Ijmrhs Vol 2 Issue 3

DOI: 10.5958/j.2319-5886.2.2.
038
International Journal of Medical Research

&
Health Sciences
www.ijmrhs.com
Volume 2 Issue 3 July - Sep
rd
Received: 3 Apr 2013

Research article
Coden: IJMRHS
nd
Revised: 2 May 2013
Copyright @2013
ISSN: 2319-5886
Accepted: 15th May 2013
LEARNING STYLES OF FIRST YEAR MEDICAL STUDENTS STUDYING PHYSIOLOGY IN

TAMIL NADU
*Suzanne Maria Dcruz1, Navin Rajaratnam2, Chandrasekhar M3
1
Department of Physiology, Sri Muthukumaran Medical College Hospital and Research Institute,
Chennai, Tamil Nadu, India
2,3
Department of Physiology, Meenakshi Medical College Hospital and Research Institute,
Kanchipuram, Tamil Nadu, India
*Corresponding author email: susandr@ymail.com
ABSTRACT
Background: Understanding the diversity of learning style preferences of first year medical students
will help teachers of Physiology design teaching-learning activities that while catering to their
preferences also challenge them to grow in categories that are against their preferences. Most research
using the VARK (Visual, Aural, Read-write, Kinesthetic) questionnaire that assesses sensory modality
preference alone showed that medical students studying Physiology were multimodal. Aim: The aim of
this study was to determine the learning styles of first year medical students studying Physiology in
India using the Index of Learning Styles (ILS) and to compare the learning styles of males and females.
Methods and Material: The Index of Learning Styles (ILS) questionnaire was administered to 150 first
year medical students studying Physiology in a private medical college in India as it assesses learning
style preferences on four dimensions - active/reflective, sensing/intuitive, visual/verbal and
sequential/global. Results: The majority of first year medical students were fairly well balanced in the
sequential/global dimension (80.66%), active/reflective dimension (68%) and sensory/intuitive
dimension (62%) of the ILS. However, in the visual/verbal dimension, the majority of students were
visual learners (72.66%). There were no significant differences in the learning style preferences of males
and females. Conclusion: The majority of our students were visual learners and were well balanced in
the other dimensions, with there being no significant gender wise difference in learning styles. With this
knowledge and findings about different dimensions of learning styles, other than sensory modality
preference alone, effective teaching-learning activities can be developed.
Keywords: Index of Learning Styles, Learning styles, Medical students, Physiology
INTRODUCTION
Students differ in their learning styles, their
approaches to learning and levels of intellectual
development.1 At present, the whole of human
Physiology is being taught to medical students in

India along with other basic science subjects in a
period of one year, - their first year in Medical
321
Suzanne Maria Dcruz et al.,
Int J Med Res Health Sci. 2013;2(3):321-327
College, when they are as it is struggling with

making the transition from school to college.
Teachers of Physiology have to be aware that
their teaching strategys effectiveness will vary
with different types of students as Physiology is
by nature a difficult subject.2
Elsewhere, many researchers have used
Flemmings VARK (Visual, Aural, Read/Write,
Kinesthetic) questionnaire3 to investigate the
learning style preferences of students of different
courses studying Physiology.2 Students are
categorized into visual, auditory, read/write and
kinesthetic learners on the basis of the sensory
modality used to assimilate information.3 Most
researchers found that the majority of their
Physiology students preferred to use at least 2 - 4
sensory modalities while learning, ie., they were
multimodal,4-6 while one study found that the
majority (54%) were unimodal.7 Some studies
showed no significant differences in the VARK
learning preferences of male and female students
learning Physiology,6,8 while one study showed
that the majority of females (54%) were
unimodal even though the majority of males
were multimodal.9
Physiologists in India too have used the VARK
or
VAK
(Visual,
Aural,
Kinesthetic)
questionnaires to determine their students
learning styles. Out of 92 medical students in one
study in Gujarat, 58.69% were multimodal.10 In a
study done on 430 first and second year medical
students in four medical colleges in Tamil Nadu
and Puducherry, it was found that 70.7%
students were multimodal.11 In another study
done in Kota, Rajasthan, 92.98% of males and
76.27% of females preferred multimodal
learning.12
However,
researchers
who
determined the learning styles of 199 medical
students in Kolar, Karnataka, found that 62.31 %
were unimodal in their first year and only
47.73% were unimodal in their final year.13
In view of these varied findings, it was decided
to study the learning style preferences of first
year medical students studying Physiology in
India. However, the VARK questionnaire,
though widely used by Physiologists, is basically
a sensory modality preference assessment that

focuses only on which sensory modality is used
to internalize information when studying.14
Given the complexity of professional courses in
general
and Physiology in particular, and
knowing that learning is more complex, it was
felt that a learning style questionnaire that took
into consideration aspects like how students
process information, what type of information
they preferentially perceive, how they progress
towards understanding, and not merely their
sensory modality preference alone should be
used. The Index of Learning styles15 (ILS) is a
questionnaire that assesses learning preferences
on four dimensions active/reflective,
sensing/intuitive,
visual/verbal
and
15
sequential/global and is based on a learning
style model formulated by Richard M Felder and
Linda K Silverman16 that takes the above aspects
into consideration. Although initially designed
for engineering students, it has subsequently
been used by different higher education students
and its reliability and validity have been proven
for medical students.17,18 Extensive research16
and reviews of studies1 on the learning styles of
engineering students using the Index of Learning
styles (ILS) revealed that most engineering
students are active, sensing and visual with most
creative students being global. A study on
veterinary students showed that they were
predominantly active, sensing, visual and
sequential.19 Orthodontic residents were found to
be highly visual learners who preferred sensing
and sequential learning styles.20 First year
osteopathic medical students who were active,
intuitive, global and/or visual were found to be
more likely to use online learning material.21
The present study was therefore undertaken to
assess the learning styles of first year medical
students studying Physiology in India using the
Index of Learning Styles. Another aim of the
study was to compare the learning styles of male
and female first year medical students. It was felt
that this information would help teachers of
Physiology effectively design their teachinglearning activities, especially in the present
322
scenario in India where many curricular reforms

are being proposed, with a growing emphasis on
student centered teaching-learning methods.
METHODS
The study was conducted in the Department of
Physiology of a private medical college in South
India. 150 first year medical students participated
in the study after obtaining due permission and
written informed consent. There were 57 male
students and 93 female students. The Index of
Learning Styles (ILS) questionnaire15, which is a
44 item instrument based on Richard M Felder
and Linda K Silvermans learning style model1
was administered to the 150 students to assess
their preferences on four dimensions
active/reflective, sensing/intuitive, visual/verbal
and sequential/global.15 In the ILS, there are 11
items (Eg: I tend to understand something better
after I15) for each dimension (Eg:
active/reflective). Each item has two forced
choices (Eg: a- try it out15; b- think it
through15) corresponding to each category of
that dimension (Eg: a corresponds to active and
b to reflective). All 150 students completed the
questionnaire and scoring was done according to
the instructions of the ILS.15 For each dimension,
the number of a and b responses were totalled
and the smaller was subtracted from the larger
(Eg: If there were 7 a and 4 b responses, then
subtraction would result in 3 a). By convention,

if the score was 1-3 it implies the student is fairly
well balanced on that dimension, while scores of
5-7 and 9-11 signify moderate or strong
preferences respectively for that category on the
scale. 15 The percentage of first year medical
students having a strong / moderate preference
for each category of the four dimensions of the
ILS and the percentage who were fairly well
balanced were obtained. Gender wise analysis
was also done. SPSS and Z-test for two
proportions were used.
RESULTS
The majority of first year medical students were
fairly well balanced in the sequential/global
dimension (80.66%), active/reflective dimension
(68%) and sensory/intuitive dimension (62%) of
the Index of Learning Styles (ILS). However, in
the visual/verbal dimension, it was found that the
majority of students were visual learners
(72.66%), with only 26.66 % being fairly well
balanced and only one student among the 150
students (0.6%) being a verbal learner (Table
1).
Comparison of the strength of learning style
preferences of male and female first year medical
students in all four dimensions of the ILS
revealed that there was no significant difference
(Table2).
Table 1 Strength of learning style preferences of first year medical students.

1. Active/Reflective
Moderate
- Strong
Active
31(20.66)
Well
balanced
102(68)
2. Sensing/Intuitive
Moderate
- Strong
Reflective
Moderate Strong
Sensing
17(11.33)
45(30)
Well
balanced
93(62)
3. Visual/Verbal
Moderate
- Strong
Intuitive
Moderate
- Strong
Visual
12(8)
109(72.66)
Well
balanced
40(26.66)
4. Sequential/Global
Moderate
- Strong
Verbal
Moderate
- Strong
Sequential
1(0.6)
24(16)
Well
balanced
121(80.66)
Moderate
- Strong
Global
5(3.33)
Strength of learning style preferences expressed as the number of students (n=150) and percentage of students (in brackets) who had moderate - strong
preference for each category and who were well balanced on each of the four dimensions of the Index of Learning Styles.15
323
Table 2: Comparison of the strength of learning style preferences of male and female first year medical
students.
1. Active/Reflective
2. Sensing/Intuitive
3. Visual/Verbal
4. Sequential/Global
Dimensions
Moderate
- Strong
Well
Active
balanced
Moderate
Moderate
Moderate
Moderate
- Strong
- Strong
Well
- Strong
- Strong
Reflective
Sensing
balanced
Intuitive
Visual
Moderate
Moderate
Well
- Strong
- Strong
balanced
Verbal
Sequential
Moderate
Well
- Strong
balanced
Global
Males
9(15.78)
40(70.17)
8(14.03)
18(31.57)
36(63.15)
3(5.26)
40(70.17)
16(28.07)
1(1.75)
8(14.03)
48(84.21)
1(1.75)
Females
22(28.65)
62(66.66)
9(9.67)
27(29.03)
57(61.29)
9(9.67)
69(74.19)
24(25.80)
0(0)
16(17.20)
73(78.49)
4(4.30)
Z- score
-1.16
0.45
0.81
0.33
0.23
-0.97
-0.54
0.30
1.28
-0.51
0.86
-0.84
p value
0.25
0.65
0.41
0.74
0.82
0.33
0.59
0.76
0.20
0.61
0.39
0.40
Strength of learning style preferences of male and female students expressed as the number of male (n = 57) and female
(n=93) students and percentage of male and female students (in brackets) who had moderate - strong preference for each
category and who were well balanced on each of the four dimensions of the Index of Learning Styles.15 Z- scores calculated
using Z- test for two proportions, p value of <0.05 taken as significant.
DISCUSSION
This study was done to determine the learning

styles of first year medical students studying
Physiology in India using the Index of Learning
Styles (ILS) 15 and to compare the learning styles
of male and female first year medical students.
While most studies on the learning styles of first
year medical students studying Physiology have
been done using the VARK/VAK questionnaire,
we have used the Index of Learning Styles.
Although strictly not comparable, our findings
about the learning styles of first year medical
students differed from the studies that used the
ILS on engineering students,1,16 veterinary
students,19
orthodontic
residents20
and
21
osteopathic online learners as the majority of
our students were fairly well balanced in three of
the four dimensions of ILS - the
sequential/global dimension; active/reflective
dimension and sensory/intuitive dimension.

However, the finding that the majority of our
students were visual learners is in agreement
with the findings of other studies using the ILS
1,16,19,20,21
. The implications are discussed for
each dimension separately.
Visual/Verbal dimension:
This dimension deals with the sensory channel
through which information is processed.1 Visual
information consists of diagrams, plots,
animations, etc. Verbal information not only
includes spoken words but also written words as
cognitive scientists have proven that the brain
converts written words into their spoken
equivalents and then processes them like spoken
words.15 In Indian medical colleges following a
didactic curriculum like the present one, teaching
is verbal as lectures and visual representations of
auditory information (in the form of words
324
written in PowerPoint slides, overhead projector

transparencies or on black boards) are
predominantly used. Since the majority of our
students are visual learners, potential for a
learning/teaching
style
mismatch
exists.
However, if teachers of Physiology are aware
that most of their students are visual learners and
include many pictures, sketches, flow charts,
graphs, animations, videos and even live
demonstrations in their teaching-learning
activities, this can be avoided.
Unlike the VARK/VAK questionnaire used by
other researchers, Felder and Solomon have only
two categories - visual and verbal, in this
dimension of the ILS. As kinesthetic learning
involves both information perception and
processing, it has been included in the
active/reflective learning style dimension under
the active category16. The findings of our study,
therefore differ from other studies using the
VARK/VAK questionnaire that showed that the
majority of students were multimodal and
preferred two or more modalities 4,5,6,10,11,12 since
ours showed that the majority prefer only one
modality - visual. A study done to determine the
learning styles of first year medical students in
Turkey using the VARK questionnaire found a
higher percentage of multimodality (63.9%) than
other studies, with only 7.7% of students being
auditory learners.22
Sequential/Global dimension:
This dimension categorizes students based on
how they progress towards understanding - in a
step by step manner (sequential) or in large
jumps, holistically (global).1 The majority of first
year medical students in our study were fairly
well balanced (80.66%) or had moderate or
strong preferences for sequential learning (16%).
As most formal learning favors sequential
learners16, the students of our study too would
not possibly have much difficulty. Topics in
Physiology are presented to them in an orderly,
logical manner, starting from the simple and
progressing to the complex. For the sake of the
3.33% of global learners, teachers should strive
to present the big picture of any teachinglearning activity first, before presenting details
and should encourage creativity. However, it is
important to realize that we are not analyzing
individual learning styles to teach each student
according to their preference. Rather, as
suggested by Felder and Brent, a good teacher
would adopt a balanced style, at times matching
their students preferences, but at other times
going against their preferences, thus forcing them
to grow and develop the abilities of both
learners.1 In this case, they should eventually
possess the abilities of both sequential and global
learners which would be invaluable to them once
they begin practicing medicine.
Active/Reflective dimension:
In our study, only 11.33% of our students were
reflective and 68% were well balanced.
However, 20.66% were active learners.
Classification into the active/reflective category
of this dimension is on the basis of how students
prefer to process information.1 Felder and
Silverman who formulated the learning style
model on which the ILS is based point out that
this dimension of the ILS is a component of
another learning style model developed by
Kolb.16 Since active learners prefer actively
participating in discussions or physical activities
they are unable to learn in passive situations like
lectures. However, reflective learners too would
not learn much during lectures unless given a
chance to think about or examine the perceived
information.16 Lectures by most teachers do not
give them this chance. But it is possible for
teachers of Physiology to help both active and
reflective learners simultaneously even during
their lectures by using brainstorming or
providing a few minutes for students to think
about what is being taught in the lecture.
Sensing/Intuitive dimension: Although the
majority of our students were fairly well
balanced in the sensing/intuitive dimension, 30%
of them had a moderate or strong preference for
sensing. The division into sensing/intuitive
learners is based on whether the student
325
preferentially perceives external information

(sensing) or internal information (intuitive).1 This
dimension, according to Felder and Silverman
themselves is based on Jungs theory of
psychological types and even the Myers-Briggs
Type Indicator (MBTI) measures the degree to
which sensing or intuition is preferred.16 Sensors
like concrete information or facts while intuitive
learners prefer abstract concepts like principles
and theory. In engineering, a mismatch exists as
intuitors are favoured, with concepts rather than
facts being emphasized and lectures (consisting
of words and symbols that intuitive learners
prefer) being predominantly used, while the
majority of engineering students are sensing.1
Teaching of Physiology involves both
explanations of concepts and stating of facts and
to that extent, generally caters to both sensors
and intuitors.
Gender wise analysis of learning style
preferences: The findings of our study are in
agreement with those of Slater and MeechanAndrews6,7 and the study on medical students in
Turkey22 as there was no significant difference in
the learning styles of male and female students.
Limitations of the study: The findings of the
present study are not representative of Indian
medical students in different years of study, or
students of Physiology of other courses or even
first year medical students of other colleges in
India. Also, since there is more to learning than
just learning styles (for example, the learning
approaches of students, their levels of intellectual
development, motivation, etc.) an oversimplified
approach in terms of addressing learning styles
alone as a solution to all learning problems
cannot be assumed.
Implications for future research: Longitudinal
studies can be done to determine if there is any
change in the learning styles of first year medical
students with time, or even more relevantly, after
implementation of the proposed curricular
reforms in India. It would also be worthwhile to
study the association between learning styles of
first year medical students and other factors like
performance in Physiology and attendance; and

to analyze the learning styles of other
undergraduate students studying Physiology
(dental, nursing, etc.) and the learning styles of
post-graduate students studying Physiology.
CONCLUSION
Our study done to assess the learning styles of

first year medical students studying Physiology
in India using the Index of Learning Styles (ILS),
which we thought was more relevant instead of
the commonly used VARK questionnaire,
showed that the majority of our students were
visual learners and were well balanced in the
remaining three dimensions, namely the activereflective, sensing/intuitive and sequential/global
dimensions with there being no gender wise
difference in learning styles. Given that the
dimensions of the Index of Learning styles are
components of other learning style models and
classification of learners is not on the basis of the
sensory modality preferences alone, the findings
of our study are more informative. With the
knowledge of these dimensions and the findings,
teachers of Physiology can adopt balanced
teaching styles to reach all their students; help
them learn better using their learning style
category in each of the four ILS dimensions; and
challenge them to develop the abilities of the
other category of learners in each dimension;
instead of just focusing on sensory modality
preference alone.
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327
DOI: 10.5958/j.2319-5886.2.2.039

&
Health Sciences
www.ijmrhs.com
th
Received: 10 Mar 2013

Original research article
Coden: IJMRHS
Copyright @2013
rd
Revised: 23 Apr 2013
ISSN: 2319-5886
Accepted: 30th Apr 2013
ANTIMICROBIAL
RESISTANCE
PROFILE
AND CHARACTERISATION OF
ENTEROCOCCUS SPECIES FROM VARIOUS CLINICAL SAMPLES IN A TERTIARY
CARE HOSPITAL
Saraswathy Palanisamy*, Sankari Karunakaran, Shankara Narayanan
Department of Microbiology, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and
Research (MAPIMS), Melmaruvathur, Tamil Nadu, India
*Corresponding author email: drmpsaraswathy@gmail.com
ABSTRACT
Background: Enterococcus is one of the leading causes of nosocomial infections, with E faecalis and E
faecium accounting up to 90-95% of clinical isolates. During recent years, the occurrence of other
Enterococcal species from clinical samples increased with the properties of resistance to many
antibiotics. Thus appropriate identification of Enterococci at species level is crucial for the management
and prevention of these bacteria in hospital settings. Hence, this study was undertaken to highlight the
incidence of multi drug resistant enterococcal species from various samples from human infections, in a
tertiary care hospital. Methods: This work was conducted in our institution from January 2009 to
December 2011. About 112 enterococcal isolates from various clinical specimens were included in the
study. The isolates were identified by standard microbiological methods. Antimicrobial susceptibility
testing was carried out by using Kirby-Bauer disc diffusion method. The prevalence of High level
Gentamicin resistance was identified. Vancomycin resistance was assessed by E-test. Result: The
commonest species identified was E faecalis (87.5%), followed by E faecium (8.9%). 14% of isolates
produced beta haemolysis and gelatinase. 15% and 24% were the haemolytic and gelatinase producing
enterococci. High level resistance was shown towards tetracycline, Amikacin, Cholramphenicol.
Vancomycin resistance was identified in single isolate. Conclusion: There is achange in isolation
pattern of enterococcal species. Besides, there is an increased rate of infection with multidrug resistant
enterococci species, which necessitates frequent antimicrobial surveillance.
Keywords: Enterococcus, E.faecalis, Antimicrobial resistance pattern, High level Gentamicin resistance
INTRODUCTION
In recent decades, most of the pathogenic

bacteria developed resistance to one or more
antimicrobial
agents.
Enterococci
are
commensals ism of the gastrointestinal tract of
human beings. They have gained more clinical
importance due to their multidrug resistance1, 2.

The ability of Enterococci to colonize the
gastrointestinal tract of hospitalized patients for
long periods is a crucial factor that influences the
development of drug resistance3. The CDC in a
328
Saraswathy et al.,
survey indicated that a high percentage of

hospital acquired infections are caused by
Enterococcus next to MRSA and ESBL
producers4. Infection with Vancomycin resistant
Enterococci is associated with increased
mortality, length of hospital stay, admission to
the ICU, surgical procedures & cost5. The
common species which causes infection are
E. Faecalis (80-90%) and E faecium (5-10%)6.
Recently there is an increase in isolation rate of E
faecium & other species from various clinical
samples 4, 7.This study aimed to determine the
prevalence of multi drug resistant Enterococcus
from various clinical specimens and changing
trends in isolation along with their virulence
characterisation.
MATERIALS AND METHODS
This study was conducted in the department of

microbiology, Melmaruvathur Adhiparasakthi
Institute of Medical Sciences and Research,
Tamil Nadu, India from January 2009 to
December 2011. The samples were collected
from both outpatients and inpatients of all age
groups of both genders. Enterococcal species
isolated from urine, blood, pus, sterile body
fluids and aspirates were included in the study. A
total of 112 Enterococcal isolates were included
in the study.
Identification of Enterococcus was done using
the following parameters (i) Colony morphology
on blood agar, Cystine Lactose Electrolyte
Deficient agar and Mac Conkey agar (ii) Grams
stain (iii) Catalase (iv) Bile Esculin (v) Heat
resistance (vi) Salt tolerance. Subsequently,
speciation was performed by sugar fermentation,
pyruvate fermentation, motility and reduction of
tellurite
in
tellurite
blood
agar
8
plate .Determination of virulence factors like
haemolysis and gelatinase were carried out by
appropriate tests 9.
Antibiotic susceptibility pattern

Antimicrobial susceptibility test was performed
by Kirby-Bauer disc diffusion method using the
following antibiotic discs: Vancomycin (30g),
Erythromycin (15g), Amoxycillin (10g),
Ofloxacin (5 g), Amikacin (30 g), High Level
Gentamicin (120 g), Ciprofloxacin (5 g),
Chloramphenicol (30 g), Tetracycline (30 g).
E.faecalis ATCC 29212 was used as a control
strain for disc diffusion tests10.
RESULTS
Out of 112 Enterococcal isolates consists of 98 E

fecalis (87.5%), 10 E faecium (8.9%), 3 E durans
(2.6%) and 1 E raffinosus (0.89%). The
maximum number of Enterococcus was isolated
from urine 98/112 (87.5%), followed by blood
6/112(5.3%) (Table-1).The baseline data of
patients infected with Enterococcus were given
in Table -2. Sixty four Enterococcus species had
been isolated as a mixture and their pattern of
isolation was described in Table-3.
Fifty eight (51.7%) isolates were gamma
haemolytic and 31 (27.6%) 37 (33 %) were and
alpha haemolytic Enterococci respectively.
Description of virulence characteristics has been
shown in Table-4.
E faecalis was resistant to tetracycline (67%),
Chloramphenicol (63%) and Amikacin (60%). E
faecium showed high level resistance to
Ciprofloxacin (100%), Erythromycin ( 80%),
Amikacin (60%). E durans was resistant to
Ciprofloxacin (100%), Erythromycin (66%),
Amoxycillin (66%), tetracycline (66%) &
tetracycline (66%).
Enterococcus showed
maximum sensitivity for Vancomycin (99%),
amoxicillin (65%), Ofloxacin (58%).
329
Saraswathy et al.,
Table .1: Specimen wise distribution of Enterococcus

Specimens
E faecalis (98)
E faecium (10)
E durans (3)
Urine (98)
90
Blood(6)
Pus(3)
Tracheal aspirate (1)
Ascitic fluid (1)
Table.2: Basic data of patients with Enterococcus infection

Variable
No. of Enterococcal isolates
Sex
OP/IP
Age
Eraffinosus (1)
Percentage
Male
83
74
Female
29
26
Inpatient
64
57
Outpatient
48
43
<20 years
11
10
20-40
56
50
40-60
23
20.5
60-80
22
19.6
Table.3: Pattern of Enterococcus isolation

Isolate
No. of isolates
Percentage
Enterococcus
60
53.5
Enterococcus+E. coli
14
12.5
Enterococcus+Klebsiella species
10
8.9
Enterococcus+Candida species
8.0
Enterococcus+ Staphylococcus aureus
6.2
Enterococcus+ CONS
6.2
Enterococcus+ CONS+ Candida species
4.4
Table.4: Virulence characteristics of Enterococcus

Virulence factor
No. Of isolates
Percentage
Beta haemolysis
17
15.15
Gelatinase production
27
24
Both
14
12.5
330
Saraswathy et al.,
Table-5 Antimicrobial susceptibility pattern of Enterococcus

Drug
E faecalis (98)
E faecium (10)
E durans (3)
E raffinosus (1)
Erythromycin
51
47
Amoxycillin
77
21
Ciprofloxacin
53
45
10
Ofloxacin
57
41
Tetracylin
32
66
Chloramphenicol
36
62
Amikacin
39
59
High level gentamicin
68
30
Vancomycin
98
99%
100
90
80
70
60
50
40
30
20
10
0
71%
65%
49%
58%
48%
38%
41%
41%
Fig.1: Sensitivity pattern of Enterococcus species

DISCUSSION
The Enterococcus species have now emerged as

important nosocomial pathogens. Hence, it is
important to know the changing patterns of the
Enterococcus infections and the antimicrobial
susceptibility pattern of isolates. In our study,
about 112 Enterococcal isolates were recovered
from various specimens. The maximum number
of isolates was obtained from urine followed by
blood. In some studies, pus isolates were high
compared to isolates from urine11-13.
Enterococcal infections were common in males

(74%) than in females (26%). About 10% of
isolates were recovered from patients below 20
years of age, of which 3 (27%) were obtained
from neonates. Although the recent studies stated
there is an increase in isolation of E faecium and
other enterococcal species14. In our study, E
fecalis (87.5%) constitute the major isolate,
followed by E faecium(8.9%), E durans 2.6 %15
and similar findings were shown by Facklam et
331
Saraswathy et al.,
al study16-18.About 53.5% of Enterococcus was

isolated in pure culture. The remaining 46.5%
were recovered with other organisms as mixture,
commonly associated with E.coli (12.5%),
Klebsiella (9%) and Candida (8%).
About 12.5% of isolates produced gelatinase and
haemolysin. Seventeen (15%) and twenty seven
(24%) isolates were positive only for beta
haemolysis and gelatinase respectively.
E faecium and E durans showed 100% resistance
to Ciprofloxacin, one of the commonest
antibiotic used to treat urinary tract infection.
HLGR was observed in 30.6% of isolates, which
partially correlates with finding by studies19. In
some studies 66% HLAR were observed20.
About 59% of E.fecalis was found to be resistant
to one of the commonly used antibiotic
Amikacin. Twenty percentages of isolates
showed intermediate sensitive to vancomycin by
Kirby-Bauer disc diffusion method. All became
sensitive to Vancomycin by E-test strip except
one.
CONCLUSION
There is increased frequency of isolation of

uncommon Enterococcal species. Thus, definite
identification of Enterococci at species level is
mandatory to assess their variable sensitivity
pattern and treat accordingly. Detection of beta
haemolysis can be taken as an additional
virulence marker in routine laboratory testing.
Since nearly half of the Enterococcal isolates
were identified as a mixed bacterial growth,
ultimate care should be taken before choosing
empirical antibiotic therapy.
REFERENCES
1. Murray BE. Diversity among multidrugresistant enterococci. Emerging Infectious

Diseases 1997; 4: 3747.
2. Donskey CJ, Chowdhry TK, Hecker MT,
Hoyen CK, Hanrahan JA, Hujer AM et al.
Effect of antibiotic therapy on the density of
vancomycin-resistant enterococci in the stool
of colonized patients. New England Journal

of Medicine 2000; 343:192632.
3. Patel R. Clinical impact of vancomycinresistant
enterococci.
J
Antimicrob
Chemother 2003; 51 (3): 1321.
4. Desai PJ, Pandit D, Mathur M, Gogate A.
The prevalence, identification and the
distribution of various species of enterococci
which were isolated from clinical samples,
with special reference to the urinary tract
infections in catheterized patients. India J
Med Microbial 2001; 19: 132-37.
5. Carmeli Y, Eliopoulos G, Mozaffari, E., &
Samore M. Health and economic outcomes of
vancomycin-resistant
enterococci. Arch
Intern Med 1997; 162, 2223-28.
6. Ross PW. Streptococci and Enterococci.
Mackie and Mccartneys Practical Medical
Microbiology, 14th edition. Elsievier, 2006;
268-69.
7. Murray BE. The life and the times of the
Enterococci. Clin Microbiol Rev 1990;3:4665.
8. Facklam RR. Recognition of the Group D
Streptococcal species of human origin by
doing biochemical and physiological tests. J
Appl Microbiol 1972; 23(6):1131-39.
9. Chow JW, Thal LA, Perri MB, Vazquez JA,
Donabedian SM, Clewell DB. Plasmidassociated hemolysin and aggregation
substance production contribute to virulence
in
experimental
enterococcal
endocarditis. Antimicrob
Agents
chemother 1993;37: 24747.
10. The Clinical and Laboratory Standards
Institute.
Performance
standards
for
antimicrobial susceptibility testing, Wayne,
PA.17 the informational supplement; 2007;
M100-S17.
11. Ruoff LK, Spargo DJ, Ferraro JM. The
species identification of the Enterococci
isolates from clinical specimens. J Clin
Microbiol 1990; 28: 435-37.
12. Vandamme P, Vercauteran E, Lammens C
,Pensart N, Ievan M, Pot B et al. Survey of
Enterococcal Susceptibility Pattern in
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Belgium. J Clin Microbial 1996; 34: 257276.

13. Sreeja S, Sreenivasa Babu PR, Prathab AG.
The prevalence and characterization of the
Enterococcus species from various clinical
samples in a tertiary care hospital. J Clin
Diagn Res. 2012; 6(9): 148688.
14. Jain S, Kumar A, Kashyap B, Kaur RI. The
clinico-epidemiological profile and the highlevel
aminoglycoside
resistance
in
enterococcal septicemia at a tertiary care
hospital in east Delhi. Int J App Basic Med
Res 2011;1(2):80-83.
15. Vittal P P, Sambasiva R R and Subash C P.
Emergence of unusual species of enterococci
causing infections, South India. BMC
infectious diseases 2005,5:14
16. Facklam RR, Teixeira LM. Enterococcus. In:
Lollier L, Balows A, Sussman M, editors.
Topley & Wilsons microbiology and
microbial infections. 9th ed. New York:
Oxford University Press; 1998. p. 669-82.
17. Bhat KG, Paul C, Ananthakrishna NC. Drug
resistant enterococci in a south Indian
hospital. Trop Doct 1998; 28:106-7.
18. Facklam RR., Sahm DF. & Teixeira LM.
Enterococcus. In Manual of Clinical
Microbiology, 7th edn 1999; pp. 297305.
ASM Press, Washington, DC, USA.
19. Jones RN, Sader HS, Erwin ME, Anderson
SC. Emerging multiply resistant enterococci
among clinical isolates. I. Prevalence data
from 97 medical centre surveillance study in
the United States. Enterococcus Study Group.
Diagn Microbiol Infect Dis 1995; 21:85-93.
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Antimicrobial resistance of enterococcal
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Saraswathy et al.,
DOI: 10.5958/j.2319-5886.2.2.040

&
Health Sciences
www.ijmrhs.com
Received: 3rd Apr 2013

Research Article
Coden: IJMRHS
Revised: 5th May 2013
Copyright @2013
ISSN: 2319-5886
A STUDY ON CONGENITAL VAGINAL MALFORMATIONS IN RURAL POPULATION OF

NORTH MAHARASHTRA REGION
* Sarita Ajit Deshpande1, Ajit Balkrishna Deshpande 2
1
Assistant Professor, 2Professor, Department of OBGY, Rural Medical College, Pravara Institute of
Medical Sciences, (Deemed University), Loni, Maharashtra, India.
*Corresponding author email: saritadr_anr@yahoo.co.in
ABSTRACT
Objective: To find out types of vaginal malformations in rural population of North Maharashtra, to
study various operative procedures designed for vaginal malformations and to evaluate the use of rubber
mould for McIndoe operation. Method: Eighteen cases of congenital vaginal malformations were
screened in OPD. We found seventeen patients of primary amenorrhea were having congenital vaginal
malformation. One patient of stricture of upper vagina was having normal menstruation. They were
investigated according to the standard protocol. After clinical examination patients were investigated by
U.S.G. and I.V.P. sos and diagnostic laparoscopy, the investigations for operation were Hb, Urine (Alb.
Sug. Microscopy), BSL (R), BUL, Serum creatine. Then all of them were operated between Jan.1985 to
Oct. 2002 under general anaesthesia & the analysis was done. The type of operations done were 1)
Mcindoe operation 2) Pull through operation 3) Excision of imperforate hymen. Results: Twelve cases
of Rokitansky-Kuster-Hauster Syndrome were operated by McIndoe technique. None of the patients
developed V.V.F. or R.V.F. The average vaginal length was 8.76 cms.; Four cases of imperforate hymen
had undergone excision & Two cases of congenital stricture in upper vagina had undergone pull through
operation Conclusions: Use of foam rubber mold is without any pressure necrosis of bladder or rectum.
Keywords: Foam rubber mould, Vaginal malformations, McIndoe
INTRODUCTION
Malformations of vagina though not very

common, are well known to us. About 10% of
infants are born with some abnormality of the
genitourinary system and anomalies in one
system are often mirrored by abnormalities in
another system1. Three main principles govern
the practical approach to malformations of the
genital tract.
The mullerian and wolffian ducts are so closely
linked embryologically that gross malformations
of the uterus and vagina are commonly

associated with congenital anomalies of the
kidney and ureter.
The development of gonads is separate from that
of the ducts. Normal and functional ovaries are
usually present when the vagina, uterus, and
fallopian tubes are absent or malformed.
Gross malformation such as absence of vagina
and uterus may be associated with anomalies in
sex chromosome of the individual.
334
Deshpande SA et al.,
Int J Med Res Health Sci. 2013;2(3):334-340 334

334
In our practice we have come across a variety of

them, from imperforate hymen to congenital
absence of vagina. All of them were operated
accordingly and follow up was done.
The types of Malformations of vagina commonly
reported in the literature are: 2
Absence of vagina: The vagina may be
completely absent or more often, the mullerian
duct portion is absent and the urogenital sinus
part is present as a depression of variable depth.
The condition may be associated with inter
sexuality.
Vaginal Hypoplasia: It is caused by an inherent
fault in Mullerian ducts or by absence of
estrogen stimulus from ovary.
Congenital Stricture or Imperforate vagina: A
congenital incomplete membrane or stricture of
varying thickness in the upper or lower vagina
occurs due to failure to canalise the mulletrian
and sinovaginal bulb tissues which forms the
vagina.
Imperforate hymen
Septate and subseptate vagina: A sagittal
septum may be present in upper vagina or
throughout its length. This is due to late fusion of
mullerian ducts giving rise to two mullerian
tubercles, or because of failure of proper
canalisation of two sinovaginal bulbs.
Double vagina (duplication): It occurs in
association with double vulva, double uterus,
doubles bladder, and urethra, and sometimes
supernumerary lower limb.
Aims and Objectives: 1) To find out types of
vaginal malformations in rural population 2) To
study various operative procedures designed for
vaginal malformations 3) To evaluate the use of
rubber mould for McIndoe operation.
MATERIAL AND METHODS
This was a prospective study done at Mohini

Hospital, Shrirampur & Shri. Sainath Hospital,
Shirdi between 1985 & 2002.
Sample size: 18 patients were included
according to inclusion and exclusion criteria.
Study period: The Study period was seventeen

years starting from January 1985 till December
2002. Patients attending OPD at Mohini
Hospital, Shrirampur, & Shri. Sainath Hospital,
Shirdi, was diagnosed clinically (by taking
history, physical examination) to be having a
congenital malformation of the vagina, were
enrolled in the study. They were investigated
latter by USG, Diagnostic laparoscopy and IVP
(in patients of congenital absence of vagina).
Inclusion criteria: 1) Patients ready to give
informed consent 2) Patients from the age of
menarche to menopause 3) Patients willing to
come for regular follow up 4) Patients who are
married or about to marry within six months of
time in cases of absence of the vagina.
Exclusion criteria: 1. Uncooperative patients 2.
Patients not willing to follow the protocol 3.
Patients above the reproductive age 4. Acquired
vaginal anomalies.
Written informed consent was taken from each
patient.
Out
of eighteen
patients
of vaginal
malformations twelve had undergone McIndoe
operation under spinal anaesthesia. The surgical
technique of McIndoe operation was as follows:
With the patient in lithotomy position, bladder
was catheterised & the balloon of the foleys
catheter was inflated. A transverse incision was
given in the vaginal vestibule and a space
dissected between urethra, bladder anteriorly and
rectum posteriorly, until the under surface of
peritoneum was reached. A split thickness skin
graft was taken from the lateral side of thigh with
the help of Blair Brown dermatome. This was
sutured with chromic catgut No.3 0 on a mould
prepared from foam rubber covered with
condom. The size of mould used was 10 cm. x 5
cm. at the widest part of its circumference. The
mould covered with skin graft was kept in the
space created for vagina. Labial stitches were
applied over the mould.
Mould was kept in place for 7 days and again put
in after cleaning daily for 2 months, and then
kept overnight for 6 months. Follow up was done
335

335
every month for 3 months and then every 3

months interval.
Out of eighteen cases of vaginal malformations
two were of congenital stricture in the upper
vagina. Surgical technique under spinal
anaesthesia was as follows:
Lithotomy position and catherization of bladder
was done. A transverse incision was made
through the vault of short vagina. Sharp and
blunt dissection was made till cervix was
visualised. The lateral margin of the excised
septum was extended widely to avoid
postoperative stricture formation. The edges of
the upper and lower margin of excised septum
were mobilized and anastomosis made of both

margins using 20 chromic catgut.
III. Excision of imperforate hymen: In four
patients of vaginal malformations there was
imperforate hymen. The imperforate hymen was
incised at 2, 4,8,10 Oclock position and cut
edges were excised and sutured with 20
chromic catgut. The Collected altered menstrual
flow was allowed to drain on its own. Vulva was
covered with sterile pads till flow had stopped.
Follow up of all patients were done for two
years at various intervals as mentioned
depending on the type of case.
RESULTS
In our study various types of malformations which we came across are given in table no 1.
Table.1: Type of malformations
Type of malformations
Imperforate hymen
Congenital stricture in upper vagina
Congenital absence of vagina
TOTAL
No.of cases
4
2
12
18
Percentage
22.22
11.11
66.67
-
The various symptoms for which patient visited

O.P.D. were as follows: Seventeen out of
eighteen patients had Primary amenorrhea. One
patient of stricture of upper vagina had normal
menstruation, through a tiny hole situated
laterally. Three patients of imperforate hymen
had pain in the abdomen, while thirteen patients
had dyspareunia and infertility. Out of eighteen
patients five patients were unmarried. The rest of
them were married. In that four were of
imperforate hymen and one was of stricture of
the upper vagina. The cases of imperforate
hymen were under 15 years of age. The

remaining were above 15 years. On examination
in our study all patients were found to be having
normal secondary sex characters. patients of
congenital absence of vagina all patients were
having dimple at introitus with P/R examination
has revealed absence of uterus. In all four cases
of imperforate hymen bulging of blue membrane
at introitus was noticed. The examination
findings of all patients are tabulated in table no 2
as given below.
Table .2: Examination findings

Examination findings
Normal Secondary Sex characters
Bulging blue memberane at introitus
Stricture of upper vagina with pinhole lateral opening
Stricture of upper vagina without opening
Dimple at introitus
Absence of uterus at P/R examination
No.of cases
18
4
1
1
12
12
Percentage
100
22.22
5.56
5.56
66.67
66.67
336
336
Out of eighteen cases of vaginal malformations

two patients of congenital
absence of vagina
had absent left kidney. They were detected by
USG & confirmed on IVP. Out of eighteen
patients
of
vaginal
malformation,
on
laparoscopy, patients of congenital stricture in
upper vagina and imperforate hymen had normal
development of uterus, F. Tubes, fimbrae and
ovaries. Remaining twelve patients, who were of

congenital absence of vagina, all of them had an
absent uterus replaced by a fibrous band with
normal ovaries. Only two out of twelve patients
of congenital absence of vagina had absent
fimbrae and F. Tubes replaced by fibrous bands.
Showed in tables no 3.
Table . 3: Laparoscopy findings

Laproscopy finding
Uterus replaced by fibrous bands
Normal fimbrae with part of normal Fallopian tubes.
Fimbrae and fallopian tubes replaced by fibrous band
Normal ovaries
Nothing abnormal detected
Since the facility of genetic study was not
available nearby, and patients were not willing to
go to the higher center, genetic study could not
be done in all eighteen cases. Out of eighteen
patients twelve had undergone McIndoe
operation where there was a congenital absence
No.of Cases
Percentage
12
66.67
10
55.56
2
11.11
18
100
6
33.33
of vagina, In four patients of imperforate hymen
excision of imperforate hymen was done and in
two patients of congenital stricture in the upper
vagina pull through operation was done as shown
in table no 4.
Table. 4: Surgical procedures done

Types of surgical procedure done
McIndoe operation
Pull through operation
Excision of imperforate hymen.
TOTAL
No.of Cases
12
2
4
18
Percentage
66.67
11.11
22.22
-
Complications
No.of cases
Percentage
Post operative infection
11.11
Accidental injury of bladder during operation
11.11
Accidental injury of rectum during operation
5.56
Table no.5. Complications in McIndoe operation
Results of Follow Up
In McIndoes operation in four out of twelve
patients 100 % graft was taken within 7 days.
While remaining had patchy accepted which

healed within 3 to 4 weeks of operation. In the
337
pull through the operation and excision of

imperforate hymen, the raw area had healed
within 7 days. Patients had come for follow up
for various lengths of time varying from 6
months to 2 years. The mean vaginal length
obtained in McIndoe operation was 8.76 cms.
One patient of congenital stricture of
upper
vagina had conceived and delivered at home
within a year from operation.
Patient of
imperforate hymen had normal regular
menstruation for one year and then was lost to
follow up. Eight out of 12 patients of McIndoe
complained of dyspareunia.
DISCUSSION
Failure of normal development of the vagina may

be due to any embryologic or genetic
abnormality. Briefly, the vagina is developed
from urogenital sinus and the paired mullerian
ducts. The urogenital sinus is formed from
Primitive cloaca as a result of separation of
hindgut by urorectalseptum at 6 wks3The upper
2/3rd and sometimes the whole vagina is formed
from a solid down growth of lower end of fused
mullerian duct. While lower 1/3rd or part or it is
formed from the proliferation of urogenital sinus
tissue (i.e. Sinovaginal bulb). The Process of
canalization is complete until 21st weeks of foetal
life4.
Failureof development of mullerian ducts and
sinovaginal bulb will result in failure of
development of uterus and vagina i.e. Rokitansky
- Kuster - Hauser syndrome.3
While the failure of Mullerian duct down growth
or failure of two components of vagina i.e. upper
2/3rd and lower 1/3rd results in either congenital
stricture in upper vagina or transverse vaginal
septum3 .
The failure of development of hymenal orifice is
not a rare congenital malformation .
Other
aberrations of vaginal development are veginal
adenosis, due to the effect of oestrogen during
organogenesis of vagina and a variety of cloacal
dysgenesis is seen which include congenital

rectovaginal firstula3.
In the present series we have come across twelve
cases of Rokitansky- Kuster-Hauser syndrome,
four cases of imperforate hymen and two cases
of congenital stricture of the upper vagina as
shown in Table No.1
Veginal agenesis was first described in 1572 by
Realdus Columbus5. According to Engstadt6etal
(1949) found it in 1:4000 female admissions in
Mayo Clinic. When a patient with Rokitansky
syndrome are explored surgically the outer
portion of Fallopian tubes are seen continuous
with
attenuated
medallion
cords
of
underdeveloped uterus. There may be bilateral
non-cannulated muscular buds of rudimentary
uterus, described by Kuster7 as uterus biparticus
solidus rudimentarius cum vagina solida. The
ovaries are always present and function quite
well.
In the present series only two patients had total
failure of development including fimbrae, tube
and uterus. While in ten patients fimbrae and part
of fallopian tubes were normal as shown in Table
No.3.
Ulfelder8 suggested that use of I.V.P. to
determine associated anomalies and examination
of nuclear chromatin to determine genetic sex,
would avoid laparotomy. A high percentage of
patients with vaginal agenesis also have urinary
tract anomalies such as absence of one kidney,
horse shoe shaped kidney, pelvic kidney or
duplicate collecting system. Concomitant
urological anomalies are estimated to occur in
25-50% of patients with vaginal agenesis.
According to Counsellor9 and Devis I.V.P. is
must in all cases. Garcia10 & Jones found urinary
tract anomalies in 17 out of 35 patients (48.5 %)
on I.V.P. Unilateral agenesis was most frequent
within 8 cases and 4 of them had pelvic kidney.
In present series, U.S.G. was done in all cases.
Normal USG kidney findings were found in 16
patients. Two patients had absent left kidney
which was confirmed on IVP i.e. in 11.1 % of
cases. Counseller11 and Sluder investigated 15
338
cases of congenital absence of vagina by I.V.P.

and found an absence of left kidney in 6 cases
i.e. 40 %.
Formation of an artificial vagina was first
attempted by Dupuytren12 in 1817. Since then
numerous procedures have been described which
include Franks no surgical method, Williams
Wharton operation, and McIndoe operation.
McIndoe13 and Banister described the procedure
of split thickness skin graft into the newly
formed vagina which was kept in place with
vaginal mold. This is still the procedure of choice
today. As it is simple, and safe. It produces
vagina with almost normal depth and diameter.
In our series final vaginal depth achieved was
from 8.4 to 9.2 cms, with an average of 8.76 cms.
The coitus was painful in eight cases. It is very

important as functional result is more important
than the depth of vagina achieved. Thompson14
et al have reported 81 % success rate after 10
years follow up. Complication in our series is
given in Table No.5 occurred in cases of
congenital vaginal agenesis.
Out of twelve patients of McIndoe, only two had
a postoperative infection which was then cured
with change of antibiotic. The incidence was
almost 16.6 % as compared to an incidence of 17
% in series of Evan s15 (1967). The accidental
injury of the bladder and rectum during operation
was sutured immediately on the table with 3 0
chromic catgut. None of the patients developed
V.V.F. or R.V.F.
Fig.1: A congenital incomplete membrane or stricture in the upper vagina

It is a rare condition. In our series patient of
congenital stricture in upper vagina did not have
the post operative complication. One patient out
of 2 was then seen after 6 months with normal
pregnancy. She had home delivery without
complication. Patients of imperforate hymen also
did not have the post operative complication. All
of them had normal menstruation following an
operation. All of them were seen for two to three
cycles and then were lost for follow up.
SUMMARY
Eighteen cases of vaginal malformations were

operated by various techniques, depending on the
malformations, between Jan 1985 to Oct 2002
are reported. Four cases of imperforate hymen

had undergone excision, two cases of congenital
stricture in upper vagina had undergone pull
through the operation and the remaining twelve
cases
were of
Rokitansky-Kuster-Hauser
syndrome. These twelve cases were operated by
McIndoe technique. One patient of congenital
stricture in upper vagina had conceived within
six months of operation and patient operated with
McIndoe technique had an average vaginal
length of 8.76 cm.
CONCLUSION
The rubber mould is found to be a useful

alternative to acrylic solid mould to reduce the
339
postoperative complications
necrosis of bladder.
like
pressure
REFERENCES
1. Norman Jeffcoate, Pratap Kumar, Narendra

Malhotra.
Jeffcoates
Principles
of
th
gynecology. Jaypee Publishers. 7
edition,
Page no 196,211
2. Hendren Wh, Donahoe PK. Correction of
congenital abnormalities of the vagina and
perineum, J Peadiatr Surg. 1980;15(6):75163
3. Richard F, Mattingly Te. Lindes operative
Gynecology, Lippincott International Edition.
5th Edition, Page No.453.
4. Norman Jeffcoate. Principles of Gynaecology
4th edition Page No.132, 135.
12. McIndoe A, Baniste JB. AutotransfusionConstruction-of-Vagina. J. Obstet. Gynec.

Brit. Emp.1938; 45:490
13. Thompson JD, Wharton LR, TE Linde RW.
Congenital absence of the vagina; ananalysis
of thirty-two cases corrected by the McIndoe
operation. Am J ObstetGynecol. 1957;
74(2):397-404.
14. Evans. Lindes operative Gynecology,
Lippincott International Edition. 1967. 5th
edition Pg;461.
5. Bryan AL, Nigro JA, Counseller VS. One

hundred cases of congenital absence of the
vagina. Surg Gynecol Obstet. 1949; 88(1):7986.
6. Kuster, Leduc B, Campenhout J.Van, sinard
R.Mayer-Rokitansky-Kster-Hauser(MRKH)
syndrome. Am. J.Obstet, Gynec.1968;
100:512
7. Ulfelder H. Agenesis of the vagina. A
discussion of surgical management and
functional and morphologic comparison of
end results, with and without skingrafting.
Am J Obstet Gynecol. 1968 ;100(6):745-51.
8. Counseller VS, Davis CE. Atresia of the
vagina. Obstet Gynecol. 1968; 32(4):528-36.
9. Garcia J, Jones HW Jr. The split thickness
graft technic for vaginal agenesis. Obstet
Gynecol. 1977; 49(3):328-32.
10. Counseller VS, Flor FS. Congenital absence
of the vagina; further results of treatment and
a new technique. Surg Clin North Am. 1957;
37(4):1107-18.
11. Dupuytren,
Linde
R.W.
Operative
th
Gynecology, Ed. 5 , Philadelphia, 1977, J.B.
Lippincott company, page 454.
340
340
DOI: 10.5958/j.2319-5886.2.2.041
pInternational Journal of Medical Research

&
Health Sciences
www.ijmrhs.com
Received: 7th Apr 2013

Research Article
Coden: IJMRHS
Revised: 30th Apr 2013
Copyright @2013
ISSN: 2319-5886
INTRA UTERINE INSEMINATION AN EXPERIENCE IN RURAL POPULATION

* Sarita Ajit Deshpande1, Ajit Balkrishna Deshpande 2
1
Assistant Professor, 2Professor, Department of OBGY, Rural Medical College, Pravara Institute of
Medical Sciences, (Deemed University), Loni, Maharashtra, India.
*Corresponding author email: saritadr_anr@yahoo.co.in
ABSTRACT
Objective:1) To find out efficacy of various ovulation induction protocols in IUI 2) To find out the
efficacy of IUI in treatment of infertility Method: All infertility patients of our OPD underwent a
standard investigation protocol The infertility work-up included patients history, physical examination,
conformation of ovulation by follicular monitoring, tubal patency test by diagnostic laparoscopy, and
semen analysis of male partner & PCT. All women underwent a standard treatment protocol that
included either natural cycle or ovulation induction to achieve superovulation by clomiphene citrate
alone, or combined with gonadotrophins. Follicula monitoring using transvaginal sonography was done
from D6-8 onwards and all women were given injection Human chorionic gonadotrophin 5000 U for
LH surge when the dominant follicle was 18 mm. IUI was Performed at 18 hours and 40 hours from the
time of HCG injection. Semen for IUI was prepared by the standard Swim Up technique, or by the
Density Gradient method. Progesterone (Transvaginal micronized progesterone 200mg/day) for luteal
phase support for 14 days following IUI was given to patients who were affording. Results: Majority of
couples were having primary infertility (60.97%) Patients of secondary infertility were of 39.03% only.
In our study only 11.82% patients were having multiple factors contributing to infertility. Male factor
was in 42.59% of couples as against 30.34% of couples were having only anovulation as causative factor
for infertility. Unexplained infertility was present in 13.82% patients only. The outcome variable for
success of IUI was occurrence of pregnancy. This was defined by delay in menses associated with
presence of positive pregnancy test or a detectable rise in serum beta HCG levels. In our study overall
pregnancy rate per cycle was 8.01% & per couple it was 21.65%. Per cycle fecundity according to the
factor responsible for infertility, the highest success rate was observed in cervical factor (33.33%). For
male factor it was 7.74% and for combined factors overall it was 5.92%. Out of 152 pregnancies that
occurred during study 108 had Full Term live birth of the baby (71.05% Miscarriage was there in 9.87%
patients only. Only three patients had multiple pregnancies (1.97%) and one patient had ectopic
pregnancy. Per cycle fecundity was little better in patients with only anovulation( 10.51%). When we
compared various regimen used for ovulation induction for IUI we found that though percentage of
pregnancies achieved by Low dose HMG either with (13.89%) or without Clomiohene (15.58%),
pregnancy rate achieved with clomiphene alone was 7.43% . This was promising at low affordable cost.
341
Sarita AD et al.,
In our study, we achieved 40.13% pregnancy with second attempt and collectively with first two
attempts pregnancy rate achieved was 71.71%.
Keywords: Intra uterine insemination, Assisted reproduction, Ovarian stimulation in intra uterine
insemination. Swim up technique, Density gradient method
INTRODUCTION
Despite revolutionary advances in the field of

assisted reproduction such as in vitro fertilization
(IVF) intracytoplasmic sperm injection (ICSI)
and subzonal insemination (SUZI), intrauterine
insemination (IUI) remains an inexpensive, noninvasive and effective first line therapy for
selected patients with cervical factor, moderate
male
factor,
unexplained
infertility,
immunological infertility and infertility due to
ejaculatory defects. It is also proposed as therapy
for endometriosis, ovarian dysfunction, and even
for tubal factor. 1 Though the technique of IUI
has remained same, several advances in type of
stimulation protocol, gonadotrophins, sperm
preparation
techniques
and
ultrasound
monitoring have led to promising success rate
with IUI. IUI is preferred conception- enhancing
technique for women 35 years, with functional
tubes, short period of infertility and moderate
male factor, particularly in a rural set up due to
monitory limitations. It is a method of choice vs.
timed intercourse or natural cycle IUI.
MATERIAL AND METHOD
It is Prospective study done at Mohini Hospital

Shrirampur. Written informed consent was taken
from each patient.
Sample size: 702 Patients
Study period: Between May 2001 to December
2012
Inclusion criteria: 1) Patients ready to give
informed consent 2) Patients willing to come for
regular follow up 3) Patients 35 years, with
antral follicular count 5 4) Patients with at least
one functional tube 5) Patients with mild to
moderate male factor sub fertility. 6) Patients

with anovulation and unexplained infertility
Exclusion criteria: 1) Uncooperative patients. 2)
Patients not willing to follow the protocol. 3)
Patients with azoospermia 4) Patients with
bilateral fallopian tube block. 5) Patients with
advanced stage endometriosis ( stage III & IV )
6) Patients with documented failure with
endometriosis stage I & II
All infertility patients of our OPD underwent a
standard investigation protocol.
The infertility workup included patients history,
physical examination, and conformation of
ovulation by follicular monitoring; tubal patency
test by diagnostic laparoscopy, and semen
analysis of male partner & PCT All women
underwent a standard treatment protocol that
included. either natural cycle or ovulation
induction to achieve super ovulation by
clomiphene citrate alone, or combined with
gonadotrophins. Follicular monitoring using
transvaginal sonography was done from D6-8
onwards and all women were given injection
Human chorionic gonadotrophin (HCG) 5ooo IU
for LH surge when the dominant follicle was 18
mm.
IUI was performed at 18 hours and 40 hours
from the time of HCG injection. Semen for IUI
was prepared by the standard Swim Up
technique, or by Density Gradient method.
Progesterone
(Transvaginal
micronized
progesterone 200mg/day) for luteal phase support
for 14 days following IUI was given to patients
who were affording.
342
Sarita AD et al.,
RESULTS
exclusion criteria were observed for 1897

Seven hundred and two sub fertile couples
treatment cycles.
enrolled in our study acc/to the inclusion and
Table. 1: Baseline Characteristics of Couples Undergoing IUI
Variable
No. Of Couples Percentage Of Couples
Age Of Female
30 years
442
62.96%
30 years
260
37.04%
Age Of Male Partner
30 years
372
52.99%
30 years
330
47.01%
Duration Of Infertility
5 years
485
69.09%
5-10 years
147
20.94%
10 years
70
9.97%
Tpe Of Infertility
Primary
428
60.97%
Secondary
274
39.03%
It is evident from table no1, in most of the

couples both the partners were 30 years of age.
Female partners of 30 years were 62.96% &
male partner were 52.99%. Majority of couples

were having primary infertility (60.97%) Patients
of secondary infertility were of 39.03% only.
Table. 2: Cycle fecundity by factor causing infertility

diagnosis
No Of Patients No Of cycles No Of Pregnancy Fecundity
Male Factor
299
749
58
0.08%
Anovulation
213
495
52
0.11%
Tubo-Peritoneal
a)Endometriosis
2
8
1
0.13%
b)Peritubal adhesions
2
6
1
0.17%
c)one side tubal block
1
6
0
0%
Cervical factor
5
12
4
0.33%
Combined factors
a)Male Factor + Anovulation
82
249
14
0.06%
b)Endometriosis + Anovulation
1
4
1
0.25%
Unexplained
97
368
21
0.57%
In our study only 11.82% patients were having

multiple factors contributing to infertility. Male
factor was in 42.59% of couples as against
30.34% of couples were having only anovulation
as a causative factor for infertility. Unexplained
infertility was present in 13.82% patients only.
The outcome variable for success of IUI was
occurrence of pregnancy. This was defined by
delay in menses associated with presence of
positive pregnancy test or a detectable rise in
serum beta HCG levels. In our study overall

pregnancy rate per cycle was 8.01% & per couple
it was 21.65%.
Per cycle fecundity according to the factor
responsible for infertility, the highest success rate
was observed in cervical factor (33.33%) . For
male factor it was 7.74% and for combined
factors overall it was 5.92%. . Per cycle fecundity
was little better in patients with only anovulation
(10.51%).
343
Sarita AD et al.,
Table. 3: Pregnancy Outcome In Patients Conceived By IUI

outcome variable
No. Of Females Percentage of Females
Live Births
Term
108
71.05%
Preterm
3
1.97%
Still Births
1
0.66%
Miscarriage
15
9.87%
Ectopic Pregnancy
1
0.66%
Multiple Pregnancy
3
1.97%
Ongoing Pregnancy
8
5.26%
Lost To Follow Up
13
8.55%
Out of 152 pregnancies that occurred during study 108 had Full Term live birth of the baby (71.05%).
Miscarriage was there in 9.87% patients only. Only three patients had multiple pregnancies (1.97%) and
one patient had ectopic pregnancy.
Table.4: The regimens and clinical evidence of their benefits
Type of regimen used for superovulation No Of Cycles No Of Conceptions % of prenancy per Cycle
Natural cycle
16
1
6.25%
CC+HCG
1548
115
7.43%
HMG+HCG
a)Low Dose
154
24
15.58%
b)High dose
19
1
5.26%
CC+HMG + HCG
a)Low Dose
72
10
13.89%
b)High Dose
15
1
6.67%
When we compared various regimens used for

ovulation induction for IUI we found that though
the percentage of pregnancies achieved by Low
dose HMG either with (13.89%) or without

Clomiohene (15.58%), pregnancy rate achieved
with clomiphene alone was 7.43% . This was
promising at low affordable cost.
Table. 5: Cycle Fecundity By Attempt Of IUI

No. Of Attempts For IUI
No Of Patients
1
2
3
4
5
702
648
392
82
45
28
Pregnancy/cycles Fecundity
48
0.068
61
0.094
36
0.092
4
0.049
2
0.044
1
0.036
In our study, we achieved 40.13% pregnancy with second attempt and collectively with first two
attempts pregnancy rate achieved was 71.71%.
344
Sarita AD et al.,
Table.6: Effect of sperm parameter on IUI
Sperm Parameters
No Of Cycles No Of Patients No Of Conceptions % of Conception Conception/Cycle
Sperm Count
a) 5
66
10
1
10%
0.015
b) 5 - 10
573
143
30
20.98%
0.052
c) 10- 20
340
141
25
17.73%
0.074
d) 20
918
403
96
23.82%
0.105
Sperm Motility
WHO Motility grade
a) a+b 50 with grade a 25
807
409
101
24.69%
0.125
b) a+b 50
1090
293
51
17.41%
0.047
Table.7: Complications in IUI
Complictions in IUI
No of Females Percentage of Females
Cervical contact bleeding
68
9.69%
Abdominal Cramping
104
14.82%
Spontaneous abortions
10
1.43%
Blighted ovum
5
0.71%
Ectopic Pregnancy
1
0.14%
Infections
nil
0%
OHSS
nil
0%
Multiple pregnancy
3
0.43%
DISCUSSION
Super ovulation coupled with intrauterine

insemination is considered to be a popular
treatment option for women 35 years, functional
tubes, short period of infertility and moderate
male factor, particularly in rural population. The
universal preference for this method is based on
the hypothesis that both these methods increase
the proximity of gametes in the reproductive
tract. Therefore this treatment modality is often
advised before attempting more invasive
therapies such as IVF, gamete intrafallopian
transfer2 The National Institute of Clinical
Excellence (NICE), UK has revised the evidence
for assessment and treatment of infertile couples
and recommended that the IUI should be offered
to couples with infertility because it is as
effective as IVF, less invasive and requires fewer
resources3 The rational put forth in support of
super ovulation & IUI is that ovarian stimulation

corrects
subtle,
unpredictable
ovulatory
dysfunction and there is increased probability of
conception if increased density of motile
spermatozoa is placed closer to multiple
fertilizable oocytes. Hence it is considered to be a
viable treatment option for male factor, cervical
factor and unexplained infertility.4
\In this study we have analysed couples with
male and female subfertility undergoing
superovulation with IUI. In our study the overall
pregnancy rate per cycle was 8.01% as against
8.2% and 9.2 percent reported by Steures et al5 &
Iberico et al6 respectively are comparative. The
pregnancy rate per couple was 21.65% in our
study as compared to 28.1% reported by
Shibahara et al.7
Sarita AD et al.,
345
IUI may be performed with or without

superovulation depending on the patients
characteristics.
Better IUI outcome is seen in terms of number of
preovulatory follicles, clinical and ongoing
pregnancy rates (OPRs), and live birth rates
following ovulation induction(OI) compared with
the natural cycle8,9 However, Chen and Liu
concluded though stimulated cycles of IUI is
superior to natural cycle of IUI in patients 35
years, natural cycle is preferable for
Patients 35 years8 In our study conception rate
of natural cycle was 6.25% as against with
Superovulation by various methods was 8.037%
Ovarian stimulation by clomiphene citrate (CC)
and IUI remains the first choice treatment for
ovulatory dysfunction, unexplained infertility,
endometriosis, male subfertility. 9 with pregnancy
rate averaging 7% per cycle 10 Owing to the
negative influence of CC on endometrial
thickness, the medication should be reduced to
three days in patients with retarded endometrial
growth confirmed on USG. 11 In our study
pregnancy rate was 7.43%.
Gonadotrophin such as FSH and HMG, alone or
in conjunction with the GnRH agonist /
antagonist, are often used for ovulation
induction. In our study we used HMG in a daily
low dose of 75IU of HMG + HCG and in 19
patients higher doses of HMG were required with
HCG. Low dose protocols are advised since
pregnancy rates do not differ from those obtained
with high dose regimens. Prospective
randomized trials are needed to determine
whether daily or alternate day FSH is to be given
for better results. 12
Clomifene citrate may be used in conjunction
with
gonadotrophins/dexamethasone
for
stimulation. Combination protocols are less
costly and equally effective, with potentially less
multiple births than with gonadotrophin alone.
In our study we used CC+HMG+HCG in low
doses of 75 IU HMG in 72 patients, while 15
required higher doses of HMG,.the conception

rate was 13.89% & 6.67% respectively.
There are several sperm separation techniques,
and these are based on different principles like
migration, filtration or density gradient
centrifugation (DGC). Swim up yields a high no.
of progressively motile sperm count and
effectively separates sperm from bacteria and cell
debris; it is of limited use in case of low sperm
count and asthenozoospermia, where DGC is
useful. A single sperm defect may be rescued by
DGC. The time of centrifugation is more
important than g-force for inducing ROS
formation in semen, and shorter centrifugation
period in preparation for ART may be beneficial.
13
In our study centrifugation time was 10
minutes for Swim up method & 20 minutes for
DGC..
Luteal phase support with vaginal progesterone
gel (Cione 8%) yields significantly higher
CPR/cycle and per patient compared to patients
who received no luteal phase support 14
In our study Progesterone (Transvaginal
micronized progesterone 200mg/day) for luteal
phase support for 14 days following IUI was
given to patients who were affording.
Studies have reported significantly better
pregnancy rates following double insemination
(18 and 42 hour after HCG ) versus single
insemination ( 34 hours after HCG ) 15 Despite
the 36 hour being preferred timing for IUI, no
statistical differences regarding pregnancy rates
has been reported between 24 hour and double
insemination ( 12h & 36h )16
In our study the cycle fecundity by no of
attempts was6.84 % after first IUI & increased
subsequently to 9.41 % after second IUI.
Thereafter fecundity declined sharply from fourth
IUI. Khalil et al., a reported highest pregnancy
rate in first treatment cycle 17 Four to Six IUI
cycles may be performed before considering
alternate therapy such as IVF 18
Patients age 35years is a favourable predictor
of outcome of IUI, irrespective of the method of
346
Sarita AD et al.,
sperm preparation used 19 According to aetiology,

