arousal with a
higher probability but slower response times than
NFSC, while in the second case both parameters
performed similarly.25,26 Moreover, they found that
measured NFSC correlates well with numerical pain
rating score (NRS) in postoperative setting and they
proposed a cutoff value of NFSC of 0.1 (sensitivity
89% and specificity 74%) for indicating
intraoperative painful stimuli with NRS>3 (moderate
and severe pain). Yet, in a second study, a year later
they reported 88.5% sensitivity and 67.7% specificity
of the same cutoff value. 27
In addition, in contrast to BIS, SC parameters (NFSC
and area under curve (AUC)) are found to be
influenced by the timing of remifentanil cessation, i.e.
by remifentanil suppression of surgical stress. Hence,
it became obvious that SC may measure nociceptive
pain fast and continuously, specific to the individual,
with higher sensitivity and specificity than other
available objective methods. Nevertheless, AUC did
not improve any further SC monitoring in patients
awaking from total intravenous anesthesia.28
Along with that, Gjerstad et al. reported that state
entropy
(SE)
which
measures
electroencephalographic signals, response entropy
(RE) which includes also frontal electromyographic
activity and the derivate of the mean SCL showed a
similar discrimination between sound responses
(98dB stimulus) at the different sedation levels
(assessed with observer's assessment of alertness
sedation scale).29 Mobascher al. correlate pain with
EDA, electroencephalography (EEG), and functional
magnetic resonance brain imaging (fMRI).30
In 2009, Ledowski et al. report moderate sensitivity
(50%) and specificity (60%) for both NFSC and
surgical stress index (SSI) to detect NRS>3
postoperative pain.31 Moreover, both methods only
partially reflected changes in plasma noradrenaline
(stress hormone) levels. 32 Recently, a report with
best sensitivity (77.9%) but relatively poor specificity
(41.2%) was obtained for the detection of NRS>2 by
criterion number of fluctuations of skin conductance
690
Aslanidis T.,
(NFSC) >0.13 doubted the ability of NFSC to

distinct pain from other stressor factors.33 The
uncertainty continues with Gnther et al. (2013) who
claim that NSCF may be more useful evaluating
emotional distress rather than pain alone.34
Pediatric population: In 2008 Eriksson et al. found
that SCR can differentiate painful from tactile
stimulus in infants and neonates.35 On the contrary,
when the NFSC is used in pediatric postoperative
population, it has 90% sensitivity and 65% specificity
in identifying pain.36 Yet, an attempt to find a cutoff
value for severe postoperative pain (NRS>7),
reported only 56.3% sensitivity and 78.4% specificity

(NFSC 0.23). Dalal et al. found a sensitivity and
specificity of 90.9% and 51.4% respectively for peak
values and 0.66, 54.5% and 79.4% respectively for
EDR/sec values in indication unmitigated pain in
infants 6-12 months.37 In a small study, Valkenburgh
et al. suggest that in PICU patients, there may be
other parameters apart pain that influence EDA.38
However, Gjerstad found that compared with
COMFORT sedation scale, NFSC is considered an
objective measurement of perioperative stress in
artificially ventilated children.39
Table 1: Studies for application of electrodermal activity monitoring in the perioperative setting: OR-operating room,
ED emergency department, PACU- postanesthesia care unit, ICU- intensive care unit, PICU paediatric intensive
care unit.*trachea suction and patient turnover.**mechanical ventilation, aspiration, blood sampling.
Population
Reference
N
Setting
Stimulus
Response
Compared with
Storm, 2002
11
OR (propofol and
Perioperative stress
NFSC
remifentanil)
Storm, 2005
14
OR
Surgical stimulation NFSC,SCL CSS, BIS
Ledowski,2006
25
OR (propofol and
Arousal
NFSC
BIS
remifentanil)
Ledowski,2006
25
OR (sevoflurane and
Arousal
NFSC
BIS
remifentanil)
Ledowski,2006
25
PACU
Postoperative pain
NFSC
NRS
Ledowski,2007
75
PACU
Postoperative pain
NFSC
NRS
Storm, 2007
50
OR (propofol and
Intraoperative pain
NFSC,
remifentanil)
AUC
Adults
Ledowski,2007
25
OR (propofol and
Arousal, Extubation AUC
NFSC,BIS,
remifentanil)
Hemodynamics
Gjerstad , 2007
25
OR (propofol and
White sounds
NFSC,
SE, RE
remifentanil)
(98dB)
SCL
Mobascher, 2009
12
Healthy
Pain
SCR
fMRI, EEG
Ledowksi, 2009
100
PACU
Postoperative pain
SCR
SSI
Ledowski, 2010
20
OR (bolus analgesia
Intra-operative pain
NFSC
SSI, Stress
fentanyl)
hormone
plasma levels
Czaplik, 2012
44
PACU
Various*
NFSC
NRS
Gnther, 2013
40
ICU
Various*
NFSC
MAAS
Eriksson,2008
32
Neonates Healthy
Pain
SCL,SCR
Tactile stimulus
Gjerstad , 2008
20
PICU
Trachea suction
NFSC
COMFORT
Children
Hullett, 2009
165
Postoperative pain
NFSC
VAS
Choo, 2010
90
Postoperative pain
NFSC
NRS
PACU
Valkenburg, 2012
11
Temperature
SCR
Infants
Dalal, 2013
31
Postoperative pain
EDR/sec,
BPS
SCL
Sabourdin, 2013
12
OR (desflurane and
Intra-operative pain
SCR
ANI
remifentanil)
Hemodynamics
Children
Strehle , 2013
67
ED
Minor injury
NFSC
Wong-Baker
FACES
Scaramuzzo, 2013
158
Neonates Ward
Minor procedure
SCR
ABC
Macko, 2013
57
Infants
Ward
Pain
SCR
Prechtl's Scale
Karpe, 2013
32
NICU
Various**
SCR
Neonates
Jesus, 2013
41
Ward
Pain
EDR/sec,
NIPS, NFCS,
AUC
COMFORT
691
Aslanidis T.,
Table 2: Presentation of the so far (2013) studied EDA

parameters in the perioperative setting. *paediatric
population.
Control
No of
EDA
References
parameter
parameter
studies
Strom,200524
BIS
3
Ledowski,200625
Ledowski,200625
CSS
1
Strom, 200524
Ledowski,200625
Ledowski,200727
NRS
4
Choo,2010*
Czaplik,201233
NFSC
SSI
1
Ledowski, 201032
VAP
1
Hullett,2009*36
Stress
1
Ledowski, 201032
hormone
RE
1
Gjerstad , 200729
SE
1
Gjerstad , 200729
COMFORT
1
Gjerstad , 2008*39
Wong-Baker
1
Strehle , 2013*42
(FACES)
MAAS
1
Gnther, 201334
BIS
1
Storm ,200524
BPS
1
Dalal, 2013*37
Tactile
SCL
1
Eriksson,2008*35
stimulus
RE
1
Gjerstad , 200729
SE
1
Gjerstad , 200729
EDR/sec
NIPS
1
Jesus, 2013*46
COFORT
1
Jesus, 2013*46
NFSC
1
Jesus, 2013*46
BPS
1
Dalal, 2013*37
AUC
NFSC
1
Ledowski,200727
Jesus, 2013*46
BIS
1
Ledowski,200727
Hemodynamic 1
Ledowski,200727
s
NIPS
1
Jesus, 2013*46
COMFORT
1
Jesus, 2013*46
SCR
SSI
1
Ledowksi, 200931
Hemodynamic 1
Sabourdin,
s
2013*40
ANI
1
Sabourdin,
2013*40
ABC
1
Macko, 2013*45
In 2013, Sabourdin et al. after studying children

under general anesthesia concluded that SC was
inferior to analgesia-nociception index (ANI) in
identifying pain.40 Yet, other authors doubted the
results, as they claimed that there were not used the
recommended preset values for the SC equipment.41
Aslanidis T.,
Strehle et al. measured SC in children after minor

injury. Wong-Baker FACES Pain Rating Scale was
used as a standard method. There was a significant
correlation between self-reported pain and the NFSC
in girls, but not boys. There may be a number of
reasons for this gender variation, including difficulty
in rating pain and lack of sensitivity in the pain
rating scale.42
Scaramuzzo et al. also reported that SC
measurement device is a reliable method to evaluate
pain, in comparison with ABC scale.43 In case of
infants, peaks per second proved to be the best SC
parameter as it is not influenced by gestational age.44
When SC was measured in neonate intensive care
unit patient, it was shown that patients experience
discomfort despite the use of sedation and
analgesia.45 Finally, Jesus, found a good correlation
of EDR/sec and AUC with Neonatal Facial Coding
System (NFCS), Neonatal Infant Pain Scale (NIPS)
and modified COMFORT scale.46
DISCUSION
Future perspectives: Dysautonomias range from
transient, occasional episodes of neurally mediated
hypotension to progressive neurodegenerative
diseases; from disorders in which altered autonomic
function plays a primary pathophysiologic role in
disorders in which it worsens an independent
pathologic state.47 Monitoring of autonomous
nervous activity in certain clinical settings where the
variety of causes that can alter this activity is
enormous and the rhythm of its change rapidly (e.g.
ICU) it is vital to be able to monitor autonomous
nervous system (ANS) status.
Only limited data are currently available about

EDA monitoring in ICU. Since most of the
currently used pain measurement scales in
clinical practice rely on patients cooperation
and are hence bound to fail in unconscious,
demented or uncooperative patients or young
children; EDA monitoring is a potential tool for
more
objective
assessment
of
acute
perioperative pain and stress. It seems that in
adult populations has the role of stress detector,
while in pediatric populations it works more
efficiently as algesimeter. Yet, we need larger
studies to reach a safe conclusion. Apart from
that, EDA monitoring can be added to and combined
692
with the so far developed CNS and ANS examining

methods. In this case, the use of trend or change
(up or down of an EDA parameter) is seems more
logical than a cutoff value, which is used in
pain/stress detection. Thus, e.g. it would be
interesting to combine EDA monitoring with Heart
Rate Variability (HRV) measurement- a tool already
used in ICU for examining ANS48, with salivary amylase (sAA) activity (used for relaxation of
sympathetic nerve system49), Transcranial Doppler,
pupilometry in order to examine situations that
modify or injure ANS, like e.g. sepsis, diabetic
ketoacidosis, trauma brain injury, major surgery,
drugs or substances that interfere with ANS activity
(e.g.cortisteroids, alcohol). It will also be useful to
measure EDA in brain death cases or in patients
previously treated for ANS dysautonomias (e.g.
Guillain- Barre syndrome).
CONCLUSION
We are still far from a definitive decision about the
use of EDA measurement in perioperative setting. It
may serve as a pain or stress detector in the
operating room, postanesthesia care unit and
emergency department, with different results in adult
and pediatric patients. However, the potential of
EDA measurements offers numerous possibilities in
ICU setting, where future studies will determine its
use as algesimeter, stress detector or ANS
monitoring.
ACKNOWLEDGEMENT
Author would like to thank Dr M. GiannakouPeftoulidou for her support.
Competing interests; None declared.
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DOI: 10.5958/2319-5886.2014.00419.6

&
Health Sciences
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Volume 3 Issue 3
th
Coden: IJMRHS
Revised: 22nd Jun 2014
Copyright @2014
ISSN: 2319-5886
Review article
COEXISTENCE OF HASHIMOTOS THYROIDITIS WITH PAPILLARY CARCINOMA THYROID: A

RARE CASE REPORT WITH REVIEW OF LITERATURE
*Mahajan Meera S1, Bindu Suparna M2, Taksali Reeta N3, Kale Apurva V4, Mulay Smita S5
1,3
Lecturer, 2Associate Professor, 4Resident, 5HOD and Professor, Department of Pathology, MGM Medical
College and Hospital, N-6 Cidco, Aurangabad, Maharashtra
*Corresponding Author email ID: meeramahajan12@gmail.com
ABSTRACT
Hashimotos thyroiditis is an inflammatory disease of the thyroid gland. It has an autoimmune etiology. A higher
incidence of papillary thyroid carcinoma with Hashimotos thyroiditis was reported in several studies. 51 year old
female patient presented with a swelling in front of the neck region since 5 years. Clinical examination revealed a
swelling about 4x4x3 cm, smooth, tender, non-pulsatile and moved with deglutition. Ultrasonography revealed
multinodular goiter without evidence of lymphadenpathy. Thyroid profile was done. Patient was euthyroid.
FNAC reported as benign lesion. Hemithyroidectomy was done. Grossly thyroidectomy specimen i.e.
hemithyroid 6x3x3 cm was received which was externally capsulated and nodular. Cut section showed a greyish
white area and cystic areas each of size 1x1 cm filled with haemorrhagic and mucoid material respectively.
Microscopy showed thyroid follicles with lymphoid infiltrate in the stroma forming follicles with germinal
centres. Hurthle cell change was also noted. Section from both cystic areas showed plenty of complex branching
papillae with fibrovascular core lined by cuboidal cells showing ground glass nuclei. The case was diagnosed as
papillary carcinoma in Hashimotos thyroiditis. The frequency of the association of Hashimotos thyroiditis and
differentiated thyroid carcinoma is approximately 30%. However, the presence of Hashimotos thyroiditis has no
effect on the diagnostic evaluation and management of papillary carcinoma of thyroid. Yet, one has to keep an
eye for the features of papillary carcinoma in case of Hashimotos thyroiditis. So a thorough grossing of thyroid
specimen is recommended especially in patients who have Hashimotos thyroiditis.
Key words: Hashimotos thyroididtis, papillary carcinoma thyroid, coexistence.
INTRODUCTION
Hashimotos thyroiditis , characterized by the
presence of diffuse lymphocytic and plasma cell
infiltration of the thyroid parenchyma and reactive
germinal centres, is most typically seen in the adult
population with a female predominance.1 Papillary
carcinoma is defined as a malignant epithelial tumour
showing evidence of follicular cell differentiation and
characterized by nuclear distinctive feature.2
Several studies report a higher rate of papillary
thyroid carcinoma in patients with Hashimotos
thyroiditis indicating possible correlation between the

two diseases.3-5
There is approximately 30% frequency of the
coexistence of Hashimotos thyroiditis and
differentiated thyroid carcinoma. The presence of
coexistent Hashimotos thyroioditis does not affect
the diagnostic evaluation and management of
papillary thyroid cancer.6
696
Mahajan Meera et al.,
CASE REPORT
51 years old female patient presented with swelling in
front of the neck region since 5 years. Patient had
difficulty in swallowing and change in voice since 2
months. Clinical examination revealed a swelling
about 4x4x3 cm, smooth, tender, non-pulsatile and
moved with deglutition. On ultrasonography thyroid
gland appeared diffusely bulky with well defined
nodules. It was reported as features suggestive of
multinodular
goiter
without
evidence
of
lymphadenopathy. Thyroid profile was done. Patient
was Euthyroid.FT4 1.06[N.R.- 0.8-1.9 ng/dl] FT3
3.05 [N.R.- 1.5-4.1 pg/dl] TSH 0.973[N.R.- 0.44Uiu/ml] FNAC reported as benign lesion.
hemithyroidectomy was done. Grossly thyroidectomy
specimen i.e. hemithyroid of size 6x3x3 cm was
received which was externally capsulated and
nodular. Cut section showed a greyish white area and
cystic areas each of size 1x1 cm filled with
haemorrhagic and mucoid material respectively. (Fig1) Microscopy showed thyroid follicles with
lymphoid infiltrate in the stroma forming follicles
with germinal centers.(Fig-2,3)
Fig 3: Lymphoid follicles with germinal centres (H& E

10x)
Hurthle cell change was also noted. Section from

both cystic areas showed plenty of complex
branching papillae with fibrovacular core lined by
cuboidal cells showing ground glass nuclei.(Fig-4,5)
The case was diagnosed as papillary carcinoma in
Hashimotos thyroiditis.
Fig 4: Papillary carcinoma (H& E 10x)
Fig 1: Cut section of a thyroid showing nodule with

cystic and haemorrhagic areas
Fig 5: Papillae and ground glass like appearance of

nuclei. (H& E 40x)
DISCUSSION
Fig 2: Thyroid having lymphoid follicles & papillary
carcinoma (H& E 10x)
Hakaru Hashimoto, a Japanese surgeon, working in

Berlin, Germany, first described Hashimotos
thyroiditis as a histological diagnosis. It is a part of
697
the spectrum of autoimmune thyroid diseases. It is

known that women express thyroid autoimmunity
more frequently than men and this tendency is even
more obvious in the postmenopausal period.7
Papillary thyroid cancer is the most common form of
cancer in the thyroid. It is 2.5 times more likely to
develop in women than in men.8 In our case, patient
is of 51 years female.
The relationship between Hashimotos thyroiditis and
papillary thyroid carcinoma was first proposed by
Daily, et al. in1955. A clear association between the
two diseases among patients of different ethnic origin
was determined by Okayasu et al. The causative
relationship between Hashimotos thyroiditis and
Papilllary Carcinoma thyroid is not yet clear, careful
observation of Hashimotos thyroiditis patient is
recommended. The literature quotes a number of
proposed mechanisms of both of these diseases and
some attempts are made to explain the association.
For example, Wirtschafter et al. described expression
of the RET/PTC1 and RET/PTC3 oncogenes in
Hashimotos thyroiditis patient.8
Arif, et al. concluded papillary thyroid carcinoma and
Hashimotos thyroiditis overlap in morphological
features, immunohistochemical pattern and most
importantly, molecular profile. Although considered a
benign condition, Hashimots thyroiditis can
harbour the RET/PTC rearrangement which is an
early specific marker that is strongly associated with
papillary thyroid carcinoma.9
In addition, expression of p63 in Hashimotos
patients with papillary thyroid cancer was found by
Unger,et al. Thus was further examined by Burstein,
at al. who proposed the two diseases are both initiated
by pleuripotent p63 positive stem cell remnants.8
Larson, et al. investigated this relationship based on
the link between chronic inflammation and cancer,
resulting from chronic immune response activation
leading to repeated cellular damage and alteration of
stromal elements. Their work revealed that patients
with HT were 3 times more likely to present with
associated well differentiated thyroid carcinoma in
comparison to patients without HT, supporting the
existence of a link between chronic inflammation and
cancer development.1
According to Pino et al an immunological and
autoimmune mechanism can be possible in
etiopathogenia of papillary carcinoma stimulating
lymphocytic infiltration.10
Segal K et al11 states that Hashimotos thyroiditis

does not appear to be a premaliganant lesion. Thyroid
carcinoma originated in the proliferating epithelium
of Hashimotos thyroiditids does not have any
evidence. It would appear that thyroid carcinoma
stimulate the development of HT in some patients.
Autoimmune inflammatory reaction and the
circulating antibodies hamper growth and metastasis
of carcinoma of thyroid gland.11
Neoplastic transformation is a multistep process that
results in a continuous spectrum from the normal
(physiological) state to a fully established neoplasm.9
The crux of papillary thyroid carcinoma diagnosis
relies on nuclear changes: overlapping elongated
ground
glass
nuclei
with
grooves
and
pseudoinclusions are characteristic and are most
reliable features. In fact, nuclear features are the
essential diagnostic component and although
frequently associated with papillae, the diagnosis of
papillary thyroid carcinoma can be made in their
absence. The gold standard nuclear features for the
diagnosis of papillary thyroid carcinoma are related
to RET/PTC rearrangement.9
Total thyroidectomy is the surgical procedure of
choice for treatment of Hahimotos thyroiditis with
papillary thyroid carcinoma.12 The survival of the
patients who have papillary thyroid cancer may be
superior in coexistent Hashimotos thyroiditis.13
There is a need to be cautious while screening FNAC
smears if any focus of papillary thyroid carcinoma is
seen. A thorough grossing of thyroid specimen is
recommended. If sample sections are not taken
properly and careful grossing is not done then foci of
microcarcinoma may be missed in a patient who has
Hashimotos thyroiditis.14
CONCLUSION
There is approximately 30% frequency of the
coexistence of Hashimotos thyroiditis and
differentiated thyroid carcinoma.
Relationship
between Hashimotos thyroiditis and papillary
thyroid carcinoma was first proposed by Daily, et al.
in1955. A clear association between the two diseases
among patients of different ethnic origin was
determined by Okayasu et al.
The literature quotes a number of proposed
mechanisms of both of these diseases and some
attempts are made to explain the association. For
example, Wirtschafter et al. described expression of
698
the RET/PTC1 and RET/PTC3 oncogenes in

Hashimotos thyroiditis patient.8 Arif et al. concluded
that Neoplastic transformation is a multistep process
that results in a continuous spectrum from the normal
(physiological) state to a fully established neoplasm.9
Expression of p63 in Hashimotos patients with
papillary thyroid cancer was found by Unger et al.
According to Pino et al an immunological and
autoimmune mechanism can be possible in
etiopathogenia of papillary carcinoma stimulating
lymphocytic infiltration.10 Segal K, et al. States that
Hashimotos thyroiditis does not appear to be a
premaliganant lesion.
The presence of coexistent Hashimotos thyroioditis
has no effect on the diagnostic evaluation and
management of papillary carcinoma of thyroid. Yet,
one has to keep an eye for the features of papillary
carcinoma in case of Hashimotos thyroiditis. So a
thorough grossing of thyroid specimen is
recommended especially in patients who have
Hashimotos thyroiditis.
6.
7.
8.
9.
10.
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Andrew Buchan, Brian DC. Synchronous
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Haymart, Herbert Chen. Is Hashimotos
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Arif S, Blanes A, SJ Diaz- cano. Hashimotos
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Gonzalez Palomino A, Blasco Huelva A. The
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thyroiditis our experience and literature review.
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Sidi J. Hashimotos thyroiditis and carcinoma of
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Kurukahvecioqlu O, Taneri F, Yuksel O, Aydin
A, Tenzel E, Onuk E. Total thyroidectomy for
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Bhuvanesh Sing, Ashok R Shaha, Hemali
Trivedi, John F Carew, Ashok Poluri, Jatin P
Shah. Coexist Hashimotos thyroiditis with
papillary carcinoma: Impact on presentation,
management and outcome. Surger, 1999;126(6):
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Rumana Makhdoomi, Farhat Mustafa, Rais
Malik, Salma Bhat, Khurshid Alam, Humaira
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endocrinology and metabolism
2013;11(3); 191-94
699
DOI: 10.5958/2319-5886.2014.00420.2

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Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
nd
Review article
HOW BEST CAN WE PLAN & IMPLEMENT HIV PREVENTION? A REVIEW OF SUCCESSFUL
EVIDENCE BASED PRACTICES & RESEARCH
*Vijay Kumar Chattu
Researcher, Africa Center for HIV/AIDS Management, Department of Economic & Management Sciences,
Stellenbosch University, Matieland, South Africa
*Corresponding author email:drvkumar.ch@gmail.com
ABSTRACT
Context: Around 2.5 million people become infected with HIV each year and its impact on human life and public
health can only be tackled and reversed only by sound prevention strategies. Aim: This paper aims to provide the
reader about different types of prevention strategies that are effective and practiced in various countries with
special emphasis on evidence for success. It also highlights the importance of to the evidence based medicine&
strategies. It describes about the importance of combination prevention, which encompasses complementary
behavioral, biomedical and structural prevention strategies. Methods & Materials: Searches for peer reviewed
journal articles was conducted using the search engines to gather the information from databases of medicine,
health sciences and social sciences. Information for each strategy is organized & presented systematically with
detailed discussion. Results: For a successful reduction in HIV transmission, there is a great need for combined
effects of radical & sustainable behavioral changes among individuals who are potentially at risk. Second,
combination prevention is essential for HIV prevention is neither simple nor simplistic. Reductions in HIV
transmission need widespread and sustained efforts. A mix of communication channels are essential to
disseminate messages to motivate people to engage in various methods of risk reduction. Conclusions: The effect
of behavioral strategies could be increased by aiming for many goals that are achieved by use of multilevel
approaches with populations both uninfected and infected with HIV. Combination prevention programs operate
on different levels to address the specific, but diverse needs of the populations at risk of HIV infection.
Keywords: Biomedical interventions, Behavioral strategies, Combination prevention, HIV/AIDS, STIs,
Structural interventions
INTRODUCTION
Around 2.5 million people become infected with HIV
each year. This extraordinary toll on human life and
public health worldwide will only be reversed with
effective prevention. There is a need for combination
prevention as there is for combination treatment,
including biomedical, behavioral, and structural
interventions. Combination prevention should be
based on scientifically derived evidence, with input
and engagement from local communities that fosters

the successful integration of care and treatment.
Combination prevention relies on the evidence
informed;
strategic,
simultaneous
use
of
complementary behavioral, biomedical and structural
prevention strategies. Combination prevention
programs operate on different levels (e.g., Individual,
relationship, community, society) to address the
700
Vijay Kumar.,
specific, but diverse needs of the populations at risk

of HIV infection.
The Joint United Nations program on HIV/AIDS
(UNAIDS) Prevention Reference Group agreed in
December, 2009 that combination prevention
programs are: rights-based, evidence-informed, and
community-owned programs that use a mix of
biomedical, behavioral, and structural interventions,
prioritized to meet the current HIV prevention needs
of particular individuals and communities, so as to
have the greatest sustained impact on reducing new
infections.
Well-designed combination prevention programs are
carefully tailored to national and local needs and
conditions; focus resources on the mix of
programmatic and policy actions required to address
both immediate risks and underlying vulnerability;
and they are thoughtfully planned and managed to
operate synergistically and consistently on multiple
levels (e.g. individual, relationship, community,
society) and over an adequate period of time.
This paper discusses about different types of
prevention strategies that are effective and practiced
in various countries with special emphasis on
evidence for success thereby contributing to the
evidence based medicine. It describes & advocates
about combination prevention, which relies on the
evidence informed, strategic, simultaneous use of
complementary behavioral, biomedical and structural
prevention strategies. It also emphasizes the
importance and need of both behavioral & biomedical
interventions which are both traditional and modern
using the biomedical & information technology.
Behavioural Strategies: defined as interventions to
motivate behavioral change in individuals and social
units by use of a range of educational, motivational,
peer-led, skill-building approaches as well as
community normative approaches (Coates and
Gable 2008)
They include sexual debut delay, Sexual partner
reduction, Consistent condom usage, HIV counseling
and testing, sexual abstinence, Monogamy,
Biomedical intervention uptake and consistent usage,
Adherence to harm reduction strategies. Behavioral
interventions fall into two broad categories:
A. Interventions to minimize sexual risk
behaviors / increase protective behaviors
Evidence
They
include
sexual
behavior
change
communications (SBCC) that employ a variety of
channels to communicate a range of messages.
Studies have been undertaken to assess both channels
of communication and the content of the messages.
Channels of communication
1. Mass media: Much of the research on mass media
has focused on changes in intermediary indicators
such as knowledge, risk perception, and selfefficacy. Reviews of this research have generally
found small but positive effects on each of these
indicators1. Studies have also linked mass media
to reported positive behavioral outcomes such as
delay of sexual debut2, decreases in number of
sexual partners3-5, increases in condom use6-8 and
utilization of HTC and PMTCT services9,10.
Current research suggests that mass media is
most effective when used to: facilitate advocacy
efforts11and complement other community-level
and interpersonal activities. Mass media
programming has been shown to produce a doseresponse effect, in which higher exposure to
messaging resulted in increased self-reported
positive behavioral change12.
2. Community-level interventions: Community
mobilization campaigns have been shown to
increase uptake of HTC in discordant couples13
and youth14. Specific activities such as
community-based dramas have been shown to
increase HTC utilization and condom use15.
Locally-based media programs have been shown
to impact social norms, including perceptions of
HIV-positive
individuals16.
While
their
geographic reach is often limited, effective
community-based activities generally provide
good results at a low cost per beneficiary,
although the duration of these effects is
unknown17. Community level activities are most
effective when they: focus explicitly on
community norms; develop key opinion leaders
with the abilities and desire to diffuse messages
widely; and facilitate support systems and
networks18.
3. Interpersonal communication: Interpersonal
communication and counseling are defined as a
person-to-person or small group interaction and
exchange19, 20. A recent meta-analysis of research
examining interpersonal communication found
701
Vijay Kumar.,
that exposure was significantly associated with

increased knowledge and condom use21. In
addition to these outcomes, peer education has
demonstrated some success in changing
community attitudes and norms22. Costeffectiveness
studies have
shown that
interpersonal communication has the ability to
reach hard-to-reach population groups in a costeffective manner23.
Focus of messages:
a. Multiple partnerships: Sexual activity with more
than one partner plays a central role in all
sexually-driven HIV epidemics. Ecological and
associational evidence from generalized and
concentrated epidemics points to a consistent
pattern of significant decline in the proportion of
men and women reporting multiple partners,
followed by population-level declines in HIV
infection24-26. Behavioral interventions utilizing
various communication channels have had a
demonstrable impact on reducing numbers of
sexual partners in numerous populations
including MSM, adult men and women, and
young people27,28. While debate exists around the
role of concurrent, as opposed to sequential,
partnerships in HIV transmission29, efforts to
evaluate concurrency reduction interventions are
on-going30.
b. Intergenerational and transactional sex: In many
settings, intergenerational sex and transactional
sex are closely related31,32. Both practices are
driven by economic needs or wants, as well as
deeply-entrenched norms supporting age
differences between partners and male dominance
in relationships33. Womens ability to refuse sex
or negotiate condom use, which may already be
limited, may be further compromised by age
differences between partners or exchange of
money or gifts. These factors, in combination
with young womens biological vulnerability to
HIV infection, contribute to heightened risk for
both young women and their male partners34.
c. Age of sexual debut: A number of national
population-based surveys35,36have found a
correlation between early initiation of sex and
higher HIV prevalence among young people.
Increased mean age of sexual debut is thought to
be one contributing factor in declining HIV
prevalence in some generalized epidemics in subSaharan Africa37. A multi-country study of youth

in sub-Saharan Africa found that programs
promoting abstinence, including those utilizing
mass media, could produce increases of up to one
year in mean age of sexual debut38.
d. Alcohol use: Alcohol use plays a critical role in
sexual risk behavior that can lead to HIV
transmission. Multiple studies have found that
persons who use alcohol in sexual situations are
more likely to have unprotected sex, casual sex,
and multiple partners, than persons who do not
use alcohol in sexual situations39. Alcohol
consumption is linked with increased risk of STI
and HIV infection40, gender-based violence, and
non-adherence to ART.
B.
Supportive interventions to optimize
biomedical interventions by creating demand for
services and improve adherence and aftercare.
i)
Creating Demand for Services
Evidence
Social and Behavior Change Communication (SBCC)
has been widely used over the past decade to create
demand for biomedical prevention approaches,
including HTC and VMMC. HTC-focused mass
media campaigns in Kenya and South Africa have
been shown to increase uptake of testing services,
with a clear dose-response effects41, 42. Evidence from
South Africa further indicates that exposure to SBCC
programs is associated with discussing HIV and that
discussion of HIV is associated with testing
suggesting a possible indirect effect of HTC
promotion interventions43,44.
ii) Improving Adherence and aftercare through
Client Education
Evidence
Creating demand for services, while essential, is not
sufficient in isolation to ensure positive outcomes.
Helping clients identify side effects and adverse
events, take medication correctly, and care for
themselves following medical procedures can all
contribute to optimal use of medical technologies. A
randomized control trial in Kenya found that SMS
reminders significantly improved ART adherence
among patients45. Similar approaches have been used
to support attendance at VMMC follow-up visits.
I.
BIOMEDICAL
INTERVENTIONS:
defined as the interventions are those that act
702
Vijay Kumar.,
directly on the biological systems through which the

virus infects a new host.Some of the biomedical
interventions include:
1. Male condoms: When used consistently and
correctly, male latex condoms are highly
effective in preventing the sexual transmission
and acquisition of HIV and other STIs at the
individual level46,47. Among Most At-Risk
Populations (MARPs), increasing condom
availability, accessibility, acceptability, and use
has had a demonstrable population-level effect in
several epidemics48, 49. In heterosexual serodiscordant relationships in which condoms were
consistently used, HIV-negative partners were
80% less likely to become infected compared
with persons in similar relationships in which
condoms were not used50.
2. Female condoms: Laboratory studies indicate that
the female condom is an effective mechanical
barrier to semen and viruses, including HIV51. In
2006, WHO concluded that female condoms,
when used consistently and correctly, have
comparable effectiveness to male condoms. In
2009, the FDA approved the second generation of
the female condom (FC2) for prevention of HIV,
other STIs, and unintended pregnancy. A
growing body of evidence shows that effective
female condom promotion to both women and
men can increase the proportion of protected sex
acts52-54. Studies conducted in a variety of
contexts show that the female condom is widely
acceptable and a realistic alternative to the male
condom55.
3. Voluntary medical male circumcision: Voluntary
medical male circumcision is the surgical
removal of the foreskin from the penis by trained
medical personnel under aseptic conditions.
Three randomized control trials indicated that
VMMC reduces mens risk of HIV acquisition by
50-60%56-58. Extended follow-up of participants
at up to five years post-trial indicated that the
protective effect increased to 68%59. WHO and
UNAIDS have concluded that VMMC should be
actively promoted as part of comprehensive HIV
prevention efforts in settings where circumcision
rates are low and HIV prevalence is high60. A
prospective study enrolling HIV sero-discordant
couples found a promising, although not
statistically significant, 40% reduction in seroconversions of women whose male partners were
circumcised61. A recent study suggests that
VMMC, with the lifelong protection it provides,
is a cost-effective strategy to prevent HIV in
high-prevalence areas62.
4. HIV testing and counseling (HTC): The evidence
for the direct impact of HIV testing and
counseling on HIV incidence is mixed. However,
HTC, knowledge of HIV sero-status, and
successful linkages to other services are critical
for access to effective prevention interventions
for those who test negative, and to treatment and
other HIV-specific services for PLWH. In
particular, HTC process allows for identification
of PLWH, which in turn supports programs like
treatment that can protect their HIV negative
partners from infection63. Recent Demographic
and Health Surveys from 13 sub-Saharan African
and five non-African countries show a median of
12% of women and 7% of men having been
tested in the 12 months preceding the survey, and
a median of 34% of women and 17% of men
reporting having ever been tested.
5. Diagnosis and treatment of sexually transmitted
infections (STIs): Studies have shown that STIs,
including those that are asymptomatic, increases
susceptibility to HIV infection two- to fivefold
for several reasons, including direct damage to
the mucosa through ulceration that facilitates
infection, and through inflammatory processes
that increase the proliferation of immune cells
that are also targets for HIV64, 65. STIs also leads
to higher HIV loads in the genital secretions of
HIV-positive individuals, thereby increasing the
chance of infecting their sexual partners66. STIs
are biological markers for risky sexual behaviors,
increase susceptibility to HIV acquisition through
genital ulcers, and increase onward transmission
of HIV associated with HIV viral spikes67-69.
6. Antiretroviral drug (ARV) -based prevention:
There are four opportunities for HIV prevention:
before exposure, at the moment of exposure,
immediately after exposure, and as prevention
focused on infected persons. Until recently, most
prevention resources have been directed toward
strategies aimed at preventing exposure. There is
growing evidence that ART of infected
703
Vijay Kumar.,
individuals has an added prevention benefit.