Pregnancy rates/cycle may vary among women
with different aetiologies. The cumulative
pregnancy rates varied greatly by diagnosis from
16% for patients with male factor infertility to
60% for patients with ovulation disorder 20
Cervical factor yields a favourable outcome 5 In
our study pregnancy rate per cycle for cervical
factor was 33.33% , for male factor alone it was
7.74% but with anovulation it was 5.62%. For
anovulation alone pregnancy rate per cycle was
better (10.51%).
Patients with original sperm motility 30% had
a higher cumulative pregnancy rate (74%) than
patients with motility 30% with a four times
increase in PR with an increase in motility of
30% 21 Significantly higher PR have been
reported with samples with normal sperm
morphology of 4% (according to Krugers
criteria) compared to 4% 22 In our study
conception rate per cycle in the group between
sperm count 5 - 10 was marginally better
(20.98%) as compared to count between 10 -
20 (17.73%). According to WHO criteria for
sperm motility, patients having motility grade
a+b 50% before sperm wash with grade a
25% had a better conception rate 24.69% as
compared to other group of sperm motility grade
a+b 50% ( 17.41%).
Though complications after IUI are rare we
observed mild abdominal discomfort and or
cramps (14.82%) and cervical contact bleeding in
9.69% of patients. Studies have reported slight
cervical contact bleeding and mild abdominal
discomfort and or cramps. 24
Vaginal administration of misoprostol at the time
of IUI is associated with a significant increase in
vaginal bleeding and abdominal cramping rates
does not seem to enhance the outcome 25
Spontaneous abortions, blighted ovum, and
ectopic pregnancies have been reported in COHIUI cycles 26 In our study spontaneous abortion
was to the tune of 1.43% and blighted ovum was
in 1.43% of patients.
Infectious complications associated with IUI are

frequently cited. According to Sacks and Simon,
Most reported cases of infection fail to show
evidence for the actual presence of infection, and
the prevalence is unaltered by the administration
of prophylactic antibiotic or washing the semen
sample with antibiotic. 27 In our study we did not
have an infection or OHSS.
The adverse effect of COH, such as OHSS and
Multiple pregnancies are a concern 28 Miscarriage
rate ranging from 11.8% 29 to 34% 30
Sarita AD et al.,
CONCLUSION
In rural areas where masses cannot afford

expensive health care, IUI is a simple, cost
effective, non-invasive first line therapy for
cervical factor, anovulatory infertility, moderate
male factor, unexplained infertility, and
immunological infertility. Strict patient selection
criteria
with
individualizing
stimulation
protocols tailored according to age and
aetiological factor with a strict cycle canccelation
policy will help to reduce the associated
complications, such as multiple pregnancies and
OHSS, while maximising the overall pregnancy
outcome. Three to six IUI cycles should be
offered to patients before considering alternative
therapy with IVF/ICSI.
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DOI: 10.5958/j.2319-5886.2.3.042

&
Health Sciences
www.ijmrhs.com Volume 2 Issue 3 July - Sep Coden: IJMRHS Copyright @2013 ISSN: 2319-5886
Received: 1st Apr 2013
Accepted: 2nd Mar 2013
Research article
CONSOLIDATE EFFECT OF VIBHAGHA PRANAYAMA, NADISHUDDI PRANAYAMA,
SAVITHIRI PRANAYAMA AND KAPALABHATI PRANAYAMA ON THE PULMONARY
FUNCTIONAL STATUS OF YOUNG HEALTHY MALE SUBJECTS
Senthil Kumar K1, Jeneth Berlin Raj T2, Prema Sembulingam1, Tripathi PC3
1
Department of Physiology, Madha Medical College & Research Institute, Chennai

Department of Physiology, Kapaga Vinayagar Institute of Medical Science & Research Center
3
Department of Physiology, Rajah Muthiah Medical College, Annamalai University, Chidambaram.
2
*Corresponding author email: drksk.cool@gmail.com

ABSTRACT
Introduction: Pranayama is believed to increase the respiratory stamina, relax the chest muscles,
expand the lungs, raise energy levels, calm the body and cause over-all improvement in lung functions.
In the present study an attempt had been made to assess the authenticity of such changes.
Methods: 60 male medical students in first year MBBS in the age group of 18 to 20 were recruited for
this study. Thirty were in the control group who did not practice pranayama and the other thirty were in
the study group who underwent the regular practice of pranayama daily for 30 minutes in the morning.
Four types of pranayama namely Vibhagha pranayama, Kapalabhati pranayama, Nadi suddhi pranayama
and Savithri pranayama were chosen for this study. Pulmonary function test was done to measure vital
capacity, forced vital capacity, forced expiratory volume in first second, peak expiratory flow rate and
maximum ventilatory volume before and after six weeks. Results: There was significant increase in all
these variables (p < 0.001) in the study group after 6 weeks of pranayama, whereas, control group did
not show any significant change in these variables. Conclusion: The results of this study show the
combined effect of different types of pranayama in improving the lung functions within the short period
of six weeks.
Keywords: Yoga, Pranayama, Pulmonary function tests, Autonomic nervous system,
INTRODUCTION
Pranayama is a type of breathing technique in

Yoga. Yoga is an age-old Indian Science but was
not very popular until recent periods because it
was practiced in some remote ashrams by
selected group of people known as yogis and
sadhus. However, in last two decades, it has
become popular among common men and the
importance, techniques and application of

pranayama and its validity in maintaining overall
health of an individual have been understood and
accepted by public, thanks to the research
documentation in the literature1-5.
The yogis claim that secret of normal health is
the harmony between mind and body. Yoga
350
Senthil Kumar et al.,
Int J Med Res Health Sci.2013;2(3):350-356
brings this harmony through three main

practices, viz., asanas, pranayama and
meditation. As per Indian philosophy, the word
Pranayama refers to prana and prana is
considered to be the core of energy in the
universe. Prana refers to breathing which is the
vital link between the body and the mind.
Disruption of this vital link creates chaos in the
harmony
of
physical,
physiological,
psychological, emotional and spiritual aspects of
life2.
There are different methods of practicing
Pranayama. Some are on slow and soft rhythm
and some are on fast and forceful rhythm.
Whatever may the type of pranayama, the
beneficiary effects of it are well documented
both in normal healthy conditions6-10. and in
diseased conditions11-14. Its positive effects on
respiratory system are amazing. It increases the
respiratory stamina, relaxes the chest muscles,
expands the lungs, raises energy levels, calms the
body and causes over-all improvement in lung
functions15, 16. Lung functions are assessed by
pulmonary function tests (PFT) which help in
physiological and clinical assessment of the
respiratory status of a person.
However, acceptance of Pranayama as a natural
health process by the young college going
students is still a query. In the present study, an
attempt had been made to see the willingness of
the young healthy medical students in practicing
pranayama and the outcome of the practice on
some vital respiratory parameters, viz., vital
capacity (VC), forced vital capacity (FVC),
forced expiratory volume in first second (FEV1),
Peak expiratory flow rate (PEFR), and maximum
ventilatory volume (MVV)
MATERIALS & METHODS
60 male medical students in the age group of 1820 years were recruited from Rajah Muthiah
Medical College for the present study. All were
normal healthy students without any history of
allergic disorders, respiratory disorders, systemic
diseases,
cardiovascular
diseases
and
neurological disorders. None of them were

smokers or drug abusers. They were not athletes
or sports persons and they were not involved in
any sort of routine exercise like regular walking.
Ethical clearance was obtained from the
Institutional Ethical committee. Written informed
consent was obtained from all the subjects after
explaining the procedure and giving the
assurance that they could withdraw from the
study whenever they want.
Anthropometric measurements were taken to
ensure that there was no significant difference in
the age, height and weight of the subjects. They
were divided into two groups viz., control group
and study group with 30 subjects in each. The
control group did not undergo pranayama
practice. The study group practiced pranayama
for six weeks. The PFT was done for all the
students on the first day and one day after the
end of six weeks. The respiratory parameters
were recorded by using Medikro windows
spirometer (Model-M9831-1.8-04).
The subjects were instructed to report in the
Physiology laboratory between 6.30 8.00 AM.
The first phase of recording of PFT was done
before beginning the session of pranayama. The
second phase of recording was done after six
weeks: in study group with pranayama training
and in control group without pranayama training.
All recordings were done around the same time
to avoid any time bias. Pranayama was taught by
a yoga master and the daily practice was
supervised by the same person.
Procedure for pranayama: Four types of
pranayama,
viz.,
Vibhagha
Pranayama,
Kapalabhati,
Nadishuddi,
and
Savithiri
Pranayama were chosen for the present study.
Out of these four types, Vibhagha Pranayama,
Nadishuddi pranayama and Savithiri Pranayama
are on slow and soft rhythm and Kapalabhati
pranayama is on fast and forceful rhythm. All
procedures were carried out for half an hour
daily. The subject was instructed to sit in normal
sitting position with legs crossed on one another
and both the arms stretched straight and placed
351
on respective knees (padmasana) or sitting erect

in any comfortable position17, 18, 19
Vibhagha Pranayama: It is otherwise called as
sectional breathing. It comprises of three
sections:
Abdominal
breathing,
thoracic
breathing and clavicular breathing.
1. Abdominal breathing (Adhama): It is also
known as diaphragmatic breathing. The subject
was instructed to sit in an erect posture with his
fingers on either side of the naval and elbows
resting at the sides. He exhaled slowly,
continuously and completely by drawing the
abdomen inwards followed by inhalation into the
naval area taking two seconds for each. Then he
stopped the breath for a second and the cycle was
repeated.
2. Thoracic breathing or chest breathing
(Madhyama): In the same posture, the hands
were kept on either side of the rib cage and three
breaths were taken starting with inhalation
followed by exhalation taking two seconds for
each. Here the air was filled in the chest and not
in the abdomen
3. Clavicular breathing (Adhya): In the same
erect posture, the fingers were placed underneath
the clavicles and the breathing was carried out by
inhaling for 2 seconds, holding the breath for one
second, exhaling for 2 seconds and holding the
breath for one second. The whole procedure was
repeated 10 times
Kapalabhati pranayama:
In padmasana
position, the subject was instructed to exhale
with full force by squaring the stomach inwards
after deep inspiration. This act throws the
abdominal gas out with a jerk. The whole
procedure should be completed in one second. It
was repeated ten times
Nadisuddhipranayama: It is also known as
alternative nostril breathing: In padmasana
position, the subject was instructed to block the
left nostril with the tip of the right hand ring
finger and exhale and inhale through his right
nostril. This was followed by blocking his right
nostril and exhaling and inhaling through the left
nostril. Exhalation was done in two seconds and
inhalation was done in one second. This whole
performance was considered as one cycle.

During this process, the breathing was kept slow
and rhythmic. This was repeated ten times.
Savitri pranayama: In this type of pranayama,
Inhalation and exhalation were followed by
retention of air also. Inhalation was done for six
seconds; retention was done for 3 seconds
followed and exhalation for 6 seconds and
retention 3 seconds.
This procedure was
repeated
for
10
times
Statistical Analysis: The data were analyzed in
SPSS, version 17. As there were significant
differences in the values of first phase reading
between study group and control group, (except
MVV), these two groups were randomized
before analyzing the values by applying
ANCOVA (Analysis of Co-variance).
Reason for selecting ANCOVA: In many
experiments, the outcome of a variable depends
on the magnitude of the variable before
subjecting
the
experimental
units
for
experimentation. As such, it may be necessary to
analyse the outcome values in relation to initial
values. In some other cases, the outcome of a
particular variable may be dependent on the
outcome of another variable. Analysis of Covariance is a technique that enables such
analysis. This technique combines features of
analysis of variance and regression analysis.
RESULTS
Anthropometric parameters: There was no
significant difference in the age, height and
weight between the study group and control
group (Table 1)
First Phase VC, FVC, FEV1 and PEFR were
significantly higher in control group than in the
study group. MVV did not show any significant
difference between the groups (Table 2).
Second phase There was significant increase in
VC, FVC, FEV1, PEFR and MVV (p < 0.001) in
the study group after 6 weeks of pranayama,
whereas, control group did not show any
significant change in these variables after six
weeks (Table 3)
352
Table. 1: Anthropometric parameters
Study group
Control group
Parameters
Mean SD
Age (Years)
Mean SD
t
value
p
value
18.833 0.747
18.600 0.770
1.370
< 0.182
Height (cm)
174.200 5.610
173.300 4.340
0.606
< 0.527
Weight (kg)
70.167 6.613
70.933 7.172
0.430
< 0.670
Significant level fixed as p < 0.05

Table. 2: Comparison of first phase of readings of Respiratory parameters in study and Control groups
Study group
Control group
Parameters
Mean SD
VC (L)
Mean SD
t
value
p
value
3.595 0.697
4.138 0.772
2.859
< 0.006
FVC (L)
3.432 0.656
3.804 0.627
2.247
< 0.028
FEV1 (L)
3.335 0.639
3.736 0.619
2.468
< 0.017
PEFR (L/sec)
7.540 1.857
9.320 2.053
3.520
< 0.001
MVV (L/min)
95.031 19.089
96.927 11.112
0.470
< 0.640

Table 3: Comparison of first and second phase of readings of Respiratory parameters in study group and
Control groups
Para
Study group
Control group
p value
meters
ANCOVA
Before
After
Before
After
3.5950.697
4.095 0.79
4.14 0.772
4.004 0.575
Group 9.017
Pretest 45.394
G < 0.004
p < 0.001
3.4320.66
3.9780.66
3.80 0.627
3.781 0.622
Group 38.219
Pretest 184.827
G < 0.001
p < 0.001
FEV1
(L)
3.3350.64
3.901 0.62
3.74 0.619
3.638 0.563
Group 49.486
Pretest 158.250
G < 0.001
p < 0.001
PEFR
(L/sec)
7.541.86
8.6831.80
9.32 2.053
9.127 2.035
Group 14.916
Pretest 169.831
G < 0.001
p < 0.001
94.4929.989
Group 134.644
Pretest 80.163
G < 0.001
P < 0.001
VC (L)
FVC
(L)
MVV
(L/min)
96.93 11.11
95.0319.09
113.2571.80

DISCUSSION
The results of the present study confirms the

claim of the previous studies that pranayama is
beneficial in improving the lung volumes and
capacities6, 7, 10, 12, 19, 20. Literature also throws
light on the improvement of respiratory

efficiency after pranayama by observing the
increase in chest expansion, breath holding time
and PEFR10, 21. The unique feature of the present
353
study is that only breathing technique

(pranayama) was used here without the
involvement of physical movements (yogasanas)
and mental control (meditation) whereas most of
the previous studies employed all the three parts
of Yoga to show their positive effects. So our
results reflect exclusively the effect of
pranayama alone on the betterment of respiratory
functions.
Kapalbhati pranayama is the only physical and
breathing
technique
useful
for
mind
detoxification and purification. In all of the
cleansing routines of yoga, kapalbhati is the only
one which can cleanse both the mind and the
body using only breath. As a de-stressing tool,
kapalbhati breathing has shown remarkable
results. Some of the more prominent yoga gurus
have worked hard to popularize this technique all
over the world. It is this reason that the technique
is often also known as baba Ramdev kapalbhati.
It is interesting to know how practice of any type
of pranayama improves the respiratory
efficiency. It is speculated that pranayama
influences the functional status of the autonomic
nervous system through a neural reflex
mechanism in the superior nasal meatus7, 8.
Basically breathing is an automatic process
regulated by the respiratory centers in the brain
stem. This center, in turn, is controlled by the
higher centers in the cerebral cortex. Normally,
dorsal group of neurons in the medulla oblongata
maintains the rhythmicity of respiration and the
pneumotaxic center in the pons controls the
duration of inspiration by transmitting the
suprapontine impulses that are responsible for
voluntary inspiration and expiration22, 23.
According to Ankad RB etal6 and Makwana K et
al24, daily practice of pranayama slows down the
rhythmicity of respiration by prolonging the
phases of inspiration and expiration voluntarily
resulting full stretching and strengthening of
respiratory muscles. This enables the maximum
working capacity of the respiratory apparatus
which is reflected in the increased lung volumes
and capacities as seen in the present study also
and more expansion of the chest wall and

increased breath holding time 7, 10.
Another interesting factor is that, in normal
course of breathing, inspiration is an active
process and expiration is a passive process. But
practice of pranayama, especially kapalabhati,
reverses the episode; expiration becomes active
process and inspiration becomes a passive
process. It is believed to induce the reverse flow
of nerve impulses to and from the brain
facilitating the stimulation and awakening of the
centers20.
In the present study, only young boys with the
narrow age group of 18 to 20 years participated.
This is important because it eliminates the gender
influence and age bias. And also the results of
our study proves the beneficial effects of
pranayama alone which otherwise called as
breathing exercise. So anybody can do it without
religious stigma. Fortunately the young medical
students willingly participated in this study and
the feed-back was very encouraging: even after
research study period was over, they were
willing to continue pranayama and some more
students joined them also.
However, there are limitations in the present
study like less number of subjects, non-inclusion
of female subjects and omission of noting heart
rate, blood pressure, body mass index and body
fat percentage. Further study is underway to
rectify these drawbacks and to understand the
exact mechanism by which any type of
pranayama influences the betterment of the overall health.
CONCLUSION
In summary, all types of pranayama or breathing

techniques are beneficiary in improving the
respiratory functions in normal young healthy
college going male students. As the results are
encouraging, this can be popularized among the
students of both genders for improving not only
respiratory efficiency but also general health.
354
ACKNOWLEDGEMENT
The authors would like to acknowledge the vital

role played by the following persons in
successfully completing this project:
We are thankful to Dr. M S Viswanathan, MS,
Medical Superintendent of Rajah Muthiah
Medical College & Hospital, who is also in
charge of Yoga Center for permitting us to use
the Yoga Center.
Our thanks are due to Dr. A. John William Felix,
M.Sc., Ph.D, Reader cum Statistician,
Department of Community Medicine, Rajah
Muthiah Medical College & Hospital for his
valuable guidance in Statistical analysis of our
Data.
We are deeply indebted to S. Natarajan, M. Phill,
Yoga Master in Yoga Center at Annamalai
University who took the responsibility of training
and supervising the students while performing
Pranayama.
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DOI: 10.5958/j.2319-5886.2.3.043

&
Health Sciences
Accepted: 2nd May 2013
Research article
EVALUATION OF UNDERGRADUATE MEDICAL STUDENTS LEARNING ENVIRONMENT
IN GOA: A CROSS- SECTIONAL STUDY
*Dsouza Delia
Assistant Professor, Department of Preventive and Social Medicine, Goa Medical College, Bambolim,
Goa, India.
*Corresponding author email: deliadsouza@rediffmail.com
ABSTRACT
Background: An increase in the medical student intake capacity from 100 to 150 seats in Goa Medical
College during the academic year 2012-2013, led the author to assess the undergraduate Medical
students learning environment with a view to suggest policy changes that enhance learning experience.
Objective: To describe some of the preferences of the undergraduate Medical students regarding their
learning environment with the aim of making the environment more conducive to learning. Methods: A
cross sectional study design was used. Student volunteers from all the three phases of MBBS course
were invited to participate in the study and after obtaining informed consent, data was collected through
predesigned pretested self administered structured anonymous questionnaires. Of the total 446
undergraduate students from various semesters, 387(86.77%) students participated in the study. Data
were entered in SPSS software (version.17) and analyzed using descriptive statistics. Results: For
lectures 53.7% of the study participants preferred small group teaching (20-30 students). Most (62%)
believed that 30-45 minutes was the ideal duration for a lecture, the attention span during lecture classes
as admitted by 44.2% was only 20-30 minutes. Most of the students (66.9%) thought multimedia to be
the most effective teaching tool followed by traditional blackboard teaching and transparencies. Most
students (62.5%) favored the multiple choice question and short question system of assessment.
Conclusion: Duration of lectures should be reduced to 30-45 minutes. More of multiple choice and
short questions rather than long questions need to be part of our student assessment.
Keywords: Medical students, Attention span, Medical education, Learning environment, Teaching
methods.
INTRODUCTION
The Bachelor of Medicine and Bachelor of

Surgery (MBBS) course in India is about four
and a half years duration which is followed by
one year of compulsory rotational Internship.
The period of four and a half years is divided

into three phases covering nine semesters: Phase
I (two semesters) where Pre-clinical subjects
such as Human Anatomy, Physiology,
357
Dsouza et al.,
Biochemistry and Introduction to Community

Medicine including Humanities are taught. Phase
II (three semesters): During this phase Paraclinical and clinical subjects namely Pathology,
Pharmacology, Microbiology, Forensic Medicine
including Toxicology and part of Community
Medicine are taught. In Phase III (four
semesters) subjects taught are Medicine and its
allied specialties, Surgery and its allied
specialties, Obstetrics and Gynecology and
Community Medicine.
The learning environment of a medical school
has a significant impact on students
achievements and learning outcomes1, 2. Students'
experiences of the learning environment are
related to their achievements, satisfaction and
success 3, 4. Therefore a feedback from students
on their learning environment plays an important
role in the teaching learning process so as to
achieve the desired Institutional objectives.
Medical education is a dynamic process and
modifications in teaching-learning methodology
should be periodically considered 5. An increase
in the number of seats for medical students from
100 to 150 during the academic year 2012-2013
led the author to assess the learning environment
with a view to planning for the future. The
Objective is to describe some of the preferences
and perceived difficulties of the undergraduate
Medical students regarding their learning
environment so that remedial measures could be

taken to enhance students learning experiences.
A cross sectional study was conducted at Goa

Medical College, Goa, India from November
2012 to January 2013.Student volunteers
belonging to all the three phases of Bachelor of
Medicine and Bachelor of Surgery (MBBS)
course were invited to participate in the study
and after obtaining informed consent, data was
collected using predesigned, pretested self
administered
structured
anonymous
questionnaires. Enrollment of students during the
academic year 2012-2013 in the first semester
was 150 students, third semester was 100
students, and 98 students each in the fifth and
seventh semesters. The clinical phase students of
eighth and ninth semesters were not part of this
study. Of the total 446 registered in Pre and Para
clinical phases, all students (149 males and 238
females) present on the day, volunteered to
participate in the study with a total of
387(86.77%) respondents. The study received
approval by the Institutional Ethics Committee.
Data were entered in a Statistical Package for
Social Sciences (SPSS trial version.17) and
analyzed using descriptive statistics. Chi square
test was used to assess differences between the
genders,with a significance level set at p<=0.05.
RESULTS
Table: 1. Preferences of students pertaining to their learning environment.

Student preferences
Male
n=149(%)
Preferred strength of (20-30) students for 73(48.9)
lecture
Break between lectures >15 minutes
19(12.8)
Female
n=238(%)
135(56.7)
Total
n=387(%)
208(53.7)
p value
13(5.5)
32(8.3)
0.011
Lab coat required during practicals

Attendance be made Compulsory
Web enabled e-learning practical sessions
227(95.4)
104(43.7)
81(34)
360(93)
150(38.8)
147(38)
0.021
0.011
0.042
133(89.3)
46(30.9)
66(44.3)
0.137
Multiple responses taken into consideration hence the total of percentages do not add to 100.p <= 0.05 taken as statistically
significant.
358
Dsouza et al.,
Table: 2. Student preferences for teaching methods and assessment.

Student preferences
Male
Female
Total
p value
n=149(%) n=238(%) n=387(%)
Quiz as beneficial method of
learning
23(15.4)
13(5.5)
36(9.3)
0.001
Use of projector with LCD for 87(58.4)
172(72.3)
259(66.9) 0.004
teaching
Use of blackboard
57(38.2)
68(28.6)
125(32.3) 0.047
Multiple choice questions
107(71.8)
135(56.7)
242(62.5) 0.002
Short questions
58(38.9)
119(50)
177(45.7) 0.033
Multiple responses taken into consideration hence the total of percentages do not add to 100.
P <= 0.05 taken as statistically significant.
DISCUSSION
The study comprised of 149(38.5%) males and

238(61.5%) female student participants from the
Pre and Para clinical semesters. First semester
n=138 (52males vs.86 females), third semester
n=83(32 males vs. 51 females), fifth semester
n=85(32 males vs. 53 females) and seventh
semester n=81 (33 males vs. 48 females)
volunteered to participate in the study. Ages
ranged between 17 and 24 years (mean age 18.9
years), with 68.5 % of males vs. 73.9% of
females coming from urban backgrounds,
whereas 31.5% males vs. 26.1% of females came
from a rural background. Male to female ratio of
the study respondents was 1:1.6. Around 39.6%
of males and 41.6% of female students reported
having at least one doctor in their family
(mother, father, sibling or a close relative).This
finding in our study was higher compared to
another study 6 which reported 29% of students
having a doctor parent. More than half of the
study participants opted for medical profession
due to interest in the field (50% males vs. 69.8%
females, p=0.02), a good proportion reported
they chose Medicine to be of service to the
people (36.5% males vs.59.3%, p=0.009). More
males (32.7%) than females (12.8%) chose
Medicine for social recognition which was
similar to findings of other similar study 7 and
the difference was statistically significant (p=0.
004). Multiple responses were taken into
consideration hence the total of percentages does

not add to 100. Around 19.2% males and 15.1%
females from first semester felt that they were at
a disadvantage with the increase in the number of
MBBS seats from 100 to 150.
Almost half the participants (53.7%) preferred
the classroom strength of only 20-30 students for
a lecture session, however 30.2% vs. 20.6%
female participants were comfortable with the
class strength of 120-150 students, this difference
between the genders was found to be statistically
significant (p= 0.03). Most (62%) believed that
30-45 minutes was the ideal duration of a lecture
session, similar findings were reported by yet
another study 8, understandably so since the
attention span during lecture classes as admitted
by 44.3% of the male students vs. 44.1% of the
female students was only 20-30 minutes. A small
proportion of students (17.4% among males and
10.1% among females) agreed to their attention
span being less than 20 minutes and this
difference between the genders was found to be
statistically significant (p=0.03). A 10-15
minutes break between lecture classes was
wished for by 39.6% males and 48.7% female
participants, however a break of more than 15
minutes was favored by a few students and this
difference between the genders was found to be
statistically significant (table 1). Lecture classes
at 12 noon and 2 pm (immediate pre and post
359
Dsouza et al.,
lunch periods respectively) were acceptable only

to 24% of the study participants. Interestingly
71.1% males and 62.6% females preferred
technology enabled e- learning for lectures,
whereas it was 38% for practical sessions and
this difference between the genders was
statistically significant (table 1).
About 45.6% males preferred Group Discussion,
while 47.5% of females felt that Demonstrations
were a beneficial method of learning but Quiz
was favored by 9.3% and this difference among
the genders was statistically significant (table 2).
The conventional lecture method was preferred
only by 25% of the students. The debate was also
mentioned by a few students (10% males vs.
5.9% females) as a beneficial method of learning.
Most of the students (66.9%) favored the use of
multimedia and a projector with liquid crystal
display (LCD) as an effective supporting
teaching aids as compared to traditional
blackboard teaching (32.3%) and use of
transparencies (6.6%). Similar results have been
documented by other authors 8. Most students
(62.5%) favored the multiple choice question
(MCQ) and short question system of assessment;
this finding was comparable to another study
conducted in India 9
A good proportion of participants (38.8%) agreed
with attendance being made compulsory and the
difference among the genders was found to be
statistically significant (table1). The majority of
the students (79.9%males vs. 89.9% females)
found that the seating capacity in the college
library was adequate and this difference among
the genders was statistically significant
(p=0.005). About 61% males vs.70% females
found that there were adequate number of
reference books in the library.
Around 46.9% males vs. 58.8% females in our
study agreed with the existing duration of four
and half years for entire MBBS course and the
difference among genders was statistically
significant (p=0.02), while the others (26% males
vs. 16.8% females) opined that the duration of
entire MBBS course should be less than four and
half years, this difference among genders was

also found to be statistically significant (p=0.02)
a significant proportion (49.1%) was of the
opinion that the duration of first year MBBS
course should be of one year whereas 46.8%
agreed with the existing duration of one and half
years. The inclusion of Preventive and Social
Medicine subject in the first MBBS curriculum
was agreed upon by almost half of the study
participants (49.4%). Around 14 males and eight
females out of 387 voiced a regret for having
joined MBBS and the difference among the
genders was statistically significant (p=0.01).
The questionnaire for seventh semester students
also sought additional information on their post
graduate career preferences.
The fields of
specialization chosen in order of preference were
General Medicine (24.7%), Obstetrics and
Gynecology (20.9%), Pediatrics (16%), and
Ophthalmology (14.8%). The specialties of
Surgery,
Orthopedics,
Dermatology,
Otolaryngology, Radiology, Pharmacology and
Psychiatry were chosen by only 6-8% of the
students, while other subjects (1-2%) seemed
unattractive to the respondents at this point in
time. However 23% of respondents thought it
was too early to decide and 9.9% were willing to
take up any subject offered to them as per the
merit list. Results of a Nigerian study revealed
similar preferences by students towards Pre and
Para clinical subjects 10.
Although 79% of the study participants showed
an interest in research activities , only 16 males
and 11 females out of 387 participants had heard
of Short Term Studentship research program for
undergraduate medical students initiated by the
Indian Council of Medical Research (ICMR) and
this difference between the genders was
statistically significant (p=0.02). Medical
research, which on paper is an integral part of
medical education, is perhaps the most neglected
field in a large majority of colleges 11 which is
also true in our setting. The focus should be on
strengthening the short term studentship
program for the students11.
360
Dsouza et al.,
A significant proportion (84.9% females and

69% males) found the overall environment in the
Medical college conducive to learning, and the
difference among the genders was statistically
significant (p=0.0002).
CONCLUSIONS AND RECOMMENDATIONS
Based on the study findings small group

teaching for lectures in batches of 20-30 students
would be preferable , with the average duration
of lecture not exceeding 30-45 minutes since the
attention span as voiced out by the students was
not more than 20-30 minutes. There is a felt need
expressed for a short break of 10-15 minutes in
between lecture classes by a significant majority
of students which can be easily implemented.
Teaching faculty may use Group discussions and
Demonstrations as a teaching method more often
than the conventional lecture method.
Multimedia and projector with LCD screen may
be used whenever possible as a supporting
teaching tool to make learning more attractive to
the present day undergraduate students as a
significant majority of students favored elearning as a beneficial method of learning. More
of Multiple choice and short questions could be
incorporated into our student assessments. The
majority seemed satisfied with the adequacy of
reference books and seating capacity in the
college library. There needs to be a re- thinking
on the inclusion of Preventive and Social
Medicine subject in the first MBBS curriculum
as the students are already burdened with
preclinical subjects and tend to pay less attention
to subjects that are not part of the syllabus for
first MBBS exams, so also the existing duration
of MBBS course needs re-thinking. Significant
proportion found the overall environment in the
Medical College conducive to learning. Based on
the present study findings one can conclude that
the teaching learning environment should be reevaluated in our University with specific
attention to the class size, duration of lectures as
well as the methods used for teaching and
assessment. To increase the exposure of students
to medical research, the Department of

Preventive and Social Medicine encourages the
undergraduate students to take up guided
research projects as part of their training in
Community medicine. The ICMR short term
studentship research program needs to gain
popularity in our setting. Given the proper
environment students could contribute in a major
way to scientific research. The study highlights
some aspects of the curriculum the faculty needs
to address so to make the teaching learning
environment more acceptable to the Medical
students.
The clinical phase (Eighth and ninth semester
students) could also be included in the study so
as to complete the representation of the
undergraduate student population. This study
may be replicated in other Medical colleges in
the country with larger sample size to make
recommendations for policy changes at the level
of the Medical Council of India regarding the
teaching curriculum that is being followed by all
Medical colleges in India
ACKNOWLEDGEMENT
The author would like to thank all the pre and

para-clinical undergraduate Medical students of
Goa Medical College (Academic year 20122013) who participated in the study.
REFERENCES
1. Veerapen K, McAleer S. Students

perception of the learning environment in a
distributed medical programme. Medical
Education Online. 2010; 15:5168.
2. Abraham R, Ramnarayan K, Vinod P, Torke
S. Students perceptions of learning
environment in an Indian Medical School.
BMC Medical Education. 2008; 8: 20.
3. Genn JM. AMEE medical education guide
no. 23 (part 1): curriculum, environment,
climate, quality and change in medical
education a unifying perspective. Med
Teacher. 2001; 23:33744.
361
Dsouza et al.,
4. Genn JM. AMEE medical education guide

no. 23 (part 2): curriculum, environment,
climate, quality and change in medical
educationa
unifying
perspective. Med
Teacher. 2001; 23:44554.
5. Shankar PR, Dubey AK, Subish P, Upadhyay
DK. Medical student Attitudes towards and
perception of the Basic Sciences in a Medical
college in Western Nepal. Medical Science
Educator. 2007; 17:67-73.
6. Ferrinho P, Fronteira I, Sidat M, Da Souza F,
Dussault G. Profile and professional
expectations of Medical students in
Mozambique: a longitudinal study. Human
Resources for Health. 2010; 8: 21.
7. Deressa W, Azazh A. Attitudes of
undergraduate medical students of Addis
Ababa University towards medical practice
and migration, Ethiopia. BMC Medical
Education. 2012;12:68
8. Manzar B, Manzar N. To determine the level
of satisfaction among Medical students of a
public sector medical university regarding
their academic activities. BMC Res Notes.
2011; 4:380.
9. Muneshwar JN, Mirza Shiraz Baig, Zingade
US, Khan ST. A questionnaire based
evaluation of teaching methods amongst
mbbs students. Int J Med Res Health
Sci.2013; 2(1):19-22.
10. Oyebola DD, Adewoye OE. Preference of
preclinical medical students for medical
specialities and the basic medical sciences.
Afr J Med Sci 1998;27(3-4):209-12
11. Deo M G. Undergraduate medical students'
research in India. J Postgrad Med 2008;
54:176-9.
362
Dsouza et al.,
DOI: 10.5958/j.2319-5886.2.3.048

&
Health Sciences
Revised: 3rd May 2013
Research article
TREATMENT OF IDIOPATHIC CONGENITAL TALIPES EQUINO VARUS DEFORMITY
BY PONSETI TECHNIQUE IN RURAL POPULATION
*Sharma Gaurav1, Balkrushna Mangukiya1, Prasad DV2, Abhishek Pandey1, Anish Kumar Singh1,
Rakesh Singh1, Suraj Gharat1, Krishna Badgire1
1
Post graduate student, 2Professor, Department of Orthopaedics, Pravara Institute of Medical Sciences,
Loni
*
Corresponding author email: sharmagaurav@live.com
ABSTRACT
Background: Congenital talipes equinovarus is one of the commonest congenital anomaly of the foot
with an incidence of 1 to 2 per 1000 live births. Most of the Clubfoot deformities are not recognized at
birth and when recognized, there is no treatment available due to lack of awareness among the people.
Nonoperative correction of the Clubfoot by Ponseti is an effective modality of treatment with excellent
results. Methods: 38 feet of Idiopathic Congenital Talipes Equinus Varus Deformity were treated in
children between the age group of 1 month- 1.8 months. The severity of foot deformity was assessed as
per the Pirani scoring system. Results: 16 Males (66.66 %) and 8 Females (33.33 %) patients were
included in the study with 10 (41.7%) Unilateral and 14 (58.3 %) bilateral cases. The mean of Pirani
scores after the final cast was 3.02 and at 1,2 and 6 months are 0, 0 and 0.08 respectively. Standard
deviation and Standard error were 0.070 and 0.014 respectively. Therefore p = 0.01, that is highly
significant Conclusion: Treatment of Idiopathic clubfoot by Ponseti technique is an effective, time
tested, simple technique with a low learning curve and minimizing the need for extensive surgeries.
Keywords: Ponseti technique, Idiopathic Clubfoot
INTRODUCTION
Congenital talipes equinovarus or clubfoot is

one of the commonest congenital deformities,
incidence being 1-2 per thousand births. Since
Hippocratess time, the treatment of clubfoot
has remained perplexing. There has been much
debate in the past two decades as to whether
conservative or operative treatment was more
effective in the treatment of clubfoot deformity.1
Now, most of the centers consider non operative

treatment as the first choice for early cases and
favor surgical corrective procedure for rigid
clubfoot which does not respond to treatment by
manipulation.2,3 The genes responsible for
clubfoot deformity are actively starting from the
12th to the 20th weeks of fetal life and lasting
until three to five years of age1-3. Idiopathic
363
Sharma Gaurav et al.,
clubfoot, when detected early can be treated by

a simple conservative method of ponseti
technique requiring minimal or no surgical
intervention at the end of the treatment.
MATERIALS AND METHOD
The present study was done in the department of

Orthopaedics, Rural Medical College, Loni
from the month of June 2011 to July 2012 in
children between the age group of 1 month to
1.8 months after the permission of the
Institutional Ethics Committee. Total 38 feet (10
unilateral, and 14 bilateral) Idiopathic Congenital
Talipes Equinus varus deformity were treated.
Males and Females of less than 2 years of age
with Idiopathic CTEV, who have not received
any other modality of treatment in the form of
Conservative or Operative method or included
in the present study. Resistant, Recurrent and
Neglected (>2 years of Age) cases of CTEV.
Pirani scoring (Table 1) of all the patients was
done every week after the cast removal and
noted as hind foot score, mid foot score, and
total score. Manipulation and casting were done
on OPD basis. The correction of the deformity
as described in the literature was divided into
two phases. Treatment Phase comprising of
gentle manipulation and above knee casting
which was done weekly holding the foot in the
permitted range of abduction (Fulcrum at the
lateral aspect of the talus). The order of

correction started with the cavus deformity and
Equinus corrected at the last. Percutaneous
tendo Achilles tenotomy was done when the
Midfoot score was zero or 0.5. The suppleness
of the foot was assessed before performing the
tenotomy which was done in the minor
operation theatre. The patient was applied above
knee cast application after performing the
tenotomy, 30- 40 abduction and 10- 20
dorsiflexion which was kept for 3weeks
dutation. Maintenance Phase: Consisted of use
of Steenbeek abduction foot braces with 6070. External rotation and 10-15 dorsiflexion
(Unilateral cases the external rotation was kept
to 35-40). The width of the bar between the
brace was equal to the width of the shoulder and
the bar was bent 5 to 10 with the convexity
away from the child, to hold the feet in
dorsiflexion. The measurements of the brace
were taken after 3 weeks follow up of the
patient (Post tenotomy) and parents were
explained to use it for 23 hours a day for first
3months followed by gradual tapering the
braces. Patients were regularly assessed every
week for the first month, every fortnight for the
second month and thereby once every month.
During the subsequent follow-ups, the feet were
assessed for dorsiflexion and amount of
abduction achieved.
Fig.1: Initial cost
364
Fig.2: After final (5th) cast

RESULTS
16males (66.66%) and 8 females (33.33%) patients were included in the study with 10 (41.7%)
unilateral and 14 (58.3%) bilateral cases. The average number of casts applied was between 5-7 (One
patient required 9 cast applications). The end results were assessed on the basis of Pirani scoring and the
mean of initial Pirani score and the final Pirani score was .575 and 0 respectively. Mean at 1,2 and 6
months are 0,0 and 0.08 respectively. The standard deviation was 0.070 and the standard error was
0.014. Therefore p=0.01 and it is highly significant.
Table.1 : Pirani scoring
Hind foot score
Score name
Posterior crease
Rigidity of Equinus
Empty Heel
Mild (0)
Multiple
fine creases
Normal ankle
dorsiflexion
Tuberosity of the
calcaneum easily
palpable
Mid foot score

Curvature of lateral Straight
border of foot
Severity of medial crease Multiple
fine creases
Palpation of lateral part Navicular
of head of talus
completely
reduces;
the
lateral talar head
cannot be felt
Moderate (0.5)
One or two deep
creases
Ankle dorsiflexes
upto neutral
Tuberosity of
calcaneus more
difficult to palpate
Severe (1)
Deep creases change contour
of the arch
Ankle dorsiflexes beyond
neutral
Tuberosity of calcaneus not
palpable
Mild distal curve
Curve at calcaneocuboid joint
One or two deep

creases
Navicular partially
reduces; lateral
headless palpable
Deep creases change contour

of arch
Navicular does not reduce;
lateral talar head easily felt
DISCUSSION
The goal of the treatment in CTEV is to obtain

functional, pain free, normal looking, plantigrade
foot with good mobility and requiring no
modification with shoes. Correction of the

idiopathic clubfoot deformity by poinsettias
method, requires dedicated and tiring efforts on
365
the part of both, the treating surgeon as well as

the parents. Ponseti treatment for clubfoot has
been gaining in popularity due to the good results
demonstrated by Ponseti and other institutions4.
The percutaneous tenotomy which is done for
the correction of the equines deformity forms an
integral and important part of the treatment. The
guidelines regarding patient selection and
treatment
protocol
vary
between
5,6,7
investigartors . In our study we started the
treatment as early as 1month of age. In the babies
who presented to us before the age of 1 month,
gentle manipulation was taught to the mother
who was asked to do it 4-6 times a day
preferably during feeding the baby. In the series,
the male to female ratio is high (2:1) in
comparison to the series of Cowell and Wein1
and Yamamoto3 (3:1). The reason for such a
variation can be due to the fact that more
attention is being given to the males as compared
to the female counter parts in our area. In our
study, 1 patient had been applied 9 casts, the
reason for which can be noncompliance from the
parents regarding proper care of the plaster casts.
CONCLUSION
Although it was a small study with the sample

size of only 38feet, yet the results of the Ponseti
methodology for the treatment of Idiopathic
clubfoot is very effective with very low
recurrence when the technique is used
effectively. Ponseti and Smoley8 reported that
open surgery was avoided in 89% of cases by
this technique of manipulation, casting and
limited surgery. Kite9,10 illustrated his method of
clubfoot correction in 1964. He suggested that
the abduction of the foot can be corrected if the
fulcrum is kept at the calcaneocuboid joint.
Ignacio Ponseti, in the year 1948 described a
technique in which the whole foot is held in
supination and in flexion, it can be gently and
gradually abducted under the talus secured
against rotation in the ankle mortice by applying
counter-pressure with the thumb against the
lateral aspect of head of the talus 11.The

correction of deformity can start from 4to 6 week
from birth & the treatment phase can end in 3to 4
months from the beginning of treatment followed
by steenbeck abduction foot brace use till 3-4
years of age.
REFERENCE
1. Cowell HR, Wein BK. Genetic aspect of

clubfoot. J Bone Joint Surg Am.
1980;62(1);1381-84
2. Palmer Rm. Genetics of talipes equines
varus. J Bone Joint Sur Am. 1964;46;542-56
3. Yamamoto H. A clinical genetic and
epidemiologic study of congenital clubfoot.
Jinrui Idengaku Zasshi. 1979;24(1):37-44
4. Lehman WB, Mohaideen A, Madan S, Scher
Dm, Van Bosse HJP et al., A method for the
early evaluation of the Ponseti (Iowa)
technique for the treatment of idiopathic
clubfoot, J Peadiatr Orthop B. 2003;12:13340
5. Brand Ra, Laaveg SJ, Crowninshield RD.
The center of pressure path in treated
clubfoot. Clin Orthop relat Res. 1981;160:4347.
6. ColburnM, Williams M. Evaluation of the
treatment of idiopathic clubfoot by using the
ponseti method. J Foot Ankle Surg.
2003;42(5):259-67
7. Coooper Dm, Dietz FR. Treatment of
idiopathic clubfoot: a thirty year follow up
note.J
Bone
Joint
Surg
Am.
1995;77(10):1477-89
366
DOI: 10.5958/j.2319-5886.2.3.065

&
Health Sciences
www.ijmrhs.com
th

Research article
Coden: IJMRHS
rd
Revised: 3 May 2013
Copyright @2013
ISSN: 2319-5886
th
Accepted: 6 May 2013
A STUDY ON CORRELATION BETWEEN POSTERIOR CAPSULAR OPACIFICATION AND

VISUAL FUNCTION BEFORE AND AFTER NEODYMIUM: YAG LASER POSTERIOR
CAPSULOTOMY IN RURAL POPULATION OF NORTH MAHARASHTRA
Misra Somen, *Kumar Ashish, Suryawanshi Sachinkumar
Department of Ophthalmology, Pravara Institute of Medical Sciences, Loni, Ahmednagar, Maharashtra,
India
*Corresponding author email: gupta.ashish64@yahoo.com
ABSTRACT
Posterior capsular opacification is the opacity which follows after extra capsular cataract extraction and
can be treated by surgery or laser. The laser is the procedure of choice because it is non invasive,
outpatient procedure that clears visual axis and improves vision instantaneously. Aims: The aim of this
study is to correlate density of Posterior capsular opacification in relation to visual deterioration and
subsequent improvement after Nd: YAG laser, amount of energy required to cut the posterior capsule
and to observe any complications during and after the procedure. Methods: It was a prospective study
which was carried out over a period of two years. 40 eyes with posterior capsular opacification were
included. Visual acuity and intraocular pressure were recorded before and after the procedure. Result:
After the YAG capsulotomy 85% patients showed improvement by 3 snellens line or more while 12.5%
patients improved by 2 snellens line or more and remaining 2.5% patients showed 1 snellens line
improvement. The average energy required per shot to break the posterior capsule was 3.08 ( 1.12) mj.
Average total energy used in our study is 50.1322.32mj. The 77.5% patients had no significant rise of
IOP while 15% patients had rise of 2.2 to 5 mmHg and 7.5% patients had rise of IOP of 5 to 10 mmHg
after YAG capsulotomy. 7.5% cases had IOL damage in the form of pitting but there were no visual
complaints, 5% patients had mild iritis and 2.5% patient had iris bleed.
Keywords: Posterior capsular opacification, Laser, Posterior Capsulotomy
INTRODUCTION
Cataract is any lens opacity on or inside the lens

or functionally as only those lens opacities that
interfere with vision1. Now days, extra capsular
cataract extraction is the procedure of choice. In
extra capsular cataract extraction, anterior
capsulotomy is done and intra ocular lens is put
in the capsular bag with the posterior capsule

intact. Posterior capsular opacification (PCO) is
the opacity which follows after extra capsular
cataract extraction of the lens2. PCO occurs as a
result of formation of opaque secondary
membrane by active lens epithelial cells
367
Misra Somen et al.,
Int J Med Res Health Sci.2013;2(3): 367-371
proliferation, transformation of lens epithelial

cells into fibroblast with contractile elements and
collagen deposit. The anterior lens epithelial cells
proliferate onto posterior capsule at the site
apposition of anterior capsular flaps to posterior
capsule3. The treatment for PCO is surgery or
LASER (Light Amplification by Stimulated
Emission of Radiation). The laser is the
procedure of choice because it is non invasive,
outpatient procedure that clears visual axis and
improves vision instantaneously. It can be
performed with or without topical anesthesia and
has the added benefit of elimination of surgical
complications like endophthalmitis4. The aim of
this study is to correlate density of Posterior
capsular opacification in relation to visual
deterioration and subsequent improvement after
Nd: YAG (Neodymium: Yttrium Aluminum
Garnet) laser, amount of energy required to cut
the posterior capsule and to observe any
complications during and after the procedure.
The study is a hospital based prospective study
which was carried out over a period of two years
in the department of ophthalmology, Rural
Medical College, Loni. 40 eyes of 40 patients
having Posterior capsular opacification attending
ophthalmic outpatient department were included
in the study after taking approval from
institutional ethical committee. Inclusion
criteria: Patients above the age of 40 years and
both sexes having PCO with the presence of
posterior chamber intraocular lens were included
in the study. Written informed consent was taken
from all the patients. Exclusion criteria:
Patients with active ocular pathology, previously
treated with laser, were not included in the study.
Prior to the procedure complete ophthalmic
history was taken. Visual acuity with and without
pinhole and intraocular pressure (IOP) with

schiotz tonometer were recorded. Slit lamp
examination was done to evaluate the type of
PCO and fundus examination with direct
ophthalmoscope was done. After the procedure
visual acuity and IOP were recorded and fundus
examination was performed again. Patients were
given prednisolone acetate (1%) eye drops four
times a day for 5 days and timolol maleate
(0.5%) eye drop twice daily for 7 days. Patients
were followed after 1 hour, on 7th day and after 1
month. Parameters like visual acuity, IOP
(intraocular pressure), slit lamp and fundus
examination were done in every visit and
recorded. The statistical correlation between
posterior capsular opacification and visual acuity
before and after Nd-YAG laser posterior
capsulotomy was calculated by using t-test.
RESULTS
In our study, 13 patients (Table 1) with visual

acuity less than 6/60 group improved with 2
patients improving to 6/36, 3 patients improved
to 6/24, 2 patients improved to 6/18, 3 patients
improved to 6/12, and 2 patients improved to 6/6.
Of the 11 patients having pre YAG visual acuity
of 6/60, 4 patients improved to 6/18 while 3
patients improved to 6/12, 2 patients each
improved to 6/9 and 6/6. 6 patients having pre
YAG visual acuity of 6/36, 1 patient improved to
6/24 and 5 patients to 6/6. 4 patients had pre
YAG visual acuity of 6/24, of this 1 patient
improved to 6/12 and 2 patients to 6/9 and 1
patient to 6/6. Of the 6 patients of pre YAG
visual acuity of 6/18, all 6 patients improved to
6/6. The post YAG visual acuity improvement is
statistically significant (p value < 0.01).
SYSTAT version 12 was used to for the
statistics.
368
Misra Somen et al.,
Table 1: Showing pre YAG and post YAG visual acuity

Pre YAG
visual acuity
Less than
6/60
6/60
6/36
6/24
6/18
6/12
6/9
6/6
Total
6/60
01
6/36
02
Post YAG visual acuity

6/24
6/18
6/12
03
02
03
02
01
04
01
04
06
Total
03
01
07
6/9
-
6/6
02
13
02
02
04
02
05
01
06
16
11
06
04
06
40
Table 2: Showing energy requirement per pulse

Energy required per pulse (mj)
1-2
2.1-3.0
3.1-4.0
4.1-5.0
>5.1
Total
Number of patients
07
12
16
01
04
40
Percentage
17.50
30.00
40.00
2.50
10.00
100
Table 3: Showing total amount of energy required per patients

Total energy required ( mJ)
Number of patients
Percentage
<50
50-100
>100
Total
22
16
02
40
55
40
05
100
Table 4: Showing post laser IOP changes

IOP changes
Number of patients
<2.5 mmHg
31 (77.5%)
2.5 to less than 5 mmHg
06 (15%)
5- 10 mmHg
03 (7.5%)
Total
40 (100%)
In our study (Table 2) the average energy
required per shot to break the posterior capsule
was 3.08 ( 1.12) mJ with a range of 1.4mj 5.9mj. Maximum number of patients required
energy in between 2 to 4mj i.e. 70%. The results
were statistically significant (p value < 0.05) (t
table= 2.0201, t cal. = 14.63).
Average total energy used in our study is

50.1322.32mj (Table 3). The maximum number
of patients (55%) required a total energy of less
than 50 mJ (Ranged between 12 to 49 mJ). The
results were statistically significant (p value <
0.01) (t table= 2.71, t cal. = 2.99).
Misra Somen et al.,
369
In our study, (Table 4) the maximum number of

patients (77.5%) had no significant rise of IOP
while 15% of patients had rise of 2.2 to 5 mmHg
and 7.5% of patients had rise of IOP of 5 to 10
mmHg after 1 hr of YAG capsulotomy. The

results were statistically not significant (p value
> 0.05) (t table= 2.021, t cal. = 0.0681).
Table 5: Showing complications after YAG capsulotomy

Complications after YAG capsulotomy
Number of patients
IOL pitting
03
Iris bleed
01
Mild iritis
02
Retinal detachment
00
Vitreous floaters
00
Reopacification
00
Cystoid macular edema
00
Total
06
In our study, 7.5% cases (3 patients) had IOL damage in the form of pitting but there were no visual
complaints (Table 5). 2 patients (5%) had mild iritis and 1 patient (2.5%) had iris bleed.
DISSCUSSION
We observed marked improvement in visual

acuity (Table 1) in all patients which is
comparable to the studies done by Hayashi K et
al5, Gardner KM and associates6, Wang J et al7
who also reported marked improvement in visual
acuity in all patients. In our study after the YAG
capsulotomy 85% patients showed improvement
by 3 snellens line or more while 12.5% patients
improved by 2 snellens line or more and
remaining 2.5% patients showed 1 snellens line
improvement. There was no patient showing any
decrease in snellens line after YAG
capsulotomy. Skolnick KA and associates8 who
in their study reported best corrected visual
acuity in 45.3% improving by 3 or more lines, in
20.3% by 2 lines and 51% by 1 line.
The average energy used in our study (Table 2)
to break the posterior capsule is comparable to
the study done by Wang J et al7 who reported
average energy required per pulse was
2.930.63mj. The maximum number of cases
(70%) was done between 2 to 4mj. Flohr et al9 in
their study used 1.7mj energy per pulse in 67%
of cases.
The average total energy used in our study (Table

3) is comparable with the study of Chen et al10
who used average energy of 52.4424.62mj. The
amount of laser energy used is proportional to
the capsulotomy size as patients subjected to
lower amounts of laser energy may benefit by
having fewer complications. However we could
not correlate the amount of energy used and the
complications encountered.
In our study 7.5% of patients had rise of IOP of 5
to 10 mmHg (table 4) which is comparable to the
study of Skolnick KA et al8 who reported 6.8%
of IOP rise in 212 patients. Terry AC et al11
reported the rise of 5mmHg of IOP is extremely
common after 1 to 4 hr of post laser treatment.
We could not correlate the increase in IOP to
capsulotomy size and laser power used, though
Channel et al12 reported higher pressure rise for
larger capsulotomy. The IOP rise subsided in all
our patients within 5 days post YAG
capsulotomy with anti glaucoma medications like
Timolol (0.5%) eye drop twice daily. There is no
evidence that the temporary IOP rise actually
cause damage to a patients long term vision.
There are no reports of vein occlusions, arterial
370
Misra Somen et al.,
occlusions or optic nerve damage as a result of

Nd: YAG capsulotomy unprotected by pressure
lowering drops.
We observed (Table 5) 7.5% cases of intra ocular
lens (IOL) pitting which is comparable to Wang
J and associates7 who reported 6.8% of cases,
while Flohr MJ et al9 noted a very high incidence
of IOL pitting (81%). In our study, 2.5% cases (1
patient) had iris bleed, which was mild and
subsided immediately. This was comparable with
2% incidence of iris bleed as noted by Navin S et
al13. There are no reports of iris bleed causing
any significant long term reduction of vision. 5%
cases (2 patients) had mild iritis in our study
which was treated with Prednisolone acetate 1%
eye drop four times a day for another 7 days. Our
values are comparable with Navin S et al13 who
reported 6% of incidence of iritis in their study.
The low incidence reported by us could be due to
the prophylactic treatment of all eyes with
prednisolone acetate (1%) eye drops four times a
day for 7 days post laser.
CONCLUSION
Nd: YAG laser is safe, easy, non invasive

outpatient procedure, usually performed in few
minutes and without discomfort to the patient. It
is highly effective in restoring visual acuity in
eyes with posterior capsular opacification with
minimum complications.
REFRENCES
1. Peyman, Sanders, Goldberg, Principles and

Practice of ophthalmology, Published by
W.B. Saunders company, Philadelphia, P.A.
1987; 1st edition, Vol. 1, PgNo. 415, 617-618.
2. Sihota Ramanjit, Tandon Radhika, Parsons
diseases of the eye, Edited by Shihota
Ramanjit and Tandon Radhika, , Published
by Elsevier, a division of Reed Elsevier India
Private Limited New Delhi, 2002; 19th edition
. Page no. 274-76,290-91,297-98.
3. Daniel M Albert, Fredric k A, Jackobiec M
Basic sciences, principles and practice of
ophthalmology,2000; 2nd edition, 2: 1576-79.
Misra Somen et al.,
4. Norman S Jaffe, Mark S Jaffe, Gary F Jaffe,

Cataract surgery and its complications, 6th
edition, Published by C. V. Mosby company
Missouri, USA, 1997; 410.
5. Hayashi K, Hayashi H, Nakado F, Hayashi F,
Correlation between posterior capsule
opacification and visual function before and
after Nd: YAG laser posterior capsulotomy.
Am J Ophthalmol. 2003; 136(4):720-6.
6. Gardner KM, Straatsma BR, Pettit TH,
Neodymium:
YAG
laser
posterior
capsulotomy: the first 100 cases at ULCA.
Ophthalmic surg. 1985; 16(1):24-8.
7. Wang J, Sun B, Yang X, Chen J, Evaluation
of visual function following Nd: YAG laser
posterior capsulotomy. Zhonghua Yan Ke Za
Zhi. 2002 ; 38(9):556-61.
8. Skolnick KA, Perlman JI, Long DM, Kernan
JM, Nd: YAG laser posterior capsulotomies
performed by residents at a veterans
administration hospital. J Cataract Refract
Surg. 2000; 26(4):597-601.
9. Flohr MJ, Robin Al, Kelly JS, Early
complications following Q- switched Nd:
YAG
laser
posterior
capsulotomy.
Ophthalmology 1985; 02:360-363.
10. Chen T, Gao T, Hou Y, Li L, Post operative
use of YAG laser for cataract surgery.
Zhonghua Yan Ke Za Zhi. 2001; 37(4):29194
11. Terry AC, Stark WJ, Maumenee AE,
Fagadau W. Neodymium: YAG laser
posterior capsulotomy. AM J. ophthalmol
1983; 96: 716-20
12. Channell MM, Beckman H, Intraocular
pressure changes after Nd: YAG laser
posterior capsulotomy. Arch Ophthalmol
1984; 102:1024-26.
13. Navin Sakhuja, Harsha Kumar, HK Tewari,
PK Khosla. Mechanics of Nd: YAG laser
posterior
capsulotomy.
Indian
st
Ophthalmology
Today51
Annual
Conference AIOS-Proceedings 1993; 481.
371
DOI: 10.5958/j.2319-5886.2.3.066

&
Health Sciences
www.ijmrhs.com

Research article
Coden: IJMRHS
Copyright @2013
ISSN: 2319-5886
A CROSS SECTIONAL STUDY OF THE MORBIDITY PATTERN AMONG THE ELDERLY

PEOPLE : SOUTH INDIA
Piramanayagam A1, *Bayapareddy N2, Pallavi M3, Madhavi E4, Nagarjuna reddy N5, Radhakrishna L6
1
Velammal Medical College Hospital & Research Institute, Anuppanady, Madurai, Tamilnadu.
Chennai Medical College Hospital & Research Centre, Irungalur, Trichy, Tamilnadu, India.
3
Sree Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
4
Chettinad Medical College, Chettinad University, Chennai, Tamilnadu, India.
5
Kanchi Kamakoti Child trust Hospital, Chennai, Tamilnadu, India.
2& 6
* Corresponding author email:bayapreddy916@gmail.com

ABSTRACT
Background: In 1950, just 8% of the world population was aged 60 years or over, by 2005 that
proportion had risen to 10% and it is expected to be more than double over the next 45 years, reaching
22% by 2050. Evaluation of the morbidity profile will have implications for providing health care for
the elderly population and its costs. Aim: To find out the morbidity pattern among geriatric population.
Methodology: A community based cross sectional study conducted during the period of December 2011
to June 2012. In the first stage twenty two villages were selected, in a second stage by simple
random sampling method twenty seven elderly persons who were aged 60 years and above willing to
participate were selected, from each of the selected village a total of 594 were included. Data was
analyzed by SPSS Version 12 Statistical Software. Results: Out of the 594 elderly persons, 309
(52.1%) were males and 285 (47.9%) were females; 498 (83.9%) were affected by one or more diseases.
Prevalence of morbidity among elderly males and females was 240 (77.6%) and 258 (90.9%)
respectively. Most prevalent diseases were related to ocular 422 (71%) followed by cardiovascular
291 (49%). Respiratory system disorders were present in 77 (12.9%) elderly. Conclusions: Current
status of the elderly in India introduce to a new set of medical, socio-cultural, and economic
problems that would arise if a timely initiative has not been taken in this direction by the policy
makers; hence this data will enhance understanding of the health status of the elderly and morbidity
pattern and it will help to prepare appropriateintervention strategies.
Keywords: Geriatrics, chronic morbidity, acute morbidity.
INTRODUCTION
Ageing is a universal process and is regarded as a

normal biological phenomenon. From the time
immemorial people have tried to conquer aging
and live a long and healthy life. In 1950, just 8%

of the world population was aged 60 years or
over, by 2005 that proportion had risen to 10%
372
Bayapareddy et al.,
and it is expected to more than double over the

next 45 years reaching 22% in 2050.1
Hippocrates (460 BC - 377 BC) considered that
diet and exercise were the chief factors in living
a long and healthy life.2 The elderly are one of
the most vulnerable and high risk group in terms
of health status in any society. Evaluation of the
morbidity profile will have implications for
providing health care for the elderly population
and its costs. The health of the aged is a public
health issue and needs to be addressed. More
than 75% of the elderly people are residing in
rural areas; the geriatric health care should be
addressed by primary health care.3
A community based Cross sectional study

conducted during the period of December 2010
to June 2011. In the first stage by stratified
random selection method twenty two villages
were selected in the Trichy district of Tamilnadu,
one of the South Indian state. In the second stage

by simple Random sampling method twenty
seven elderly persons who were aged 60 years
and above willing to participate were selected
from each of the selected villages. The minimum
Sample size of 552 was calculated by using the
formula 4pq/d2 and 7% of assuming nonresponse error 39, a total of calculated was 591,
finally a total of 594 individuals were studied.
Institutional ethical committee clearance was
obtained prior to conduct the study. From this
selected study sample data were collected
regarding age, sex, current morbidity, chronic
morbidity with the help of closed ended personal
interview questionnaire which was prepared by
us and pre tested. Data was analyzed by Chisquare test and Z test, at 95% confidence
interval; p value less than 0.05 was considered
significant, SPSS Version 12 Statistical Software
was used to analyze the data.
RESULTS
Table.1: Demographic Distribution of study group
Parameters
Male
Females
Mean age
Illiterates
Just literate
Educated up to primary level
Secondary school and above
No of subjects
309
285
68.67.8
416
55
40
83
Among the 594 elderly persons, 498 (83.9%)

were affected by one or more diseases.
Prevalence of morbidity among elderly males
and females was 240 (77.6%) and 258
(90.9%) respectively. This difference was
found to be statistically significant (2 =12.95,
%
52.1
47.9
70.1
9.3
6.7
13.9
df=1, at 95% Level p=<0.001). The average
number of diseases per person was 3.34; among
men and women it was 2.96and 3.90
respectively. Details of morbidity by different
systems have been provided in table 2.
373
Bayapareddy et al.,
Table.2: Distribution of morbidity among Elderly Population
OR
p value
%
71.0
0.55
7.39
<0.01#
292
49.1
0.76
2.01
>0.05*
52.2
233
39.2
0.34
27.30
<0.001#
97
34.0
140
23.5
0.25
27.62
<0.001#
24.2
65
22.8
140
23.5
1.08
0.12
>0.05*
58
18.7
79
27.7
137
23.0
0.59
4.91
<0.05#
Respiratory
45
14.5
32
11.2
77
12.9
1.35
1.01
>0.05*
Genitourinary
19
6.1%
3.1
28
4.7
2.06
2.13
>0.05*
Female reproductive -tract

Neurological
15
2.1
1.0
--
--
--
4.8
2.4
22
3.7
2.08
1.86
>0.05*
Diabetes
15
4.8
2.4
22
3.7
2.08
1.86
>0.05*
Skin
2.9
16
5.6
25
4.2
0.57
1.31
>0.05*
Anaemia
45
14.5
59
20.7
106
17.8
0.67
2.41
>0.05*
7.7
29
10.1
53
8.9
0.76
0.61
>0.05*
Diseases
Ocular
Male
No.
201
%
65.0
Female
No.
%
221
77.5
Total
No.
422
Cardiovascular
141
45.6
151
52.9
Musculoskeletal
84
27.1
149
Mental Illness
43
13.9
Gastrointestinal
75
Ear
Other
Health 24
Problems
# Significant, * Not significant
Most common morbidity among elderly was

ocular diseases 422 (71%). Most common ocular
diseases were cataract (152, 36%) and refractive
error (85, 20.3%). Others include diseases of
lacrimal apparatus (19, 4.6%), pterygium (17,
4.1%), corneal scar (7, 1.7%) and acute keratitis
or corneal ulcer (7, 1.7%). Among women,
Cataract (87, 57%) and diseases of lacrimal
apparatus (12, 62.1%) were more common, while
refractive error (48, 59.2%) and corneal scar (5,
71.4%) were more common among men. Mean
Systolic Blood Pressure (SBP) among elderly
was 135.422.8 mm of Hg; males 134.221.9
mm of Hg and females 136.623.7 mm of Hg.
Statistically there was no significant difference
between the means (Z= -1.07, P>0.05, Not

significant, at 95%level). Mean Diastolic Blood
Pressure (DBP) among elderly persons was 77.5
12.2 mm of Hg; males 77.711.9 mm of Hg
and females 77.212.5 mm of Hg. Statistically
there was no significant difference between the
means (Z=0. 42, P>0.05, Not significant at
95%level). In total 266 (44.7%) elderly had
systolic hypertension; men 136 (44.0%) women
130 (45.6%) statistically there was no significant
(p>0.05) difference between them, details of the
Cardiovascular diseases and details of
Hypertension has been provided in the table 3.
374
Bayapareddy et al.,
Table.3: Cardiovascular Diseases among Elderly and Classification of Hypertension According to JNC VII.
Blood Pressure (mm Hg)
Male
No.
6
0
136
%
1.94
0.00
44.01
Female
No.
19
2
130
%
6.67
0.70
45.61
Total
No.
25
2
266
%
4.21
0.34
44.78
Ischemic Heart Disease

Congestive Heart Failure
Hypertension
Normal *SBP <120 & **DBP
100
16.84
85
14.31
185
31.14
<80
Pre Hypertension SBP 12074
12.46
69
11.62
143
24.07
139 & or DBP 80-89
Stage I Hypertension SBP 14085
14.31
63
10.61
148
24.92
159 & or DBP 90-99
Stage II Hypertension SBP
50
8.42
68
11.45
118
19.87
160 & or DBP 100
Total
309
52.02
285
47.98
594
100.00
2
( =4.44, DF=3, p>0.05 Not significant).* SBP= Systolic Blood Pressure, ** DBP= Diastolic Blood
Pressure.
among women. Of the 594 elderly, 97 (23.6%) were
Of the 594 elderly, 76 (12.8%) suffered with
affected by gastrointestinal diseases; men and
respiratory system disorders. The elderly were
women 52 (24.3%) and 45 (22.8%) respectively, the
affected with upper respiratory tract infection
difference was not significant (p>0.05). Most
(AURTI), chronic obstructive pulmonary disease,
common gastrointestinal disease was dyspepsia
pulmonary tuberculosis and asthma, 26 (4.4%), 27
62 (15.1%) followed by constipation 13 (3.2%),
(4.6%), 4 (0.7%) and 19 (3.2%) respectively. A
haemorrhoids 11 (2.7%) and diarrhoea 5 (1.2%),
higher proportion of males 86 (14.5%) were
three (0.7%) were affected by hernia. Dyspepsia
found to be affected by respiratory diseases
was more common among females 36 (18.3%)
compared to females 23 (11.3%), it was not
than males 26 (12.2%); while constipation,
statistically significant (p>0.05). Among the 594
hemorrhoids and Hernia were more common
elderly persons 138 (23.3%) were affected by
among men 9 (4.2%), 10 (4.7%) and 3 (1.4%)
ear diseases; 58 (42.1%) were men and 80
respectively. Among 594 elderly subjects, 27
(57.8%) were women.
(4.5%) were suffering from genitourinary
11 (1.8%) of which suffering from reduced
problems.
10 (1.7%) each complained of
hearing. Wax in the ear was found among 10
difficulty in micturition and incontinence, while 7
(1.7%) subjects. Higher percentage of women 69
(1.2%) complained of increased frequency of
(24.3%) were suffering from reduced hearing
urination. More men 19 (6.2%) were affected by
compared to men 46 (14.9%). Locomotor
genitourinary problems compared to women 9
problems were observed in 233 (39.3%) elderly;
(3.2%) but the difference was not statistically
women 149 (52.3%) and men 84 (27.2%)
significant (p>0.05). Difficulty in micturition
suffering from musculoskeletal problems. Arthritis
was common in males 10 (3.3%), incontinence
of various joints 114 (19.2%), backache 57 (9.6%)
was common in females 7 (2.5%). Out of the 285
and kyphosis 55 (9.3%) among the elderly. All the
females, 3 (1.1%) were affected by uterine
musculoskeletal problems, arthritis, backache,
prolaps. Only 23 (3.9%) were suffering from
kyphosis and neck pain were more common
375
Bayapareddy et al.,
neurological disorders, among this 16 (69.8%)

were men and 7 (30.2%) were women, but the
difference was not statistically significant
(p>0.05). 14 (4.5%) men and 7 (2.5%) women
were affected by paralysis or paresis and one
(0.2%) was suffering from Parkinsonism. Skin
diseases affected 25 (4.3%) o f elderly, among
this 14 (61.1%) were females and 11 (38.9%) were
males, but it was not significant (p>0.05). Nearly
17 (2.8%) of the elderly were suffering from
dermatitis and 5 (0.8%) with vitiligo. Among the
594 elderly persons, 140 (23.6%) suffered with
mental illness; of which women were 98 (70.0%)
and men were 42 (30.0%) (p<0.001). Depression
was present in 117 (19.7%). It was significantly
higher among women, 87 (30.6%) compared to
men, 31 (10.0%) (p<0.001). 13 (2.2%) and 10
(1.7%) elderly persons were suffering from
anxiety disorder and dementia respectively.
Overall 24 (4.2%) of the study subjects were
affected by diabetes mellitus. Nearly 16 (5.2%)
of elderly men and 7 (2.5%) of elderly women
were affected by diabetes mellitus. Of the total
elderly subjects vitamin deficiencies, fever and
dental caries were found to be 25 (4.2%), 17
(2.8%) and 12 (2.1%) respectively. Higher
proportion of females were suffering from fever,
10 (3.5%) and vitamin deficiency, 15 (5.3%)
compared to males 10 (3.2%) and 7 (2.2%)
respectively.
DISCUSSION
In the present study 59.6% of the elderly were

found in the age group 60 to 69 years, with males
and females contributing 57.0% and 62.4%
respectively. Similar studies conducted by Anjali
and Aarti,4 Rajan5 and Ansan Geriatric cohort
study in South Korea6 reported similar age
distribution. The sex ratio was found to be 921
females per 1000 males in the present study, the
finding was quite lesser than the findings of the
National Family Health Survey- III (2005-2006)7
wherein the sex ratio of the elderly population
was 1078 females per 1000 males. Most of the
(83.9%) elderly persons were affected by one
or more morbidities. Prevalence of morbidity
among elderly males and females was 77.6% and

90.9% respectively. Prevalence of morbidity
varied between 78 to 88% in various studies
across the
world6, 9 & 10 Similar to the present study, a
significant difference in the prevalence of disease
between elderly men and women was found in
studies of Goswami A et al11 and Youssef RM.12
The average number of illnesses per person was
3.29 among the elderly; males and females it was
2.91 and 3.70 respectively. In other similar
studies by Joshi et al,8 Party et al,13 and Dey et
al14 the mean number of morbidities reported
from 2.5 to 6.1.
Most common ocular diseases affecting the elderly
were cataract and refractive error, 36% and 20.3%
respectively. Cataract and diseases of lacrimal
apparatus were more common among women,
while refractive errors and corneal scars were
more common among men. Purty et al13 study
found 32.1% of elderly persons were suffering
from cataract and 24.6% from refractive errors,
comparable to the present study. In a study by
Prakash et al15 observed similar findings like the
present study; Mean SBP (Systolic Blood Pressure)
among the elderly was 135.422.8 mm of Hg;
men and women was 134.221.9mmHg and
136.623.7 mm Hg, respectively. In a multi
centric study carried out by the hypertension
study group16 and Mittra et al17 mean SBP among
elderly men and women were 14225 and
14527, and 126.9 & 129.8 mm Hg,
respectively; In a study by Garg et al18 mean SBP
among aged persons was 123.03.65 mm of Hg,
lower compared to the present study. Mean
Diastolic Blood Pressure (DBP) among elderly
persons was 77.512.2 mm of Hg; males and
females 77.711.9 mm of Hg and 77.212.5 mm of
Hg respectively. Mittra et al17 found that the mean
DBP among elderly men and women was 76.8 and
78.3 mm of Hg respectively, similar to the present
study. In another study by Garg etal18 mean DBP
was 81.5+3.64 mm of Hg, little higher compared to
present study. In this study a total of 33.0% elderly
had systolic hypertension; men 44.0% women
376
Bayapareddy et al.,
45.6%. In a study by Chou et al19 reported only

2% of the elderly persons suffered systolic
hypertension (SH), lower compared to the
present study. Nearly half of the elderly persons
were affected by cardiovascular diseases, more of
females (53%) compared to males (45.6%). Most
common cardiovascular disease of the elderly was
hypertension 45% and 4% were suffering from
ischemic heart disease. In other studies of Joshi
et al8 and Prakash et al15 reported the prevalence
of hypertension was 49% & 48%.
In this current study 39.2% of the elderly; women
52.3% and men 27.1% were suffering from
musculoskeletal problems. Arthritis of various
joints was present in 19.2%, followed by backache
in 9.7% and kyphosis in 9.3. Kishore et al20 were
observed that 40% and 36.8% of the elderly
were affected by locomotor problems.
Worldwide estimates 9.6% men and 18.0%
women aged 60 years and above were affected
by symptomatic osteoarthritis.21
Around 13% of elderly persons were suffering
from diseases of the respiratory system. More
men 15% than women 11% were affected. Mittra
et al17 found 8.4% bronchitis and 2% asthma
among elderly. In this study pulmonary
tuberculosis was only 0.7% whereas Garg et al 18
and Dey et al14 found it in 2.4% and 2.8% of
elderly respectively. Nearly 23% of elderly
persons were affected by ear problems. Lal et al22
and Joshi et al8 found that 20% and 19% of the
aged persons, respectively, were affected by
hearing problems. This study noticed that 23.6%
of the elderly were affected by gastrointestinal
diseases; men and women 24.3% and 22.8%
respectively. The most common gastrointestinal
diseases among elderly were dyspepsia (15.1%),
constipation
(3.2%),
hemorrhoids
(2.7%),
diarrhea (1.2%) and hernia (0.7%). The
prevalence of gastrointestinal diseases varied
from 5% to over 50% in various studies.3, 13, 15,
20 &22
Such variations might be due to
different
food
habits,
lifestyles
and
environmental conditions. Mittra et al17
reported diarrhea in 1.7% and enteritis in 1% of

the elderly.
Around 5% of the elderly subjects were suffering
from genitourinary problems. Purty et al13 and
Medhi et al23 found urinary symptoms among
5.6% and 5.1% of the elderly persons
respectively. Of all the females 1% were affected
by uterine. In a study by Raj et al24 diseases of
the female genital tract were found among 2.7%
of the women, similar to the present study. Only
4% of the elderly persons were suffering from
neurological disorders; men 4.5% and women
2.5%, were affected by paralysis/paresis. Similar
observations were made by Gourie et al.25 and
Medhi et al.23 Skin diseases were present among
4% of elderly persons, among 3% were suffering
from dermatitis. More commonly females (6%)
were affected. In studies of Mittra17 and Raj
B24 skin diseases were found among 3% and
2.4%
of
elderly
persons respectively.
Prevalence of Mental illness was 23.6% among
the elderly persons; women 34.1% and men
14.0% (p<0.001). Dube et al26 and Premarajan27
found psychiatric morbidity of 22.34% and
17.3% respectively. In the present study the
prevalence of depression was 19.7%. It was
significantly higher among women (30.5%)
compared to men (9.8%) (p<0.001). In studies of
Muller et al28 and Ramachandran et al29
Depression was observed among 22% and 24%
of study subjects respectively. Overall 4% of the
study subjects were affected by diabetes mellitus.
Nearly 5% of elderly men and 2.5% of elderly
women were affected by diabetes mellitus. Garg
et al18 and Joshi et al8 reported the prevalence of
diabetes mellitus as 4.2% and 5.5% among
elderly. Vitamin deficiencies, fever and dental
caries were found among 4%, 3% and 2% of
elderly persons respectively. In Mittra et al17 and
Raj et al24 avitaminosis and other deficiency
diseases were found between 5 and 6.7%
ofelderly persons. Garg et al18 found dental
caries among 2.1% of the elderly persons.
377
Bayapareddy et al.,
CONCLUSION
Over the past two decades, India's health

programs and policies have been focusing on
population stabilization, maternal and child
health, and disease control. However, current
status of the elderly people in India introduce to a
new set of medical, socio-cultural, and economic
problems that would arise if the initiative has not
taken in this direction by the policy makers
hence this data will enhance understanding of the
health status and patterns of health problems
among elderly Indians it will help to prepare
appropriate intervention strategies. The health of
the aged is a public health issue and needs to be
addressed through primary health care, for that
every medical officer has to undergo training in
geriatric health care. There should be separate
geriatric clinics in both private as well as
government hospitals to deal with the problems
faced by the elderly. The need of the hour is to
set up geriatric wards that would in the district
hospitals fulfill the specific needs of the geriatric
population. Separate Geriatric OPD services it
should provide screening services as well as
curative and rehabilitative services and
convalescent homes to provide long-term care. In
the medical education also a separate Subspecialty Gerontology has to be started at the
earliest possible time to address the geriatric
people. Community Based Health Insurance
system for elderly people has to be developed to
support them financially.
Conflict of Interest: None declared
REFERENCES
1. United Nations; Economic and social affairs.

Population
division.
WorldPopulation
rospects, the 2010 Revision: United Nations;
New
York.
2011.
Pp
30-32.
http://esa.un.org/unpd/wpp/documentation/pdf
/WPP2010_Volume- I_ ComprehensiveTables.pdf
2. Hobson W. Modern Trends in Geriatrics.

Butterworths Medical Publications. 1956;2:13.
3. Gopal K Ingle and Anita Nath. Geriatric
Health in India: Concerns and Solutions.
Indian J Community Med. 2008; 33(4): 214
218.
4. Anjali R, Aarti K. Living conditions of
Elderly in India: An overview based on
nationwide data. Ind Jr of Geront. 2006; 20:
250-63.
5. Rajan S I. Centre for Enquiry into Health and
Allied Themes. Population Ageing and
Health in India.2006. Available from
http://www.cehat.org/humanrights/rajan.pdf.
6. Eun-kyung W, Changsu H, Sangmee AJ, Min
KP, Sungsoo K, Eunkyung K, et al.
Morbidity and related factors among elderly
people in South Korea: results from the
Ansan Geriatric (AGE) cohort study. BMC
Public Health. 2007; 7:10.
7. National Family Health Survey, India. NFHS3 Tamilnadu Publications. 2005 available
from
http://www.rchiips.org/nfhs/NFHS3%20Data/TamilNadu_report.pdf
8. Joshi K, Kumar R, Avasthi A. Morbidity
profile and its relationship with disability and
psychological distress among elderly people
in Northern India. Int Jr of Epid.
2003;32:978-987
9. Fuchs Z, Blumstein T, Novikov I, Walter GA,
Lyanders M, Gindin J, et al., Morbidity, co
morbidity and their association with
disability among community-dwelling oldestold in Israel. J Gerontol A Biol Sci Med Sci.
1998;53:447-55.
10.Wolff JL, Starfield B, Anderson G:
Prevalence, expenditures, and complications
of multiple chronic conditions in the elderly.
Arch Intern Med. 2002;162:2269-76.
11.Goswami A, Reddaiah VP, Kapoor SK, Singh
B, Dey AB, Dwivedi SN, et al., Health
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problems and health seeking behavior of the

rural aged. IND Jr of Geront, 2005;19 (2):
163-80.
12.Youssef
RM.
Comprehensive
health
assessment of senior citizens in Al-Karak
governorate, Jordan. East Medit Hlth Jr.
2005;7 (3): 334-48.
13. Purty A J, Bazroy J, Kar M, Vasudevan K,
Veliath A, Panda P. Morbidity Pattern among
the Elderly population in the Rural Area of
Tamilnadu, India. Turk Jr Med Sci. 2006;36:
45-50.
14.Dey AB, Soneja S, Nagarkar KM, Jhingan
HP. Evaluaion of the health and functional
status of older Indians as a prelude to the
development of a health programme. Nat.
Med. Jr. Ind.2001;14 (3):135-8.
15. Prakash R, Choudhary SK, Singh US. A
study of morbidity pattern among geriatric
population in an urban area of Udaipur
Rajasthan. Ind Jr. Com. Med. 2004;29 (1):
35-40.
16.Hypertension study group. Prevalence,
awareness, treatment and control of
hypertension among the elderly in
Bangladesh and India: a multi centric study.
Bul. W.H.O, 2001;79(6): 490-500.
17.Mittra R.N, Prasad B.G, Jain V.C, Jain P.C.
Health status of the aged in an urban
community in India. Geriatrics. 1972;27(10):
114-121.
18.Garg B.S, Gupta S.C, Mishra V.N, Singh R.B.
A Geriatric study of an Urban area. Ind Jr.
Pub Hlth. 1982;27(2): 77-85.
19.Chou P, Chen CH, Chen HH, Chang MS.
Epidemiology
of
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Morbidity profile of elderly persons . JK
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musculoskeletal conditions. Bul WHO. 2003;
81(9): 646-56.
22.Lal S, Mohan B, Punia M.S. Health and social

status of senior citizens in rural areas. The
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Individuals in two population groups from
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Subbakrishna DK. Prevalence of neurological
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urban community in Uttar Pradesh, India.
Acta Psychiatr Scand.1970; 46: 327-32.
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R. Prevalence of psychiatric morbidity in an
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1993; 35: 99-102.
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fifty. Ind Jr Psy. 1979;22: 193-98.
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DOI: 10.5958/j.2319-5886.2.3.067

&
Health Sciences
Research article
PANCREATOBILIARY VERSUS INTESTINAL TYPE OF HISTOLOGICAL DIFFERENTIATION: A
COMPARATIVE STUDY WITH HISTOMORPHOLOGICAL PROGNOSTIC FACTORS IN
PERIAMPULLARY CARCINOMA
*Vissa Shanthi, Mohan Rao N, Swathi Sreesailam, Lakshmi Kalavathi C, Kasinath Soniya Rao B,
Appala Ramakrishna B
Department of Pathology, Narayana medical college, Nellore, Andhra Pradesh, India.
*Corresponding author email: santhijp@gmail.com
ABSTRACT
Objectives: Periampullary carcinoma is a term widely used to define a heterogenous group of

neoplasms arising from the head of the pancreas, ampulla of Vater, terminal common bile duct and the
duodenum. Periampullary carcinomas typically have either the intestinal type or pancreatobiliary type of
the differentiation. The prognostic importance of the type of differentiation is studied in relation to the
other prognostic factors like resection margin involvement, tumour size, nodal involvement, vascular
infiltration, perineural growth and degree of differentiation. Methods: 50 whipples resected specimens
were analyzed. In these cases 33 were periampullary carcinomas and the remaining were chronic
pancreatitis. The clinical features, laboratory investigations and histopathological features of
periampullary carcinomas were studied. Prognostic factors were studied in two histological types of
periampullary carcinomas i.e. intestinal type and pancreatobiliary type. Results: Out of 33
periampullary carcinomas 24 were intestinal type and 9 were pancreatobiliary type. Periampullary
carcinomas were common in females (54.5%) and were seen mostly in the age above 60yrs (36.4%).
Jaundice was the most common presenting symptom. Independent adverse prognostic factors seen in the
pancreatobiliary type of differentiation were tumor size more than 2.5cm (66.7%), tumor stage, regional
lymphnode involvement (77.8 %), vessel involvement (55.6%), perineural growth, areas with poor
differentiation (66.7%) and serum CA19-9 levels more than 200U/ml (77.8%). Conclusion: In
periampullary carcinomas histological type of differentiation is very important independent prognostic
factor. In the two histological types of carcinomas pancreatobiliary has worse prognosis when compared
to intestinal type.
Key words: Periampullary carcinoma, Pancreatobiliary, Intestinal, Prognostic factor.
INTRODUCTION
Periampullary carcinoma is a term widely used to

define a heterogeneous group of neoplasms
arising within 1 cm of the ampulla of vater
including head of the pancreas, ampulla of vater,

terminal bile duct and the duodenum. Carcinoma
originating from these sites exhibit different
380
Vissa Shanthi et al.,
clinical
behavior.1
In
periampullary
adenocarcinoma, the histological and biological
features associated with ductal pancreatic
adenocarcinoma are different from nonpancreatic Periampullary tumors. The precise
origin of Periampullary adenocarcinoma is
difficult to determine even with standardized
histopathological evaluation particularly if the
tumor is large and involves more than one
potential site of origin. Adenocarcinoma
originating in the ampulla of vater may be
classified as having either intestinal or
pancreatobiliary type of differentiation, of
which patients with the latter type consistently
have been shown to have worse prognosis.2
Tumors of periampullary region were treated by
Whipples operation, which involves radical
pancreatico-duodenectomy with an extensive
gastric resection.3 In our study, we analyzed the
different clinicopathological features and
prognostic factors in two different histological
types i,e. pancreatobiliary and intestinal type of
Periampullary carcinomas.
This study included 50 cases who underwent

Whipples pancreatoduodenectomy for the
suspicion of malignancy of the periampullary
region. The presenting clinical features and the
laboratory investigation findings were recorded.
Pancreaticoduodenectomy specimen received in
the pathology department was examined after the
formalin fixation.
The bile duct and the main pancreatic duct were
probed through the ampullary opening in the
duodenum and the whole specimen was cut
horizontally along the probes. The site of the
origin of the tumor is recorded along with the
dimensions of the tumor, local tumour extension
into the adjacent structures and its relation with
the common bile duct and the pancreatic duct.
Gross appearance of the tumor is noted (Figure
1). Peripancreatic lymphnodes and the
lymphnodes along the common bile duct are
examined.
Sections are given from the different areas of

tumor, resected end of the pancreatic head,
retroperitoneal resection margin, superior part
and inferior part of pancreatic head, bile duct
resected margin and resected ends of duodenum.
After paraffin embedding all sections obtained
were stained by Haematoxylin and Eosin stain.
The sections were analyzed to know the
histological typing of the tumor and its relation
with other prognostic factors like resected margin
involvement, vascular invasion, perineural
invasion, lymphnode status and serum CA 19-9
levels.
RESULTS
Whipple pancreaticoduodenectomy specimens of

50 patients were studied. Out of which 17 were
diagnosed as pancreatitis and 33 were diagnosed
as periampullary carcinoma.
The incidence of periampullary carcinomas in
both sexes was analyzed and was found to be
slightly more in females (54.5%) (Table 1).
Incidence in different age groups were also
studied by dividing the patients into 5 groups i.e.
20-30 years, 31-40 years, 41-50 years, 51-60
years and above 60 years (Table 2). Maximum
numbers of cases were seen in the age group
above 60years (36.4%).
The most common presenting symptom in these
cases was jaundice (76%). The other symptoms
in the order of frequency were anorexia/malaise,
weight loss, abdomen pain, steatorrhea,
vomiting, fever, malena, back pain and diarrhea
(Table 3).
Histologically, the periampullary carcinomas
were categorized into intestinal type and
pancreatobiliary type. In our study maximum
number of cases were of intestinal type
(72.7%)(Figure 2,3) when compared to
pancreatobiliary type (27.3%) (Table 4) (Figure
4,5).
Different prognostic factors were studied in
relation to these two histological types of
periampullary carcinomas. Analysis on the tumor
staging has shown that maximum numbers of
381
intestinal type of periampullary carcinoma were

in T3 stage and no tumor was in T4 stage. In the
tumors of pancreatobiliary type, 2 cases were in
T4 stage (Table 5). Association between
histological type of differentiation and tumor size
were studied by dividing them into two
categories i.e. tumor measuring less than 2.5cms
and more than 2.5cms. Maximum number of
both intestinal and pancreatobiliary type were
more than 2.5cms (Table 5). Lymph node
involvements in these two histological types of
periampullary carcinoma were assessed (Figure
6). Maximum number of intestinal type did not
show lymph node involvement whereas in
pancreatobiliary type, most of the cases showed
lymph node involvement (Table 5). Involvement
of deep resected margins in these two
histological types of periampullary carcinomas
were studied and maximum number of
pancreatobiliary type of periampullary carcinoma

showed involvement of deep resected margins
(Table 5). Vessel involvement was seen in most
of the cases of pancreatobiliary type when
compared to intestinal type (Figure 7) and
perineural invasion was noted only in few cases
of both histological types of periampullary
carcinomas (Table 5) (Figure 8). Maximum
number of pancreatobiliary type of periampullary
carcinomas showed areas of poorly differentiated
tumor when compared to intestinal type (Table
5). Serum CA 19-9 levels were analyzed in both
the histological types of periampullary
carcinomas.
Maximum
number
of
pancreatobiliary type of carcinoma had CA 19-9
levels >200U/ml when compared to intestinal
type where maximum number of cases had levels
<200U/ml (Table 5).
Table.1: Incidence of periampullary carcinoma in different sexes
Sex
Male
Female
Total (n=33)
15
18
Percentages (%)
45.5
54.5
Table.2: Incidence of periampullary carcinoma in different age groups
Age group
20-30years
31-40years
41-50years
51-60years
Above 60 years
Total (n=33)
1
7
7
6
12
Percentage (%)
3.03
21.2
21.2
18.2
36.4
No. of patients
Percentage (%)
Abdominal pain
12
46
Jaundice
Anorexia/ malaise
20
19
76
73
Weight loss
19
73
Vomittings
Back pain
4
3
15
11
Diarrhea
Steatorrhea
2
12
7
46
Table.3: Symptoms in periampullary carcinoma
Symptoms
382
Table.4: Incidence of different histological types of periampullary carcinoma
Histological type of differentiation
No of cases (n=33)
Percentage (%)
Intestinal type
24
72.7
Pancreatobiliary type
27.3
Table.5: Association between the histological type of periampullary carcinomas and various prognostic
factors
Prognostic factors
Tumor stage
T1
T2
T3
T4
Tumor size
Less than 2.5cms
More than 2.5cms
Lymph node status
No lymph node involvement
Lymph node involvement
Resected margin status
Resected margin not involved
Resected margin involved
Vessel involvement
Present
Absent
Perineural involvement
Present
Absent
Poorly differentiated areas
Present
Absent
CA 19-9 levels
less than 200U/ml
more than / equal to 200U/ml
Intestinal type
Pancreatobiliary type
1 (4.2%)
11 (45.8%)
12 (50%)
-
3 (33.3%)
4 (44.5%)
2 (22.2%)
9 (37.5%)
15 (62.5%)
3 (33.3%)
6 (66.7%)
13 (54.2%)
11 (45.8%)
2 (22.2%)
7 (77.8%)
18 (75%)
6 (25%)
3 (33.3%)
6 (66.7%)
10 (41.7%)
14 (58.3%)
5 (55.6%)
4 (44.4%)
7 (29.2%)
17 (70.8%
1 (11.1%)
8 (88.9%)
6 (25%)
18 (75%)
6 (66.7%)
3 (33.3%)
20 (83.3%)
4 (16.7%)
2 (22.2%)
7 (77.8%)
383
384
DISCUSSION
Periampullary carcinoma is a term widely used to

define a heterogeneous group of neoplasms
arising from the head of the pancreas, ampulla of
vater, terminal common bile duct and the
duodenum.
In the United states, pancreatic cancer is the 4th
frequent cause of cancer death in males as well
as females after lung, prostate or breast and
colorectal cancer. Each year approximately
30,000 Americans are diagnosed with pancreatic
cancer and about the same number die from it.
Africans and Americans have appreciably higher
rate than whites.4 In the studies done by Carlos
Chan et al5 and in our study the periampullary
carcinoma was found to be more common in
men. The highest incidence of periampullary
carcinoma was found to be in the age group
below 60 years in our study and it coincided with
the study done by Taxiarchis Botsis et al (2009).6
There is increased risk of pancreatic cancer in
syndromes like familial adenomatous polyposis
(FAP), hereditary non-polyposis colorectal
cancer (HNPCC), Peutz-jeghers syndrome and
familial breast ovarian syndrome.7 Germline
mutations in the few genes including P16 and
BRCA2 have been implicated in a small fraction
of cases.8 Disruption of the PRb, P16INK4
pathways also plays a role in ampullary
carcinogenesis.9 Other risk factors include
chronic pancreatitis, cigarette smoking, increased
meat and cholesterol intake and decreased risk
with fruits and vegetable consumption.10
The risk of pancreatic carcinoma is also
increased in conditions of excess gastric acidity
and by repeated gastrointestinal exposure to Nnitroso compounds or their precursors. The
pancreatic ductal epithelium can metabolically
activate the carcinogen, if activation has not
already occurred in the liver. Chronic secretion,
stimulation and N-nitroso compounds exposure
potentially overwhelm DNA repair capabilities
synergistically to induce tumor development.11
The colonization of Helicobacter pylori and

history of Diabetes mellitus are also risk factors.
The clinical presentations in patients with
periampullary
carcinomas
are
jaundice,
abdominal pain, severe and rapid weight loss,
nausea and vomiting, pancreatitis and migratory
thrombophlebitis. According to Talamini MA et
al, in his 28 years experience most common
presenting symptom was jaundice(71%) which
coincided with our study (76%).12
In the periampullary adenocarcinoma it is
difficult to identify the site of origin because as
the tumor growth invades the adjacent areas and
makes it difficult to identify the exact site of
origin. In these cases the type of differentiation
of tumor either intestinal or pancreatobiliary type
is more important prognostically than the
anatomic site of origin.13
The histological type of differentiation was
classified according to the criteria first suggested
by Kimura W et al14 later revised by Albores
Savedra J et al.2 Pancreatobiliary tumors typically
have simple or branching glands and solid nests
of cells surrounded by desmoplastic stroma
having cuboidal to low columnar epithelium
arranged in a single layer without nuclear
pseudostratification and the nuclei are rounded.
Intestinal tumors typically resemble colon
cancer, which consists of solid nests with
cribriform areas having tall and often
pseudostratified columnar epithelium with oval
nuclei, located in the more basal aspects of the
cytoplasm and there may also be often presence
of mucin. Cases with mixed patterns of
differentiation were classified according to the
dominant pattern.
Tumor stage and tumor size are the important
prognostic factors in periampullary carcinoma. In
the studies done by Westgaard A13 maximum
number of pancreatobiliary types of carcinomas
had tumor size more than 2.5cm and were in the
stage of T3 which coincided with our study.
385
Resected margin status is also one of the

important prognostic factors which influences the
survival of the patients. In the studies done by
Westgaard A, maximum number of intestinal
type (85%) did not show resected margin
involvement and in the pancreatobiliary type of
carcinomas, nearly half of the cases showed
resected margin involvement. 13 In our study also
maximum number of pancreatobiliary types of
carcinomas showed resected margin involvement
(66.7%).
The presence of metastatic cancer in lymphnodes
excised during pancreatoduodenectomy is
generally accepted as an evidence of surgically
incurable disease and lymph node dissection is
therefore considered to be an important
prognostic factor. 3 In our study maximum
number of pancreatobiliary types of carcinoma
showed lymph node involvement (77.8%).
Perineural growth, which is a phenomenon in
which cancer cells grow in close apposition to
nerves is one of the prognostic factors in
periampullary carcinomas.15 It was suggested
that the production of growth factors by the
nerves contribute to tumor progression. Over
expression of transformed growth factor by the
nerves combined with presence of its receptors,
epidermal growth factor receptor in the
pancreatic cancer cells provides a plausible
explanation for the cancer progression by
paracrine stimulation.16 Perineural growth was
seen in maximum number of pancreatobiliary
type of carcinoma in the studies done by
Westgaard A (2008), whereas in our study
maximum number of both intestinal and
pancreatobiliary
type
of
periampullary
carcinomas did not show perineural growth.
Serum CA 19-9 levels above 200U/ml is
considered as an independent prognostic factor
for patients with resectable pancreatic
adenocarcinoma.17
In our study maximum
number of cases with pancreatobiliary type of
carcinomas showed CA 19-9 levels more than
200U/ml (77.8%) and most of the cases with
intestinal type of periampullary carcinomas

showed less than 200U/ml (83.3%).
CONCLUSION
This diagnostic observational study on 33

patients with periampullary carcinoma gives
valuable information about the prognostic
importance of histological type of differentiation
of periampullary carcinoma. In two histological
types
of
periampullary
carcinoma
pancreatobiliary type has worse prognosis when
compared to intestinal type. The histological type
of differentiation acts as an independent
prognostic factor in periampullary carcinomas.
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DOI: 10.5958/j.2319-5886.2.3.068

&
Health Sciences
Research article
A STUDY ON SOME PSYCHOLOGICAL HEALTH EFFECTS OF CELL-PHONE USAGE
AMONGST COLLEGE GOING STUDENTS
*Jayanti P Acharya1, Indranil Acharya2, Divya Waghrey3
1
Associate Professor, 2Assistant Professor, 3III year MBBS student, Department of Community
Medicine, Bhaskar Medical College, Moinabad, Hyderabad.
*Corresponding author Email id: gitucapricorn@gmail.com
ABSTRACT
Background: Cell phones have come to stay. Their use without any knowledge of their harmful effects
like cancers and other health effects is not quite safe. Studies on cancers due to electromagnetic
radiations from cell phones are available but there is a need to research on the detrimental physical and
psychological effects esp. on rampant users like college-goers. This study focused on certain
psychological or mental health effects of cell phone usage amongst students pursuing professional
courses in colleges in a big city. Materials and methods: Students of both sexes in the age group 17-23
yrs from urban and rural backgrounds were selected at random and administered a pretested
questionnaire which included aspects related to few common adverse psychological health signs and
symptoms attributed to cell phone over-usage. Results: Headache was found to be the commonest
symptom (51.47%) followed by irritability/anger (50.79%). Other common mental symptoms included
lack of concentration and academic performance, insomnia, anxiety etc. Suggestions: This study
confirms that the younger generation, who are the most frequent cell phone users, needs to be aware
about the adverse health effects of cell phone usage esp. the mental aspects and take preventive
measures to minimize and control the same. Less dependence on the device, a curtailing time period
spent on talking, communicating more by texting, etc. are some of the practical measures suggested.
Keywords: Cell phones, adverse psychological health effects
INTRODUCTION
The first handheld mobile phone was

demonstrated by John F. Mitchell and Dr Martin
Cooper of Motorola, almost four decades ago, in
1973, using a handset weighing around a
Kilogram. In 1983, the Dyna TAC 8000x was the
first mobile set to be commercially available. In
the last 20 years, worldwide mobile phone
subscriptions have grown from 12.4 million to
Jayanti P Acharya et al.,
over 5.6 billion, penetrating about 70% of the

global population1.Though a Godsend for better
communication and reasons of convenience,
regular and constant mobile phone usage, has
now become a considerable cause of alarm and
an important public health problem. There have
been reports of health hazards, both mental and
physical, in people of all age groups. While some
388
Int J Med Res Health Sci. 2013;2(3): 388-394
of these effects are critical like cancers, there are

others that cause definite morbidity. On 31 May
2011 the World Health Organisation confirmed
that cell phone use indeed represents a health
menace, and classified such phone radiation as a
carcinogenic hazard, possibly to humans2. Not
surprisingly then, this addiction of humans to
mobile phones has even led to a new term being
coined Nomophobia- the fear of being out of
mobile phone contact! A study in Britain found
that about 58% of men and 48% of women suffer
from this phobia, and an additional 9% feel
stressed when their mobile phones are off1. In
spite of some unfavorable health effects, the
usage of cell phones has increased dramatically
especially since the time they have become more
affordable and available. Almost 87-90 % of the
population in an advanced country like the
United States of America, use cell phones, and a
sizeable number of these are school and college
going students 4. In India too, we all see that the
scenario is quite similar with people from all
walks of life, educated or not so, and belonging
to almost various age groups; owning and
dependent on, a cellular phone. Cell phones have
become a part and parcel of our daily lives.
One alarming fact is that many of these devices
reach the market without any safety testing on
their electromagnetic radiation5. The brighter
side is that the concerns are also being given due
attention by manufacturers lately. Today's mobile
phone models have to adhere to a strict regime of
maximum SAR (Specific Absorption Ratio)
limit. Cell phone use by children and adolescents
is a special area of concern. Due to their
relatively smaller heads, thinner skull bones, and
higher tissue conductivity, children absorb more
energy from the electromagnetic fields of cell
phones leading to earlier onset of some
psychological and physical health effects6. There
have been many studies about the risk of ionising
electromagnetic radiation due to cell phone
usage, towards cancers like Glioma, Acoustic
Neuroma, and some Salivary Gland tumours; but
few on the other health effects7. Hence a study
on the impact of mobile phone use on the mental

health of students in an urban college setting in
the densely populated city of Hyderabad (Andhra
Pradesh) was deemed apposite.
The methodology adopted in the present study

has been divided into three sections sample,
study design and the process of obtaining data
and analysis.
Sample:
Inclusion criteria:
After due ethical clearance from the concerned
authority, students of both sexes within the age
group of 17-23 from both rural as well as urban
backgrounds enrolled in professional courses
such as engineering, medicine, pharmacy, were
included in this study. The colleges selected were
situated near to each other, for easy logistics.
Any person, staff, visitor, worker, etc. not
studying in the above mentioned colleges were
not included in the study. Similarly any student
having an age lower than 17 years and above 23
years was excluded.
Subjects:
Since each of the colleges had over five hundred
students, a few from each were included in the
study so that the assessment was would be
relatively accurate with minimal bias.
Study design:
The study plan was a Cross sectional or
Prevalence one. Simple observations were made,
based on a single examination of a cross-section
of a population by administering a pre-tested
questionnaire, at one point in time. The study
focused on the distribution of the effects of cell
phone usage in the population included as
etiology
was
known.
Accordingly,
a
retrospective study was carried out.
Process of obtaining data and analysis:
The above mentioned colleges were visited with
the questionnaires that had just Yes or No
answers. All the students in the selected classes
attending college on the day the survey was
administered were eligible to participate. Thirty
389
minutes of recess or free time was the chosen

duration. Due information was given to the
respondents about the purpose of this
study.Voluntary consent was obtained after
explaining to them the purpose of this study.
Confidentiality of records was assured. Data
collected was compiled and summarized for
further analysis.
Duration:
The survey was conducted for a period of 2

months between July and August 2012.
RESULTS
a. General Information:
The total number of respondents was 459. Two
hundred and twenty (48.5%) of the respondents
were from the medical college and the rest (236,
51.5%) from non-medical courses.
Table 1: No. of students included in the study, from diverse professional courses
Professional Course
Medical
Nos. (%) (n=459)

223 (48.5)
Engineering
Pharmacy
56(12.2)
181(39.3)
As mentioned already, the age group of 17-23

years was chosen for the present survey. It was
noted that a higher percentage of subjects (363,
79%), were below 20 years of age i.e. from 1720 years. An almost equal number of females
(228, 49.7%) and males (231, 50.3%)
participated in the study. A majority (293,
63.8%) of the students included in the research
understandably belonged to an urban background
as compared to 166 (36.2%) who came from a
rural milieu. On the aspect of possessing a cell
phone, it was noted and not surprisingly so, that a
very high percentage (441, 96.1%) of the
subjects had one.
b. Psychological Health Effects:
The objective of this study, as mentioned before,
was to find out about the adverse psychological
or mental health effects amongst students using
cell phones, some of which they themselves may
not be aware of, and to spread awareness
amongst them so as to help reduce those, if
possible. This part of the questionnaire was
administered to all those 441 students who
owned a cell phone. On an inquiry about existing
illnesses, few (10, 2.3%) of the students
mentioned that they were already suffering from
ailments like asthma and migraine. The
commonest complaint was that of headache.
Almost 52% (227) of the students carped about

and attributed frequent attacks of headache to
their continued usage of mobile devices. Again,
224 i.e. more than half the subjects (50.8%)
admitted that they got irritated or angry over
things told to them on the cell or by the end of
the day by which time they had used their cell for
prolonged duration. Two hundred and nine
(47.4%) students responded positively when
queried on lack of concentration. They perceived
that they were more or less disturbed by frequent
calls/messages from people, which did not allow
them to proceed with their academic activities at
a stretch. One hundred and seventy (38.5%) said
that they got anxious while using the phone.
Certain information or messages communicated
to them at odd times caused apprehension. This
can be understood as with the advent of cell
phones, news is passed to one another, almost on
an immediate basis. One hundred and fifty six
students (35.4%) did answer in the affirmative
about some amount of sleeplessness. They
complained of getting sleep much later after they
retired for the night, in spite of a tiring day and
/ or disturbed sleep in which they woke up
several times in-between. Lack of academic
performance was attributed to increase in cell
phone habit, by 153(34.7%); while the rest did
390
not think that was the actual cause. Frequent

disturbances due to communication from friends
or parents did affect continuity and attentiveness
in studies, and the subsequent marks secured in
the examinations were proof of fall in scholastic
performance. One hundred and nine (24.7%) of
the respondents said that advent of some sad
news, differences with close friends or siblings /
parents, in that they did not respond to their
calls/texts, etc. did lead to them being sad and
gloomy and they attributed the same to cell
phones. One hundred and five students (23.8%)
said that they were more forgetful than they were
before or had frequent memory lapses due to
dependency on various features in cell phones
which stored information. Important days,
activities and events were no longer required to
be memorised and hence slipped away from
recall. One hundred and two (23.1%) reported in

the confirmatory about their habit of lying. They
did lie about their location and as to what they
were doing when asked by someone on the other
end of the phone, due to various reasons. When
inquired about the lack of affection from friends
and parents, 91 respondents (20.6%) did confirm
the same. When friends and close ones did not
respond to their calls or cut them off, and when
their messages were not answered to; these
persons felt unwanted. Many students did feel
indisposed due to the continuous stress caused by
cell phones in their day-to-day lives. Vague and
non-specific symptoms resulted in them missing
their classes in the college. The main symptoms
detected amongst the subjects are summarized in
Table 2 below.
Table 2: Adverse psychological health effects, in descending order of occurrence
Mental health symptoms
Nos. (%) (n=441)
Headache
Irritability
Lack of concentration
227 (51.5)
224 (50.8)
209 (47.4)
Anxiety
Lack of sleep
170 (38.5)
156 (35.4)
Contrastingly, some of the health benefits which

were mentioned by the users of cell phones were
that listening to music and talking to people
helped them relax. Another benefit they
mentioned was that it helped them get some
exercise as some were in the habit of walking or
jogging during their talks or while listening to
music.
DISCUSSION
a. General Information:
An almost equal number of subjects from both
medical and engineering colleges were included
in this study to avoid any bias that can result
from the presumption that medical students had
greater awareness about adverse health effects of
cell phones and its radiations than their
counterparts in other professional colleges.

Similar studies on specific groups have been
carried out. Sara Thomee et al 8 of Gothenberg,
Sweden and her colleagues, carried out a
research on perceived stress, depression, sleep
disturbances and other mental symptoms on
students of medicine and information
technology8. In this study, a majority of the
subjects were below 20 years of age. A similar
survey was conducted by MACRO in Mumbai in
20049 where respondents were in the age group
15-29 years. They had observed that exposure to
cell phones had increased drastically in the past
few years among those under 20. Almost an
equal number of male and female participants
were included in this study. There is a relative
increase in the number of female students
391
registered in professional courses today such as

pharmacy, medicine and engineering, as
compared to the past. In the landmark MACRO
study more females participated in the study as
compared to males9. Most respondents here
belonged to the urban background. Probably
there is a rural to urban shift due to availability
of better educational facilities as compared to
their original place of stay. The MACRO study
has comparable results. Almost all students
owned a cell phone. Of the 4% who did not, it
was revealed that they had either lost theirs and /
or would procure one shortly. It is therefore clear
that cell phones are a basic necessity in todays
life and amongst students almost all have one. In
the 2008 study of the American Cancer Society,
87% of the population in the USA possessed a
cell phone4.
Psychological Health Effects:
Though it is understood that there can be
numerous causes of headache; stress of studies
and daily travel as well as exposure to pollutants,
etc. being a few important ones, yet in this study
it was assumed that the perceived view of the
respondents was correct. That more than 50%
complained of the same is a cause of worry and
necessary suggestions were made to prevent
headache. More studies are required in this
direction, as existing literature is limited. Also
more than half of the subjects mentioned that
they did get irritated at things told to them over
phone. Many attributed that the habit of listening
to music also made them irritable by the end of
the day. Studies done in Sweden10, on teenagers,
disclose that restlessness and fatigue do result
amongst those who use their phones excessively.
Another common symptom observed was that
many students complained of inability to
concentrate on studies and other important
aspects of their daily lives, due to phone calls or
texting activities to which they had to respond to,
mostly on an immediate basis. Jennifer Meckles
in her study reports that attention gets affected
due to increase in mobile phone usage12. Anxiety
- a displeasing feeling of fear and concern was
seen among approximately two-fifths. Subjects

complained of performance-related anxiety,
especially with regard to examinations, so as to
get better career opportunities later. Francisca
Lopezs study states that most mobile addicts are
people with low self-esteem and are prone to
develop friction in their social relations. They
feel the urge to be constantly connected and / or
be in contact. If they are deprived of their cell
phones, regardless of the reason they tend to
become anxious and irritable. Lack of sleep or
insomnia in 35%, was the next common
symptoms observed among this class of subjects
the students in this study. Besides, long hours of
travel and the stress of studies, continuous usage
of cell phones was thought to be responsible for
this outcome. Sara Thomme et al found out that
high mobile phone use was associated with sleep
disturbances and symptoms of depression8. Gaby
Badre reported the same thing from Sweden15.
The Daily Galaxy reports that top sleep experts
have raised serious concerns over the more than
sufficient evidence showing that radiation from
headphones affects deep sleep11. Almost 35 %
also confessed that they lagged behind in
academics, due to their cell phone addiction. In
the study by Ms Jennifer Meckles12 conducted
last year, a similar finding on lack in
performance has been documented. As a trait
was inquired into, to relate to depression,
actually. This term was used as it was assumed
that the non-medical students may have certain
amount of stigma attached to the worddepression. One-fourths of the students in the
study told that sad happenings or souring
relationships conveyed to them on their cell,
resulted in gloominess and depression. Leisure
boredom is reportedly due to dependency on
cell phones as per Ms Alexia Corbetts study of
impact of cell phones on social interactions and
interpersonal relationships14. In a cohort study
done by Sara Thomee et al, 50% of the men and
65% of the women confirm that they lost interest
in things and/or felt depressed or hopeless, due to
mobile devices8. Many confessed to not
392
remembering important events like birthdays,

anniversaries etc. due to constant reminders they
expected their cell phones to give them. Such
dependency resulted in memory lapses elsewhere
too, wherein information was not stored in the
cell device on time. Md Ashrafur Rahim13 in his
thesis paper has probed into this aspect and
found social relations getting affected due to
such slips. Habit of lying or dishonesty is another
area of concern especially among the younger
generation. A good number (23%) admitted that
they either did not tell their exact location when
asked over the cell phone or indulged in not
telling the truth after giving blank calls. This
compares with The Pew Internet and American
Life Project found that 39% of cell-users aged
18-29 say that they are not always truthful about
where they are, when they are on the phone3.A
few of the respondents stated that they did not
receive adequate love and affection at home. It
was found that many a household had avoidable
quarrels amongst siblings, ego troubles with
parents and other related problems due to the
subjects regular use of cell phones. Md Ashrafur
Rahim has probed into this characteristic in his
thesis paper13. That mobile addicts tend to
neglect obligations of important activities and
drift apart from friends and close family, has
been documented in Francisca Lopez Torrecillas
research too, on mobile phone addiction and
severe psychological disorders10. It comes to
light then that alarming percentages of the cell
phone using student community in professional
colleges suffer from common and uncommon
symptoms of psychological nature which cannot
and should not be ignored. Some literature on the
matter of health benefits was reviewed, since few
of the students did mention exercise and
relaxation as pluses of having a cell phone.
Scientists have found out that phone radiation
actually protected the memories of mice
programmed to get Alzheimer's disease. They are
now testing more frequencies to see if they can
get better results. This study is being carried out
by the Florida Alzheimer's Disease Research
Centre and is published in the Journal of

Alzheimer's Disease16. PJ Skerrett in Harvard
Health edition of 23 February 2011 mentions that
cell phones stimulate brain activity17.
Suggestions: During the process of data
collection, the investigators interacted with the
respondents and gave short talks on minimizing
undesirable health effects due to cell phone
usage. The point on limiting the usage of the cell
phones in two aspects was emphasised upon
cutting down both on the number and duration of
the calls. It was informed to the clientele that,
though cell phones have many obscure short term
effects like generalised aches and pains, the long
term effects esp. those affecting the
psychological aspects were more manifest and
well-defined. The subjects were also warned
about electromagnetic radiations emanating from
the phones as the cause of various cancers of the
human body
CONCLUSION
Addiction to a cell phone device and lack of

adequate knowledge about the harmful effects
due to cell phones could be the important reasons
that have contributed to the increased incidence
of some psychological health symptoms amongst
the younger college-going generation
It is thought that side-effects due to cell phone
usage esp. those that affect the health of a person
can be minimized or eliminated by spreading
awareness on the subject matter especially on
restricted use and not getting habituated to the
devices.
More surveys need to be conducted amongst
various strata of the society, in urban as well as
rural settings, in younger as well as older age
groups, among the educated and not so educated
and in different parts of the country, in this
regard. The effects of cell phone usage need
constant surveillance and monitoring and an
effective reporting system in this regard can go a
long way in helping authorities to formulate
policies that will check the ill-effects due to cell
phone usage.
393
REFERENCES
1. Wikipedia, the free encyclopedia (online):

(i) Mobile Phone radiation and health, and
(ii) Electromagnetic Radiation and health.
2. World Health Organization. Electromagnetic
Fields and public health-Mobile phones:
Fact sheet June 2011, No.193,
3. Centre on Media and Child Health 2007,
Childrens Hospital, Boston. cmchmentors
for parents and teachers. Hot Topics Cell
phones.
4. American Cancer Society : Cellular phones
:Learn about Cancer:31 May 2011
5. Sue Kovach. The Hidden dangers of Cell
phone Radiation. Life Extension Magazine,
Aug 2007
6. Aruna Tyagi, Manoj Duhan and Dinesh
Bhatia. Effect of mobile phone radiation on
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(Link:
http://www.ijstm.com/archive/aruna_0401.p
df)
7. Environmental Working Group. Cell phone
Radiation- Science Review on Cancer Risks
and Childrens Health: Do cell phones cause
cancer or other illnesses. 2009;1, 8-10
8. Sara Thomee, Annika Harenstam and Mats
Hagberg. Mobile phone use and stress, sleep
disturbances and symptoms of depression
among young adults-a prospective cohort
study. BioMed Central Public Health, 2011,
11:66.1-11
9. MARCO (Market Analysis and Consumer
Research Organisation) : A report on study
of mobile usage among the teenagers and
youth in Mumbai: April-May 2004
10. Francisca Lopez Torrecillas. University of
Granada : Mobile phone addiction in
teenagers may cause severe psychological
disorders: 2007; 27 February
11. Rebecca Sato. The Daily Galaxy. New

study finds that Mobile phones affect our
brains and disrupts sleep:22 Jan 2008.
12. Jennifer Meckles, wbir.com:Sleep affected
by late night cell phone, technology use: 24
Feb 2012
13. Ashrafur Rashim. Negative effects of Cell
phones: Physical, Economical and Social.
Journal or Thesis paper.04 Sep 2009
14. Alexia Corbett: Cellular phones influence(s)
and impact(s) on social interactions and
interpersonal relationships: Perspectives- the
University
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New
Hampshires
undergraduate Journal for Sociology. 03 Dec
2009
15. Gaby Badre: Science Daily: Excessive
mobile phone use affects sleep in teens,
study finds: 09 Jun 2008 BBC News.
Mobile phone radiation protects against
Alzheimers. 07 Jan 2010
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activity:23 February 2011
394
DOI: 10.5958/j.2319-5886.2.3.069

&
Health Sciences
Research article
A STUDY ON SERUM ENZYME LEVELS IN VARIOUS LIVER DISEASES
*Salma Mahaboob R1, Jayarami Reddy U2, John Basha S3,
1
Lecturer, 2Professor, 3Asst. Professor Department of Biochemistry, Fathima Instituted of Medical

Sciences, Kadapa, Andhrapradesh, India.
*Corresponding author email: salmamahaboob9@gmail.com
ABSTRACT
Patients with chronic liver diseases are asymptomatic or have only vague non-specific symptoms.
Effective medical treatments for chronic liver disease (before cirrhosis is established) are becoming
increasingly available and since abnormal LFTs may be the only indication of these diseases. Aims:
Enzymes study of various liver diseases. Discussion: serum Alkaline phosphatase (ALP), Gamma
Glutamyl transferase (Gamma GT), Alanine and Aspartate amino transferases were estimated in viral
Hepatitis, Alcoholic liver diseases, Obstructive jaundice, cirrhosis of the liver. It was observed that
obstructive jaundice shows higher levels of ALP levels followed by alcoholic liver disease, viral
hepatitis, cirrhosis of the liver. Viral hepatitis shows higher rise of SGOT, SGPT levels, followed by
alcoholic liver disease, obstructive jaundice, and cirrhosis of the liver. Gamma Glutamyl transferase
enzymes highest levels are seen in alcoholic liver disease. Conclusion: These enzymatic variations are
useful to diagnose the disease and classify them according to etiology.
Keywords: Gamma Glutamyl transferase, cirrhosis of liver, alcoholic liver disease.
INTRODUCTION
Liver disease is a general term for any damage

that reduces the functioning of the liver. As a
large organ the liver shares with many other
abilities to perform its functions with extensive
reserve capacity. Elevated levels of Gamma
glutamyl transferase (GGT) are observed in
chronic
alcoholism,
pancreatic
disease,
myocardial infarction, renal failure, chronic
obstructive pulmonary disease, and in diabetes
mellitus. In liver diseases GGT elevation
Mahaboob etal.,
parallels that of serum alkaline phosphatase

(ALP) and is very sensitive of biliary track
disease. The GGT level in alcoholic liver disease
roughly parallels the alcoholic intake1. GGT is a
key enzyme for the detection of alcoholic liver
disease. Very high levels of ALP are noticed in
patients with obstructive jaundice, it is also
elevated in serum in disease of bone, kidney,
leukocytes, placenta and intestine. ALP is
elevated in obstructive jaundice due to cancer,
395
common duct stone, cholangitis, or bile duct

structure1. ALP is a key enzyme for the
diagnosis of obstructive jaundice. ALP
Transaminases increases in liver disease and also
serum glutamate oxaloacetate transaminase
(AST) level are significantly elevated in
myocardial infarction. However a marked
increase in AST may be seen in primary
hepatoma1. Increased serum glutamate pyruvate
transaminase (ALT) levels are seen in chronic
liver disease such as cirrhosis of the liver,
hepatitis, and non alcoholic SEATO hepatitis
(NASH) 2
Thus it has been reported that all the four
enzymes namely GGT, ALP, SGOT, SGPT, are
useful parameters for diagnosis of various liver
diseases. However in a recent review some of
these enzymes were not listed for their use in the
diagnosis of various liver types of liver disease.
Under these circumstances the aim of the present
investigation was to study these enzymes in
various types of liver diseases to asses their
diagnostic importance3.
After the institutional Ethical Committee

approval and inform consent obtained from the
each patient, total 80 various liver disease
patient admitted in the general medicine
department of Fatima Hospital over a period of
six months from June to December of 2012, were
included in the present study. All are age group
between 35 to 50 years of both sexes.
Grouping of the patients: Group1: Control
healthy volunteers (N=20). Group2: Diagnosed
as cirrhosis (N=20), Group3: Diagnosed as
alcoholic liver disease=20), Group 4: Obstructive
jaundice. Grope 5: viral hepatitis.
The data on personal history, regarding the onset
of the disease, alcohol consumption and
treatment history of liver disease were collected
through standard questionnaire. 10 ml of venous
blood samples were collected in plain tubes, the
serum was separated by centrifugation and the

obtained serum was used for the estimation of
SGOT, SGPT, ALP & Gamma GT4.
Serum SGPT was estimated by the International
Federation of clinical chemistry (IFCC) method
kinetic, SGPT is present in high concentration in
the liver and to a lesser extent in kidney, heart,
skeletal muscle, pancreas, and lung. Increased
levels are generally a result of primary liver
disease such as cirrhosis, carcinoma, viral or
toxic hepatitis, Decreased levels may be
observed in renal dialysis patients and with
vitamin B6 deficiency.
Principle:
L-alanine+2-oxoglutarate--ALT Pyruvate+L-Glutamate,pyruvate+NADH--LDH L-Lactate+NAD
(ALT=Alanine
aminotransferage, LDH=Lactate dehydrogenase)
values expressed in IU/L, Normal values;
Females:0-31IU/L, in males:0-40IU/L, at 370C,(57)
.SERUM SGOT was estimated by IFCC
Method, Kinetic without Pyridoxial Phosphate,
SGOT occurs in all human tissues and is present
in large amount in liver, renal, cardiac, and
skeletal muscle tissue. Increased levels are
associated with liver disease or damage
myocardial infarction, muscula dystrophy and
cholecystitis. Decreased levels are observed in
undrgoing renal dialysis and those with B6
deficieny.
values
are
expressed
in
IU/L.Priciple:L-spartate+2xoglutarate SGOT
oxaloacetate
+L-Glutamate,
oxaloacetate+
NADH MDHMalate +NAD+ sample pyruvate
+NADH L-Lactate+NAD,(AST=Aspartate
aminotransferage, LDH=Lactate dehydrogenase,
MDH=Malate dehydroginase) Normal values;
Women: upto 31IU/L,Men:upto37IU/L(8-10).
SERU ALP is found in practically all tissues of
the body but in higher concentrations in the
osteoblasts of bone, liver placenta, kidney, and
lactating mammary glands. Increase ALP is seen
in osteomalacia and rickets, low levels of ALP
may be observed in conditions which causes
arrested bone growth or in hepophosphatasia.
SERUM ALP was estimated by P-Nitro phenyl
396
Mahaboob etal.,
phosphate method Principle : AMP+4NPP+H2O----ALP 4-nitrophenol+phosphate,

and values expressed in IU/L Normal values;
Females:50-170 IU/L. Male:50-96IU/L10-14.
SERUM GGT elevation parallels that of ALP
and is sensitive of biliary track disease. GGT is
the key enzyme for diagnosis of alcoholic liver
disease. SERUM GAMMA GT was estimated
by
kinetic
method,
principle:
GlupaC+Glycyglcine L-Gamma
-GlutamylGlycyglycine+5-Amino-2-nitrobenzoicacid,
GLUPA-C:L-Gamma-glutamyl-3-carboxy-pnitroanilide, and values expressed in U/L,
Normal
45u/L.
values;Females:5-32U/L,Males:10-
RESULTS
The bio-chemical findings of this study are
expressed in the form of the following results the
results were expressed as mean and SD, the
normal values are used to compare values, for all
parameters of the study the mean and SD were
calculated for patients and controls. The p- value
<0.001 is comparatively highly significant.
Table.1: Serum Enzymes In Various Liver Disease *

CIRRHOSIS ALCOHOLIC
OF LIVER
LIVER DISEASE
PARAMETER
VIRAL HEPATITIS
OBSTRUCTIVE
JAUNDICE
SGOT(IU/L)
95.09.7
239.215.4
290.017.05
91.99.5
SGPT (IU/L)
98.59.9
152.012.3
499.322.3
96.359.81
ALP (IU/L)
151.212.3
222.1517.45
183.8513.6
678.4526.04
GGT(IU/L)
90.3 9.2
480.021.9
70.56.8
180.612.5
*Date presented as MeanSD.