Treatment of HIV and prevention of HIV must be
considered as elements of a single continuum and
deployed together.
Post-exposure Prophylaxis (PEP) for HIV: PEP
refers to the set of services that are provided to
manage specific aspects of exposure to HIV and to
help prevent HIV infection in a person exposed to the
risk of infection. These services might include first
aid, including counseling, assessing the risk of HIV
exposure, HTC, and, depending on the outcome of
exposure assessment, a limited course of ARVs, with
appropriate support and follow-up.
Evidence
Strong evidence suggests that a short course of ARVs
started within 72 hours after exposure effectively
reduces HIV transmission rates following needle stick
exposure to HIV-infected blood. This comes largely
from a single-case control study involving health care
workers from France, UK & USA that revealed
strong inverse associations between the likelihood of
HIV infection following a needle stick injury and the
post-exposure use of zidovudine70. However, data
available from animal transmission models71,
perinatal clinical trials72, studies of healthcare
workers receiving prophylaxis after occupational
exposures73, and observational studies74 indicate that
PEP may reduce the risk of HIV infection after nonoccupational exposures as well.
Treatment as Prevention
Evidence
An important determinant of risk of HIV transmission
from an HIV-positive person to an HIV-negative
person is the concentration of HIV in plasma. ART
for the HIV-positive partner is associated with both
reduced viral load75,76 and reduced risk of HIV
transmission to sex partners within discordant
partnerships, potentially by over 90%77-80. These
observational data were recently confirmed by HPTN
052, a randomized trial among 1,763 HIV sero
discordant couples in which the HIV-positive partner
had a CD4 count between 350 and 550 cells/L. The
trial evaluated the effect of immediate versus delayed
ART (initiated at CD4 of 250 cells/L) in the HIVpositive individual.
Pre-exposure Prophylaxis (PrEP) for HIV:
Evidence: In the CAPRISA 004 study in South
Africa, 889 high-risk women used 1% Tenofovir gel
vaginally up to 12 hours before intercourse and

within 12 hours after intercourse81. This study
reported a 39% reduction in HIV acquisition overall,
and maximal reduction of 54% in women who were
the most adherents. HIV acquisition was inversely
correlated with detection of Tenofovir in the vaginal
secretions, an indication of the strong association
between product adherence and efficacy.
In the iPrEx study completed in 201082, HIV-negative
MSM were provided daily Emtricitabine and
Tenofivirdisoproxilfumarate (TDF+FTC) for up to
2.8 years. The study found a 44% reduction in HIV
acquisition, and as with the CAPRISA trial, efficacy
was strongly associated with ARV drug
concentrations.
Another study, conducted by CDC in partnership with
Botswana Ministry of Health, found that a once-daily
tablet containing TDF+FTC reduced the risk of
acquiring HIV infection by roughly 63% overall in
the study population of uninfected heterosexual men
and women83.
II.
STRUCTURAL INTERVENTIONS: They
can be divided into 3 broad categories shown in
figure 1 shown below84
Figure 1: Interacting causes of HIV risk and

vulnerability (source: UNAIDS)
A. Social & Cultural interventions: strategies

which include Community dialogue &
mobilization, to demand services, for AIDS
competence, etc., Stigma reduction programs,
Advocacy and coalition building for social
change, Media and interpersonal communication
to clarify values, change harmful social norms
Education curriculum reform, expansion and
quality control, Support youth leadership etc.
704
Vijay Kumar.,
B. Political, legal and economic strategies: They

include Human rights programming, Prevention
diplomacy with leaders at all levels, Community
Microfinance/microcredit
Training/advocacy
with police, judges, etc. Policies regarding access
to condoms (schools, prisons etc.), Review and
revise workplace policies, Stakeholder analysis &
alliance building, Strategic advocacy for legal
reform, Regulation/deregulation, taxes etc.
C. Intervention strategies addressing physical
environment: They address issues like Housing
policy and standards, Enhance farming, other
modes of subsistence, for food security,
Infrastructure development transportation,
communications, etc.
CONCLUSION
There is an urgent need for greater demand and
greater support from communities and policymakers
for rights-based, evidence-informed combination
prevention. To build this support, prevention experts
need to speak with one voice, responding in real time
with strategic advocacy to overcome the prejudices
and political sensitivities that have often impeded
implementation of the programs most likely to reduce
HIV incidence. Effective implementation of
combination prevention requires sufficient personnel
to define and tailor programs at the sub-national
level, to synthesize available evidence, to manage
multi-component programs for specific results, to
conduct and apply needed research, and to implement
robust monitoring, evaluation and program
improvement systems as strategies are brought to
scale. Quality assurance and quality improvement are
just as important in behavioral and structural
interventions as in the biomedical ones. And to
succeed, these must be coordinated, efficient,
consistent, and inspired by a shared commitment to
common goals. Its worth to remember always
Prevention is better than Cure.
ACKNOWLEDGEMENTS
The researcher acknowledges the Director & staff of
Africa center for HIV/AIDS Management for
imparting knowledge in HIV/AIDS Management.
The researcher is also grateful to authors / editors /
publishers of all those articles, journals and books
from where the literature for this article has been
reviewed and discussed. The author thanks the

IJMRHS editorial board members and team of
reviewers who have helped to bring quality to this
manuscript.
Conflict of Interest: The Author declares that there
is no conflict of interest
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load and heterosexual transmission of human
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709
Vijay Kumar.,
DOI: 10.5958/2319-5886.2014.00421.4

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Volume 3 Issue 3
Received: 27th Feb 2014
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
Revised: 15thApr 2014
Case report
ACUTE AORTIC DISSECTION IN A YOUNG HEALTHY ATHLETE WITH ANDROGENIC

ANABOLIC STEROID USE: A CASE REPORT
Barman M, Djamel B, Mathews J
Heart Care Center, Department of Cardiology, Al Ahli Hospital, Doha, Qatar
*Corresponding author email:drbarman@yahoo.com
ABSTRACT
Background: Acute aortic dissection can occur at the time of intense physical exertion in strength-trained athletes
like weight lifters, bodybuilders, throwers, and wrestlers. Rapid rise in blood pressure and history of hypertension
are the most common causes of aortic dissection in athletes. It is a very tragic event because of its high mortality
rate of about 32% in young patients. We report a case of aortic dissection in a young weightlifter with a history of
anabolic steroid usage with an extensive intimal tear of the aorta at Sino tubular junction and arch. All athletes
must be assessed for predisposing factors for aortic dissection, and all patients should be encouraged to undergo
appropriate diagnostic studies, like echocardiography and blood pressure monitoring while weightlifting to
recognize possible predisposing factors for aortic dissection. Athletes who do have a problem should be
encouraged to avoid or limit their exercise or activity by their cardiologist. It is vital that this disastrous event be
prevented in young people. In conclusion, although a rare occurrence, AD should be considered in symptomatic
patients with any family history of early cardiac deaths, a history suggestive of a connective tissue disorder (that
is, multiple joint surgeries) or who practice weightlifting.
Keywords: Acute aortic dissection; Athlete; Anabolic steroids.
INTRODUCTION
Acute aortic dissection results from a tear in the
intima and media of the aortic wall, with the
subsequent creation of a false lumen in the outer half
of the media and elongation of this channel by
pulsatile blood flow. Dissection of the aorta is
associated with a high degree of morbidity and
mortality despite continuing improvements in
diagnostic and surgical techniques 1and hypertension
is present as the most common cause in 7090% of
patients with aortic dissection.2. A number of normal
daily and athletic activities require isometric or static
exercise. Sports such as weightlifting and other highresistance activities are used by power athletes to gain
strength and skeletal muscle bulk. These exercises
significantly increase blood pressure, heart rate,
myocardial contractility, and cardiac output.
Barman et al.,
Hypertension has long been recognized as an

important risk factor for the development of aortic
aneurysms and dissections.1,3 Also, it has been
speculated that the very high blood pressure
generated during the lifting of weights, particularly
with staining accompanied by a Valsalva maneuver,
may be the cause of an aortic intimal tear.3Preparticipation cardiovascular evaluation of young
competitive athletes is warranted on the basis of the
available evidence.4 Any person, regardless of age
with predisposing conditions to aortic dissection,
including hypertension, should be sturdily
encouraged to refrain from weightlifting. We present
a case of aortic dissection in a young athlete with no
history of hypertension.
710
CASE PRESENTATION
Mr. A, 34 Year old athlete an active runner and
weightlifter was seen by cardiologist on referral
request from Internal Medicine for evaluation of
cardiac murmur in emergency section of our hospital.
Relevant History: Mr. A. visited ER with complaints
of cough with expectoration [blood tinged], low grade
fever with gradual onset shortness of breath and
orthopinea since 2 days. Generalized fatigue and
body aches. Right upper abdominal pain, No chest
pain. No syncope/No palpitations. He gave history of
daily exercises in the gym, bodybuilding, takes
protein supplements and anabolic steroids.
Past History: None significant except recently seen
two days ago In ER with pain abdomen which was
diagnosed as renal colic.
Risk
Profile:
No
hypertension,
diabetes,
dyslipidemia or cardiovascular disease. Anabolic
steroids for body building. Non smoker and no
alcohol consumption
Physical Examination: BP: 120/65 mmHg [R],
114/65 mmHg [L], PR: 95/min regular, Peripheral
pulses palpable normal bilaterally symmetrical. No
radio-femoral delay. No edema. CVS- mid-late
relatively loud diastolic murmur. Chest- bilateral
scattered R>L coarse repitation with wheeze and
tubular breath sounds at Right infra scapular region.
Investigations: ECG: NSR 95/minute. No acute STT changes.
CT ratio <0.5. ECHO: Normal LV dimensions and

systolic function. Dilated Aortic root with visible
intimal flap in Aorta. Mod-severe AR.
Fig 2: Echocardiogram shows intimal tear/flap in

different views.
Course: Mr. A was diagnosed with acute aortic
dissection with mod-severe AR and acute heart
failure in context with Lower respiratory tract
infection. He was immediately referred to
cardiothoracic surgeon and was operated the same
day. Operative findings revealed ascending aortic
aneurysm 8 cms. Dissection within the aneurysm and
tears at Sino tubular junction and arch. Severe aortic
incompetence due to dilated root and normal leaflets.
Surgery included tube graft replacement of root,
ascending and arch with preservation and
reimplantation of valve leaflets within the tube graft
[Davids Procedure].
Postoperative period was
complicated with bleeding renal impairment requiring
temporary dialysis and hepatic impairment. He was
subsequently discharged with normal renal and
hepatic function.
DISCUSSION
Fig 1: ECG at presentation.

Labs: CBC, WBC13.63 X 103ul, Hb 15.7G/dl, N
10.72[78.6%] L 11%, M 8.5%. D-dimer 1.76 mg/l
[n<0.5], CRP 85. BNP 7853. RFT deranged, Normal
LFT. CX-ray, R>L lower lobe consolidation. Heart,
Mediastinum normal. No pneumothorax or pleural
effusion. No hilar or Mediastinal lymphadenopathy.
Barman et al.,
Hypertension is a main risk factor of aortic sclerosis

and subsequent aortic aneurysm formation and aortic
dissection. Smoking and hypercholesterolemia are
additional risk factors. 15%20% of death secondary
to high speed accidents are related to aortic trauma,
frequently associated with myocardial contusion.
Iatrogenic aortic dissection is often related to cardiac
catheterization, angioplasty, or surgery. Inammatory
diseases can aect the aorta as in Takayasu arteritis
and syphilis as well as in Behcets or Ormonds
disease. Cocaine and amphetamine associated with
aortic aneurysm formation and dissection are newly
detected etiologies.10
Aortic dissection -common presenting symptoms 10
Pain: Pain alone, Pain with syncope, Pain with signs
of
congestive
heart
failure,
-Pain
with
cerebrovascular accident (stroke), Congestive heart
711
failure without pain, Cerebrovascular accident

without pain, Abnormal chest roentgenogram without
pain, Pulse loss without pain.
Aortic dissection: deferential diagnosis 10
Acute coronary syndrome with and without STelevation, Aortic regurgitation without dissection,
Aortic
aneurysms
without
dissection,
Musculoskeletal pain, Pericarditis, Mediastinal
tumors, Pleuritis, Pulmonary embolism, Cholecystitis,
Atherosclerotic or cholesterol embolism
The cardiovascular system adapts to exercise. Toplevel training is often associated with morphological
changes in the heart including increases in the left
ventricular chamber size, wall thickness, and mass.
The increase in the left ventricular mass as a result of
training is called" athletes' heart".5 Morgan Roth and
his colleagues6 distinguished two different
morphological forms of athletes' heart: a strengthtrained heart and an endurance-trained heart.
According to their theory, athletes involved in
endurance training, sports with a high dynamic
component like running, are presumed to demonstrate
eccentric left ventricular hypertrophy, characterized
an unchanged relationship between left ventricular
wall thickness and left ventricular radius (i.e. ratio of
wall thickness to radius), which means an increased
left ventricular chamber size with a proportional
increase in wall thickness. On the other hand,
strength-trained athletes involved in mainly static or
isometric exercise like weightlifting, bodybuilding,
and wrestling, are presumed to demonstrate
concentric left ventricular hypertrophy, which is
characterized by an increased ratio of wall thickness
to radius, which means an increased left ventricular
wall thickness with an unchanged left ventricular
chamber size. In addition to the aforementioned
changes, in weight lifters as strength-trained athletes,
cardiac output, heart rate, and blood pressure tend to
increase. A rapid increase in the systemic arterial
blood without a decrease in the peripheral vascular
resistance, in combination with aortic medial
degeneration, may contribute to the development of
the aortic dissection 7; this is an event that may occur
in non-trained weightlifters or those with
predisposing factors for aortic dissection, like
hypertension, congenital cardiovascular disease (e.g.
coarctation of aorta, congenital stenotic aortic valve,
and unicuspid and bicuspid aortic valve),
Barman et al.,
supravalvular aortic stenosis, connective tissue

disorders (e.g. the Marfan syndrome and familial
cystic medial degeneration syndromes), and fibro
muscular dysplasia. Also in athletes who have mildto-moderate aortic enlargement, an increased blood
pressure due to heavy weightlifting, raises aortic wall
stress to a level that begets aortic dissection.8 Aortic
dissection is a very tragic event because of its high
mortality rate of about 32%, and the most common
causes of death after aortic dissection involving the
ascending aorta include the rupture into the
pericardial cavity with resultant tamponade, occlusion
of the coronary arteries, and free rupture into the
chest or abdomen 2
Fig 3: Classification of Aortic dissection

The majority of reports describes ascending Aortic
dissection (the area of greatest hemodynamic
stress), which is also the most common location for
dissection secondary to connective tissue disorders
and congenital anomalies.2 In these cases, the medial
portion of the aorta is weakened not from
hypertension induced degeneration (as is the case
with the older population1, but instead is secondary to
a congenital defect.
Perhaps the most well-known connective tissue
disorder is Marfans syndrome. However, this entity
represents only one end of a spectrum of conditions
that stem from defective fibrillin-1 synthesis,
collectively known as fibrillinopathies. Fibrillin-1 is
the lipoprotein that serves as the framework for
elastin, the major elastic component of the aortic
wall. While Marfans syndrome is a dominantly
inherited condition, other fibrillinopathies vary in
penetrance and expression, and familiar non-Marfans
dissections have been described. Recent work
suggests that aortic involvement may be related to
premature termination codon mutations, and to other
712
mutations in the gene for fibrillin-1 (chromosome

15q21.1)9
All athletes must be assessed for predisposing factors
for aortic dissection, and all patients should be
encouraged to undergo appropriate diagnostic studies,
like echocardiography and blood pressure monitoring
while
weightlifting
to
recognize
possible
predisposing factors for aortic dissection. Athletes
who do have a problem should be encouraged to
avoid or limit their exercise or activity by their
cardiologist. It is vital that this disastrous event be
prevented in young people.
Prevention of aortic dissection in inherited
diseases (Marfans Syndrome, Ehlers-Danlos
Syndrome, Annuloaortic ectasia) 10
1. Life-long beta-adrenergic blockade
2. Periodic routine imaging of the aorta
3. Prophylactic replacement of the aortic root before
diameter exceeds 50 cm in patients with a family
history of dissection
4. Prophylactic replacement of the aortic root before
diameter exceeds 55 cm
5. Moderate restriction of physical activity
CONCLUSION
In conclusion, although a rare occurrence, AD should
be considered in symptomatic patients with any
family history of early cardiac deaths, a history
suggestive of a connective tissue disorder (that is,
multiple joint surgeries) or who practice
weightlifting. The investigation and surveillance of
fibrillinopathies patients is ill defined, but prompt
referral and/or admission for further investigation is
merited. Cessation of weight lifting or isotonic stress
activities until a definitive investigation has been
obtained is prudent. Data for Anabolic steroid usage
and acute aortic dissection is inadequate till date so
an alert and suspicious mind in the emergency room
should be always welcome.
Funding: Nil.
REFERENCES
2. Gammie J, Katz WE, Swanson ER, Anrew P.

Acute aortic dissection after blunt chest
trauma.Trauma. 1996; 40:126127
3. Ficar CR, Koch S. Etiologic factors of acute
aortic dissection in children and young
adults. Clin Pediatric. 2000; 39:7180.
4. Corrado D, Pelliccia A, Bjornstad HH, Vanhees
L, Biffi A, Borjesson M etal., Cardiovascular
pre-participation
screening
of
young
competitive athletes for prevention of sudden
death: proposal for a common European
protocol Consensus Statement of the Study
Group of Sport Cardiology of the Working
Group of Cardiac Rehabilitation and Exercise
Physiology and the Working Group of
Myocardial and Pericardial Diseases of the
European Society of Cardiology. Eur Heart
J. 2005; 26:51624.
5. Pluim BM, Zwinderman AH, Laarse A van der,
Wall EE van der. The athlete's heart. A metaanalysis
of
cardiac
structure
and
function. Circulation. 2000; 101:33644
6. Morganroth J, Maron BJ, Henry WL, Epstein SE.
Comparative left ventricular dimensions in
trained athletes. Ann Intern Med. 1975; 82:521
524.
7. de Virgilio C, Nelson RJ, Milliken J, Synder R,
Chiang F, MacDonald WD, Robertson JM.
Ascending aortic dissection in weight lifters
with cystic medial degeneration. Ann Thorac
Surg.1990;49:638642
8. Hatzaras I, Tranquilli M, Coady M, Barrett PM,
Bible J, Elefteriades JA. Weight lifting and
aortic dissection: more evidence for a
connection. Cardiology. 2007; 107:103106
9. Hogan CJ. An aortic dissection in a young
weightlifter with non-Marfan fibrillinopathy.
Emerg Med. J 2005;22:4 304-305
10. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber
B, Haverich A, etal.,Diagnosis and management
of aortic dissection. European Society of
Cardiology European Heart Journal (2001) 22,
164281
1. Biddinger A, Rocklin M, Coselli J, Milewicz

DM. Familial thoracic aortic dilations and
dissections: A case control study. J Vasc
Surg. 1997; 25:50611.
Barman et al.,
713
DOI: 10.5958/2319-5886.2014.00422.6

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Volume 3 Issue 3
st
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ISSN: 2319-5886
th
Case report
SALIVARY DUCT CARCINOMA OF PAROTID GLAND- AN INCIDENTAL FINDING

*Suparna Suvernakar V1, Shubha Deshpande A2, Prabha Mulay S1
1
Associate professor, 2Professor, Department of Pathology, Dr SC GMC Nanded, Maharashtra, India
*Corresponding author email: supi2020@gmail.com

ABSTRACT
Salivary duct carcinoma, a recently added separate entity of salivary gland tumor is a rare tumour with its
aggressive behaviour. Due to morphological similarities with ductal carcinoma of breast the name salivary duct
carcinoma is given. It is more common in male than in female. But our case is of 45yr female with mass in the
parotid region. The diagnosis on USG and CT was organized collection. But on excision the diagnosis turned to
be salivary duct carcinoma of the parotid gland
Keywords: Salivary gland, Salivary duct carcinoma, Incidental finding
INTRODUCTION
Salivary duct carcinoma is a rare tumor comprising
about 1 to3% of malignant salivary gland tumours. It
was first described by Klinsasser et al in 1968.1 was
not formally recognized in the World health
organization classification on until 1991. Tumour is
considered separately due to aggressive growth with
regional or distant metastases.2-4
CASE REPORT
A 45 yr female with tender swelling in left parotid
region since 1 month. On examination globular
swelling of 4x3cm, firm to hard and fixed to
underlying structures. No lymph node was palpable.
USG-showed an organized collection in deep parotid.
FNAC gave a diagnosis as a benign cystic lesion. CT
finding suggestive of a collection of infective origin.
Clinical diagnosis kept was parotid abscess. Then
the swelling was excised, which was cystic
multilobular 4x4 cm in deep lobe with adhesions.
Histopathological examination showed ductal lesion
containing tumour cells. Also seen tumour cells
invading the stromal tissue.
Fig 1: Presence of duct lining with proliferation of

epithelial lining with presence of duct lumen and
central necrosis.
Fig 2: Section shows presence of tumor cells infiltrating

in the stroma with desmoplastic reaction
714
Suparna et al.,
Fig 3: A high power view of tumor cells with less

pleomorphism &eosinophilic cytoplasm
The normal parotid gland is also seen at places.
Tumour cells are present in cords with desmoplastic
reaction [fig 1, 2, 3]
DISCUSSION
It is a rare salivary gland tumour with similarity to
comedo type of breast carcinoma hence named as
salivary duct carcinoma. Represents 1to3% of all
salivary gland tumours and 0.9to 65 of all parotid
tumours.1-5 It is a rapidly growing tumour. It
frequently involves temporal bone via perineural
spaces.6 Gingival metastases also occurs.7 Facial
paralysis seen in 40 to 60 % of cases and
lymphadinopathy in 35% cases.4 It is common in
males than in females with a range between 55 to65
yrs.4 USG and CT finding are not specific. Positive
diagnosis mainly depends upon the histopathological
findings. Fine needle aspiration cytology is not
always reliable. Gross finding shows tumour of
variable size and predominant cystic component and
at places invasive part seen. Intraductal compant is
papillary, solid, and cribriform with central necrosis.
The infiltrative component is made of glands, cords
of cells with desmoplastic reaction. Several variants
are described such as sarcomatoid, low grade
7
neoplasm
and
mucin
rich
neoplasm.
Immunohistochemical finding are not useful but a
constant over expression of keratin HER-2/new, CEA
and c-erd-B2 have been described.4
The differential diagnosis includes, mucoepideromoid
carcinoma, adenocarcinoma not otherwise specified,
Metastatic adenocarcinoma, oncocytic carcinoma,
and the most relevant morphological feature is the
presence
of an intraductual component which is specific for

the diagnosis. Therapeutic approach seems to be
non-consensual because of the limited data, but
many other authors recommend, in parotid gland
tumors, a total parotidectomy even in T1 tumors
because local disease
recurrence is often life
8
threatening. If facial paralysis is present, a radical
paritoidectomy is mandatory. 4 Postoperative
radiation therapy is indicated in case of extra parotid
extension, pathological resection margins ,cervical
lymph node involvement, lymphatic embolus and
neurologic invasion. Chemotherapy is generally
reserved for distant metastases.9
CONCLUSION
Salivary duct carcinoma is an aggressive tumour with
worst prognosis because of its metastatic potential.
Nearly 50%die within 4to 5 years. The diagnosis may
be missed on FNAC, USG, CT due to large areas of
necrosis. Histopathological examination is a simple
and confirmative.
REFERENCES
1. Kliensasser O, Klien HJ, Hubner G. Salivary duct
carcinoma. A group of salivary gland tumors
analogous to mammary duct carcinoma. Arch
Klin Exp Ohren Nasen Kehlkopfhilkd 1968; 192;
100-05
2. Seifert G, caselitz J. Epithelial salivary gland
tumors. Progressing in surgical pathology. New
York: Field and Wood; 1989;9:157-87.
3. Gal R, Strauss M, Zohar Y, Kessler E., Salivary
duct carcinoma of the parotid gland. Cytologic
and histopathologic study. Acta Cytol.
1985;29:454-56
4. Jaehne M, Roeser K, Jaekel T, Schepers JD,
Albert N, Loning T.Clinical and immune
histologic typing of salivary duct carcinoma: A
report of 50 cases. Cancer. 2005; 103:2526-30
5. Etges A, Pinto DS, Jr Kowalski Lp, Soares FA,
Araujo
VC.
Salivary
duct
carcinoma:
Immunohistochemical profile of an aggressive
salivary gland tumour.J.Clin pathol. 2003;56:9148
6. Nguyen BD, Roarke MC. Slivary duct carcinoma
with perineural spread to facial canal: F-18 FDG
PET/CT detection. Clin Nucl Med. 2008; 236-8
715
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7. Brandwein-gensler, Skalova A, Nagao T,

Salivary duct carcinoma. In: Barnes L, Eveson
JW, Sidransky D, editors. World Health
Organization
Classification
of
tumours,
Pathology and genetics of head and neck
tumours. Lyon: IARCC Press; 2003-pp236-8.
8. De Ritu G, Meloni SM, Massarelli O, Tullio A.
Management of midcheek masses and tumors of
the accessory parotid gland . Oral Surg Oral Med
Oral Pathol Oral Radiol Endod .2011;111:e5-11
9. Pons y, Alves A, clement P,Conessa C. Salivary
duct carcinoma of the parotid. Eur Ann
Otorhinolaryngol head Neck Dis.2011;128:194-6
716
Suparna et al.,
DOI: 10.5958/2319-5886.2014.00423.8

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Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
Accepted: 2ndMay 2014
Case report
A CASE OF SYNOVIAL LIPOMATOSIS WITH CHRONIC SYNOVITIS PRESENTING AS ACUTE

KNEE PAIN
*SushmaHM1, Anoosha K1, Vijay Shankar S2, Amita K2
1
Post graduate student, 2Associate Professor, Department of Pathology, AdichunchanagiriInstitute of Medical