DISCUSSION
In this study higher levels of ALP and GGT were

observed in serum in all cases of Alcoholic liver
disease. However, the latter showed an average
increase of about 6 times their mean normal
values which was much higher than that of GGT
in all cases of Alcoholic liver disease. It is well
known that serum GGT and ALP are elevated in
all cases of alcoholic liver disease, it shows that
the importance of these enzymes are key
enzymes of alcoholic liver disease. Further these
enzymes are elevated in other liver diseases like
obstructive jaundice; etc. through this increase
above normal values was marginal to that
observed in alcoholic liver disease. Comparing
the significance of GGT and ALP in alcoholic
liver disease, the former seemed to be a better
parameter for the diagnosis. SGPT and SGOT
Mahaboob etal.,
levels in serum increased to 6 times the normal

value in viral hepatitis whereas the levels of ALP
increased only 3 times the normal value. The
much higher increase of SGPT compared to
SGOT suggests the former to be a better index of
viral hepatitis. Mild elevation in serum levels of
both enzymes was observed in most of the other
cases of liver disease through significant increase
was only seen in viral hepatitis. ALP levels in
serum increased to 8 times the normal value in
obstructive jaundice, it is a key enzyme for the
diagnosis of the obstructive jaundice.
Estimation of these parameters is a guide for
assessment of severity of the damage to the liver
and also a measure of good prognostic value.
Irrespective of the etiology of liver, estimation of
397
these parameters substantially

complete picture of liver disease.
provides
CONCLUSION
In conclusion it shows that levels of GGT

(Kinetic Method) are more use full than ALP, for
diagnosis of alcoholic liver disease. Where as
SGPT (IFCC Method, Kinetic) is definitely a
better index of viral hepatitis, than SGOT (IFCC
Method, Kinetic without pyridoxal phosphate).
ALP (P-Nitropheny phosphate) is a specific
diagnostic parameter to indicate obstructive
jaundice. The present work supports their
inclusion and use as reliable tests for diagnosis of
specific liver disease.
As the study is done in the rural community,
around Kadapa most of the patients are found to
be with jaundice at later stages. The season was
thought to be because of illiteracy, superstition
and unawareness of these varieties of the disease.
For this reason it is very important to bring
awareness among the rural society about the
importance of alcohol abuse, drug abuse,
malnutrition, hepatitis and vaccination for
children.
6. Bradley DW., Maynard JE,.Emery G,

Webster H.Clinical chemistry. 1975; 18:
1442
7. Wolf PL, william D, Coplon N. And Coulson
AS. Clinical chemistry.1956;18:567
8. Bergmeyer HU, Horder M ,Rej R.:Clinical
chemistry,clinical biochemistry. 1986;24,
481-95
9. Ellis G, Goldberg DM,Spooner RJ, Ward
MA. Serum enzyme tests in diseases of liver
and biliary tree.Am. J.Clin. Pathol.1978; 70:
248-54.
10. Tietz NW ed.Clinical Guide to Laboratory
Tests, 3rd ed. philadelphia, PA :WB.
Saunders,1995
11. Zilva JF,Pannall PR, Plasma Enzymes in
Diagnosis in Clinical chemistry in Diagnosis
and treatment. Lloyd London 1979: Chapter
15:343.
12. IFCC Method for the measurement of ALP
j.clin.chem.clin.Biochem.1983:21:731-48.
13. Young DS. Effects of drugs on Clinical
Laboratory tests. Third Edition 1990:3:19-25.
14. Kaplon and PESCE (Eds) Clinical
chemistry,Theory
analysis
and
Correlation.Second
Edition.CV
Mosby
Co.1989.
REFERENCES
1. Harrison. Harrisons principles of internal

medicine,.17th edition, II volume p.19181980.
2. Davisons.The principles and practice of
medicine,.21st edition 2010.p 922-969.
3. Vasudevan DM, Sreekumari S. Textbook of
biochemistry,.5th edition.,2007; p,54-55.
4. Raghavendra DS, Srinivas B.Rao.Studies on
some serum enzyme levels in various liver
diseases. Indian journal of clinical
biochemistry. 2000;15(1):48-51.
5. Varley,
H.
In:
Practical
Clinical
th
Biochemistry. 4
ed. Arnold Heinman.
(India) Ltd. New Delhi p 465,1975.
398
Mahaboob etal.,
DOI: 10.5958/j.2319-5886.2.3.070

&
Health Sciences
Research article
EFFECT OF BODY POSITION AND TYPE OF STRETCHING ON HAMSTRING
FLEXIBILITY
Amr Almaz Abdel-aziem1, Amira Hussin Draz2, Dalia Mohammed Mosaad2, Osama Ragaa Abdelraouf3
1
Assistant Professor, 3Lecturer, Department of Biomechanics, Faculty of Physical Therapy, Cairo

University, Egypt
2
Lecturer, Department of Basic Science, Faculty of Physical Therapy, Cairo University, Egypt
*Corresponding author email: amralmaz@yahoo.com ; amralmaz74@gmail.com
ABSTRACT
Background and objective: Stretching exercise protocols, as part of outpatient treatment or home
exercise programs, are used to improve muscle flexibility. So, the aim of the study was to examine the
body position effect (standing and supine) and dynamic range of motion (DROM) stretching technique
on hamstring flexibility. Material and Methods: Seventy five subjects with decreased flexibility of
hamstring (defined as 30 loss of active knee extension, from 90hip flexion position), participants
were randomly assigned to one of three equal groups. The first group performed static stretch from
standing for 30 sec. The second group performed static stretch from supine for 30 sec. The third group
performed DROM stretch. The stretching procedure conducted three times per week for four weeks.
Results: There was a significant increase in the knee extension range of motion for standing, supine and
DROM stretch (p < 0.05). Stretch from standing and supine was significantly higher than DROM
stretching (p < 0.05). There was no significant difference in hamstring flexibility between standing and
supine stretch (p > 0.05). Conclusion: Both standing and supine stretches displayed improvement in the
hamstring flexibility, and both of them produced higher improvement than DROM stretch during
hamstring flexibility training
Keywords: Body position, Hamstring flexibility, Stretch
INTRODUCTION
Muscle flexibility exercises are among the
exercise types most commonly used in
rehabilitation and sports practice. Their aims
usually include reducing the risks of injuries,
minimizing late-occurring muscle pain and
improving general muscle performance.1 The
muscle flexibility defined as muscle ability to
lengthen, permitting one joint (or joints in a

series) to freely move through a range of
motion.2
Improvement of flexibility is postulated to
prevent athletic injuries. Stretching exercises
were found to benefit athletes and social
exercisers in many ways, including increased
399
Amr Almaz Abdel-aziem et al.,
flexibility, decreased incidence of injury, and

better athletic performance. 3 Low back and
lower extremity injuries are strongly correlated
to poor hamstring flexibility.4,5 Hamstring stretch
training significantly improved its flexibility and
decreased the risk of lower extremity injuries in a
sample of military trainees as compared with a
control group.4
Hamstring stretch from standing position has
been found to improve hamstring flexibility.610
However, pelvic position is an important factor
determining stretch efficacy;11 therefore, proper
performance must be considered. The usual
static stretching technique from supine does not
appear to have been investigated. It is easily
taught and requires less supervision than
standing stretch, thereby making the patients and
athletes can perform it effectively.12
Dynamic range of motion (DROM) could be an
alternative to static stretching; it was suggested
as a better stretch technique than static stretching
for increasing muscle flexibility. During DROM,
the antagonist contraction allows the joint
crossed by the agonist (muscle to be stretched) to
move at a controlled pace through a full range of
motion (ROM). All movements are performed
slowly and deliberately.13
Dynamic range of motion includes a slow
movement of the limb that starting from a neutral
position toward end of range of motion, a brief
hold at the end range of motion, and, finally,
slow movement of the limb back to return to the
original neutral position through an eccentric
contraction. The antagonist contraction leads to

relaxation of the agonist (lengthening muscle) as
described by the principle of reciprocal
inhibition. So, DROM is more natural and
relaxed way of stretching, as the muscle is
reflexively inhibited, and the strength is
improved because the movement is performed by
the muscles that move the involved joint.13
Therefore, the aim of the current study was to
evaluate the effect of static stretch from standing
and supine position and dynamic range of motion
hamstring stretching in increasing hamstring
flexibility.
Subjects: Seventy five subjects participated in
the study, they were randomly allocated into
three equal groups; supine stretch, standing
stretch and DROM stretch group. Exclusion
criteria are: 1) lower extremity or back injury
through the last year that required medical
treatment and 2) any pathological conditions that
negatively affecting on hamstring flexibility.
Inclusion criterion is the loss of at least 30 of
active knee joint extension with the hip joint
flexed to 90.7 Subjects agreed to maintain their
physical activity level, especially level of
exercise, throughout the 4 weeks of the study.
Table I, presents the demographic characteristics
of the participants. The study was approved by
the research ethics committee of the Faculty of
Physical Therapy, Cairo University.
Table.1: Demographic data for supine, standing and DROM stretch groups
Groups
Age, years
Weight, kg
Height, cm
SD: standard deviation
Supine stretch group,

(n = 25)
Mean SD
25.54 3.72
75.44 6.73
172.8 5.07
Standing stretch group, DROM stretch group,

( n = 25)
(n=25)
Mean SD
Mean SD
23.92 3.87
24.20 4.19
77.34 7.84
76.34 7.77
170.88 5.61
173.24 6.53
Procedures
Hamstring muscle flexibility was measured with
a transparent plastic goniometer marked off in
1-degree increments. Each subject was lying

supine with the right hip and knee joint flexed to
400
90 degrees. The greater trochanter, lateral

epicondyle and lateral malleolus of the right
lower extremity were then marked with a felttipped pen for later goniometric measurement.
Ninety degrees of hip flexion was maintained by
one researcher, while the tibia of the knee was
passively moved to the terminal position of knee
extension by the second researcher. The terminal
position of knee extension was defined as the
point of range of motion at which the subject
complained of a feeling of discomfort or
tightness in the hamstring muscles or the
experimenter perceived resistance to stretch.
Once the subject reached the terminal position of
knee extension, the second examiner measured
the degree of knee extension range of motion
with
the
universal
goniometer.14
All
measurements were performed in the same way
before and after the stretching techniques (4
weeks), without warm-up before measurement.
All participants received a handout describing
Fig.1: Standing stretching procedure for hamstring
The third group (DROM stretch) the subjects

lying supine on the evaluation table with the hip
joint maintained in 90 of flexion. The subjects
extended the knee joint actively (5 sec), maintain
the leg at the end of the knee extension for 5 sec,
and then slowly move the leg to flexion (5 sec),
which was considered one repetition. The
DROM stretching movement was repeated for
six times. DROM stretch performed for six
repetitions of 5 sec each allowed 30 sec of actual
the ideal way the three types of stretch technique.

They randomly assigned to the three groups by
using a computer-generated number table. First
group (standing stretch), subjects stands facing
the table of evaluation with the heel placed on
the table edge, then the subjects instructed to
bend forward, the subjects maintain a flat back
with the pelvis move in the direction of anterior
rotation, they must maintain a neutral position of
the head and maintains the stretched leg in full
extension as shown in figure (1). The second
group (supine stretch) subjects positioned in
supine lying on the floor with the stretching leg
elevated on the cupboard or wall and the other
leg straight on the floor, the subjects adjust the
distance from the wall to feel a hamstring stretch.
When the supine stretch position cannot
produced a stretching sensation to the hamstring,
the examiner instructs the subject to slide their
body closer to the cupboard or the wall12, as
shown in figure (2).
Fig.2: Supine stretching procedure for hamstring
stretching duration, which is equal to the

stretching duration performed by the first and
second groups13
The three stretching techniques were performed
3 times/week for 4 weeks, at the same time of
day. Each stretching session consisted of 3 times
stretching for 30 sec. Subjects rested for 15 sec
between stretches, for the supine stretch group
the subjects removed their leg from the wall, for
standing stretch group the subjects move their leg
down from the table, from DROM stretch group

the subjects take the sitting position. No warmup exercise was performed before stretching
sessions. One of the researchers supervised the
stretching sessions to ensure that stretching
techniques were being performed in the same
way. If a subject missed 2 stretching sessions
during stretching program would be excluded.
Two days existed between the last bout of
stretching procedure and final measurement. To
eliminate bias effect the 2 researchers who
recorded the measurements did not review the
initial flexibility measurement values.
Statistical analysis
Data were analyzed by using a Statistical
Package for Social Sciences (SPSS) for
Windows version 16.0. (SPSS, Inc., Chicago,
Illinois). Dependent t-test was used to compare
between pre and post values of each group. Oneway ANOVA was used to investigate the effect
of the training program on hamstring flexibility.
Least significant difference (LSD) test used to
locate the source of differences. Level of
significance was set at 0.05 for all tests.

RESULTS
The descriptive statistics of the pretest and
posttest values of the supine, standing and
dynamic range of motion stretch groups were
illustrated in Table II. Paired t-test of the pre and
post values of the three groups revealed that
there was significant improvement in the knee
extension ROM of knee joint of the three groups
(p=0.00).
One-way ANOVA of the pre values of the
supine, standing and dynamic range of motion
stretch groups revealed no significant difference
between the three groups (p > 0 0.05). One-way
ANOVA of the post values of the supine,
standing and dynamic range of motion stretch
groups revealed that there was no significant
difference between post values of supine and
standing stretch (p = 0.929), the improvement of
supine stretch group was significantly higher that
dynamic range of motion stretch group (p =
0.006), the improvement of standing stretch
group was significantly higher that dynamic
range of motion stretch group (p = 0.007).
Table.2: Knee-extension measurements pre and post stretch of the three groups
Pre test
Post test
Gain (difference
posttest)
Supine
Extension ROM
138.24 6.11
145.56 5.34
between
pretest
and
Finally, to summarize the data, a one-way

ANOVA on gain values of the three groups was
calculated, it revealed a significant difference
between groups (p < 0.05). Post hoc analysis
using LSD test indicated the gain of the supine
and standing stretching groups was significantly
higher than the gain of the DROM stretch group
(p = 0.000), as well as no significant difference
in gain of the standing and supine stretch groups
(p = 0.980).
7.32 1.80
Standing
DROM
Extension ROM Extension ROM
137.12 7.81
136.48 7.07
145.40 7.99
140.44 5.32
8.28 1.93
3.96 2.32
DISCUSSION
This study was conducted to compare the effect
of standing, supine and DROM stretch on
hamstring flexibility. The musculotendinous
units have the properties of creep and stress
relaxation. Creeping is known as muscle
lengthening due to an applied constant load.
Stress relaxation is defined as decrease in force
that necessary to hold a tissue at a particular
length over time.15 The musculotendinous unit
lengthens as it is being stretched and goes
402
through elastic deformation followed by plastic

deformation before complete failure.16 The
proprioceptors located within the muscle fibers
and tendons relay information about muscular
tension to the central nervous system. The two
proprioceptors related to stretching are muscle
spindles and Golgi tendon organs. Muscle
spindles are located in the intrafusal fiber of the
muscle, and responds to any changes in
length.17,18
Hamstring static stretching from standing
position allowing trunk flexion with knees
extended that produced a greater degree of
lumbar spine flexion and anterior pelvic tilting
with lower degree of thoracic spine kyphosis. So,
hamstring stretching is recommended before
sport activities required trunk flexion with both
knees maintained in a full extension position to
obtain a higher degree of hamstring flexibility.19
The groups that performed standing and supine
stretch illustrated significantly greater gains in
hamstring extension ROM than the third group
that performed dynamic range of motion
stretching. This is consistent with the results of
Bandy et al.6 who compared the effects of 30 sec
of static stretching with dynamic range of
motion, the gain of static stretching was 11.42
but the gain of dynamic stretching was only
4.26, the gains of the current study were 7.32
for the supine hamstring stretching group, 8.28
for the standing hamstring group and 3.96 for
the dynamic stretching group, these results
appear to be less than that reported by Bandy et
al.6, the reason may be due to the short duration
of the present study (4 weeks) in comparison to
the study conducted by Bandy et al.6, which
conducted through 6 weeks of stretch training.
Many factors contribute to the clinical success of
a stretching program. The frequency, intensity,
and duration are critical to achieve plastic
deformation of the tissue and lasting gains in
range of motion.20 The time frames for a stretch
program used in the previous studies11,21 ranging
from 2 to 8 weeks of stretching programs. The
participants of the current study performed
stretching 3 times per week for 4 weeks, which is

consistent with the duration and frequency used
by previous studies.6,7,21,22 Moreover, stretching
exercises performed three times a week were
sufficient to improve flexibility and range of
motion compared to subjects exercised five times
a week.23 Moreover, Cipriani et al.24 stated that
stretch training produces the same results,
whether the subjects conducted daily or 3 times
per week.
The standing hamstring stretch is common and
has been considered as valid and effective
method of increasing hamstring flexibility,6,7,10
the present study proved that supine stretching is
equally effective as standing stretch. During
standing stretch the subject can achieve an
adequate stretch by bending his trunk forward
without flexing the spine, so the pelvic position
is very important during standing stretch.7,11 In
contrast, during supine lying stretch the pelvic
position was free, for this reason it is preferable
to use the supine lying stretch in unsupervised
settings, such as group therapy, home exercise
programs or during athletic training. Moreover,
supine lying stretch isolate the hamstring
muscles during stretching, so it is safe and
comfortable for people suffering from low back
pain which will improve the relaxation during
stretch.12
The duration of static stretch (standing and
supine) used during this study was 30 sec that in
accordance with the study of Bandy et al. 7
indicated that a 30 sec stretch duration was more
effective than a 15 sec stretch and its effect is
equal to 60 sec stretch. Moreover, the 30 sec of
stretch and the procedure of DROM stretch
repeated for three times that was trial to
overcome the problem facing Bandy et al.6
during conduction of their study, they stated that
the stretching activities of DROM group were
higher than that performed in standing and
supine static stretching groups. In spite of this
increment in the total duration of stretch of the
DROM group, the groups of standing and supine
stretching for 30 sec (3 repetitions) increased
403
hamstring flexibility to a significantly greater

than the DROM group (3 repetitions), that is
coincident with the study conducted by Bandy et
al.6, who proved that the standing static stretch is
more effective in improving hamstring flexibility
than DROM.
However, Guissard and Duchateau 17 reported
that active dynamic stretching results in length
changes similar to passive static stretch, the
major advantage to active dynamic stretching
compared to passive static stretching is its effect
on the nervous system, and elastic properties of
the muscle during a stretch. As stated earlier, the
nervous system regulation of tension and length
is performed by a golgi tendon organ and muscle
spindle, respectively. When a muscle is
repeatedly stretched, a muscle spindle records the
change in length, thus activating the stretch
reflex and causing a change of the muscle length
through a muscle contraction. As a direct result
of an increase in muscle spindle activity, a fast,
dynamic stretch will increase a stretch reflex
response causing an agonist muscle to contract
with greater force. So, the dynamic range of
motion stretch is more effective in increasing the
muscle power and performance which did not
evaluated during this study.
Perrier et al.25 proved that flexibility was greater
after both static stretch and dynamic stretch
compared to after no stretch, with no difference
in flexibility between static stretch and dynamic
stretch. Athletes in sports requiring lowerextremity power should use dynamic stretch
techniques in warm-up to enhance flexibility
while improving performance.
The result of the current study was against the
findings of Meroni et al.26 who found that active
stretching of hamstring produced a greater
increase in the active knee extension range of
motion, and the improvement of hamstring
flexibility was maintained 4 weeks after finishing
the training. However, the maintaining effect of
static stretch is less than active stretching. So,
active stretching was more efficient than static
stretching in producing positive effects on

hamstring flexibility.
This study was limited by the following: First,
the study was restricted for the male subjects and
female subjects not represented in this study. So,
the reader must be careful during generalization
of the results of this study on all populations.
Second, the sample of the current study was
young. So, the results of the present study will be
more suitable for a similar age group and further
research evaluates the effects of the three
methods of stretching in individuals in other age
groups would be interested. Third, no warm up
activity applied before stretching which may
increase the ROM gains, that is in agreement
with the findings of O'Sullivan et al.27, who
stated that the hamstring flexibility increased by
warm-up exercise, static stretching, however
dynamic stretching did not. Finally, there is no
control group in the design of the present study
that is due all the previous literature6,7,21,28
proved that no changes in the knee extension
ROM of the control group as they did not
perform any type of stretch.
CONCLUSION
In conclusion, the results of the study proved that

standing, supine and DROM stretching increases
the hamstring flexibility. Moreover, standing and
supine stretch is significantly higher than DROM
stretching, as well as there is no significant
difference between supine and standing stretch in
increasing the hamstring flexibility. Supine
stretch requires less instruction and supervision.
So, it is effective for home exercise programs or
during athletic training.
Funding
Authors didnt receive any form of fund or
technical support from any agencies for this
research study.
ACKNOWLEDGMENTS
The authors wish to thank Dr. Mostafa Sayed

Abdel-Fattah, Lecturer of cardiopulmonary
404
disorders, Faculty of Physical Therapy, Cairo

University for revising the manuscript of this
study.
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DOI: 10.5958/j.2319-5886.2.3.071

&
Health Sciences
Research article
TOXIC EFFECTS OF HIGH NITRATE INTAKE IN OESOPHAGUS AND STOMACH OF
RABBITS
Manoj kumar Sharma1, Hemlata Sharma2, Neelam Bapna3
1
Associate Professor, 2 Lecturer, Department of Anatomy, Jhalawar Medical College, Jhalawar,

Rjasthan, India
3
Professor, Department of Anatomy, National Institute Of Medical Sciences, Jaipur, Rajasthan, India
*Correspondence author email: drmanojsharma2002@yahoo.co.in
ABSTRACT
Introduction: In India especially in Rajasthan people drink water containing high level of nitrates and
concentration up to 500 mg of nitrate ion per liter is not unusual. The ingested nitrate is converted to
nitrite in the digestive system and absorb in blood causing methemoglobinemia. Methaemoglobin is not
restricted to infants alone but it is prevalent in higher age groups also. The peak of methaemoglobin is
observed at 45-95 mg/liter of nitrate concentration of water. Aim of study: To find out the correlation
between drinking water nitrate concentration and histopathological changes in esophagus and stomach
of rabbits of different groups. Material & Methods: Therefore an experimental study was conducted in
10 rabbits according to guideline of ICMR, New Delhi between three and half month to four months of
age having weight ranging 1.310 kg to 10720 kg. Five groups A, B, C, and D & E were formed with two
rabbits in each group. The control group A was administered water orally having 06 mg/liter .Group B
to E (experimental groups ) were administered water orally having a concentration of 100mg/liter,
200mg/liter, 400mg/liter & 500mg/liter of nitrate respectively for 120 days. Then all rabbits were
anaesthetized & sacrificed according to the guidelines of the ICMR and oesophagus and stomach were
removed & processed for paraffin sections. Hemotoxyllin and eosin staining was done for microscopic
observations. Results: The results showed mononuclear infiltration in the esophagus which started in
group B and in stomach, histopathological changes appeared in sub-mucosa, muscularis mucosa ,
muscularis externa and seosa started from group c. The changes were more pronounced in stomach of
group D & E in the form of congestion of blood vessels in sub mucosa and mild infiltration of
lymphocytes in muscularis externa.
Keywords: Oesophagus, Stomach, Nitrate, Nitrite, Histopathology, Rabbits.
INTRODUCTION
The majority of Indian population is exposed to

nitrate through ground water and dietary
sources1. Excessive nitrate concentration in
drinking water is reported to have caused
methaemoglobinemia in infants up to 6 months

of age2, 3. The maximum permissible limit for
nitrate ion in drinking water have been set at
50mg/liter by WHO and 45 mg/liter by Bureau
of Indian standard (IS-10500)5,6,7. In several
407
Manoj et al.,
developing countries with high nitrate

concentration at times up to 500mg/liter is not
uncommon8.In body, nitrate are reduced to nitrite
& leads to methaemoglobinemia which occurs
through microbial action either in the
environment or in the body9. There are three
stages of interaction between sodium nitrite and
blood as :- an induction period , a reactionary
period & a terminal period , often prolonged
during which the product of the reaction, chiefly
methemoglobin pass into hematin and other
degradation products10.The health risk from
exposure to nitrate is therefore related not only to
their concentration in drinking water and food
but also condition conducive to their reduction to
nitrites11,12.
This action may be brought about in one of the
following way13----By direct action of the
oxidant or by the action of hydrogen donor in the
presence of oxygen or by auto oxidation. In the
presence of nitrites, the ferrous ion of
hemoglobin gets directly oxidized to the ferric
state. Normally the methemoglobin is formed is
reduced by the following reaction:
Hb+3 +Red.Cyt b5 ----------> Hb+2 + Cyt b5
Reduced cytohrome b5 is generated by the
enzyme cyt.b5 reductase:
Oxy cytb5 + NADH
----------> Red cyt b5 +
NAD.
Thus the enzyme cyt b5 reductase plays a vital
role in counteracting the effect of nitrate
ingestion.
We choose the rabbits for the study because pH
of their stomach is similar to human beings. so it
is proposed to study the effect of nitrate toxicity
in blood of rabbits .
The present research work was permitted by

Departmental research committee and university
of Rajasthan, Jaipur and principal & controller of
SMS Medical College, Jaipur Rajasthan. The
study was conducted in Department of Anatomy
at SMS Hospital and Medical College, Jaipur
(INDIA) on five groups of 2 rabbits each. The

rabbits were used for the study because their
stomach pH is similar to infant (pH= 3.0-5.0) 10.
The age of rabbits were three and half to four
months & weight varied from 1.310 kg to 1.720
kg. These groups were identified as A,B,C,D &
E. Ad libitum quantity of water containing
45,100,200,400 and 500 mg/liter nitrate (in form
of NaNO3) and food soaked in the same water
were given to group A to E respectively. The
group consuming 45mg/liter served as a control
group. After 120 days the animals were
anaesthetized and sacrificed according to the
guidelines of ICMR10,11 and dissected. The
Oesophagus and stomach were removed and
biopsy was taken from the organ. These tissues
were fixed in 10% formalin solution and
subjected to histopathological examination.
RESULTS
Histopathological changes in oesophagus: No

changes were observed in oesophagus of rabbits
subjected to water ingestion containing
45mg/liter (control group). The histopathological
changes associated with high nitrate in drinking
water indicated a change in mucosa which started
at 200mg/L nitrate. The changes were more
pronounced as the nitrate concentration
increased, in the form of mononuclear
infiltration.the changes in submucosa were
observed in group E only. The changes were in
the form of moderate infiltration.
Histopathological changes in stomach: No
changes were observed in stomach of rabbits
subjected to water ingestion containing
45mg/liter (control group) & 100mg/litre (group
B). The changes appeared in submucosa,
muscularisexterna and serosa of rabbits in group
C in the form of mild mononuclear infiltration.
The changes were more pronounced in group D
& group E in thr form of congestion of blood
vessels in sub mucosa and mild infiltration of
lymphocytes in mscularis externa.
408
Manoj et al.,
Table.1: Comparative histopathological changes in Oesophagus of Rabbits in all groups.
5 Groups of
Rabbits
OESOPHAGUS
(+)
MUCOSA
SUB-MUCOSA
ADVENTITIA
NORMAL
MUSCULAR
IS
EXTERNA
NORMAL
GROUP A
NORMAL
GROUP B
GROUP C
NORMAL
+
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
GROUP D
GROUP E
++
++++
NORMAL
++++
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
= Mild inflammation, (++) = Moderate inflammation, (+++) = Severe inflammation
Table-2: Comparative histopathological changes in stomach of Rabbits in all groups.
5 Groups of Rabbits
STOMACH
(+)
MUCOSA
SUB-MUCOSA
NORMAL
MUSCULARI
S EXTERNA
NORMAL
GROUP A
NORMAL
GROUP B
GROUP C
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
++
GROUP D
++
GROUP E
++++
++
NORMAL
+++
++++ $$
SEROSA
++
NORMAL
= Mild inflammation, (++) = Moderate inflammation, (+++) = Severe inflammation
($) = Congestion of blood vessels, NORMAL= Normal histology.
409
Manoj et al.,
DISCUSSION
OESOPHAGUS-
No references regarding study of

histopathological changes in oesophagus
associated with ingestion of high nitrate
STOMACH- The findings of present research
work are consistent with Xu G et al14 (1992) who
analyzed 178 samples of drinking water for
nitrate and nitrite. The results suggested that
nitrate in drinking water probably plays an
important role in gastric mucosal lesions and
even carcinogens.
Manoj et al.,
concentration in the drinking water could be

found inspite of our best efforts made to search
the literature.
No more study has performed regarding
histopathological analysis of stomach when high
nitrate ingested in drinking water till date
CONCLUSION
Nitrate are reduced to nitrite by micro flora in the

oral cavity & increased consumption of nitrite
410
leads to : increased production of nitrates, excess

nitric oxide generation which has vasodilator
effects , enhanced absorption of sodium from
intestinal lumen , and increased production of
oxygen which will react with other cell
constituents possibly causing irreversible damage
ACKNOWLEDGEMENT
I am extremely thankful to my esteemed teacher,

distinguished guide and true mentor Dr.(Mrs.)
Neelam Bapna, Ex professor & Head,
Department of Anatomy, Swai Man Singh
Medical College, Jaipur and presently Professor
, Department of Anatomy, National Institute Of
Medical Sciences, Jaipur, Rajasthan for the
precise guidance, valuable suggestions and
constant encouragement without which it would
not have been possible to start and finish this
Research work.
Mrs. Hemlata Sharma, Lecturer, Department of
Anatomy, Jhalawar Medical College, Jhalawar,
Rajasthan , India helped me in quite a lot of leg
work and basics.
REFERENCES
1. Epidemiological Evaluation of Nitrate

toxicity
and
DPNH
dependent
Methemoglobin
Diaphorase activity in
infants. SMS Medical College & NEERI
Zonal Laboratory, Jaipur. Project report,
council of Scientific & Industrial Research
,New Dehli.1994-1970
2. Bodansky O.
Methemoglobin and
Methemoglobin
producing
compounds.
Pharmacol. Rev. 3: 144-195. 1951.
3. Cornblath
M
&
Hartmann
AF.
Methemoglobinemia in young infants. J
Pediat. 33: 421-425. 1948.
4. Drinking water specification. IS 10500:1991,
Bureau
of
Indian
standards,
New
Dehli.1995:3
5. World Health Organization .Guidelines for
research on acute respiratory infection.
Memorandum from a WHO Meeting Bulletin
of the World Health Organization. 60; 521533. 1982.

6. World Health Organization. A programme
for controlling acute respiratory infection in
children. Memorandum from a WHO
Meeting Bulletin of the World Health
Organization. 62; 47-58. 1984.
7. World Health Organization. Respiratory
infection in children .Management in small
hospitals. Manual for Doctors. WHO.
Geneva 1998.
8. WHO. Guidelines for dinking water quality,
Volume 1.Genava. 52-53. 1993.
9. Gupta SK, Gupta RC et al. Recurrent acute
respiratory tract infection in areas with high
nitrate concentration in drinking water.
Environmental
Health
Prespectives.
2001;108(4):363-66.
10. Gupta
SK,
Gupta
RC
et
al.
Methemoglobinemia in areas with high
nitrate concentration in Drinking water. The
national Medical Journal of India. 13(2):5861. 2000.
11. Li H, Duncan C, Townend J, Kilham K, et
al. Nitrate reducing bacteria on rat tongue.
Applied and environmental Microbiology.
1997; 63:924-930.
12. Shuval HI & Gruener N. Epidemiological
and toxicological aspects of nitrates and
nitrites in the environment. Am J Public
Health. 1972; 62 :1045-1052.
13. Marshall CR & Marshall W. Action of
nitrates on blood. J Biol Chem . 158:187-208.
1945.
14. Xu G, Song P , Reed P.The relationship
between gastric mucosal changes and nitrate
intake via drinking water in high risk
population for gastric cancer in moping
country, china,Europian Journal of Cancer
Prevention 1992;`(6):437-443.
411
Manoj et al.,
DOI: 10.5958/j.2319-5886.2.3.072

&
Health Sciences
www.ijmrhs.com Volume 2 Issue 3 July - Sep
th
Coden: IJMRHS
Copyright @2013
th
Revised: 16 May 2013
ISSN: 2319-5886
Research article
CLINICOPATHOLOGICAL STUDY OF ENDOMETRIUM IN IUCD USERS

Pratima Suryakumar, Shagufta Roohi*, Vijaykumar L Pattankar
Department of Pathology, MR Medical College, Gulbarga, Karnataka, India
*Correspondence author email: shaguftaroohi@yahoo.com
ABSTRACT
Background and Aims: Use of intrauterine contraceptive device (IUCD) is now a common practice.
The present study was taken up to study the clinicopathological changes in endometrium following use
of IUCD. Methods: Endometrium obtained from 65 cases who had IUCD of varying duration,
presenting with different symptoms were studied by Hematoxylin and Eosin stained slides. Results:
Patients presented with various menstrual irregularities and pelvic inflammatory disease. Duration of
IUCD use ranged from 4 months to 10 years. The spectrum of endometrial changes were interstitial
edema 22(33.8%), hemorrhage 36(55.3%), focal hyperplasia 18(27.6%), diffuse hyperplasia 2(3%),
cystoglandular hyperplasia 4(6.1%), predecidual changes 5(7.6%), inflammatory cell infiltrate 9(13.8%),
lymphoid follicles 2(3%), vascular changes 2(3%), metaplasia 1(1.5%). Conclusion: The present study
tries to focus on the spectrum of endometrial changes associated with IUCD use, their clinical
symptomatology and possible pathogenetic mechanisms. The endometrial changes were possibly due to
inflammation, hyperplasia and metaplasia induced by IUCD.
Keywords: Endometrium, Intrauterine contraceptive device, IUCD.
INTRODUCTION
Intrauterine contraceptive device (IUCD) is one

of the very effective contraceptive methods,
which has been used widely in family planning
and population control programs for many
years1. It is thought to be safe with minimal side
effects. However complications like abnormal
uterine bleeding, infection and spontaneous
expulsion are the main drawbacks.
The value and applicability of IUCD as a method
of contraception on one hand and reports from
varied quarters of medical profession about
effects of these devices on uterine mucosa to

which they are opposed are conflicting.
It was Sujan-Tejuja et al. 2 in 1964 who stated
use of IUCD did not interfere with dating the
endometrium. Wynn RM3 1968 studied 168
biopsies at intervals from 6 weeks to 3 years with
pre insertion control biopsy in 51 women. He
showed that there are cyclic alterations
characterized by early maturation and
asynchronous development. The endometrial
alterations per say did not vary with length of
time the device was in use.
412
Pratima et al.,
Int J Med Res health Sci. 2013;2(3):412-417
Despite increase in knowledge and investigative

procedures, the etiopathogenesis underlying
menstrual irregularity is still incompletely
understood.
Several studies4,5,6 have focused attention on the
menstrual irregularities after IUCD use such as
menorrhagia, polymenorrhoea and pelvic
inflammatory disease. An attempt to observe the
spectrum of endometrial changes after IUCD
with a possible correlation with the duration and
a clinicopathological correlation of clinical
symptomatology with histopathologic features
was considered worthwhile. The present study is
an effort to resolve the endometrial changes in
relation to IUCD with clinicopathologic
correlation
and
to
explain
pathologic
mechanisms.
The present study was undertaken to find out

endometrial changes following the use of IUCD
in the department of pathology, MR Medical
College, Gulbarga.
A total of 65 cases, who had IUCD (copper T) of
varying duration and reported for different
symptomatology were subjected to clinical and
histological examination. None of the cases
showed clinical evidence of gross anaemia or
pelvic pathology.
Dilatation and curettage was done immediately
following removal of IUCD. The endometrial
tissue was fixed in 10% formalin and paraffin
blocks were processed. Sections were cut at 4
microns thickness and stained with H&E and
studied. Endometrial findings were carefully
analysed.
An attempt was also made to study age
distribution, duration of IUCD use, clinical
presentations after use of IUCD and to categorise
clinical symptomatology and changes in each
group of menstrual irregularities. The findings
were correlated with the symptoms and possible
mechanisms playing a role for various clinical
and histopathological changes that are evident in
this study.
Observations
A total of 65 cases of endometrial biopsies were
carefully analysed. The mean age was 34.2 years.
The youngest patient was 19 years old and the
oldest 48 years old. Majority (69%) of the cases
were in the age group of 20-30 years.
Analysis of presenting symptoms showed
menorrhagia 35(53.8%), pelvic inflammatory
disease 18(27.6%), vaginal discharge 15(23%),
low
backache
3(4.6%),
polymenorrhoea
22(15.3%),
and
one
case
each
of
oligomenorrhoea and amenorrhoea.
The duration of IUCD ranged from few months
to the other extreme of 10 years with an average
of 2.9 years. The cases were grouped into less
than one, 1-5 and 6-10 years depending on the
duration of use. Majority 46(70.7%) cases were
in range of 1-5 years of duration of use.
The cases were further categorised into groups
depending upon the symptomatology into those
with menorrhagia, pelvic inflammatory disease
and polymenorrhoea.
It
was
observed
that
menorrhagia,
polymenorrhoea and pelvic inflammatory disease
occurred in all the duration groups. While single
case of oligomenorrhoea was observed after 3yr
and amenorrhoea after 7yr duration. It was
apparent that with increasing duration of IUCD
the incidence of menorrhagia decreased and
incidence of pelvic inflammatory disease
increased, while polymenorrhoea was consistent
finding in all the duration groups.
Present study showed proliferative phase
42(64.6%), secretory phase 15(23%), necrotic
3(4.6%) and no endometrial tissue 5(7.6%) cases.
Interstitial edema was seen in 22(33.8%),
hemorrhage 36(55.3%), focal hyperplasia
18(27.6%),
diffuse
hyperplasia
2(3%),
cystoglandular
hyperplasia
4(6.1%),
inflammatory infiltrates mainly lymphocytes,
plasma cells and neutrophils 9(13.8%), lymphoid
follicles 2(3%) cases. Predecidual changes seen
as large pale cells of stroma with nuclei showing
open chromatin and which were arranged in
groups in edematous stroma were seen in
413
Pratima et al.,
5(7.6%). Vascular changes in the form of

capillary dilatation were seen in 2(3%) cases and
squamous metaplasia in 1(1.5%) cases. However
no bacterial or fungal colonies were
demonstrated and the present series did not have
any neoplastic changes.
On comparison of the microscopic findings in 3
symptomatic groups, finding of endometrial
hyperplasia
stand
out
prominently
in
menorrhagia and polymenorrhoea group. Diffuse
hyperplasia
was
more
obvious
in
polymenorrhoea group and vascular dilatation
was seen only in menorrhagia group.
Menorrhagia group (35 cases) showed edema
12(34.8%), hemorrhage 23(66.7%), focal
hyperplasia 14(40.6%), diffuse hyperplasia
1(2.9%), cystoglandular hyperplasia 2(5.8%),
inflammatory
cell
infiltrates
3(8.7%),
predecidual change 3(8.7%), lymphoid follicles
1(2.9%) and squamous metaplasia 1(2.9%) of the
cases in present study. Proliferative endometrium
was seen in 24(69.6%) cases as compared to

9(26.1%) cases of secretory endometrium. No
endometrial tissue was seen in 2(5.8%) cases.
Pelvic inflammatory disease group (18 cases)
showed interstitial edema 6(33.6%), hemorrhage
in 9(50.4%), focal hyperplasia 1(5.6%),
cystoglandular hyperplasia 1(5.6%), lymphocyte
and plasma cell infiltrate in 4(22.4%), lymphoid
follicles 1(5.6%) and predecidual change
1(5.6%) case. However no group showed fibrosis
or neoplasia. Proliferative endometrium was seen
in 9(50.4%) and secretory in 4(22.4%) of the
cases. Necrotic tissue was seen in 3(16.8%) and
no tissue in 2(11.2%) cases.
Polymenorrhoea group (10 cases) showed focal
hyperplasia 3(30%), diffuse hyperplasia 1(10%),
cystoglandular
hyperplasia
1(10%),
lymphomononuclear infiltrates 2(20%), edema
4(40%), hemorrhage 4(40%) and predecidual
change 1(10%) case.
414
Pratima et al.,
DISCUSSION
The introduction of a foreign body into the uterus

as a contraceptive device is not new. The original
device first used in 1909 was made of silkworm
gut. Currently there are two types of devices, the
medicated and the non-medicated. The
medicated devices release either metal
ions(copper) or hormones(progesterone) and are
devised to reduce the incidence of side effects
and to increase the contraceptive effectiveness.
During proliferative phase giant mitochondria are
seen in epithelial cells of glands and after
ovulation, stromal cells undergo predecidual
changes3.
Predecidualization of stroma is mediated by
prostaglandins F2 and E2.
Histochemically
endometrium revealed no significant change in
enzyme reactions, contents of nucleic acid and
glycogen, but acid mucin levels were increased7.
The premature secretory and decidual changes
explain the contraceptive action. They also
induce a local hormonal dysfunction secondary
to inflammation, alterations in tubal transport,
mechanical interference, local chemotactic
effects on endometrium and focal release of
cytotoxic products due to surface interactions
with endometrium are also seen8.
The copper incorporated into IUCD is absorbed
by superficial layers of endometrium and present
in secretory vacuoles of glandular epithelium, but
electron microscopic studies failed to
demonstrate binding of copper ions to cell
organelles due to their rapid excretion9.
Biochemical estimations prove that copper and
protein concentrations increase. Glycogen
metabolism is also affected. The role of
immunological mechanisms needs to be
elucidated.
In the reported studies the average age was 332
years and age range was from 20-30 years10.
Present study had an age range from 19-48 years.
The duration of use of IUCD was around 3 years
in most studies, but we have presently studied
endometrium of much longer duration i.e. up to

10 years.
Wynn RM3 reported alterations in cycle showing
premature maturations and asynchronous
development and changes not corresponding to
the day of the cycle. Ober et al.11 divided his
group into 2 categories, symptomatic 112 cases
and asymptomatic 96 cases.
The present group had 35 cases of menorrhogia,
10 cases of polymenorrhoea, and 18 cases of
pelvic inflammatory disease.
IUCD may lead to an enhanced decidual reaction
in the endometrium12,13. Inflammation, stromal
bleeding, necrosis, cystic hyperplasia and
vascular congestion have been reported by
several authors. The present study showed edema
in 33.8% cases and hemorrhage in 55.3% cases.
Vascular changes notably dilatation seen in 3%
of cases.
Histological dating of the endometrium was
done. In presence of predecidual reactions,
dating was performed based on pattern of
endometrial glands. Lee YB et al.14 showed the
IUCD insertion brings about inflammatory
reaction
and
asynchronous
endometrial
maturation.
The possible pathogenesis of menorrhagia in
relation to IUCD appears to be endometrial
hyperplasia, along with other contributing factors
like, increased fibrinolytic activity, plasminogen
activators, permeability due to Prostaglandins I2
and D2 and local proteolysis, and vascular injury
and endothelial defects.
Polymenorrhoea was another bleeding disorder
seen in 10 cases in the present study. It is
considered to be due to increased ovarian
function. Diffuse hyperplasia was observed in
this group and may be a contributory factor.
The oligomenorrhoea and amenorrhoea cases in
the present study were one each case. The
possible explanation could be atrophy of
functional endometrial layer and fibrosis.
415
Pratima et al.,
On comparison of microscopic findings in 3

symptomatic groups findings of endometrial
hyperplasia
stand
out
prominently
in
menorrhagia and polymenorrhoea groups.
Pelvic inflammatory disease was another major
group. The present study showed pelvic
inflammatory disease in 27.6% cases. Fiorino
AS(1996)15 cited an incidence of 7 percent of
Actinomyces species seen on cytology smears
from women using IUDs compared with less
than 1 percent in nonusers. In some cases, pelvic
inflammatory disease may develop (Dunn et al.
2006) 16. The pathomechanisms could be
introduction of microbes, mechanical trauma,
chemotactic factors like degraded and
degenerated endometrial cells, increased vascular
response, and local or general immunological
depression.
Squamous metaplasia was reported by Ober et
al.11 (2cases) and Tamada et al.10 (3 cases). The
presence of squamous metaplasia, atypical
hyperplasia or adenocarcinoma suggests that a
long term observation of women using IUCD is
advisable. In the present study one case of
squamous metaplasia was observed.
It is noted that curettage tissue does not reflect
the entire spectrum of changes in the whole
endometrium. The changes depend upon the site
of biopsy. Not infrequently there are various and
differing findings in endometrium itself in both
pathological and physiological conditions. Since
IUCDs constitute a mechanical and chemical
stimulus, greater variations are expected.
Hysterectomy specimens are preferred if feasible
as multiple sections from different sites can be
studied.
CONCLUSION
The present study highlights the microscopic

endometrial changes in women using IUCD
(Copper T) and their clinical presentation with
IUCD use of varying duration and tries to
suggest pathomechanisms to explain clinical
features.
REFERENCE
1. Margulies L. History of intrauterine devices.

Bull N Y Acad Med.1975;51:662-67.
2. Sujan-Tejuja S, Virick RK, Malkani PK.
Uterine histopathology in the presence of
intra-uterine device. In: Segal SJ, Southam
AL
and
Shafer
KD.
Intrauterine
contraception. New York, Excerpta Medica,
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3. Wynn RM: Fine structural effects of
intrauterine contraceptives on the human
endometrium. Fertile Steril.1968;19: 867882.
4. Zatuchni GI, Goldsmith A, Shelton JD,
Sciarra JJ. Long acting contraceptive
systems. Philadelphia Harper & Row.1984.
5. Kaufman DW, Shapriro S, Rosenberg
L,Monson RR, Miettinen OS, Stolley PD,
Slone D. Intrauterine contraceptive device
use and pelvic inflammatory disease. Am J
Obster Gynecol.1980 Jan 15;136(2):159-62.
6. Faulkner WL, Ory HW. Intra uterine device
and acute pelvic inflammatory disease.
JAMA.1976; 235: 1851.
7. Hester LL, Kellett WW, Spicer SS
Williamson HO, Pratt-Thomas HR.. Effects
of the intrauterine contraceptive device on
endometrial enzyme and carbohydrate
histochemistry. Am J Obstet Gynecol.1970
Apr 15;106(8):1144-54.
8. Davis HJ, Lesinski J. Mechanism of action of
intrauterine contraceptives in women. Obstet
Gynecol.1970;36(3):350358.
9. Gonzalez-Angulo A, Aznar-Ramos R.
Ultrastructural studies on the endometrium of
women wearing TCu-200 intrauterine
devices by means of transmission and
scanning electron microscopy and X-ray
dispersive
analysis.
Am
J
Obstet
Gynecol.1976;125: 170-179.
10. Tamada T, Okagaki T, Maruyama M,
Matsumoto S. Endometrial histology
associated with an intrauterine contraceptive
device. Am J Obstet Gynecol. 1967;98: 811817.
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11. Ober WB, Sobrero AJ, DeChabon AB,

Goodman J: Polythelene intrauterine
contraceptive device. Endometrial changes
following long term use. JAMA.1970;212:
765-769.
12. Dallenbach-Hellweg G. Histopathology of
the endometrium, 4th ed. New York:
Springer-Verlag; 1987.
13. Bonney WA, Glasser SR, Clewe TH, Noyes
RW, Cooper CL. Endometrial response to the
intrauterine device. Am J Obstet Gynecol.
14. Lee YB, Kim CS, Ro JY, Kwak HM, Song
CH. Long term effects of IUD on human
endometrium: Histologic, histochemical and
ultrastructural study. Yonsei Med J.1983; 24,
2, 144-148.
15. Fiorino AS: Intrauterine contraceptive device
associated actinomycotic abscess and
Actinomyces detection on cervical smear.
Obstet Gynecol.1996;87:142.
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Pelvic actinomycosis. A case report. J
Reprod Med.2006;51:435.
417
Pratima et al.,
DOI: 10.5958/j.2319-5886.2.3.073

&
Health Sciences
th

Research article
Coden: IJMRHS
Copyright @2013
th
ISSN: 2319-5886
A STUDY ON HISTOPATHOLOGICAL SPECTRUM OF UPPER GASTROINTESTINAL

TRACT ENDOSCOPIC BIOPSIES
*Krishnappa Rashmi, Horakerappa MS, Ali Karar, Gouri Mangala
Department of Pathology, MS Ramaiah Medical Teaching College, Karnataka, India
*Corresponding author email : rashmikrishnappa@yahoo.co.in
ABSTRACT
Background: Upper gastrointestinal tract disorders are one of the most commonly encountered
problems in clinical practice. A variety of disorders can affect the upper GIT (gastro intestinal tract).
The definitive diagnosis of upper gastrointestinal disorders rests on the histopathological confirmation
and is one of the bases for planning proper treatment. Objectives: To determine the spectrum of
histopathological lesions of upper gastrointestinal tract. To establish endoscopic biopsies as an effective
tool in the proper diagnosis and management of various upper gastrointestinal tract lesions. Patients
and Methods: A prospective study was conducted on the upper GIT endoscopic biopsies and the
histopathological assessment was done at the department of pathology, M.S. Ramaiah medical college
and teaching hospital from November 2006 to July 2008. Results: Of the total 25 cases of esophageal
biopsies, 56% constituted non neoplastic lesions and 44% had neoplastic pathology. The most common
malignancy was SCC (squamous cell carcinoma) occurred most commonly (73%) in the middle one
third of the esophagus. In stomach biopsies, 41 (60%) had non neoplastic pathology and 27 patients
(40%) had neoplastic pathology. The most common malignancy was adenocarcinoma. Conclusion: In
our study, the commonest site for upper GI endoscopic biopsy was from the stomach (68%) with 60%
non neoplastic and 40% neoplastic lesions. Most common neoplasm of the stomach was
adenocarcinoma.. Out of the 100 cases, there was a consensus between endoscopic and histopathological
diagnosis in 78% of the cases. Whenever there was a disagreement, the histopathological appearances
served to correct a mistaken endoscopic finding. We therefore conclude that endoscopy is incomplete
without biopsy and so the combination of methods provides a powerful diagnostic tool for better patient
management.
Keywords: Upper GIT, endoscopy, Biopsy, Histopathology
INTRODUCTION
Upper Gastrointestinal tract disorders are one of

the most commonly encountered problems in
clinical practice with a high degree of morbidity
and mortality and endoscopic biopsy is common
procedure performed in the hospital for a variety

of benign and malignant lesions.
The esophagus and stomach can be sited for a
wide variety of infections, inflammatory
disorders, vascular disorders, mechanical
418
Krishnappa Rashmi et al.,
conditions, toxic and physical reactions,

including radiation injury and neoplasm1.
Introduction of the endoscopes in 1960s has
greatly improved the diagnostic facility for
fiberoptic endoscopy because they are readily
accessible and can easily be sampled for specific
histopathological or microbiologic investigation
with available biopsy forceps. Tissue specimen
can be removed from the lesions under direct
vision using biopsy forceps. The procedure
causes minimal discomfort and thus can be
repeated. Histopathological study of biopsy
specimens are used to confirm endoscopic
diagnosis in suspected malignancy or to rule out
in the endoscopically benign appearing lesion.
The endoscopic biopsies are performed not only
for the diagnosis of the disease but also for
monitoring the course, determining the extent of
a disease, as responses to therapy and for the
early detection of complications. As a result, the
reasons for obtaining mucosal biopsy from the
upper gastrointestinal tract have increased and
are no longer performed only for the detection of
neoplasm.
Aims and objectives
1 To
determine
the
spectrum
of
histopathological
lesions
of
upper
gastrointestinal tract.
2 To establish endoscopic biopsy as an
effective tool in the proper diagnosis and
management of various upper gastrointestinal
tract lesions.
PATIENTS AND METHODS
The present study included one hundred (100)

endoscopic biopsies. They were taken from
patients who were clinically diagnosed to have
an upper gastrointestinal tract lesion needing
biopsy at the department of Gastroenterology,
M.S.Ramaiah medical college teaching hospital,
during the period of Nov 2006 to July 2008.
Inclusion criteria: All endoscopic biopsies of
the upper gastrointestinal tract.
Exclusion criteria: 1. All lesions of the mouth
and pharynx 2. All duodenal biopsies below the

second part
Endoscopies were performed using a large
channel endoscope Pentax EG-2901. Biopsy
specimens were obtained with large 10 mm open
span biopsy (KW2218CS). A smaller 7.5 mm
open span biopsy forceps (KW 1815 S) was used
if a smaller caliber endoscope was needed
because of the stricture or patients clinical
condition.
The biopsy specimen was put in saline and
placed on the filter paper with mucosal surface
upwards. Then the filter paper was immersed in
10% formalin for fixation. After adequate
fixation entire tissue was routinely processed and
embedded in paraffin with mucosal surfaces
uppermost. Five micron thick sections were cut
perpendicular to this surface and four to five
sections were prepared on each slide. Each
section was stained with H and E and studied
microscopically. Adequacy of biopsy was
assessed. An attempt was made to diagnose the
lesion on gross visualization during endoscopy
and to correlate them histopathologically. Special
stains were done whenever required. Tumors
were diagnosed as per WHO histological
classification of gastrointestinal tumors.
OBSERVATIONS
From November 2006 to July 2008, 100 upper

gastrointestinal endoscopic biopsies were
prospectively included in this study. Among all
the upper gastrointestinal tract biopsies,
esophageal biopsies were 25 (25%), gastric
biopsies were 68 (68%), and duodenal biopsies
were seven (7%) (Figure1). Table 1 shows the
distribution on neoplastic and non neoplastic
lesion.
Of the 100 cases with upper gastrointestinal
biopsies, 33 patients were females and the rest
were all males. This could probably due to the
large number of male patients attending the
outpatient department compared to the female
patients, and increase the number of
419
gastrointestinal tract malignancies in males than

females.
There were 67 males and 33 female patients with
a male: female ratio of 2.03:1. The highest
incidence was seen in 4th and 5th decades, the
lowest incidence was seen in 2nd, 8th, 9th
decades.
The youngest patient was 10 years old and oldest
patient was 95 years old. Of all the 100 cases, 56
cases (56%) were non neoplastic and 44 cases
(44%) were neoplastic.
Of the total 11 cases of esophageal neoplastic
lesions, all (100%) were malignant, were
squamous cell carcinoma (Figure2). Carcinoma
of the esophagus which was most common in the
middle third accounted for eight cases (73%),
followed by lower third, two cases (18 %) and
upper third, one case (9%).
For all the 11 cases of carcinoma esophagus,
histopathological grading is shown in table 2.
Proliferative and ulceroproliferative lesions had
four cases each followed by ulcerative and
stenosis/stricture endoscopically.
The commonest site for gastric biopsy was
pylorus (45%) followed by a body (32%), cardia
(13%) and fundus (10%). Of the 68 cases of
gastric biopsies, 27 cases (40%) were neoplastic
and 41 cases (60%) were non neoplastic. The
majorities (37%) of the non neoplastic lesions in
gastric biopsies were chronic nonspecific
gastritis (table 3) (Figure 3). Of the 27 neoplastic

lesions of the stomach, 19 cases (70%) were
malignant and eight cases (30%) were benign.
Among the total 27 neoplastic lesions of the
stomach, malignant lesions exceeded benign
lesions in both the sexes, with males having 13
malignant cases and four benign lesions, and
females had six malignant and four benign
lesions. Of the total eight cases of benign lesions
of the stomach, adenomatous polyps were five
cases (63%) and hyperplastic polyp were three
cases (37%).
In the site wise distribution of gastric carcinoma,
pyloric region had eight cases (43%), followed
by cardia and fundus with five cases (26%) each
and followed by one case in the fundus (5%).
The majority of the cases of gastric carcinoma
were poorly differentiated adenocarcinoma
(56%) followed by moderately differentiated
adenocarcinoma (44%). There was one patient
with well differentiated adenocarcinoma, signet
ring cell carcinoma (Figure 4). The endoscopic
findings in gastric carcinoma are seen in table 4.
There were seven patients for histopathological
diagnosis of endoscopic biopsy involving the
upper two parts of the duodenum. Four patients
had chronic nonspecific duodenitis followed by
one patient each with duodenal ulcer, well
differentiated adenocarcinoma of ampulla of
Vater and tubular adenoma (Figure 5).
Table.1: Distribution of all lesions

Nature of lesion
Non neoplastic
Neoplastic
Total
No. of cases
56
44
100
Percentage
56 %
44 %
100%
Table.2: Histopathological grading of esophageal squamous cell carcinoma

Type
Well differentiated
Moderately differentiated
Poorly differentiated
Total
No. of cases
2
8
1
11
Percentage
18%
73 %
09%
100 %
420
Table.3: Distribution of non neoplastic lesions of stomach
Diagnosis
Acute non specific gastritis
Chronic nonspecific gastritis
Chronic gastritis with H. pylori positive
Chronic gastritis with intestinal metaplasia
Chronic gastritis with mild atypia
Acute on chronic nonspecific gastritis
Gastric ulcer
No specific pathology seen
Total
No of cases
2
15
3
2
1
6
8
4
41
Percentage
5%
37%
7%
5%
2%
15%
20%
10%
100%
Table.4: Endoscopic and histopathological findings of gastric carcinoma
Endoscopic findings
Ulcerative growth
Proliferative
Ulceroproliferative
Flattening of mucosa
Erythematous appearance
Total
Fig.1: Pie chart representation of site of

endoscopic biopsies
Adenocarcinoma
07
04
06
01
01
19
Fig.2: Moderately differentiated squamous cell

carcinoma of esophagus (H&E, 160X)
Fig.3: Chronic gastritis helicon-bacter pylori (H Pylori)

(160X)
Percentage
37%
21%
32%
5%
5%
100%
Fig.4: Signet ring adenocarcinoma stomach

induced (400X)
421
Fig.5: Tubular adenoma of duodenum (40X)

DISCUSSION
The study was conducted from November 2006

to July 2008 comprised of one hundred upper
gastrointestinal endoscopic biopsies, of which 25
(25%) cases were esophageal biopsies, 68 (68%)
were gastric biopsies and seven cases (7%) were
duodenal biopsies.
In the present study most common site for upper
gastrointestinal endoscopic biopsy is from the
stomach, followed by esophagus and duodenum.
Sex distribution of all cases:
Of the 100 patients with upper gastrointestinal
tract endoscopic biopsies, 33% were females and
67% were males. This was also proved by
another study done by Shennak MM et al2.
The male: female ratio was 2.03: 1. This gender
ratio favoring males could be reflective of the
fact that males are exposed to more risk factors
than females and gastrointestinal malignancies
are more common in males according to JC
Paymaster et al3.
Age distribution of all cases:
In the present study there was a predominance of
upper gastrointestinal tract disease between the
age groups of 51-60 yrs accounting for 27%. The
youngest patient was 10 yrs old and the oldest
patient was 96yrs old. The age related difference
could be due to variation in the risk factors
among the different age groups.
Distribution of esophageal lesions:

Of the total 25 patients with esophageal disorder
non-neoplastic (56%) lesions were more
compared to the neoplastic lesions (44%). The
majority of the non neoplastic lesions were
chronic nonspecific esophagitis which was also
shown by the study conducted by Shennak MM
et al2.
In our study we found all the cases of esophageal
malignancy as SCC. Though the incidence of
adenocarcinoma is on the rise in many countries
including India, our study did not prove that,
may be partly because of the limited number
(25%) of patients with esophageal biopsies than
those of the stomach and only 11 cases of
malignancy with the total 25 biopsies.
Esophageal carcinoma most commonly occurred
in the middle third in our study which accounted
for eight patients (73%). The next most common
site was lower third with two patients (18%) and
one patient had it in the upper third. This was
also confirmed by a study conducted by Rao et
al4, where they have compared the distribution of
esophageal carcinoma among six hospitals
cancer registries in India.
This was also confirmed by another Indian study
done by Rumana et al5. SCC of esophagus
endoscopically presented as proliferative and
ulceroproliferative lesions with four cases (36%)
422
each, while ulcerative with two cases (18%) and

stenosis/stricture as one case (9%).
Of all the 11 cases of esophageal carcinoma,
eight
cases
(73%)
were
moderately
differentiated; two cases (18%) were well
differentiated SCC, and one case was diagnosed
as poorly differentiated SCC.
Distribution of gastric biopsy site
In our study, the majority (68%) of the upper
GIT endoscopic biopsies were carried from
stomach. This was also confirmed by Shennek
MM et al2. The pylorus and body of the stomach
were biopsied in 30 and 22 patients with a
percentage of 45% and 32% respectively. This
was followed by cardia in nine patients (13%)
and fundus in 7 patients (10%). Of the total 68
patients biopsied for gastric pathology, 41
patients (60%) had non neoplastic lesions and 27
patients (40%) had neoplastic lesions.
Among the non neoplastic lesions of the
stomach, chronic non specific gastritis was a
leading diagnosis with 15 s(37%), followed by
gastric ulcer. Helicobacter pylori positive cases
were seen among three patients. Our study
correlated with study done by Shennak MM et al
with respect to chronic nonspecific gastritis, but
number of gastric ulcer patients nearly doubled
(20%) in our study when compared to their
study.
Neoplastic lesions of the stomach:
Of the 27 neoplastic lesions of the stomach about
19 cases were malignant and eight cases were
benign. This has also proven by many studies,
suggesting that malignant neoplasm are more
common than benign ones.
Sex distribution of neoplastic lesions of
stomach:
Of the total 27 neoplastic lesions of the stomach,
malignant lesions exceeded benign lesions in
both the sexes with 13 males having malignant
disease and four benign. In females six had
malignant and four benign lesions. The sex ratio
for gastric carcinoma in our study was 2.2:1.
Flamant et al in their study noted the sex ratio for
all gastric cancers was 2.3:1 which correlated

with our study.
Comparison of site wise distribution of gastric
carcinoma:
In the present study, the distribution of gastric
carcinoma was as follows: Pylorus with
43%,cardia and body with 26% each followed
lastly by fundus with 5%,which is similar to
study done by Morson etal, where they reported
an incidence of 47% in the antrum, followed by
pylorus 23% and 21% in the body and cardia6.
In our study, adenocarcinoma of stomach
endoscopically presented as ulcerative growth
(37%), followed by ulceroproliferative growth
(32%) proliferative growth (21%), flattening of
mucosa and erythematous
appearance (5%
each), which is similar to study done by
Qizilbash and Stevenson where ulcerative lesions
constituted majority (70%) of the cases7.
In our study, with respect to differentiation of
gastric carcinoma, poorly differentiated (56%)
adenocarcinoma was slightly more common than
moderately
differentiated
(44%)
adenocarcinoma. Kato Y et al in their study
noted that there was a significant decrease in the
well differentiated carcinoma in Japan which
correlated with our study8.
Our study constituted, four signet ring cell
carcinoma, two cases showed growth in the body
of stomach, one each in fundus and pylorus.
Male: Female was 3:1. Signet ring cell
carcinomas may form lacy or delicate trabecular
glandular growth and they may display a zonal or
solid arrangement. Special stains (PAS,
mucicarmine or alcian blue) help to detect sparse
dispersed tumor cells in the stroma9.
Duodenal lesions in upper gastrointestinal
tract biopsies:
There were only seven patients for
histopathological diagnosis of endoscopic biopsy
involving the upper two parts of duodenum. Four
patients had chronic nonspecific duodenitis
followed by one patient each with duodenal
ulcer, well differentiated adenocarcinoma of
ampulla of vater and tubular adenoma.
423
Endoscopic correlation with Histopathology:

Endoscopic diagnosis of esophageal lesions was
made in 17 out of the 25 cases. With respect to
malignant lesions endoscopic diagnosis was
made in 10 out of the 11 cases of esophageal
carcinoma. Hence the correlation between
endoscopy and histopathology with respect to
esophageal carcinoma was 91%.
Out of the total 68 stomach biopsies, the
endoscopic correlation was made in 56 cases
including neoplastic and non neoplastic. In
carcinoma stomach endoscopic correlation with
histopathology was 14 cases out of 19 cases
(74%), less than that seen with esophageal
carcinoma. This may be because esophageal
carcinoma presents late in the disease course and
hence can be picked up by endoscopy easily and
stomach malignancies present mostly as ulcers or
flat lesions especially in younger individuals
with diffuse type of carcinoma, which may lead
to misinterpretation endoscopically.
Hence care should be taken in choosing the
correct site for biopsy, with adequate clinical
information along with meticulous processing of
the tissue and reporting by the pathologist in
order not to miss any pre malignant and
malignant lesions.
CONCLUSION
In our study, the commonest site for upper

endoscopic biopsy was from the stomach (68%)
with 60% non neoplastic and 40% neoplastic
lesions. Most common neoplasm of the stomach
was adenocarcinoma. The second most common
site was esophagus with 25 cases having 14 non
neoplastic and 11 neoplastic lesions and seven
cases were from the upper half of the duodenum.
Out of the 100 cases, there was a consensus
between endoscopic and histopathological
diagnosis in 78% of the cases. Whenever there
was a disagreement, the histopathological
appearances served to correct a mistaken
endoscopic finding. We therefore conclude that
endoscopy is incomplete without biopsy and so
the combination of methods provides a powerful

diagnostic tool for better patient management.
REFERENCES
1. Rosai J In: Rosai and Ackermans surgical

pathology. 9th ed. St. Louis: Mosby; 2004.
pp648-11
2. Shennak MM, Tarawneh MS, Al-Sheik.
Upper
gastrointestinal
diseases
in
symptomatic Jordanians: A prospective
endoscopic study. Ann Saudi Med 1997;
17(4): 471-74.
3. Paymaster JC, Sanghvi LD, Ganghadaran P.
Cancer of gastrointestinal tract in western
India. Cancer 1968; 21: 279-87.
4. Rao DN, Desai PB, Ganesh B.
Epidemiological observation of cancer of the
esophagus-A review of Indian studies. Indian
J Cancer 1996; 33:55-75
5. Rumana M, Khan AR, Khurshid N. The
changing pattern of oesophago-gastric cancer
in Kashmir. JK-Practitioner.2005;12(4): 18992.
6. Marson
BC,
Dawson
IMP
In:
nd
Gastrointestinal pathology. 2 edn. London:
Black Well Scientific Publications; 1998.
ppl48-51.
7. Qizibash AH, Stevenson GW. Early gastric
cancer In: Sommers SC, Rosen PP editors.
Pathology Annals. New York: AppletonCentury-Crofts; 1979:14-24.
8. Kato Y, Kitagawa T, Nakamura K. Changes
in the histologic types of gastric carcinoma in
Japan. Cancer 1981; 48:2084-87.
9. Mills SE, Carter D, Greenson JK, Oberman
HA, Reuter V, Stoler MH editors. In:
Sternbergs diagnostic surgical pathology.
4th ed. Philadelphia: Lippincott Williams and
Wilkins; 2004.pp1562- 73.
424
DOI: 10.5958/j.2319-5886.2.3.074

&
Health Sciences
Research article
PATTERNS OF COMMUNICATIONS BETWEEN MUSCULOCUTANEOUS AND MEDIAN
NERVE: A CADAVERIC STUDY
Dr.Mariya1, Nitya J2
1
Asst. Professor, 2 Lecturer, Department of Anatomy, Shadan Institute of Medical Sciences, Hyderabad,
Andhra Pradesh, India.
*Corresponding author email: drmariya@gmail.com
ABSTRACT
The brachial plexus is a complex communicating neural network formed in the axilla. The branching,
union and reseparation of its nerve fibres frequently persists as communications between its branches,
mostly the Musculocutaneous and the Median nerve. The knowledge of variable patterns of
communications between Musculocutaneous nerve (MCN) and Median nerve (MN) explains the
unexpected clinical signs and symptoms and also helps in having a better understanding of the field
during surgeries in order to avoid neurological damage. In the present study, 38 cadavers (76 upper
limbs) were dissected and the communications between MCN and MN were noted in 6.6% of the total
cases (5 upper limbs). Some of these variations were rare.
Keywords: Brachial plexus, Communications, Median Nerve, Musculocutaneous Nerve.
INTRODUCTION
The median nerve is formed in the axilla by the

union of lateral (C5,C6,C7) and medial
roots(C8,T1) of the lateral and medial cords of
brachial plexus respectively, while the
musculocutaneous nerve is the continuation of
the lateral cord (C5,C6,C7)1. These nerves
subsequently traverse the anterior compartment
of arm without any interconnections with the
neighbouring nerves2.
Anastamoses between different nerves in the arm
are rare, but those between the Median nerve
(MN) and the Musculocutaneous Nerve (MCN)
have been reported since 19th century3. The
frequent presence of communications can be
attributed to the common root value (C5, C6, C7)
shared by the lateral root of MN and the MCN.