Sciences, B.G. Nagara, Mandya, Karnataka, India
*Corresponding author email: sushmaaradhya20@gmail.com
ABSTRACT
Background: Synovial lipomatosis is a rare, benign, intra-articular lipoma-like lesion characterized by villous
proliferation of the synovium, most commonly affecting the knee joint. The usual presentation is long standing
progressive swelling of the affected joint, with or without pain and restriction of movements. Histopathology is
confirmatory. Case Report: We present the case of a 35- year old male patient with long standing history of
swelling, short history of pain in the left knee joint. X-Ray and magnetic resonance imaging scans of the left knee
showed the characteristic features of synovial lipomatosis with chronic synovitis. The patient underwent
diagnostic arthroscopy with lavage of left knee joint. Histopathological study confirmed synovial lipomatosis with
chronic synovitis. Conclusion: Synovial lipomatosis is a rare, benign, intra-articular lipoma-like lesion. Although
rare, clinically it should be considered as an important differential in evaluating neoplastic and non- neoplastic
conditions of the knee joint.
Keywords: Synovial lipomatosis, chronic synovitis, knee joint.
INTRODUCTION
Synovial lipomatosis is known by the name, Hoffas
disease after a German surgeon, Albert Hoffa, who
described this condition in the year 1904 in
infrapatellar fat pad in young athletes.1 He also called
it as lipoma arborescens due to the presence of
macroscopic fronds which bear a tree- like
resemblance.2
Synovial lipomatosis is an infrequent lesion which
mimics tumorous lesions like synovial lipoma or
hemangioma and inflammatory conditions like
osteoarthritis and septic arthritis.1
In our study, we have analyzed the histopathological
features of this rare condition with an aim to
distinguish it from the aforementioned lesions and to
know the associated lesions of synovium.
Sushma et al.,
CASE REPORT
A 35 year old male patient presented to the
Orthopedic outpatient department with swelling and
pain in the left knee joint since 3 years and acute
exacerbation of pain since 3 days. Swelling was
insidious in onset and gradually progressive. Pain was
intermittent in nature, aggravating on walking and
relieved on rest. There was no history of trauma or
any chronic diseases.
On examination, a diffuse swelling was present over
the left suprapatellar and infrapatellar regions with
tenderness in the medial and lateral aspects of the left
knee joint with local rise of temperature and
restriction of movements.
717
The patient was admitted to the Orthopedic ward for

thorough work- up and detailed investigations.
During his stay in the hospital for a duration of three
days, the following tests were carried out.
Routine hematological investigations were normal.
Qualitative study of Anti- Streptolysin O (ASLO)
was negative and C-Reactive protein (CRP) showed
positive results. Plain radiograph of the joint showed
no radiological abnormality. Ultrasound scan
revealed
supra
and
infrapatellar
effusion.
Subsequently, synovial fluid was aspirated and sent
for culture and sensitivity, which showed plenty of
pus cells with no organism. Magnetic resonance
imaging scan showed multiple, frond- like synovial
proliferations. The patient underwent diagnostic
arthroscopy with lavage and the post-procedure
period was uneventful. The sample received by the
department of Pathology was subjected to
histopathological examination.
On gross examination, the specimen consisted of
multiple, papillomatous, fatty tissue bits, which were
soft in consistency (Fig.1).
Microscopically, the H&E stained sections showed
villous/ frond- like architecture of synovial tissue
lined by hyperplastic synovial lining infiltrated by
dense mononuclear cell infiltrates (Figs.2&3). Sub
synovial tissue showed diffuse infiltration of adipose
tissue infiltrated by moderate amount of mononuclear
cell infiltrates and there were areas of fibrosis seen
which were characteristic of synovial lipomatosis
with chronic synovitis (Fig.4).
Fig 2: Villous or frond- like architecture of synovial

tissue (H&E,100)
Figure 3: Hyperplastic synovial lining with dense

mononuclear cell infiltration and sub- synovial adipose
tissue (H&E,400).
Fig 4: Dense mononuclear cell infiltration (H&E,400)
DISCUSSION
Fig 1: Gross specimen- Multiple, papillomatous,

yellowish fatty tissue bits
Sushma et al.,
Synovial lipomatosis is a rare, benign, intra-articular

lipoma-like lesion, commonly affecting the knee
joint, particularly the suprapatellar pouch and
accounts for less than 1% of the lipomatous lesions.1,2
It rarely affects glenohumeral joint, sub-deltoid bursa,
hip,wrist and elbow.3 It may be mono, bi or
polyarticular. Men are affected more commonly than
women. It most commonly occurs in the elderly age
group(50-70 years) but can also affect young adults,
the mean age group being 45.6 years.4
718
Clinically, the typical presentation consists of

insidious swelling of the knee joint with intermittent
effusions followed by progressive pain and
debilitation.3 It can also present with symptoms of
secondary degeneration, restriction of movements and
crepitus. Extensive involvement may cause a pressure
effect in the joint space.1 A rare variant termed as
giant lipoma arborescens, presents with bloody and
purulent effusions.2
Plain X- ray, ultrasonography, computed tomography
and joint aspiration are the routine modes of
investigations, though none is diagnostic of synovial
lipomatosis. Tissue density may be noted in the
affected joint on radiography.5In majority of the cases
clear, yellow synovial fluid will be aspirated with no
significant findings on microscopy and culture.
Extent of the lesion can be accurately determined by
ultrasonography. Computed tomography scan is nonspecific.6 Magnetic resonance imaging reveals a
synovial mass with frond- like architecture with
images clearest on fat suppressed sequence.
Arthroscopically, the affected area shows multiple,
globular and villous projections covered by the
synovium. Magnetic resonance imaging and
arthroscopic findings are diagnostic of synovial
lipomatosis though histopathology is the gold
standard for confirmation of the disease. 4,5
The excised mass on gross examination consists of
the synovium with marked papillary, yellow and fatty
appearance.7 Microscopically, there are villus or
frond- like projections lined by hyperplastic and
reactive synovial cells. Individual cells have an
enlarged nucleus, prominent nucleoli and abundant
eosinophilic cytoplasm. Sub- synovial tissue shows
hyperplastic, mature adipocytes which are infiltrated
by chronic inflammatory cells.1, 3
Synovial lipomatosis has been documented to be
associated with other disease processes like joint
trauma, meniscal lesions, chronic synovitis, diabetes
mellitus, septic arthritis, psoriatic arthritis,
osteoarthritis, rheumatoid arthritis.1, 2, 3In the present
case there was an associated chronic synovitis with
synovial lipomatosis.
The exact etiology of synovial lipomatosis is unclear.
One of the proposed hypothesis is that, the
mesenchymal stem cells in the synovium differentiate
into adipocytes.6 It is a stepwise phenomenon starting
with adipocyte metaplasia and inflammation. Fibrosis
occurs at a later stage.1 A positive co-relation has
Sushma et al.,
been established between abnormal fat metabolism

and occurrence of synovial lipomatosis, as evidenced
by increased incidence of the same in obesity, protein
energy malnutrition and short bowel syndrome.1
Synovectomy is the treatment of choice and it is
curative upon complete excision. However
recurrences have been reported.4 Erselcan et al., have
attempted treatment with non-surgical alternatives
such as yttrium- 90- radiosynovectomy and chemical
synovectomy using osmic acid. No recurrences were
reported for a year following this treatment.8
The prognosis is good with complete recovery if there
are no associated risk factors causing exacerbation of
the disease. 1
Although rare, it is important to distinguish this entity
from other conditions since it mimics a number of
neoplastic and non- neoplastic conditions for which
the prognosis and treatment varies. The most
common conditions which need to be distinguished
clinically, radiographically and histologically are
synovial lipoma, synovial chondromatosis, pigmented
villonodular synovitis, synovial hemangioma,
degenerative conditions like rheumatoid arthritis and
osteoarthritis.
CONCLUSION
Although rare, synovial lipomatosis should be
considered while evaluating lesions around the knee
joint with acute or chronic presentation to distinguish
it from other neoplastic and non- neoplastic lesions in
order to determine the appropriate management and
prognosis.
REFERENCES
1. Rao S, Rajkumar A, Elizabeth MJ, Ganesan V.
Kuruvilla S. Pathology of synovial lipomatosis
and its clinical significance. J Lab Physicians
2011;3:84-88
2. Cukur S, Belenli OK, Yucel I, Yazici B. Giant
synovial lipoma arborescens of the right knee in a
76- year- old diabetic woman with purulent joint
effusion. J Aegean Path 2006;3:10-13
3. Weiss SW, Goldblum JR. Benign lipoblastoma
and lipoblastomatosis. Enzinger and Weisss
Soft tissue Tumors, Elsevier ,4th Ed 2001:613-15
4. Liddle A, Spicer DDM, Somashekar N, Thonse
C. Lipoma arborescens of both knees- Case
719
5.
6.
7.
8.
report and literature review. Journal of

Orthopaedic Case Reports 2012;2:3-7
Kloen P, Keel SB, Chandler HP, Geiger RH,
Zairns B, Rosenberg AE. Lipoma arborescens of
the knee. J Bone Joint Surg 1998;80:298-301
Ikushima K, Ueda T, Kudawara I, Yoshikawa H.
Lipoma arborescens as apossible cause of
osteoarthritis. Orthopaedics. 2001;19:385-89
Bullough PG. Joint diseases. Sternbergs
Diagnostic Surgical Pathology. Lippincott
Williams & Wilkins, 4th Ed 2004:237-38
Erselcan T, Bulut O, Bulut S, Dogan D, Turgut
B, Ozdemir S Et al, Lipoma Arborescens;
successfully
treated
by
yttrium90radiosynovectomy. Ann Nucl Med. 2003;17:59396
Sushma et al.,
720
DOI: 10.5958/2319-5886.2014.00424.X

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Health Sciences
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Volume 3 Issue 3
rd
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Accepted: 23rd May 2014
Case report
VARIATIONS IN THE INNERVATIONS TO THE GLUTEUS MAXIMUS MUSCLE: A CASE REPORT

*
Vanitha1, Antony Sylvan DSouza2, Vanishri Nayak3
Department of Anatomy, ESIC Medical College Gulbarga, India

Department of Anatomy, KMC Manipal, India
2,3
*Corresponding author email: vanithasanjeev@gmail.com

ABSTRACT
Gluteus Maximus is the largest and superficial muscle in the gluteal region. Rhomboidal in outline, possesses
coarse muscle fasciculi. Supplied by inferior gluteal nerve, a branch from the sacral plexus. During routine
dissection for undergraduate medical students, we observed, a branch from sciatic nerve, which supplied the
gluteus maximus muscle. Its rare variation. Knowledge of such variations may be useful for surgeons.
Keywords: Gluteus Maximus, Inferior gluteal nerve, Nerve supply, Origin.
INTRODUCTION
The gluteal region is an important anatomical and
clinical area which contains muscles and vital
neurovascular bundles. They are important for
clinical and morphological reasons.1 .Gluteus
Maximus is the largest and most superficial
muscle in the gluteal region. It is broad, thick
quadrilateral mass, which, with its overlying
adipose tissue forms the buttock. Gluteus maximus
is thicker and more extensive in man than any nonhuman primate, developments that are associated
with the evolutionary transition to bipedality and a
permanently upright posture. The muscle has a
coarse fascicular architecture, with large bundles
of fibres separated by fibrous septa. It arises from
the posterior gluteal line of ileum, rough area of
bone, including the crest above and behind it,
from the aponeurosis of Erector spine, dorsal
surface of the lower part of sacrum , side of
coccyx , the sacrotuberous ligament, and from the
gluteal aponeurosis. Most of the fibres get inserted
to the iliotibial tract of fasciae latae and deep
fibres of the lower part of muscle inserted to
the gluteal tuberosity. It is innervated by the
Vanitha et al.,
Inferior gluteal nerve (L5, S1, S2), a branch from

the sacral plexus. The inferior gluteal nerve arises
from the dorsal divisions of the fifth lumbar and first
and second sacral ventral rami. It leaves the pelvis
through the greater sciatic notch below the piriformis
muscle and divides into branches that pass posteriorly
into the deep surface of the gluteus maximus muscle.
The position of the inferior gluteal nerve makes it
vulnerable to iatrogenic injury during posterior and
posterolateral approaches to the hip. To preserve the
function of the gluteus maximus muscle, the precise
knowledge of the origin and course of the inferior
gluteal nerve is mandatory.2
CASE REPORT
During routine dissection for undergraduate medical
students, we observed an anomalous branch from
sciatic nerve supplied gluteus maximus on left side,
while the Inferior gluteal nerve was absent [Fig 1].
Innervation of gluteus maximus on right side was
normal.
721
GMM
IGA
AB
SN
PM
Fig 1: Showing an anomalous branch (AB) from the

sciatic nerve (SN) which supplies the gluteus
maximus muscle (GMM) from its deeper surface.
Inferior gluteal artery (IGA). Piriformis muscle (PM)
DISCUSSION
The present case showed on the left side of the
gluteal region, a separate branch from the sciatic
nerve, which supplied the gluteus
maximus
muscle in the absence of inferior gluteal nerve.
But the nerve supply on the right side was normal. In
general variations of the gluteus maximus muscle
is very rare. As per the previous literature the most
medial fibers may be separate to get inserted on
the lateral lip of the linea aspera. The muscle
may have an independent additional origin from
the lumbar aponeurosis of the ischial tuberosity.
A distinct slip at the lower border, arising from
the coccyx and attached to the femur may also
be found
representing the caudal head. The
fibres arising from the sacrotuberous ligament
and the
margins of the sacrum normally
separated from the superficial part by a layer of
areolar tissue, a very rare variation is the fusion
of gluteus maximus and fascia lata.3 Paval et al.,
noticed inferior gluteal nerve consisting of two
branches, these branches were one above and one
below the lower slip of the piriformis muscle. The
two branches united in front of the piriformis muscle
and formed a common trunk and then supplied the
gluteus maximus muscle.4 Yan et al5, noticed an exit
of inferior gluteal nerve from the upper edge of the
piriformis (suprapiriformis fora-men) in 4.26%
Japanese cases (4/94 sides ). The inferior gluteal
nerve frequently provides
a communicating
branch that joins the posterior femoral cutaneous
nerve, or may also join with the nerve to the short
head of Biceps.3 Kirici et al., reported bilateral
Vanitha et al.,
muscular and neurovascular anomalies of the

gluteal region in a cadaver on the right side , the
gluteus maximus had two parts , one of which
was fibrous and the other muscular. In addition,
there were duplicated piriformis muscle and high
division of sciatic nerve.6 Bhattacharya et al.,
observed on the left side, double piriformis with a
dual nerve supply of gluteus maximus and additional
supply of the gluteus maximus was from the common
peroneal nerve.7
CONCLUSION
The knowledge of such variations may be of
importance to the clinicians during surgeries of
the hip joint, hip replacement therapy, during
intramuscular injections.
REFERENCES
1. Rdeey S, Vollala VR, Rao M. Absence of
inferior gluteal artery : a rare observation. Int J
Morphol. 2007;25 (1):95-8.
2. Apaydin N, Bozkurt M, Loukas M, Tubbs RS,
Esmer AF. The course of the inferior gluteal
nerve and surgical landmarks for its localization
during posterior approaches to hip. Surg radiol
anat 2009;57(1):121-5.
3. Bergman RA, Thomson SA, Afifi AK , Saadesh
FA. Compandium of human anatomical
variations, Urban and Schwarzenberg.1988,
Germany.
4. Jaijesh Paval, Satheesha Nayak. A case of
bilateral high division of sciatic nerve with a
variant inferior gluteal nerve. 2006;5:33-34
5. Jun Yan, Masaki Takechi, Jiro Hitomi.
Variations in the Course of the Inferior Gluteal
Nerve and Artery: A Case Report and Literature
Review. Surgical Science, 2013;4, 429-32
6. Kirici Y, Ozan MH. Double gluteus maximus
muscle with associated variations in the
gluteal region; Surg radiol anat. 1999;21(6):397400
7. Bhattacharya Santanu, Chakraborty Pitbaran,
Majumdar Sudeshna, Dasgupta Hasi. Different
neuromuscular variations in the gluteal region;
International Journal of Anatomical Variations.
2013;6: 13639
722
DOI: 10.5958/2319-5886.2014.00425.1

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Health Sciences
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Volume 3 Issue 3
Received: 3rd Apr 2014
Coden: IJMRHS
Copyright @2014
Revised: 6th May 2014
ISSN: 2319-5886
Case report
STROKE IN A CHILD AS A COMPLICATION OF IRON DEFICIENCY ANEMIA: A CASE REPORT

*Srinivas Madoori1, Sridevi B2, Srinivas Dasari3, Mohd Juned Ahmed4, Sandeep G4
1
Professor, 2Senior Resident, 4Resident, Department of Pediatrics, Chalmeda Anand Rao Institute Of Medical
Sciences, Karimnagar, AP, India
3
MD, DM Neurology, Jayasree Neuro Clinic, Karimnagar, AP, India
*Corresponding author email: madoorisrinivas@gmail.com
ABSTRACT
Stroke is characterized by the sudden loss of blood circulation to an area of the brain, resulting in monoparesis,
hemi paresis and dysphasia. Nutritional anemia is a common problem all over the world. Especially Iron
deficiency anemia is common cause for nutritional anemia in developing countries. It has been a common cause
stroke in the literature. We report a case of 6 year old girl presented with severe iron deficiency anemia and
developed stroke. She was successfully treated with blood transfusion, oral iron supplementation and
anticoagulation. There are number of confirmed case reports regarding anemia as a risk factor for stroke in
children.
Keywords: Children, Iron Deficiency Anemia, Stroke.
INTRODUCTION
Acute infarct presenting as stroke is a rare cause in
children. They will present with nonspecific clinical
features. Diagnosis may be delayed because of the
nonspecific presentation. Cerebrovascular diseases
are having higher mortality and morbidity in children,
current incidence ranging between 2- 5/10000
children per year for childhood stroke.1 Children may
present with raised intracranial pressure symptoms
and signs like headache, vomiting, seizures and
encephalopathy. Risk factors for stroke are
dehydration, cyanotic congenital heart disease
(untreated), iron deficiency anemia, infections and
prothrombotic factors.2 Almost 25% of children all
over the world are affected with Iron deficiency
anemia (IDA).3 NFH survey (NFHS-3) data shows
that 7 out of every 10 children in India are suffering
with anemia. Iron deficiency as a one of the causative
factor leading to stroke. We report a child who
presented with severe anemia and developed
stroke. We also reviewed the literature.
Srinivas et al.,
CASE REPORT
A 6 year female child born to non consanguineous
parents brought to casualty with chief complaints
of weakness of left upper and lower limb. There is no
history of fever, convulsions, head injury, ear
discharge, worm infestation and repeated blood
transfusions. No history of similar illness in the past.
No history of genetic or neurological disorders in the
family and child belongs to class IV Kuppuswamy's
socioeconomic scale. On examination, severe pallor
present, no icterus, cyanosis, clubbing and
lymphadenopathy. On Central Nervous System
examination child is conscious, coherent, speech
normal. On motor system examination her muscle
tone was normal, but reduced muscle power and
reflexes were brisk on left side. The rest of her
systemic
examination
was
normal.
Laboratory analysis of childs haematological profile
showed haemoglobin-5.4gm/dL, hematocrit-22.9 %,
723
Serum Ferritin-6ng/mL, Iron-8 g/dL, Total iron

binding capacity-524 g/dL, Transferrin-366 g/dL,
Iron saturation-1.5 %, RBCs-4.1 millions/cu mm,
MCV-55.2fL, and MCH-12.8pg/cell, MCHC-23.1%
which were all below normal limits, and the
peripheral blood picture
showed microcytic,
hypochromic anemia admixed with few pencil forms
and tear drop cells . The patient is having platelet
count of 600,000/cu.mm (thrombocytosis). The
hemoglobin electrophoresis (Hb A0 94.6%, Hb A2
1.5%), osmotic fragility, sickling test and lipid panel
were normal. The other laboratory parameters
including antinuclear antithrombin II, protein C and S
antigen, bleeding time, prothrombin time, partial
thromboplastin time were also within normal limits.
The patient was treated with stroke protocol, CT scan
(Fig 1) of the head was done, which revealed
hypodensity noted in right parietal and occipital
region rest of the cerebral parenchyma, basal ganglia,
thalami, posterior fossa structures, ventricle system
and bony calvarium appears normal. No intra or extra
axial fluid and midline shift or mass effect seen.
Findings suggestive of acute infarct in right
high
parietal and occipital region Fig 1 showing
hypodensity noted in right parietal and occipital
region.
Fig 1; Hypodensity noted in right parietal and occi

pital region
With this history, examination findings and
investigations, we made a provisional diagnosis of
stroke secondary to iron deficiency anemia. The child
was started on acetylsalicylic acid (5mg/kg/day)
(which blocks prostaglandin synthetase action, in turn
inhibits prostaglandin synthesis and prevents
formation of platelets aggregating thromboxaneA2),
subcutaneous
Low-molecular-weight
heparin
(100U/kg/day) and oral iron therapy. She had been
evaluated by the physiotherapy department and a

programme of rehabilitation has been arranged which
consists of muscle strengthening exercises to improve
functional activity out any weakness. As the child's
condition was improved quickly, MRI with MRV was
not done.
DISCUSSION
Iron is important for the neuronal maturity and
development. Iron deficiency anemia is associated
with motor developmental delay, behavioral problems
like decreased concentration, attention span, breath
hold spells, febrile seizures, pica, stroke, cranial
nerve palsies.4 Current pediatric literature described
IDA has been associated with stroke.5,6 Hartifield et al
described the three children with cerebral sinus
thrombosis and three children with arterial stroke.7
Maguire et.al study found anemia is more common in
children with stroke than in controls (53%:9%).8 IDA
children are 10 times more prone to develop stroke
than normal healthy children. There are various
pathophysiological mechanism proposed to explain
association between iron deficiency and stroke. Iron
plays important role in normal thrombopoises.9
Normal levels of iron acts as inhibitor of
thrombopoises. Low levels of iron stimulates the
thrombopoises resulting in increased platelets. This
thrombocytosis is responsible for hypercoagulable
state.5 Iron deficiency increases erythropoietin levels,
which stimulates megakaryocytes. Microcytosis due
to iron deficiency decreases the cell deformability
and increases the viscosity, resulting in abnormal
flow patterns.10 Whenever there is increase in
metabolic demand at tissue levels in conditions like
infection or stress results in anemic hypoxia which
predisposes to venous thrombosis.11 In our case the
child is having severe IDA with left hemiparesis with
thrombocytosis. On evaluation no other predisposing
factors for stroke were present in this child. MRI or
MR is preferred imaging modality for investigating
stroke. Treatment of stroke includes symptomatic
treatment along with anticoagulation therapy. Low
molecular weight heparin is preferred in the absence
of any major haemorrhage.12, 13 So iron deficiency
anemia may not be benign, especially during
infections which may predispose for developing
stroke.
724
Srinivas et al.,
CONCLUSION
Stroke is a life threatening serious medical emergency.
Early diagnosis can prevent permanent neurological
damage and death. Iron deficiency anemia in one of
the common preventable cause of stroke. With proper
counseling and management, we can overcome the
stroke, behavioral abnormalities & febrile
convulsions (under 6years) in iron deficiency anemia.
Diabetic Ketoacidosis. Arch Dis Child 2002;

86:204-05
12. Barnes C, Newall F, Furmedge J, Mackay M,
Monagle P. Cerebral sinus venous thrombosis in
children. J Paediatr Child Health 2004; 40:53-5
13. Johnson MC, Parkerson N, Ward S, de Alarcon
PA. Pediatric sinovenous thrombosis. J Pediatr
Hematol Oncol 2003; 25:312-15
REFERENCES
1. Donnan GA, Fisher M, Macteod M, Davis SM.
Stroke. Lancet 2008:371:1612-23
2. Ajay Gaur. Stroke, Recent advances in pediatrics.
2011;20:445-459.
3. Lozoff B, Jimenez E, Wolf AW. Long-term
developmental outcome of infants with iron
deficiency. N Engl J Med 1991; 325:687-94
4. Yager
JY,
Hartfield
DS.
Neurologic
manifestations of iron deficiency in childhood.
Pediatr Neurol. 2002;27: 85-92
5. Belman AL, Roque CT, Ancona R, Anand AK,
Davis RP. Cerebral venous thrombosis in a child
with iron deficiency anemia and thrombocytosis.
Stroke 1990; 21:488-93
6. Benedict SL, Bonkowsky JL, Thompson JA, Van
Orman CB, Boyer RS, Bale JF Jr, et al. Cerebral
sinovenous thrombosis in children: Another
reason to treat iron deficiency anemia. J Child
Neurol 2004;19:526-31
7. Hartfield DS, Lowry NJ, Keene DL, Yager JY.
Iron deficiency: A cause of stroke in infants and
children. Pediatr Neurol 1997; 16:50-3
8. Maguire JL, deVeber G, Parkin PC. Association
between iron-deficiency anemia and stroke in
young children. Pediatrics 2007; 120; 1053-57
9. Bruggers CS, Ware R, Altman AJ, Rourk MH,
Vedanarayanan V, Chaffee S. Reversible focal
neurologic deficits in severe iron deficiency
anemia. J Pediatr 1990;117:430-32
10. Gold DW, Gulati SC. Myeloproliferative
Diseases. In: Isselbacher KJ, Braunwald E,
Wilson JD, Martin JB, Fauci AS, Kasper DL,
editors. Harrisons Internal Medicine. 13th ed.
New York: McGraw Hill; 1994:1757-64
11. Keane S, Gallagher A, Ackroyd S, McShane MA,
Edge JA. Cerebral venous thrombosis during
725
Srinivas et al.,
DOI: 10.5958/2319-5886.2014.00426.3

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Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 8 May 2014
Case report
ORAL MALIGNANT MELANOMA OF THE MANDIBULAR GINGIVA A CASE REPORT

*
Hegde Vinuta1, Naikmasur Venkatesh G2, Burde Krishna N3, Sirur Dhirendra G4, Hallikeri Kaveri5
Post Graduate student, 2Professor, 3Professor and Head, Department of Oral Medicine and Radiology, SDM
College of Dental Sciences and Hospital, Dharwad, Karnataka, India.
4
Assistant Professor, 5Professor and Head, Department of Oral Pathology, SDM College of Dental Sciences and
Hospital, Dharwad, Karnataka, India.
*Corresponding author email: drvinu07@yahoo.co.in
ABSTRACT
Oral Malignant Melanoma (OMM) is a rare, aggressive neoplasm of melanocytic origin, which is known to have
the worst prognosis than that of cutaneous melanomas. The five-year survival reported in the literature for OMM
varies from 0 - 45 % whereas the overall survival for head and neck melanomas ranges between 20 and 48%.
Maxillary gingiva and palate are commonly affected. Very few cases have been reported in the mandibular
gingiva. It can occur at any age with the range of 20 to 80 years, but less common below 30 years. OMM may
appear in various forms including pigmented macule, pigmented nodule, or a large pigmented exophytic lesion or
an amelanotic variant of any of these three forms. Here we are reporting a rare case of large exophytic,
multilobulated OMM involving whole of left mandibular gingiva in a 40 year old male patient.
Keywords: Melanocytes, Malignant Melanoma, Oral, Mandibular gingiva
INTRODUCTION
Malignant melanoma is the neoplasm which arises
from melanocytes present in the basal layer of the
epidermis of the skin and the mucous membrane of
squamous epithelium. Hence melanoma is seen in
oral cavity, eyes, meninges and skin.1,2 Melanomas of
mucosal surfaces have more aggressive growth phase
with early invasion of submucosa.1 Weber first
described Oral Malignant Melanoma (OMM) in the
year 1859.3 The relative incidence of OMM was
0.07% according to Hormia and Vuori (1969) and
0.2% to 8% of all malignant melanomas according to
Pliskin (1979) and these account for 0.5% of all oral
malignancies.4,5 In a study of 1546 melanomas, 26
were found arising in the upper respiratory tract and
oral cavity; of these only 12 were primary oral
melanomas. 6 Palate and the maxillary gingiva are
most commonly affected intra-oral sites.2,5-7 A very
few cases of OMM involving mandibular gingiva

have been reported. The prognosis of OMM is poor
and the five-year survival rate range varies from 0% 45% 8 to 5% to 20%.9
OMM can present with different forms such as
pigmented macule, nodule or large pigmented
exophytic growth.9 The color of OMM varies from
uniformly brown or black to shades of black, brown,
grey, purple and red and sometimes depigmented.5, 9
It can spread to distant sites via vascular or lymphatic
routes.
Here we are reporting a rare case of large exophytic,
multilobulated OMM involving whole of left
mandibular gingiva in a 40 year old male patient.
726
Vinuta et al.,
CASE REPORT
A 40 year old male patient reported to the
Department of Oral Medicine and Radiology, S D M
College of Dental Sciences and Hospital, Dharwad,
Karnataka, India, with a chief complaint of painless
growth in the left lower jaw since two months, which
was gradually increasing in size. Patient had no major
systemic illness or any history of trauma to the head,
neck or face region. Patient had the habit of betel
quid chewing 5-6 times per day since 15 years. Exrtaorally there was a diffuse swelling on the left side of
the face extending from corner of the mouth to about
4cm posteriorly and from ala-tragus line to lower
border of mandible. Skin over the swelling was
stretched. The swelling was pointing outwards, but
there was no discharge (Fig 1).
2nd premolar was (35) missing, with which patient

gave a history of exfoliation recently. On palpation
growth was firm in consistency and it was slightly
tender and was fixed to the underlying bone. Grade 1
mobility was elicited with 37 and 38, grade 2
mobility with 33 and grade 3 mobility with 34 and
36. There was no other pigmented lesion in the oral
mucosa or any suspicious cutaneous lesions on any
part of the body. With the clinical appearance of the
growth we came to the provisional diagnosis of
OMM. Orthopantomograph was taken to evaluate
possible bone destruction, which revealed diffuse
radiolucency of alveolar bone in the region of 33 to
36 with permeative border, loss of lamina dura with
34 and 36, and mesial displacement of 36 and lingual
displacement of 34 (Fig 3). Haematological and urine
examinations did not reveal any significant findings.
Chest radiograph showed normal radiological
findings (Fig 4).
Fig 1: Extra oral swelling on the left side of the face
Single left submandibular lymph node was palpable;

it was about 2cm in size, nontender and not fixed to
underlying structure. On examination of the oral
cavity, there was a lobulated growth of the left
mandibular
gingiva
which
was
extending
buccolingually from buccal vestibule to lingual
vestibule and anteroposteriorly from the midline to
third molar region. The surface was irregular with
multiple lobulation. Growth was blackish brown in
colour(Fig2).
Fig 2: Intra oral photograph showing growth in the left

mandibular gingiva
Fig 3: Cropped OPG image showing diffuse

radiolucency in the region of 33 to 36, loss of lamina
dura with 34 and 36, and mesial displacement of 36
Fig 4: Chest radiograph showing normal

radiological findings
Incisional biopsy was done, which confirmed our
clinical diagnosis. The H and E stained section
showed
parakeratinized
stratified
squamous
727
Vinuta et al.,
epithelium with dysplastic changes, increased

melanin component at the junction and invasion into
the connective tissue. The atypical Melanocytes
showing the junctional activity and invasion were
round to spindle shaped. Pleomorphic melanocytes
were also seen in the stroma. Well differentiated
melanocytic cells were seen in the form of nests,
islands and sheets in the fibrovascular stroma with
minimal chronic inflammatory cell infiltration
(Figure 5a and 5b).
Figure 5a; H and E stained photomicrograph shows

invading tumor cells with junctional activity (10x) 5b;
H and E stained photomicrograph shows islands of
tumor cells which are spindle shaped with minimal
cytoplasm (40x)
Whole body scanning, including computerized

tomograms of head, neck & brain, radiographs of
long bones, abdominal ultrasonography was advised
for the patient to see any distant metastasis. However
the patient failed to turn up for the further
investigations and treatment.
DISCUSSION
Primary oral malignant melanoma is a rare neoplasm
of unknown etiology. Depending on the clinical and
histopathological findings Union for International
Cancer Control (UICC) has staged malignant
melanoma from 1 to 3. Stage 1- localized disease,
stage 2 - with regional lymph node metastases, stage
3 with distant metastasis. Possible risk factors can
be exposure to sunlight, betal quid chewing, cigarette
smoking, alcohol consumption, denture irritation
etc.2,5,10-12 Our patient had the habit of betal quid
chewing for about 15years. At high internal body
temperature inhaled or ingested environmental
carcinogens may play some role in the etiology.5
OMM develops from melanocytes of the basal layer
of the oral mucosa which arises de novo or preceded
by oral pigmentations for several months to years.5,11
It can occur at any age, average is 56 years but is less
common in people below 30years.13 Previous studies
showed more prevalence of mucosal melanoma in

males than in females with male to female ratio of
2:1,6,14,15 our patients gender also was male which is
supportive to the previous reports.
Most commonly affected intra-oral sites are maxillary
gingiva and palate. Pliskin found that 77% of all
melanomas occurred in either the palate or the upper
alveolus.16 Takagi et al. in a total of 120 cases, found
34% in the palate and 24% in the maxillary gingiva.17
In other series of cases 73.3% (11 of 15) and 91.4%
(32 of 35) of cases occurred in the hard palate and
maxillary gingiva.18,19 Very few cases of OMM of
mandibular gingiva have been reported. In our patient
whole of the left mandibular gingiva was involved,
which is a rare finding.
A malignant melanoma can present with different
morphologic and macroscopic characteristics such as
flat (maculae) or elevated (nodule or tumour) lesion
with or without ulceration or an erythematous border
and it can vary in size and colour or can present with
an amelanotic variant of any of these forms which are
rare. The prognosis for amelanotic melanoma is
poorer than that of pigmented melanomas. According
to Tanaka et al. there are five types of OMM
depending on the clinical appearance: pigmented
macular type, pigmented nodular type, nonpigmented
nodular type, pigmented mixed type and
nonpigmented mixed type.5 Our case could be
identified as the pigmented nodular type of OMM
involving whole of mandibular gingiva on left side
which is a rare finding.
The differential diagnosis for OMM includes
smoking
associated
melanosis,
nevi,
post
inflammatory pigmentation, melanotic macule,
medication induced melanosis, Addison's disease,
Peutz-Jeghers
syndrome,
amalgam
tattoo,
melanoplakia, melanoacanthoma, Kaposi's sarcoma
etc.20 22 Biopsies of pigmented lesions are done to
exclude malignant melanoma when no other etiology
is found. Malignant melanoma must be suspected
when there is variation in colour (red to black-brown)
within a pigmented lesion, particularly when it has an
asymmetrical or irregular outline or sudden
appearance of a large pigmented lesion, particularly
when it has an exophytic component, or has
erythematous or ulcerated areas in the pigmented
area. Once diagnosed with biopsy radical resection of
the primary lesion is the treatment of choice which
728
Vinuta et al.,
could
be
combined
with
radiotherapy
and/chemotherapy.5
OMM often go unnoticed since they are clinically
asymptomatic in the early stages and they usually
merely present as a hyperpigmented patch on the
gingival surface. However biopsy becomes necessary
when there is a change in colour or asymmetric
growth present within the pigmented lesion. Delayed
diagnosis and its biological aggressiveness make the
prognosis extremely poor. Hence a high index of
suspicion, early detection and diagnosis for any
pigmented
gingival
lesions
cannot
be
overemphasized.
In a follow up study of 15 oral malignant melanoma
patients a mean survival time was 16.9 months, and
5-year survival rate was 6.6% after the treatment.16
Because of the aggressive growth, metastasis and
local recurrence even after treatment it has poor
prognosis. Hence meticulous clinical examination of
the oral and oropharyngeal mucosa should be
performed in all patients.
CONCLUSION
A high level of suspicion, a careful history and a
thorough examination, including the oral cavity and
neck, from health providers regarding these
malignancies are essential. Any change in the signs
and symptoms must be seriously considered so that
early diagnosis and prompt treatment will be possible
with better prognosis.
ACKNOWLEDGEMENTS
We would like to thank the management and Dr.
Srinath Thakur, Principal, S D M College of Dental
Sciences and Hospital, Dharwad for the financial
support extended to investigate the patient and to
send for the publication.
REFERENCES
1. Shwetha V K, Niharika S. Oral Malignant
Melanoma: A Case Report. Int j of oral and maxil
path 2011;2(3):50-54
2. Goel A, Srinivasan V, Patil P, Juneja N. Oral
malignant melanoma A review. Int Dent J of
Stu Rresearch Oct 2012-Jan 2013;1(3):74-77
3. Liversedge MB. Oral malignant melanoma. Br J
Oral Surg 1975;13(1):40-55
4. Ebenezer J. Malignant melanoma of the oral

cavity. Indian J Dent Res 2006;17(2):94-96
5. Marco M, Leemans C, Mooi P, Vescori P, Wall I.
Oral malignant melanoma; A review of literature.
Oral Oncol 2007;43:116-21
6. Moore ES, Martin H. Melanoma of the upper
respiratory tract and oral cavity. Cancer
1955;8:1167-1176.
7. Gondivkar SM, Indurkar A, Degwekar S,
Bhowate R. Primary oral malignant melanoma--a
case report and review of the literature.
Quintessence Int 2009;40:41-46
8. Masahiro U, Maho M, Hiroaki S, Tadahiko Y,
Yasuyuki S And Takahide K. A Case of
Malignant Melanoma of the Oral Cavity Alive
with Liver Metastasis for a Long Period with
Administration of a Biologic Response Modifier,
OK432. Kobe J. Med. Sci. 2010; 56( 3): E140-47
9. Vijaykumar B, Rahul L, Surekha B. Late
Diagnosis of Oral Mucosal Melanoma: Case
Report Journal of Dental & Allied Sciences
2012;1(2):85-87
10. Thomas M, Anna B, Klaus-Dietrich W, David A
M
Oral
Malignant
Melanoman
www.intechopen.com oct 2011
11. Tremblay JF, O'Brien EA, Chauvin PJ.
Melanoma in situ of the oral mucosa in an
adolescent with dysplastic nevus syndrome. J Am
Acad Dermatol 2000;42:844-46
12. Parvathi D, Thimmarasa B, Ravi R. J, Cherry W
and Sharad S. Malignant melanoma of the oral
cavity showing satellitism. J Oral Sci 2011:53(
2): 239-44
13. Kumar K, Santhosh BS, Priya NK. Primary oral
malignant melanoma - a case report Nig Dent J
2011;19(1):44-47
14. Luna-Ortiz K, Campos-Ramos E, Pasche P,
Mosqueda-Taylor A. Oral mucosal melanoma:
conservative treatment including laser surgery.
Med Oral Patol Oral Cir Bucal.2011;16(3):e381
85
15. Aguas SC, Quarracino MC, Lence AN,
Lanfranchi-Tizeira HE. Primary melanoma of the
oral cavity: ten cases and review of 177 cases
from literature. Med Oral Patol Oral Cir
Bucal.2009;14(6): E26571
16. Pliskin ME. Malignant melanoma of the oral
cavity. In: Clark YM Jr., Golman LI, Mastrangelo
729
Vinuta et al.,
17.
18.
19.
20.
21.
22.
MJ, editors. Human Malig- nant Melanoma. New

York: Grune and Stratton, 1979. p. 125-37
Takagi M, Inhikawa G, Mori W. Primary
malignant melanoma of the oral cavity in Japan.
With special reference to mucosal melanosis.
Cancer 1974;34:358-70
Lopez-Graniel CM, Ochoa-Carrillo FJ, MenesesGarc A. Malignant melanoma of the oral
cavity: diagnosis and treatment Experience in a
Mexican population. Oral Oncol 1999;35:425-30
Tanaka N, Mimura M, Ogi K, Amagasa T.
Primary malignant melanoma of the oral cavity:
assessment of outcome from the clinical records
of 35 patients. Int. J. Oral Maxillofac. Surg. 2004;
33: 76165
Tanaka N, Mimura M, Ichinose S, Odajima T:
Malignant melanoma in the oral region:
ultrastructural and immunohistochemical studies.
Med Electron Microsc 2001;34:198-205
Hicks MJ, Flaitz CM. Oral mucosal melanoma:
Epidemiology and pathobiology. Oral Oncol
2000;36:152-69
Notani K, Shindoh M, Yamazaki Y, Nakamura
H, Watanabe M, Kogoh T, Ferguson M, Fukuda
H: Amelanotic malignant melanomas of the oral
mucosa. British Journal of Oral and Maxillofacial
Surgery 2002, 40(3):195-200
730
Vinuta et al.,
DOI: 10.5958/2319-5886.2014.00427.5

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Volume 3 Issue 3
th
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Case report
A PRODIGIOUS LICHEN PLANUS PIGMENTOSUS: THE WOLFS ISOTOPIC RESPONSE
*Yugandar I1, Shiva Kumar2, Sai Prasad3, Srilakshmi P1, Akshaya N1, Abhiram R1, Sujalalitha K1, Meghana GB1
1
Postgraduate Students, 2Professor, Department of DVL, P.E.S. Institute of Medical Sciences and Research,
Kuppam, Andhra Pradesh, India
3
Associate Professor, Department of Pathology, S V Medical College, Tirupati, Andhra Pradesh, India
*Corresponding author email:dryugandar@gmail.com
ABSTRACT
Lichen planus is a pruritic, benign, papulosquamous, inflammatory dermatosis of unknown etiology that affects
either or all of the skin, mucous membrane, hair and nail. In its classic form, it presents with violaceous, scaly,
flat-topped, polygonal papules. A female patient aged 43 years with a history of pruritic eruptions for a period of
one month over the right armpit and back of the right chest (C8, T1, T2, T3 Dermatomes). She had a history of
herpes zoster in the same localization, which had been treated with topical and oral acyclovir two months prior to
this visit. This variant may represent as an example of the Wolfs isotopic response. We presented our case
because of its rarity as a Dermatomal distribution of lichen planus pigmentosus (LPP) and its appearance in the
area of healed herpes zoster as an isotopic response. The case well highlights this unusual condition and
represents the first case reported in Indian dermatology literature to our best of knowledge. The clinical and
histological features of this case are described here.
Keywords: Herpes, Koebner phenomenon, Lichen planus pigmentosus, Unilateral, Wolfs isotope response,
Zosteriform
INTRODUCTION
The term lichenoid is used by clinicians to describe
a flat-topped, shiny, papular eruption resembling
lichen planus or by histopathologists to describe a
type of tissue reaction consisting principally of basal
cell liquefaction and a band-like inflammatory cell
infiltrate in the papillary dermis.1
The term lichen is derived from the Greek verb to
lick2. However, the use of the term is adapted to a
noun in both Greek and Latin for a symbiotic form of
plant life. The dermatosis, lichen planus was first
described by Erasmus Wilson in 1869.3
Lichen planus pigmentosus (LPP) variant of Lichen
Planus, it is a chronic pigmentary disorder that shows
diffuse or reticulated hyper pigmented, dark brown
Yugandar et al.,
macules on the sun-exposed areas such as the face,

neck and other flexural folds.4 Clinically, it is
different from classical lichen planus by the presence
of dark brown macules.
LPP was first described by Bhutani et al.5 The Wolfs
isotopic response, as defined by Wolf et al., describes
the occurrence of a new skin disorder exactly at the
site of another, unrelated, and already healed skin
disease. Several types of cutaneous lesions have been
described occurring within cleared cutaneous herpes
zoster, or, less frequently, herpes simplex lesions.6 A
viral origin, an immunologic origin, a vascular origin
and a neural origin are possible pathogenetic
mechanism of isotopic response. The isotopic
response induce Koebner phenomenon.
731
It is not a type of cancer. It has been recognized that

there is an association between LP and cancer,
although the association is rare. One case of LPP has
been reported in association with Bazex syndrome,
head and neck cancer.7
CASE REPORT
A 43 year old female, House wife reported to our
department with a one month history of pruritic
eruptions over the back of the chest. She also gave
history of two months duration of herpes zoster, had
been received topical and oral acyclovir. Following it,
she developed multiple pruritic skin eruptions over
same localization.
No history of similar skin lesion in the past or in
family members. She had no history of systemic
complaints. The physical examinations were within
normal limits. Laboratory investigations revealed
normal values.
On cutaneous examination, there were multiple
unilaterally distributed dark brown, flat macules of
variable sizes distributed diffusely over Right
Dermatomes C8, T1, T2, T3. It was distributed from
the right armpit to back of the chest, but it never
crossed midline of the body. Few were Violaceous.
(Fig 1, 2) Hair, nail and oral mucosa were not
involved.
A differential diagnosis of post inflammatory
hyperpigmentation,
Erythema
dyschromicum
perstans, fixed drug eruptions and LPP were
considered. Advised full thickness Punch biopsy.
Fig 1: Dark brown, flat macules of variable sizes over

back of chest (right side)
Fig 2: Pigmentary eruptions over Right Dermatomes C

8,T 1,T 2,T 3.
Histopathological examination from one of the

papules on skin under hematoxylin and eosin staining
(H & E) showed epidermal atrophy, lamellar
keratinisation and local basal cell vacuolization.
Superficial dermis shows Pigment incontinency,
mononuclear and lymphocyte cell infiltrate. Civatte
bodies also identified (Fig: 3, 4, 5). Histology
confirmed diagnosis of LPP.
Fig 3: Atrophic Epidermis with mild keratinisation.

Blunting of Rete Ridges, Melanin pigment and few
perivascular lymphocytes in superficial dermis. (H&E
Low Power)
Fig 4: Atrophic Epidermis with absence of Rete Ridges

and presence of Melanin Pigment. (H&E stain, 200)
732
Yugandar et al.,
Fig 5: Basal cell vacuolar degeneration,Pigment

incontinence, Perivascular Lymphohistiocytic infiltrate
and Civatte bodies at DEJ. (H&E stain 200)
DISCUSSION
Lichen planus is an idiopathic inflammatory disease
of the skin and mucous membrane. It is characterized
by 6 Ps": planar (flat-topped), purple, polygonal,
pruritic, papules, and plaques. In addition to the
classical appearance, about 20 different variants are
described.
LPP is characterized by mottled or reticulated hyper
pigmented, dark brown macules on the sun exposure
skin areas, varies from slate grey to brownish black, it
is mostly diffuse. The macular hyper pigmentation
involves chiefly the face, neck and upper limbs.
Striking predominance of pigmentary lesions at
intertriginous sites, especially the axillae.1 The
mucous membranes, palms and soles are usually not
involved. The duration at presentation ranged from 2
months to 21 years in one series.8
The cause of LPP is unknown, but an immunologic
mechanism mediates its development, as well as that
of lichen planus. Based on the distinctive
lymphocytic inflammatory response of the lichenoid
reactions, cell mediated immunity seems to play a
pivotal role in triggering the clinical expression of the
disease.9 In our case it was induced Koebner
phenomenon by Preceding Herpes infection.
Histopathology of LPP shows atrophic epidermis,
basal hydropic degeneration, hypergranulosis,
Perivascular Lymphohistiocytic infiltration, pigment
incontinence, irregular elongation of rete ridges
appeared saw tooth pattern and multiple apoptotic
cells i.e. Civatte bodies present in dermoepidermal
junction. Few melanophages are also seen.
Our case showed lamellar keratinisation, local basal
cell vacuolization. Superficial dermis shows Pigment
incontinence, mononuclear and lymphocyte cell

infiltrate. Civatte bodies also identified.
No effective treatment is available. In the references,
Tacrolimus ointment could have a beneficial role in
the treatment of LPP.10 Topical agents include
hydroquinone, which is the most commonly used
agents, often in combination with retinoic acid,
corticosteroids, azelaic acid, Kojic acid, and glycolic
acid in case facial LPP along with photoprotection.
Other drugs used with inconsistent results are
griseofulvin,
Prednisolone,
etretinate
and
11
chloroquine.
Our patient advised betamethasone
ointment along with sun protection.
There have been only a few reports in the
dermatology literature. Lutz et al also described a
zosteriform pattern of lichen planus developing at the
site of healed herpes zoster.12 Shemer et al reported a
case of zosteriform lichen planus at the site of healed
herpes zoster.13 Cho s reported a case of LPP
presenting in zosteriform pattern.14 Laskaris G.C et al
reported a case of LPP of the Oral Mucosa.15
CONCLUSION
LPP is an uncommon variant of lichen planus, for
which no definite etiology, no precipitating factors
are known and no effective treatment is available.
Many cases go away within two years. About 1 in 5
will have a Second outbreak.
We describe a case of a rare variant of LPP with a
past history of herpes zoster; this abnormal
presentation can be mistaken for other common
inflammatory dermatosis. To the best of our
knowledge, is the first case report of LPP with a past
history of Herpes zoster in Indian Literature. So we
suggest that the title name Bizarre or Unusual or
Zosteriform
or
Prodigious
Lichen
Planus
Pigmentosus because of variable etiology or
presentation or treatment.
ACKNOWLEDGEMENT
We gratefully acknowledge the help of the Principal,
PESIMSR, Kuppam, the professor and head,
department of DVL, PESIMSR, Kuppam
REFERENCES
1. Breathnach SM. Lichen Planus and Lichenoid
Disorders. In: Burns T, Breathnach S, Cox N,
733
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2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Griffiths C, editors. Rooks Textbook of

Dermatology. 8th ed. Wiley-Blackwell; 2010:
41.1- 41.28.
Kanwar AJ, De D. Lichen planus in children.
Indian J Dermatol Venereol Leprol 2010;76:36672
Neerja Puri, Asha Puri. A study on lichen planus
in children. Our Dermatol Online 2013; 4(3):
303-05
Jong Keun Seo, Hyun Jae Lee, Deborah Lee,
Joon Hee Choi,Ho-Suck Sung. A case of linear
lichen planus pigmentosus. Ann Dermatol 2010;
22(3):323-25
Bhutani L, Bedi T, Pandhi R. Lichen planus
pigmentosus. Dermatologica 1974; 149: 43-50
Aylin Turel, Serap ozturkcan, M.Turhan Sahin,
Peyker Turkdog an. Wolfss Isotopic Response:
A Case of Zosteriform Lichen Planus. J Dermatol
2002; 29: 33942
Sassolas B, Zagnoli A, Leroy JP, Guillet G.
Lichen planus pigmentosus associated with
acrokeratosis of Bazex. Clin Exp Dermatol.
January 1994; 19(1):70-73
Kanwar AJ, Dogra S, Handa S. A study of 124
Indian patients with lichen planus pigmentosus.
Clin Exp Dermatol 2003; 28: 481-85
Jong Keun Seo, Hyun Jae Lee, Deborah Lee,
Joon Hee Choi, Ho-Suck Sung. A Case of Linear
Lichen Planus Pigmentosus. Ann Dermatol 2010;
22(3): 323
Ru-zhi Zhang, Wen-yuan Zhu. One case of
unilateral linear lichen planus pigmentosus. The
Open Dermatology Journal 2012; 6; 25-28
Kanwar AJ, Dogra S, Handa S. A study of 124
Indian patients with lichen planus pigmentosus.
Clin Exp Dermatol 2003; 28: 481-85
Lutz ME, Perniciaro C, Lim KK. Zosteriform
lichen planus without evidence of herpes simplex
virus or varicella-zoster virus by polymerase
chain reaction. Report of two cases. Acta Derm
Venereol 1997; 77: 491-92
Shemer A, Weiss G, Trau H. Wolfs isotopic
response: A case of zosteriform lichen planus on
the site of healed herpes zoster. JEADV 2001; 15:
445-47
Cho S, Whang KK. Lichen planus pigmentosus
presenting in zosteriform pattern. J Dermatol
1997, 24(3):193-97
15. Laskaris GC, Papavasiliou SS, Bovopoulou OD,

Nicolis GD. Lichen planus pigmentosus of the
Oral Mucosa: A Rare Clinical Variety.
Dermatologica 1981;162:6163
734
Yugandar et al.,
DOI: 10.5958/2319-5886.2014.00428.7

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Volume 3 Issue 3
th
Coden: IJMRHS
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ISSN: 2319-5886
th
Revised: 8 May 2014
Case report
BILATERAL INTERNUCLEAR OPHTHALMOPLEGIA AS FIRST MANIFESTATION OF EXTRA

PONTINE MYELINOLYSIS
Tushar Kanti Bandyopadhyay1, *Rudrajit Paul1, Amit K Das2, Rathindranath Sarkar3
1
Assistant Professor, 2Resident, 3Professor, Department of Medicine, Medical College Kolkata88, College Street,
Kolkata, West Bengal
*Corresponding author email: docr89@gmail.com
ABSTRACT
Extrapontine myelinolysis (EPM) is a rare clinical entity affecting anterior basal ganglia. This is one of the
osmotic demyelination syndromes. It occurs due to rapid correction of hyponatremia and also rarely occurs in
alcoholics. It generally presents with extrapyramidal symptoms. We here report a case of EPM in a 13 year old
boy presenting with bilateral internuclear ophthalmoplegia and ptosis. The patient also had generalised weakness,
but no psychiatric symptoms. The patient slowly recovered over six months. EPM can affect any age group,
although the elderly are more likely to be affected due to frequent electrolyte abnormalities. Ocular movement
disorders or brainstem signs are rarely reported in EPM. When present, it can create diagnostic confusion with
multiple sclerosis. We believe this is the first report of this entity from India. The relevant literature regarding
brainstem manifestations in myelinolysis syndromes is also discussed, along with the radiological findings.
Keywords: Internuclear ophthalmoplegia, Extrapontine myelinolysis, Ptosis, CIDP, Basal ganglia
INTRODUCTION
Extrapontine myelinolysis (EPM) is a rare clinical
entity occurring mainly after rapid correction of
hyponatremia. It is usually associated with its
counterpart: central pontine myelinolysis (CPM). 1
However, very rarely, EPM can occur in absence of
CPM and this makes the diagnosis challenging. The
clinical manifestations of EPM vary and may range
from extrapyramidal features to neuropsychiatric
manifestations.1, 2 Such atypical features, along with
the rarity of the entity often delay the diagnosis. We
here report a case of EPM presenting with bilateral
internuclear ophthalmoplegia (INO). To our
knowledge, this is probably the first report of EPM
presenting with INO from India. Other reported cases
from India have shown parkinsonian features and
bulbar symptoms.3 Another case was reported with
flaccid quadruparesis.4
Tushar et al.,
CASE REPORT
A13 year old boy presented with acute onset
generalised weakness without loss of consciousness
for two days. He had been admitted elsewhere with
increasing abdominal pain and vomiting for twenty
days. He was there documented to be dehydrated and
resuscitated with intravenous fluids. He apparently
improved with the conservative management but
deteriorated again with severe generalized weakness
and blurring of vision. With this complaint, he was
referred to our tertiary care center.
At our centre, on admission, the boy was found to be
severely weak with power 2-/5 in all four limbs. He
could not turn in bed or lift his head from pillows. His
abdomen was found to be distended and his parents
complained of severe constipation for the last ten
735
days. Immediate straight X-ray of abdomen (Fig. 1)

Showed air fluid levels consistent with intestinal
obstruction.
Further examination revealed bilateral ptosis (fig. 2)
with bilateral internuclear ophthalmoplegia. Pupillary
reactions were normal and there was no weakness of
any other cranial nerve. Ophthalmoscopy was normal.
The blurring of vision was probably due to nystagmus
on lateral gaze. The deep tendon jerks were all
depressed and plantar response was absent. There was
generalised hypotonia. There was no muscle
tenderness or nerve thickening. Higher functions
remained normal throughout. The pulse rate was
120/min with loss of respiratory variation and there
was marked postural hypotension (fall of SBP by 35
mm of Hg on sitting).
Past history revealed recurrent episodes of similar
abdominal distension and constipation over three
years. However, each time, he had responded to
conservative management. He had no history of
abdominal surgery or tuberculosis. Past CT scans of
abdomen were normal. Also, he had three episodes of
generalized weakness lasting for one to two months
over past three years. In one such episode, he was
investigated in detail and diagnosed as Acute
Inflammatory
Demyelinating
Polyneuropathy.
However, he was lost to follow up after that. His
parents said that he had some residual weakness of
the limbs from that episode and needed support while
walking.
Laboratory examinations revealed hemoglobin of
9.9G/dl with total leukocyte count of 7100/cmm
(Neutrophil 67% and lymphocyte 28%). The Platelet
count was 1.9 lakhs/mm3 with normal red cell indices
and normal ESR. Blood sugar 108mg/dl, /urea
31mg/dlcreatinine was 0.7 mg/dl respectively. Liver
function test was normal and blood electrolytes
revealed Na 135 mEq/L and K 4.2 mEq/L. Serum
calcium was also normal. After admission, the
generalised power improved to 3/5 but the INO
persisted. A CT scan of brain was normal. CSF study
revealed 8 cells/cmm with protein of >2g/dl and high
globulins. CSF ACE level was normal and TB-PCR
done from CSF was negative. Also, CSF VDRL was
negative. Blood for HIV, Hepatitis B, C and Herpes
Simplex serologies were negative. A nerve
conduction study was done which revealed decreased
amplitudes of mainly motor nerves in all four limbs
with relatively normal conduction velocity,
Tushar et al.,
suggestive of axonal degeneration. Also, needle EMG

revealed spontaneous fibrillation, suggestive of
denervation. This picture, along with the CSF report
was
suggestive
of
Chronic
Inflammatory
Demyelinating Polyneuropathy. This could also
explain the autonomic dysfunction as manifested in
cardiovascular examination. Probably the intestinal
obstruction was a manifestation of autonomic
involvement in CIDP. Repeat ultrasonography of
abdomen and barium meal study did not reveal any
mechanical obstruction.
Fig 1: straight X ray abdomen showing multiple

air fluid levels
Fig 2: Face of the patient with bilateral ptosis

(Photo was taken with consent of patient)
Chest X ray was normal. MRI scan of brain was done
which revealed symmetric marked hyperintensity in
T2 images in anterior part of basal ganglia involving
putamen and anterior part of caudate nucleus (Fig. 3).
Also there was some hyperintensity in tegmental part
of midbrain involving periaqueductal grey matter
(Fig. 4). However, the T1 images were completely
normal and coronal section of pons in T2 imaging did
not reveal any signal changes also. MRI spectroscopy
was done, but was reported to be essentially normal.
Blood lead levels and porphyrin levels
736
(Porphobilinogen and delta ALA) were normal.

Serum magnesium, thyroid function tests and vitamin
B12 levels were also normal.
Fig 3: T2 weighted MRI images showing bilateral

anterior basal ganglia hyperintensity
Fig 4: FLAIR image of midbrain showing the

lesion (red arrow)
Thus, based on the imaging findings, the case was
diagnosed as extra pontine myelinolysis probably due
to overzealous correction of hyponatremia (normal
135145 mEq/L.) in dehydration in the background
of CIDP with autonomic features.
The patient was treated with physiotherapy and
braces. At six months follow up, his INO had
improved. Repeat MRI showed resolution of the
lesions. Also, he had not developed any Parkinsonian
features. However, the power in his limbs remains 4/5 and he can now walk only with support.
DISCUSSION
EPM is a rare entity occurring mainly after rapid
correction of hyponatremia. 5 Thus, this can occur in
disease states like renal failure, diarrhea, diuretic
abuse, heart failure, vomiting and salt losing states. It
is due to osmotic damage to brain tissues which
occurs due to rapid shift of osmotically active
particles across neuronal cell membranes. CPM and
Tushar et al.,
EPM can also occur rarely in chronic alcoholics or

malnourished persons. 6 In our patient, the
hyponatremia was never documented, but since the
patient had a prolonged history of vomiting with
intestinal obstruction, this was probably the most
likely underlying abnormality. Our patient had the
typical feature of early improvement followed by
sudden deterioration, which is found in osmotic
demyelination
syndromes.
In
EPM,
the
manifestations can vary from extrapyramidal features
like tremor or dystonia to psychiatric illness2, 5Even
quadriplegia has been reported in this disease.
INO is a manifestation of brain stem dysfunction at
the level of medial longitudinal fasciculus. The chief
causes of INO are multiple sclerosis and brain stem
infarction, although it can also be seen rarely in any
local tumour or congenital malformation.7
In CPM, brain stem features like nystagmus and gaze
palsy are reported.8 This is due to edema in pons and
its connections with the cerebellum. Also, presence of
nystagmus in CPM, especially in an alcoholic patient,
should prompt a search for coexisting Wernickes
encephalopathy (WE).9 In these cases, MRI imaging
of brain can help in differentiation. In CPM, we get
trident shaped lesion in T2 image in pons on sagittal
section. In WE, there will be additional hyperintense
lesions in FLAIR and T2 in bilateral thalami.9
Nystagmus has very rarely been reported in EPM.
One case report from Denver showed a patient of
EPM with medullary lesions, presenting with
downbeat nystagmus.10 Like our case, this case also
had resolution of brain stem symptoms with time.
Like CPM, the prognosis of EPM is variable. Some
patients recover completely while others may have
residual motor, psychiatric or memory related
dysfunctions. The mortality rate has decreased now
with early diagnosis.
INO is almost never reported with CPM or EPM.
Sometimes, a patient with INO is first thought to have
CPM, but later new features emerge and a diagnosis
of multiple sclerosis is made. Thus, in a patient
presumed to have CPM, the presence of INO should
alert the clinician to the possibility of multiple
sclerosis. However, in our case, the presence of clear
basal ganglia lesions in MRI was conclusive.
Literature search revealed only one other reported
case of EPM with presence of INO.11 In that case,
there was also gaze palsy with gaze evoked rotatory
nystagmus.11 However, due to rarity of EPM, the
737
ocular movement disorders in this disease have not

been well studied.
In INO, the lesions are usually found in paramedian
pontine tegmentum or periaqueductal region.12 In our
patient, the lesions in periaqueductal midbrain in MRI
accounted for the INO. In EPM, the typical MRI
features include symmetrical bilateral hyperintensity
in T2/FLAIR in putamen and caudate nucleus with
relative sparing of globus pallidus.1 Also T1 images
in these areas will be normal and this helps to
differentiate this condition from similar presentations
with CO poisoning. The diagnosis of EPM is mainly
clinical with added MRI findings.
Our patient recovered slowly over time. The MRI
lesions also resolved. This temporal profile of EPM
was also documented in other reported cases.8, 10
However, since our patient had underlying CIDP, he
did not regain full power of the limbs.
This is probably the second reported case of EPM
with INO. This case depicts the possible varied
presentation of osmotic demyelination syndromes
with brain stem signs.
5.
6.
7.
8.
9.
10.
CONCLUSION
Central nervous system osmotic demyelination is a
rare complication of electrolyte correction. It may
present with atypical features like ocular movement
disorders. Thus, clinicians should have a low
threshold for brain imaging if atypical neurological
signs appear in a patient of hyponatremia.
ACKNOWLEDGEMENT: the Principal of our
College for his guidance
REFERENCES
11.
12.
Diffusion weighted imaging and diffusion tensor

imaging on follow-up. Neurol India 2012;60:4268
Hsu M, Choi W. Extrapontine Myelinolysis: A
Case Report. J Emerg Crit Care Med. 2008; 19:
172-6
Yoon B, Shim YS, Chung SW. Central Pontine
and Extrapontine Myelinolysis After Alcohol
Withdrawal. Alcohol 2008; 43: 6479
Obuchowska I, Mariak Z. Internuclear
ophthalmoplegia--causes,
symptoms
and
management. Klin Oczna. 2009;111:165-7
Kilinc M, Benli US, Can U. Osmotic
myelinolysis in a normonatremic patient. Acta
neurol. belg., 2002; 102: 87-9
Sutamnartpong P, Muengtaweepongsa S,
Kulkantrakorn K. Wernicke's encephalopathy and
central pontine myelinolysis in hyperemesis
gravidarum. J Neurosci Rural Pract. 2013; 4(1):
3941
Neumann R, Pelak VS, Bennett J. Isolated
extrapontine myelinolysis with gaze-paretic and
downbeat nystagmus. 2000. Available online
from
http://content.lib.utah.edu/cdm/ref/c
ollection/ehsl-nam/id/3922
Hawthorne KM, Compton C, Vaphiades MS,
Kline LB. Eye Movement Abnormalities in
Osmotic
Demyelination
Syndrome.2009.
Available online from http://content.lib.utah.edu/
utils/getfile/collection/ehsl-nam/id/114/filename
/68.pdf
Deleu D, Sokrab T, Salim K, El Siddig A, Hamad
AA. Pure isolated unilateral internuclear
ophthalmoplegia from ischemic origin: report of
a case and literature review. Acta Neurol Belg.
2005;105:214-7
1. Sajith A, Ditchfield A, Katifi HA. Extrapontine

myelinolysis presenting as acute parkinsonism.
BMC Neurology 2006; 6:33
2. Seok JI, Lee DK, Kang MG, Park JH.
Neuropsychological findings of extrapontine
myelinolysis
without
central
pontine
myelinolysis. Behav Neurol. 2007;18 :131-4
3. Panagariya A, Sureka RK, Udainiya DK.
Parkinsonism and recovery in central and
extrapontine
myelinolysis.
Neurol
India.
2005;53:219-20
4. Nair SR, Ramli NM, Rahmat K, Mei-Ling ST.
Central pontine and extrapontine myelinolysis:
Tushar et al.,
738
DOI: 10.5958/2319-5886.2014.00429.9

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
Received: 11th Apr 2014
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
Revised: 20th May 2014
Case report
A RARE CASE OF OCCUPATIONAL LUNG DISEASE TALCOSIS

Sathish Kumar M1, Dhipu Mathew2, Thilagavathy3, Aruna Shanmuganathan4, Srinivasan R5
Department of TB & CHEST Medicine, Meenakshi Medical College, Hospital and Research Institute, Enathur,
Kanchipuram, Tamilnadu, India.
*Corresponding author email: ruzansathish@gmail.com
ABSTRACT
Talcosis/ Talcpneumoconiosis is one of the rarer forms of magnesium silicate induced lung disease, It usually
occurs in the fourth decade and affects people working in talc related industries like roof, shingle, pharmaceutical
companies, talcum powder industries, electric ceramics, rubber industry etc. We report a case of talc
pneumoconiosis/talcosis in a 51yr old male who presented with breathlessness and dry cough for the past 5 yrs and
progressively worsening for the past 5 days. Who was working in a talcum powder manufacturing company for
>28yrs in the packaging section. The diagnosis was possible by history, clinical examination, Chest X-ray,
PFT/DLCO, HRCT chest, Bronchoscopy & Trans bronchial lung biopsy showing interstitial fibrosis.
Keywords: Talcosis, Pneumoconiosis, Interstitial fibrosis
INTRODUCTION
Talcpneumoconiosis is one of the rarer forms of
occupational lung diseases. The International Labour
Organization has defined pneumoconiosis as the
accumulation of mineral dust in the lungs and the
tissue reaction to its presence.1Themost common
occupational lung diseases in India are silicosis,
asbestosis, by sinosis, bagassosis and coal worker
pneumoconiosis.2
In 1896 Thorel reported the first case of talcosis.3Talc
is a hydrated magnesium silicate. Talcosis is one of the
rarer forms of silicate induced lung diseases most
commonly in the fourth decade in persons working in
industries like roof industry, shingle industry,
asphalting industry, cosmetics, toilets, electric
ceramics, tiles, rubber industry, accumulator plates,
leather finishing, fertilizers, paper industry, textile
industry, and also used as an agent for pleurodesis.4
Industrial hygiene and personal protective measures
plays a vital role in prevention of occupational lung
diseases. We report a case of talcosis in a person
working in a talcum powder manufacturing company

in the packing section. This case is a pure form of
occupational lung disease due to talcum powder
exposure.
CASE REPORT
A 51 year old male was admitted in chest ward at
Meenakshi Medical College and Research Institute,
with complaints of dry cough for 5yrs which was
progressively worsening for the past 5 days and
complaints of breathlessness for the past 2 years,
which is of grade 1MRC [Medical Research Council],
and progressively worsening and increased for the past
5days which is of grade 3 MRC. The cough is mostly
dry and there is no diurnal and postural variation
associated complaints are loss of appetite and sleep.
No history of hemoptysis, orthopnea, paroxysmal
nocturnal dyspnea, wheeziness and chest pain.
His occupational history revealed he was working in a
talcum powder manufacturing company in the
739
Satish et al .,
packaging section for more than twenty eight years.