Williams et al. stated that few fibres of the MN
may travel through the MCN and finally leave it
to rejoin the main trunk4. The present study
throws light on some rare patterns of
communications which may be clinically
valuable to anatomists, neurophysicians,
neurosurgeons and orthopedicians dealing with
entrapment neuropathies, trauma, nerve repair
and surgical explorations in and around the
axilla.
Aims and Objectives: The present study is
carried out with an aim to provide additional
information about the different patterns of
communications between MN and MCN and to
425
Mariya et al.,
emphasize on the importance of knowledge of

variations during surgical procedures.
76 upper limbs of 38 embalmed cadavers (34

Male and 4 Female) were studied. The
.
anastomosis between the MN and MCN were

observed, the findings were noted after
meticulous dissection of the branches of the
brachial plexus. The photographs of anastomosis
were
taken
for
proper
documentation
RESULTS
Fig: 5.Absence of MCN
MN: Median nerve, MCN: Musculocutaneous nerve, LCNFA: Lateral Cutaneous nerve of forearm, CM:
Communication, CB: Coracobrachialis, PT: Pronator Teres,
BA: Brachial artery, CM1:
Communication1, CM2: Communication 2
In the present study some rare variations of the
MN and MCN were noticed. The incidence of
communications was 6.6% (5 out of 76 limbs).
Case 1: Bilateral variation. Splitting of Median
Nerve. (Variation 1): In the right upper limb the
formation of the median nerve was normal. The
MN split into medial and lateral divisions, of

which the medial division continued as MN
proper and the lateral division continued as MCN
to supply the muscles of the anterior
compartment of the arm. Further, a twig from the
MCN joined the MN distal to coracobrachialis
426
Mariya et al.,
(CB). The branch to pronator teres arose from the

MN 2-3cms above the elbow joint. The rest of
the course of the nerves was observed to be
normal. (Fig.1)
Communication between MCN and MN.
(Variation 2): In the left upper limb of the same
cadaver, a communication was noted between the
MCN and MN distal to CB. The branch to
pronator teres arose from the MN 4-5 cms above
the elbow joint. The rest of the course of both the
nerves was normal. (Fig.2)
Case 2: Short MCN (Variation 3): An extremely
rare variation was observed in a female cadaver.
In the right upper limb the MCN had an
abnormally short course terminating abruptly at
the level of the elbow by supplying the brachialis
muscle. A branch from the middle of the median
nerve in the arm coursed distally as the lateral
cutaneous nerve of forearm. (Fig.3)
Case 3: Double communication between MCN
and MN. (Variation 4): In a male cadavers left
upper limb, MCN bifurcated within the CB
muscle, the medial branch passed medially to

join the MN and returned back to the lateral
branch forming a double communication
between the two nerves which had a close
proximity to the brachial artery. (Fig.4)
Case 4: Absence of MCN. (Variation 5): In one
male cadaver, absence of MCN was noted on left
side and the muscles of anterior compartment of
left arm were supplied by MN. (Fig.5)
DISCUSSION
The brachial plexus due to its complex formation
is prone to be a common site for variations, most
common and frequent being the communications
between the MCN and MN5. Increased frequency
of communications between these two nerves
could be a result of their common origin from the
primary ventral rami of C5, C6, C7 spinal
nerves6. According to Iwamotos analysis the
root of communicating branch consisted of fibres
arising from C5
and
C67.
Li Minor (1992)8 classified these variations into five types:
Fig.6: Schematic representation of Li Minor classification.LR-Lateral root of median nerve, MR-Medial root of
median nerve, CB-Coracobrachialis, MCN-Musculocutaneous Nerve, MN-Median Nerve, UN-Ulnar Nerve.
In our study, we observed Type 2 variation [case 1 bilaterally], Type 4 variation [Case 1 : right upper
limb], Type 5 [ case 4].
Case 2 and Case 3 were rare variants, which
could not be classified into any of the types of Le
Minor classification and have not been
previously cited in the literature to the best of our
knowledge. C5,6,7 fibres of MCN forming the
Lateral cutaneous nerve of forearm( LCNFA)

must have passed through the median nerve
resulting in Short MCN and LCNFA arising from
Median nerve.
427
Mariya et al.,
Venieratos and Anangnostopoulou (1998)5

suggested
classification
in
relation
to
coracobrachialis muscle.
Type I: communication is proximal to
coracobrachialis muscle;
Type II: communication is distal to muscle
Type III: neither the nerve nor the
communicating
branch
pierce
the
coracobrachialis muscle.
In the present study, Type II variations were
noted in Case 1 bilaterally. Case 3 could not be
classified into any of these groups, as a
communicating branch was seen to arise within
the coracobrachialis.
Bilateral communications have been rarely
cited4,6. In the present study, bilateral variation
was noted in one male cadaver (Case 1).
Splitting of MN in the arm was reported by
Avinash et al, 2006 where MCN arose from the
lateral aspect of MN and after supplying biceps
brachii and brachialis continued as lateral
cutaneous nerve of forearm9. Buch reported in
his cadaveric study, the MCN originated from
the MN in 3-6%10. Budhiraja et al reported
splitting of the MN in 5.12% of specimens9.
Tsikaras et al, revealed that MCN arose from
MN unilaterally in a male cadaver11. In the
present study, similar finding was noted in
Case 1: Right upper limb (Variation1).During

shoulder reconstruction procedure it is important
to identify and palpate MCN as it is vulnerable to
injury from retractors placed under coracoid
process 9. Origin of MCN from split MN, may
produce
confusion
during
shoulder
reconstruction. Awareness of such variations
prevents unwanted complications.
Sargon et al, found an interconnecting branch
between MCN and MN. They added that the
close relation of this interconnecting nerve to
brachial artery could result in compression of
artery and result in the impairment of blood
supply to upper limb12. In the present study, a
double communication (Case 3) was noted in
relation to brachial artery.
Absence of MCN has been previously reported
by some authors (Jahanshahi et al , 2003 , Aydin
et al , 2006, Budhiraja et al 2011)9 .In the present
study musculocutaneous was absent in Case 4.
The absence of MCN neither leads to paralysis of
flexor muscles of arm nor
hypoesthesia of
lateral surface of forearm since the motor and
sensory fibres can arise from other nerves more
frequently from Median nerve.
Review of literature reports a wide variation in
the incidence of communication between MCN
and MN irrespective of the site or type ranging
from 1.4% - 63.5%13 as shown in table 1.
Table.1: Incidence of Communications between Musculocutaneous and Median nerve

Author
Wantanabe et al 13
Kosugi et al14
Yang et al13
Venieratos and Anagnostopoulou5
Chiarapattanakom et al13
Rao and Chaudhary et al6
Choi et al 13
Loukas and Aqueelah 13
Guerri-Guttenberg and Ingolotti13
Maeda et al 13
Sawant et al 13
Present study
Year
1985
1986
1995
1998
1998
2000
2002
2008
2009
2009
2012
2013
Incidence (%)
01.4
21.8
12.5
13.9
16
33.3
26.4
63.5
53.6
41.5
30
6.6
428
Mariya et al.,
The presence of significantly variant nerve

patterns can be explained on the basis of
embryology and phylogenetics. The highly
coordinated, site specific direction of growth,
course and innervation of mesenchymal cells by
the spinal nerves is under the control of
chemotactic and circulatory factors14. Altered
signals occurring at the time when the cords of
brachial plexus fuse lead to such developmental
defects15. Iwata, explained on the embryological
basis that the brachial plexus appeared as a single
radicular cone in the upper limb which was
divided into ventral and dorsal segments. The
ventral segments gave roots to MN and ulnar
nerve, MCN arose from the MN16. Comparative
anatomical
studies
have
reported
communications in monkeys and apes,
persistence
of
variable
patterns
of
communications in the present study are in
accordance with the theory Ontogeny
recapitulates Phylogeny.
CONCLUSION
The communications between the MN and MCN

though not rare and have no effect on the
functioning of the upper limb, a thorough
knowledge
of
variable
patterns
of
communications is essential to explain the
unexpected clinical signs and symptoms and is
helpful during surgical interventions like
neurotisation of brachial plexus, shoulder
arthroscopy, shoulder reconstruction surgeries
and surgical exploration of axilla.
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1. Drake RL, Vogl AW, Mitchell AWM.

Grays Anatomy for Students, first
edition. Elsevier
Churchill
Livingstone, Philadelphia. 2005, Pp. 661663.
2. Hollinshead WH. Functional anatomy of
the limbs and back. 4th edition: WB
Saunders Philadelphia, 1976;10:134-140.
3. Harris W. The true form of brachial

plexus. J Anat Physiol. 1904; 38: 399
422.
4. Remya K, Ashwin Krishnamurthy,
Kavitha K. Communication between the
musculocutaneous and median nerve:
Occurrence on both sides. Nitte
University journal of health sciences.
2011;1(4):55-56.
5. Venieratos D, Anagnostopoulou S.
Classification
of
communications
between the musculocutaneous and
median
nerves.
Clinical
Anatomy.1998;11:327331.
6. Prasada Rao PV, Chaudhary SC.
Communication of the musculocutaneous
nerve with the median nerve; East African
Medical Journal.2000;77:498503.
7. Iwamoto S, Kimura K, Takahashi Y,
Konishi
M. Some aspects of the
communicating branch between the
musculocutaneous and median nerves in
man. Okajimas Folia Anat. Jpn.1990;67:
47-52.
8. Li Minor JM. A rare variant of median
and musculocutaneous nerves in man.
Archives
Anatomy
Histology
Embryology.1992;73:33-42.
9. Budhiraja, Rakhi Rastogi, Ajay Kumar
Asthana, Priti Sinha, Atul Krishna, Vikas.
Concurrent variations of median and
musculocutaneous nerves and their
clinical correlation a cadaveric study.
Italian Journal of Anatomy and
Embryology.2011;116(2):67-72.
10. Buch, Hansen K. Uber Varietaten des
Nervus Musculocutaneous undderen
Beziehungen; Anat Anz.1955;102:187203.
11. Tsikaras PD, Agiabasis AS, Hytiroglou
PM. A variation in the formation of
brachial plexus characterized by the
absence of C8 and T1 fibers in the trunk
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(Nancy).1983;67:501-505.
12. Sargon M, Uslu S, Celik H et al. A
variation of the median nerve at the level
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Anatom.1995;79:25-6.
13. Sharadkumar Pralhad Sawant, Shaguphta
T Shaikh, Rakhi Milind More. Study of
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nerve; International Journal of Analytical,
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Sciences.2012; 1(3):37-43.
14. Kosugi K, Morita T, Koda M, Yamashita
H.
Branching
pattern
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musculocutaneousnerve: Case possessing
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15. Abhaya A, Bhardwaj R, Prakash R.
Bilaterally symmetrical dual origin of
musculocutaneous nerve. Journal of
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2006;55(2):56-59.
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the brachial plexus in Japanese embryo.
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Mariya et al.,
DOI: 10.5958/j.2319-5886.2.3.075

&
Health Sciences
th
Received: 25
Apr 2013
Coden: IJMRHS
th
Copyright @2013
ISSN: 2319-5886
Research article
DENTAL AIR FORCE HOME DENTAL CLEANING SYSTEM: A REVOLUTIONARY ORAL

HYGIENE DEVICE TO PREVENT SYSTEMIC DISEASES CAUSED BY PERIODONTAL
INFECTION
Rajiv Saini
Assistant Professor, Department of Periodontology & Oral Implantology, Rural Dental College, Rahata,
Ahmednagar, Maharashtra, India.
* Corresponding Author email: drperiodontist@yahoo.co.in
ABSTRACT
Aim : The study outlined to estimate the clinical, laboratory and microbiological efficacy of Dental Air
Force home dental cleaning system of adult chronic periodontitis patients. Material and Method: 50
adult chronic periodontitis subjects were recruited volunteers for this study. Clinical (plaque index,
gingival index and clinical attachment loss), Laboratory (C-reactive protein levels and Glycated
Hemoglobin) and Microbiological parameters were measured prior to phase-1 therapy; at 3rd and 6th
month post phase 1 therapy. Comparative assessment was done among all the patients that were divided
into two groups with student paired t test and ANOVA. Results: The results of this study showed that
there was significant decrease in clinical, laboratory and microbiological parameters from baseline to 6
months in both the groups (p<0.01). The subjects under groups using Dental Air Force home dental
cleaning system showed a highly significant reduction to all the parameters as compared to subjects
under groups using a toothbrush. Conclusion: The regular use of Dental Air Force home dental cleaning
system as oral hygiene device is most advantageous for suppressing both periodontal infection and
associated markers like CRP, HbA1c for systemic diseases as compared to conventional tooth brushing.
Key Words: CRP, Periodontitis, HbA1c, Diabetes
INTRODUCTION
The mouth acts as a window to lot of systemic

diseases and serves as a port of entry of the
various infections that can alter and affect the
immune status of the person. The oral cavity has
the potential to harbor at least 600 different
bacterial species, and in any given patient, more
than 150 species may be present, surfaces of
teeth can have as much as billion bacteria in its
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attached bacterial plaque.1 Periodontitis has

been proposed as having an etiological or
modulating
role
in
cardiovascular,
cerebrovascular disease, diabetes, respiratory
disease and adverse pregnancy outcome; several
mechanisms have been proposed to explain or
support such theories. One of these is based
around the potential for the inflammatory
431
phenomenon of periodontist to have effects by

the systemic dissemination of locally produced
mediators such as C-reactive protein (CRP),
interleukins -1 beta (IL-1) and -6 (IL-6) and
tumor necrosis factor alpha (TNF-).2
Periodontal diseases are recognized as
infectious processes that require bacterial
presence and a host response which are further
affected and modified by other local,
environmental, and genetic factors. The oral
cavity works as a continuous source of
infectious agents, and its condition often reflects
the progression of systemic pathologies.
Periodontal infection happens to serve as a
bacterial reservoir that may exacerbate systemic
diseases. [3] So, this study was outlined to
determine the efficacy of Dental Air Force
home dental cleaning system on chronic
periodontitis patients as a potential oral hygiene
device to prevent systemic diseases caused by
periodontal infections.
The present study was conducted in the

department of Periodontology, Pravara Institute
of Medical Sciences, Loni, Maharashtra, India.
The research protocol was approved by the
University research and ethics committee.
Verbal and written informed consent was
obtained from all subjects prior to their
voluntarily enrollment in the study.
Study Population
The subjects enrolled in this study were selected
from the Out Patient Department of
Periodontology, Rural Dental College and
Hospital, Loni, Ahmednagar, Maharashtra,
India. The study included a total of 50 subjects
with chronic periodontitis. All the 50 subjects
were grouped into two categories and each
group was comprised of 25 subjects each as
illustrated in table 1. Exclusion criteria for the
patient enrolled in the study were : (1) Presence
of any systemic neurological disorder (e.g.,
epilepsy or schizophrenia), (2) Presence of a
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disease with possible effects on the immune

system (e.g., chronic infections or cancer), (3)
Patient who have received antibiotics or
NSAIDS (like Ibuprofen) in past 9-11 weeks,
(4) Patients who have received periodontal
treatment in past 6 months, (5) Pregnant and
lactating mother, (6) Patient with artificial
prosthesis, (7) Patients who smokes or
consumes tobacco in any form, (8) Patients
suffering with Arthritis, (9) Patient with any
type of heart disease (MI, CHD, etc), (10)
Female patient using intrauterine birth control
devices or birth control pills, (11) Obese
Individuals (30 & above range as per WHO
BMI cut off for weight categories for Asians),
(12) Presence of Diabetes Mellitus (13)
Participants not willing to participate in the
study.
Clinical Protocol
After the enrollment of the subjects in the study,
phase 1 therapy (Scaling and root planing) was
done by similar EMS ultrasonic scaler by the
same operator to all the 50 subjects at first
visit/base line only. After phase 1 therapy,
subjects under group A were advised to use
Dental Air Force home dental cleaning system
(technique demonstrated to each subject) twice
daily for 5 minutes. After phase 1 therapy,
subjects under group B were advised to brush
twice daily for 5 minutes by modified bass
method (technique demonstrated to each
subject) and similar medium bristle toothbrush
and toothpaste is provided to each of the
subjects during the study course. Recall visits
were scheduled for all the subjects belonging to
both the groups (A and B) on third and sixth
month and no phase 1 therapy (scaling and root
planing) was done at the recall visits. All the
clinical, laboratory and microbiological
parameters of 50 subjects enrolled in the clinical
trial were recorded at the base line, third and six
month.
Estimation of Clinical parameters
432
Clinical parameters of periodontal disease that

were evaluated were gingival index (GI), plaque
index (PI) and clinical attachment Loss (CAL).
Gingival Index
The teeth selected as Index teeth were 16, 12,
24, 32, 36 and 44. The tissues surrounding each
tooth were divided into four gingival scoring
units: disto-facial papilla, facial gingival
margin, mesio-facial papilla and the entire
lingual gingival margin. A blunt instrument
such as a periodontal probe was used to assess
the bleeding tendency of the tissues. The index
for each index tooth was recorded and then
calculated by dividing total number of index
teeth examined. This provided the gingival
index for the individual.
Gingival Index
All teeth were examined on four surfaces (i.e.
Mesiobuccal,
Buccal,
Distobuccal
and
Lingual/palatal) after using a disclosing agent
Total Plaque Score
Plaque Index (PI) = -----------------------------No. of surfaces examined
Clinical Attachment Loss
The clinical attachment level was examined
with Williams graduated probe.
Clinical
attachment level represents distance from
cementoenamel junction to the base of gingival
sulcus or periodontal pocket. Average clinical
attachment loss of the person is calculated by
dividing the total clinical attachment level by
the number of teeth examined. Chronic
periodontitis is sub classified as mild or slight,
moderate and severe periodontitis based on
clinical attachment loss according to AAP 1999
classification of periodontal diseases. If gingival
recession is present then loss of attachment is
calculated by the distance between the cementoenamel and gingival margin to be added to
pocket depth.
Estimation of C-reactive protein (CRP)
RHELAX CRP slide test kit was used for the in
vitro detection of CRP in human serum by
qualitative and quantitative rapid latex slide test.
RHELAX CRP slide test for detection of CRP is
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based on the principle of agglutination. If CRP

concentration is greater than 0.6 mg/dl a visible
agglutination is observed. If CRP concentration
is less than 0.6 mg/dl, then no agglutination is
observed.
Estimation of Glycated Hemoglobin (HbA1c)
The venous blood was subjected to an
assessment of HbA1c test using NycoCard
HbA1c is a boronate affinity assay. The
NycoCard HbA1c test is a 3 minute point of
care test for measurement of HbA1c. NycoCard
HbA1c provides an accurate and reliable
method to monitor metabolic control for
Diabetes Mellitus.
Estimation of Microbiological Pathogens
Subgingival plaque samples were collected for
specific
bacterial
examination
i.e
Aggregatibacter
actinomycetemcomitans,
Fusobacterium nucleatum, Porphyromonas
gingivalis
and
Prevotella
intermedia.
Subgingival plaque samples were then collected
from the sample sites using the standardized
paper point (Dentsply) which were inserted to
the depth of the periodontal pocket until
resistance was felt. The paper points were
retained for 20 seconds in the collection sites.
The samples site selected was maxillary first
molar in all the cases to maintain the standard
protocol. After 20 seconds the paper point was
removed from the sample site and immediately
transferred into the Robertsons cooked meat
transport (RCM) in a test tube for specific
bacterial culturing. In the laboratory the
Robertsons cooked meat medium (RCM) was
subjected to vortex homogenization for 60
seconds before incubated anaerobically (Gas
pack system) for 2-3 days
Dental Air Force home dental cleaning
system
Dental Air Force home dental cleaning system
used in this study is approved by FDA Vide No
K001493 as safety device for plaque removal in
order to prevent gingivitis. It is an electrical
delivery device that uses a 1/8th HP oil-less
electric air compressor air source with twin
433
pistons connected to a handpiece by a

pneumatic cord directed through a handpiece
and tip where air at 40 psi though a .020 size
orifice has the introduction of a slurry of dental
cleaner. This produces a jet stream of wet
abrasive whereby the user directs the cleaner
components and air into the sites between the
teeth and below the gum line. One normal
application uses one teaspoon of dental cleaner.
The cleaner ingredients include sodium
bicarbonate, the most widely accepted and
totally natural buffering agent that promotes a
neutral environment. It also contains mint
flavoring, Xylitol and Stevia as natural
sweeteners. The formula is free of sodium laurel
sulfate, the ingredient in most toothpaste that
causes sensitivity and irritation.4
(A and B) were illustrated in Figure 1 to 3. After

applying Students Paired t test there was a
highly significant decrease in clinical,
laboratory and microbiological parameters from
baseline to 6 months in groups A and B (i.e.
p<0.01). It was observed that group A showed
more significant decrease as compared to group
B (i.e. p<0.01). Also by applying Students
Unpairedt test there was a highly significant
difference between mean values of all clinical,
laboratory and microbiological parameters in
group A v/s B (i.e. p<0.01). It was concluded
that the mean clinical, laboratory and
microbiological parameters in group A showed
larger decrease than group B (p<0. 01) as shown
in Table 4, 5 and 6 (A v/s B). By applying two
way ANOVA (Tukey-Kramer Multiple
Comparison Test) test there was a significant
difference between group A and B when
compared together in respect to clinical,
laboratory and microbiological parameters
(p<0.05).
RESULTS
Distribution of mean and standard deviation

values of all the clinical, laboratory and
microbiological parameters of both the groups
Table.1: Distribution of chronic periodontitis patients in study groups

Groups
Group A
Group B
Patient Clinical Protocol

No. of Subjects
Chronic periodontitis patients receiving phase I therapy at 25
base line followed by use of Dental Air Force home dental
cleaning system as regime for oral hygiene.
Chronic periodontitis patients receiving phase I therapy at 25
base line followed by conventional use of tooth brush and
tooth paste as regime for oral hygiene.
Group A
At baseline
At 3 months
At 6 months
5.88
5
3.69
4
3
2
2.53
2.52
2.48
1.55
0.82
1.1 0.97
1
0
Gingival Index Plaque Index (%)

Clinical
(%)
Attachment Loss
Fig. 1: Distribution of mean values of all clinical parameters in Group A

434
Rajiv
At baseline
At 3 months
At 6 months
Group B
5.8
6
5
4.09
3.29
4
2.64
2.6
1.41 1.42
1.19 1.21
1
0
Clinical
Gingival Index(%)Plaque Index(%)
Attachment Loss
Fig. 2: Distribution of mean values of all clinical parameters in Group B

Group A
5.56
5.34
5.26
At baseline
At 3 months
At 6 months
5
4
2.78
1.7
1.22
1
0
C-Reactive ProteinGlycated Hemoglobin

(mg/dl)
(mmol/mol)
Fig. 3: Distribution of mean values of all CRP and HbA1c in Group A
Group B
5.48
6
5.36
5.32
At baseline
At 3 months
At 6 months
5
4
3
2.95
2.11
1.99
2
1
0
C-Reactive ProteinGlycated Hemoglobin

(mg/dl)
(mmol/mol)
Fig. 4: Distribution of mean values of all CRP and HbA1c in Group B
435
Rajiv
(Group A)
30
29.72
28.24
At baseline
At 3 months
28.4
28.04
At 6 months
25
20
18.24
17.32
16.4
13.68
15
10
7.32
6.08
6.48
5.76
5
0
Aa*
Fn*
Pg*
Pi*
Fig.5: Distribution of mean values of all microbiological parameters in Group A

*Aa: Aggregatibacter actinomycetemcomitans, Fn: Fusobacterium nucleatum, Pg: Porphyromonas
gingivalis and Pi: Prevotella intermedia.
Group B
30
25
28.76
28.4
25.88
23.36
26.32
24.44
26.92
24.28
26.04
23.04
At
baseline
At 3
months
At 6
months
21.2
20.96
20
15
10
5
0
Aa*
Fn*
Pg*
Pi*
Fig.6: Distribution of mean values of all microbiological parameters in Group B

*Aa: Aggregatibacter actinomycetemcomitans, Fn: Fusobacterium nucleatum, Pg: Porphyromonas
gingivalis and Pi: Prevotella intermedia.
DISCUSSION
Dental plaque biofilm cannot be eliminated.

However, the pathogenic nature of the dental
plaque biofilm can be reduced by reducing the
bioburden (total microbial load and different
pathogenic isolates within that dental plaque
biofilm) and maintaining a normal flora with
appropriate oral hygiene methods.5 The clinical
data of this study showed that subjects using
Dental Air Force home dental cleaning system as
regular oral hygiene device showed significant
reduction of clinical parameters from base line to
six months as compared to subjects in Group B
using conventional tooth brush. Thus there is

huge potential of this device in combating the
colonization of microbial biofilm in the oral
cavity. The results of this study showed that there
was significant mean reduction in CRP level
from 2.780.57 to 1.220.74 in the subjects
using Dental Air Force home dental cleaning
system as regular oral hygiene device. This will
conclude that the cardiovascular diseases
associated with increased level of CRP can be
prevented by regular use of this device. In case
of subjects using toothbrush there was not
436
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significant reduction in CRP levels from baseline

to six month i.e. 2.950.42 to 1.990.87 thus
with increased level of CRPs possibilities of
periodontitis associated atherosclerosis as well as
cardiovascular events exists in these subjects.
Many clinical studies have been published
describing the bidirectional inter-relationship
exhibited by diabetes and periodontal disease.
Studies have provided evidence that control of
periodontal infection has an impact on
improvement of glycemic control evidenced by a
decrease in demand for insulin and decreased
HbA1c.6-9 In this present study subjects under
group A showed more reduction in HbA1c from
base line to six month i.e. From 5.560.51 to
5.260.52 as compared to group B. These results
further highlighted the potential benefits of using
Dental Air Force home dental cleaning system in
controlling the blood glucose level. The
microbiological evaluation of key four pathogens
associated with periodontitis i.e. Aggregatibacter
actinomycetemcomitans (Aa), Fusobacterium
nucleatum (Fn), Porphyromonas gingivalis (Pg)
and Prevotella intermedia (Pi) were also
significantly reduced in subjects using Dental Air
Force home dental cleaning system as compared
to conventional tooth brush. The possible
mechanism of greater efficiency as compared to
toothbrush is that Dental Air Force home dental
cleaning system uses air and a dental cleaner
with water to break through the plaque barrier.
The air oxygenates the spaces between teeth and
along the gum line, making it difficult for the
anaerobic plaque-causing bacteria to live.
Sodium bicarbonate is a neutralizing agent that
acts on the acids produced by the bacteria. It is
an abrasive that breaks up the plaque's sticky
film. It also removes the odor caused by the
plaque. The water flushes away the bacteria and
debris off the surfaces of the teeth. Dental Air
Force home dental cleaning system with access
to subgingival area lead to removal of biofilm
and
prevent
further
proliferation
of
periodontopathic microorganisms.
CONCLUSION
This study confirmed that there was strong

relation between localized periodontal infections
to systemic health. There was an encouraging
correlation with non surgical phase 1 periodontal
therapy on lowering the systemic health markers.
This study also established the scientific
magnitude of Dental Air Force home dental
cleaning system as a true choice for lowering
possibilities of systemic diseases (Cardiovascular
disease and diabetes mellitus) initiated by
periodontal infections. The regular use of Dental
Air Force home dental cleaning system as oral
hygiene device is optimal for suppressing both
periodontal infection and associated systemic
diseases as compared to conventional tooth
brushing.
REFERENCES
1. Saini R, Saini S, Sharma S. Oral sex, oral

health and orogenital infections. J Global
Infect Dis 2010; 1: 57-62.
2. Saini R, Saini S, Saini SR. Periodontal
diseases: a risk factor to cardiovascular
disease. Ann Card Anaesth 2010; 13:159-61.
3. Saini R, Saini S, Saini SR. Periodontitis: A
risk for delivery of premature labor and low
birth weight infants. J Nat Sc Biol Med 2010;
1:40-42.
4. Mani A, Vadvadgi V, Anarthe R, Saini R,
Mani S. A clinical study on Dental Air Force
home dental cleaning system on adult chronic
periodontitis patients and its assessment to Creactive protein levels. Int J Experiment Dent
Sci 2012; 1: 14-18.
5. Saini R, Saini S, Sharma S. Biofilm: A dental
microbial infection. J Nat Sc Biol Med 2011;
2:71-5.
6. Southerland JH, Taylor GW, Offenbacher S.
Diabetes and periodontal infection: Making
the connection. Clin Diabetes 2008;4:171-8
7. Danesh J, Appleby P: Persistent infection and
vascular disease: A systematic review. Expert
Opin Invest Drugs 1998;7:691-713.
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8. Fiehn NE, Larsen T, Christiansen N,

Holmstrup P, Schroeder TV. Identification of
periodontal pathogens in atherosclerotic
vessels. J Periodontol 2005;76:731-6.
9. Saini R, Saini S, Saini SR. Periodontal
disease: The sixth complication of diabetes. J
Fam Community Med 2011; 18: 31.
438
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DOI: 10.5958/j.2319-5886.2.3.076

&
Health Sciences
th

Research article
Coden: IJMRHS
Copyright @2013
th
ISSN: 2319-5886
Accepted: 1st Jun 2013
A STUDY ON MEASUREMENT AND CORRELATION OF CEPHALIC AND FACIAL

INDICES IN MALES OF SOUTH INDIAN POPULATION
*Praveen Kumar Doni.R, Janaki CS, Vijayaraghavan. V, Delhi raj U
1
Department of Anatomy, Meenakshi Medical College & Research Institute, Enathur, Kanchi Puram,
Tamilnadu, India.
*Corresponding author email: sudprav@gmail.com.
ABSTRACT
Cranial, facial measurements and indices are used to estimate the sex and different shapes of head, and
face. It is highly important for Anatomists, forensic scientists, plastic surgeons, physical
anthropologists. Six craniofacial indices namely, head length, head breadth, cephalic index, face length,
face breadth, facial index were calculated. Method: The present study was performed on 100 male
medical students of south India of 18-23 year age groups, anthropometric points were measured by using
spreading, sliding caliper. Result: The present study showed the correlation is statistically significant
between the cephalic and facial indices in males. Conclusion: predominant head type in males was
Dolico cephalic in 19 year age group.
Key words: Craniofacial indices, Dolicocephalic. Anthropometric points, Correlation.
INTRODUCTION
The Study of Humankind, physically, and

culturally is known as Anthropology. And it has
been developed by the following biologists
Samuel George Morton, Charles Darwin and
Alfred Russell Wallace and Comte De Buffon,
Paul Broca, John Frederick Blumenbach.
Classical & New Physical Anthropology :
Methodological
approach
of
physical
1
anthropology is primarily based on compute
indices, Statistics, defined measurements.
However, the recent technical advancement and
realization of role of genetics in anthropology,
the global acceptance of anthropometry is linked
with genetic heterogeneity to understand the
variability of traits. The traditional physical
anthropology concerns to describe the features of
bones, whereas New physical Anthropology
concern to explain the functional significance of

bones, and the normal features of bone and its
measurements are described by Traditional
physical anthropology. Understanding the
processes of the mechanism responsible for a
specific trait is important and should be given
due attention than to make a simple statement
about its presence or absence .It necessitates
the development of descriptive, quantitative
methods. Physical anthropology is concerned
with the direction of change age groups, and
among individuals of past and present. It
continues to be study of biological variation and
human evolution. And Genetic differences and
environmental modifications are responsible for
the changes of sources, like the age group of
individuals past to present. Human biology is
439
Praveen et al.,
Int J Med Res Helath Sci. 2013;2(3):439-446
approached by the physical anthropology with

emphasis on humanity. Since cultural context is
considered as basic key to understanding, and
proper appreciation of the problems of human
evolution. Hence the physical anthropology is
concerned with the communication of
environmental2 and socio-cultural factors.
Physical anthropology is important in forensic
sciences. It made some significant contributions,
and also age and sex have determined by
individual
characterization.
Physical
anthropology helps in the fields of
dermatoglyphics,
serology,
osteology,
osteometry, and solves the problems of forensic
science3.
Cephalic index and physical anthropology :
The cephalic index is nothing but the ratio of the
maximum breadth of the head to its maximum
length. Sometimes multiplied by 100 for
convenience. It was given by Ander Retzius
(1796-1860). In Twentieth century the index
widely used by anthropologists to categorize
human populations. Today it is mainly used to
describe individuals appearances and estimating
age of fetuses for legal, obstetrical reasons4-8.
Cephalic index and sexual dimorphism:
Variety of metric and non-metric measurements
accesses the ethnic and sex differences of skull.
The non-metric measurements are more
subjective, and the actual measurements like
cephalic indices provide a metrical recording of
sizes, proportions of cranial features, Since these
indices fall under numerical category, it
prioritizes the evaluation of inter and intra
population comparison of crania as well as
sexual dimorphism.
Cephalic indices play a crucial role in
comparison of cephalic morphometry between
parents, offsprings and siblings and provide
information on inheritance pattern. Also, it
provides the roots for diagnostic comparison as
in cases of Dolicocephalics (less prone to Otosis
media16), and in the individuals with Aperts
syndrome who are hyperbrachycephalic17.
Studies that were carried on different ethnic
groups, populations and comparisons clearly
Praveen et al.,
Human populations were characterized as either

Dolicocephalic (long headed), Mesaticcephalic
(Moderate headed), Brachycephalic (Short
headed). These were earlier issues on the role of
cephalic index in determining the race and
mapping of the ancestral population. The lack of
plastic evidence9 led to implementation of
advanced techniques in 2002, 2003 and provided
a genetic back drop in head shape10-13.
Cephalic indices: Cephalic index is derived
from the Greek word Kephalic meaning
Head, The Greek work ikos meaning
Pertaining to and the Latin word Index
meaning that which points out. Header length
is the distance from the glabella to opistocranion.
And head breadth is the distance between two
irons.
Formula: Cephalic index (CI) = [Head width/
Head length] X 100
According to Frankfort agreement of 1882 ,
martin and smaller classification14. Skulls can be
classified on the basis of cephalic indices,
According to Banisters classification15 ; the
following facial types are classified according to
facial index. (Table.1)
indicated that the cephalometric dimensions and
indices have clear racial trend. Amount of
population and age specific data on cephalic
indices which gives an indication of growth and
development and abnormalities of cranial shape
and size of individuals.
Proscopic (Facial) index: For the evolution of
craniofacial morphology during development
which differs among races and ethnic groups,
Proscopic index (PI) becomes an important
anthropological parameter. PI was reported to be
different among races and current investigations
are moving around the changes in closely related
populations. Precipice index is the relation to the
length of the face to its maximum width between
zygomatic prominences. The length of face
measured from the nasion to mental tubercle and
breadth is measured as bizygomatic width. The
total
facial
index
is
calculated
Formula: Proscopic (facial) index (FI) = Total
facial height/ Bizygomatic width] X 100
440
Table.1: Classification of human head and face based on cephalic indices and facial index
Facial index
Cephalic index
CI range Scientific term
FI range
<75.9
Dolico cephalic ( long headed)
<79.9
76 80.9 Mesatic cephalic(medium headed) 80 84.9
Scientific term
Hyper Euryproscopic (very broad face)
Euryproscopic face ( Broad face)
81 85.9 Brachycephalic (short headed)

86 90.9 Hyper Brachycephalic
>91
Ultra Brachycephalic
Mesoproscopic face ( round face)

Leptoproscopic face ( long face)
Hyperlepto Proscopic face ( very long face)
85 89.9
90 94.9
>95
METHODOLOGY
Study Design: A cross sectional study was

conducted in the Department of Anatomy,
Meenakshi medical college, Kanchipuram,
including 100 subjects (100 males) together from
south India. The participants who volunteered in
the study were healthy and without any obvious
craniofacial abnormalities like developmental
disability, oculofacial trauma, craniofacial
congenital anomaly, and had no history of plastic
or reconstructive surgery. The age group of 1823 years male volunteers was selected.
Instruments used include weighing machine,
measuring tape, sliding and spreading calipers.
The following measurements namely, age, sex,
weight, height, head length, head breadth,
Bizygomatic breadth, Total facial height, From
above measurements the following indices
calculated.
Cephalic index, Proscopic index (Facial index)
Cephalofacial measurements:
Hrdlickas method 18 used for the Assessing

Cephalic index, Hootens Method19 used for
Assessing Total facial index.
Head length = Glabella to opisthocranion (GOP), it was measured by spreading caliper.
Head breadth = Euryon Euryon (Eu-Eu), it was
measured by spreading caliper.
Total facial height (Nasion Gnanthion) (N-Gn),
it was measured by sliding caliper.
Bizygomatic breadth (Bizygomatic, Zy- Zy), it
was measured by Sliding caliper.
Cephalic index (CI) = ( Eu-Eu/ G OP)100
Prosopic (facial) index (FI) = (N Gn/ Zy-Zy)
100
Depending on these indices the types of head &
face shapes were classified according to Martin
& saller (1957) method and Farkas (1981, 1994)
method.
Microsoft Excel and by a statistical software
SPSS (Statistical Package for Social Sciences)
RESULTS
Table 2: Ranges of head length, head breadth of males

Head length
No of cases Head breadth
16.01 17.00
1
11.01 12.00
17.01 18.00
17
12.01 13.00
18.01 19.00
47
13.01 14.00
19.01 20.00
32
14.01 -15.00
20.01 21.00
3
15.01 16.00
16.01 17.00
No of cases
1
6
29
53
10
1
441
Praveen et al.,
Table.3: Showing the incidence of Cephalic index

Cephalic index Noof
Cephalic index No
of Cephalic index
No of observed
observed
observed
66.01 67.00
1
73.01 74.00
5
80.01 81.00
7
67.01 68.00
0
74.01 75.00
6
81.01 82.00
1
68.01 69.00
2
75.01 76.00
8
82.01 83.00
5
69.01 70.00
1
76.01 -77.00
13
83.01 84.00
2
70 .01 71.00
3
77.01 78.00
9
84.01 85.00
0
71.01 72.00
8
78.01 79.00
5
85.01 86.00
1
72.01 73.00
7
79.01 80.00
16
MeanSD of Cephalic index in male volunteers of different age groups is 76.483.84.
Table 4: Distribution of head shapes according to observed cephalic index
Age Dolicocephalic Mesocephalic heads Brachy cephalic heads Hyper Brachy
Ultra Brachy
heads
cephalic heads
cephalic heads
7
9
3
0
0
18
12
8
1
0
0
19
6
3
4
0
0
20
6
9
0
0
0
21
3
16
1
0
0
22
6
6
0
0
0
23
Above the table shows a number of different types of headings, among of that and mesocephalic
cephalic head was predominantly observed.
Table 5: Ranges of face length and face breadth
No of cases Face breadth (cm) No of cases
Face length (cm)
9.01 10.00
5
10.01 11.00
10
10.01 11.00
51
11.01 12.00
39
11.01 12.00
43
12.01 13.00
43
12.01 - 13.00
1
13.01 14.00
7
13.01 14.00
0
14.01 15.00
1
14.01 15.00
0
15.01 16.00
0
More number of volunteers have face length ranges from 10.01 to 11.00, and 11.01, to 12.00, and face
breadths ranges from 12.01 to 13.00 and 11.01 to 12.00.
Table 6: Showing the incidence of facial index
Facial index
No
of Facial index
No
of Facial index
No of observed
observed
observed
74.01 75.00 2
85.01 86.00
9
96.01 97.00
8
75.01 76.00 2
86.01 87.00
2
97.01 98.00
7
76.01 77.00 0
87.01 88.00
1
98.01 99.00
5
77.01 78.00 2
88.01 89.00
2
99.01 100.00
3
78.01 79.00 1
89.01 90.00
4
100.1 101.00
1
79.01 80.00 0
90.01 91.00
9
101.01 102.00
0
80.01 81.00 2
91.01 92.00
4
102.01 103.00
1
81.01 82.00 3
92.01 93.00
3
0
82.01 83.00 1
93.01 94.00
9
0
83.01 84.00 4
94.01 95.00
8
0
84.01 85.00 2
95.01 96.00
5
0
442
Praveen et al.,
MeanSD facial index of male volunteers of different age groups is 90.956.448, the correlation
between the facial index and cephalic index showing significant difference, and statistically significant,
the p value is p<0.0001 at 95% confidence interval.
Table 7: Distribution of face shapes according to observed facial index
Age Hyper Euri Euri Proscopic Meso Proscopic Lepto Proscopic faces
Hyper Lepto
Proscopic faces
faces
faces
Proscopic faces
18
1
2
7
4
19
3
1
3
9
20
1
1
1
6
21
0
2
4
4
22
0
3
1
5
23
0
3
2
5
The Hyper Lepto Prospect face was a dominant face shape than other face shapes.
5
6
4
5
11
2
DISCUSSION
The determination of sex, is an important

concern of the osteologist and forensic
anthropologist as it is critical for individual
identification. Sex determination eliminates
approximately 50% of the population from
further considerations in cases of missing
persons. Moreover, many individualization
criteria are sex specific20. Several factors such as
genetic factors are responsible for Morphological
differences between the sexes. However, the
phenotypic expression is due to mixture of
genetic and environmental factors Gravlee,
Clarence, Russell Bernard21, and William R.
Leonard. Studies on sexual dimorphism are
primarily based on biological differences
between male and female. Male are more robust
than female. The weight of axial skeleton in male
is relatively and absolutely heavier than female
approximately by 8%.Estimation of stature is an
important tool in forensic examinations
especially in unknown, highly decomposed,
fragmentary and mutilated human remains.
Stature being one of the criteria for personal
identification helps to narrow down the
investigation processes. Stature has a definite and
a proportional biological relationship with each
and every part of the human body. Though most
parts of the body are essentially helpful in stature
Praveen et al.,
estimation, Cephalo-facial region has its

potential effect.
The present study provides valuable new data
pertaining to cephalic indices and the shapes of
the head in individuals between 18-23 years of
age; belonging to south Indian. Comparatively
these following previous studies Shah GV
jadhav22 Mean values of cephalic index is 80.42,
Mahajan et al23 Mean is 81.34, and Anitha MRet
al24 Mean is 79.14. Have more mean values than
the present study. The present study mean is
76.48. Present study facial index mean 90.95 is
more than the previous studies Singh and
Purkait25 mean is 82.5 in Ahiwar of Khurai block
of MP, And 85.1 in Dangi of Khurai block of
MP26. Shetti R26 mean is 87.19.
Interaction of gene expression, and cranial
dimensions can make the gene expression differs
in various racial, and ethnic groups in
geographical
zones27.
Because
cranial
dimensions depends on gene expression. It
becomes a determining factor. The first
generation of Hawaii immigrants had higher
cephalic index than their parents. Thus, it is an
interesting factor to know that cephalic indices
very significantly among populations in different
geographical zones. The cephalic indices in the
present study are valid for the age group 18-23
year population. Cranial dimensions can differs
443
with the age of individuals, it reaching peak

around 16-23 years of life and also genetic
expression influenced by age factor. Genetic
information can induce by age factor.
Sexual dimorphism is an important factor in
morphological
variation
in
biological
populations. The cranial morphology explains
the significance of anatomical variation data to
individuals of a population. And it also
influences the growth rates of skeletal maturity in
male and female during the course of growth and
development. The significance of age, gender
and population specific cephalometric data is of
multifold. Comparison between cephalic indices
and the head shapes with race and age, and sex is
important, which are valuable for treatment
monitoring and prediction of orthodontic
treatment and the knowledge is valuable in
plastic and reconstructive surgeries concerned28
with craniofacial deformities. . It also provides
important evidence in the forensic craniofacial
reconstruction.
Causes for variations in cephalic index:
Craniosynostosis is defined as premature
closure of the cranial sutures and is classified as
primary or secondary. Primary Craniosynostosis
refers to the closure of one or more sutures due
to abnormalities of skill development, Secondary
Craniosynostosis results from failure of brain
growth.
Incidences of primary and Craniosynostosis:
The Incidence of primary Craniosynostosis
approximates 1/ 2,000 Births. The cause is
unknown in the majority of children; however,
genetic syndromes account for 10 -20% of cases.
Development and Etiology: The cause of
Craniosynostosis is unknown, but the prevailing
hypothesis suggests that abnormal development
of the base of skull creates exaggerated forces on
the Dura that act to disrupt normal cranial suture
development.
Factors Responsible for variations in cephalic
index: The shape of the head depends on the
timing and order of suture fusion but most often
is a compressed back- to front diameter or
Praveen et al.,
Brachycephaly due to bilateral closure of the

coronal sutures. The orbits are underdeveloped,
and ocular proptosis is prominent. Hypoplasia of
the maxilla and orbital hypertelorism are typical
facial features.
CONCLUSION
The primary aim of the study was to evaluate and

report, the association of sexual dimorphism and
stature with cephalic, proscopic indices in
individuals of 18-23 year male age group from
the south Indian population. The statistical
correlation between cephalic, facial index is
significant the up value is p< 0.0001 at 95%
confidence interval. And correlation of age,
height, with cephalic, facial index was not
significant statistically. These observations also
indicate that there is existence of sexual
dimorphism with reference to proscopic index.
ACKNOWLEDGMENT
At the outset I would like to thank Dr. M.

Chandrasekar Dean, Meenakshi Academy of
Higher Education and Research Institute. I would
like to express my deep and sincere gratitude to
my guide Dr.v. Vijaya Raghavan, professor and
head of department of anatomy. I must convey
my heartfelt thanks to Dr.c.s. Janaki, Assistant
professor for her continues support and guidance
in completing these works.
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Praveen et al.,
DOI: 10.5958/j.2319-5886.2.3.077

&
Health Sciences
st
Received: 1 May 2013

Research article
Coden: IJMRHS
Copyright @2013
th
ISSN: 2319-5886
MORPHOMETRY OF JUGULAR FORAMEN AND DETERMINATION OF STANDARD

TECHNIQUE FOR OSTEOLOGICAL STUDIES
*Delhi raj U, Janaki CS, Vijayaraghavan. V, Praveen Kumar Doni R
Department of Anatomy, Meenakshi Medical College & Research Institute, Enathur, Kanchipuram,
Tamilnadu, India
*Corresponding author email: delhirajphysio@gmail.com
ABSTRACT
The Jugular foramen is large openings which are placed above and lateral to the foramen magnum in the
posterior end of the petro-occipital fissure and the anterior part of jugular foramen is allows the cranial
nerves IXth, Xth, XIth the direction of the nerves from behind forwards within the jugular foramen and
sometimes jugular tubercle it has acted as a groove and later it becomes enter of the foramen. They lie
between the inferior petrosal sinus and the sigmoid sinus. Methods: The Antero-Posterior Diameter and
Transverse Diameter of the jugular foramen were analysed exocranially for both right and left sides. All
the parameters were examined by two methods, Method.1: Mitutoyo Vernier Calliper, Method.2: Image
J Software. Results: The present study showed the measurement is statistically significant between the
Mitutoyo Vernier Calliper and Image J Software. Conclusion: The Image J software value is more
precise than the Mitutoyo Vernier Calliper values.
Key words: Jugular Foramen, Exocranial measurement, Image J software, Mitutoyo Vernier Calliper
INTRODUCTION
The Jugular formen it consists two borders upper
border is irregular it allows the glosspharyngeal
nerve through the notch. Lower border is smooth
it allows posterior sigmoid sinus and which
continuous has an internal jugular foramen.
Jugular foramen is large openings which are
placed above and lateral to the foramen magnum
in the posterior end of the petro-occipital fissure
and the anterior part of jugular foramen is allows
the cranial nerves IXth , Xth, XIth the direction of
the nerves from behind forwards within the
jugular foramen and sometimes jugular tubercle
it has acted as a groove and later it becomes enter
Delhiraj et al.,
of the foramen. Sometimes inferior petrosal sinus

might have been accompanied by meningeal
branch of ascending pharyngeal arteries
simultaneously sigmoid sinus accompanied by
meningeal branch of occipital arteries and the
posterior part of jugular foramen allows occipital
and ascending pharyngeal arteries.1 According to
imaging based jugular foramen have bony ridge
which is known as jugular spine this spine
divides in to anterior and posterior parts and
jugular foramen acted as a main route of venous
outflow from the skull sometimes it his
dominated each sides. Ligation of the internal
447
jugular vein it may causes risk of venous

infraction.9 jugular canal was placed deeply and
surrounded by the vital structures with related to
the internal carotid artery anteriorly, hypoglossal
nerve medially, facial nerve laterally, vertebral
artery inferiorly.8 Sometimes intracranial and
extracranial lesion are responsible to produce
intrinsic abnormalities and also it produces
pathologically
intracranial
meningiomas,
paragangliomas,
metastatic
lesions
and
occasionally it reaches middle ear also and
jugular lesions are prevented by using micro
surgical techniques.9
A total number of 100 Jugular foramens were

examined from 50 skulls (Right & Left). The
skulls were obtained from the osteological
collections of the dry skulls in the Department of
Anatomy at Meenakshi Medical College and
Research Institute, Enathur, Kanchipuram and
Melmaruvathur Adhiparasakthi Institute of
Medical Sciences and Research, Melmaruvathur
were used for this study.
All the parameters were examined by two
methods, Method.1: Mitutoyo Vernier Calliper,
Method.2: Image J Software
Method 1: (Mitutoyo Vernier Calliper): The

Antero-Posterior Diameter and Transverse
Diameter of the jugular foramen were analysed
exocranially for both right and left sides. This
was done by measuring Mitutoyo Vernier
Calliper.
Method 2: (Image J Software): The AnteroPosterior Diameter and Transverse Diameter of
the jugular foramen were analysed exocranially
for both right and left sides. This was done by
taking Photographs of jugular foramen for all
50skulls exocranially. These images were taken,
and images were saved. The digitally saved
images were opened and measured with the
software Image J (software offered by the
National Institute of Health USA (NIH), and
Antero-posterior Diameter and Transverse
Diameter were calculated and recorded.
RESULTS
We have done the examination of length and

width of 50 skills exocranially by two methods.
The obtained data analysis was performed with
SPSS version 11software. According to previous
studies they have used Mitutoyo Vernier
Calliper. In our present study I have done the
measurements with Mitutoyo Vernier Calliper
and Image J software.
Table 1: Comparison of Antero-posterior diameter of jugular foramen with Mitutoyo Vernier Calliper and
Image J software
Left side
Jugular Foramen
Right side
Antero-posterior
Diameter
Mitutoyo Vernier Image

Calliper
Software
J Mitutoyo Vernier Image J

Calliper
Software
Mean
8.92
9.508
7.651
Standard Deviation
1.893
2.015
1.457
1.441
P Value
0.0156
0.0001
448
Delhiraj et al.,
Table: 2 Comparison of Transverse diameter of jugular foramen with Mitutoyo Vernier Calliper and
Image J software
Jugular Foramen
Transverse Diameter
Right side
Mitutoyo Vernier Image
Calliper
Software
Left side
J Mitutoyo Vernier Image J
Calliper
Software
Mean
13.54
14.14
11.8
12.9
Standard Deviation
2.012
1.998
2.611
2.482
P Value
0.0001
0.0001
Table.3: Comparison of largeness of antero-posterior diameter and transverse diameter on each side of
jugular foramen with Mitutoyo Vernier Calliper
Jugular foramen
Antero-Posterior Diameter
Right side
88%
Left side
12%
Transverse Diameter
80%
20%
DISCUSSION
Internal jugular vein depends on the size and

shape of the jugular foramen, Right jugular
foramen is larger than the left jugular foramen.
Comparison of Length of Jugular foramen
with other study: OE Idowu measured the
length of jugular foramen on the right as ranging
from 11.6 mm to 17mm and the mean length
was 13.9mm, and on left it was 9.2mm to
20.2mm and the mean length was 14.11mm.9
Hussain Saheb found the minimum length of
jugular foramen 19.4mm and maximum
29.3mm on right side and the mean was
23.62mm, on the left side the length was 12mm
to 27.4mm and the mean length being
22.86mm.8 The present study of 50 skulls the
length of jugular foramen on right side ranging
from 10.00mm 19.00mm and the mean was
13.54mm, on the left side ranging from 8.00mm
19.00mm and the mean was 11.8mm which is
slight closer to the O.E. Idowus value and
much lower than the values of Hussain Saheb
Comparison of width of Jugular foramen
with other study : O.E. Idowu (2004) measured
the width of jugular foramen on the right as
ranging from 6.80mm to 14.40mm and the mean
was 10.22mm, and on left side it was 7.40mm to
Delhiraj et al.,
12.80mm and the mean was 9.57mm.9 Hussain

Saheb (2010) found the minimum width of right
side jugular foramen as 3mm and maximum as
11.4mm, and the mean being 7.83mm, on the
left side the width was 4mm to 11mm and the
mean being 6.83mm.8 The present study of 50
skulls the width of jugular foramen ranging as
4.0mm 14.00mm and the mean was 8.92mm
on right side, on the left side ranging from
4.0mm 10.00mm and the mean was 7.0mm
which is slightly higher than the values of
Hussains Sehebs study but the values is
slightly lower than the values of Idouws study.
Statistical comparison of variables with
others study: The present study the length and
width of the jugular foramen higher significance
than the Idouws study and Hussains study.
Merit and Demerit of Mitutoyo Vernier
Calliper
Merits: Mitutoyo Vernier Calliper is anyone
can handle this instrument, Easy measurement.
Demerits: Have to prevent Inter Intra observer
difference, "Reading error" of 0.02.
449
Merit and Demerit of Image J Software:

Merits: Image J Software is free software
available from the internet, more precise, No
reading error
Demerits: Image J Software is Knowledge about
basic computers is needed, Accessories like
camera are needed, Photo magnification error
should be avoided.
3. Chong VFH, Fan YF.
4.
5.
CONCLUSION
The bony growth from jugular fossa which

converted the foramen into a slit like appearance
It produces some neuro vascular diseases,
glomus, jugular meningiomas, Jugular tumors
and even a nodule reducing size of jugular
foramen in Varicella -Zoster virus infection.
The involvement of IXth, Xth and XIth cranial
nerves at jugular foramen is known as Vernets
Syndrome, which might occur in this case due
to narrowing of the jugular foramen. As jugular
foramen is a large deeply placed aperture. The
need for familiarity with detailed anatomy of
this region becomes greater importance for a
neurosurgeon to approach this region. The
Image J software value is more precise than the
Mitutoyo Vernier Calliper values.
6.
7.
8.
9.
10.
11.
ACKNOWLEDGEMENT
I would like to thanks the Dr.M. Chandrasekhar,

Dean, Dr. V.Vijayaraghavan, Professor & Head,
Dr. Janaki CS, Assistant professor, Department
of Anatomy, Meenakshi Medical College &
Research Institute. For valuable support,
guidance and provided to me in the department
to work prodigiously to achieve great height
with plenary knowledge
12.
13.
REFERENCES
1. Gray's Anatomy, Intracranial Region
posterior cranial fossa.40th Edition. chapter

27, 424-425
2. Chong VFH, Fan YF. Radiology of the
jugular foramen. Clinical Radiology.
1998:53: 405-16.
14.
15.
Jugular foramen
involvement in naso-pharyngeal carcinoma.
J Larynx Otology. 1996:110:897-900.
Daniels DL, Williams AL, Haughton VM.
Jugular foramen: anatomic and computed
tomographic study. Am J Radiology. 1984:
142: 153-158.
Di Chiro G , Fisher RL , Nelson KB. The
jugular foramen. J Neurosurgery. 1964:21:
447-52.
Dodo Y. Observations on the bony bridging
of the jugular foramen in man. J
Anat.1986:144:153-65.
Hatiboglu MT. Structural variations in the
jugular foramen of the human skull. J
Anat.1992: 180:191-96.
Hussain Saheb S, Thomas ST, Prassana LC,
Muralidhar P. Morphological variations of
jugular foramen in South Indian adult skulls.
Biomedical Research 2010; 21 (4): 349-350
Idowu OE.
The
jugular foraman- a
morphometric study. Folia Morphol.2004:
63:419-22.
Sturrock RR. Variation in the structure of
the jugular foramen of the human skull. J
Anat. 1988;180:227-30.
Navsa N, Kramer B. A quantitative
assessment of the jugular foramen.
Anatomischer Anzeiger. 1998: 180: 26973.
Nayak S. Partial obstruction of jugular
foramen by abnormal bone growth at jugular
fossa. Internet J Biol Anthrapol.2007:1.2:
10
Patel and Singel. Variations in the structure
of jugular foramen of the human skulls in
saurashtra region.
J Anat Soci India.
2007:56(2):34-37.
Patridge EJ. The relation of the
glossopharyngeal nerve at its exit from the
cranial cavity. J Anat, 1918: 52: 332-334.
Pereira, GAM, Lopes PTC, Santos AMPV,
Krebs WD. The morphometric study of the
jugular foramen in Southern Brazil human
Dry skulls. J.Morphol Sci. 2010:27:3-5.
450
Delhiraj et al.,
DOI: 10.5958/j.2319-5886.2.3.078