He was working 8hrs/day and for 6days/week with no
personal protective measures. The type of work
involved is crushing of the raw material into powder
which is then subsequently packed and supplied.
Patient is diabetic for the past 3yrs and not on regular
treatment, there is no history of Anti Tuberculous
Treatment, he is not an asthmatic, hypertensive and
non smoker.
For general physical examination patient was
moderately built and moderately nourished,
tachypneic with RR>28, grade 2 clubbing present,
there is no pallor, Icterus, cyanosis, lymphadenopathy
and pedal edema. Blood pressure and pulse were
normal. On auscultation of the respiratory system
revealed B/L end inspiratory Velcro crackles were
heard in mammary, inter scapular, infra scapular
region and scattered wheeze was present.
Cardiovascular, Abdomen and CNS system
examination were all normal.
Investigations: Complete haemogram showed an
elevated total count with neutrophilicleucocytosis,
blood sugar, renal and liver function tests were normal
and there was no induration on mantoux test.
Microbiological investigations on sputum for AFB
smear and culture were negative.
Radiological imaging was done Chest xray (fig-1)
showed B/L diffuse reticulo nodular pattern more in
the upper and mid zone, a non homogenous nodular
opacity was noted in right mid zone. B/L
hilarprominence was present with conglomerulate
nodules, fiber-optic strands and B/L hyperinflation
were present.
Fig 2: HRCT Chest showing a conglomerulate nodule in

the apicoposterior segment with reticulonodular
opacities.
High Resolution Computed Tomography chest

showed diffuse reticulo nodular opacities,
predominantly in the right upper, middle lobe and left
upper lobe, fibrotic strands with pleural tags(fig-2) in
the apical andconglomerulate nodules in anterior
segment of right upper lobe(fig-3) and superior
segment of left lower lobe, empysematous changes in
B/L lower zones(fig-4) and mildly prominent
pretracheal and subcarinallymphnodes.
Fig 3: HRCT Chest showing, a.emphysematous

changes and b.interstitial reticular pattern.
Fig 1: X-ray Chest PA shows b/l hyperinflation and

diffuse reticulo nodular pattern with nodular opacity
Fig 4: HRCT Chest showing a conglomerate

noduleinthe right apical segment.
740
Satish et al .,
Six minute walk test5 was done for this patient total
distance covered is 290meters, baseline spo2 is 92%
post test is 88%, MRC baseline is 1 and post test is
2.ECHO findings are normal Lv function, normal
PAP.
PFT shows restriction with severe small airway
obstruction and DLCO showed 50% reduction.
Bronchoscopy with Transbronchial lung biopsy
revealed interstitial fibrosis, in bronchial wash for
AFB and culture were negative however
Candidaalbicans was grown. Biopsy specimen could
not be sent for electron microscopic examination to
detect talc crystals due to unavailability of the electron
microscope in our hospital.
DISCUSSION
The occurrence of occupational lung diseases is
decreasing due to improvements and awareness in
occupational health in recent years. Talc
pneumoconiosis is a rarer form of occupational lung
disease. Talc is a heterogenous group of hydrated
magnesium silicate that are commonly found in
mineral deposits containing other minerals like
carbonates, quartz, amphiboles and serpentines6with
multiple uses as a lubricant and filter in cosmetics,
paper, rubber manufacturing, paints, building
materials, leather finishing, fertilizer industry, ferrous
and non ferrous castings, textile industry, and also
used as an agent for pleurodesis. Cosmetic talc should
be free of asbestos, but industrial grades may contain it
as well as other minerals such as quartz etc., hence
should be carefully handled.
The first case of talcpneumoconiosis was reported by
Thorel in 1896 and the first fatal case due to massive
aspiration of baby powder in 1954 by Cless and
Anger.2 There are only a few reports of pulmonary
talcosis associated with talcum powder use.
Four different forms of pulmonary disease by talc have
been described: 1.Talc associated with silica particles
in mine workers (talco silicosis), 2. Talc associated
with asbestos fibers (talco-asbestosis), 3.inhalation of
cosmetic talc (talcosis) is uncommon, 4. Intravenous
administration of talc which is commonly seen.7
Clinical manifestations of talcosis consist of dry
cough, dyspnea and can progress to pulmonary
fibrosis, pulmonary artery hypertension, corpulmonale
and death. When fine particles of talc dust are
deposited in the lungs, macrophages that ingest the
dust particles will set off an inflammation response by
releasing tumor necrosis factors, interleukin-1,

leukotriene B4 and other cytokines. In turn, these
stimulate fibroblasts to proliferate and produce
collagen around the talc particle, thus resulting in
fibrosis and the formation of the nodular lesions.
Talc miners have shown to have an increased risk of
pleural plaques, diffuse pulmonary fibrosis and lung
cancer. There is no evidence that exposure to talc is
carcinogenic unless associated with fibrous tremolite.
Talc may also initiate broncho constrictive episodes
when inhaled by babies and is of course one of the
means by which intravenous drug abusers accidentally
kills them. The pure form of talc has relatively fewer
health effects on humans, but talc contaminated with
asbestos, especially asbestos, particulates that are
longer than 5 m with a length-to-width ratio of 3:1 or
more, causing severe health problems. 8 Inhalation of
asbestos can result in a chronic inflammatory
response.
In this case the company did not provide any personal
protective measures to the workers and there was no
education about the nature of work was given.
Patients coworkers also suffered by these same
complaints and few of them died who were having >
30 years exposure.
Fraser and Pare9 reported a case of a young woman
who had inhaled large quantities of talc from her hands
during a postpartum depression. When seen, she had
dyspnea on exertion for several months and interstitial
infiltrates were reported on chest roentgenograms. The
diagnosis was established by open-lung biopsy. Gould
and Barnardo8 reported a case of a- seven-year- old
girl who had acute respiratory distress after
accidentally inhaling large quantities of powdered talc.
Chronic bronchiectasis developed in this child and
pulmonary function studies had all the features of both
obstructive and restrictive defects.
The high-resolution computed tomography (HRCT)
finding of small centrilobular nodules associated with
heterogeneous conglomerate masses containing
high-density amorphous areas, with or without
panlobular emphysema in the lower lobes, is highly
suggestive of pulmonary talcosis.10-11
Confirmation of talcosis is by open lung biopsy and
demonstration of bifringent talc crystals in fluoresence
electron
microscopy.
The
characteristic
histopathologic feature in talc pneumoconiosis is the
striking appearance of birefringent, needle-shaped
particles of talc seen within the giant cells and in the
741
Satish et al .,
areas of pulmonary fibrosis with the use of polarized

light in light microscope, and other methods are
radiographic
fluorescence
scanning
electron
microscopy and energy dispersions radiographic
spectroscopy can demonstrate talc crystals (fig-5). In
Our patient the biopsy specimen could not be
subjected for electron microscopic study due to
technical issues. However diagnosis of talcosis was
made in our case of strong clinical history (mainly
occupational exposure), radiological imaging studies
and biopsy findings of interstitial fibrosis.
6.
7.
8.
9.
10.
11.
Fig 5: Lung biopsy specimen and electron microscopic
view of bifringent talc crystals.8
CONCLUSION
test. ATS committee on proficiency standards for

clinical pulmonary function laboratories. Am J
Respir Crit Care Med 2002; 166(1): 111-17
Paoletti L, Caiazza S, Donelli G, Pocchiari F.
Evaluation by electron microscopy techniques of
asbestos contamination in industrial, cosmetic,
and pharmaceutical talcs. Regul
Toxicol
Pharmacol.1984;4(22): c235.
Fraser RG, Pare JAP: Diagnosis of Diseases of the
Chest. Philadelphia. WB Sauinders, 1978, vol 2;
2nd ed:1189-95
Gamble JF, gibbs GW. An evaluation of the risks
of lung cancer and talcosis from exposure to
amphibole fragments. Regul Toxicol Pharmacol
2008;52:s154-58
Abraham JL: Diagnostic applications of scanning
electron microscopy andmicroanalysis in
pathology. Israel J Med Sci 1979; 15:716-22.
Feigin DS. Talc: Understanding its manifestations
in the chest. AJR AmJ Roentgenol.1986; 146;
295301.
Edsonmarchiori,
silvialourenco,
Taisa
Davausgasparetto. Springer lung pulmonary
talcosis. imaging findings lung.2010;188(2):16571
Although various cases of talcosis have been reported,

our case is reported because of rare exposure to pure
talc as an occupational hazard. Hence, early diagnosis
and recognition of these underlying diseases is
important in order to institute personal protective
measures and avoidance of exposure in the industrial
settings.
Conflict of interest; Nil
REFERENCES
1. International labour office (ILO). Guidelines for
the use of ILO, occupational safety and Health
series, no .48, ILO Geneva.1980,124-26
2. Gamble J, Greife A, Hancock J, An epidemiologic
study of a group of talc workers. Ann occu phyg.
1977;26(3):841-59
3. Gouild SR, Barnardo DE: Respiratory distress
after talc inhalation. Br J Dis Chest 1972;
66:230-233.
4. Leigh J, Macaskill P, Mandryk J, Global burden of
diseases and injuries due to occupational factors.
Epideomology 1999;10:301-09
5. ATS statement: guidelines for the six minute walk
742
Satish et al .,
DOI: 10.5958/2319-5886.2014.00431.7

&
Health Sciences
www.ijmrhs.com
Received: 17th Mar 2014
Volume 3 Issue 3
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
Accepted: 22ndApr 2014
Case report
VENTRICULAR ARRHYTHMIAS IN PATIENTS OF ATRIAL FIBRILLATION TREATED WITH

FLECAINIDE: A CASE REPORT
*Barman M1, Djamel B2
1
Specialist Cardiology, Al Ahli Hospital, Doha. Qatar

Consultant Interventional Cardiologist, Al Ahli Hospital, Doha, Qatar
*Corresponding author email:drbarman@yahoo.com

ABSTRACT
Purpose: Flecainide is a class 1C antiarrhythmic drug, especially used for the management of supraventricular
arrhythmia. Flecainide also has a recognized proarrhythmic effect in all age groups of adult patients treated for
ventricular tachycardia. It is used to treat a variety of cardiac arrhythmias including paroxysmal fibrillation,
Paroxysmal Supraventricular tachycardia and ventricular tachycardia. Flecainide works by regulating the flow
of sodium in the heart, causing prolongation of the cardiac action potential. The proarrhythmic effects however
noted are not widely reported. Case report: We report a case of paroxysmal atrial fibrillation with structurally
normal heart who was treated with oral Flecainide. Despite subjective improvement and no adverse events [QTc
prolongation] a repeat holter detected him to have multiple short non sustained ventricular arrhythmias. Results:
Development of ventricular arrhythmias, salvos &non sustained ventricular tachycardia after a month of initiation
of oral Flecainide detected by 24 hours ECG holter lead to discontinuation of Flecainide and subsequent early
electro physiological studies and successful ablation. Conclusion: Initiation of oral Flecainide in a case of atrial
fibrillation with subjective improvement and regular ECG monitoring, no QTc prolongation can still lead to
development of dangerous ventricular arrhythmias. A cautious approach and thorough investigations and follow
up are recommended.
Key words: Flecainide; Ventricular arrhythmias; Atrial fibrillation.
INTRODUCTION
Atrial fibrillation (AF) is the most common
arrhythmia in clinical practice and its prevalence is
increasing. Over the last 25 years, flecainide has been
used extensively worldwide. Flecainide is a class 1C
antiarrhythmic drug used especially for the
management of supraventricular arrhythmias like
atrial fibrillation (AF)1 and its capacity to reduce AF
symptoms and provide long-term restoration of sinus
rhythm (SR) has been well documented.2 It causes
rate- dependent slowing of the rapid sodium channel
slowing phase 0 of depolarization and in high doses
inhibits the slow calcium channel.2 Flecainide also
Barman et al.,
slows conduction in all cardiac fibers, increasing

conduction times in the atria, ventricles, atrioventricular node and His-Purkinje system. Flecainide
can also cause myocardial depression. In overdose
cases, flecainide can induce life treating ventricular
arrhythmias and cardiogenic shock3
CASE REPORT
We Report a case seen and managed by Cardiology
department, AL Ahli Hospital. Mr. RJN, 44 years
male was diagnosed with paroxysmal atrial
fibrillation in May 2013 and was under beta blockers
and acetyl salicylic acid. He was reviewed in our
748
hospital in September 2013 because of his disturbing

symptoms of palpitations and fatigue. Beta blockers
were stopped and he was started with Flecainide
(50mg BD) and Dabigatran (110mg BD) with the
possibility of electrical cardioversion later if required.
Regular follow ups were done and he reported
subjective improvement starting after 3 days. Periodic
ECG done did not show any QTc prolongation. He
was reassessed with holter after one month of
Flecainide treatment and found to have multiple short
episodes of ventricular arrhythmias [salvos and nonsustained ventricular tachycardia] while still
remaining in paroxysms of atrial fibrillation.
Thereafter he was admitted to CCU and flecainide
was stopped. He was switched back to Beta blockers
and again reassessed with holter after a week which
showed persistent atrial fibrillation with no
ventricular tachyarrhythmia.
Risk Profile: No hypertension or diabetes.
Nonsmoker.
Physical examination: 110/70 mm of Hg, PR
102/minute irregular. No evidence of heart failure.
ECG: Initial: Atrial fibrillation, rate ~110/minute.
On beta blockers currently.
With Flecainide:
Paroxysmal AF with multiple
nonsustained ventricular arrhythmias.
Fig 1. Ventricular arrhythmias on holter
Barman et al.,
ECHO: Atrial fibrillation, Normal LV dimensions

and systolic function.
He underwent electrophysiological studies and was
successful isolation of all four pulmonary veins for
paroxysmal atrial fibrillation with termination of
focal site for AF initiation near mid/proximal
coronary sinus roof.
DISCUSSION
Pharmacological treatment for atrial brillation:
Pharmacological cardioversion of AF can be achieved
using a number of drugs with different
pharmacological properties, including disopyramide,
procainamide, quinidine (all class IA), ecainide,
propafenone (both class IC), dofetilide, ibutilide,
sotalol, and amiodarone (all class III). Currently, the
most commonly used drugs for chemical
cardioversion are ecainide, sotalol, and amiodarone.
Little difference is observed between the routes of
administration for cardioversion rates, although
intravenous administration results in faster
conversion. Indeed, in patients with recent onset AF,
successful cardioversion is reported in 80% of cases
with oral therapy, rising only to 90% with
1
intravenous
administration
.Unfortunately,
recurrence of AF is common, often requiring longterm drug therapy to improve maintenance of sinus
rhythm. For most current antiarrhythmic agents, the
relapse rate is at least 50% during the rst year 2-5
although slightly better gures are seen with
dofetilide6 and amiodarone7,8. A number of studies
have also demonstrated that ecainide and
propafenone are effective drugs for preventing AF
recurrence 9-11. The effectiveness of ecainide is
comparable to quinidine, but with fewer side
effects12. In contrast, propafenone is more effective
for maintenance of sinus rhythm than quinidine. It is
as effective as sotalol13, 14. Generally, however, class
IC drugs are preferred to class IA drugs in view of
their better safety prole12, 13. The success of
electrical cardioversion for AF has been quoted as
between 75 and 93%, although this depends on left
atrial size and co-existing structural heart disease, and
ultimately on the duration of AF15-17. Where there is
some concern about a successful restoration of sinus
rhythm (for example, previous cardioversion failure
or early recurrence of AF), concomitant amiodarone
or sotalol can be used pre-cardioversion to improve
749
the success of electrical cardioversion18.Such an

approach is advocated by the ACC/AHA/ESC
guidelines on AF management2.The frequency of
recurrence of AF after electrical cardioversion is
high, and maintenance therapy with antiarrhythmic
drugs such as amiodarone or sometimes b-blockers is
somewhat useful to prevent AF relapses1. B-blockers
are very effective at controlling ventricular rate and
also may reduce the risk of AF recurrence following
successfulcardioversion
(whether
spontaneous,
pharmacological, or electrical) and are currently used
as rst-line prophylactic agents in paroxysmal AF. Bblockers have also been shown to reduce the
frequency of post-operative AF, although sotalol
(which also has class III effects) appears to be the
most effective in this setting. As AF commonly
coexists with hypertension or congestive heart
failure, b-blockers may also be part of conventional
therapy in such patients. Rate-limiting, nondihydropyridine calcium channel blockers (diltiazem,
verapamil) are frequently used to optimize rate
control where b-blockers are contraindicated or
ineffective. An intravenous b-blocker (for example,
esmolol or metoprolol) or rate-limiting calcium
antagonists (diltiazem, verapamil) are indicated
where urgent pharmacological rate control is
required. Intravenous amiodarone is a useful
alternative in situations where the administration of
b-blockers or calcium antagonists is not feasible, such
as in the presence of heart failure. All current class
IA, IC, and III antiarrhythmic drugs have signicant
side effects. This includes non-cardiovascular effects
(e.g. pulmonary brosis and thyroid dysfunction with
amiodarone), and of particular importance, the risk of
life-threatening ventricular proarrhythmia including
TdP in up to 5% of patients19, 20Most of these
antiarrhythmic drugs prevent or terminate AF by
altering the function of potassium or sodium channels
within the atrial cells. Blockade of potassium
channels may prolong ventricular repolarization
and hence, the refractory period resulting in QTinterval prolongation. Given the risk of severe
proarrhythmia, the safety prole of many current
antiarrhythmic drugs is far from ideal.
From the early twentieth century, drug therapy has
played an important role in the management of atrial
arrhythmias. Quinidine was the rst antiarrhythmic
used to successfully restore and maintain sinus
rhythm in atrial brillation (AF). Subsequently, a
Barman et al.,
large number of other drugs have become available.

Although the efcacy of many of these agents is
impressive, side effects are a frequent occurrence.
Amongst the most worrying side effects are QTinterval prolongation and risk of proarrhythmia,
including torsade de pointes (TdP) 21
Flecainide, a class 1C anti-arrhythmic agent,
depresses the rate of depolarization of cardiac action
potentials producing a membrane stabilizing action. It
is a very effective anti-arrhythmic agent against
supraventricular arrhythmias, nevertheless flecainide
is contraindicated in patients with structural heart
disease because it increased mortality22. The
proarrhythmic effect of flecainide may be related to
promoting a reentry in ventricular tissue. The
phenomenon is due to a rate-dependent blockade of
rapid sodium channels slowing phase 0 of
depolarization and an inhibition of the slow calcium
channel 23. In cases of overdose, the mortality with
class IC agents has been reported to approach 22%.
Conduction disturbances began with widening of
QRS complex which can rapidly progress to
ventricular
tachycardia,
electromechanical
dissociation and asystole leading to cardiac arrest.
Despite the large number of available antiarrhythmic
agents, signicant QT-interval prolongation and risk
of severe proarrhythmia, including torsade de pointes,
limit pharmacological opportunities in the
management of atrial arrhythmias. The risk of
proarrhythmia has been demonstrated in class I and
class III drugs, but signicant variability has been
observed between agents of the same class.
Electrophysiological drug effects found to be
important in the etiology of proarrhythmia include
QT- interval prolongation through selective blockade
of the delayed rectifying potassium current (IKr),
early afterdepolarizations, transmural dispersion of
repolarization, and a reverse rate dependence.
Interestingly, less proarrhythmic potential is seen or
anticipated with agents that are able to block multiple
ion channels and those with atrial selectivity, despite
moderate QT prolongation. This observation has
helped steer the development of newer drugs, with
some promising preliminary results.
CONCLUSION
In conclusion, despite the large number of
antiarrhythmic agents that are currently available,
modern cardiology is still waiting for the introduction
750
of new efcient and safe drugs for the treatment of

atrial arrhythmias. The ideal antiarrhythmic agent
must efciently cardiovert AF patients and prevent
relapses without proarrhythmic potential. To achieve
this, it seems that such drugs should be atrial
selective, should have multi ion-channel effects,
should not increase
transmural dispersion of
repolarization, should not produce early after
depolarization , and should not exhibit reverse usedependency.
ACKNOWLEDGEMENT
I would like to thank Aaranya Dev Barman for proof
reading, computer typing and internet search on the
topic.
REFERENCES
1. Hersi A, Wyse DG. Management of atrial
brillation. Curr Probl Cardiol 2005; 30:175233.
2. Fuster V, Ryden LE, Cannom DS, Crijns HJ,
Curtis AB, Ellenbogen KA et al. ACC/AHA/ESC
2006 Guidelines for the Management of Patients
with Atrial Fibrillation: a report of the American
College
of
Cardiology/American
Heart
Association Task Force on Practice Guidelines
and the European Society of Cardiology
Committee for Practice Guidelines (Writing
Committee to Revise the 2001 Guidelines for the
Management of Patients With Atrial Fibrillation):
developed in collaboration with the European
Heart Rhythm Association and the Heart Rhythm
Society. Circulation 2006; 114:e257e354.
3. Courand PY, Sibellas F, Ranc S, Mullier
A, Kirkorian G, Bonnefoy E. Arrhythmogenic
effect of flecainide toxicity. Cardiol J. 2013;
20(2):203-5.
4. Roy D, Talajic M, Dorian P, Connolly S,
Eisenberg MJ, Green M et al. Amiodarone to
prevent recurrence of atrial brillation. Canadian
trial of atrial brillation investigators. N Engl J
Med 2000; 342:91320.
5. Waldo AL. Management of atrial brillation: the
need
for
affirmative
action.
AFFIRM
investigators. Atrial brillation follow-up
investigation of rhythm management. Am J
Cardiol 1999; 84:698700.
Barman et al.,
6. Pedersen OD, Bagger H, Keller N, Marchant B,

Kober L, Torp-Pedersen C. Efcacy of dofetilide
in the treatment of atrial brillation-utter in
patients with reduced left ventricular function: a
Danish investigations of arrhythmia and mortality
on dofetilide (diamond) sub study. Circulation
2001; 104:2926.
7. Affirm. First Antiarrhythmic Drug Sub study
Investigators. Maintenance of sinus rhythm in
patients with atrial brillation: an AFFIRM sub
study of the rst antiarrhythmic drug. J Am
CollCardiol 2003; 42:209.
8. Wyse DG, Waldo AL, DiMarco JP, Domanski
MJ, Rosenberg Y, Schron EB et al. A comparison
of rate control and rhythm control in patients with
atrial brillation. N Engl J Med 2002; 347:1825
33.
9. Anderson JL, Gilbert EM, Alpert BL, Henthorn
RW, Waldo AL, Bhandari AK et al. Prevention
of symptomatic recurrences of paroxysmal atrial
brillation in patients initially tolerating
antiarrhythmic therapy. A multicenter, doubleblind, crossover study of ecainide and placebo
with Trans telephonic monitoring. Flecainide
Supraventricular Tachycardia Study Group.
Circulation 1989; 80:155770.
10. Pietersen AH, Hellemann H. Usefulness of
ecainide for prevention of paroxysmal atrial
brillation
and
utter.
Danish
NorwegianFlecainide Multicenter Study Group.
Am J Cardiol 1991; 67:713-17
11. A randomized, placebo-controlled trial of
propafenone in the prophylaxis of paroxysmal
supraventricular tachycardia and paroxysmal
atrial brillation. UK Propafenone PSVT Study
Group. Circulation 1995; 92:255057.
12. Naccarelli GV, Dorian P, Hohnloser SH, Coumel
P. Prospective comparison of ecainide versus
quinidine for the treatment of paroxysmal atrial
brillation/utter. The Flecainide Multicenter
Atrial Fibrillation Study Group. Am J Cardiol
1996; 77:53A59A.
13. Lee SH, Chen SA, Chiang CE, Tai CT, Wen ZC,
Wang SP et al. Comparisons of oral propafenone
and quinidine as an initial treatment option in
patients with symptomatic paroxysmal atrial
brillation: a double-blind, randomized trial. J
Intern Med 1996; 239:25360.
751
14. Reimold SC, Cantillon CO, Friedman PL,

Antman EM. Propafenone versus sotalol for
suppression of recurrent symptomatic atrial
brillation. Am J Cardiol 1993; 71:55863
15. Gallagher MM, Guo XH, Poloniecki JD, Guan
YY, Ward D, Camm AJ. Initial energy setting,
outcome and efciency in direct current
cardioversion of atrial brillation and utter. J
Am CollCardiol 2001; 38:1498504.
16. Lundstrom T, Ryden L. Chronic atrial brillation.
Long-term results of direct current conversion.
Acta Med Scand 1988; 223:5359.
17. Dittrich HC, Erickson JS, Schneiderman T,
Blacky
AR,
Savides
T,
Nicod
PH.
Echocardiographic and clinical predictors for
outcome of elective cardioversion of atrial
brillation. Am J Cardiol 1989; 63:1937
18. Singh SN, Singh BN, Reda DJ, Fye CL,
Ezekowitz MD, Fletcher RD et al. Comparison of
sotalol versus amiodarone in maintaining stability
of sinus rhythm in patients with atrial brillation
(Sotalol-Amiodarone Fibrillation Efcacy Trial
[Safe-T]). Am J Cardiol 2003; 92:46872
19. Friedman PL, Stevenson WG. Proarrhythmia.
Am J Cardiol 1998; 82: 50N58N.
20. Sanguinetti MC, Jurkiewicz NK. Two
components of cardiac delayed rectier K
current. Differential sensitivity to block by class
III antiarrhythmic agents. J Gen Physiol 1990;
96:195215.
21. Eduard Shantsila, Timothy Watson, and Gregory
YH Lip, Drug-induced QT-interval prolongation
and proarrhythmic risk in the treatment of atrial
arrhythmias. Europace. 2007: 9 (suppl 4): iv37iv44
22. The Cardiac Arrhythmia Suppression Trial
(CAST) Investiga- tors. Preliminary report:
Effect of encainide and flecainide on mortality in
a randomized trial of arrhythmia suppression
after myocardial infarction. N Engl J Med, 1989;
321: 40612.
23. Krishnan SC, Antzelevitch C. Flecainide-induced
arrhythmia in canine ventricular epicardium.
Phase 2 reentry? Circulation, 1993; 87: 56272
Barman et al.,
752
DOI: 10.5958/2319-5886.2014.00432.9

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th
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Copyright @2014
th
ISSN: 2319-5886
Case report
PYREXIA DUE TO MEGALOBLASTIC ANEMIA: AN UNUSUAL CASE

*Singh PS1, Vijay Verma2, Vidyasagar3, Granth Kumar4
1
Professor & Head, 2Assistant Professor, 3 Lecturer, 4Lecturer, Dept of Medicine, UP Rural Institute of Medical
Sciences & Research, Saifai, Etawah, UP, India
*Corresponding Author email: premshanker0354@gmail.com
ABSTRACT
Postmenopausal vegetarian female presented with short febrile illness associated with generalized weakness
Clinical and investigative findings evidenced megaloblastic anemia Since none of investigations could pinpoint
the cause for pyrexia and patient did not respond to empirical antibiotic and conservative antimalarial therapy,
megaloblastic anemia itself was suspected to be cause for febrile episode Patient was treated with parenteral B12
and oral folic acid for megaloblastic anemia and she responded to it and became afebrile within 72 hours.
Subsequently megaloblastic anemia was correlated to be cause of febrile illness.
Keywords: Megaloblastic anemia, Pyrexia of unknown origin, B12 and folic acid deficiency
INRTODUCTION
Megaloblastic anemias are a group of disorders which
are most commonly caused by nutritional deficiencies
of either vitamin B12 or folate or both, inherited
disorders of DNA synthesis or following certain drug
therapy. Megaloblastic anemia rarely may be a cause
of pyrexia which may be difficult to differentiate
from pyrexia of unknown origin (PUO) even after
exhaustive laboratory investigations.1 The aim of the
present article is to highlight megaloblastic anemia as
a rare cause of fever and create awareness amongst
practicing physicians about a treatable condition.
CASE PRESENTATION
A 55 year old postmenopausal vegetarian female
presented with complaints of fever, nausea, vomiting
and dry cough of 7 days duration. The fever was
intermittent, mild to moderate grade and associated
with generalized weakness, easy fatigability and loss
of appetite. There was no history of burning
micturation, arthralgia or skin rash. There was no
history of recent travel to malarial endemic zone or

exposure to any patient suffering from communicable
diseases e.g. Tuberculosis, etc.
Clinical examination revealed a pulse rate of 110 per
minute, blood pressure of 120/70 mm Hg (supine x
right arm) and oral temperature of 101F. She had
moderate pallor and mild icterus. There was no
significant lymphadenopathy, dyspnoea or skin
rashes. Examination of cardiovascular, respiratory,
abdomen and nervous system examinations were
within normal limits. X-ray chest was within normal
limit and ultrasound abdomen revealed no significant
abnormalities.
Routine hematological evaluation revealed low
hemoglobin (Hb); 6 G%, low hematocrit; 18% , low
total leukocyte count (TLC): 4000c/mm with
P60L37E02M01,
low
total
platelet
count
(TPC):100000 c/mm, high reticulocyte count: 3.5%
and high mean corpuscular volume (MCV): 115 fL .
Peripheral smear showed pancytopenia with a
moderate degree of anisopoikilocytosis and a good
number of macrocytes, macro-ovalocytes and
753
Singh et al.,
hypersegmented neutrophils. Bone marrow aspiration

from the left anterior superior iliac spine revealed
marked hypercellularity, florid erythroid hyperplasia
with an altered myeloid to erythroid ratio (1:2),
megaloblastic dyspoiesis and numerous giant
metamyelocytes. Perl stain showed adequate marrow
iron stores without any ring sideroblasts. There was
no evidence of blast prominence, granulomas,
hemoparasites, malignancy or increased reticulin. The
bone marrow morphology was suggestive of
megaloblastic anemia which was confirmed
biochemically by low levels of serum vitamin
B12 59.6 pg/mL ( reference; 180- 900), low folic acid
3.9 ng/mL ( reference; 4-24) and markedly elevated
serum lactate dehydrogenase (LDH) 7500 IU/L
(reference: 225-420]. The patients routine liver and
renal function tests were within normal limits except
for mild unconjugated hyperbilirubinemia with total
bilirubin: 4.2 mg/dL (reference: 0.2-1.2), direct: 0.4
mg/dL and indirect: 3.8 mg/dl. Her routine
microbiological
(blood
culture),
serological,
autoimmune, inflammatory (serum C-reactive
protein) and endocrine work-up were negative.
Normal viral titre along with the absence of reactive
lymphocytes in the peripheral smear ruled out the
possible viral etiology.
Pending laboratory investigative reports and in view
of neutropenia, the patient was started empirically
with broad spectrum intravenous antibiotics
(Ceftriaxone) which was given for a period of 05
days, but the patient continued to be febrile even after
05 days of antibiotic. Thereafter she was given course
of antimalarial ( Artisunate) for period of five days.
But she still continued to remain febrile, even after 10
days of hospitalisation and none of investigations
were contributory to determine the cause of fever
Therefore, in view of the positive laboratory
investigations pointing towards megaloblastic anemia
along with the absence of any positive contributory
findings, the patient was started on injection vitamin
B12: 1000g IM and folic acid: 5mg oral daily.
Pyrexia settled on day 13th day of hospitalisation
within 03 days of vit B12 and folic acid treatment
which was further continued and in view of low Hb,
she was transfused with 2 units of packed cell
volume. The patient improved symptomatically after
being prescribed vitamin B12 and folic acid
supplements, following which the patient was
discharged in a stable condition. Routine follow-up at
two months showed normalization of vitamin B12 and

folate levels as well as improvement in hematological
parameters (hemoglobin; 12gm, MCV; 87fL) without
any febrile episode.
DISCUSSION
Dramatic response to nutritional supplements in our
case supports that the pyrexia was attributable
directly to megaloblastic anemia secondary to vitamin
B12 and folate deficiency rather than anything else, as
was ruled out by appropriate available diagnostic
modalities. As per the modified Petersdorf
criteria2, FUO is defined as: 1) a temperature
exceeding 1010 F 2) duration of the fever of more
than three weeks and 3) evaluation of three outpatient
visits or three days in hospital. Our patient satisfied
two out of the three criteria (1 and 3).
In a study by Tahlan etal3, the incidence of low-grade
fever in nutritional megaloblastic anemia varied from
28% to 60%. Another study from Northern India
described persistent low-grade fever in 70% of the
females with B12 and/or folate deficiency.4
McKee5 reviewed 122 patients of nutritional
megaloblastic anemia for the presence of pyrexia
(temperature100F) and found that 40% pyrexia was
attributable solely to the megaloblastic disease. In the
majority of the patients, fever subsided 24 to 72 hours
after supplementation of vitamin B12 and/or folate,
suggesting the rapid correction of ineffective
hematopoiesis.. Negi et al6 reported a case of
anicteric male with pyrexia (100.20f), bicytopenia and
macrocytosis
secondary to B12 deficiency
Singanayagam et al.7 reported a young male with
pyrexia of 6 weeks duration , severe pancytopenia
and mild hyperbilirubinemia secondary to folate
deficiency. The present report described a case of
megaloblastic anemia in a postmenopausal vegetarian
female patient who presented with low-grade pyrexia,
pancytopenia, macrocytosis (115 fL), very high LDH:
7500 IU/L (reference range: 225-420 IU/L) and mild
unconjugated hyperbilirubinemia secondary to
combined deficiency of B12 (59.6 pg/mL) and folate
(3.9 ng/mL). Pyrexia subsided within 03 days after
initiation of supplementation therapy.
The exact cause of fever in megaloblastic anemia is
unknown and at present, seems more hypothetical
rather than conclusive. An association of pyrexia and
megaloblastic anemia appears to be causal, whereas
in other types of anemias, it seems more coincidental.
754
Singh et al.,
Megaloblastic anemia is a panmyelosis characterized

by
hypercellular
marrow
and
ineffective
hematopoiesis.
Premature
destruction
of
hematopoietic
precursors
possibly
releases
intracellular substances which might function as
systemic pyrogens. As was suggested by the
researchers, dramatic response to B12 and/or folate
supplementation (within 72 hours) strongly supports
the above said hypothesis. Alternatively, the defective
oxygenation at the thermoregulatory centre of the
hypothalamus might be the explanation for pyrexia.
However, lack of correlation between neurological
manifestation and pyrexia in megaloblastic disease
does not support this theory5 Moreover studies have
also shown that a rise in temperature might cause
depletion of folate stores, both in red blood cells and
serum, leading to disturbance of folate metabolism.
So whether pyrexia is the cause of folate deficiency
or vice versa is yet to be fully understood
4. McKee LC Jr. Fever in megaloblastic

anemia. South Med J. 1979;72:142324
5. Manuel Kevin,Padha Somnath,Varghese Renu.
Pyrexia in a patient with megaloblastic anemia. A
case report and literature review. N Engl J
Med. 2000;343:195158
6. Negi RC, Kumar J, Kumar V, Singh K, Bharti V,
Gupta D, et al. Vitamin B12 deficiency
presenting as pyrexia. J Assoc Physicians
India. 2011;59:37980
7. Singanayagam A, Gange N, Singanayagam A,
Jones H. Folate deficiency presenting as pyrexia:
a case report. Cases J. 2008;1:275
CONCLUSION
All patients presenting with pyrexia, megaloblastic
anemia and cytopenia should be carefully evaluated
for possible vitamin B12 and folate deficiency in order
to prevent delay in diagnosis, initiate appropriate
curative treatment and unnecessary use of antibiotics
and other empirical medication
ACKNOWLEDGEMENT
We extend our sincere thanks to Mrs Aala Singh for
her support and encouragement to enable us to
complete this article well in time
Source of funding: None
Conflict of Interest: None declared
REFERENCES
1. Kucukardali Y, Oncul O, Cavuslu S, Danaci M,
Calangu S, Erdem H, et al. The spectrum of
diseases causing fever of unknown origin in
Turkey: a multicenter study. Int J Infect
Dis. 2008;12:7179
2. Tahlan A, Bansal C, Palta A, Chauhan S.
Spectrum and analysis of bone marrow findings
in anemic cases. Indian J Med Sci. 2008;62:336
39
3. Khanduri U, Sharma A. Megaloblastic anaemia:
prevalence and causative factors. Natl Med J
India. 2007;20:17275
755
Singh et al.,
DOI: 10.5958/2319-5886.2014.00433.0

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ISSN: 2319-5886
th
Case report
PERIORBITAL DERMOID CYST

*Nigwekar Shubhangi P1, Gupte Chaitanya P2, Chaudhari Sagar V2, Kharche Prajakta S2
1
Professor, 2Post Graduate Student, Department of Ophthalmology, Rural Medical College, Loni, Maharashtra
*Corresponding author email: shubhangi2501@yahoo.in

ABSTRACT
Dermoid cysts are a developmental benign choristomas, which are congenital lesions representing normal tissue/s
in an abnormal location. These consist of ectodermal and mesodermal elements, lined with epithelium and contain
hair with other skin structures. Periorbital dermoid cyst is commonly located at lateral one third of the eyebrow. It
is asymptomatic however school going child suffers from social stigma. So its surgical excision for cosmetic
purpose becomes necessary. Excision also prevents bony remoulding and recurrent inflammatory responses due to
leakage of cyst contents. In this article we are presenting a six years old male child having periorbital dermoid in
lateral right eyebrow. The intact dermoid cyst was excised surgically and sent for histopathological examination,
which confirmed the diagnosis of dermoid cyst. We highlight the merits of early surgical intervention, even in an
asymptomatic periorbital dermoid cyst.
Keywords: Periorbital dermoid, Surgical excision of periorbital dermoid.
INTRODUCTION
Dermoid cysts are a developmental benign
choristomas, which are congenital lesions
representing normal tissue/s in an abnormal location.
These consist of ectodermal and mesodermal
elements, lined with epithelium and contain hair with
other skin structures.1 These results from the
sequestration of embryonic epithelium between
orbital bones, usually along suture lines.2 They are
often evident soon after birth.3 Depending on location
dermoid cysts are divided into superficial periorbital
and deep orbital dermoid cysts. The most common
location of the dermoid cyst is lateral one third of the
eyebrow.4 Periorbital dermoid cysts can be
asymptomatic or present in infancy with mild to
moderate ptosis depending upon the size while,
orbital deep dermoids present in adults with proptosis
and asymptomatic school going child suffers from
social stigma. Leakage of contents may lead to
inflammatory response & fibrosis around cyst. Thus,
in asymptomatic patient also complete surgical

excision with an intact capsule of periorbital dermoid
cyst is needed not only for the cosmetic benefit, but
also to prevent the recurrence and the acute
inflammatory response due to leakage of cyst
contents. Here we are presenting the surgical
management of a periorbital dermoid, located in
lateral part of right eyebrow and involving upper
eyelid, in a six year old male child.
CASE REPORT
A 6 years old male child accompanied by parents
came to Pravara Rural Hospital, with painless,
progressive swelling at lateral part of right eyebrow
involving the right upper eyelid since childhood. (Fig
1)
General and systemic examination of the patient was
normal. Family history was not contributory. Slit
756
Shubhangi et al.,
lamp examination and direct ophthalmoscopy showed

normal anterior and posterior segment in both eyes.
Visual acuity in both eyes was 6/6 (snellens chart).
Extraocular movements were full and free in all
directions of gaze.
In local examination the swelling was 110.5cm
present just below the right eyebrow at the lateral
1/3rd of the upper eyelid and there was mild
mechanical ptosis. The swelling was soft, non tender,
freely mobile, non adherent to the overlying skin.
Assessment of posterior aspect of mass with a finger
was possible.
Patient had normal Haemogram. Radio-imaging
showed normal chest X-ray and X-ray orbit showed
no bony involvement. CT scan ruled out the
intracranial extension.
Fig 4: Histology showing cyst hair follicle, sebaceous

and sweat glands.
Fig 5: First post-operative day.
Fig 1: Dermoid cyst Located in lateral aspect of right

upper eyelid
With proper consent and anaesthetic fitness complete

excision of intact dermoid cyst was carried out under
general anaesthesia (Fig 2) and the intact cyst (Fig 3)
was sent for histopathological examination which
showed lining of squamous epithelium with dermal
elements as hair follicles, sebaceous, and sweat
glands which confirmed the diagnosis of dermoid
cyst (Fig 4). First post operative day event full. (fig
5) Follow up examination showed no inflammatory
response or any recurrence for 18 months.
DISCUSSION
Fig
2:
Surgical
excision
of
dermoid
in-toto.
Dermoid cysts account for 3-9% of orbital tumours in

children and are one of the most common noninflammatory space-occupying orbital lesions in the
paediatric population.5,6 Dermoid cysts results from
the sequestration of embryonic epithelium between
orbital bones. They are usually present along suture
lines.
Dermoid cyst contains sebaceous fluid, keratin,
calcium and cholesterol crystals with adnexal
structures as hair follicles, sebaceous glands and
sweat glands.7
Fig 3: Removal of Intact dermoid.
757
Shubhangi et al.,
Incomplete removal of cyst can result in recurrence.

Superficial periorbital dermoids may present at
superolateral aspect of the orbit at frontozygomatic
suture or rarely medially along frontoethmoidal or
frontolacrimal sutures.8
In superficial periorbital dermoids palpation of
posterior aspect of dermoid cyst rules out the
posterior extension and its localized nature without
extension is diagnosed clinically. However, inability
to palpate the posterior aspect of periorbital dermoid
cyst, radio-imaging becomes mandatory to know the
posterior extent of lesion where a CT imaging helps.
In all orbital dermoids radio-imaging is necessary. 9,10
MRI is another imaging modality for dermoid cysts
which gives the added advantage of non exposure to
radiation.
Though periorbital dermoid cyst is asymptomatic, it
requires surgical excision not only for cosmetic
reason and social stigma in school going child but
also to prevent complications like (i) bony
remoulding (ii) exaggerated inflammatory response
due to leakage of its content and (iii) malignant
transformation.11,12
In our case, since the periorbital dermoid cyst was
localised, non adherent to surrounding tissue or
orbital margins, complete excision with an intact wall
of dermoid cyst was carried out, which gave good
post operative cosmetic result and 18 months
postoperative follow up showed no postoperative
inflammation or recurrence
CONCLUSION
Periorbital dermoid cyst presenting in early
childhood, though asymptomatic, has to be removed
surgically for better cosmetic effect, to prevent bony
remoulding, to prevent cyst leakage inflammatory
response and to prevent rare teratogenic-malignant
transformation in later life. Complete excision with
an intact wall of dermoid cyst give good post
operative result.
REFERENCES
1. Gupta M. Epibulbar Dermoid in
Goldenhar
Syndrome. DJO 2013;23(4):311-312.
2. Shields J, Shields C. Orbital Cysts of Childhood

Classification,
Clinical
Features
and
Management. Surv Ophthalmol. 2004;49(3):28199
3. Ahuja R. Orbital Dermoids in Children. Semin
Ophthalmol. 2006;21:207-11
4. Yeola M, Joharapurkar SR, Bhole AM, Chawla
M, Chopra S, Paliwal A. Orbital floor dermoid:
An unusual presentation. Indian J Ophthalmol
2009;57:51-52
5. Srikanth R. Orbital dermoid mimicking a
monocular elevation deficiency. Oman J
Ophthalmol. 2012; 5(2): 118-20
6. Pfeiffer RL, Nicholl RJ. Dermoid-epidermoid
tumours of orbit. Arch Ophthalmol 1948;46:39
7. Gandhi N, Syed NA, Alen R. Dermoid Cyst.
EyeRounds.org. posted July 23, 2010;
8. Jakobiec FA, Bonanno PA, Sigelman J.
Conjunctival adnexal cysts and dermoids. Arch
Ophthalmol 1978;96:1404-9
9. Sherman RP, Rootman J, Lapoint JS. Dermoids clinical presentation and management. Br J
Ophthalmol 1984;68:642-52
10. Yanoff M, Fine BS. Ocular pathology. 3rd ed.
Philadelphia: Harper and Row; 1988. p. 520
11. Abou-Rayyah Y, Rose GE, Konrad H, Chawla
SJ, Moseley IF. Clinical, radiological and
pathological examination of perioculardermoid
cysts: evidence of inflammation from an early
age. Eye. 2002;16(5):507-12
12. Karatza EC, Shields CL, Shields JA, Eagle RC.,
Jr Calcified orbital cyst simulating a malignant
lacrimal gland tumor in an adult. Ophthal Plast
Reconstr Surg. 2004; 20:3979
ACKNOWLEDGEMENT
We are thankful to HOD (Professor) Dr. Dongre and
Professor
Dr.
Karle
for
providing
the
histopathological report and slide.
758
Shubhangi et al.,
DOI: 10.5958/2319-5886.2014.00434.2

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rd
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ISSN: 2319-5886
th
Case report
PYOGENIC GRANULOMA: POST OPERATIVE COMPLICATION OF PTERYGIUM SURGERY

*Nigwekar Shubhangi P1, Chaudhari Sagar V2, GupteChaitanya P2, BankarMahima S2
1
Professor, 2Post Graduate Student, Department of Ophthalmology, Rural Medical College, Loni, Maharashtra,
India
*Corresponding author email: shubhangi2501@yahoo.in
ABSTRACT
The most common complication of pterygium surgery is postoperative recurrence. These recurrences are reduced
with conjunctival autograft technique. However, with this graft surgery, post surgical wound-healing response
may be more intense and may lead to Tenons granuloma or pyogenic granuloma or stitch granuloma. These
granulomas are treated either with frequent topical instillation of steroid eye drops or surgical excision. A 27
years old lady presented with painless, progressive nodular mass after her left eye pterygium excision with
conjunctival autograft surgery on her follow up of 15th post operative day. The clinical diagnosis was postoperative granuloma and patient underwent excisional biopsy. Histopathology confirmed the diagnosis of
pyogenic granuloma. The patient was treated with postoperative tapering topical steroid drops and there was no
recurrence even after 1 year.
Keywords: Pyogenic granuloma, Pterygium exicision with conjunctival autograft.
INTRODUCTION
CASE REPORT
Pterygium is a common degenerative condition of the

subconjunctival tissue. It affects temporal or nasal
perilimbal area, enchroaches over cornea and leads
cosmetic and visual disturbances.1 Surgical excision
is the treatment of choice. The most common
complication of pterygium surgery is postoperative
recurrence. These recurrences are reduced with
conjunctival autograft.2 However with this graft
surgery, post surgical wound-healing response may
be more intense and may lead toTenons granuloma
or pyogenic granuloma or stitch granuloma. These
granulomas are treated either with frequent topical
instillation of steroid eye drops or surgical excision.
Here we are describing the surgical management of
the post pterygium surgery -pyogenic granuloma.
A 27 years old lady came to Pravara Rural Hospital,

Loni for first follow up after her left eye progressive
pterygium excision with conjunctival autograft
surgery. She presented with nasal limbal mass in the
operated eye, which was painless and gradually
increasing in size without any visual problems.
On local examination, left eye showed a vascularized,
pedunculated, nontender and well-defined pinkish
mass measuring approximately 5 5 mm close to the
nasal limbus on the graft bed (Fig- 1).
Ophthalmological examination of both eyes showed
normal anterior and posterior segments except this
mass. General and systemic examination of the
patient was noncontributory. Patient was sero
negative for HIV. Clinical diagnosis was
postoperative granuloma and patient underwent
excisional biopsy of the lesion under local anesthesia
759
Shubhangi et al.,
(Fig- 2). The mass was sent for histopathology which

revealed granulation tissue lined by squamous cells
suggestive of a pyogenic granuloma (Fig- 3). Patient
was advised for instillation of topical steroids for a
month in tapering dose. One year follow up showed
no recurrence (Fig- 4).
Fig 1: Post pterygium surgery-Pyogenic granuloma
Fig 2: Surgical excision of pyogenic granuloma
Fig 3: Histopathology of pyogenic granuloma showing

granulation tissue lined by squamous cells
Fig 4: Postoperative
DISCUSSION
Pterygium is a degenerative condition of the
subconjunctival tissue. It proliferates as vascularized
granulation tissue, invade the cornea, destroy the
superficial layer of the stroma and Bowmens
membrane and it is covered by conjunctival
epithelim. These patients present with complaints of
redness, lacrimination, foreign body sensation,
growing mass in the eye and a rarely visual
disturbance in the form of blurring and diplopia. 3
There are two types of pterygium. Progressive
pterygium and atrophic pterygium.
Progressive
pterygium presents as thick, fleshy, reddish mass with
prominent blood vessels and atrophic pterygium
presents as thin, pale, flat whitish mass devoid of
fresh blood vessels and leads to ocular surface
disorder.4
If the pterygium is small atrophic and without any
symptoms, it is best left alone with lubricant drops
and periodic follow up. In case of progressive
pterygium surgeries like pterygium excision with bare
sclera, excision with conjunctival autograft, excision
with Mitomycin-C (MMC) application and excision
with Amniotic Membrane Transplant (AMT) are
considered as treatment modalities. 5
Pterygium excision with only bare sclera leads to
recurrence up to 80-90 %. Conjunctival autograft or
AMT
or MMC application
prevent these
6
recurrences. However post operative complications
like pyogenic granuloma can occur with these
surgeries due to excess intra-operative tissue
handling.
Hirst LW showed the incidence of pyogenic
granuloma up to 40%, 7.9%, and 9.2% when bare
scleral excision is accompanied by an intraoperative
application of MMC, conjunctival autograft, and
AMT, respectively.7
The formation of granuloma occurs within 1 week
after pterygium surgery as a proliferative,
inflammatory lesion. Localized suture irritation and
excessive tissue handling intra-operatively are some
of the causes for the granuloma formation.8,9
Small granulomas may spontaneously resolve with
the frequent application of topical steroids, but larger
granulomas require the simple surgical excision.
Histologically, they have a lining of stratified
squamous epithelium which is ulcerated at one focus.
The subepithelial area shows granulation tissue
760
Shubhangi et al.,
composed of proliferating small capillaries fibroblast

and infiltration by chronic inflammatory cells mainly
lymphocytes.10
In our present case the patient was young; pterygium
was in progressive stage, which was a high risk factor
for postoperative recurrence. To reduce the
recurrence, we performed the pterygium exicision
with conjunctival autograft using absorbable 8-0
vicryl suture. Intraoperative excess handling of tissue
and conjunctival autograft suture irritation might have
lead to pyogenic granuloma after the conjunctival
autograft surgery.
Complete surgical excision of the pyogenic
granuloma and post-operative frequent topical
steroids gave good results and there was no
postoperative recurrence for 1 year.
6. Levy RL, Naidu S, Jacobson L. Safety and

efficacy of the technique of complete Tenon's
membrane excision and mitomycin C in
pterygium
surgery.
Eye
Contact
Lens.2005;31:105-08
7. Hirst LW. The treatment of pterygium. Surv
Ophthalmol. 2003;48:145-80
8. Fryer RH, Reinke KR. Pyogenic granuloma: a
complication of transconjunctival incisions. Plast
Reconstr Surg. 2000;105:1565-66
9. Bekibele CO, Baiyeroju AM, Olusanya BA.
Pterygium treatment using 5-FUas adjuvant
treatment compared to conjunctiva autograft. Eye
(Lond).2008;22(1):31-34
10. Varssano D, Michaeli-Cohen A, Loewenstein A.
Excision of pterygium and conjunctivalautograft.
Isr Med Assoc J. 2002; 4:1097-100
CONCLUSION
Pyogenic granuloma may present after pterygium
excision with conjuntival autograft technique.
Surgical excision of large pyogenic granuloma with
post-operative topical steroids gives good result
without recurrence.
ACKNOWLEDGEMENT
We thank Professor and HOD Dr. Dongre and
Professor Dr. Karle from Department of pathology,
RMC, Loni for providing the histopathological report.
REFERENCES
1. Janey L. Wiggs, David Miller, Yanoff & Duker
Ophthalmology; Cornea and ocular surface
disorders, Mosby Elsevier;2009:3rded:248-49
2. John E Sutphin , JR, AAO. External disease and
cornea section 8,LEO;2007-2008;429-32
3. Ramanjit Shhota, Radhika Tandon. Parsons
diseases of the eye; disease of conjunctiva,
Elsevier; 2007:20th edition: 175-177.
4. Jack
J
Kanski,
Brad
Bowling.clinical
ophthalmology a systemic approach; conjunctiva,
Elsevier;2011:7th edition;163-66
5. Frau E, Labetoulle M, Lautier-Frau M,
Hutchinson S, Offret H. Corneo-conjunctival
autograft transplantation for pterygium surgery.
Acta Ophthalmol Scand. 2004; 82:59-63
761
Shubhangi et al.,
DOI: 10.5958/2319-5886.2014.00435.4

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Volume 3 Issue 3
Coden: IJMRHS
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th
Revised: 5 Jun 2014
ISSN: 2319-5886
Case report
AN UNUSUAL CASE OF INTRACYSTIC PAPILLARY CARCINOMA OF BREAST WITH INVASIVE

COMPONENT
*Suryawanshi Kishor H1, Nikumbh Dhiraj B2, Damle Rajshri P1, Dravid NV3, Tayde Yogesh4
1
Assistant Professor, 2Associate Professor, 3Professor and Head, 4Assistant Lecturer, Department of Pathology,
JMFs ACPM Medical College, Dhule, Maharashtra
*Corresponding author email: ompathologylab@gmail.com
ABSTRACT
Papillary carcinoma of the breast is a rare malignant tumor, constituting 1-2 % of breast neoplasms mostly
affecting elderly postmenopausal women. Intracystic (Encysted) papillary carcinoma (IPC) is a rare distinct entity
with slow growth rate and overall favourable prognosis regardless of whether it is in situ alone or associated with
invasive component. Treatment modalities vary from conservative surgery to radical surgery with or without
adjuvant therapy depending upon the associated component (DCIS or invasive) of the tumor.
Herein, we report a case of 55-year-old female presented with a painless lump in the right breast. FNAC yielded
haemorrhagic fluid with scanty cellularity of atypical ductal epithelial cells. Patient underwent wide local
excision. The final histopathological diagnosis revealed intracystic papillary carcinoma associated with invasive
ductal carcinoma, NOS type.
Keywords: Intracystic, Invasive, Papillary carcinoma, Wide local excision.
INTRODUCTION
Intracystic (encysted) papillary carcinoma (IPC) is a
rare distinct entity of breast cancer, accounting for 12 % of all breast tumors.1 IPC usually occur in an
elderly postmenopausal woman with the subtle
clinical presentation of painless breast lump and
bloody nipple discharge. Papillary lesions of breast
are categorised into invasive and noninvasive
papillary carcinoma by Carter et al.2 Noninvasive
papillary carcinoma is further subdivided into a
diffuse form of papillary variant of DCIS and a
localised form of solitary intracystic (encysted)
papillary carcinoma. IPC are further classified into
pure IPC or associated with DCIS or with invasive
component. 3 We report a case of IPC with invasion in
an elderly woman along with the brief review of
literature.
CASE REPORT
A 55-year-old postmenopausal woman presented with
a lump in the right breast since 6 months. Initially the
lump was small in size, gradually enlarged to present
size. There was no history of nipple discharge or
family history of breast carcinoma. Local
examination revealed a lump measuring 4cmsx3cms
in the right upper and outer quadrant. Overlying skin
was not involved. There was no evidence of axillary
lymphadenopathy.
Contralateral
breast
was
unremarkable. FNA cytology was repeatedly
haemorrhagic and smears revealed few clusters of
atypical ductal epithelial cells admixed with cyst
macrophages and biopsy was advised. Laboratory
investigations, including the haematological and
biochemical parameters were within normal limits
762
Kishor et al.,
Ultrasonographic findings revealed a complex cystic

mass with solid component. Patient underwent wide
local excision of right breast lump without sentinel
lymph node biopsy. On gross examination excised
specimen measured 6cmsx4cmsx2cms, externally
well circumscribed. Cut section showed a cystic mass
4cmx3cm filled with friable papillary greyish white
tumor mass. The surrounding areas show irregular
greyish white tumor measuring 2cmsx1cm. The
margins of excised mass appeared grossly uninvolved
by tumor [Fig-1].Histopathological examination
showed tumor arranged in papillary pattern, at places
showing solid and trabecular pattern with individual
tumor cells showing hyperchromatic pleomorphic
nuclei with prominent nucleoli and moderate
eosinophilic cytoplasm [Fig-2]. Mitotic count was 810 /hpf. Focal areas of necrosis evident in between
papillae. [Fig-2] Surrounding breast parenchyma
showed an invasive component with the morphology
of infiltrating duct carcinoma (NOS) type [Fig-3].
Final histopathological diagnosis given was
Intracystic papillary carcinoma with invasive
component. Immunohistochemistry (IHC) study
revealed tumor cells were negative for estrogen (ER),
progesterone (PR), Her2neu and smooth muscle actin
(SMA) revealing absent myoepithelial cell layer.
Proliferative index (Ki 67) was 80% suggestive of
high grade tumor [Fig-4]. Patient was referred for
adjuvant treatment and was free from disease after 6
months of follow up.
Fig 2: Histopathological examination of tumour

Showing tumour arranged in papillary pattern, at
places showing solid and trabecular pattern with
individual tumour cells showing hyperchromatic
pleomorphic nuclei with prominent nucleoli and
moderate eosinophilic cytoplasm.
Mitotic count was 8-10 /hpf. Focal areas of necrosis
were evident in between the papillae. [Haematoxylin
and Eosin, X 100]
Fig 3: Surrounding breast parenchyma

Showed invasive component with morphology of
infiltrating
duct
carcinoma
(NOS)
type
[Haematoxylin and Eosin, X 100]
Fig 1: Gross photograph of excised specimen

Wide local excision specimen, 6x4x2 cms, externally
well circumscribed. Cut section-- cystic mass 4x3
cms filled with friable papillary greyish white tumour
mass with infiltration in the surrounding breast
parenchyma.
Fig 4: IHC study revealed tumour cells