&
Health Sciences
Received: 3rd May 2013
Accepted: 2nd Jun 2013
Research article
STUDY ON EFFECT OF CIGARETTE SMOKING ON SPERM COUNT AND SEMINAL
MALONDIALDEHYDE LEVELS OF INFERTILE MEN
Gaisamudre KB1, Waghmare AR2, Naghate GR3, Muneshwar Jaya4
1
Assistant Professor, Dept. of Physiology, Govt. Medical College, Kolhapur, MHS, India
Assistant Professor, Dept. of Physiology, Dr.V.M.Govt. Medical College, Solapur, MHS, India
3
Associate Professor, 4Associate Professor Dept. of Physiology, Govt. Medical College, Aurangabad
2
*Corresponding author Email: kgaisamudre81@gmail.com

ABSTRACT
The highest prevalence of smoking is observed in young adult males during their reproductive period.
Smoking has been suggested to contribute to a number of diseases including male infertility. Although
much is known now about the carcinogens in tobacco cigarette smoke and their resultant effects on
organs like lungs and urinary bladder, their effects on fertility status have been less documented. The
present study was aimed at studying the effect of cigarette smoking on sperm count and seminal MDA
levels of infertile men. A total of one hundred infertile men (50 Nonsmokers and 50 Smokers) between
the age group 20-45 years were taken into study. The Sperm count and seminal MDA levels in the
infertile Nonsmokers and the infertile Smokers group were compared using Z Test. Infertile Smokers
which were divided into Group A (1 and 10 cigarettes/ day) , Group B (>10 and <20 cigarettes/ day)
and Group C (20 cigarettes/ day) were analyzed for Sperm count and MDA levels of ANOVA Test.
We observed that the sperm count was significantly lower (p<0.01) and the seminal MDA levels were
significantly higher (p<0.01) in an infertile Smokers group than the infertile Nonsmokers group. We
also observed that the sperm count was significantly decreased (p<0.05) and the seminal MDA levels
were significantly increased (p<0.05) in accordance with the severity of smoking.
Keywords: Smokers, Non smokers, Infertile, Sperm count, Seminal MDA levels.
INTRODUCTION
The highest prevalence of smoking is observed in

young adult males during their reproductive
period. Smoking has been suggested to
contribute to a number of diseases including
male infertility. It has been reported that tobacco
smoke contains some of the most deadly toxic
chemicals. Smokers inhale directly and absorb
the following substances: nicotine, carbon

monoxide, nitrogen oxide, mutagenic pyrolysisderived compounds and cadmium. Most of them
are known to be mutagens and carcinogens,
directly affecting male and female gametes and
embryos.1 Although much is known now about
the carcinogens in tobacco cigarette smoke and
451
Gaisamudre KB et al.,
their resultant effects on organ like lungs and

urinary bladder, their effects on fertility status
have been less documented.2 Infertility is one of
the most tragic of all marital problems. Facing
infertility can be very difficult for both men and
women. It is emotionally stressful and physically
taxing on most couples. Infertility is defined as
the inability to achieve pregnancy after one year
of unprotected intercourse.3 It is estimated to
affect 10%15% of all couples.4
Male infertility plays a key role in conception
difficulties of up to 40% infertile couples.2 The
term male infertility does not constitute a
defined clinical syndrome but rather a collection
of different conditions exhibiting a variety of
etiologies and varying prognosis.5 Although in
some men a specific disorder may be present, in
majority no apparent reason for infertility could
be found. This has drawn attention to the impact
of lifestyle and environmental factors, especially
diet, obesity, smoking, alcohol intake,
recreational drug use, and exposure to
environmental toxins, on the reproductive health
of such men. 2 The male factor, in the form of
defective sperm quality, is a major cause.5 There
is a correlation between cigarette smoking in
infertile men and increased leukocyte infiltration
into semen .The latter has been linked to
significantly increased levels of seminal oxidants
i.e.
Reactive
Oxygen
Species
(ROS).
Undercompromised conditions such as stress,
may adversely affect reproductive health leading
to infertility.4 ROS attack polyunsaturated fatty
acids in the cell membrane leading to chain of
chemical reactions called Lipid Peroxidation.
Malondialdehyde (MDA) is a byproduct of lipid
peroxidation which represents the level of lipid
peroxidation. 1
Cigarette smoking is an avoidable lifestyle factor
observed to have a negative impact on male
fertility. 6,7,8,9,10,11 The aim of our study was to
compare sperm count & seminal MDA levels of
infertile men who were cigarette smokers with
infertile non-smoking men, in order to ascertain
the effect of cigarette smoking on the quality of

seminal fluid.
Aims and objectives
Aim: To study the effect of cigarette smoking on
Sperm count and Seminal Malondialdehyde
(MDA) levels of infertile men.
Objectives: Primary:
1. To study sperm count in infertile Nonsmoker
and infertile Smoker men.
2. To estimate seminal MDA levels in infertile
Nonsmoker and infertile Smoker men.
Secondary:
1. To compare sperm count in infertile
2. To compare seminal MDA levels in infertile
The present study was carried out in the

Department of Physiology in collaboration with
the Department of Biochemistry. The study
protocol was approved by the Institutional
Ethical Committee. Before enrollment in the
study, informed written consent was obtained
from each subject.
The subjects referred to semen analysis from the
couples attending the outpatient department
(O.P.D.) of obstetrics and gynecology (OBGY),
for infertility evaluation, were enrolled in the
present study.
Inclusion criteria:
Clinically infertile subjects with a history of
infertility persisting longer than one year in
reproductive age group were included in the
study.
Primary infertile subjects were included in the
study.
A total of one hundred infertile men (fifty
Nonsmokers and fifty Smokers) between the age
group 20-45 years were taken into study. The
study was undertaken for duration of 12 months.
Nonsmokers were the men who had never
smoked.
452
Smokers were the men who smoke cigarettes for

5 years or more and smoking till date.
The infertile Smokers were in turn divided into
the following groups:
Group A (n = 28) - (1 and 10 cig arettes/ day),
Group B (n = 17) - (>10 and <20 cigarettes/ day)
Group C (n = 5) - (20 cigarettes/ day)
Exclusion criteria: 1. History of tobacco
chewing and alcohol intake. 2. History of injury
to tests, varicocele, hydrocele or undescended
testes. 3. History of any chronic illness like
Tuberculosis, diabetes, hypertension, thyroid
disease. 4. History of UTI, occupational exposure
to chemicals or excess heat. 5. Azoospermic
Subjects. 6. A history of taking drugs like
Vitamin E, Vitamin C or Glutathione
supplementation.
Sample collection and semen analysis: Semen
samples were collected by masturbation into a
sterile, wide mouthed container, after at least 72
hours (3 days) of sexual abstinence. Samples
were allowed to liquefy at room temperature
(25c) for at least 45 minutes. After liquefaction,
samples were analyzed for sperm count
according to World Health Organization (WHO)
guidelines.12 MDA levels were estimated by
using Thiobarbituric acid (TBARS) assay by Rao
et al method13
Semen sample preparation: Liquified semen

samples were centrifuged at 1200 rpm for 20
minutes for separation of plasma. This plasma
used for biochemical assay. Thiobarbitutric acid
(TBA) reacts with malondialdehyde (MDA) in
acidic medium at temperature 95c for 60 min to
form thiobarbituric acid reactive substance
(TBARs). The absorbance of the resultant pink
product was measured Spectrometrically at
530nm The results were expressed as nmol
MDA/ ml of seminal plasma.
RESULTS
In the present study, all the calculations and

statistics were done using Microsoft Excel 2007
and graph pad prism 5 software" version 5.01
was used. A p value of less than 0.05 (p < 0.05)
was considered to be statistically significant. A
p value of less than 0.01 (p < 0.01) was
considered to be statistically highly significant.
For each parameter, the mean value and standard
deviation were calculated. Z test was applied to
study the difference between infertile
Nonsmokers group and infertile Smokers group.
Sperm count and MDA levels in all three groups
of infertile Smokers were compared using one
way ANOVA (analysis of variance) test. The
observations and results of the present study
were tabulated as below:
Table.1: Comparison of sperm count, MDA in infertile Nonsmokers and infertile Smokers group*
Parameter
Nonsmokers (N=50)
Smokers (N=50)
P Value
Sperm Count (millions/ejaculate)
60.88 31.94
42.14 37.92
<0.01**
MDA (nmol/ml)
0.15970.0952
0.24520.1397
<0.01**
* Data presented as Mean SD, ** Significant

Table.2: Comparison of Sperm count, MDA in three groups of infertile Smokers
GROUP N
Sperm Count
P Value
(millions/ejaculate)
Seminal MDA
P Value
(nmol/ml)
28
54.3539.80
<0.05
0.2100.122
17
30.2332.01
0.2610.155
14.2 14.42
0.3860.081
<0.05
453
DISCUSSION
Cigarette smoking is a serious health problem of

most societies. Consumption of tobacco exerts
widely adverse effects on different aspects of
health.
The results obtained in the present study showed
that the mean SD of sperm count in infertile
Nonsmoker men was 60.88 31.94
(millions/ejaculate) and in infertile Smoker men
the value was 42.14 37.92 (millions/ejaculate).
The intergroup comparison of the sperm count
has shown that the sperm count was decreased in
the infertile Smokers group. The difference of
the mean sperm count in both the groups was
statistically significant (p<0.01). The individuals
with cigarette smoking thus are related to the
reduced sperm count.
The sperm count decreased in accordance with
severity of smoking and these values were
statistically significant (p<0.05).
The above results of the present study are in
accordance with the following studies:
Chia et al14 reported that sperm concentration
decreased due to smoking. Goverde et al15
disclosed the sperm count difference between
heavy smokers and nonsmoking men. Zhang et
al16 showed that the sperm count was negatively
correlated with the amount and duration of
cigarette smoking and concluded that medium
heavy, and long term smoking adversely affected
the semen quality. Kunzle et al7 found a
significant decrease in sperm density of smoking
males, compared to non-smoking controls.
Ramlau-Hansen et al6 found a 19% lower sperm
concentration in smoking men, compared to nonsmokers. Also they observed a statistically doseresponse relationship between current cigarette
smoking and sperm concentration. Mehrannia11
showed that sperm concentration was
significantly lower in the nonsmoker men than in
smoker men. Ochedalski et al17 found that sperm
count was lower in smokers when compared to
nonsmokers. Olayemi3, Mostafa18 and Collodel

et al19 also found similar results.
The serum level of nicotine & cotinine adversely
affects spermatogenesis. 20 Zinc is vital for
spermatogenesis. Its deficiency leads reversibly
to reduce sperm count.21 Cigarette smoking
causes significant decrease in seminal plasma
zinc in smokers. Decrease in seminal plasma zinc
may be associated with a decrease in antioxidant
defenses which could be a contributor to the
effects of cigarette smoking on sperm parameters
like sperm count. Also there is a clear correlation
between seminal plasma zinc levels and the
extent of smoking. 22 Zn deficiency induces
atrophy of seminiferous tubules and causes
failure of spermatogenesis.23
Cigarette smoke adversely affected germ cells in
testis.24 and there is secretory deficit of Leydig
and Sertoli cells on exposure to cigarette
smoke.25 Cigarette smokers were also shown to
have higher levels of circulating estradiol and
decreased levels of LH, follicle-stimulating
hormone (FSH) and prolactin than non-smokers,
all of which can negatively impact
spermatogenesis.17
The results obtained in the present study showed
that the mean SD concentration of seminal
MDA in infertile Nonsmoker men was 0.1597
0.0952 (nmol /ml) and in infertile Smoker men
the value was 0.2452 0.1397 (nmol /ml). The
intergroup comparison of the seminal MDA
levels has shown that the seminal MDA levels
increased in the infertile Smokers group. The
difference of the mean concentrations of MDA in
both the groups was statistically significant
(p<0.01). The individuals with cigarette smoking
thus are related to the elevated MDA levels.
The seminal MDA levels increased in
accordance with the severity of smoking and
these values were statistically significant
(p<0.05).
454
The above results of the present study are in

accordance with the following studies:
Agarwal and Prabakaran26 in their review article
stated that smoking enhances ROS generation
which has destructive effects on sperm DNA.
Mehran27 evaluated direct effect of seminal
plasma from smokers on spermatozoa of non
smokers and found impairment in membrane
integrity
by
elevation
in
MDA
28
(Malondialdehyde) levels. Kiziler et al showed
that MDA levels in the smoker group were
significantly higher than those in nonsmoker
male. Hammadeh et al29 showed that Reactive
oxygen species (ROS), Malondialdehyde
(MDA), 8-Hydroxyguanosine (8-OHdG) and
cotinine were significantly higher in smokers
than in nonsmokers.
Smoking increases Reactive Oxygen Species
(ROS) levels and decreases seminal antioxidants
and ROS produced by spermatozoa is negatively
correlated with the quality of sperm in semen.30
Analysis of the fatty acid content of human
spermatozoa has revealed a high degree of
polyunsaturation and this factor together with the
capacity of these cells to generate reactive
oxygen species (ROS) render them particularly
susceptible to oxidative stress. Unfortunately the
spermatozoa are unable to repair the damage
induced by oxidative stress because they lack the
cytoplasmic enzyme systems that are required to
accomplish this repair.31,32
Normally, a balance is maintained between the
amount of ROS produced (pro-oxidants) and that
scavenged by a cell (antioxidants). Cellular
damage arises when this equilibrium is disturbed,
especially when the cellular scavenging systems
cannot eliminate the increase in ROS33. ROS
attack Polyunsaturated Fatty Acid (PUFA) in the
cell membrane leading to a chain of chemical
reactions
called
lipid
peroxidation.
Malondialdehyde (MDA) is a byproduct of lipid
peroxidation which represents the level of lipid
peroxidation. 1
The presence of tobacco smoke constituents in
seminal plasma could provide a warning of the
adverse effects of cigarette smoke on the
physiology of reproduction. The clinical

significance of present finding should be to
develop effective interventions aimed at helping
patients stop smoking for the benefits to the
general health and for their fertility. Hence we
suggest that every smoker should be encouraged
to stop smoking especially if pregnancy is
planned.
CONCLUSION
It is concluded that cigarette smoking adversely

affects Sperm count and seminal MDA levels
and in turn semen quality. Deterioration in semen
quality appears in direct proportion to the
number of cigarettes smoked.
ACKNOWLEDGEMENT
We acknowledge this work to all the staff of

Department of Physiology, Government Medical
College, Aurangabad who directly or indirectly
helped us to get this work completed.
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antioxidants in normal and abnormal sperm
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3. Olayemi FO. A Review on some causes of
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5. Brugo-Olmedo S, Chillik C, Kopelman S.
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JP. Is smoking a risk factor for decreased
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7. Knzle R, Mueller MD, Hanggi W,
Birkhauser MH, Drescher H, Bersinger NA.
Semen quality of male smokers and
nonsmokers in infertile couples. Fertil Steril.
2003;79(2):287-91.
8. Jarow JP. Semen quality of male smokers
and nonsmokers in infertile couples. The
journal of Urology. 2003; 170(2)1:675-76.
9. Gaur DS, Talekar M, Pathak VP. Effect of
cigarette smoking on semen quality of
infertile men .Singapore Med J. 2007;
48(2):119.
10. Chari MG, Colagar AH. Seminal plasma
lipid peroxidation, total antioxidant capacity,
and
cigarette
smoking
in
asthenoteratospermic men. Journal of mens
health. 2011;8(1):43-49.
11. Mehrannia T. The effect of cigarette smoking
on semen quality of infertile men. Pakistan
journal of medical sciences quarterly. 2007;
23(1)5:717-19.
12. WHO laboratory manual for the Examination
and processing of human semen fifth edition
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13. Rao B, Souflir JC, Martin M, David G. Lipid
peroxidation in human spermatozoa as
related to midpiece abnormalities and
motility. Gamete Res 1989; 24:127-34.
14. Chia SE, Xu B, Ong CN, Tsakok FM, Lee
ST. Effect of cadmium and cigarette smoking
on human semen quality. Int J Fertil
Menopausal Stud. 1994; 39(5):292-8.
15. Goverde HJ, Dekker HS, Janseen HJ,
Bastiaans BA, Rolland R, Zielhaus GA.
International Journal of Fertility and
Menopausal Studies 1995; 40(3): 135-138.
16. Zhang JP, Meng QY, Wang Q, Zhang LJ,
Mao YL, Sun ZX. Effect of smoking on
semen quality of infertile men in Shandong,
China. Asian j androl. 2000;2(2):143-6.
17. Ochedalski T, Lachowicz-Ochedalska A, Dec

W, Czechowski B. Evaluating the effect of
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in men of reproductive age. Ginekologia
Polska.1994;65(2): 80-86
18. Mostafa T. Cigarette smoking & male
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2010 July; 1(3):179-186.
19. Collodel G, Capitani S, Pammolli A,
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Semen quality of male idiopathic infertile
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Miyagawa I. Effects of smoking on testicular
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DuMouchelle
E.
Experimental
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25. Kapawa A, Giannakis D, Tsoukanelis K,
Kanakas N, Baltogiannis D, Agapitos E et al.
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from smokers on sperm function in nonsmokers. Zhonghua Nan Ke Xue. 2005;
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28. Kiziler AR, Aydemir B, onaran I, Alici B,
Ozkara H, Gulyasar T et al . High levels of
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subjects.Biol Trace Elem Res. 2007;120(13):82-91.
29. Hammadeh ME, Hamad MF, Montenarh M,
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31. Alvarez JG, Touchstone JC, Blasco L, Storey
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32. Aitken RJ, Clarkson JS, Fishel S. Generation
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Biol Reprod. 1989; 40:183-97.
33. Dandekar S P, Nadkarni G D, Kulkarni V S,
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457
DOI: 10.5958/j.2319-5886.2.3.079

&
Health Sciences
www.ijmrhs.com
nd

Research article
Coden: IJMRHS
Copyright @2013
th
ISSN: 2319-5886
ASSESSMENT OF SYMPATHOVAGAL RESPONSE TO VARIOUS PHYSIOLOGICAL

STIMULI IN PREHYPERTENSIVE AND HYPERTENSIVE INDIVIDUALS.
*Nirmala N, Kavitha U, Arunkumar.B, Lavanya V
Department of Physiology, Sri Venkateshwara Medical College & Research Centre, Pondicherry,India
*Corresponding author email id: drnirmamuthu@yahoo.co.in
ABSTRACT
Background : It is well known that there is correlation between autonomic nervous system and blood
pressure. Sympathetic hyperactivity is the major cause for the pathogenesis of hypertension. This study
is undertaken to analyse the sympathovagal response to various physiological stimulus in both
prehypertensive and hypertensive individuals. Aim: To compare the sympathovagal response in
prehypertensive and hypertensive individuals. Materials & Methods : Around 40 subjects were
selected and they were divided into 2 groups. Group 1 prehypertensive, Group 2 - hypertensive 20 in
each group. Orthostatic test and Cold pressor test were done to assess the sympathovagal balance.
Results: There was a significant increase (p<0.5) in systolic and diastolic blood pressure in both
prehypertensive and hypertensive to cold pressor test. The response of blood pressure to orthostatic test
showed no significant difference in both hypertensive and prehypertensive individuals. Conclusion: The
rise of both systolic and diastolic blood pressure was slightly higher in prehypertensive than
hypertensive a individual which indicates sympathetic impairment in prehypertension and sympathetic
failure in hypertension. Prehypertensives who showed sympathetic hyperactivity to cold pressor test
may develop hypertension in later life.
Keywords: Hypertension, Prehypertension, sympathovagal balance.
INTRODUCTION
Hypertension is one of the major cardiovascular

causes of morbidity and mortality. There is an
established relationship between hypertension
and cardiovascular risk factors1. Cardiovascular
Disease
(CVD)
contributes
to
large
proportions
of
deaths
and
disability
worldwide. In 1990, there were 5.2 million
deaths from CVD in developed countries and 2.3
million deaths in India which is predicted to be
increased by 111% by 20202.
Blood pressure regulation is maintained by

multiple regulatory physiologic mechanisms.
Autonomic system is one of the most
important regulatory mechanisms of blood
pressure(BP) 3,4. Autonomic cardiovascular
regulation
is
usually
investigated
by
measurement of blood pressure and heart rate
responses to laboratory stimuli which interfere
in different ways with the central and reflex
control of circulation 5.
458
Nirmala etal.,
The people who are at high risk for elevated

blood pressure might have an exaggerated
stress induced cardiovascular response at
younger age6. Sympathetic hyperactivity is the
major cause for the pathogenesis of
hypertension7 and Autonomic dysfunction is
important factor for the progression of
hypertension8.
Prehypertension is considered to be precursor of
stage I hypertension9, 10, 11. Though there is
strong correlation between hypertension and
sympathetic reactivity few were conducted on
prehypertension. So this study was undertaken to
assess
the
sympathovagal
balance
in
hypertensive and prehypertensive individuals.
AIMS AND OBJECTIVES
To assess the sympathovagal response in

prehypertensive individuals and in hypertensive
individuals.
To compare the sympathovagal response
between prehypertensive and hypertensive
subjects.
To find the autonomic imbalance in
prehypertensives and hypertensives thereby to
identify the prehypertensives who are prone to
become hypertensive and to identify the
hypertensives who are going to develop
complications at early stage.
MATERIALS & METHODS
This present cross sectional observation study
was done in Sri Venkateshwara Medical College
and Hospital, Pondicherry using purposive
sampling technique during the months of June to
August 2012.
After
obtaining
the
institutional ethical
committee clearance, subjects were screened for
BP from OPD and staff of our college and
hospital. Blood pressure is recorded by
standard sphygmomanometer in sitting posture
after 10 minutes rest and those found to be
prehypertensive and hypertensive are then
screened for 3 consecutive reading at an interval
of 3 weeks in the morning 1 hour after breakfast.
Phase 1st and 5th korotkoff sounds were used to

determine
systolic
and
diastolic
BP
12
respectively .
Subjects
have
been
selected
(N=20)
prehypertensive (120-139/80-89 mmHg ) as
group I and (N=20) stage I hypertensive (140159/90-99mmHg) as group II according to joint
National Committee (JNC7) classification13,14
with the age group of 25 to 55 years of both
sexes. Exclusion criteria: Alcoholics, smokers,
diabetes, BMI>30 and the subjects using drugs
are excluded from our study.
Autonomic function test like orthostatic test and
cold pressor test were carried out in our clinical
physiology research lab, in the morning 1hr
after breakfast at a pleasant temperature (230-250
C) using the instrument Physiopac-PP4,
Medicaid system Chandigarh.
The subjects are informed about the purpose
of the study in their own language and the
written consent was obtained. Before proceeding
with the test the anthropometric parameters
like height, weight of the subjects were
measured to calculate BMI, height was
measured by stadiometer to nearest to 0.1cm.
Subjects weight was measured by using
weighing scale.
Orthostatic test: The subject was asked to relax
in supine position for 10 minutes. The test was
conducted after 10 minutes. Then he was asked
to stand within 3 seconds. Blood pressure and
heart rate was recorded serially at 0.5th, 2nd, 5th
minute. 30:15 ratio was calculated from ECG.
This ratio is the measure of parasympathetic
function15, 16.
Cold pressor test: Before cold pressor test
baseline BP was recorded by tying the cuff on
the left arm. Then the subject was directed to
dip his/her right upper limb upto the wrist in ice
cold water at 10oC for 60 sec, if the subject was
not able to bear cold water the hand was taken
out, and BP was recorded in right arm,
immediately and 5 minutes after the
procedure. It assesses the sympathetic activity15,
16
.
459
Nirmala etal.,
Statistical analysis: All the values were

expressed as mean SD. Independent student `t
test was used to find the significance of the study
parameters between the groups. P < 0.05 was
considered as statistically significant. Statistical

software SPSS 17.0 version, was used for the
analysis.
RESULTS
Table.1: Anthropometric analysis of prehypertensive and hypertensive group.
Parameter
Age (years)
Height (cm)
Weight (kg)
BMI (Kg/m2)
Basal SBP (mmHg)
Basal DBP (mmHg)
Prehypertensive (N=20)
33.008.13
159.68.97
57.911.63
22.633.68
126.854.91
84.402.58
Hypertensive (N=20)
4111.29
161.258.09
69.8912.02
26.763.16
147.354.90
95.03.43
Table.2: Basal heart rate and HR variability (30:15 ratio) from supine to standing.
Parameter
SBP
Basal BP (mmHg)
DBP
0 min
Systolic BP (mmHg) 2 min
5 min
0 min
Diastolic
BP 2 min
(mmHg)
5 min
Prehyperstensive (N=20)
123.854.91
84.402.58
119.056.98
133.87.52
132.856.99
76.607.77
87.558.45
87.554.48
Hypertensive (N=20)
147.354.90
95.03.43
145.5519.47
157.5020.49
156.714.89
92.311.00
96.9513.50
95.956.66
There is no significant difference. p>0.05. In orthostatic test both heart rate and blood pressure showed
no significant difference.
Table.3: BP variation with the cold pressor test in prehypertensive and hypertensive
Parameter
SBP
DBP
0 min
Systolic BP (mmHg) 5 min
0 min
Diastolic BP (mmHg) 5 min
Basal BP (mmHg)
Prehyperstensive (N=20)
126.854.91
84.402.58
140.859.78
136.5510.70
90.056.63
88.205.22
Hypertensive (N=20)
147.354.90
95.03.43
154.3010.07*
162.0014.49
98.9511.00
100.805.24*
*p<0.005 (siginificant)
DISCUSSION
In this present study it was observed that basal

heart rate in hypertensives is higher than the
prehypertensives which may be due to
sympathetic hyperactivity. In our study also
30:15 ratio and basal heart rate showed no

significant difference between prehypertensives
and hypertensives. Wouter wieling et al. noted
that the influence of basal heart rate on the
460
Nirmala etal.,
magnitude of test score is small compared to

other tests17.
In orthostatic test an initial overshoot of systolic
and/or diastolic pressure followed by baseline
blood pressure is generally observed in healthy
adult subjects. Its absence has been suggested as
an indicator of sympathetic vasomotor
dysfunction18. In this study immediate rise of
blood pressure was seen but the raised blood
pressure was sustained even after five minutes in
both prehypertensive and hypertensive groups.
Though both the groups have not showed the
statistical significance the sustained response
may be due to sympathetic hyperactivity or by
sympathetic vasomotor dysfunction.
Prehypertensives have shown increased systolic
blood pressure more than 20 mmof Hg as an
immediate response to cold pressure test but it
was sustained even after the withdrawal of cold
stimuli. The rise of blood pressure is statistically
significant
which
indicates
sympathetic
hyperactivity.
Little or absence of rise in diastolic blood
pressure is supposed to indicate failure of
efferent sympathetic activity19.In this study
hypertensive group has shown very little rise of
diastolic blood pressure around 3 mm of Hg than
prehypertensives to cold pressor test. From our
result it can be concluded that prehypertensives
are having sympathetic hyperactivity and
hypertensive
individuals
are
having
sympathovagal dysfunction.
CONCLUSION
When compared to orthostatic test cold pressor

test can be used to predict the sympathetic
hyperactivity
in
prehypertension
and
sympathovagal dysfunction in hypertension to
prevent the further complication. In this study the
sample size is less and very few tests have been
done to assess the autonomic function. In future
further studies are needed to evaluate the relation
between elevated blood pressure and autonomic
dysfunction.
ACKNOWLEDGEMENT
Being an ICMR approved project we thank

ICMR for their support.
REFERENCES
1. Nalina
N, Venkatesh
D, Jaisri
G.
Autonomic reactivity in normotensive
children
of hypertensive parents.
Biomedicine. 2012;32:45-51.
2. Murray CJ, Lopez AD. Mortality by cause
for eight regions of the world. Global Burden
of disease study. Lancet 1997;349:1269-76
3. Kalpan
NM.
Systemic
hypertension:
mechanisms and diagnosis. Braunwalds
heart
disease
:
a
textbook
of
th
cardiovascular medicine.7 ed .Philadelphia:
Elsevier Saunders. 2005:959-87.
4. Cole RC, Lauer MS, Bigger JT. Clinical
assessement of the autonomic nervous
system.In: Topol EJ editor. Textbook of
cardiovascular medicine
.2nd
ed.
Philadelphia:
Lippincott
Williams &
Wilkins;2002.p.1615-32
5. Parati G, Rienzo Di M, Omboni S et al.
Computer analysis of blood pressure and
heart rate variability in subjects with normal
and abnormal autonomic cardiovascular
control ,chapter 22.211-223.
6. Matthews KA
,Woodall KL, Allen
MT.cardiovascular reactivity
to stress
predicts future blood pressure status.J
Hypertension.1993;22:479-485.
7. Oparil S, Zaman MA, Calhoun DA,
Pathogenesis of hypertension.Annals of
Internal Medicine.2003;139;761-776. 18.
8. Pagani
M,
Lucini
D.Autonomic
dysregulation in essential hypertension:
insight from heart rate and arterial pressure
variability. Auton Neurosci. 2001;90:76-82.
9. Chobanian AV, Bakrish
GL, Black HR,
Cushman WC, Green LA,Izzo Jr,et al.
Seventh report of the joint National
Committee
on
prevention, Detection,
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Evaluation, and Treatment of High Blood

Pressure. Hypertension. 2003;42:1206-52
10. Mancia G, De Backer G, Dominiczak
A,Cifkova R, Fagard R, Germano G, et al.
Guidelines for the management of arterial
hypertension:T he Task Force for the
management of Arterial Hypertension of
the European Society of hypertension(ESH)
and of the European Society of
cardiology(ESC). Eur Heart J. 2007;28:1462536.
11. Vasan RS, Lason MG, Leip EP, Kannel
WB, Levy D. Assessment of frequency of
progression to hypertension in nonhypertensive participants in Framingham
Heart Study: a cohort study. Lancet
2001;358:1682-6
12. Farah Khaliq, Keshav Gupta, Pawan Singh.
Autonomic reactivity to cold pressor test in
prehypertensive and hypertensive medical
students. Indian J Physiol Pharmacol
2011;55:246-252.
13. Kotchen
TA.
Hypertensive
vascular
disease. Harrisons principle of internal
medicine
2008. 17th ed. Mc Graw Hills; Chapter 241:
1549-62.
14. Seventh
report
A
joint
National
Committee on prevention & detection,
Evaluation
& treatment of high Blood
Pressure, J Hypertension. 2003; 42: 1206-52
15. Ryder REJ, Hardisty CA. battery of
cardiovascular autonomic function tests.
diabetologia 1990;33:177-179.
16. Ewing DJ,Martyn CN ,Young RJ, Clarke
BF. The value of cardiovascular autonomic
function tests:10 years experience in
diabetes care 1985;8:491-498.
17. Wouter wieling and John M.Karemaker,
Measurement oh heart rate and blood
pressure to evaluate disturbances in
neurocardiovascular control, capter 2000:21:
197-210.
18. Lindqvist A, Torffvit O. Rittner R, Agardh
CD, Pahlm O. Artery blood pressure
oscillation after active standing up; an

indicator of sympathetic function in diabetic
patients. Cli. Physiol. 1997;17: 159-69.
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DOI: 10.5958/j.2319-5886.2.3.080

&
Health Sciences
Received: 4th May 2013
Revised: 3rd Jun 2013
Accepted: 5th Jun 2013
Research article
A CROSS SECTIONAL STUDY OF SOCIO-DEMOGRAPHIC DETERMINANTS OF
ANAEMIA IN ADOLESECENT BOYS OF URBAN SLUM AREA IN SOUTH INDIA
*Pravin N Yerpude, Keerti S Jogdand
Associate Professor, Dept of Community Medicine, Gujarat Adani Institute of Medical Sciences, Bhuj,
Gujarat, India.
*Correspondence author email:drrajupravin007@yahoo.com
ABSTRACT
Background: Adolescence a period of transition between childhood and adulthood is a significant

period of human growth and maturation. The term adolescence has been defined by WHO as those
including between 10 to 19 years. During this period, more than 20% of the total growth in stature and
50% of adult bone mass are achieved and iron requirement increases dramatically in both adolescent
boys and girls. Available literature from India confirms that anaemia is common among adolescent girls
but there is a paucity of information on status of anaemia among adolescent boys and most of the studies
are based on school going population and are not from the community. Materials and methods: The
present cross-sectional study was conducted in 440 Adolescent boys aged 10 to 19 years residing in the
registered families in the urban slum area of Andhra Pradesh. Results: The prevalence of anemia in
adolescent boys aged 10 to 19 years were found to be 36.14%. The various sociodemographic
determinants which were found to be statistically significant in boys includes type of family , socioeconomic status, adolescents educational status, H/o of malaria infection, habit of taking meal.
Conclusion: Iron supplements have to be provided to the adolescent boys also as in our country, most
of the National programmes related to supplementary nutrition are focusing only on adolescent girls, but
none of the programmes include adolescent boys.
Key words: Adolescent boys, Anaemia, Urban slum
INTRODUCTION
Adolescence a period of transition between

childhood and adulthood is a significant period
of human growth and maturation. The term
adolescence has been defined by WHO as
those including between 10 to 19 years 1. The
health of adolescents attracted global attention in
adolescent boys. There are 1.2 billion
adolescents in the world, 85% of them live in
developing countries 2. The adolescent
population constitutes about 18 to 25% of the

total population of the South East Asia Region 3
.Adolescents represent
About a fifth of Indias population4, during this
period, more than 20% of the total growth in
stature and 50% of adult bone mass are achieved5
and iron requirement increases dramatically in
both adolescent boys and girls, from a
preadolescent level of 0.7-0.9 mg Fe/day to as
463
Pravin et al.,
much as 2.2 mg Fe/day. This increase in iron

requirement is the result of expansion of total
blood volume; increase in lean body mass and
the onset of menstruation in adolescent females6.
Iron needs are highest in males during peak
pubertal development because of a greater
increase in blood volume, muscle mass and
myoglobin7.
Globally, according to WHO, a total of 1.62
billion people are anaemic.8 Every 9 out of 10
persons affected by anaemia live in developing
world 9 .WHO also estimates the benefits of
anaemia correction and suggests that timely
treatment can restore personal health and raise
national productivity levels by as much as 20%10.
Available literature from India confirms that
anaemia is common among adolescent girls but
there is a paucity of information on status of
anaemia among adolescent boys and most of the
studies are based on school going population
and are not from the community. So the
community based study was planned to highlight
the problem of anaemia in adolescent males and
to study socio-demographic factors and other
determinants related to anaemia.
Total 440 boys in the age group of 10 to 19 years

were selected for the present cross-sectional
study. The sample size was calculated assuming

prevalence of anemia to be 50% with 95%
confidence interval and relative precision of
10%. So the minimum required sample size was
400 and adding 10% for incomplete responses to
it, the total sample size came out to be 440.
Adolescents aged 10 to 19 years residing in the
registered families in urban slums, ShrinavasRao
Thota, Guntur, Andhra Pradesh, a catchment area
of urban health and training centre, department
of Community Medicine, Katuri
Medical
College, Guntur were included for the study. The
period of study was from April 2011 to March
2012. From the 1560 registered families, 440
families were selected randomly by lottery
method and if there were more than one
adolescent in the selected family, one adolescent
was randomly selected from each family.
A pre designed semi structured schedule was
used to elicit the necessary information from
participants. For hemoglobin estimation, direct
cyanmethaemoglobin method was used using
Photochem-Micro digital calorimeter. Informed
written consent was obtained from each
participant after explaining about the study.
Statistical analysis was done by using the
statistical software, SPSS Version 10.0,
proportions were calculated and chi square test
was used as a test for significance.
RESULTS
Table.1: Distribution of anaemia in adolescent boys according to its severity
Severity (Hb g/dl)

No of adolescents
Prevalence (%)
Mild (>10 cut-off)
87(54.72)
19.77
Moderate (7-10)
54(33.96)
12.28
Severe (<7)
18(11.32)
04.09
Total
159(100)
36.14
The prevalence of anaemia in adolescent boys aged 10 to 19 years was found to be 36.14%, with 54.72
% of the boys had mild anaemia and 11.32% boys had severe anaemia.
Table.2: Distribution of prevalence of anaemia in adolescent boys according to age
Age group
10-13
14-16
17-19
Total
No of boys (%)
217(49.32)
159(36.14)
64(14.54)
440(100)
Anaemic cases (5)

87(40.09)
56(35.22)
16(25.00)
159
464
Pravin et al.,
Table. 3: Prevalence of anaemia in adolescent boys according to socio-demographic determinants
Socio-demographic determinats
Type of family
Nuclear
Joint
Socio-economic status
Upper(I)
Upper middle(II)
Lower middle(III)
Upper lower(IV)
Lower(V)
Educational status
Illiterate
Primary
Middle
High School
Intermediate
X2, df,
p-value
14.8
1
0.0001*
Boys (%)
Anaemic
boys
Prevalence
(%)
338(76.82)
102(23.18)
139
20
41.12
19.61
21(04.77)
147(33.41)
189(42.96)
66(15.00)
17(03.86)
03
48
71
30
07
14.29
32.65
37.57
45.45
41.18
7.96
4
0.09
11(02.50)
97(22.05)
189(42.95)
126(28.64)
17(03.86)
04
37
83
33
02
36.37
38.14
43.92
26.19
11.76
14.9
4
0.004*
*Significance
The various sociodemographic determinants
which were found to be statistically significant in
boys and includes type of family (prevalence of
anaemia was more (41.12%) in those belonging
to nuclear families in comparison to 19.61% in
joint families) and socio-economic status (the
prevalence of anaemia decreased with increase in

socio-economic
status)
and
adolescents
educational status (prevalence of anaemia was
maximum in those who were illiterate/just
literate and minimum in those who had
completed intermediate class).
Table 4: Prevalence of anaemia in adolescent boys according to other determinants

Determinants
Hand washing before eating
main meal
Every time with soap & water
Sometimes with soap & water
With water only
Never
History of malaria infection
Yes
No
Frequency of main meal(daily)
Once
Twice
Thrice
Daily consumption of
lemon/sour fruits
Yes
No
Boys (%)
Anaemic boys
Prevalence
(%)
X2 , df, p-value
187(42.50)
123(27.96)
91(20.68)
39(08.86)
54
49
38
18
28.87
30.82
41.76
46.15
7.94
3
0.04
38(08.64)
402(91.36)
21
138
55.26
34.33
5.72
1
0.01
27(06.14)
254(57.72)
159(36.14)
16
104
39
59.26
40.94
24.53
18.08
2
0.0001
78(17.73)
362(82.27)
13
146
16.67
40.33
14.56
1
0.0001
465
Pravin et al.,
The various other determinants which were

found to be statistically significant in adolescent
boys & includes practice of hand washing before
eating main meals (the prevalence of anaemia
was maximum(46.15%) in those who never
washed their hands before eating main meal and
minimum(28.87%) in those who always washed
their hands every time with soap and water
before eating main meal), history of malarial
infection (prevalence of anaemia was
more(55.26%) in those who had positive history
of malarial infection) and frequency of main
meals daily (prevalence of anaemia was more
(59.26%) in boys who were taking only one main
meal daily as compared to those boys taking
meals twice(40.94%),daily consumption of
lemon/sour fruits(prevalence of anaemia was
more in adolescent boys (40.33%) who were not
taking daily lemon/sour fruits as compared to
those who were taking daily lemon, sour
fruits(16.67%).
DISCUSSION
The present study yielded relatively low

prevalence (36.14%) of anaemia among
adolescent boys when compared to studies
conducted by Jain et al12 in Urban Meerut, Hyder
et al13 in Bangladesh and Hettiarchi et al14 in Sri
Lanka who found prevalence of anaemia to be
42.8%, 69%, and 49.5% respectively. Basu et
al15, however, reported the prevalence of
anaemia among school going adolescent boys of
Chandigarh to be 7.7%. These differences may
be due to difference in age groups studied,
different study settings and difference in cut-off
values for diagnosis of anaemia.
Prevalence of anemia in 10-13 yrs, 14-16 yrs and
17-19 yrs age group was found to be 40.09%,
35.22% and 25% respectively. Prevalence of
anemia was reported to be 27.8% in 12-14 yrs
and 41.3% in 15-18 yrs age group of adolescent
boys of schools of rural Delhi by Anand et al 16.
In the present study, the prevalence of anemia
varies significantly among adolescents when
associated with socioeconomic class. But high

prevalence of anemia was also reported in upper
and upper middle class (14.0% and 39.4%
respectively) among urban school children (5-15
years) of Punjab (Verma et al., 1998)17 However,
severe anemia was more common among lower
socioeconomic classes. Similar results have been
reported by a study done by population council
in Egypt (Population Council)18. A high
prevalence of anemia was found in upper
(27.3%)
and
upper
middle
(39.1%)
socioeconomic class. Thavraj and Reddy19 had
also noted iron deficiency among 20% of
healthy, non-anemic, high income group
children. In the study on anemia among Egyptian
adolescents it was found that the prevalence of
anemia was relatively high among adolescents
belonging to higher socioeconomic stratum
(43.4%) 20. They suggested that anemia in a
higher stratum of society may be related to their
choice in dietary habits.
Daily frequency of main meals influence
anaemia to a large extent as it was very high
(59.26%) among those boys who had their main
meals once daily when compared to 24.53% in
those who had their main meals thrice daily.
ICRW 21 and Jain et al 12 also documented that
anaemia to be significantly more in those who
eat two or fewer meals in a day.
CONCLUSION AND RECOMMENDATIONS
The present study highlights the high prevalence

of anaemia among adolescent boys in the urban
slum population of Andhra Pradesh, thus
indicating that the problem of anaemia was
related to a wider population than the traditional
groups of the adolescent, pregnant and lactating
females and children. We suggest that there is a
need for well planned, systematic and large-scale
studies by using standardized methodologies to
estimate the prevalence of anaemia as well as the
causes of anaemia at the community level among
males in all the age groups, with the
representation of the different regions of India. It
466
Pravin et al.,
is seen that anemia affects the overall nutritional

status of adolescent males .So iron supplements
have to be provided to the adolescent boys also
as in our country, most of the National
programmes related to supplementary nutrition
are focusing only on adolescent girls, but none of
the programmes include adolescent boys.
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ACKNOWLEDGEMENTS
We would like to thank the study participants for

their co-operation.
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DOI: 10.5958/j.2319-5886.2.3.081

&
Health Sciences
th
Coden: IJMRHS
Copyright @2013
th
Revised: 5 Jun 2013
ISSN: 2319-5886
Research article
BACTERIOLOGICAL PROFILE OF WOUND INFECTION IN RURAL HOSPITAL IN R.R

DISTRICT
Neelima, Praveen Kumar D, Suresh P, Nandeeshwar4
1,2
Asst. Prof, 4Professor, Department of Microbiology, Medi Citi Institute of Medical Sciences (MIMS)
Ghanpur, Medchal Mandal, Ranga Reddy Dist, Andhra Pradesh, India.
Tutor, Department of Microbiology, Ashwini Rural Medical College Hospital & Research Centre,
Kumbhari, Solapur, Maharashtra, India.
*Corresponding author email: neelimasudharshan@yahoo.com
ABSTRACT
Background: Wound infection is a major problem in hospitals in developing countries. Wound

infection causes morbidity and prolonged hospital stay thus the study was undertaken to know the
bacteriological profile of wound infection and antibiogram of organisms isolated. Methods: pus from
various sites of wound area was collected using sterile swab under aseptic precautions and further
processed by Grams stain and culture. Culture was done on Blood agar, Mac Conkeys agar, incubated at
37c for 24hrs.Isolates confirmed by biochemical tests, antibiotic susceptibility testing was done using
muller Hinton agar by Kirby Bauers method as per standard CLSI guidelines. Results: out of 396 pus
samples, 236 were culture positive. Most common organisms isolated was staphylococcus aureus 81
(34.3%) followed by Staph.epidermidis. Other isolates included were Enterococci, E.coli, Klebsiella,
Pseudomonas, and Proteus spp. Conclusion: Present study showed bacteria causing wound infection.
High rates of bacterial growth were seen in samples collected from surgery wards followed by
orthopedics. S.aureus (34.3%) was the predominant isolated followed by CoNS (15.8%), E.coli (10.5%)
MRSA incidence in our study was 10% and ESBLs detected in 20% of E.coli strains and 6.6%
Klebsiella strains.
Keywords: Wound infection, Pus, Staphylococcus aureus, MRSA, ESBL.
INTRODUCTION
The development of wound infection depends on

the integrity and prospective function of skin. 1
The potential for infection depends on a number
of patient variables such as the state of hydration
nutrition and existing medical conditions as well
as extrinsic factors such as pre, intra and
postoperative care if the patient has undergone
surgery. Thus it is difficult to predict which

wound will become infected.2 The overall
incidence of wound sepsis in India is from 1033%. Relative resistance to antibiotics relatively
more virulent strains and capacity to adapt
quickly to changing environment make the
469
Neelima et al.,
pathogens acquired in hospitals a matter of

concern.3
Wound infection is one of the most common
hospital acquired infections and important cause
of morbidity and accounts for 70-80% .4 The
importance of wound infections in both
economic and human terms, should not be
underestimated.5 In a study on an average,
patients with wound infections stays about 610days more in hospital than if the wound had
heel without infections.6 This additional stay
doubles the hospital cost. Wound infections can
be caused by different groups of microorganisms,
most commonly isolated aerobic microorganisms
includes S.aureus,CoNS, Enterococci, E.coli,
P.aeurginosa,
Klebsiella
pneumoniae,
Enterobacter, Pr.mirabilis, other streptococci,
Candida, Acinetobacter.7
The study was done over a period of time of

1year from November 2011 to December 2012.A
total of randomly selected 396 samples received
by a bacteriology section of the microbiology
department from various departments of MIMS
Medchal AP, rural hospital were processed. Pus
samples were collected with sterile disposable
cotton swabs and immediately inoculated onto
Blood agar & Mac Conkeys agar media and
incubated at 370c for 24hrs. After incubation,
identification of bacteria from positive cultures
was done with a standard a microbiological
technique which includes Grams stain,
biochemical reactions.8
The antibiotic sensitivity testing of all isolates
was performed by modified Kirby Bauers disc
diffusion method on Muller hinton agar using

antibiotics of Hi media as per the CLSI (Clinical
Laboratory Standard Institute) guidelines.
MRSA was detected using cefoxitin disk (30g)
according to CLSI guidelines. ESBL (Extended
Spectrum Betalactamases) was detected using
ceftazidime (30g) as an indicator drug by disc
diffusion as per CLSI guidelines as a screening
method and confirmation was done by a
phenotypic disc confirmatory test using
Ceftazidime (30g) and Ceftazidime/clavulanic
acid combination disk (20g/10g). Klebsiella
ESBL ATCC (American Type Culture
Collection) (700603) as a positive control and
E.coli non ESBL strain ATCC 25922 as a
negative control was used.
RESULTS
A total of 396 samples received by the laboratory

of which, 297 were from different wards and 99
from OPD, were randomly selected for the study.
Out of 396 samples 236 showed aerobic growth
& 160 remained sterile even after 48hrs
incubation. The highest rate of bacterial growth
was seen in samples collected from the surgical
wards followed by orthopedics. (Table 1).
Majority of the wound was infected with single
organism. Gram positive cocci 64% and Gram
negative bacilli 36%. Most frequently isolated
organism was S.aureus 81(34.3%) followed by
Staph.epidermidis, other isolates included
Enterococci, E.coli, Klebsiella, Pseudomonas,
and Proteus spp. (Table 2) 8 were MRSA out of
81 S.aureus strains. ESBLs were reported 5
E.coli and 1 Klebsiella strains.
Table 1: Ward wise distribution of samples
SURGICAL
WARD NO
%
GSW
117
39.3%
GOW
48
15.4%
GENT 3
1%
MEDICAL
WARD
NO
GMW
10
GDMW
14
MICU
12
TB CHEST
1
PSYCHATRY 1
%
3.3%
4.7%
4%
0.3%
0.3%
OTHERS
WARD
NO
SPL W
14
NICU
1
PICU
2
CTICU
3
LR & GY 36
%
4.7
0.3
0.6
1
12.1
470
Neelima et al.,
Table.2 : Bacteriological profile of pus
ISOLATES
S.aureus
CoNS
Enterococci
E.coli
Klebsiella spp
P.aureginosa
Proteus
Citrobacter
Prt spp
Acinetobacter
Total
Total No.
81
44
25
25
15
8
19
9
9
1
236
percentage
34
18.6
10.5
10.5
6.3
3.3
8.5
3.8
3.8
0.4
100
Table 3: Antibiogram of wound infection

S.aureus
penicillin
1
gentamicin
28
cotimoxazole Cefuroxime
4
Erythromycin 37
Vancomycin
29
Cefoxitin
8
Ampicillin
Amikacin
66
Cefotaxime
33
Piercillin41
tazobactum
Ciproflox/levo 15
CoNS E.coli
4
13
6
4
2
26
14
2
40
12
12
8
19
15
klebsiella pseudomonas acinetobacter proteus enterococci

1
8
11
5
14
8
4
2
2
12
13
1
2
2
15
16
6
21
7
13
5
4
20
19
8
7
11
11
12
36
12
2
8
-
2
3
3
8
3
3
4
-
7
5
2
2
flox/lomeflox
Amoxy-clav
Caz
ImipenemCephlexin
43
16
4
DISCUSSION
As a wound infection is becoming the major
hospital acquired infection, hospital environment
plays a major role in causing wound infection. In
our study, 58% of pus samples showed bacterial
growth with 9 different bacterial species and the
most common isolate was S.aureus (34.3%)
followed by CoNS (28.6%) and E.coli (10.5%).
It correlated with the study conducted by Tapan

at Navoday Medical college, Raichur who also
reported S.aureus (27.5%) as the most common
isolate followed by CoNS (8.5%) 9 In a similar
study conducted at Kathmandu model hospital,
50% of Pus samples showed bacterial growth
with 15 different species and the most common
471
Neelima et al.,
isolate was S.aureus (41.31%) followed by E.coli

(20.89%) CoNS (15.44%) 10 similar study was
conducted in TUTH showed 82.5% bacterial
growth and 13 different bacterial species of
which S.aureus was predominant (57.7%)
followed by E.coli (11%) and CoNS (3%) .11
Similar studies conducted at Dhiraj general
hospital, Sri Ramchandra medical college and at
Namakkal showed S.aureus as predominant
isolate 3,12,13
In our study, most of the Enterobacteriaceae
members and Pseudomonas were susceptible to
Amikicin, 3rd generation Cephalosporins and
Pipercillin with Tazobactam in case of gram
positive bacteria the highly effective antibiotics
were Oxacillin, Erythromycin, Vancomycin,
amoxy-clav least effective antibiotics were
Penicillin & Cephalexin.
The incidence of methicillin-resistant S.aureus in
our study was 8 (10%). This finding is in
agreement with the reported incidence of 10%
MRSA in a study which was conducted by
Agarwal and Khanna14. A similar study
conducted by Gaythree Naik at kasturba medical
college, Mangalore showed an incidence of
9.6%15, In our study ESBL were reported in 5
strains of E.coli (20%) & 1 strain of Klebsiella
(6.6%)
CONCLUSION
This study revealed the presence of wound
infection causing bacteria. High rates of bacterial
growth were seen in samples collected from
surgery wards followed by orthopedics. S.aureus
(34.3%) was the predominant isolated followed
by CoNS (15.8%), E.coli (10.5%). MRSA
incidence in our study was 10% and ESBLs
detected in 20% strains and 6.6% Klebsiella
strains. Due to increased morbidity and mortality
which are associated with these drug resistant
organisms an early detection and intervention is a
prerequisite in surgical patients. The government
should take proactive steps in setting up hospital
antibiotic policy guidelines in instituting hand
washing among health care personnels. Hospitals
should screen MRSA among their staff and treat

those who are affected.
REFERENCES
1. Calvin M. Cutaneous wound repair.Wounds.

1998;10:12-14
2. Karia JB, Gadekar HB, Lakhani SJ. Study of
bacterial profile of pus culture in Dhiraj
general
Hospital.
www.themedicalacademy.in
3. Plummer D. Surgical Wound infections as a
performance indicator:
agreement
of
common definitions of wound infections in
4773 patients. BMJ. 2004;329:720-22
4. Collier M. Recognition and management of
wound infections Wounds. available from
URL:http://www.worldwide wounds.com.
5. Plowman R. The Socio economic burden of
hospital acquired infection. Euro saweill.
2005;5(4):49-50.
6. Henzelmann M, Scott M, Lam T. Factors
predisposing to bacterial invasion and
infection. AmJ Surg 2002;183(2):179-90
7. Tayfour MA , Al-Ghamdi SM and Al-ahamdi
AS. Surgical wound infections in King Fahed
Hospital
at
Al-baha
Saudi
Med.J.
2005;26(8):1305-07
8. Mackie and
Mc Cartney. Tests for
identification of bacteria .14th edition:131149.
9. Tapan Kr Mandal, Rajeshwari Surpur, Achut
Rao.
Dept. Of Microbiology, Navoday
Medical College, Raichur:36th National
conference souvenir pg 108.
10. Shrestha B, Basnet RB. Wound infection and
antibiotics sensitivity pattern of of bacterial
isolation PMJN. 2009;9(1).1-5
11. Kensekar P, Pokharel BM, Tuladhar NR. A
study on bacteriology of wound infection and
antibiotic sensitivity pattern of isolates.
Fourth congress of association of clinical
pathologists of Nepal(ACPN) feburary 21-22
souvenir 2003;pg 35
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12. Anbumani N, Klyen J, Mallika M.

Epidemology and microbiology of wound
infections.Indian Journal for the Practicing
doctor. 2006:3(5);1-5
13. Valermathi S, Rajashekar Pandian M, Senthil
Kumar B. Incidence and screening of wound
infection causing microorganisms. J.Aced
Indan res. 2013;1(8): 508-510
14. Aggarwal A, Khanna S, Arora U, Devi P.
Correlation
of
beta-lactamase
production/methicilline resistance and phage
pattern of S.aureus: Ind.J Med sciences.
2001;55:253-56
15. Gayathree Naik, Srinivas R Deshpande. A
study on surgical site infections caused by
S.aureus with a special search for methicillinresistant isolates.journal of clinical &
diagnostic research 2011;5(3):502-08.
473
Neelima et al.,
DOI: 10.5958/j.2319-5886.2.3.082

&
Health Sciences
www.ijmrhs.com
th

Research article
Coden: IJMRHS
th
Revised: 5 Jun 2013
Copyright @2013
ISSN: 2319-5886
ANTI INFLAMMATORY ACTIVITY OF ETHANOLIC EXTRACT OF NYMPHAEA ALBA

FLOWER IN SWISS ALBINO MICE
*Jacob Jesurun RS1, Senthilkumaran Jagadeesh2, Somasundaram Ganesan3, Venugopala Rao K4,
Madhavi Eerike4
1
Department of Pharmacology, Shri Sathya Sai Medical College and Research Institute, Chennai,
Tamilnadu, India
2
Department of Pharmacology, Sree Balaji Medical College and Hospital, Chennai, Tamilnadu
3
Department of Pharmacology, Mahatma Gandhi Medical College and Research Institute, Pondicherry.
4
Department of Pharmacology, Chettinad Hospital and Research Institute, Chennai, Tamilnadu
*Corresponding author email: drrsjj@gmail.com
ABSTRACT
Inflammation plays an important role in various diseases with high prevalence within populations such
as rheumatoid arthritis, atherosclerosis and asthma. The aim of the present context to investigate the anti
inflammatory activity of extract of Nymphaea Alba flower (NAF) in Swiss Albino mice. The anti
inflammatory activity was test using acute inflammatory models like acetic acid-induced vascular
permeability chronic models like; cotton-pellet induced granuloma. Oral administration of ethanolic
extract of Nymphaea Alba flower at the doses of 100mg/kg and 200mg/kg of body weight in
mice.Diclofenac sodium used as standard drug Exhibited dose dependent and significant antiinflammatory activity in acute (acetic acid-induced vascular permeability, p< 0.001) and chronic (cotton
pellet granuloma < 0.001). But at the dose of 200mg/kg of extract shown high significant than
100mg/kg. Hence, the present investigation established ethanolic extract of Nymphaea Alba flower has
anti-inflammatory activity.
Keywords: Nymphaea Alba Flower, Ethanolic extract, Anti-inflammatory, Diclofenac sodium.
INTRODUCTION
Inflammation is the response to injury of cells

and body tissues through different factors such as
infections, chemicals, and thermal and
mechanical injuries1. Most of the antiinflammatory drugs now available are potential
inhibitors of cyclooxygenase (COX) pathway of
arachidonic acid metabolism which produces
prostaglandins. Prostaglandins are hyperalgesic,

potent vasodilators and also contribute to
erythema, edema, and pain. Hence, for treating
inflammatory diseases, analgesic and antiinflammatory agents are required 2. Nonsteroidal
anti-inflammatory drugs (NSAIDs) are the most
clinically important medicine used for the
474
Jacob et al.,
treatment of inflammation-related diseases like

arthritis, asthma, and cardiovascular disease 3.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
are among the most widely used medications due
to their efficacy for a wide range of pain and
inflammatory conditions 4.
However, the long-term administration of
NSAID may induce gastro-intestinal ulcers,
bleeding, and renal disorders due to their
nonselective inhibition of both constitutive
(COX-1) and inducible (COX-2) isoforms of the
cyclooxygenases enzymes 5-7. Therefore, new
anti-inflammatory and analgesic drugs lacking
those effects are being searched all over the
world as alternatives to NSAIDs and opiates 8, 9.
Medicinal plants are believed to be an important
source of new chemical substances with potential
therapeutic effects. The research into plants with
alleged folkloric use as pain relievers, antiinflammatory agents, should therefore be viewed
as a fruitful and logical research strategy in the
search for new analgesic and anti-inflammatory
drugs.
The practice of herbal medicine dates back to the
very earliest period of known human history.
There is evidence of herbs having been used in
the treatment of diseases and for revitalizing
body system in almost all ancient civilization.
Ayurveda, the Science of Life, has provided a
rationale basis for treatment of various ailments.
Pain, inflammation and fever are very common
complications in human beings.
Nymphaea alba, also known as the European
White Waterlily, White Lotus, or Nenuphar, is an
aquatic flowering plant of the family
Nymphaeaceae. It grows in water from 30-150
centimeters deep and likes large ponds and lakes.
The leaves may be up to thirty centimeters in
diameter and they take up a spread of 150
centimeters per plant. The flowers are white and
they have many small stamens inside. The root of
the plant was used by monks and nuns for
hundreds of years as an anaphrodisiac, being
crushed and mixed with wine. It is rich in tannic
acid, gallic acid, alkaloids, sterols, flavonoids,
glycosides, hydrolyzable tannins and highmolecular-weight polyphenolic compounds 10

MATERIALS & METHODS
Experimental Animals: Swiss albino mice (20

to 25 g) were obtained from King Institute,
Chennai, India. The animals were housed in
standard environmental conditions (12 h light/12
h dark; 222C) for one week prior to the
experiments to acclimatize to the laboratory
conditions. They were allowed free access to tap
water and pellet rodent diet. The animal care and
experimental protocols were in accordance to the
Guidelines of the Committee for the Purpose of
Control and Supervision of Experiments on
Animals (CPCSEA), India. Ethical approval was
obtained from Institutional Animal Ethics
Committee Chettinad hospital and research
institute, chennai.
Preparation of plant extract: Nymphaea alba
flower (NAF) powder purchased from Mother
Herbs (P) Ltd Delhi. A fine dried powder (25
mesh) of sample (Nymphaea alba flower) was
extracted using 50 ml of 70% ethanol at 75 C for
2.5 h by reflx. The extracts were filtered through
Whatman No.4 filter paper under reduced
pressure, frozen and then lyophilized (Ly-8FMULE, Snijders). All the samples were
redissolved in 70% ethanol at a concentration of
5.0 mg/ml .
Acute Toxicity Studies : The acute oral toxicity
study was carried out as per the guidelines set by
Organization for Economic Co-operation and
Development (OECD) received from Committee
for the Purpose of Control and Supervision of
Experiments on Animals (CPCSEA). One-tenth
of the median lethal dose (LD50) was taken as an
effective dose. 11
Acetic acid-induced vascular permeability:
The Animals were divided in four groups each
group having six animals. Group 1: Control
(Distilled Water vehicle 1% (w/v) 10ml/1kg, (p
o), Group 2: Treated with NAF 100 mg/ kg (p
o), Group 3: Treated with extract of 200mg/ kg
(p o), Group 4 : Standard drug diclofenac (10
475
Jacob et al.,
mg/kg) received by intra peritoneal. After 1h of

administration of extract and diclofenac sodium,
mice were injected with 0.25 ml of 0.6 % (v/v)
solution of acetic acid intraperitoneally (ip).
Immediately, 10 ml/kg of 10 % (w/v) Evans blue
was injected intravenously via tail vain. After 30
min of Evans blue injection, the animals were
anaesthetized with ether anesthesia and
sacrificed. The abdomen was cut open and
exposed viscera. The animals were held by a flap
of abdominal wall over a Petri dish. The
peritoneal fluid (exudates) collected, filtered and
made up the volume to 10 ml using normal saline
solution and centrifuged at 3000 rpm for 15 min.
The absorbance (A) of the supernatant was
measured at 590 nm using spectrophotometer 12.
Cotton pellet-induced granuloma: The mice
were divided into four groups, each group
consisting of six animals. After shaving of the
fur, the animals were anaesthetized (80 mg/kg
ketamine i.p) and an incision was made on the
lumbar region by blunted forceps, a
subcutaneous tunnel was made and a sterilized
cotton pellet (100 1 mg) was inserted in the
groin area. All the animals received diclofenac
sodium (10 mg/kg i.p) as standard, vehicle (distil
water), and extract 100 and 200 mg of extract

orally depending upon their respective grouping
for seven consecutive days from the day of
cotton pellet insertion10. On the 8th day, animals
were anesthetized the cotton pellets were
removed surgically and made free from
extraneous tissues. The pellets were incubated at
37 C for 24 h and dried at 60 C to constant
weight. The difference between the initial weight
and the final weight of the cotton pellet gives the
amount of granulation tissue formed. The
percentage inhibition of granulation tissue
formation was measured by the following
method,
% Inhibition = (X - Y)/X *100,
Where X = mean increase in cotton pellet weight
of rats in the control group = mean increase in
cotton pellet weight of mice in the drug treated
group13.
Statistical analysis: The mean SEM values
were calculated for each group. Significant
difference between groups was determined using
analysis of variance (ANOVA) followed by
Dunnetts t test. P<0.05 was considered as
significant.
RESULTS
Table. 1: Acetic acid-induced vascular permeability
Group Treatment
Dose
OD at 590 nm
Inhibition (%)
I
Control (Distilled water)
10 ml/kg
0.16550.00205
II
NAF
100 (mg/kg)
0.132750.0023*
20.35
III
NAF
200 (mg/kg)
0.110750.0016*
33.54
IV
Diclofenac Sodium
10 (mg/kg)
0.094250.0014*
43.13
*p<0.05 as compared to vehicle treated group, NAF Nymphaea alba flower powder
Table. 2: Cotton pellet-induced granuloma
Group Treatment
Dose
Granuloma dry wt Inhibition (%)
I
Control(Distilled water)
10 (ml/kg)
67.66750.6013
II
NAF
100 (mg/kg)
60.82750.613*
10.1
III
NAF
200 (mg/kg)
39.30750.541*
41.5
IV
Diclofenac Sodium
10 (mg/kg)
28.4550.6213*
57.3
*p<0.05 as compared to vehicle treated group. NAF Nymphaea alba flower powder
476
Jacob et al.,
DISCUSSION
Acetic acid-induced vascular permeability:

Effect of ethanolic extract of Nymphaea Alba
flower (100 and 200 mg/kg), Diclofenac.sod.
(10 mg/kg) and control vehicle on acetic acidinduced increased vascular permeability in rat
was studied. Results of the activity showed that
extract at dose (100 and 200 mg/kg) significantly
inhibited (Table no.1) the vascular permeability
(20.35%, 33.54 and 43.13% respectively) when
compared with vehicle control group (Table-1)
Acetic acid induced vascular permeability
indicates acute phase of inflammation where
there is increased vascular permeability and
migration of leukocytes in to the inflamed area
occurs14. Decreased concentration of dye with
respected to absorbance indicates reduction in
permeability
Cotton pellet-induced granuloma : In cotton
pellet induced granuloma formation study,
regarded as an animal model for sub acute
inflammation, there was a statistically significant
(p<0.05) reduction in granuloma formation at all
dosesin comparison to the control group. (Table
no 2)The extract exhibited 10.1% and 41.5 %
inhibition of granuloma formation at the doses
100 and 200mg/kg b.w respectively, whereas
diclofenac sodium showed 57.30% when
compared to control. The cotton pellet-induced
granuloma is widely used to assess the
transudative and proliferative components of
chronic inflammation15. The weight of the wet
cotton pellets correlates with transude material
and the weight of dry pellet correlates with the
amount of granulomatous tissue. It is well known
fact that diclofenac sodium act by inhibiting the
prostaglandins synthesis at the late phases of
inflammation. This effect may be due to the
cellular migration to injured sites and
accumulation of collagen, an important
mucopolysaccharide16. Decreasing granuloma
tissue, prevention of occurring of the collagen
fiber and suppression of mucopolysaccharids are
indicators of the ant proliferative effect by

NSAIDs.
Nymphaea Alba all the parts of the plant have
medicinal uses in traditional system of medicine.
It is used as an aphrodisiac, anodyne,
antiscrophulatic,
astringent,
cardiotonic,
demulcent, sedative and antiinflammatory.
Further, it also produces calming and sedative
effects upon the nervous system, and is useful in
the treatment of insomnia, anxiety and similar
disorders 17-20.
CONCLUSION
The present study reveals that ethanolic extract

of Nymphaea Alba flower has anti-inflammatory
activity in acetic acid-induced vascular
permeability and cotton pellet granuloma model.
In both model they exhibited anti-inflammatory
effect in a dose Dependent manner which can be
comparable with that of Diclofenac.sod
ACKNOWLEDGEMENT
Authors are very much thankful to Sree Balaji

Medical College and Hospital Chennai and
Mahatma Gandhi Medical College and Research
Institute, Pondicherry for providing the facilities
necessary to carry out the research work and
Mother Herbs (P) Ltd Delhi for providing herbal
powders.
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478
DOI: 10.5958/j.2319-5886.2.3.083

&
Health Sciences
Revised: 5th Jun 2013
Research article
BILATERAL OBJECT EXPLORATION TRAINING TO IMPROVE THE HAND FUNCTION

IN STROKE SUBJECTS
*Janakiraman Balamurugan1, Paulraj Anantha raja1, Mahil.A2, Venkatraj R2
1*
School of Medicine, Dept of Physiotherapy, University of Gondar, Ethiopia

Madha College of Physiotherapy, Chennai,Tamilnadu, India
1, 2
*Corresponding author email: bala77physio@gmail.com

ABSTRACT
Recovery of upper extremity sensory and motor function is still one of the complicated and an under
achieved task in rehabilitation of the stroke subjects. We believed that object exploration training could
play a role in improving the sensory function that helps to improve the motor and overall functions of
the hand in stroke subjects. This study attempts to establish the efficacy of Bilateral Object Exploration
Training on improving the hand function in stroke subjects. The study design is an experimental study
design. Outcome measures are Wolf motor function test score, Moberg pick up test score, 3-D common
object identification test score. A total of 60 stroke subjects were selected using random sampling and
were allocated into three groups with 20 in each group (Experimental Group-Bilateral object exploration
training, Control Group 1-Unilateral object exploration training, Control Group 2 -Conventional Stroke
therapy), the mean age(S.D) of the subjects was 54.4(10.3) . The groups were respectively treated for
six weeks with bilateral object exploration training, unilateral object exploration training, and
Conventional Stroke therapy, each subjects were trained for 60 min for 4 days in a week for a total of 24
training sessions after which the post measure were recorded. The mean value of bilateral object
exploration training group (between pre and post test scores of WMFT 58.25, 53.25 (in seconds),
Moberg pick up test scores58.70, 55.95 (in seconds), 3-D Common object identification test scores
59.25, 56.30 (in seconds)) shows significant difference in improvement than unilateral object
exploration training group and conventional stroke therapy group. Paired t test and ANOVA was used
to analyze the research data, the results showed that the values of bilateral object exploration training
group shows significant difference than control group 1 and control group 2, ANOVAs shows
significance level (p<0.001).Bilateral object exploration training proves to provide tactile experience,
improve explorative skills and there by enhance performance of motor task.
Key words: Object exploration training, Stroke, Hand function, 3D common object identification test,
Stereo gnosis.
479
Balamurugan etal.,
INTRODUCTION
Stroke is one among the leading causes of disability and death globally. According to World Health
Organization (WHO) about 15 million people suffer stroke worldwide each year. Of these, 5 million die
and more than 5 million are permanently disabled. The increase in incidence rate and decline in
mortality rate imposed by modern medicines has eventually resulted in an increased number of stroke
survivors with residual neurological deficits and persistently impaired function , especially the recovery
of upper extremity sensori motor functions as for a long time been a challenging task in stroke
rehabilitation. Recent statistical evidences suggest only about 15 % of those suffering from stroke
recover more than 50 % of hand functions and a proportion of less than 3% of adult stroke subject
regain more than 70 % of their hand functions.
The process of Object exploration involves a combination of somatosensory perception of patterns on
the skin surface and proprioception of hand position and conformation.1 People can rapidly and
accurately identify three-dimensional objects by touch.2, 3 They do so through the use of exploratory
procedures, such as moving the fingers over the outer surface of the object or holding the entire object in
the hand.4 Sensory input is essential for fine manual dexterity and a lack of sensory input causes delayed
learning of new motor tasks, clumsiness, lack of precision, and can result in an unused extremity 5, 6.
Although visual information can guide the hand in space and prepare it to grasp, tactile input regulates
the force of the grasp provides the control to avoid slippage of objects, and guides the manipulation of
an object within the hand disturbed sensibility can influence the manual performance and assessing
tactile sensibility can provide an understanding of one attribute that might lead to difficulties in task
performance and give guidance for treatment 7.
Varying sensory input patterns created as people move their hands over an object during perceptual
exploration and manipulation tell us about its properties-for example its smooth, hard, cold, shape and
weighs with the help of information processing perceptual system that uses inputs from receptors
embedded in skin, tendon muscles and joints which forms the bases of object recognition judgments. For
a long time hand rehabilitation of stroke subjects has only offered less consideration to object
exploration training, hence this study attempts to identify the role of unaffected hand in facilitating
learning in affected one using alternative designed treatment protocol which consist of a set of objects
with highlighted features like textures, shape, size and weighs to improve hand function in adult stroke
subjects, which would definitely rejuvenate the spastic hand rehabilitation programs in future. So, tactile
object recognition can be viewed as complex information processing that evolves from modalityspecific perception of different classes of object features into recognition of object explored.
Participants: Sixty adults aged from 40 to 65 years (both sex) with middle cerebral artery involved
stroke and without any major musculoskeletal injury volunteered to participate and after obtaining
informed consent the subjects were recruited from various neurological centers around Chennai, India.
All subjects were in chronic stage, having suffered stroke 10 to 39 months prior to the experiment.
Exclusion criterion were bilateral impairment, severe deformities of hand, aphasia, cognitive impairs,
other severe medical problems. After obtaining consent form according to our institutional ethical
committee guidelines, the subjects were randomly assigned to one of the three groups: experimental
group (n=20) that received bilateral object exploration training or control group 1 that received
unilateral (affected hand) object exploration training or control group 2 that received conventional stroke
therapy. Proposal of study was presented to Institutional ethical review committee of Madha Medical
College & Hospital, Chennai and approval obtained.
479
Balamurugan etal.,
Materials: The training tool consists of objects of different perceptual dimension with a highlighted
property: textures, shape, size and weighs, cock up splint. The mobergs pick up test consist of a square
plastic box, with dimension 5x5x1cm. The object set includes 12 small common objects that fit within
the box, including screw, nail, and paper clip. Safety pin, coin (diameter 1.0 cm), small button (diameter
0.7cm), nut shaft diameter 0.8 cm), padlock key, washer, spike, large button (diameter 2.0cm) and a coin
with central circular hole (diameter 2.0 cm, hole diameter 0.5cm).3-D common object identification task
consist of a set of 30 objects with high diagnostic property on the basis of Ledermen and Klatzky study.
The diagnostic properties include size, form, temperature, texture, weight and hardness.
Training: The training consist of 60 min per day of object exploration training for 4 days a week for 6
weeks- 24 training sessions for the experimental (bilateral hand) and control group 1(affected hand
alone). Subjects were seated in a chair and the vision of the objects placed in a table in front of them was
blocked during exploration and visual guidance, verbal cues, and explorative guidance were provided
when needed. As to size, the objects were deliberately chosen to allow convenient tactile exploration.
The subjects with improper hand presentation were given cock up splints 8 to the affected side during
training sessions to improve contact area of the hand. In later stages the subjects were informed to touch,
hold and identify the objects without the help of examiner Klatzky exploratory procedures (skills) like
lateral motion, pressure, static contact, unsupported holding, enclosure and slow contour tracking were
taught, demonstrated and trained to improve exploration compatibility and subsequently the patients
were required to explain about texture, shape, hardness, weigh of the objects to the examiner during the
course of the exploration task9. Importantly at most care was taken to place objects with different
hardness, shapes, weigh and sizes in same similarity pile and objects that were not correctly identified
tactually were presented again to the subjects. Several exploration trials were given to improve
identification and to reduce response time. For control group 1 the subjects were informed to use only
the affected hand to touch and hold the object for identification with the guidance of examiner in the
form of visual exploration, verbal cues, and explorative guidance when needed. For subjects of control
group 2 Conventional exercises approaches like (ROM exercises, functional training), activities to
retrain upper extremity postural support, weight bearing activities involving upper limb and lower limb,
peg board task, stretch, Neuro-developmental treatment, rolling, supine -to sit and sit- to supine, sitting
bridging, sit- to- stand and sit- down- transfers, standing ,modified plantigrade, standing, transfers,
bilateral arm training with auditory cueing, constraint induced movement therapy.
Testing: The pretest and posttest consist of Wolf motor function test 10, which was selected for its high
reliability in measuring functional ability in a variety of functional activities and also appears to be more
sensitive than other upper extremity tools5 this scale appears to test the speed of performance (timed
items) through the ability to lift a weight assesses functional strength and quality of motor functions.
The Moberg pick up test 11 was used to evaluate fine dexterity functions of hand, it was performed using
single hand and the order in which the object were presented with in each block was also randomized
and the response time (secs) was the dependent variable. As each object was lifted up, the subject was
required to name it.
In 3-D 30 common object identification tests12, 13, 14 were done with the subjects sitting in front of a
table, a board eliminating visual input of object identity and 15 secs of exploration time with 5 secs of
pause then the subjects were requested to answer questions about the object placed in their hand after
due exploration. The objects were presented in random orders, response time (secs) were measured and
a binary response (Yes or No) was noted. Throughout the experiment the rights of the subjects were
protected.
List of objects used in 3-D 30 common object identification tests: Flask, Spoon, Towel, Paper clip,
Tooth paste tube, Coffee bottle, News paper, Wrist watch, book, Sharpener, Spaghetti, Plush towel,
480
Balamurugan etal.,
Wood pegs, Paper table cloth, Hard cover book, Dry doughs, Pencil Eraser, Match box, Shirt Button,
Hotel soap, Can, Sun flower seed, Dessert fork, Fine sand paper, Metallic clip, Metallic pencil, House
key, Metallic glasses, Wooden table, Board with hole.
Fig.1: Training materials
Fig.2: Object exploration training

DATA ANALYSIS AND RESULTS
The investigation of datas from dependent variables WMFT, Moberg pick up test and 3-D Common
object identification test of 60 sampled subjects were analyzed by employing suitable statistical
techniques such as descriptive, interferential paired t test and one way ANOVA performed on the
mean response time(in seconds). The datas were carefully assessed and recorded with precise accuracy.
In experimental group descriptive statistics shows that in WMFT the observed mean 55.55 with standard
deviation 4.045 of WMFT before training is decreased to the mean of 45.85 with standard deviation of
3.117 after training the percentage as decreased in 48.5% and in Moberg pick up test the mean 58.15
with Std.Dev 4.705 before the training as decreased to the mean of 50.00 with standard deviation of
3.387 after the training the percentage is decreased in 40.75 %. The more specific outcome measure the
3-D common object identification test recorded a pre and post mean of 57.15 &43.05 respectively with
S.D of 7.02-4.51imparting a time decrease of 70.5%. Both control group1 and control group2 showed
reasonable decrease in time between pre and post test in all the outcomes, interestingly control group
2(Pre test- WMFT:58.25, Moberg: 58.70, 3D object test:59.25.Post test- WMFT: 53.25, , Moberg:
55.95, , 3D object test: 56.30) exhibited a marginally better outcome than control group 1(Pre testWMFT:57.05, Moberg: 57.70, 3D object test:57.60.Post test- WMFT: 53.70, , Moberg: 54.10, , 3D
object test: 53.45) i.e. subject those received object exploration training with only the affected side had
minimal prognosis in motor and tactile skills. Paired t test was used to assess the statistical significance
of pre test and post test. The mean value of (independent variable) bilateral object exploration training
group (between pre and post test scores of WMFT (in seconds), Moberg pick up test scores (in
seconds), 3-D Common object identification test scores (in seconds)) shows significant difference in
481
Balamurugan etal.,
improvement than unilateral object exploration training group and conventional stroke therapy group.
Paired t test values of the bilateral object exploration training group showed significant difference than
unilateral object exploration training group, conventional stroke therapy group, but both the control
groups did showcase significant difference between their pre and post test values in all variables. In
table 02 Analysis of variance (ANOVA) of bilateral object exploration training group showed a
significant difference in improvement on hand function in stroke subjects. Analysis of variance in
WMFT (in sec) shows the mean square of 388.617 in between the groups, Moberg pick up test (in sec)
shows the mean square of 185.450 in between the groups, 3-D common object identification test (in
sec) shows the mean square of 972.817 in between the groups.
Table.1: Descriptive analysis
Dependent variables
WMFT scores (seconds)

Experimental group
Control group 1
Control group2
Moberg pick up test scores
(seconds)
Experimental group
Control group1
Control group 2
3-D common object
identification test scores
(sec)
Experimental group
Control group1
Control group 2
Mean S.D
Minimum
age
Maximum
age
20
20
20
48.853.117
53.703.389
53.255.056
41
49
45
52
58
60
41
49
50
56
61
62
32
33
48
51
60
60
20
20
20
50.003.387
54.104.012
55.953.364
20
20
20
43.054.513
53.456.565
56.303.614
Table.2:Analysis of variance for groups
Dependent Variable
Sum
Squares
WMFT scores (seconds)

Between the group
777.233
Moberg pick up test scores
370.900
(seconds)
Between the group
3-D
common
object
1945.633
identification test scores (sec)
Between the group
Significant at 1% level (i.e) (p<0.01) in degrees
of df
Mean
square
Sig
388.617
24.931
.000
185.450
14.309
.000
972.817
38.134
.000
482
Balamurugan etal.,
Fig.3: Comparison of Mean Value of 3-D common

object identification test
Fig.4: Comparison of mean value of WMFT
Fig.5: Comparison ofmean value of Moberg pick up test

DISCUSSION
Because of the highly variable extent of recovery both neurological and functional during the first
months after stroke, it is very difficult to evaluate the effects of therapeutic intervention during this
period. For this trial, we therefore choose patients well beyond the period in which effects of
spontaneous recovery might be wrongly attributed to therapy 15
The current study offers a more comprehensive outcome measure and specific treatment tool in
developing object explorative skills with the assistance of the unaffected side in stroke rehabilitation,
which as shown to improve the dexterity of hemiplegic hand. The current results highlighted that
substantial improvement in tactile knowledge and motor ability is seen in subjects trained with bilateral
object exploration training though the other two control group showed significant changes between pre
and post test, it was noticeable that the experimental group exhibited better object handling skills with
lesser trials and early recognition of objects during the course of the research, bilateral hand exploration
would have possibly increased the magnitude of the informations about the geometric properties of
objects and the procedure of visual blocking would have placed enough demand on the tactile and
kinaesthetic senses16. A study done by Nicola Bruno et al on haptic perception after a change in hand
size (2009) is one of the evidence for our explanation of using both hands being effective by increasing
483
Balamurugan etal.,
multi-sensory stimulations and large receptive area. It is important to integrate sensory stimulus in
functional training of stroke because the efficiency and speed of the (motor) recovery process depends
partly on the availability of sensory information provided by motor activity 17.
Tactile object recognition can be viewed as complex information processing that evolves from modalityspecific perception of different classes of object features into recognition of objects explored. Training
with objects that handled in day today activities serves as early simulated experience for the subjects to
enhance their exploratory skills this statement is also supported by a study done by Amy Needham
(2002) on infants showed that early simulated experiences improves object exploration strategies in
comparison with their inexperienced peer group18, 19. The findings of this study reveals that conventional
stroke rehabilitation and object exploration training of the affected hemiplegic hand showed
improvement, but bilateral object exploration training showed significant improvement in both
explorative skills and motor tasks. The limitations of the study were selection of objects for explorative
training was few in numbers. Further works will provide a better understanding of the complex
interdependencies between tactile input, exploratory training strategies and bimanual handling in
neurological subjects.
CONCLUSION
In keeping with our hypothesis, we found that stroke subjects of all three groups showed prognosis
which were notable statistically. But the experimental group showed significant improvement and a
better transformation of explorative skills to motor performance. We conclude that integration of
bilateral object exploration would make hemiplegic hand rehabilitation program more comprehensive
and effective clinical implication.
ACKNOWLEDGEMENT
We express our deep gratitude to Madha medical college and hospital. The authors acknowledge the
help of scholars whose articles are cited. We would like to thank the subjects and physical therapist
involved in protocol development and the members of ethical committee.
The authors declare that they have no competing interest.
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Psychophysics.1992;52: 661-70.
Klatzky RL, Lederman SJ. Toward a computational model of constraint-driven exploration and
haptic object identification. Perception. 1993;22.
Lederman SJ, Klatzky RL. Hand movements: A window into haptic object recognition. Cognitive
Psychology. 1987; 19, 342-368.
Taub E. Movement in nonhuman primates deprived of somatosensory feedback. Exercise and Sport
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Taub E, Wolf SL. Constraint induced movement techniques to facilitate upper extremity use in
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Gordon AM, Duff SV. Relation between clinical measures and fine manipulative control in children
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Fess EE, Gettle K, Strickland J: Hand Splinting: Principles and Methods. St Louis, MO, C V Mosby
Co, 1981
Reed, C, Lederman SJ, Klatzky RL. Haptic integration of planar size with hardness, texture, and
planar contour. Canadian Journal of Psychology.1990; 44, 522-45.
Wolf SL, Catlin PA, Ellis M, Archer AL, et al. Assessing wolf motor function test as outcome
measure for research in patients after stroke. Stroke 2001; 32:163539.
Moberg E. Criticism and study of methods for examining sensibility in the hand, Neurology 1962;
12:8-19.
Travieso D, Lederman SJ. Assessing subclinical tactual decits i n the hand function of diabetic
blind persons at risk for peripheral neuropathy. Arch Phys Med Rehabil 2007; 88:1662-72.
Lederman SJ, Klatzky RL. Haptic classication of common objects:knowledge driven exploration.
Cogn Psychol 1990; 19:342-48.
Rosch E. Principles of categorization. In: Rosch E, Lloyd B, editors. Cognition and categorization.
Hillsdale: Erlbaum; 1978. P: 27-48.
Wade DT, Hewer RL, Wood VA, Skilbeck CE, Ismail HM. The hemiplegic arm after stroke:
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Cauraugh JH, Summers JJ: Neural plasticity and bilateral movements:A rehabilitation approach for
chronic stroke. Prog Neurobiol 2005, 75(5):309-20.
Nicola Bruno, Marco Bertamini: Haptic perception after change in hand size. ElsevierNeuropsychologia 2010;48: 1853-56.
Amy Needham,Tracy Barrett, Karen Peterman A pick-me-up for infants exploratory skills: Early
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DOI: 10.5958/j.2319-5886.2.3.084

&
Health Sciences
www.ijmrhs.com Volume 2 Issue 3 July - Sep Coden: IJMRHS
Research article
Copyright @2013 ISSN: 2319-5886

CORRELATION BETWEEN ALLERGY SKIN TESTS AND ASTHMA IN CHILDRENS OF

PRISHTINA KOSOVO
*Hajdin Ymeri, Drita Telaku-Qosaj, Majlinda Berisha, Arlinda Maloku
Pediatric Clinic, University Clinical Center of Kosovo, Prishtina Kosovo
*Corresponding author email: dr_ymeri@yahoo.com
ABSTRACT
Aim: of this study was to present the correlation between allergy skin prick tests and asthma in children
treated in Pediatric Clinic. The examinees and methods: The examinees were children aged 2.5-16
years with asthma, treated in the Pediatric Clinic during the calendar year November 2011-November
2012. In this research, in total, were included 58 children treated with asthma, both as inpatient and
outpatient. To all children allergy skin tests were done. Results: Out of all children included in the
research, in 30 (51.71%) children allergy skin tests were positive while 28 (48.29%) of them had
negative skin prick tests. According to the age of 2.5-6 years were 18 children or (31.04%), from 6-11
years were 29 children or (50%) and from 11-16 years were 11 children or (18.96%). From the positive
skin prick test group highest number 17 (56.6%) children belong to the age group 6-11 years, than
regarding the gender ratio males : females was 3:2. From the positive skin prick test group children were
sensitive towards D. Pteronissinus, D.Farine and less to pollen, epithelial pets (dog, cat) and other
reagents inhalation. Conclusion: From our data noted that the allergy skin tests are an auxiliary method
in asthma diagnosis. Higher incidence was noted in male children. We can conclude that there is a
evident relation between asthma and skin allergy tests.
Keywords: Asthma and skin allergy tests.
INTRODUCTION
Asthma is a chronic inflammatory condition of

the airways that is characterized by chronic
inflammation followed by airflow obstruction
that can pass spontaneously or with medication 1.
Most epidemiological studies show increased
prevalence and incidence in the last 10 years in
many countries with a tendency of increase in the
future2. Asthma is a disease in which many
factors affect genetic predisposition or mutations
and their polymorphism affect disease

development, genes responsible are localized in
long arm of chromosome 6 and 11, in the short
arm of chromosome 20 and chromosome 17.3,4
Common symptoms include wheezing, coughing,
chest tightness, and shortness of breath. Asthma
management is aimed to reduce airway
inflammation exposure, using daily controller
anti-inflammatory medications, and controlling
Hajdin Ymeri et al.,
487
comorbid conditions that can worsen asthma5. It

is presumed that bacterial colonization of the
throat in neonates increases the risk for wheezing
and asthma later in childhood6. Until the puberty
boys are more attracted from asthma due to
bronchal hyper reagibility, also the skin allergy
test reactivity to inhaled allergens and level of
IgE is increased7. Obesity, pneumoallergens
(D.Pteronissinus, D.farine), tobacco smoke, as
well environmental pollution, combustion of oil
products, plastic and other contaminants have a
positive impact on development of asthma8. In
most cases, asthma is associated with atopy with
a predisposition to increased IgE in allergens
surrounding the child9.
Aim: Aim of this study was to present the
correlation between allergy skin tests and asthma
in children treated in the Pediatric Clinic during
one year (November 2011-2012).
group aged 2.5-6 years (N=18), second group 611 years (N=29) and third group 11-16 years
(N=11). From the research were excluded
children suffering from chronic diseases,
systemic and other diseases that could have an
impact on the skin prick test. Also written
permission from parents was obtained for
participation in the research. Diagnosis was done
based on the anamnestic data, clinical and
laboratory evaluation for asthma. Skin prick test
was done in the forearm, whereas allergens were
apart 2-3 cm from each other. Positive skin prick
test was considered when diameter of swelling
was over 3 mm, histamine test was positive
reaction in physiological solution was negative.
The tests were not done in children who 24 hours
earlier had taken oral corticosteroids, 2 agonist
or even 72 hours antihistaminic agents.
RESULTS
PATIENTS AND METHODS
In the research were in total 58 children. In the

figure 1 were presented children treated from
asthma that were hospitalized 19 of which 11
(18.9%) were males, 8 (13.8%) were females and
treated as an outpatient were 39, 22 males
(37.9%) and 17 females (29.4%)
The examinees were children with asthma treated

in Pediatric Clinic- Department of Pulmonary
diseases. In the research were included 58
childrens, both hospitalized and children treated
as an outpatient. According the age, the
examinees were divided in three groups, first
Table.1: Children treated from asthma in Pediatric Clinic
Hospitalized children (inpatient)
Outpatient
Total
Number
19 inpatients
11 males
8 females
22 males
39 outpatients
17 females
58 children
Percentage
18.9
13.8
37.9
29.4
100
Fig.1: Comparison of skin prick positive test by gender
488
Regarding the gender, out of children that had

positive skin prick test results, 18 (60%) children
were males and 12 (40%) children were females.
Total number of prick skin test was 58,with

positive tests were 30 (51.27%)children.
30
30
25
20
17
15
8
10
5
0
Age 2.5-6 y
Age 6-11
age 11-16
Total postive tests
Fig.2: Age distribution in positive skin prick test group

DISCUSION
From the total number of children included in the

research, in which skin prick test was done 18
(32.75%) children were hospitalized, while 39
(67.24%) children were treated as an outpatient.
Regarding the age highest number of children 29
children (50%) belonged to the age group 6-11
years, then comes age group 2.5-6 years with 18
children (31.04%) and age group 11-16 years
with 11 children (18.96%). This distribution is
justified by the fact that allergy can lead to
persistent asthma usually over age 610, 11.
Analyzing data of the positive skin prick test
group highest number of children belonged to the
age group 6-11 years with 17 children (56.6%),
then comes age group 2.5-6 years with 8 children
(26.6%) and age group 11-16 years with 16.6%).
According to gender from the positive skin prick
test group ratio males : females was 3:2, what
can be explained by the fact that the incidence of
asthma in prepuberty children is 1.5-2:1 in favor
of males, while in puberty ratio narrows to 1:1.
Skin prick tests in our research group showed
greater positivity toward D.Ptronissinus,
D.Farine, less to pollen and epithelial domestic
animals (dog, cat). Prick skin test is a very
important diagnostic tool in children with
asthma, although in 25-50% of cases it can be
negative due to non atopic asthma, while even in

cases (5-15%) when it is positive, children do not
have asthma 12
CONCLUSION
As we can see from the results, skin prick test

have an important role in diagnosing asthma.
This method has also its economic advantages as
it is less expensive than the RAST method
(Specific IgE ). The skin tests may be a reliable
indicator for diagnosing children with asthma.
Our data correspond well with the data of other
authors (13).
Eliminating
and
reducing
problematic
environmental exposures: limiting smoke
exposure both in utero and after delivery,
breastfeeding, to avoid pats, akarien, reducing or
eliminating compounds know to sensitive to
children from home may be effective.
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www.ginasthma.org
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3. Meyers DA.Genetiks of astma and allergy .
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Immunol Rev 2011;242:10-30
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sur. Rhinovirus illnesses during infancy
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Childhood asthma after bacterial colonization
of airway in neonates. N Engl J Med 2007
;357:1487-95
7. Osman M. Therapeutic implications of sex
differences in asthma and atopy. Arch Dis
Child. 2003;88:587-90
8. Rusznak C, Sapsford RJ,Devalia JL.
Cigarette smoke and house dust mite
allergens on inflammatory mediator release
from primary cultures of human bronchial
epithelial cells.Am J Respir Cell Mol Biol
1999;20:1238-50
9. Sly PD, Boner AL, Bjrksten B. Early
identification of atipy in the prediction of
persistent asthma in children .Lacent
2008;372:1100-6
10. Nelson textbook of Pediatric 19th edition,
2011, 130:743-747
11. Kurukulaaratchy RJ, Matthews S, waterhouse
L, Arshad SH. Factors influencing symptom
expression in children with bronchial
hyperresponsiveness at 10 years of age. J
Allergy Clin Immunol 2003; 112:311-6
12. EvdaVevecka, Luljeta Kote. Illness of
children with respiratory tract. 2005:215-216
13. Kova K, Dodig S, Tjei-Drinkovi D, Raos
M. Correlation between asthma severity IgE
in asthmatic children sensitized to
Dermatophagoides pteronyssinus. Arch Med
Res 2007;38:99105.
490
DOI: 10.5958/j.2319-5886.2.3.085

&
Health Sciences
Research Article
VALIDATION OF ENDOMETRIAL CURETTAGE IN ABNORMAL UTERINE BLEEDING IN
A TEACHING INSTITUTE OF CENTRAL INDIA: A PROSPECTIVE STUDY
*Smita S Patne1, Manik S Sirpurkar2
1
Associate Professor, 2Associate Professor, Department of Obstetrics and Gynaecology, L.N. Medical
College and J.K. Hospital, Bhopal, Madhya Pradesh, India.
*Corresponding author email:smitaspatne@yahoo.com
ABSTRACT
Background: Abnormal uterine bleeding (AUB) is one of the common reasons for female patients to
consult a gynecologist. AUB include bleeding from structural causes like polyps, endometrial
hyperplasia, chronic endometritis, proliferative endometrium, fibroids, carcinoma and pregnancy related
complication and dysfunctional uterine bleeding. Methods: A prospective study done in one year
duration among 210 patients of 20-70 years age group. A tissue sample is taken after endometrial
curettage and examined by a pathologist for various lesions. The results: Largest number of AUB
patients were about 31-40 years age group. The most common cause of AUB is endometrial hyperplasia.
AUB is found in more multiparous women and menorhhagia is a most common bleeding pattern.
Conclusion: Endometrial curettage is a sensitive tool for AUB diagnosis. Very little pathology can
escape this investigating tool. It also avoids unnecessary hysterectomy.
Keywords: Abnormal Uterine Bleeding, Endometrial curettage, Hysterectomy, Menorrhagia,
Dysfunctional Uterine Bleeding.
INTRODUCTION
Abnormal uterine bleeding (AUB) is one of the

common reasons for female patients to consult
gynecologist1. AUB affects one-third of female
at one or the other time in their life span. It is one
of the leading causes of female morbidity and is
of special concern in developing country as it
adds to the causes of anemia which is already
prevailing in women of our setup.
AUB include bleeding from structural causes like
polyps, endometrial hyperplasia, chronic
endometritis,
proliferative
endometrium,
fibroids, carcinoma and pregnancy related
complication and dysfunctional uterine bleeding

(DUB). 2 Term DUB is used when the cause of
AUB is not organic; there are no demonstrable
pelvic or systemic diseases and no anatomical
lesion3. AUB denote any bleeding which does
not fill the criteria of normal bleeding. AUB in
itself is not a disease but it denotes the
underlying pathology responsible for it. AUB
may be the most common presenting complaint
in patients with pre-malignant or malignant
endometrial lesion4.
Various diagnostic techniques are available for
Smita et al.,
491
evaluation of AUB which include USG,

endometrial biopsy, hysteroscopy, dilatation and
endometrial curettage (EC) etc5. Out of them EC
is most effective as even small focal lesion can
also be picked up, thus allowing few pathologies
to escape. Also it is used when cervical os is
stenotic and also as a therapeutic procedure in
DUB when medical treatment fails6,7. The
endometrial curettage technique is now
considered as a fine line diagnostic tool because
of its diagnostic accuracy, safety, quickness and
convenience8.
Many women with AUB may undergo unwanted
hysterectomy without a definitive diagnosis.
Endometrial curettage is sensible and the safest
method for diagnosis and evaluation of AUB.
Early diagnosis for cause of AUB is crucial as
various uterine pathologies can be picked up and
timely treatment can improve patient's quality of
life.
Menorrhagia is regular ovulatory cyclical
bleeding which is excessive in amount (>80ml)
or time (>5days), and metrorrhagia is
anovulatory irregular unpredictable bleeding9.
This study was done to evaluate the role of E.C.
in AUB and incidence of various pathologies in
different age groups.
This prospective study was conducted in our

medical college and attached Hospital during a
period of two years (January 2012 to December
2012). Total 210 subjects of age group 15-70
years were selected for the study from
Gynaecology OPD. Detail history was taken and

drug history was emphasized (so as to eliminate
the drug side effect). This study was approved by
the Institutional Ethics Committee. The detailed
information sheet was provided both in English
and in local language to all participants and
written consent was taken.
Inclusion criteria: patients of age 15-70 years
presenting to gynecology OPD with complaint of
AUB for more than 4 months
Exclusion Criteria: Patients diagnosed as
systemic diseases, genital tuberculosis, IUCD in
situ, incomplete history, bleeding and
coagulation defects, pregnancy, on an antiplatelet drugs.
General examination and routine investigations
like, BT/CT, blood count, x-ray chest etc. were
done. USG abdomen Pelvis was also performed
by expert Sonologist. Endometrial curettage
performed by a gynecologist after admitting the
patient.
The tissue sample obtained was sent to pathology
department in 10% formalin and after routine
processing tissue sections of 4-6 microns were
cut and stained with eosin and hematoxylin and
subsequently seen under light microscope by two
different pathologists so as to avoid observer
bias.
The findings were arranged in tables using
Microsoft excel sheet.
RESULTS
Total 210 patients were included in the study.

Age of the patients ranged between 14-70 years,
with a mean age of 39.6 yrs.
Table.1: Demographic distribution of patients according to age
Age groups (years)

Number of patients
Percentage
17
8.09%
< 20
45
21.43%
21-30
71
33.80%
31-40
54
25.70%
41-50
23
10.95%
> 50
210
Total
The largest number of patients of AUB belonged to 31-40 years, the second largest is 41-50years.
Smita et al.,
492
Table.2: Distribution of patients according to parity
Parity
Nullpara
Primi
Multipara(1-3)
Grand multipara (>4)
Total
No of patients
18
25
128
39
210
Percentage
8.57
11.90
60.95
18.57
The above table shows that AUB is more common in multiparous patients (128 patients, 60.95%).
Table.3: Distribution of patients according to bleeding pattern in AUB
Bleeding pattern
Menorrhagia
Metrorrhagia
Poly menorrhagia
Postmenopausal bleeding
Intermenstrual bleeding
Total
No of patients
90
59
25
22
14
210
Percentage
42.85
28.09
11.90
10.47
6.66
The above table shows that the most common bleeding pattern is menorrhagia (42.85%) followed by
metrorrhagia (28.09%), and polymenorrhagia.
Table.4: Histopathological findings
Pathology
Proliferative endometrium
Endometrial hyperplasia
Pregnancy complications
Endometrial polyp
Chronic endometritis
Fibroids
Carcinoma Endometrium
Total
No of patients
51
88
29
12
15
10
5
210
Percentage
24.28
41.90
13.80
5.71
7.14
4.76
2.38
It shows that most common pathological finding in AUB patients is endometrial hyperplasia (41.90%)
followed by proliferative endometrium (24.28%), pregnancy complication, chronic endometritis,
endometrial polyp.
DISCUSSION
AUB continues to be one of the most frequently

encountered and significant morbidity in
gynaecological OPD10. As endometrium is
dynamic and hormonally sensitive and
responsive tissue which constantly undergoes
changes throughout the reproductive life,

therefore is vulnerable for pathological lesions.
Endometrial curettage is the most common mean
for assessing AUB. In this procedure scrapping
of the endometrial lining and histopathological
Smita et al.,
493
examination of tissues is done without injuring

the nearby structures this is well accepted by
patients. Whereas in the hysterectomy whole
uterus is removed and also there are chances of
operative co-morbidity therefore hysterectomy is
reserved as final procedure.
The most susceptible age group to AUB in the
present study was 31-40 yrs with 33.80% of
patients. Ara and Roohi noted maximum
(59.02%) number of patients in perimenopausal
group11. Doraiswami et al noted in 41-50 yrs age
group with 33.5% patients12. Rajesh Patil et al
found maximum number (45.26%) of patients in
31-40 yrs group13. The incidence is lower in
adolescent girls as mostly abnormal bleeding in
that age group resolve spontaneously.
We found a maximum incidence (60.95%) of
AUB in multiparous women. A similar result
was also found by Rajesh Patil et al with a
percentage of 71.58%13. Other authors like Pilli
et al14, mehrotra et al15, Joshi S.K. & Deshpande
D.H16 also found the similar results.
Most common bleeding pattern was found to be
menorrhagia in 90 patients (42.85%) followed by
metrorrhagia in 59 patients (28.09%),
polymenorrhagia (11.90%), post menopausal
bleeding (10.47%) . Similar results were found
by Moghul N17 where they were 48%, 41%,
1..3% and 6% respectively. Our result values are
also nearer to results found by Mehrotra VG et
al15 and Pilli et al14.
We found endometrial hyperplasia as a most
common pathological lesion on histopathology
(41.90%), followed by proliferative endometrium
(24.28%). Ara and Roohi11 noted hyperplasia in
27.95% of cases. Vakiani et al18 noted
hyperplasia in just 5.5% of patients.
CONCLUSIONS
According to our study, the most susceptible age

group is 31-40 yrs. Multiparity is also an
important risk factor for the development of
abnormal uterine bleeding. Commonest bleeding
pattern found was to be menorrhagia.
Endometrial hyperplasia is the commonest
Smita et al.,
pathological finding in relation to abnormal

uterine bleeding.
REFERENCES
1. Nicholson WK, Ellison SA, Grason H, Power

NR. Patterns of ambulatory care use for
gynecological conditions: a national study.
Am J Obstect Gynecol 2001;184: 523-530
2. Albers JR, Hull SK, Wesley MA. Abnormal
uterine
bleeding.
Am
Fam
Phys
2004;69:1915- 26.
3. Dallenbach,
Hellwig
G.
Functional
disturbances of endometrium. Chapter-11.
Haines
&
Taylor
Obstetrical
&
Gynecological Pathology. Edt.By Fox H, 4th
edition, Churchill Levinstone,1995;383-403.
4. Montgomery BE, Daum GS. Endometrial
Hyperplasia: a review. Obstet Gynecol Surv
2004;59:368-78.
5. Long CA. Evaluation of patients with
abnormal uterine bleeding. AM J Obstect
gynecol 1996;175(3) :784-86.
6. Neese RE Abnormal vaginal bleeding in
perimenopausal women. Am Fam physician
1989;40: 185-192.
7. Johnson CA. Making sense of dysfunctional
uterine
bleeding.
Am
Fam
physician.1991;14:149-57.
8. Samson, S-L, Donna G. Who needs an
endometrial biopsy? Canadian Family
Physician 2002;48:885.
9. John W Ely, Collen M, Kennedy, et al.
Abnormal uterine bleeding: A Management
Alogrithm. Midwest Centre for health
Services and Policy research 2007;105(11):
624-30
10. Sarwar A, Haque A. Types and frequency of
pathologies in the endometrial curating of
abnormal uterine bleeding. Int J Pathol
2005;3:65-70.
11. Sarwat A, Roohi M, Histological diagnosis
by conventional dilatation and curettage.
Professional Med J. 2011;18(4):587-91
494
12. Saraswathi D, Thanka J. Study of

endometrial pathology in Abnormal Uterine
Bleeding. The journal of Obstetrics and
Gynecology of India. 2011;61(4):426-30.
13. Patil R, Patil R.K., Andola S.K., Laheru V,
Bhandar M. Histopathological spectrum of
endometrium in dysfunctional uterine
bleeding. Int J Bio Med Res. 2013;4(1):279801.
14. Pilli GS et al. Dysfunctional uterine bleedingA study of 100 cases. J Obstet Gynecol India.
2000; 52(3):87-89.
15. Mehrotra VG et al. Functional uterine
bleeding-A review of 150 cases. J Obstet
Gynecol India.1972;12:684-689.
16. Joshi deshpande, Moghal N. Diagnostic value
of endometrial curettage in abnormal uterine
bleeding.
A
histopathological
study.
JPMA.1997;47(12):295-99.
17. Vakiani M ,VAviliis D, Agorastos T,
Stamatopulos P, Assimaki A, Bontis J.
Histological findings of endometrium in
patients with dysfunctional uterine bleeding.
Clin. Expo-Obstet Gynecol 1996;23 (4):23639.
Smita et al.,
495
DOI: 10.5958/j.2319-5886.2.3.086

&
Health Sciences
Research article
ANATOMICAL STUDY OF SACRAL HIATUS FOR SUCCESSFUL CAUDAL EPIDURAL

BLOCK
*Ramamurthi KS1, Anil kumar Reddy Y2
1
Assistant professor, 2Tutor, Department of Anatomy, KFMS&R, Coimbatore, Tamilnadu, India.
*Corresponding author email: kumarlucky48@gmail.com

ABSTRACT
Background: Present study determined the landmarks for caudal epidural block (CEB) after
morphometric measurements of the sacral hiatus on dry sacral bones. The CEB has been widely used
procedure for the diagnosis and treatment of lumbar spinal disorders. Anatomical features of the sacral
hiatus and the detailed knowledge about sacral hiatus. Materials & Methods: 116 sacral bones are
used for the study. Anatomical measurements were measured by using vernier caliper accuracy to 0.1
mm. Results: Agenesis of sacral hiatus was detected in two sacral bones. Various shapes of sacral hiatus
were observed which included inverted U (31%), inverted V (25.8%), irregular (20.6%), Elongated
(17.2%) and dumbbell (5%). Apex of sacral hiatus was commonly found at the level of 4 th sacral
vertebra in 50.8%. The distance between the two supero lateral sacral crests and the distance between
the apex of sacral hiatus and the right and left supero lateral crests were 69.5 (5.8) mm, 61.4 (11.2) mm,
57.4 (9.7) mm respectively, on average. The mean, mode, SD is calculated for all the measurements.
Conclusion: The sacral hiatus has anatomic variations. Understanding of these variations may improve
the reliability of CEB.
Keywords: Sacral vertebrae, Sacral hiatus, Caudal Epidural Block (CEB)
INTRODUCTION
The incomplete fusion of the posterior elements

of the 5th or 4th sacral vertebra, results in the
formation of sacral hiatus1. This inverted U
shaped sacral hiatus is covered by the
sacrococcygeal membrane and forms an
important landmark to perform caudal epidural
block (CEB) 2. Sacral hiatus has been widely
utilized for administration of epidural anesthesia
in obstetrics and surgery below the umbilicus
such as Hernia repair, Lower limb surgery, Skin
Anil et al.,
grafting, GU procedures, procedures on the anus

and rectum, orthopedic surgery on the pelvic
girdle3. The success rate CEB is depends on
anatomic variations of sacral hiatus as observed
by various authors.
The present study was conducted in the

department of anatomy, Karpagam Faculty of
Medical Sciences & Research, Coimbatore,
496
Tamilnadu. 116 complete and undamaged adult

Caucasian dry sacral bones obtained from the
department of anatomy and department of
Forensic medicine. The sex and age of the sacral
bones
were
not
known.
Anatomical
measurements were performed on these

specimens by using a vernier caliper (accuracy
0.1mm). Each sacrum was studied and below
mentioned measurements was taken from each
sacrum.
1. Length of sacral hiatus (mm) 2. Width of sacral hiatus (sacral cornua) (mm) 3. Distance from apex to the
level of S2 foramina (mm) 4. Distance from base to s2 foramina (1+3) (mm) 5. Depth of SH at the level of its
apex (mm) 6. Distance between two supero o lateral sacral crest (mm) 7. Distance between right superio
lateral sacral crest & apex (mm) 8. Distance between left superio lateral sacral crest & apex (mm)
RESULTS
Agenesis of the sacral hiatus was found in two

sacrums. Various shapes of sacral hiatus are
observed, inverted U (31%) shaped sacral hiatus
is most commonly observed (Table-1) (Fig-3).
The level of the apex of the sacral hiatus in
Table.1: Shape of Sacral hiatus (n=116)
S.No Shape
No.
relation to sacral vertebra is

percentages are given in Table
the base of the sacral hiatus
sacral/coccygeal vertebra is
percentages are given in Table-3.
observed and
2. The level of
in relation to
observed and
Percentage%
Inverted U
36
31%
Inverted V
30
25.8%
Irregular
24
20.6%
Elongated
20
17.2%
Dumbbell
5%
Table.2: Location of apex in relation to level of sacral vertebra (n=116)

S.No Location of Apex
No.
Percentage%
Anil et al.,
4th sacral vertebra
59
50.8%
3th sacral vertebra
48
41.3%
2th sacral vertebra
09
7.7%
497
Table.3: Location of base of hiatus in relation to level of sacral/coccygeal vertebra (n=116)

S.No
Location of Base
No.
Percentage%
5th sacral vertebra
84
72.4%
4th sacral vertebra
22
18.9%
Coccyx
10
8.6%
The average length of sacral hiatus was 29.5(9.5)

mm (range 17-49mm). The length of sacral
hiatus mostly between 17-30 mm. The average
width of sacral hiatus (sacral cornua) was 16.2
(2.7) mm (range 10-22 mm). The distance
between the right superio lateral sacral crest and
the sacral apex was 61.4(11.2) mm (range 36-88
mm). The distance between the left superio
Anil et al.,
lateral sacral crest and the sacral apex was

57.4(9.7) mm (range 35-73 mm). From the above
mean values, it is important to know that the
distance from the right and left sacral crests to
the hiatus were similar in each sacrum. The
anatomical measurements and statistical data are
given in Table-4.
498
Table.4: Morphometry of sacrum

Mean Median SD
Max Min
Length of sacral hiatus (mm
29.5
24
9.5
49
17
Width of sacral hiatus (sacral cornua) (mm)
16.2
13
27
22
10
Distance from apex to the level of s2 foramina (mm)
30.2
27
10.5
53
12
Distance from base to s2 foramina (1+3) (mm)
59.5
51
8.8
74
42
Depth of SH at the level of its apex (mm)
05
07
1.4
07
02
Distance between two supero lateral sacral crest (mm)
69.5
67
5.8
86
59
Distance between right supero lateral sacral crest & apex (mm)
61.4
58
11.2
88
36
Distance between left supero lateral sacral crest & apex (mm)
57.4
57
9.7
73
35
DISCUSSION
Study on the anthropometric measurements of
sacral hiatus and its anatomical features are
related to its clinical application in caudal
epidural anaesthesia. Standard textbooks (peter
L. William et al, 2000)4 mentions the lower end
of sacral canal is an arch shaped sacral hiatus.
Many authors have been mentioned various
shapes of sacral hiatus (vinod kumar et al 1995,
Trotter et al 1946)5 6, most common being
inverted V and inverted U. in the present study
also the shapes of sacral hiatus were variable,
most common inverted U (31%) and inverted V
(25.8%). In 5% its outline was like a dumbbell
while in 20.6% it was irregular.
In the present study complete agenesis of dorsal
bony wall of sacral canal is observed in 1.7%.
This is similar to that previous workers namely
Trotter et al7 (1947) 1.8% and vinod kumar et al
(1992) 1.4%. The apex of sacral hiatus was seen
most commonly (50.8%) at the level of 4th sacral
vertebra. Standard textbooks (peter L. William et
al 2000) states that the apex of sacral hiatus
present at level of 4th sacral vertebra. Sekiguchi
M et al8 (2002) noted the apex of sacral hiatus at
S4 level in 64% cases. Most of the authors
including the present study noted that location of
apex can vary from upper end of S2 to lower part
of S5.
Anil et al.,
The base of sacral hiatus was seen at level of S5

vertebra in 72.4% sacra, similar to various
authors namely vinod kumar et al (1992,
83.17%) and Nagar SK9 (72.6%). It extended to
coccyx in 8.6% cases. These sacra had coccygeal
ankylosis.
Identification of the caudal epidural space is not
always possible even for experienced clinicians,
and anatomical variation may be an influence.
The apex of the sacral hiatus is an important
bony landmark in the success of CEB but it may
be hard to palpate, particularly in obese patients.
Hence other prominent anatomical landmark may
be of use, such as the triangle formed between
the posterior superior iliac spines and the apex of
sacral hiatus. Present study measurements show
this to be an equilateral triangle10. The given
measurements are useful to identify the sacral
hiatus easily and increase the success rate of
CEB.
The length of sacral hiatus varied from 17-49mm
average is 29.5(9.5). Sekiguchi and Colleagues
found the distance between the sacral cornua
(10.2 (0.35) (2.2-18.4 mm) lesser than and the
depth of sacral hiatus (6.0 (1.9) (1.9-11.4) mm)
slightly greater than those measurements in our
study (16.2 (2.7) (10-22) and 5 (1.4) (2-7) mm
respectively). The depth of sacral hiatus at apex
is important as it should be sufficiently large to
499
accommodate the needle. In the present study the

depth ranged from 2-7mm with mean of 5(1.4)
mm. mean depth reported by various authors are
similar (Trotter et al, Lanier et al, Trotter et al
and Sekiguchi et al) to present study. The
distance between the S2 foramen and the apex of
the sacral hiatus was 30.2 (10.5) mm on average
(range 12-53mm). The study by senoglu et al11
and patil dhananjay12 is similar to our studies.
Additional measurements are distance between
two supero lateral sacral crest (base of the
triangle) (69.5 (5.8) 59-86mm), distance between
right supero lateral sacral crest and sacral hiatus
apex (61.4 (11.2) 36-88mm), distance between
left supero lateral sacral crest and sacral hiatus
apex (57.4 (9.7) 35-73mm) forming nearly an
equilateral triangle between supero lateral sacral
crest and sacral hiatus apex in most of the
sacrums. This equilateral triangle can act as
guide to the location of the apex of sacral hiatus
during caudal epidural block and clinicians can
avoid problem of failure in needle placement.
Our study is similar to the studies by Anjali
Aggarwal et al and patil dhananjay.
CONCLUSION
In the present study, elongated, dumbbell shaped
hiatus and narrow space of the sacral canal at
apex of sacral hiatus was found in a significant
percentage. The Anatomical study of sacral
hiatus and knowing about anatomical variations
of sacral hiatus is significant while
administration of caudal epidural anaesthesia and
measurements of sacral hiatus may improve its
success rate.
REFERENCES
1. Standring S (Ed). Grays Anatomy. The
Anatomical Basis of Clinical practice.
Philadlphia, Elsevier Churchill Livingstone
2005.
2. Senoglu N, Senoglu M, Oksuz H, Gumusalan
Y, Yuksel KZ, Zencirci Bet al., Landmarks
Anil et al.,
of the sacral hiatus for caudal epidural block:

an anatomical study. British journal of
Anaesthesia 2005; 95 (5): 692-95.
3. Patil Dhannajay S, Jadav Hrishikesh R,
Binodkumar, Mehta CD, Patel Vipul D.
Anatomical study of Sacral Hiatus for Caudal
Epidural Block. National Journal of Medical
Research. Sept 2012;2(3) 1-6
4. Peter L William et al. Grays anatomy 38th
edition. Churchill Livingston 2000;592-31,
673-74
5. Vinod kumar, Pandey SN, Bajpai RN, Jain
PN, Longia GS. Morphometrical study of
sacral hiatus. Journal of Anatomical Society
of India 1992;41 (1):7-13.
6. Trotter M, Letterman GS. Variations of the
female sacrum; their significance in
continuous caudal analgesia. Surg. Gynaecol.
Obstet. 1944;78(4):419 24.
7. Trotter M. Variations of the sacral canal;
Their significance in the administration of
caudal analgesia. Anesthesia and analgesia
1947; 26 (5); 192-202.
8. Sekiguchi M, Yabuki S, Saton K, Kikuchi S.
An anatomical study of the sacral hiatus: a
basis for successful caudal epidural bloc.
Clin. J. Pain. 2004;20(1): 51-54.
9. Nagar SK. A study of sacral hiatus in dry
human sacra. Journal of Anatomical Society
of India 2004;53(2) 18-21.
10. Stitz MY, Sommer HM. Accuracy of blind
versus fluoroscopically guided epidural
injection. Spine 1999;24(13): 1371-76.
11. Senoglu N, Senoglu M, Oksuzl H,
Gumusalan Y, Yuksel KZ, Zencirci B et al.,
Landmarks of the sacral hiatus for caudal
epidural block; an anatomical study. British
journal of Anaesthesia, September 2005;
53:1-4.
12. Anjali Aggarwal, Harjeet kaur, Yatindra K.
Batra, Aditya K., Subramanyam Rajeev and
Daisy Sahni, Anatomic Consideration of
Caudal Epidural Space: A cadaver study.
Clinical Anatomy.2009;22:730-37.
500
DOI: 10.5958/j.2319-5886.2.3.087

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
th
Revised: 12 Jun 2013
Research article
Copyright @2013
ISSN: 2319-5886
th
Accepted: 14 Jun 2013
A STUDY OF KNOWLEDGE AND ATTITUDE OF NURSING STUDENTS TOWARDS

EMERGENCY CONTRACEPTION
Keerti S Jogdand, Pravin N Yerpude
Associate Professor,Dept of Community Medicine,Gujarat Adani Institute of Medical Scineces, Bhuj
*Corresponding author email :drpravinyerpude@gmail.com
ABSTRACT
Introduction: Out of 210 million pregnancies in the world each year, 75 million pregnancies are
unintended and/or not planned. Most of these unplanned/ unintended pregnancies are not carried to full
term, but aborted often in unhygienic conditions leading to serious consequences. Mortality and
morbidity related to abortion can be significantly reduced by the use of emergency contraceptive.
Materials and methods: A present cross-sectional study was carried out among 140 nursing students of
the first and second year studying at Katuri College of Nursing, Guntur, Andhra Pradesh, by a
convenient sample method over a period of 4 months from March 2010 to June 2010. Results: In the
present study,100% of the respondents were aware about EC. The majority (93.4%) of the respondents
were unmarried. Regarding knowledge of nursing students, only 55.71% students give the correct
response to ideal clients for EC. Only 51.43% students give the correct response to the methods of EC.
Only 57.86% students give the correct response for maximum acceptable time after sex for a woman to
take EC.65% students dont know about common side effect of EC. Regarding attitude of nursing
students towards EC, 65% students were of opinion that paramedical staff should dispense EC.
Conclusion: This study suggested that participants had overall positive attitude toward EC but there
was a lack of knowledge regarding the effectiveness, mechanism of protection from RTI/STDs. So,
there is a need to further educate them about EC.
Key words: Attitude, Nursing students, Emergency contraception
INTRODUCTION
Out of 210 million pregnancies in the world each

year, 75 million pregnancies are unintended
and/or not planned 1, 2. Most of these unplanned/
unintended pregnancies are not carried to full
term, but aborted often in unhygienic conditions
leading to serious consequences. One of the
highest risk groups for unsafe abortion is young
and unmarried women. Mortality and morbidity

related to abortion can be significantly reduced
by the use of emergency contraceptive.
Adolescent pregnancy is one of the serious social
and public health problems in India. Young
woman fail's to complete her education due to
early childbearing and due to this responsibility
501
Keerti et al.,
they have less job prospects and this will

ultimately affect both mothers and child
economic well-being. School drop-out rate was
more in adolescent females in India who gave
birth before their fourth year of secondary school
3, 4
.
After an unprotected act of sexual intercourse,
use of EC is one of the effective methods to
prevent pregnancy also called "morning-after" or
postcoital" pills. However, since emergency
contraceptive pills can be used up to three days
after unprotected intercourse, it should be used
only during emergencies .It should not be used as
a regular contraception. It has a failure rate of 0.2
% to 3%. At present the progesterone only
tablet available in the market for post coital
contraception is LNG 5. Most of the studies on
EC in India have been done among a group of
adult married women. Very few studies have
been done among nursing students. As the
nursing students are the future community health
educators and health providers. With this in
mind, the present study was conducted to explore
knowledge of and attitude about EC among
nursing students of Katuri College of Nursing,
Guntur, Andhra Pradesh.
A present cross-sectional study was carried out

among 140 nursing students of the first and
second year studying at Katuri College of

Nursing, Guntur, Andhra Pradesh, by a
convenient sample method over a period of 4
months from March 2010 to June 2010. Consent
form taken from each student. A pre-designed,
pre-tested, self-administered questionnaire in
English was devised to collect data. The data was
collected, analyzed and presented in SPSS 10.
RESULTS
In the present study,100% of the respondents

were aware about EC. Majority (93.4%) of the
respondents
were
unmarried.
Regarding
knowledge of nursing students, only 55.71%
students give the correct response to ideal clients
for EC. Only 51.43% students give the correct
response to the methods of EC. Only 57.86%
students give the correct response for maximum
acceptable time after sex for a women to take
EC. 65% students dont know about common
side effect of EC. Only 31.43% students give
correct response regarding availability of EC at
Government centers free of cost.
Regarding attitude of nursing students towards
EC, 65% students were of opinion that
paramedical staff should dispense EC.38.57%
students were of opinion that EC was good for
reproductive health.34.29% students were of
opinion that EC would discourage consistent use
of condom.
Table 1: Knowledge about emergency contraception among study population
Question of knowledge
Correct
response (%)
Who would be the ideal clients for EC?
78(55.71)
What are the methods of EC?
72(51.43)
Maximum acceptable time after sex for women to take EC?
81(57.86)
Is EC procured easily from retail outlets?
64(45.71)
Is menstrual irregularity is the most common side effect of 49(35)
EC?
Is EC provided protection from STD/RTIs?
67(47.86)
Is efficacy of EC reducing by each passing hour?
69(49.29)
Are EC available for free of cost at govt centres?
44(31.43)
Incorrect
response (%)
62(44.29)
68(48.57)
59(42.14)
76(54.29)
91(65)
73(52.14)
71(50.71)
96(68.57)
502
Keerti et al.,
Table 2: Attitude of study population about emergency contraception
Question of attitude
Should paramedical staff dispense EC?
Is EC good for reproductive health?
Is EC would discourage consistent use of condom
Is EC safe for its users?
Yes (%)
91(65)
54(38.57)
48(34.29)
86(61.43)
No (%)
49(35)
86(61.43)
92(65.71)
54(38.57)
DISCUSSION
The rates of unplanned and/or unintended

pregnancies and illegal abortions are high in
India despite the fact that India was the first
country to start a National Family Welfare
Programme. In India, 78% pregnancies are not
planned by the couple and 25% are unwanted 6.
Despite the legalization of abortion in India
through MTP Act 1971, the no of illegal
abortions are increasing.In the present study. All
the students were aware about EC. This was in
contrast to the level of awareness found among
university students in Ghana (43.2%) 7. It was
higher than among university students in the
USA(86%) and Jamaica (84%) 8, 9.
In the present study, about one-fourth of the
respondents (25.5%) thought EC is an
abortifacient, compared to 25.8% of university
students in Ghana, 51.2% of university students
in Cameroon, 49% of nursing students in Kenya,
25% of doctors in the Pakistan, and 8.1% of
doctors in Delhi (7,10-13). 35% of the respondents
correctly chose menstrual irregularity being most
common side-effect. Abdulghani et al 12 in their
study find 57.86% knowledge about the correct
time for taking ECPs after unprotected sex. This
finding is higher than 11.3% reported in Ghana, 7
and 5.7% reported in the Cameroon study10. In
our study, 28.9% respondents did not have an
accurate knowledge of the mechanism of action
of an EC. Singh et al 13 in their study find similar
findings. 52.14% were not sure whether ECs
protect
from
sexually
transmitted
diseases/reproductive
tract
infections
(STDs/RTIs). This was similar to in a study done
by Parey et al 12 who showed that 94.8% were not

sure whether ECs protect from STDs/RTIs.
In the present study, most of the study
participants think that ECPs were safe for their
users.Other authors 7,8,13 also reported similar
findings..About 34.29% participants thought
providing ECPs would discourage the consistent
use of condoms compared to 53.4% of students
in Ghana 7 and 38.4% of university students in
Cameroon 8.Participants agreed that EC should
be sold only on prescription and about 35%
discouraged its distribution by paramedical staff.
Singh et al 11 in his study revealed that 65% of
doctors agreed that EC should be sold only on
prescription and more than half discouraged its
distribution by paramedical staff. The majority
(61.43%) of the respondents did not agree that
EC is good for women's reproductive health.
Similarly, a study done by Parey et al 14 also
found that 75.8% of the participants thought that
ECs were harmful to the body.
CONCLUSION
The study suggested that participants had an

overall positive attitude toward EC but there was
a lack of knowledge regarding the effectiveness,
mechanism of protection from RTI/STDs. So,
there is a need to further educate them about EC.
The medical curriculum must be updated
regularly about the new methods of
contraceptives so that the community at large
gets benefited.
503
Keerti et al.,
ACKNOWLEDGEMENT
We would like to thank the participants for their

co-operation.
REFERENCES
1. Physicians for Reproductive choice and

Health (PRCH) and Alan Guttmacher
Institute (AGI): An overview of abortion in
the United States. New York :PRCH and
AGI;2003.
2. World Health Organization (WHO): Unsafe
abortion-Global and regional estimates of the
incidence of unsafe abortion and associated
mortality in 2004.4th edition. Geneva: World
Health Organization; 2004.
3. Dreze J, Murthi M. Fertility, education and
development: evidence from India. Popult
Develop Rev.2001;27:33-64.
4. Sarin AR. Gender apartheid and its impact in
Indian womens reproductive health. Indian J
Maternal and Child Health.1992; 3:33-35.
5. Tripathi R, Rathore AM, Sachdeva J.
Emergency
contraception:
Knowledge,
attitude and practices among health care
providers in North India. J Obstet Gynaecol
Res.2003;29:142-6.
6. Puri S, Bhatia V, Swami HM, Singh A,
Sehgal A, Kaur AP. Awareness of emergency
contraception among female college students
in Chandigarh, India. Indian J Med Sci.
2007;61:338-46.
7. Baiden F, Awini E, Clerk C. Perception of
university students in Ghana about
emergency
contraception.
Contraception.2002;66:23-26.
8. Kang HS, Moneyham L. Use of emergency
contraceptive pills and condoms by college
students:
A
survey.
Int
J
Nurs
Stud.2008;45(5):775-83.
9. Harper C, Ellerton C. The emergency
contraceptive pill: a survey of knowledge and
attitudes among students at Princeton
University. Am J Obstet Gynecol.