IHC study revealed tumour cells were negative for
estrogen (ER), progesterone (PR) and smooth muscle
actin (SMA) revealing absent myoepithelial cell layer.
Proliferative index (Ki 67) was 80%. [ IHC, X 100]
763
Kishor et al.,
DISCUSSION
The papillary carcinoma of the breast is characterized
by a papillary growth pattern with thin fibrovascular
stalk lined by neoplastic epithelial cells. Malignant
papillary neoplasms of the breast consist of a wide
spectrum of lesions that include ductal carcinoma in
situ arising in intraductal papilloma, papillary DCIS,
encapsulated papillary carcinoma, solid papillary
carcinoma and invasive papillary carcinoma. Lack of
myoepithelial cell layer within papillae differentiates
benign papillary neoplasm from malignant papillary
neoplasm.4 Intracystic papillary carcinoma is a
solitary, centrally located malignant papillary
proliferation within an encysted or cystically dilated
duct. Traditionally, IPC was considered to be a
variant subtype of DCIS but a recent review of
literature shows its association with DCIS or invasive
breast cancer in about 40% cases.5 In IPC (pure)
form, solid papillary tumor is confined within a cystic
dilated duct without DCIS or invasion into the
surrounding tissue. A minority of IPC may be
associated with invasive component without features
of papillary tumor but rather show morphological
features of invasive ductal carcinoma, not otherwise
specified type.4 Similar morphological features were
noted in our case. Detection of associated pathology
(DCIS or invasive form) is the mainstay as prognosis
and treatment modalities depend upon these
associated lesions.6 Usually intracystic papillary
breast cancers reveal low or intermediate nuclear
grade without necrosis. They show strong
immunopositivity for estrogen and progesterone
receptor and negativity for Her2 neu.7 IPC associated
with invasive carcinoma are of high nuclear grade
and necrosis. In our case IHC study showed ER, PR,
SMA, Her2 neu negativity with high proliferation
index. Histopathological findings revealed high
nuclear grade and necrosis.
Papillary carcinoma of breast generally occurs in
elderly postmenopausal women aged 63- 67 years.
Clinically, patient presents with palpable mass or
bloody nipple discharge. It may also manifest as
asymptomatic lesion identified at screening
mammography.
Radiological findings may show on mammography as
an oval or lobulated, circumscribed lesion and on
USG as a complex cystic mass with solid component
but differentiation between invasive and papillary
DCIS is difficult and requires histopathological

confirmation.8
Cytological diagnosis may be inconclusive as aspirate
from cystic component yield haemorrhagic fluid,
most of the time which could be negative for
malignancy and give false negative result as occurred
in our case. Ultrasound guided core biopsy of
suspected intracystic mass has been suggested by
many authors to differentiate benign from malignant
papillary neoplasms but failed to distinguish in situ
from invasive papillary carcinoma as invasion is
found in peripheral part of the tumor.9 Tomonori et
al10, also suggested necessity of excisional biopsy .
FNA and core needle biopsy have not found
sufficient most of the time.
Review of literature showed no definitive guidelines
for treatment of IPC. In case of IPC alone, IPC with
DCIS and IPC with invasion complete surgical
excision of the tumor with clear surgical margins is
the recommended surgical management.11 Sentinel
lymph node biopsy may be alternative to full axillary
dissection in patient with IPC and associated invasive
carcinoma.12 Wide local excision was performed in
our case in view of atypical ductal epithelial cells on
cytology and sentinel lymph node biopsy was not
done. Data published in many articles recommends
adjuvant radiotherapy for IPC associated with
invasion and or DCIS. Fayanju et al6 concluded that
most important factor determining use of
radiotherapy and endocrine therapy is associated
pathology and patients with pure IPC were less likely
to undergo radio and endocrine therapies.
Although rare, IPC has an excellent prognosis. The
largest reported study of 917 cases carried out on IPC
patients found no difference in the relative
cumulative survival rate in the patients with IPC
alone or associated invasive cancer followed up at 10
years.13
CONCLUSION
To conclude, intracystic papillary carcinoma is a rare
breast malignancy with favourable prognosis. We are
presenting this case of IPC with an invasive
component in view of its rarity with favourable
prognosis.
764
Kishor et al.,
REFERENCES
1. Rosen PP. Papillary carcinoma. In: Rosens
Breast Pathology. Philadelphia,Pa: Lippincott
Raven 1997;335-354.
2. Carter D, Orr SL and Merino MJ. Intracystic
papillary carcinoma of the breast. After
mastectomy, radiotherapy or excisional biopsy
alone. Cancer.1983; 52(1) 14-19
3. Baykara M, Coskun U, Demirci U, Yildiz R,
Benekli M, Cakir A, et al. Intracystic papillary
carcinoma of the breast: one of the youngest
patient
in
the
literature.
Med
Oncol.2010;27(4):142728.
4. Pal SK, Lau SK, Kruper L, Nwoye U,
Garberoglio
C, Gupta RK,et al. Papillary
Carcinoma of the Breast: An Overview. Breast
Cancer Res Treat. 2010; 122(3): 63745
5. Calderaro J, Espie M, Duclos J, Giachetti S,
Wehrer D, Sandid W, et al. Breast intracystic
papillary carcinoma: an update. Breast J.
2009;15(6) 63944
6. Fayanju OM, Ritter J, Gillanders WE, Eberlein
TJ, Dietz JR, Aft R, et al. Therapeutic
management of intracystic papillary carcinoma of
the breast: the roles of radiation and endocrine
therapy. Am J Surg . 2007;194(4):497500
7. Leal C, Costa I, Fonseca D, Lopes P, Bento MJ,
Lopes C. Intracystic (encysted) papillary
carcinoma of the breast: a clinical, pathological,
and
immunohistochemical
study.
Hum
Pathol.1998; 29(10):1097104
8. Liberman L, Feng TL and Susnik B. Case 35:
Intracystic papillary carcinoma with invasion.
Radiology. 2001;219(3) 78184
9. Benkaddour YA, Hasnaoui SE, Fichtali K, Fakhir
B, Jalal H, Kouchani M, et al . Intracystic
Papillary Carcinoma of the Breast: Report of
Three Cases and Literature Review. Case
Reports. Obstetrics and Gynecology. 2012,
Article ID 979563:1-4
10. Tomonori K, Takayuki S, Tadahiko T, Hojo S,
Akashi-Tanaka S, Murata Y. Clinical and
pathological features of intracystic papillary
carcinoma of the breast. Surgery Today. 2009;

39(1): 58.
11. Harris K, Faliakou E, Exon D, Nasiri N, Sacks
NP and Gui GP. Treatment and outcome of
intracystic papillary carcinoma of the breast.Br J
Surg1. 1999;86(10):1274.
12. Solorzano CC, Middleton LP, Hunt KK, Mirza
N, Meric F, Kuerer HM, et al. Treatment and
outcome of patients with intracystic papillary
carcinoma of the breast. American Journal of
Surgery. 2002;184(4):36468
13. Grabowski J, Salzstein SL, Sadler GR, Blair S.
Intracystic papillary carcinoma: a review of 917
cases. Cancer 2008;113(5) 91620
765
Kishor et al.,
DOI: 10.5958/2319-5886.2014.00436.6

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Volume 3 Issue 3
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Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 5 Jun 2014
Case report
TETANUS TRISMUS IN A 2 YEAR OLD CHILD: CASE REPORT

*Menon Narayanankutty Sunilkumar, Vadakut Krishnan Parvathy
Department of Pediatrics, Amala Institute of Medical Sciences, Amala Nagar, Thrissur, Kerala, India
*Corresponding author email:sunilsree99@gmail.com
ABSTRACT
Tetanus is still a major cause of mortality and morbidity in developing countries. It occurs in children mainly in
the unimmunized, due to parental ignorance and objection to vaccination. This potentially fatal disease caused by
a neurotoxin, tetanospasmin released from wounds infected with Clostridium tetani, an anaerobic grampositive
bacillus. As tetanus becomes less common, cases are likely to be misdiagnosed or go unrecognized. In this case
report, we present a case of tetanus in a partially immunized 2 year old girl who presented with trismus. She was
treated with the recent recommendations and adequate supportive care. Detection of tetanus at a very early stage
can favor lifesaving interventions. Trismus, infected wound and partially immunized/unimmunized status of a
child were the key features leading to the prompt diagnosis and early treatment.
Keywords: Tetanus, trismus, tetanospasmin, tetanus toxoid
INTRODUCTION
Tetanus is a preventable neurologic disease caused by
the bacterium Clostridium tetani, spores of which live
in the soil, dust, and environment and infect via a cut
or puncture in the skin or mucosa. Unfortunately,
cases of tetanus are still common in many parts of the
world. The World Health Organization estimates that
58,000 newborns died of tetanus in 2010.1 It is found
commonly in warm climates and highly cultivated
rural areas 2 and remains a life-threatening disease
that continues to have a high prevalence in
developing countries due to social problems such as
poor education of the parents when parents are not
ready to immunize their children. C. tetani spores
germinate to produce an exotoxin, tetanospasmin,
which causes rigidity and spasms of voluntary
skeletal muscles 2. The different forms of tetanus are
neonatal, generalized, localized and cephalic. The
most common forms are generalized and neonatal
tetanus.2 It usually occurs in neonates and persons
aged older than 65 (as a result of waning immunity)
whereas, the incidence occurs equally in male and

female persons.3 Neonatal tetanus remains a
significant problem in developing countries due to
poor umbilical stump hygiene and lack of maternal
antibody as a result of inadequate immunization.4
Prevention is possible with immunization. The
regimen varies depending on patients age and prior
exposure to tetanus vaccine.5 Incidence varies with
level of immunization within a population. The
highest rates are in resource-poor countries with nonuniversal immunization practices and in economically
deprived nations due to poor immunization and
unhygienic practices whereas, it is a forgotten disease
in developed countries since many practicing primary
care physicians have not seen a single case in their
career. The diminished incidence in the developed
world may probably due to the introduction of
primary vaccination.5 The management of tetanus
aims at removing the source of tetanospasmin,
neutralising circulating toxin, and providing adequate
766
Menon et al.,
supportive care for muscle spasms, respiration and

autonomic instability and timely recognition of this
serious disease helps in better outcome.5,6
CASE REPORT
A 2-year-old girl, first sibling from a poor
socioeconomic family of a non-consanguineous
couple, admitted in the Department of Paediatrics,
Amala Institute of Medical Sciences, Thrissur,
Kerala, with difficulty in opening of her mouth since
3 days. History revealed that she was partially
immunized; only BCG and 0 dose of OPV were
taken. On examination, she had lockjaw (Fig.1), low
grade fever and healing pyoderma on her upper and
lower limbs.
feeds started on 3rd day and also packed red blood

cell transfused on 3rd day. After completion of 10days
of intravenous antibiotics, she was discharged on day
11 with improvement in clinical conditions (Fig.2) on
multivitamins, hematinics and deworming drugs with
an advice to follow-up for catch up vaccination.
Fig 2: Child after 10 days of treatment.

DISCUSSION
Fig.1: Child on admission with trismus and sick

She was anxious, irritable, tonic bite present; spatula
test was positive, deep tendon reflexes were
exaggerated whereas, plantar response and sensorium
were normal. Systemic examinations were normal.
Tetany which usually manifest as Chvostek sign and
Trousseau sign were absent in our child. Laboratory
investigations showed hemoglobin (6.7 g/dl) with low
indices, total leucocyte count (11,550/cumm),
neutrophils (75%), lymphocytes (22%), platelets
(210000/l), ESR (35mm at1 hr); lumbar puncture
was done and CSF study was normal; and study on
blood culture and sensitivity was sterile. The
diagnosis of tetanus was made based on the trismus
and infected wound and the history of partial
immunization. She was treated with human tetanus
immunoglobulin (TIG), tetanus toxoidcontaining
vaccine, wound cleaning and injection of crystalline
penicillin for 10 days. Oral diazepam was given for
muscle relaxation. The patient did not progress to
severe generalized tetanus with autonomic instability.
She was given excellent supportive care, Ryles tube
Tetanus is caused by a neurotoxin, tetanospasmin

released from wounds infected with Clostridium
tetani, a Grampositive bacillus. 2,3 The bacteria enter
the body through cuts and abrasions to the skin, but
will multiply and transform into vegetative forms
only in an environment that is oxygen-free. Deep
puncture wounds and wounds with a lot of dead
tissue provide an oxygen-free environment for the
bacteria to grow, especially in the presence of a
foreign body, crush injury and suppurative infections.
Among the two exotoxins such as tetanolysin and
tetanospasmin produced by C. tetani, tetanospasmin
is the main toxin that gains access to the blood stream
directly or through lymphatics and ascends along the
nerves to central nervous system. The intial symptom
such as trismus can be ascribed to the ascending
spread of the toxin and its action on muscle supplied
by the cranial nerves. At the neuronmuscular junction
mainly at the presynaptic nerve terminal it prevents
the release of inhibitory neurotransmitters glycine and
gamma amino butyric acid that can also lead to
uncontrolled contraction of muscles. The descending
of the toxin explains the mechanism of generalised
rigidity and spasms.7 The diagnosis is based entirely
on clinical presentation and immunization history.
Symptoms such as trismus and risus sardonicus
appear 4 to 20 days after wound contamination.
Trismus is a firm closing of the jaw due to tonic
spasm of the muscles of mastication from disease of
767
Menon et al.,
the motor branch of the trigeminal nerve. It is usually

associated with tetanus, also called lockjaw. Risus
sardonicus or rictus grin is a highly characteristic,
abnormal, sustained spasm of the facial muscles that
appears to produce grinning. The name of the
condition derives from the appearance of raised
eyebrows and an open "grin" - which can appear
sardonic or malevolent to the lay observer - displayed
by those suffering from these muscle spasms.2,3
Depending on the severity of the disease, the painful
contractions can, in a few days or even hours, spread
to the whole body. Death can follow due to
respiratory failure.8 The differential diagnosis
includes meningitis, encephalitis and rabies (see these
terms), as well as peritonsillar abscess, medication
(phenothiazine, metoclopramide) -induced dystonic
reactions, subarachnoid hemorrhage, hypocalcemic
tetany and acute strychnine poisoning.2-,4 The
complications of tetanus are laryngospasm, aspiration
pneumonia, nosocomial infections (common because
of prolonged hospitalization), fractures of the spine or
long bones (from sustained contractions and
convulsions), acute renal failure (due to
rhabdomyolysis), pulmonary embolism, hypertension
and/or an abnormal heart rhythm (due to
hyperactivity of the autonomic nervous system) and
sudden cardiac death.3,6
Treatment of tetanus aims at airway maintenance,
prevention of further toxin absorption, relieving
clinical features like spasms, controlling autonomic
instability and antibiotics.3,9 The main method of
prevention of tetanus is by adequate immunization
using tetanus toxoid.10, 11 Measures such as cleansing
of new bites, burns, and wounds and prophylaxis with
antibiotics and tetanus immune globulin (TIG) should
be instituted if an asymptomatic, newly injured
patient is not adequately immunized.9,10 The side
effects of immunization with tetanus toxoid adsorbed
intramuscularly such as mild fever, joint pain, muscle
aches, nausea, tiredness, or pain/itching/ swelling/
redness at the injection site may occur. Rarely, other
side effects such as tingling of the hands/feet, hearing
problems, trouble swallowing, muscle weakness and
urticaria or neurologic complications. 3
Pharmacological eradication of C. tetani bacilli can
be achieved by either penicillin or metronidazole
based regimens.9 Treatment is symptomatic and aims
to control contractions with high doses of
myorelaxant drugs or even prolonged curarization
Menon et al.,
until elimination of the toxin.2,6 The role of

Benzodiazepine derivatives in the sedation and
muscle relaxation in the ICU during the course of
generalized
tetanus
has
prevented
rapid
progression.12,13 All patients should receive a
complete course of immunization with tetanus toxoid
once recovered, as the disease does not induce
protective antibodies. Bhatt et al described a case of
relapsing tetanus in a 60 year old female.7
For wounded individuals and with infected wounds
with an uncertain vaccination status, systematic
administration of specific gamma globulins prevents
the disease. 10,11 The incubation period of tetanus may
be up to several months, but is usually about eight
days.14 Symptoms usually occur within 8 to 12 days.
The risk of wound infection is constant. Prognosis is
variable. The disease lasts 2 to 4 weeks. With
mortality varying between 20 and 80%, depending on
disease severity, patient age, and availability of
intensive care facilities.2
Amornpol et al.15 identified tetanus in a 73yearold
man with symptom of locked jaw for one day. All
standard treatments were given. However, the patient
eventually progressed to severe generalized tetanus
with autonomic instability as TIG does not neutralize
toxin that has already bound to nerve endings. At this
stage, the main treatment is supportive care; early
protection of the upper airway, adequate ventilation,
control of muscle spasms, and limiting the
consequences of autonomic dysfunction which is the
most common cause of death in ventilated patients
with severe tetanus. Magnesium sulfate was
postulated by the team as the drug of choice to
control cardiovascular instability.12,15
In our case, clinical findings of trismus and infected
wound and unimmunized status of the child were key
features leading us to prompt diagnosis and emergent
treatments, including Tetanus immunoglobulin,
tetanus toxoidcontaining vaccine, wound cleaning
and antibiotics. Fortunately, the child did not progress
to severe generalized tetanus with autonomic
instability as is seen sometimes8,15 requiring further
advanced treatment.12
CONCLUSION
Tetanus is still a major cause of mortality and
morbidity in developing countries and occurs in
children mainly in the unimmunized, due to parental
ignorance and objection to vaccination. Since tetanus
768
is a very rare case, and a child with trismus is

vulnerable to progress, if missed. Physician education
is vital in detecting tetanus at a very early stage, so
further lifesaving interventions can be done and
prevent rapid clinical deterioration.
ACKNOWLEDGEMENT
The authors acknowledge the help of Dr Ajith TA,
Professor, Biochemistry, Amala Institute of Medical
Sciences, Amala Nagar, Thrissur, Kerala during the
preparation of the manuscript.
REFERENCES
1. Centers for Disease Control and Prevention, the
American Academy of Family Physicians and
the American Academy of Pediatrics. Diseases
and the vaccines that prevent them. Reviewed
2013. http://www.cdc.gov/vaccines
2. Cook TM, Protheroe RT, Handel JM. Tetanus: a
review of the literature. Br J Anaesth 2001;
87:477-87
3. Tetanus.
http://www.cdc.gov/vaccines/pubs/pinkbook/dow
nloads/tetanus.pdf
4. Roper MH, Vandelaer JH, Gasse FL: Maternal
and neonatal tetanus. Lancet. 2007; 370:1947-59
5. A VD, B J, Y C, C B, J B. Tetanus: a diagnostic
challenge in the Western world. Acta Clin Belg.
2013;68:416-20
6. Barry JD. Neurotoxic emergencies. Neurol Clin
2011; 29: 539-63
7. Bhatt A D, Dastur F D. Relapsing tetanus (a case
report). J Postgrad Med. 1981;27:184
8. Esslinger P, Kistler W, Berger TM: Severe
autonomic dysfunction in an 11-year-old girl with
generalised tetanus. Eur J Pediatr Surg. 2003;
13:209-12
9. Moran GJ. Antimicrobial prophylaxis for wounds
and procedures in the emergency department.
Infect Dis Clin North Am. 2008; 22: 117-43
10. CDC.
General
Recommendations
on
Immunization:
Recommendations
of
the
Advisory Committee on Immunization Practices
(ACIP). MMWR 2011;60(No RR 2): 360
11. Keller MA, Stiehm ER. Passive immunity in
prevention and treatment of infectious diseases.
Clin Microbiol Rev 2000; 13:602-14
12. Sutton DN, Tremlett MR, Woodcock TE, Nielsen

MS. Management of autonomic dysfunction in
severe tetanus: the use of magnesium sulphate
and clonidine. Intensive Care Med. 1990;16:7580
13. Okoromah CN, Lesi FE. Diazepam for treating
tetanus. Cochrane Database Syst Rev.
2004;1:CD003954
14. Vandelaer J, Birmingham M, Gasse F, Kurian
M, Shaw C, Garnier S. Tetanus in developing
countries: an update on the Maternal and
Neonatal Tetanus Elimination Initiative. Vaccine.
2003;21: 344245
15. Amornpol A, Imelda C, Pramil C, Hiren S, Baba
L. Trismus: The phantom menace. Journal of
Hospital Medicine. 2012; 7:218
769
Menon et al.,
DOI: 10.5958/2319-5886.2014.00437.8

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ISSN: 2319-5886
th
Revised: 7 Jun 2014
Case report
A HUGE CERVICAL FIBROID CAUSING UTEROVAGINAL PROLAPSE AN UNUSUAL

PRESENTATION, DIAGNOSTIC DILEMMA AND AN OPERATIVE CHALLENGE
*Chaithra TM1, Lokeshchandra HC2, Bhavani SY3
1
Assistant Professor, Department of Obstetrics & Gynecology, Sreenarayana Institute of Medical Sciences,
Chalakka, Ernakulam, Kerala, India
2
Professor and H.O.D, 3Senior resident, Department of Obstetrics & Gynecology, Mysore Medical College and
Research Institute, Mysore, Karnataka, India
*
Corresponding author email: drchaithralijesh@gmail.com
ABSTRACT
We report a rare case of a 35 yr Indian woman presenting with a mass per vagina since 2yrs and acute urinary
retention since one day secondary to prolapsed cervical fibroid (15x8cm) which was mimicking chronic inversion
and was making the anatomy unclear. It was managed by clear delineation of structures on the operating table.
We believe that it is the first case of its own kind as the diagnosis could only be confirmed intraoperatively.
Cervical fibroids present with varied manifestations posing difficulties in diagnosis and management. Thorough
preoperative evaluation and anticipating operative challenges and judicious treatment help in relieving the misery
for the patient.
Keywords: Mass per vagina, Prolapsed cervical fibroid, Acute urinary retention, Uterovaginal prolapse,
INTRODUCTION
Leiomyoma is the commonest of all pelvic tumors,
being present in 20% of women in reproductive age
group 30-35yrs.1 The paucity of smooth muscle in the
cervical Stroma makes leiomyomas in the cervix
uncommon.2 Though a rare entity 1-2% of them are
located in cervix and usually in the supravaginal
portion.3 Fibroids may be anterior, posterior, lateral
or central in location involving either the vaginal or
supravaginal portion of the cervix. Central cervical
fibroid expands the uterus equally in all directions
and the cavity of the pelvis is more or less filled by a
tumour, elevated on top of which is the uterus like
'Lantern on the dome of St. Paul.
Uterine fibroids are benign clonal tumours arising
from the smooth muscle cells of the uterus and
contain an increased amount of extracellular matrix
for which they are also referred as leiomyoma. Their
Chaithra et al.,
location in the cervix is not common and cervical

fibroid belongs to Type 8 category in the new
(International federation of gynecology and
obstetrics) fibroid classification system.4
Cervical mayomas with excessive growth may cause
pressure symptoms.5 They present with abdominal
mass6, incarcerated procidentia7, retention of urine,
constipation, sensation of something coming down,
foul smelling discharge per vagina and other variety
of symptoms depending on location. Usually there is
no evident menstrual abnormality associated with
cervical fibroid. A large cervical fibroid may cause
obstruction during Labour.5 Cervical leiomyoma
causing
uterovaginal
prolapse
with
thick
hypertrophied vaginal walls mimicking chronic
inversion is rare. Large fibroid arising from the
vaginal part of the cervix is often confused with
770
chronic inversion of uterus. Cervical fibroids prove

to be a challenge to the clinician in view of their
close proximity to important pelvic structures and of
their likelihood to cause complications and difficulty
in removal. Unusual presentations as in our case
pose challenge to the clinicians and have to be kept in
mind.
CASE REPORT
A 35 yr Indian woman P3L3 presented with mass
protruding from vagina since 2 yrs, gradually
increasing to present size of 15x8cm (Figure 1)
associated with foul smelling discharge and acute
urinary symptoms since one day. On examination,
she was anemic, malnourished and had a firm mass of
about 15x8cm from the introitus, which was
irreducible, congested and inflamed with surface
bleeding.
The exact origin of the mass couldnt be recognized
and cervix and external OS couldnt be located.
Ultrasonography revealed both ovaries were normal
in size and situated in the midline posterior to bladder
along with bilateral hydronephrosis but uterus
couldnt be visualized.
The differential diagnosis of infected submucous
fibroid polyp or chronic inversion was made and was
managed with continuous drainage of bladder,
parenteral antibiotics, local antiseptics and regular
dressings. Two weeks later she was posted for
surgery after correction of anemia.
Diagnostic laparoscopy before surgery revealed no
evidence of chronic inversion, intraoperatively a bold
incision was made on the posterior vaginal wall and
pouch of douglas opened, and uterus with intact
fundus was felt ruling out chronic inversion and an
intraoperative diagnosis of huge fibroid from anterior
lip of cervix was confirmed (Figure 2). The uterus
was pushed posteriorly, and vaginal wall and
uterovesical fold were opened anteriorly and bladder
was pushed up safely and steps of hysterectomy were
followed. Uterus with fibroid specimen was removed
and sent for histopathological examination (Figure 3
& Figure 4). The procedure and post operative period
were uneventful. HPE confirmed diagnosis of fibroid
and patient was discharged on 5th day.
Fig 1: Huge mass per vagina making clinical diagnosis

difficult
Fig 2: Thick posterior vaginal wall cut open, retracted

to show the uterus
Fig.3: Anatomical delineation of structures showing

uterus(*), cervical fibroid (straight arrow) and
thickened vaginal wall (curved arrow)
771
Chaithra et al.,
Fig 4: Specimen of cervical fibroid (straight arrow)

with hypertrophied vaginal wall (curved arrow) and
normal sized uterus (*)
Fig 5: Thickened vaginal wall (curved arrow) retracted

to show external OS (straight arrow) and showing
fibroid from anterior lip of cervix (*)
DISCUSSION
Differential presentations and sizes of cervical
leiomyomas have been reported in literature. The
most common presentation of fibroid is menstrual
disturbances and Dysmenorrhoea. But broad ligament
and cervical fibroids generally present with pressure
symptom like bladder and bowel dysfunction. 6-8. We
report an unusual case of huge cervical fibroid
causing uterovaginal prolapse mimicking chronic
inversion of uterus and presenting with acute urinary
retention.
Fibroids arising from supravaginal portion becoming
pedunculated and prolapsing into vagina are reported9
as against our case of fibroid arising from ectocervix
expanding the cervix, flushing with vagina and
causing uterovaginal prolapse, the hypertrophied
vaginal walls enclosing the prolapsed uterus made the
anatomy even more unclear. Utero-vaginal prolapse
can be caused by traction on to the cervix by heavy
myoma.9 Uterine prolapse refers to the uterus

descending down into the vagina. It typically
descends in stages until, at some point in time; it
actually appears at or behind introitus. Vaginal
prolapse refers to the dropping of other organs into
the vagina and each one of these organs has their own
name for this occurrence like cystocele,
cystourethrocele, rectocele & enterocele. Uterovaginal prolapse can be caused by traction on to the
cervix by heavy myoma.8 Symptoms from vaginal
prolapse include bladder weakness with urine
leakage, urinary tract infections, a feeling of
downward pressure in the vagina, pressure on the
rectum and inability to completely empty all fecal
matter. Dealing with prolapse can range from using a
pessary (a rubber device inserted into the vagina to
support the uterus in place), to surgery that repairs the
muscles and ligaments and repositions the pelvic
organs, to vaginal hysterectomy.
We would like to suggest that rare pathological
changes like fibroid expanding into cervix and vagina
with uterovaginal prolapse and hypertrophy of
vaginal wall should be kept in mind while diagnosing
and also while operating. In our case sticking on to
anatomical spaces and clear delineation of anatomy
on table helped to successfully complete the surgery
without any complications, relieving the misery of
the patient.
CONCLUSION
Although Cervical fibroid incidence is low (1-2%),
encountering a cervical fibroid in gynecology clinic
is not uncommon in gynecologists life. They present
with varied manifestations posing difficulties in
diagnosis and management. Thorough preoperative
evaluation and anticipating operative challenges and
judicious treatment help in relieving the misery for
the patient.
REFERENCES
1. Gompel C, Silverberg SG. Pathology in
Gynaecology
and
Obstetrics.
2nd
ed.
Philadelphia (PA): Lippincott; 1977. p. 184190.
2. Benign disorders of the uterine cervix. In: Alan
HD, Martin LP, editors. Current Obstetric &
Gynecologic Diagnosis & Treatment. New Jersey
(USA): Appleton & Lange; 1994. p. 713730.
772
Chaithra et al.,
3. Kumar P, Malhotra N: Tumours of the corpus

uteri. In:Jeffcoats Principles of Gynaecology.
7th Edn.; Jaypee Brothers Medical Publisher
(Pvt.) Ltd. New Delhi.2008;pp.487-516.
4. Munro MG, Critchley HO, Broder MS. FIGO
classifi cation system (PALM-COEIN) for causes
of abnormal uterine bleeding in nongravid
women of reproductive age. Int J Gynaecol
Obstet 2011:113:313
5. Lev-Toaff AS, Coleman BG, Arger PH, Mintz
MC, Arenson RL,Toaff ME. Leiomyomas in
pregnancy: Sonographic study. Radiology
1987;164: 37580
6. Basnet N, Banerjee B, Badani U. An unusual
presentation of huge cervical fibroid Koirala
Institute of Health Sciences: Kathmandu
University Medical Journal. 2005;3(10);173-74
7. Suneja A, Taneja A, Guleria K, Yadav P,
Aggarwal N, Incarcerated procidentia due to
cervical fibroid; an unusual presentation. AUST
NZJ Obstet Gynecol.2003;43:252-55
8. Neha Goel, Manisha Laddad. A Rare Case of
Giant Broad Ligament Fibroid with Cervical
Fibroid Mimicking Ovarian Tumour: Interesting
Case Report. International journal of recent
trends
in
science
and
technology.
2014;10(2):208-09
9. Gurung G, Rana A, Magar DB. Utero-vaginal
prolapse due to portio vaginal fibroma. J Obstet
Gynaecol Res. 2003;29 (3):157-59
773
Chaithra et al.,
DOI: 10.5958/2319-5886.2014.00438.X

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th
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ISSN: 2319-5886
nd
Case report
RARE ASSOCIATION OF FAHRS DISEASE WITH MULTIPLE MYELOMA: A CASE REPORT

*Tripathy KP1, Behera PK1, Dalai RK2, Misra GC3
1
Associate prof, 2Professor, 3Professor & HOD, Dept. of Medicine, KIMS, Bhubaneswar, India
*Corresponding author email: drkptripathy@gmail.com

ABSTRACT
Fahrs disease or Fahrs syndrome is a rare neurological disorder characterized by abnormal calcified deposits in
the basal ganglia and cerebral cortex. 47 years male who presented to us with progressive ataxia and Parkinsonian
symptoms was found to have extensive bilateral calcifications including bilateral basal ganglia in CT scan of the
brain. The secondary causes of intracranial calcifications were ruled out to make a clinical diagnosis of Fahrs
disease. While investigating for chronic low back pain with anemia and renal failure, high ESR and serum protein
electrophoresis showing M band was detected. On further investigation, the bone marrow study confirmed the
diagnosis of multiple myeloma. There are only few case reports of association of Fahrs disease and multiple
myeloma in literature. The case is being reported here in view of rarity.
Key words: Fahrs disease, Bilateral intracranial calcifications, Multiple myeloma, M-Band, Plasma cells.
INTRODUCTION
Fahrs disease was first described by a German
neurologist Karl Theodar Fahr in 1930 1,2 and is
characterized by abnormal deposition of calcium in
areas of brain that control movements including basal
ganglia, thalamus, dentate nucleus, cerebral cortex,
cerebellum,
sub-cortical
white
matter
and
hippocampus. The clinical pattern is variable and the
disease may be sporadic or Familial. Genetically a
locus at 14q has been suggested.3 A second locus has
been identified on chromosome 84 and third one on
chromosome 2, suggesting genetic heterogeneity in
this disease.5 The disease usually appears between the
age of 40-60 years.1 Neuropsychiatric, extrapyramidal
and cerebellar symptoms, convulsive seizures,
parkinsonian features; dementia and speech disorders
may accompany clinical manifestations. Diagnostic
criteria of Fahrs syndrome has been modified and
derived from Moskowiz et al 6 (1971), Elie et al 7
(1989) and Manyam 8 (2005) and can be stated as
follows:1. Bilateral calcification of basal ganglia
visualized on neuroimmaging. Other brain regions

may also be involved. 2. Progressive neurologic
dysfunction, which generally includes a movement
disorder and or neuropsychiatric manifestation. Age
of onset is usually in the fourth or fifth decade,
although this dysfunction may also present in
childhood. 3. Absence of biochemical abnormalities
and somatic features suggestive of mitochondrial or
metabolic disease or other systemic disorder
CASE REPORT
A 47 years Hindu male from middle socioeconomic
status, married and working as a clerk presented to us
in the Dept. of Medicine, with progressive
unsteadiness in walking and clumsiness of hands for
around three years. It was associated with memory
loss and emotional outbursts. Initially the symptoms
were slowly progressive and he was able to do his
daily activities. But he became more symptomatic
774
Tripathy et al.,
around 3 months prior to presenting to us. There was

progressive stiffness of limbs with a tremor of hands
and head nodding. Memory loss was progressing and
limb movements became slower and restricted so that
he was almost confined to a chair. Speech became
more and more dysarthric and social interaction
became more difficult. There was moderate to severe
back pain for around three months at the time of
hospitalization. Around two weeks prior to hospital
admission he was almost bed ridden because of stiff
limbs and back pain. There was no history of head
injury or seizure disorder. He was non- diabetic and
non-hypertensive, non alcoholic but occasional
smoker. His father had some movement disorder
which started at around age of 50 years and he died at
the age of 60 years. No other sibling had any
movement disorder or similar symptoms. He was
treated with vitamins and neuro-protectives from time
to time without any improvement.
On examination he was conscious, oriented, of
average body built with pulse rate of 70/ min and
regular and Blood Pressure 130/80 mm of Hg. There
was pallor but no icterus, cyanosis, clubbing or
lymphadenopathy. Pedal edema was absent and
Jugular venous pressure was not raised. On
examination of Central nervous system, he was
conscious and oriented with impaired recent memory
but intact past memory with mini mental score of 22.
Speech was dysarthric with presence of released
reflexes. There was no cranial nerve involvement or
nystagmus and motor examination revealed normal
bulk and power with tremor of hands, rigidity in both
upper and lower limbs and all deep tendon jerks in
both upper and lower limbs were brisk and plantar
was bilaterally extensor. There were cerebellar signs
in both upper and lower limbs. There was no sensory
abnormality and skull and spine examination revealed
no abnormality except tenderness over lumbar
vertebrae. Cardiovascular system, chest and abdomen
examination revealed no abnormality. With a
provisional diagnosis of parkinsonism- dementia
complex and cerebellar dysfunction he was planned
for thorough investigation.
On routine pathological tests Hb was 3.7G%, total
leucocyte count was 9,600/cmm with neutrophil 86%,
lymphocytes 12%, and eosinophil 2%. ESR was 120
mm 1st hour. Comment on peripheral smear showed
microcytic hypochromic anemia and routine
microscopic examination of urine was within normal
Tripathy et al.,
limits. Routine biochemical tests showed blood urea

62 mg/dl, serum creatinine 6.5 mg/dl, serum sodium137 meq/L, potassium 4.5 meq/L and calcium 8.9
meq/L . Fasting and postprandial plasma sugar was
112mg/dl and 148 mg/dl respectively. Serum
parathormone (PTH) was 32 ng/L (range 8-50) and
Thyroid function test was within normal limits.
Serum protein electrophoresis showed M-Band. (Fig
1) Further bone marrow study showed plasma cell
infiltration confirming diagnosis of multiple
myeloma. (Fig 2)
Fig 1: Serum protein electrophoresis showing M Band
Fig 2: Bone marrow showing plasma cells

Radiological imaging revealed hepatosplenomegally
with reduced cortical-medullary differentiation in the
kidney on ultrasonography of the abdomen and XRay of chest, skull and pelvis was normal. Non
contrast Computerised Tomography (NCCT) (Fig
3,4) scan of brain showed multiple and diffuse
calcification in bilateral basal ganglia, cerebellar
hemispheres, pons, thalamus, internal capsule and
cerebral hemispheres and diagnosis of Fahrs disease
was considered. Finally the case was diagnosed as a
case of Fahrs disease with multiple myeloma with
nephropathy and anemia. Neurological symptoms
were treated conservatively. Oncologists help was
sought for multiple myeloma and chemotherapy was
775
started. Four weeks after starting chemotherapy he

developed severe sepsis with multi-organ dysfunction
with septic shock and succumbed. Prognosis of
Fahrs disease is variable and there is no reliable
correlation between age, extent of brain calcification
and neurological deficit. Progressive neurological
deterioration is invariable and results in disability and
death.
Fig 3: CT Scan of Brain showing calcification in

bilateral basal ganglia and sub cortical white matter
Fig 4: CT scan of brain showing bilateral cortical

calcification
DISCUSSION
Fahrs disease otherwise known as bilateral
striopallido dentate calcinosis (BSPDC) or idiopathic
basal ganglia calcification is a rare neurodegenerative
disorder of unknown prevalence. This is among the
few inherited neurological conditions that lead to
progressive
dystonia,
Parkinsonism
and
neuropsychiatric manifestations. As Fahrs disease is
a progressive neurodegenerative disorder of unknown
etiology, till now there is no definite cure and

treatment is symptomatic.6
The most common presentations as per the
Fahrsdisease registry are movement disorders, which
account for about 55% of cases. Among these,
parkinsonism was seen in 57% cases, chorea was
seen in 19% cases, tremor in 8% cases, dystonia in
8% cases, athetosis in 5% cases and orofacial
dyskinesia was seen in 3% case. The other neurologic
manifestations include cognitive impairment,
cerebellar signs, speech disorders, pyramidal signs,
psychiatric features, gait disorders and sensory
changes. Various clinical conditions coming as
differential diagnosis to Fahrs disease are
Parkinsons disease, Juvenile parkinsonism, other
causes of secondary Parkinsonism like post
encephalitic parkinsonism, slow virus infection, drug
induced parkinsonism, multi-infarct dementia with
parkinsonism, Multisytem degeneration, Huntington,s
disease and Lewy Body disease7
Calcification generally develops within the vessel
wall and in the perivascular space, ultimately
extending to the neurons. Progressive basal ganglia
mineralization tends to compress the vessel lumen,
thus initiating a cycle of impaired blood flow, neural
tissue injury and mineral deposition.1 Deposits are
composed of minerals like calcium phosphate and
carbonate, glyconate, mucopolysacharide and metals
including Iron, Copper, Magnesium, Zinc,
Aluminum, silver and cobalt may also be found.8,9
Treatment
of
Fahrs
disease
is
only
symptomatic.Various drugs are used to improve
anxiety, depression, obsessive compulsive disorder
and to alleviate dystonia. Oxybutinin used for urinary
incontinence and antiepileptics for seizure.
Haloperidol and lithium carbonate may help in
psychotic symptoms. Levodopa therapy for
parkinsonism shows poor response.10-12
The etiology of this syndrome does not identify a
specific agent, but associated with a number of
conditions has been noted. Most common of which
are endocrine disorders, mitochondrial myopathies,
dermatological abnormalities and infectious diseases.
Among endocrine disorders parathyroid disturbances
are most commonly associated with Fahrssyndrome.1
The
abnormalities
include
idiopathic
hypoparathyroidism, secondary hypoparathyroidism,
pseudohypoparathyroidism,
pseudo-pseudo
hypoparathyroidism and hyperparathyroidism. Other
776
Tripathy et al.,
conditions associated with Fahrs syndrome are

Kenny Caffey Syndrome Type-1, Mitochondrial
myopathies like Kearn-Sayre Syndrome and MELAS
(myopathy, encephalopathy, lactic acidosis and
stroke), adult onset neurodegenerative conditions like
neuroferritinopathy and polycystic lipomembranous
osteodysplasia with sclerosing leukoencephalopathy,
dermatological conditions like lipoid protenosis,
Intrauterine or perinatal infections like toxoplasmosis,
rubella, CMV or Herpes virus infection. Cockayne
syndrome, Aicardi-Goutieres Syndrome, Tuberous
sclerosis complex, Brucellosis and Coats disease is
also associated with Fahrs syndrome.1 There is no
definite treatment available to achieve remission or
stabilization of Fahrs disease. Management is only
symptomatic with drugs and physiotherapy.1
But case report showing association of multiple
myeloma and Fahrs syndrome is few in literature.
Nishiyama et al in 1991 have first reported a 41 year
old woman with Fahrs disease associated with
multiple myeloma.13 The initial symptom of dystonia
and spasticity in the left leg started when she was 30
years old. M protienemia was detected when she was
32 years and multiple myeloma when she was 40
years old. Periodical CT scans revealed that the
intracerebral calcifications had worsened gradually
through 8 years. Kenji Isoe et al also reported the
case of a 66 yr old man with dementia, dysarthria,
rigidity, pyramidal signs and truncal ataxia with
calcification in basal ganglia, floor of cortices,
subcortical white matter and cerebellum associated
with IgG M proteinemia (MGUS).14 The patient had
also calcification of aorta, pleura, pericardium and
diaphragm. Tentolouris et al have reported three cases
of familial calcification of aorta and calcific aortic
valve disease associated with monoclonal chain
gammopathy.15
They
had
indicated
that
immunological abnormalities were associated with
calcifications. Our case is one among the rare case
reports of association of Fahrs syndrome with
multiple myeloma or MGUS and we also believe
there may be some immunological basis associated
with diffuse calcifications of Fahrs syndrome which
needs further studies.
CONCLUSION
Fahrs disease or Idiopathic basal ganglia
calcification is a rare neurological disorder with
autosomal dominant transmission. Diagnosis is based
on some clinical criteria, calcifications in bilateral

basal ganglia and other cortical and sub cortical
structures on neuroimmaging and exclusion of other
pathological conditions causing bilateral intracranial
calcifications. Progressive neurological deterioration
generally results in disability and death. Treatment is
only symptomatic and prognosis is variable. This
disorder is associated with a variety of other
metabolic, endocrine and genetic disorders, but no
specific etiology has been identified yet. From the
various case reports of association of multiple
myeloma with Fahrs disease or diffuse calcification
of aorta and aortic valves including our case report it
appears that there is some immunological basis to the
development and progression of calcification in
Fahrs disease. Further study is required to find out
exact molecular mechanism involved which may also
lead to exploration of therapeutic options.
REFERENCES
1. Saleem S, Aslam HM, Anwar M, Anwar S,
Saleem M, Saleem A, Rehmani M A K : Fahrs
syndrome: Literature review of current evidences.
Orphanet Journal of Rare Diseases. 2013;8:156
2. Fahr T. Idiopathische Verkalkung der
hirngefasse. Zentrabl Allg Pathol 1930; 50:12933
3. Geschwind DH, Loginvo M, Stern JM.
Identification of a locus on chromosome 14q for
idiopathic basal ganglia calcification (Fahrs
disease). Am. J. Hum.Genet. 1999;65(3): 764-72
4. Oliveira JR, Spiteri E, Sorbido MJ. Genetic
heterogeneity in Familial idiopathic calcification
(Fahrsdisease). Neurology. 2004;63(11):2165-7
5. Dai X, Gao Y, Xu Z. Identification of a novel
genetic locus on chromosome 8p21.1q11.23 for
idiopathic basal ganglia calcification. Am J.Med
Genet.B
Neuropsychiatr
Genet.
2010;153B(7):1305-10
6. Moskowitz MA, Winickoff RN, Heinz ER.
Familial calcification of the basal ganglions: a
metabolic and genetic study. N Engl J Med
1971;285(2):72-77
7. Ellie E, JulienJ, Ferrer X. Familial idiopathic
striopallidodentate calcifications. Neurology
1989,39(3):381-85
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8. Manyam BV. What is and what is not Fahrs

disease.
Parkinsonism
Relat
Disord.
2005,11(2):73-80
9. Athulya GA, Sydney D, Suza, Jayakumar J,
Sivananda P. Fahrs syndrome-An interesting case
presentation. Clin Diagn Res. 2013;7(3):532-33
10. Manyam B V, Waters AS, Narla KR. Billateral
striopallido
dentate
calcinosis:
clinical
characteristics of patients seen in aregistry. Mov
Disord. 2001;16(2):258-64
11. Bouras C, Giannakopoulos P, Good P, Hsu A,
Hof P, Perl D. A laser microprobe mass analysis
of trace elements in brain mineralization and
capillaries in Fahrs disease. Acta Neuropathol.
1996;92(4):351-57
12. Beall SS, Patten BM, Mallette L, Jankovic J.
Abnormal
systemic metabolism of iron,
porphyrin and calcium in Fahrssyndrome. Ann
Neurol .1989;26(4):569-75
13. Nishiyama K, Honda E, Mizuno T. A case of
idiopathic, symmetrical, non arteriosclerotic
intracerebral
calcification
(Fahrsdisease)
associated with M-proteinemia followed by
multiple
myeloma.
Rinsho
Shinkeigaku
1991;31:781-84
14. Kenji I,Katsuya U,Mikio S, Kenji N .Intracranial
calcification with IgG M -proteinemia: a case
report. J Neurol Neurosurg Psychiatry
1998;64:561-63
15. Tentolouris C, Kontozoglou T, Toutouzas P.
Familial calcification f aorta and calcific aortic
valve disease associated with immunologic
abnormalities. Am Heart J.1993;126:904-09
778
Tripathy et al.,
DOI: 10.5958/2319-5886.2014.00439.1

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
th
Coden: IJMRHS
Revised: 22nd Jun 2014
Copyright @2014
ISSN: 2319-5886
Case report
CUTANEOUS SARCOIDOSIS: A RARE CASE REPORT

*Bindu Suparna M, Joshi Shivani
Department of Pathology, MGM Medical College, Aurangabad, Maharashtra, India
* Corresponding author email: suparnapinglebindu@yahoo.co.in
ABSTRACT
Sarcoidosis is a Greek word (Sarco means flesh and Eido means type or like). Cutaneous sarcoidosis occurs in up
to one third of patients with systemic sarcoidosis. This disease is characterised by the presence of non - caseating
epitheloid cell granulomas in the skin. Cutaneous sarcoidosis presents as a diagnostic challenge to the
dermatopathologists due to its varied presentations and almost identical histologic pictures. Hence, exclusion of
infectious causes and compatibility with clinical and radiologic picture serve as significant criteria to come up to a
diagnosis. Sometimes; skin lesions are the first manifestation of systemic sarcoidosis. This is not a contagious or
allergic disease. There is a risk of development of systemic manifestations at a later date; for which a close follow
up is a must. We are presenting a case of cutaneous sarcoidosis, which later on progress to sarcoidosis with
systemic manifestations.
Keywords: Sarcoidosis, Cutaneous, Granulomas
INTRODUCTION
Almost a century ago, the relationship of sarcoid
infiltration of the skin and granulomatous changes in
other organs was recognized. Schaumann in 1914,
proposed that lupus pernio could be a manifestation
of a generalized disease.1 Sarcoidosis is best defined
in histological terms as a disease characterized by
the presence of non caseating epitheloid cell
granulomas, in several affected organs or tissues,
proceeding either to a resolution or to a conversion
into hyaline connective tissue.2 The age group more
commonly affected is between 20 to 40 years,
although any age group can be affected. It occurs in
women twice as often. It is a granulomatous disease
that commonly involves lungs, eyelids, lymph nodes
and skin.3,4. Cutaneous sarcoidosis occurs in up to one
third of patients with systemic sarcoidosis. It may
have
an
extremely
heterogeneous
clinical
presentation, so that the definitions of great imitator
and clinical chameleon have long been used.5
Bindu et al.,
Involvement may be mild or severe, self limited or

chronic, and limited or wide ranging in extent.
Unfortunately, there is no single test that can prove
the diagnosis. Hence diagnosis is mainly based on a
compatible clinical or radiologic picture along with
histologic evidence of noncaseating granulomas,
and when other potential causes such as infection are
excluded..6, 7 There are no morphological features that
enable the pathologist to make a diagnosis of
sarcoidosis. Statements such as consistent with
sarcoidosis or suggestive of sarcoidosis are helpful
and may be misleading. Hence the primary role of the
pathologist is (1) to identify and characterize the
granulomas or document their absence8 (2) to exclude
as far as possible known causes of granulomas,
primarily infections (3) to ensure compatible clinical
and radiological findings. Though rare, the worst
possible outcome in multisystem sarcoidosis is death
due to cardiac or central nervous system damage.
779
Int J Med Res Helath Sci. 2014;3(3):779-781
CASE REPORT
A 55 year female came to MGM medical college and
hospital OPD with a history of insidious onset of
gradually progressive papular, erythematous lesions
over the arms, back and legs over a period of 2 years.
3 months later, she developed cough and fever and
gave history of weight loss. Blood investigations
showed normal levels of liver function tests, kidney
function tests and serum calcium. Serum angiotensin
converting enzyme (ACE) levels were raised (62
micrograms/L). Multiple enlarged lymph nodes were
also seen in the preaortic and para-aortic, subcarinal
and aorto-pulmonary window. A skin punch biopsy
was taken. Histopathological examination of the skin
lesion revealed noncaseating granulomas consisting
of lymphocytes and epitheloid cells and ill formed
Langhans giant cells. (Fig 1). The granulomas were
seen upto deep dermis, along with a mild
lymphocytic infiltrate around blood vessels and skin
adnexa. ( Fig 2). Biopsy stains for acid fast bacilli and
periodic acid stain for fungal granulomas were
negative. HRCT scan of the chest showed patchy
areas of consolidation in the medial segment of the
medial lobe and small calcific granuloma in the left
lower lobe. (Fig 3). Thereafter, a transbronchial
biopsy from the right lower and middle lobes showed
small aggregates of epitheloid cells. After exclusion
of infectious causes, a diagnosis of cutaneous
sarcoidosis was made.
Fig 1: Depicting multiple non-caseating granulomas up

to deep dermis (10X)
Fig 2: Granuloma with epitheloid cells, lymphocytes

and ill-formed langhans giant cell (40X)
Fig 3: HRCT scan of chest showing patchy areas of

consolidation in medial segment of medial lobe
DISCUSSION
Granuloma is a small, well-circumscribed lesion, 2-3
mm in diameter consisting of collection of modified
macrophages (epitheloid cells) and a rim of
lymphocytes. Granulomatous skin lesions present as a
diagnostic challenge to dermatopathologists due to a
myriad of presentations and almost identical
histological pictures. A large group of skin diseases
enters the differential diagnosis with cutaneous
sarcoidosis. The whole word means a condition that
resembles crude flesh. Several lines of evidence
suggest that this disease is due to disordered immune
regulation in genetically predisposed individuals.
Since the clinical consequences and the prognosis of
these groups of diseases is different, it is important to
correctly plan the diagnostic work up. Cutaneous
involvement occurs in 20% to 35% of the patients
with systemic sarcoidosis. Cutaneous sarcoidosis is
divided into specific and non-specific types. The most
common non-specific manifestation is erythema
nodosum, the biopsy of which shows panniculitis
with septal inflammation. Non caseating granulomas
are rarely present in erythema nodosum. The specific
780
Bindu et al.,
skin lesions are papules, plaques, lupus pernio,

subcutaneous nodules and psoriasiform lesions.
Cutaneous involvement in systemic sarcoidosis may
occur at any stage of the disease, however most often
it presents at the onset and may even be the
presenting complaint.9 This is very true in the present
case. Many atypical lesions have also been described
in cutaneous sarcoidosis like itchyosiform lesions,
vitiligo and scar granulomas.10 Lung biopsy is now an
established procedure in the diagnosis of radiological
demonstrable pulmonary infiltration. The criteria for
diagnosis of skin sarcoidosis are: 1. Clinically and
radiologically compatible picture 2. Histologic
evidence of noncaseating granulomas 3. Exclusion
of the other granulomatous diseases like
mycobacterial, fungal and parasitic infections
At the same time one should not forget nonspecific
local sarcoid reaction that also shows noncaseating granulomas, but no signs of systemic
disease. Four main groups of skin conditions that
mimic sarcoidosis are:- 1. Infectious diseases
(Sarcoidosis is not a contagious disease) 2. Allergic
and immunological manifestations of various
etiologies (Sarcoidosis is not an allergic disease) 3.
Granulomatous diseases of various etiologies 4.
Lymphomas and pseudolymphomas
The granulomas in lupus vulgaris are caseous, those
in leprosy are around dermal nerve twigs. In contrast,
those in sarcoidosis are mainly in the dermis and
surrounded by sparse lymphocytic infiltrate (naked
tubercle). Serum angiotensin converting enzyme
(ACE) levels has been used as an important
laboratory test in sarcoidosis. ACE levels are derived
from the epitheloid cells of the granulomas and
reflect the granuloma load in the patient. It is elevated
in 60% of patients, as in the present case; and is
useful in monitoring the clinical course of the disease.
Sarcoidosis follows an unpredictable course. 65 to 70
% of affected patients recover with minimal or no
residual damage, 20 % have permanent loss of some
lung function or some visual impairment, remaining
10 to 15 % die of cardiac and nervous system damage
or succumb to progressive pulmonary fibrosis.
CONCLUSION
In conclusion, cutaneous sarcoidosis is present in
approximately 25% of patients. Sometimes; skin
lesions are the first manifestation and their
recognition is important as they are an accessible
source of tissue for histopathological examination.
There is a risk of development of systemic
manifestations at a later date; hence such patients

should have a close follow up regularly. There is no
permanent cure for sarcoidosis. The treatment is
usually designed to help relieve the symptoms with
drugs like analgesics, anti-inflammatory, steroids and
chemotherapy drugs according to severity of disease.
REFERENCES
1. Eklund A, Rizzato G. Skin manifestations in
sarcoidosis. European Respiratory monograph.
2005; 32: 150-63
2. Mitchel DN, Scadding JG, Heard BE, Hinson KF
W. Sarcoidosis: Histopathological definition and
clinical diagnosis. Journal of clinical Pathology.
1977;30:395-408
3. Reddy RR, Shashi Kumar BM, Harish MR.
Cutaneous sarcoidosis- A great masquerader: A
report of three interesting cases. Indian Journal of
Dermatology. 2011; 56(5):568-72
4. Keiko F, Hiroyuki O, Masako O, Takeshi H.
Recurrent follicular and lichenoid papules of
sarcoidosis. European Journal of Dermatology.
2000; 10(4): 303-05
5. Tchernev G, Patterson JW, Nenoff P, Horn LC.
Sarcoidosis of the skin A dermatological puzzle:
Important differential diagnostic aspects and
guidelines for clinical and histopathological
recognition. European Academy of Dermatology
and Venereology, Journal compilation. 20092010;1111: 1468-3083.
6. Rajani Katta. Cutaneous Sarcoidosis: A
Dermatologic masquerader. American family
physician. 2002; 65: 1581-84
7. Grover S, Murthy PS, Kar PK , Tewari V,
Shivyog TC,
Manjunath R. Cutaneous
sarcoidosis: Report of two cases. Medical Journal
Armed Forces India. 2006; 62: 375-77
8. Rosen Y. Pathology of Sarcoidosis. Seminars in
respirstory and critical care medicine.2007; 28:
36-52.
9. Oza H, Bhalodia N, Patel K, Oza T. Case Report.
Cutaneous sarcoidosis. National J Medical
Research. 2012; 2:520-22
10. Moller D. Rare manifestations of sarcoidosis.
European respiratory monograph. 2005; 32: 233
50
781
Bindu et al.,
DOI: 10.5958/2319-5886.2014.00440.8

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 3
rd
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Accepted: 3rd Jul 2014
Case report
GARENOXACIN IN DIFFICULT TO TREAT LUNG ABSCESS A CASE STUDY REPORT

Ghosh CK1,*Hajare A2, Krishnaprasad K2, Bhargava A2
1
Consultant Pulmonologist, City Life Hospital & Dumdum Medical Centre, Kolkata
Medical Services, Glenmark Pharmaceuticals, Mumbai
*Corresponding author email: anoophajare@gmail.com

ABSTRACT
Lung abscess results from microbial infection causing necrosis of the lung parenchyma leading to one or more
cavities. Lung abscesses usually occur in individuals who have a predisposition to aspiration,
immunocompromised individuals, patients with long standing illnesses like malignancies, diabetes, chronic lung
diseases. Both gram positive and gram negative pathogens are involved in the pathogenesis. Rising incidence of
resistant pathogens has added to the burden of treating physicians. Garenoxacin a newer desfluoroquinolone with
its broad spectrum of coverage appears to be a suitable fluoroquinolone for the treatment of respiratory tract
infections. The case study mentioned below is of pulmonary emphysema with the existing lung cyst going in for
secondary infection. The study looks to explain the utility of fluoroquinolones in the treatment of such infections.
Keywords: Garenoxacin, Lung abscess, Pulmonary emphysema, Broad spectrum
INTRODUCTION
Lung abscess refers to a circumscribed area of pus or
necrotic debris in the lung parenchyma, which leads
to a cavity and formation of bronchopulmonary
fistula, an air-fluid level inside the cavity.1, 2These
cavities often communicate with large airways,
resulting in cough with purulent sputum.3Previously it
was thought that anaerobic bacteria and
microaerophilic streptococci are the major
aetiological pathogens of lung abscess.4 However
recent reports have suggested that aerobic bacteria
might be chief pathogens of lung abscess.5, 6
On chest X-ray the usual presentation of a typical
case of lung abscess is the cavity with or without airfluid level particularly in the gravity dependent sites
of the lung.1 On CT scan, it is easily recognized as a
homogeneous area of low density surrounded by a
markedly enhanced well-formed wall.7 Necrotizing
pneumonia is another disease characterized by the
formation of cavitary lesions of low density without

rim enhancement.8, 9
CASE
A male patient aged 60 years weighing 58kgs
presented to the doctor with severe cough and fever
of 5 days duration. Patient was a known case of
pulmonary emphysema with an associated
uncomplicated lung cyst from past 20 years. Patient
was also a known case of diabetes and hypertension.
On examination patient was found to be conscious,
well-built and well nourished. Patient had fever of
104F, respiratory rate of 26 per minute. There was
no icterus or generalized lymphadenopathy. On
auscultation the air entry was reduced, vesicular
sounds along with crepitations and rhonchiwere
appreciated on the right side. Laboratory
investigations suggested normal complete blood
count. Sputum examination was negative for acid fast
782
Ghosh CK et al.,
bacilli. A chest X-ray PA view was advised to the

patient. Chest X-ray suggested of thick walled cyst
with air fluid level in the right para-hilar region (fig.
1) which made the treating physician to think of
secondary infection of the already existing lung cyst.
Hence a course of Garenoxacin at a dose of 400 mg

once a day (200 mg 2 tablets OD) was given for 10
days along with Linezolid 600 mg twice a day for 10
days. There was complete improvement in the
symptoms. A follow up Chest X-ray was done which
revealed diminution of the size of the cyst with
clearance of air fluid level inside the lesion (fig. 3).
DISCUSSION
Fig. 1: Chest X-ray before treatment

The patient was started with a course of Amoxicillinclavulanate at a dose of 625 mg three times a day for
5 days. After completing the course of the treatment
there was no improvement in the symptoms. Hence a
chest X-ray was advised which suggested no
improvement in terms of resolution of the cystic
lesion (fig. 2).
Fig. 2: Chest X-ray post amoxicillin-clavulanate

treatment
Fig. 3: Chest X-ray post Garenoxacin treatment

Ghosh CK et al.,
Lung abscess usually occur as a complication of

aspiration pneumonia and are polymicrobial
infections caused by anaerobic bacterial that are
normally present in the mouth. The most frequently
isolated anaerobes are peptostreptococcus spp.,
fusobacterium and prevotella. Microaerophilic
streptococci and viridans streptococci often are
present as well. Monomicrobial lung abscess
occasionally may be caused by bacteria, including S.
aureus, enteric gram negative rods such as klebsiella
spp.,
pseudomonas
aeruginosa,
burkholderiapseudomallei,
pasteurellamultocida,
group A streptococcus, H. influenzae types b and c,
legionella spp., actinomyces spp., and nocardia
spp.3Chest radiography usually shows a lung cavity
with an air-fluid level. Typically the wall of this
cavity is thick walled and irregular in shape.
Pulmonary infiltrates may be found in the
surrounding region. Oral antimicrobials preferred in
the treatment are amoxicillin 500 mg every 8 hours,
clindamycin 300 to 600 mg every 8 hours and
moxifloxacin 400 mg/day.3 Usually within a few days
of beginning antimicrobial therapy diminution of
fever and subjective sense of well-being is seen.
Defervescence can be expected in 7 to 10 days.
Radiographic improvement may lag well behind
clinical cure. The median time to cavity closure is 4
weeks and surrounding infiltrates may take twice the
time to resolve. This particular case was secondary
infection of the preexisting long standing
uncomplicated lung cyst ending up in the lung
abscess. Since most of the lung abscesses are due to
polymicrobial infection, the need of the hour would
be to choose an anti-infective with a broader
spectrum of antimicrobial coverage. Garenoxacin, a
newer quinolone with its significantly broader
spectrum of activity appears to be an ideal antibiotic
for treatment of difficult to treat or resisting
infections. This broader spectrum of activity is
attributed to the unique structure of Garenoxacin.10
783
CONCLUSION
Garenoxacin is a novel oral des-fluoro(6) quinolone
with potent antimicrobial activity against common
respiratory pathogens, including resistant strains.
Garenoxacin appears to be a suitable option for the
treatment of resistant or difficult to treat infections.
Garenoxacin possesses potent activity against
multidrug-resistant bacteria, especially quinoloneresistant S. pneumoniaeand other major community
pathogens
including
M.
pneumoniaeandC.
pneumoniae.
9. Hill M, Sanders C. Anaerobic disease of the lung.

Infectious disease clinics of North America.
1991;5(3):453-66
10. 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):3351-6.
REFERENCES
1. Pennza P. Aspiration pneumonia, necrotizing
pneumonia, and lung abscess. Emergency
medicine
clinics
of
North
America.
1989;7(2):279-307
2. Hirshberg B, Sklair-Levi M, Nir-Paz R, Ben-Sira
L, Krivoruk V, Kramer MR. Factors predicting
mortality of patients with lung abscess. CHEST
Journal. 1999;115(3):746-50
3. McBride WJH. Mandell, Douglas and Bennetts
Principles and Practice of Infectious Diseases 7th
edition. Bacterial Lung Abscess. 2010;7(2):
925 - 30
4. Bartlett JG. The role of anaerobic bacteria in lung
abscess.
Clinical
Infectious
Diseases.
2005;40(7):923-5
5. Wang JL, Chen K-Y, Fang C-T, Hsueh P-R,
Yang P-C, Chang S-C. Changing bacteriology of
adult community-acquired lung abscess in
Taiwan: Klebsiella pneumoniae versus anaerobes.
Clinical infectious diseases. 2005;40(7):915-22
6. Mansharamani N, Balachandran D, Delaney D,
Zibrak J, Silvestri R, Koziel H. Lung abscess in
adults:
clinical
comparison
of
immunocompromised
to
nonimmunocompromised
patients.
Respiratory
medicine. 2002;96(3):178-85
7. Naidich DP, Zerhouni EA, Siegelman SS, Kuhn
J. Computed tomography and magnetic resonance
of the thorax. 1991; 23(8): 608
8. Hoffer F, Bloom D, Colin AA, Fishman SJ. Lung
abscess
versus
necrotizing
pneumonia:
implications for interventional therapy. Pediatric
radiology. 1999;29(2):87-91
784
Ghosh CK et al.,

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DOI: 10.5958/2319-5886.2014.00387.

International Journal of Medical Research

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Int J Med Res Health Sci. 2014;3(3):509-513

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Int J Med Res Health Sci. 2014;3(3):509-513

Table 2;Standard Anthropometric values of male subjects according to age. (p<0.05)

Diff. between std and

Table 3: Levels of malnutrition and obesity

Moderate level of malnutrition.

Mid level of malnutrition.

Low weight but normal.

First grade of obesity.

Second grade of obesity.

Comparison of the anthropometric values according

Fig 1: Data of female children

Int J Med Res Health Sci. 2014;3(3):509-513

Fig2: Data of male children

a change in the weight category if individuals do not

Int J Med Res Health Sci. 2014;3(3):509-513

10. BallK, Crawford D. Socio economic status and

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Study design:The study commenced after obtaining

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