1995;73:1438-45.
10. Kongnyuy EJ, Ngassa P, Fomulu N,
Wiysonge CS, Kouam L, Doh AS. A survey
of knowledge, attitudes and practice of
emergency contraception among university
students in Cameroon. BMC Emerg Med.
2007; 7:7.
11. Muia E, Ellertson C, Lukhando M, Flul B,
Clark S, Olenja J. Emergency contraception
in Nairobi, Kenya: Knowledge, attitudes and
practices among policymakers, family
planning providers and clients, and university
students. Contraception. 1999; 60:223-32.
12. Abdulghani HM, Karim SI, Irfan F.
Emergency contraception: Knowledge and
attitudes of family physicians of a teaching
hospital, Karachi, Pakistan. J Health Popul
Nutr 2009;27:339-44.
13. Singh S, Mittal S, Ananda lakshmy PN, Goel
V. Emergency contraception: Knowledge and
views of doctors in Delhi. Health Popul
Perspect Issues .2002; 25:45-54.
14. Parey B, Addison L, Mark JK, Maurice B,
Tripathi V, Wahid S, et al. Knowledge,
attitude and practice of emergency
contraceptive pills among tertiary level
students in Trinidad: A cross-sectional
survey. West Indian Med J .2010;59:650-5
504
Keerti et al.,
DOI: 10.5958/j.2319-5886.2.3.088

&
Health Sciences
www.ijmrhs.com
Coden: IJMRHS
th
Research article
Copyright @2013
ISSN: 2319-5886
th
A STUDY ON BEHAVIOURAL CHANGES INDUCED BY COLD WATER STRESS IN

SWISS ALBINO MICE
Suresh. M1, *Chandrasekhar M1, Nikhil Chandrasekhar2, Ambareesha Kondam1, Madhuri BA1,
Gajalakshmi G1
Department of Physiology1, Department of Anesthesialogy2, Meenakshi Medical College Hospital & RI,
Enathur, Kanchipuram, Tamilnadu, India
*Corresponding author email: mchandru1959@hotmail.com
ABSTRACT
Introduction: Stressful condition induces physiological and behavioral changes in an organism to

maintain the normal homeostasis. The response to stress is regarded as a positive adaptive process of an
organism, which consist of a set of physiological and behavioral reactions to cope up with the
challenging situations. In animals, stress study has shown to affect locomotor activities and behavioral
changes. The present study was to determine the effect of cold water stress in different duration on
neurobehavioral changes in swiss albino mice. Material and Methods: Male swiss albino mice
weighing about 20 to 25gm were chosen for the study. The study consists of 4 groups (i) control, (ii) 1
day cold stress, (iii) 7 days cold stress and (iv) 14 days cold stress. The cold stress procedure was done
by allowing the animal to swim in cold water at 14C for 5minutes every day. After the stress period, the
neurobehavioral parameters were studied by using open field behavior and elevated plus maze. Results:
There was a significant decrease in ambulation, rearing, grooming with a significant (P<0.001) increase
in immobilization time of 1 day cold stress exposed group and 7th day cold stress exposed group in open
field behavior model, whereas the 14th day stress group showed a significant decrease in ambulation
only. In elevated plus maze, time spent in open arm was significantly decreased in 1st and 7th day stress
group (P<0.001) and the number of entries in open arms and closed arms was significantly decreased in
all stress exposed groups when compared with their respective control groups. Conclusion: Cold stress
can affect hypothalamic- pituitary adrenal axis and thereby increase anxiety resulting in change in
behavior and locomotor activity. When the stress period was prolonged to 7-14 days, there was a gradual
recovery back to near normal. This type of behavior of the animals to prolonged stress could be
attributed to habituation of the hypothalamo-pituitary adrenal axis.
Keywords: Cold stress, open field behavior, elevated plus maze, and immobilization.
INTRODUCTION
Stressful condition induces physiological and

behavioral changes in an organism to maintain
the normal homeostasis. The response to the

stress is regarded as a positive adaptive process
505
Suresh et al.,
of an organism, which consist of a set of

physiological and behavioral reactions to cope
up with the challenging situations. In animals,
stress study has shown to affect locomotor
activity and behavioral changes along with
exploratory behavior. The forced swimming
stress developed by has now become widely
accepted model for studying physical stress in
animals1. In swimming stress, water temperature
plays an important role. When the water
temperature falls below 18oC, it affects both the
physical and mental task. Cold water stress
affects the animal directly by cold exposure to
the whole body at a time. By varying the water
temperature, it is found that rats could survive
as long as 80 hours in lukewarm water (36oC)2.
Any kinds of stress stimulus can results in a
significant activation of the sympathoadrenal
medullary system and a measurable change in
the behavior. When the animal is subjected to
acute stress, a wide range of physiological and
behavioral changes takes place, chronic
exposure results in to habituation or adaptation
occurs, but it depends upon the intensity and
duration of the stress. In all type of stress it has
been observed that there is increase production
of corticosterone in plasma and also it has been
reported that exposure to stress situations can
stimulate numerous pathways, leading to
increased production of oxygen free radicals,
free radicals generate a cascade producing lipid
peroxidation. Lipid peroxidation is one of the
main events induced by oxidative stress7. The
present study is to determine the effect of cold
water stress by different duration on
neurobehavioral changes in Swiss albino mice.
The study was approved by Institutional Animal

Ethics Committee. Healthy adult male Swiss
albino mice weighing (20-25gms) were used for
the study. Mice were housed under standardized
conditions with free access to food and water.
Animal procedures were performed in

accordance with the Ethics Committee. The
study consist of four groups, Group I control,
Group II 1 day cold stress, Group III 7 days
cold stress and Group IV 14 days cold stress.
The cold water stress procedure was done by
allowing the animal to swim in bucket containing
cold water at the depth of 20cm and the
temperature was maintained at 14C for 5
minutes20.
Parameters : The neurobehavioral parameters
were studied by using Open field behavior model
(Saillen faint et al) and Elevated Plus Maze
(Pellow et al). Exploratory and locomotor
behavior was assessed by placing animals
individually into an open-field box marked off
into 25 equal squares. A mouse is placed on one
corner of the apparatus and is observed for 5
minutes. The parameters noted are a) Ambulation
b) Immobilization c) Rearing d) Grooming and e)
Urination.
The anxiety of the animal was assessed by using
elevated plus maze apparatus. The parameters
noted are
a) Time spent in open arm, b) Number of open
arm entries and c) Number of closed arm entries.
RESULTS
All data were analyzed by using students t-test,

There was a significant decrease in ambulation,
rearing, grooming with a significant (P<0.001)
increase in immobilization time of 1 day cold
stress exposed group and 7th day cold stress
exposed group in open field behavior model
(table-1) , whereas the 14th day stress group
showed a significant decrease in ambulation
only. In elevated plus maze, time spent in open
arm was significantly decreased (table-2) in 1st
and 7th day stress group (P<0.001) and the
number of entries in open arms and closed arms
was significantly decreased in all stress exposed
groups when compared with their respective
control groups.
506
Suresh et al.,
Table: 1 Behavioral study - Open-field test
Test name
Peripheral
Duration of stress
1 day
Mean S.D
44.1713.63
P- value
0.0001
ambulation
control : 91.55.43
Central
ambulation
control : 11.002.19
Rearing
7 days
14 days
1 day
7 days
14 days
1 day
46.6713.71
68.0011.80
3.002.37
4.172.40
6.171.83
28.505.43
0.0001
0.0030
0.0001
0.0002
0.0021
0.0127
(no of times/5min)
control : 44.8310.93
Grooming
(no of times/5min)
7 days
14 days
1 day
7 days
28.837.33
35.009.38
18.835.46
21.337.20
0.0160
0.1260
0.0103
0.0480
control : 27.673.88
Immobilization
(no of times/5min)
control 27.177.31
14 days
1 day
7 days
14 days
25.1710.32
59.3311.59
59.008.81
35.6717.40
0.5976
0.0004
0.0000
0.3078
Test name
Time spent in
Duration of stress
1 day
Mean S.D
9.837.31
P- value
0.0001
open arm
7 days
126.9
0.0001
control : 33.35.16
14 days
27.677.74
0.1709
No of open arm
1 day
0.50.55
0.0012
entries
7 days
1.171.03
0.0100
control : 3.331.21
14 days
1.51.05
0.0190
No of closed arm
1 day
10.89
0.0001
entries
7 days
1.170.75
0.0001
control : 4.00.89
14 days
2.171.17
0.0131
* Significant P < 0.05

Table: 2 Elevated plus mice
Significant P < 0.05

DISCUSSION
Cold water stress, as a natural stressor, may have

its own unique pattern of neurobehavioural
changes, results of the study provide the
information that, cold water stress may affect the
locomotor activity and increase the anxiety like
behaviour, and when the stress period continues,
there is recovery back to near normal, the
probable reason could be as follows,

Physiological response to stress is activation of
the hypothalamic pituitary - adrenal axis and
subsequent release of corticosterone which in
turn accelerate the generation of free radicals.
Excessive production of free radicals resulted in
oxidative stress, which leads to damage of
507
Suresh et al.,
macromolecules and cause degeneration of

tissues7. Excessive shivering due to cold stress
contributes to fatigue and makes performance of
motor skills more difficult and altered
excitability of the nervous system8. Repeated
stress on a daily basis may impair the antioxidant
defenses in the body leading to oxidative damage
by changing the balance between oxidant and
antioxidant factors. The increased levels of
reactive oxygen species under stress conditions
could be due to the increased concentration of
glucocorticoids. It has been reported that these
hormones exacerbate reactive oxygen species
(ROS) generation in the body9. Decreased
activities of the antioxidant enzymes have been
observed in the brain of rats treated with
glucocorticoids10. An increase in lipid
peroxidation indicates the increase in the free
radical generation due to repeated stress and a
decrease in resistance against stress. Increasing
stress was reported to enhance stress-induced
tissue damage and malfunction11. Oxidative
stress is a central feature of many diseases and
stress-induced damage to these tissues may be
the cause of severe stress disorders after repeated
stress exposure. Numerous studies have shown
that strenuous physical exercise can increase free
radical production and cause oxidative damage12.
Apart from repeated swimming exercise,
decreased water temperature also produced
severe stress in rats and these two factors
together might have caused increased free radical
production in various tissues13. Brain serotonin is
involved in mood disorders such as depression
and anxiety as well as in nociception and
thermoregulation14. The hyperactive serotonergic
system causes anxiety like behavior in rodents
and humans15,16, the activation of the
serotonergic system may thus contribute to the
development of anxiety- related disorders. The
cold stressed mice may thus be related to the
serotonergic system. Cold stress was shown to
decrease serotonin in various brain areas of mice
such as the cerebral cortex, hypothalamus,
thalamus and midbrain17.
Forced swimming stress significantly lowered

the serotonergic ratio and also markedly
enhanced the phosphorylation of ERK1/2
(extracellular signal regulated kinase) in the
hypothalamus region and this may be the key
mechanism for the development of depression to
the animal18.
Repeated cold stress produces a
specific pattern of changes in spontaneous
activity and responses to sensory stimuli in
lateral hypothalamic area (LHA) and medial
hypothalamic area (MHA) neurons; this could
underlie the behavioral changes induced by
repeated cold stress such as hyperphagia and
hyper-reactivity to sensory stimuli19-21. Behavior
changes of the animals to prolonged stress could
be attributed to habituation of the hypothalamic pituitary-adrenal axis7.
CONCLUSION
Cold stress affects the locomotor activity and

altered the behavioral parameters in open field
behavioral model and elevated plus mice. Cold
stress affect hypothalamic- pituitary adrenal axis
and when the stress period was prolonged to 7-14
days, there was a gradual recovery back to near
normal, which shows the animal is getting
adopted slowly. But the adaptation of the animal
depends on the duration of stress period and
intensity of stress.
ACKNOWLEDGEMENT
I would like to express my deep and sincere

gratitude to my guide Prof. Dr. M.
Chandrashekar, M.D., Ph.D.,and my co-guide
Dr. Gajalakshmi and It is my privilege to thank
all colleagues and friends who helped me to
successes this research work.
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Understanding
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characteristics and caveats. Alcohol Res
Health.1999;23:241-49.
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toxicological investigations. Human and Exp
Toxicol.1993;12: 265-71
16. Tan N, Morimoto K, Sugiura T, Morimoto A,
and Murakami N. Effects of running traning
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the blood glucose and lactate in rats
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M. Biological effects of single and repeated
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DOI: 10.5958/j.2319-5886.2.3.089

&
Health Sciences
Received: 18 th May 2013
Research article
STUDY OF BACTERIOLOGY IN CHRONIC SUPPURATIVE OTITIS MEDIA

*Kusuma Bai S1, Venkateswarlu K1, Bala Krishna 2, Ashokreddy3, Prasad Rao N4
1,4
Department of Microbiology, Fathima Institute of Medical Sciences, Kadapa, Andhra Pradesh, India.
Assistant professor Department of Microbiology, Shanthi ram Medical College, Nandyala, Andhra
Pradesh, India.
3
Apex diagnostic and medical imaging center, Khammam, Andhra Pradesh, India.
2
*Corresponding author E-mail: kusumabai9@gmail.com

ABSTRACT
The present study was to know the different etiological aerobic and anaerobic bacteria in chronic
suppurative otitis media and also its antibiogram. Methods: The total 128 specimens collected by
aseptical conditions and examine microscopically and cultured for bacteria, antibiotic sensitivity testing
was done by Kirby Bauer disk diffusion method. Result: The bacteriological studys on the 128 cases
124 samples yielded growth and 4 were sterile. On culture positives 84 were pure isolates and 40 were
mixed isolates. In single organism isolates 78 were aerobic and 6 were anaerobic organism in mixed
infection 40 cases aerobic organisms. Conclusion: The study revealed aerobes as prominent causative
agents of CSOM (61%) followed by mixed isolation (31%) and anaerobes (5%) highest incidence is
observed age group of 0-20 years. The prevalence is more in males.
Keywords: Chronic suppurative otitis media, aerobic, anaerobic bacteria & antibiogram
INTRODUCTION
Chronic suppurative otitis media (CSOM) is

characterized by a long standing inflammation of
the middle ear1. CSOM was found to be a single
major cause of conductive deafness and was
responsible for 60.27 % of cases2.. The
incidences are so high that about 30% of patients
who attend ENT out patient department suffer
from CSOM. Otitis media is an inflammation of
the middle ear and mastoid cavity. This presents
with recurrent ear discharges are otorrhoea
through a tympanic membrane. Otitis media may
also be categorized as acute, sub-acute, chronic,
with discharge or without discharge3. The
recurrent episodes of otorrhoea and mucosal

changes are characterized by osteoneogenesis
bony erosions and osteitis that include temporal
bone and ossicles4. The understanding of
pathology and bacteriology of otitis media
assumes practical significance in the prevention
of disease or minimize the complications.
In CSOM the wide range of microorganisms both
aerobic
(eg:
Pseudomonas
aeruginosa,
Escherichia coli, streptococcus pyogenes,
proteous mirabils, klebsiella species) and
anaerobic (eg: Bacteroids, Peptostreptococcus,
Propioni bacterium) and fungi (eg: Candida,
510
Kusuma etal.,
Aspergillus, Penicillium and Rhizopus) are

associated5 . The bacteria are frequently found in
the skin of external canal, but may proliferate in
the presence of trauma, inflammation, lacerations
are high humidity. These bacteria may entry to
the middle ear through a chronic perforation.
Among these bacteria Pseudomonas aeroginosa
has been particularly blamed for deep seated and
progressive destruction of middle ear and
mastoid structures through its toxins and
enzymes 6.
The present work was undertaken to study the
aerobic as well as the anaerobic flora involved in
the causation of CSOM and the antibiotic
susceptibility pattern.
The present study consists of the total number of

128 specimens of ear discharge from patients
suffering with chronic suppurative otitis media
attended ENT O.P and ward of either sex in
Government General Hospital, Karnool during
the period 2006 June to December 2006.
Inclusion criteria: None of them had received
antibiotics for earlier seven days. Purulent
discharge samples from the clinically diagnosed
cases of CSOM
The ear discharge collected by using 3 sterile
cotton swabs under aseptic conditions. A 1st
swab was dipped immediately in Hartleys broth
for aerobic culture. The 2nd swab was dipped
immediately in thioglycollate medium for
anaerobic culture. The 3rd swab was used for
smear preparation & stained with grams staining
and then examine microscopically for bacteria,
inflammatory cells, epithelial cells & pus cells

etc.
The first swab was sub cultured on blood ,
macconkeys and chocolate agar and incubated
aerobically at 37C for an overnight, The 2nd
swab was sub cultured on blood agar and
chocolate agar and incubated anerobically at
37C for an over night, all organisms isolated
were identified
according to standard
microbiological methods and mentioned in the
Tables: 01,02 and 03.
Antimicrobial susceptibility test was performed
using Kirby-Bauer disk diffusion method
according to practical medical microbiology text
book guide lines7 antimicrobial discs (Himedia
laboratories Pvt Ltd), used were Amikacin
(30g) (AK-SD035), Gentamicin (10g) (GENSD016), Ofloxacin (5g) (OF-SD087), Ceftazidime
(30g)(CAZ-SD062),
Pipercillin
(100g)(PISD066), Ciprofloxacin (5g)(CIP-SD060), Cotrimoxazole (25g) (COX SD071), Ampicillin
(10g) (AMP-SD0002), Cloxacillin (10g) (CMSD008) and Vancomycin (10g) (VA-SD163),
RESULTS
In this study 61 % of patients were males and

44% were females patients ranged from 0-62
years with the majority of them (80%) belonged
to 0-20 years of age. The results of the
bacteriological studies on the 128 cases 124
samples yielded growth and 4 were sterile. On
culture positives 84 were pure isolates and 40
were mixed isolates. In single organism isolates
78 were aerobic and 6 were anaerobic organism
in mixed infection 40 cases aerobic organisms.
Table.1: Type of growth, Amount of isolates and Percentage
Type of organism
Pure growthAerobes
Anaerobes
Mixed growth
No growth
Total growth
Amount of isolates
78
06
40
04
128
Percentage
65
5
31
3
100
Pseudomonas species 37 (31.65) was the commonest microbial organism to cause ear discharge followed by
staphylococcus aureus 29 (24.45) and Proteus mirabilis 19 (16.1%)
511
Kusuma etal.,
Table.2: Name of the isolated aerobic organism, Number and Percentage
Organisms
Number
Percentage
Pseudomonas aeruginosa
37
31.6
Staphylococcus aureus
29
24.5
Proteus mirabilis
19
16.1
Klebsiella pneumonia
16
13.5
Escherichia coli
7
5.93
Coagulase negative staphylo cocci
5
4.23
Streptococcus pneumonia
4
3.9
Entero cocci
1
0.84
Total
118
100
Among anaerobic isolates Bacterioides species 18(39.1%) commonest microbial organism followed by
peptostreptococci 13 (28.26%) and fuso bacterium 5(10.87%)
Table.3: Name of the isolated anaerobic organism, number and percentage
Organisms isolated
Bacterioides fragilis
Bacterioides melaninogenicus
Peptostreptococci
Fusobacterium
Veillonella
Propionibacterium
Total
Number
18
6
13
5
2
2
46
The antimicrobial sensitivities of the bacteria

were tested and the results for most common
bacteria include Pseudomonas aeruginosa was
shown to be susceptible
to ceftazidine
Amikacin, co-trimoxazole oflaxacin,gentamicin
while staphylococcus aureus was sensitive to
ceftazidine,oflaxacin erythromycin, Gentamycin
& Amikacin and Bacterioides species were
more susceptible to Chloram phenicol and
Metronidazole
DISCUSSION
Chronic suppurative otitis media (CSOM) is a

condition of the middle ear that is characterized
by persistent or recurrent discharge through a
chronic perforation of tympanic membrane. Due
to the perforated tympanic membrane, the
bacteria can gain entry into the middle ear via the
external ear canal. Infection of the middle ear
mucosa subsequently results in ear discharge.
percentage
39.13
13.04
28.26
10.87
4.35
4.35
100
Early bacteriological diagnosis of all cases will

assure accurate and appropriate effective therapy.
Treatment hence needs to be instituted early and
effectively to avoid complications.
Based on results from present study, the most
common aerobic organisms of CSOM were P.
aeruginosa, S.aureus, P. mirabilis and
Klebsiella. These findings correlate with earlier
studies8,. Similarly, P. aeroginosa was the most
prevalent organism followed by S. aureus,
isolated from CSOM cases reported in several
studies9,10. With the development and widespread
use of antibiotics, the types of pathogenic
microorganisms and their resistance to antibiotics
have changed11.
Ceftazidime was found to be the most sensitive
antibiotic from the antimicrobial profile of
testing microorganisms which is also comparable
to the study done by S.Nikakhlagh et al
12
.Almost all isolates were sensitive to
512
Kusuma etal.,
Ceftazidine.
Pseudomonas
aeruginosa,
Escherichia coli and Klebsiella sp. showed
76.2% sensitivity to Amikacin. Pseudomonas
aeruginosa were sensitive to aminoglycosides,
i.e., Amikacin and Gentamicin and it is also
supported by previous studies in Nepal 13, India
and Mansoor T et al (2009) 14, Chloram phenicol
and metronidazole were found to be most
sensitive antibiotics of anaerobic organisms15.
Bacterioides species, peptostrepto cocci and
fusobacterium, Lower sensitivity rate of
penicillin (14.4%) was comparative study done
by Indudharan et al15.In accordance to our study
shows 88% of isolates were found to be sensitive
to ceftazidime. The antibiotic sensitivity pattern
of Staphylococcus aureus in our study revealed
that 76.2% to Amikacin, 63.6% to Gentamicin,
and 69% to ofloxacin.
CONCLUSION
The present study suggests that the common

etiological agents for Chronic Suppurative Otitis
Media were aerobic organisms Pseudomonas
aeruginosa,
Staphylococcus
aureus
and
anaerobic organisms were Bacterioides species,
peptostreptococci and fusobacterium. The
antimicrobial susceptibility studies showed
ceftazidine and chloramphenicol as the most
effective antibiotics, the highest incidence
observed in the age group of 0-20 years and the
prevalence is more in male.
ACKNOWLEDGEMENTS
We acknowledge of Mr. AQ JAVVAD, The

Secretary, Fathima Institute of Medical sciences,
Kadapa District, A.P.
REFERENCES
1. Goycoolea M, Ruah L. Definitions and

Terminology. Otol Clin of North Am. 1991;
24:757-61.
2. Ogisi FO. Impedance screening for otitis
media with effusion in Nigerian children.
J.L.O.1988; 102:986-88.
3. Okafor B.C.. The chronic discharging ear in

Nigeria , J.L.O 1984, 98:113-9.
4. Daly KA, Hunter LL, Levine SC, et al.
Classification of otitis media. Laryngoscope
1998; 108:130610.
5. Shazia Parveen SJ. Aerobic bacteriology of
CSOM in ateaching hospital. Microbiol and
Biotech.Res. 2012, 2(4); 108:1306-10.
6. Hayne DS. Properative antibiotics in CSOM
. Ear Nose Throat J 2002. 81: 13-15.
7 Mackie & Mc cartney practical medical
microbiology 14th edition.2006; 151-62.
8 Saini S, Gupta N, Aparna, Seema, Sachdeva
OP. Bactriological study of paediatric and
adult CSOM . Indian J Pathol Microbiol
2005; 48:41316.
9 Shyamala R and Sreenivasulu Reddy P.The
study of bacteriological agents of CSOM . J.
Microbiol & Biotech. Res. 2012; 2 (1):15262.
10 Smith JA and Danner CJ. CSOM and
cholsteatoma. Otolaryngol. Clin. North Am.,
2006; 39: 1237-55.
11 Yeo SG, Park DC, Hong M, Cha CI and. Kim
MG, Bacteriology of CSOM a multicenter
study. Acta Otolaryngol. 2007; 127: 1062-67.
12 Nikakhlagh S, Khosravi AD, Fazlipour A,
Safarzadeh M and Rashidi N. Microbiologic
findings in patients with CSOM. Journal of
Medical Sciences . 2008; 8: 503-06.
13 Sharma S, Rehan HS, Goyal A, Jha AK,
Upadhyaya S and Mishra SC.Bactriological
Profile in CSOM. Trop Doct 2004; 34:1024.
14 Mansoor T, Musani MA, Khalid G, Kamal
M. Pseudomonas aeruginosa in CSOM . J
Ayub Med Coll Abbottabad. 2009;
21(2):120-3.
15 Indudharan, Haq JA And Aiyar S. Antibiotic
study in CSOM. Ann. Otol.Rhino
laryngol.1999; (5):440
513
Kusuma etal.,
DOI: 10.5958/j.2319-5886.2.3.090

&
Health Sciences
Received: 21 th May 2013
Research article
Copyright @2013
ISSN: 2319-5886
A STUDY OF ENTERIC PARASITIC INFECTIONS IN HIV/AIDS AND HIV SERO

NEGATIVE INDIVIDUALS IN POPULATION OF KHAMMAM DISTRICT
*Venkateswarlu K1, Kusuma Bai1, Bala Krishna2, Ashokreddy3, Prasad Rao4
1,4
Department of Microbiology, Fathima Institute of Medical Sciences, Kadapa, Andhra Pradesh, India
Assistant Professor Department of Microbiology, Shanthiram Medical College, Nandyala, Andhra
Pradesh, India.
3
Apex diagnostic and Medical Imaging Centre, Khammam, Andhra Pradesh, India
2
*Corresponding author email: kethavenkat9@gmail.com

ABSTRACT
The aim of this study was to verify that the occurrence of intestinal parasitic infections in human
immunodeficiency virus (HIV) /acquired immunodeficiency syndrome (AIDS) patients in comparison
with non-HIV individuals in Mamata General Hospital, Khammam, and Andhra Pradesh. Method: A
total of 125 cases in which Group A comprised of 55 male and 20 female HIV/AIDS positive individual
patients of age between 15 to 59 and Group B comprised of the 34 male and 16 female HIV sero
negative individuals of the same age group , stool were collected for parasitological examination from
Jan 2009 to June 2009. Results: various enteric parasites detected in sero positive patients include
Cryptosporidium (06), Isospora (01), Entamoeba histolytic (02), Giardia intestinalis (03) and Ascaris
lumbricoides (01) and in sero negative individuals include Entamoeba histolytic (03), Giardia
intestinalis (02) and Ascaris lumbricoides (01). Conclusion: The present results emphasize that
detection of intestinal parasites were 17.3% in sero positive patients and 12% in sero negative
individuals, in sero positive cases with diarrhea detection of intestinal parasites were 50% where as in
sero negative cases without diarrhea it was only 7.01%. Coccidian parasites (cryptosporidium and
Isospora) were detected only in sero positive cases with diarrhea and not detected in sero positive cases
without diarrhea or HIV negative individuals.
Keywords: Study, opportunistic parasitic infections, HIV Sero positive & Negative individuals.
INTRODUCTION
A wide variety of gastrointestinal manifestations

mainly opportunistic enteric parasitic infections
are described in patients with HIV infection1.
Identification of etiological agent of Diarrhoea in
HIV patient is very important as it can help in
institution of appropriate therapy and reduction
of morbidity and mortality2. Reports indicate that

diarrhoea occurs in 30-60% of AIDS patients in
developed countries and in about 90% of AIDS
patients in developing countries3.
Diarrhoea is the presenting symptom of
approximately a third of patients with HIV
514
Venkateswarlu et al.,
infection. Chronic diarrhoea significantly reduces

the quality of life in patients with HIV infection
and is an independent predicator of mortality in
AIDS. A variety of enteric pathogens have been
isolated from AIDS patients with diarrhoea but it
is not clear that these enteric infections are
necessarily associated with the presence of
diarrhoea4. The diarrhoea wasting syndrome in
association with a positive HIV serology test is
an AIDS-defining in World Health Organization
(WHO)s classification5.
The etiologic spectrum of enteric pathogens
causing diarrhoea includes bacteria, parasites,
fungi and viruses6. The presence of opportunistic
parasites Cryptosporidium parvum, Cyclospora
cayetanensis, Isospora belli and Microsporidia
are documented in patients with AIDS7. In
immunocompromised patients, the intestinal
opportunistic parasites probably play a major
role in causing chronic diarrhoea accompanied
by weight loss8. C. Parvum, I. belli and
E.histolytica have been reported as the most
frequently identified organisms in HIV infected
individuals with diarrhoea from India and other
parts of the world 9-16.
The Present study was conducted from January

2009 to June 2009 at the Mamata General
Hospital Khammam Andhra Pradesh. Study sero
group: 75 HIV reactive (positive) (age15 to 59
years) & comprised of 55 males & 20 females
HIV positive patients. Control group:
comprised of 50 HIV non-reactive individuals
(34 males+ 16 females) of the same age group.
Stool samples were collected from these patients,

after collecting relevant information such as age,
sex, occupation, present complaint & treatment
given etc. Both diarrheic & non diarrheic stool
samples were collected, and examined for
parasitological examination.
Examination of specimens: Every specimen
was collected in 10% buffered formalin in a
clean wide-mouthed plastic container and was
subjected to concentration by a formalin-ethyl
acetate concentration technique. Specimens were
then examined as wet saline mounts and in
iodine preparation for the detection of protozoan
cysts or oocysts, helminth eggs and larvae. Also,
a modified version of the Ziehl-Neelsen
technique was used for the staining of
Cryptosporidium and other coccidian parasites.
RESULTS
A total of 125 (75+50) stool samples were

subjected to microscopic examination for the
presence of any protozoal cyst or trophozoites,
helminthic ova or larvae followed by special
techniques to detect oocysts of coccidian
parasites various enteric parasites detected in
HIV positive and negative individuals are shown
in table 01. Among 75 HIV positive patients, 18
patients presented with diarrhoea. Difference in
isolation of enteric parasites in HIV-positive
patients with or without diarrhoea is shown in
table 02. Table 03 shows the comparative
detection of enteric parasites in patients
with/with out ART. Detection of enteric
parasites, especially coccidian parasites was
more in patients with out ART.
Table.1: Enteric parasites Detected from HIV positive patients and control group
Parasite species
Cryptosporidium parvum
Isospora
Entamoeba histolytica
Giardia intestinalis
Ascaris lumbricoides
Total
HIV positive(N=75)
06(8%)
01(1.33%)
02(2.67%)
03(4)
01(1.33%)
13(17.3%)
HIV Negative(N=50)
00
00
03(6%)
02(4%)
01(2%)
06(12%)
515
Table.2: Enteric parasites in HIV positive patients with or without diarrhoea and in HIV negative
individuals
Parasite species
Isospora
Total
HIV positive with

Diarrhoea
(N=18)
06
01
01
01
00
09
HIV positive with out

diarrhoea
(N=57)
00
00
01
02
01
04
HIV negative
individuals
(N=50)
00
00
03
02
01
06
Table.3: Association of enteric parasites and antiretroviral therapy (ART) of HIV Positive
Parasites
Isospora
Total
On ART
02
00
01
02
01
06
Without ART
04
01
01
01
00
08
DISCUSSION
The pathogens causing gastrointestinal illness in
HIV infected patients include a wide spectrum of
opportunistic and non-opportunistic parasitic
pathogens.10
Diarrhoea
is
a
common
complication of HIV infection it may be acute or
chronic, several of these parasitic infections were
almost unknown cause of human disease.
Amongst
these
enteric
parasites,
Cryptosporidium spp and Isospora belli have
gained importance and are considered to cause
AIDS defining illness.12 Common parasites such
as Entamoeba histolytica and Giardia intestinalis
associated with diarrhoea in these patients.
The present study documented that infection with
enteric parasites was common in HIV positive
patients having diarrhoea. Out of 75 HIV-sero
positive cases studied 18(24%) cases had
diarrhoea. Detection of enteric parasites from
HIV positive patients having diarrhoea was
significantly higher (9/18, 50%) and statistically
significant, compared to the patients without
diarrhoea (7.01%) and HIV negative patients
(12%). Isolation rates in this study of
Cryptosporidium (8%), Giardia (4%) and

Isospora belli (1.33%) from HIV positive
patients
Actual
rate
of
this
infection
in
immunocompromised individuals and AIDS
patients likely to be underestimated due to
asymptomatic shedding of oocysts and treatment
with trimethoprim sulphamethoxazole for other
infections in AIDS patients (Pneumocystis
carinii pneumonia) , which may confer some
protection against this parasite.
CONCLUSION
In this study detection of intestinal parasites was

17.3% in HIV positive patients and 12% in HIV
Negative individuals. HIV positive cases with
diarrhoea were 50% whereas HIV negative cases
without diarrhoea were 7.01%. Coccidian
parasites, Cryptosporidium and Isospora were
detected only in HIV positive cases with
diarrhoea. They were not detected in HIV
516
positive cases without diarrhoea or HIV negative

individuals.
ACKNOWLEDGEMENTS
We acknowledge of Mr. A. Q. JAVVAD, The

Secretary, Fathima Institute of Medical sciences,
Kadapa District, A.P. We also like to express our
thanks to Dr.Prtibha mane, Dr.Neelam Sharma
Dr. Anuradha and Dr Vijay durga, Department of
Microbiology
Mamata
Medical
College
Khammam for their help in conducting the
research work.
REFERENCES
1. Talib SH,Jeet Singh.A study of opportunistic

enteric parasites in 80 HIV seropositive
patients. Indian J. Pathol. Microbiol. 1998;
41(1):31-37
2. Kumar S S, Ananthan S, Saravanan P. Role
of coccidian parasites in causation of
diarrhoea in HIV infected patients in
Chennai. Indian J Med Res 2002; 116:85-89.
3. Framm SR, Soave R. Agents of diarrhea.
Med Clin North Am1997; 81: 427-47.
4. Mukhopadhya A, Rama Krishna BS, Kang
G,Anna B. Enteric pathogens in southern
Indian-infected patients with and without
diarrhoea. Indian J.Med Res 1999; 109:85-89
5. Hailemariam G, Kassu A, Abebe G, Abate E
et al.Intestinal parasitic infections in HIV
/AIDS and HIV sero negative individuals in a
Teaching
Hospital,
Ethiopia.
Jpn
.J.Infect.Dis.2004; 57:41-43.
6. Mitra AK, Hernandez CD, Hernandez CA,
Siddiq Z.Management of diarrhea in HIV
infected patients. Int J STD AIDS 2001; 12:
630-9.
7. Good game RW. Understanding intestinal
spore forming protozoa: Cryptosporidia,
Microsporidia, Isospora and Cyclospora. Ann
Intern Med 1996: 124: 429-41.
8. Hammouda NA, Sadaka HA, EI-Gebaly
WM,
EI-Nassery
SM.
Opportunistic
intestinal protozoa in chronic diarrheic
immunosuppressed patients. J Egypt Soc

Parasitol 1996; 26: 143-53.
9. Sapkota D, Grimier P, Manandhar S. Enteric
parasitosis in patients with human
immunodeficiency virus (HIV) Infection and
acquired
immunodeficiency
syndrome
(AIDS) in Nepal. J Nep Health Res Council
2004; 2: 9-13.
10. Gumbo Tawanda,
Sarbah Steedman,
Gangaidzo InnocentT, Ortega Ynes, Streling,
Charles R, Carville Angela, et al. Intestinal
parasites in patients with diarrhea and human
immunodeficiency virus
infection
in
Zimbabwe. AIDS 1999; 13: 819-21.
11. Prasad KN, Nag VL, Dhole TN, Ayyagari A.
Identification of enteric pathogens in HIVpositive patients with diarrhea in northern
India. J Health Popul Nutr 2000; 18: 23-6.
12. Mukhopadhyay A, Ramakrishna BS, Kang
G, Pulimood AB,Mathan MM, Zacharian A,
et al. Enteric pathogens in southern Indian
HIV-infected patients with & without
diarrhea. Indian J Med Res 1999; 109: 85-9.
13. Dwivedi KK, Prasad G, Saini S, Mahajan S,
Lal S, Baveja UK. Enteric opportunistic
parasites among HIV- infected individuals:
associated risk factors and immune status.
Jpn J Infect Dis 2007; 60: 76-81.
14. Mohandas, Sehgal R, Sud A, Malla N.
Prevalence of intestinal parasitic pathogens in
HIV-seropositive individuals in Northern
India. Jpn J Infect Dis 2002, 55: 83-4.
15. Ramakrishna K, Shenbagarathai R, Uma A,
Kavitha K, Rajemdran R, Thirumalai P.
Prevalence of intestinal parasite infestation in
HIV/AIDS patients with diarrhea in Madurai,
South India. Jpn J Infect Dis 2007; 60: 20910.
16. Anand L, Dhana chand C, Brajachand N.
Prevalence & epidemiologic characteristics
of opportunistic and non opportunistic
intestinal parasitic infections in HIV positive
Patients in Manipur. Natl Med J India 2002;
15: 72-4.
517
DOI: 10.5958/j.2319-5886.2.3.091

&
Health Sciences
www.ijmrhs.com
Volume 2 Issue 3 July - Sep Coden: IJMRHS
th
Research article

COMPARATIVE STUDY OF FLUTICASONE PROPIONATE WITH BUDESONIDE AND

BECLOMETHASONE DIPROPIONATE IN MILD PERSISTENT BRONCHIAL ASTHMA
*Sailakshmi K, Vijayal K, Sirisha JV
Department of pharmacology, Dr. V.R.K. Women's Medical College Teaching Hospital & Research
Centre Aziz Nagar, R.R. District, A.P, India
*Corresponding author email: slkodali@yahoo.com
ABSTRACT
Objective: To compare the efficacy and adverse effects of fluticasone propionate with that of
budesonide and beclomethasone dipropionate in mild persistent cases of bronchial asthma. Methods:
This was an open label, randomized parallel group study done in Government General and Chest
Hospital, Hyderabad for a period of 12 weeks. Each group had 20 patients. The group I was given
fluticasone propionate inhalation therapy 100g twice daily. Group II was given budesonide inhalation
therapy 200g twice daily. Group III was given beclomethasone dipropionate inhalation therapy 200g
twice daily. Results: Symptomatic improvement was observed in all three groups. At end point, mean
FEV1 in fluticasone propionate treatment group improved by 22.04% compared with 14.53% in
budesonide and 12.02% in beclomethasone treatment groups. At end point, mean FVC value of the
fluticasone propionate treatment group improved by 8.04% compared with 5.29% in budesonide and
4.27% in beclomethasone groups. Mean FEV1 / FVC also improved by 12.76% in the fluticasone
propionate group compared with 8.63 % in budesonide and 7.45 % in beclomethasone groups. No
adverse effects were reported in any of the treatment groups. Conclusion: This study showed that
fluticasone propionate is superior to budesonide and beclomethasone in improving lung function,
decreasing symptoms and need for rescue medication in mild persistent asthma
Keywords: Fluticasone, Budesonide, Beclomethasone, Mild persistent asthma
INTRODUCTION
Bronchial asthma is a chronic inflammatory

disorder of the airways. It is characterized by
airflow obstruction that is typically reversible
and by airway hyper responsiveness to various
stimuli. According to National Asthma
Education and Prevention Program (NAEPP) 1,
mild persistent asthma is characterized by
symptoms > 2 times a week but < 1 time a day,
exacerbations may affect activity. Night time

symptoms > 2 times a month, FEV1 or PEF >
80% predicted, PEF variability 20-30%.
This study was done to compare the clinical
efficacy of three different inhaled glucocorticoids
namely fluticasone propionate, budesonide and
beclomethasone dipropionate in mild persistent
cases of bronchial asthma.
Sailakshmi et al.,
518
This was an open label, randomized parallel

group study done in Government General and
Chest Hospital, Hyderabad for a period of 12
weeks from May 2003 to December 2003. The
study design was approved by Institutional ethics
committee. A written informed consent was
obtained from each patient.
Inclusion criteria:
1. Patients in the age group of 20-55 years of
either sex
2. Patients with a history of episodic wheezing,
difficulty in breathing, chest tightness and cough
with or without expectoration
3. Patients having nocturnal symptoms and
family history of asthma
Exclusion criteria:
1. Pregnant and lactating women
2. Smokers and patients with symptoms related
to occupation
3. Patients who were already on steroid treatment
for bronchial asthma
4. Patients with history of pulmonary
tuberculosis, chronic obstructive pulmonary
disease, recurrent pulmonary emboli, carcinoid
tumor, tropical eosinophilia
5. Patients with history of diabetes mellitus,
hypertension, chronic renal failure
6. Patients with history of bronchogenic
carcinoma and suspected malignancy anywhere
in the body
After history was taken, a detailed clinical
examination was done, these are, complete blood
picture, Sputum examination, Random blood
sugar, Serum creatinine, Chest X ray PA view,
Electrocardiography.
Pulmonary
function
tests
with
Microloop/Microlab spirometer (Figure 1): With
this, forced vital capacity (FVC), forced
expiratory volume in one second (FEV1), forced
expiratory ratio (FEV1/FVC) are measured.
The total number of patients was randomized
into 3 groups. Each group had 20 patients.
Group1:
Fluticasone propionate inhalation
therapy 100 g twice daily
Group2: Budesonide inhalation therapy 200 g

twice daily.
Group3: Beclomethasone dipropionate inhalation
therapy 200 g twice daily
All the patients were advised to take Salbutamol
inhalation (100 g per puff) as needed. Metered
dose inhaler with spacer (Figure 2) was used for
taking medication. Patients were shown
inhalation technique with spacers. They were
advised to rinse their mouth after each inhalation.
They were followed up once in every two weeks
till a period of 12 weeks. At each visit, they were
clinically assessed and pulmonary function tests
were done. Scoring was done for cough, wheeze,
breathlessness and severity of nocturnal
symptoms. 2, 3
0-Nosymptoms, 1- Mild,2- Moderate, 3- Severe.
Score for frequency of use of rescue medication4
0 - < 2 puffs/week, 1- < 2 puffs/day, 2- 2 to 4
puffs/day, 3- > 4 puffs/day
At each visit, patients were assessed for any
adverse effects.
Statistical analysis
Data is presented in mean SEM and
percentages as applicable. ANOVA was applied
for comparison of the treatment groups. Unpaired
Students t-test was applied to test the level of
significance. P< 0.05 was considered as the level
of significance
Fig.1: Patient undergoing pulmonary function

test
519
Sailakshmi et al.,
respect to baseline. A significant effect was

observed in favour of fluticasone propionate
compared with beclomethasone dipropionate
and budesonide. At end point, mean FEV1 in
fluticasone propionate group improved by 0.57L
(22.04%) compared with improvements of
0.38L (14.53%) in budesonide and 0.33L
(12.02%) in beclomethasone dipropionate
groups (P < 0.001). At end point, mean FVC
value of the fluticasone propionate group
improved
by
8.04%
compared
with
improvements of 5.29% in budesonide and
4.27% in beclomethasone dipropionate groups
Mean FEV1/FVC also improved by 12.76% in
the fluticasone propionate group compared to
8.63% with budesonide (P < 0.05) and 7.45% in
beclomethasone dipropionate groups (P<0.01).
No adverse effects were reported in any of the
treatment groups.
Fig.2: Spacer
RESULTS
Two patients each in Group II and Group III and

one patient in Group I were excluded from study
owing
to
noncompliance.
Symptomatic
improvement was observed in all three groups.
The FEV1, FVC, FEV1/FVC improved with
Table-1: Demographic data of patients with mild persistent asthma

Drug
Number of men No of women Mean age (in years) ( SEM)
Fluticasone propionate n=20
11
9
35.2 1.4
Budesonide n=20
12
8
32.9 1.1
FiGURE4
:
IMPROVEMENT
OF
SYMPTOMS
IN
PATIENTS
WITH
Beclomethasone dipropionate n=20
10
10
33.4MILD
1.2
PERSISTENT ASTHMA
76
74.36
74.24
Mean Change in Symptom Score (%)
74
72
72
71.24
69.71
70
68
71
70.76
69
68.75
67.36
67
66
64.67
64
62
60
58
Cough
Breathlessness
Fluticasone Propionate (n=19)
Wheeze
Budesonide (n=18)
Nocturnal Symptoms
Beclomethasone Dipropionate (n=18)
Fig.3: Improvement of symptoms in patient with mild persistent asthma
520
Sailakshmi et al.,
FIGURE-5 : REDUCTION IN FREQUENCY OF USE OF RESCUE MEDICATION IN PATIENTS WITH MILD

PERSISTENT ASTHMA
77
76.14
76
Mean Change in Score (%)
75
74
73.21
73
72
71.09
71
70
69
68
FIGURE-6
: ASSESSMENT OF FEV1,
FVC, FEV1/FVC IN PATIENTS
WITH
Budesonide (n=18)
MILD PERSISTENT ASTHMA
Fig.4: Reduction in frequency of use of rescue medication in patient with mild persistent asthma.
25
22.04
Mean Change (%)
20
15
14.53
12.76
12.02
10
8.63
8.04
7.45
5.29
4.27
0
FEV1
FVC
FEV1/FVC
Budesonide (n=18)
Fig.5: Assessment of FEV1, FVC, FEV1/FVC in patient with mild persistent asthma.
DISCUSSION
This study was done to compare commonly

prescribed doses of inhalational steroids in mild
persistent asthma. Fluticasone propionate 100g
twice daily, Budesonide 200 g twice daily,
Beclomethasone dipropionate 200 g twice daily
were given.
Fluticasone propionate treatment produced
significantly greater improvements in lung
function (FEV1, FVC and FEV1/FVC) than
budesonide and beclomethasone dipropionate.
Patient compliance was good which 90% in all
the groups was.
Raphael et al., 2 in a study compared two doses
of fluticasone propionate (88 g twice daily, 220
g
twice daily) with two doses of
beclomethasone dipropionate (168 g twice
daily, 336 g twice daily) in subjects with
persistent asthma. They reported that fluticasone

propionate provides greater asthma control than
beclomethasone dipropionate with a comparable
adverse event profile.
Connolly et al., 5 compared fluticasone
propionate 200 g twice daily with budesonide
400 g per day. He reported that fluticasone
propionate produced significant improvement in
asthma symptoms. Similar improvement in
pulmonary function tests was observed in both
the groups.
The present study supports the findings observed
in the above studies. No adverse effects were
reported in any of the treatment groups during
the study period.
Sailakshmi et al.,
521
CONCLUSION
It can be concluded that fluticasone propionate is

superior to budesonide and beclomethasone
dipropionate in improving lung function,
decreasing symptoms and need for rescue
medication in mild persistent asthma. Patient
compliance was good with all the three drugs.
REFERENCES
1. Tierney LM Jr, McPhee SJ. Papadakis MA,

editors. CMDT. 43rd Edn. New York: Lange
Medical Books/McGraw-Hill.2004; p.22032.
2. Raphael GD, Lanier RQ, Baker J, Edwards L,
Richard K, Lincourt WR. A comparison of
multiple doses of fluticasone propionate and
beclomethasone dipropionate in subjects with
persistent asthma. J Allergy Clin Immunol.
1999; 103: 796-803.
3. Louis R, Lau LCK, Bron AO, Rodaan AC,
Radermecker M, Djukanovic R. The
relationship between airways inflammation
and asthma severity. Am J Respir Crit Care
Med. 2000; 161: 9-16.
4. Asthma Allergy & Airway Research Center.
Information for Health Care Professionals.
Asthma assessment. Available from:
http://www.upmc.edu/AAARC/professionals.
htm.
5. Connolly A. A comparison of fluticasone
propionate 100 g
twice daily with
budesonide 200 g twice daily via their
respective powder devices in the treatment of
mild asthma. Eur J Clin Res. 1995; 7: 15-29.
522
Sailakshmi et al.,
DOI: 10.5958/j.2319-5886.2.3.092

&
Health Sciences
Research article
Copyright @2013
ISSN: 2319-5886
AN APPRAISAL OF REACTION TIME IN ELITE SPRINTERS AND ITS COMPARISON

WITH AGE-MATCHED CONTROLS
* Vandana S Daulatabad1, Prafull A Kamble2, Baji PS3
1
Assistant Professor, 2Associate Professor, 3Professor and Head, Department of Physiology, ARMCHRC,
Solapur, Maharashtra, India
*Corresponding author email: drvandanak@gmail.com
ABSTRACT
Aim: Our study aimed to quantify sprinters reaction time and compared it with age-matched controls.
Material methods: Database of 30 male sprinters and age-matched controls for reaction time (auditory,
visual and whole body reaction time) was compiled. Sprinters included those who had participated in
different state and national athletic meets. After compilation of this data, it was statistically analyzed
using unpaired T-test. Results: Our study indicated a highly significant (P value < 0.001) relationship in
auditory and visual reaction time between athletes and controls. Our study also revealed that athletes
reacted and responded quickly than controls. Whole body reaction time for front and back were highly
significant (P value <0.001). Reaction time for right side was significant (P value <0.01), whereas whole
body reaction time did not differ on left side in these two groups. Conclusion: Considering the findings
of this study, the results suggest that sprinters reacting abilities are faster and quicker than controls,
which definitely affects sprint performance. The above finding is of great interest for coaches and
athletes in sports involving reacting skills.
Key Words: Sprinters, Audio-Visual reaction time, Whole body reaction time, Solapur.
INTRODUCTION
Sprints- Short distance running, sprints include

100m, 200m, and 400m running races in track
and field competition. Although the running
distances vary, upper limit is usually 400m1.
Ward and Watts defined sprinting as running at
or close to maximum speed. It is said that
sprinters are born and not made. The shortest
common outdoor running distance is 100m. It is
one of the most popular and prestigious events in
the sport of athletics2. It has been contested at the
summer Olympics since 1896 (1928 for women).
The reigning 100m Olympic champion is often

named as the fastest man/woman in the world.
The current mens world record of 9.58 s is held
by Usain Bolt of Jamaica, set at the 2009 World
Athletics Championships final on 16 august 2009.
Runners begin in the starting blocks and race
begins when an official fires the starters pistol.
Sprinters typically reach the top speed
somewhere after between 50-60m. Their speed
then slows down towards the finish line. The
most important parameters required to be a world
class sprinter are quick reaction time, speed,
523
Vandana et al.,
agility, power, etc. Especially for 100m sprint,

one of the most important parameter to be
considered for success in the race is reaction time.
Reaction time refers to how long it takes you to
react to a stimulus or reaction time is an elapsed
time between the presentation of sensory
stimulus and subsequent behavioral response3. It
is considered to an index to the speed of
processing. The behavioral response is typical to
a button press but it can also be eye movement,
local response or some observable behavior. For
e.g. how far the sprinter gets off the blocks and
reacts to a gun. In case of football or basket ball
player, it is a lot easier to look good and carry
out their skills but a little more difficult when
you have to react and do it in fractions of a
second as in case of sprints.
Aims and objectives: The present study was
undertaken to access, analyze and compare
auditory, visual and whole body reaction time in
sprinters and age matched controls and to
compare these results with national and
international standards available from the
literature.
The present study was carried out in thirty (30)

male sprinters who were selected and playing for
university and state level. Their age ranged from
16-20 yrs with an average of 17.2yrs. All the
players who were practicing for 2-3hrs for 5days
a week since 3 to 4 years were included in our
study. Subjects excluded from the study were
those who were not regularly practicing, who had
a past history of major respiratory or
cardiovascular disease or who were injured.
Thirty (30) age matched subjects served as
control group. Ethical committee clearance was
taken. Informed consent was also taken from the
subjects.
Reaction time parameters were
assessed in Exercise and Sports Physiology Lab
in
Department
of
Physiology,
Dr.V.M.Govt.Medical College, Solapur.
Proforma
Reaction Time: (msec)
Vandana et al.,
1.
2.
3.
Auditory:
Right hand:
Left hand:
Visual:
Right hand:
Left hand:
Whole body reaction time:
Right:
Left:
Front:
Back:
Reaction time:
1. Auditory reaction time: It was measured
using a device which had stimulus box and a
switch which the subject is suppose to press
in response to the tone stimuli. Chronoscope
measured the time interval in milliseconds
between the appearance of stimulus and
response3.
2. Visual reaction time: It was measured with
stimulus box and a switch which the subject
is supposed to press in response to the green
light stimuli. Chronoscope measured the
time interval in milliseconds between the
appearance of stimulus and response. The
player was asked to place his hands on the
box in such a way that his thumbs rested on
the response buttons. He was asked to
respond to a given stimuli (tone and green
light) as quickly as possible. The time
required for the response was noted down.
The best of three trials was noted down3.
3. Whole body reaction time: Here we
assessed the players reaction time as a
whole to given stimulus. The apparatus for
whole body reaction time comprises of a
stimulus box, standing box, stepping box
and a stimulator box. The player was asked
to stand on the standing box while the
stimulus box was placed at an eye level of
the player. The four stepping boxes were
placed on four sides of the player i.e. right,
left, front and back. An arrow was blinked
on the stimulus box. After seeing the arrow,
the player stepped on the stepping box of
that side as quickly as possible. The time
interval between the initiation of response
and end of response (stepping box) were
recorded
using
chronoscope.
Two
chronoscopes were used; one starting at the
appearance of the stimulus and stopping at
the initiation of response and the other
524
chronoscope stopping at the end of the

response. From this we found out the
reaction time, movement time and the
response time3.
Time taken between the stimulus and the
initiation of response is called as the reaction
time. Time interval between the initiation of
response and the end of the response is called as

movement time. Hence the total time required for
the appearance of the stimulus and of the
response is called as response time4.
Stastical anaylysis: After compilation of the
data, it was statistically analyzed using unpaired
T-test.
RESULTS
Table.1: Audio-Visual Reaction Time
Athletes
Right
Left
Controls
Left
Right
Auditory
(msecs)
98.46.9
106.49.5
135.44.4
14315
P< 0.001***
Visual
(msecs)
99.78.5
107.39.9
130 15.1
14415.1
P< 0.001***
P value
* Not Significant; **Significant; ***Highly Significant

Table. 2: Whole body Reaction Time
Right
(secs)
Athletes
Reaction
Time
0.4 0 . 0 8
Movement
Time
0.3 0 . 1 4
0.7 0 . 1 7
Controls
0.4 0 . 0 6
0.4 0 . 1 2
0.8 0 . 1 0
Left
(secs)
Athletes
0.4 0 . 0 8
0.3 0 . 1 0
0.7 0 . 1 3
Controls
0.4 0 . 0 8
0.4 0 . 1 0
0.8 0 . 1 1
Front
(secs)
Athletes
0.4 0 . 0 8
0.3 0 . 1 3
0.7 0 . 1 4
Controls
0.4 0 . 0 6
0.45 0 . 1 0
0.9 0 . 0 9
Back
(secs)
Athletes
0.5 0 . 1 1
0.3 0 . 1 3
0.8 0 . 1 5
Response Time
Controls
0.5 0 . 0 5
0.4 0 . 1 2
0.9 0 . 1 1
*NS-Not Significant; **-Significant; ***HS-Highly Significant
P value
P < 0 . 0 1 **
P> 0.1*
P< 0.001***
P< 0.001***
DISCUSSION
In our study the reaction time in athletes for

auditory stimulus was 98.4 msec and 106.4 msec
for right and left hand respectively, while
controls had longer reaction time of 135.4 msec
and 143.9 msec. Thus it is evident that the
auditory reaction time was highly significant in
athletes. The visual reaction time in athletes was
99.7 msec and 107.3 msec while the values in
controls were 130 msec and 145 msec for right
and left hand respectively. These were again
highly significantly lower in athletes than the

controls.
Whole body reaction time is more complicated to
measure because of timing devices that has been
used. Whole body reaction time was significantly
lower in right and was not significant in left
direction but were highly significant in front and
back directions in comparison with controls.
Our study is in complete accordance with Mero
A, Komi PV, Gregor RJ5 who assessed
525
Vandana et al.,
biomechanics of sprint running and showed that

a good athlete have a short reaction time .
Brisswalter J6 investigated the influence of
physical fitness and energy expenditure on a
simple reaction time and gave the conclusion that
significant effect of physical fitness on cognitive
performance or simple reaction time is present
during the exercise. The shorter reaction time of
athletes in our study must be the added effect of
running itself, which is one of the best exercises
for improvement of physical fitness7.Collet C8
investigated the sprinters reaction time for
starters shot and concluded that reaction time is a
skill dependent upon experience and learning and
is associated with race length. Hence shorter the
race less is the reaction time.
CONCLUSION
Athletes reacted & responded quickly than

controls. Whole body reaction time for front and
back was highly significant whereas for right
direction it was significant. Whole body reaction
time did not differ in left side in these two groups.
Athletes also had shorter audio-visual reaction
time than controls. There was highly significant
difference between reaction time of two groups.
A typical reaction time is around 0.2 to 0.3 secs.
Auditory reaction time is generally 2-5
hundredth of a sec faster9. People with turtle-like
reflexes may have reaction time closer to 0.4sec,
but a world class sprinter can have reaction time
closer to 0.1 sec. Anything less than 0.2 sec is
considered excellent. Unfortunately reaction time
is highly genetic but can be improved till 10-20%
by over-speed training10. Considering the
findings of this study, the results suggest that
sprinters reacting abilities are faster and quicker
than controls, which definitely affects sprint
performance. The above finding is of great
interest for coaches and athletes in sports
involving reacting skills. Stimulants like caffeine,
acetyl-l-carnitine and l-tyrosine can also be
helpful. Stimulants enhance speed of perception
and mental processes. These stimulants have
positive stimulatory impact on reaction time.
Increased arousal also naturally boosts reaction

time.
ACKNOWLEDGEMENT
I am heartily thankful to my Head of Department,

Dr. P. S. Baji, whose encouragement, guidance
and support from the initial to the final level
enabled me to develop an understanding of the
subject. Lastly, I offer my regards to all of those
including my husband and colleague, Dr. Prafull
Kamble, who were a constant encouragement
and support during the completion of the project.
REFERENCES
1. Seth Harish Malhotra, Singhal TS Choudhary,

Textbook of rules and skills: New style
physical education and game,33-41.
2. Ashok Malhotra, A guide to be an athlete.
Press trust of India, New Delhi, 25-28.
3. Reaction time apparatus manual, Anand
agencies, Pune. P no. 12-16.
4. HB Baruwal, Significance and some facts on
reaction time in sports, Vyayam Vidnyan,
1983;16(4):3-7
5. Mero A, Komi PV, Gregor RJ, Biomechanics
of sprint running, A review. Sports Med,
1992; 13(6):376-92.
6. Brisswalter J, Arcelin R, Audiffren M,
Delignires D, Influence of physical exercise
on simple reaction time: effect of physical
fitness, Percept Mot Skills, 1997; 85(3 Pt
1):1019-27.
7. Ekta Gothi, Teaching and coaching athletics.
Press trust of India, New Delhi,
8. Collet C, Strategic aspects of reaction time in
world-class sprinters. Percept Mot Skills,
1999 Feb; 88(1):65-75.
9. Essentials of exercise physiology: William D
MaCardle, Frank I Katch, Victor L Katch,
3rd edition,
1 0 . Albert Heyman, encyclopedia of sports
sciences and medicine, MacMillan Company,
1971.
526
Vandana et al.,
DOI: 10.5958/j.2319-5886.2.3.093

&
Health Sciences
th

Research article
Coden: IJMRHS
th
Copyright @2013
ISSN: 2319-5886
GENDER DIFFERENCES IN BODY MASS INDEX AND BLOOD PRESSURE AMONG

NORMAL HEALTHY UNDERGRADUATE STUDENTS
*Prema Sembulingam1, Sembulingam K1, Glad Mohesh2
1
Madha Medical College & Research Institute, Kovur , Near Porur, Chennai, Tamil Nadu, India
Shri Sathya Sai Medical College & Research Institute, Ammapettai, Tiruporur, Kancheepuram,
Tamilnadu, India
2
*Corresponding author e-mail: prema_sembu@yahoo.com

ABSTRACT
Introduction: Obesity, measured by body mass index (BMI) is one of the morbid non-communicable
diseases in the modern world. Worldwide reports have indicated a rise in the prevalence of obesity
among adults. Generally it is believed that adolescence is the risky age for entering into the domain of
obesity and females of this age group are more prone for this than their male counterparts. Purpose:
Confirmation of this fact may help us in preventing or reducing the risk obesity by various methods like
counselling on modification of lifestyle, planning of diet and choosing of exercise regime.
Methodology: 74 normal healthy undergraduate students of both genders participated in this study (37
each). Blood pressure and heart rate (HR) were measured along with body mass index (BMI), basal
metabolic rate (BMR) and body fat percentage (BFP) by using the Semi-Automatic BP Monitor and
Body Fat Monitor (OMRON). Result: Mean BMI was more in females than in males but it was not
statistically significant (p < 0.275). BFP was significantly more in females than in males (p < 0.000).
Systolic blood pressure was less and HR was more in females than in males with high significance (p <
0.000). Conclusion: The results of the present study showed that adolescent age group (17 to 20 years)
was not in the risk of obesity. However, the BMI values in both the genders are at the higher side
nearing overweight. So awareness of susceptibility towards obesity must be created among this age
group to avoid this morbidity.
Keywords: BMI, Obesity, Non-communicable diseases, Blood pressure, Rate-pressure product
INTRODUCTION
The Body Mass Index (BMI) is a statistical

measurement to differentiate obesity and nonobese. Generally BMI and body fat go hand in
hand. However, BMI does not express the
quantity of fat in the body because, BMI depends
upon the height and weight of the person and
Prema et al.,
body fat depends upon the gender and age also.

For example, one male and one female of the
same age may have the same BMI but the fat
content may be more in females than in males;
similarly, BMI may be the same in older and
younger group of people but the body fat may be
more in older people than the younger ones1.
527
Thus, BMI helps to identify the individuals with

underweight, normal weight, overweight and
obese2 (Table 1). Identification of the obesity is
important because it is considered to be a morbid
non-communicable disease (NCD) in which the
quality or/and the span of life of an individual is
at risk3, 4
Table 1. Body status depending upon Body Mass Index
BMI (kg/meter2) Classification

< 18.5
Underweight
18.5 24.9
Normal weight
25.0 29.9
Over-weight
30.0 34.9
Class I obesity
35.0 39.9
Class II obesity
Class III obesity

(Morbid obesity)
BMI Body mass index
> 40.0
NCDs have become a greater threat to the human

race than the communicable diseases in the
modern world. The study of Global Burden of
Disease (GBD) states that by 2020, deaths due to
NCDs such as hypertension, diabetes mellitus,
coronary heart diseases, stroke and metabolic
disorders will be four times more than
communicable diseases which are infectious,
contagious and transmissible5. Obesity seems to
be one of the common risk factors in many of
these NCDs and considered to be the most
prevailing and threatening public disaster in the
developed countries6.
At which period of life this threat of obesity
starts is still a mystery because it varies from
infancy to childhood, adolescence and
adulthood1. The present study was planned on
this basis.
3. If affected or on the verge of to be affected,

how best it can be handled?
METHODS
Seventy four normal and healthy students of both

sexes (thirty seven in each) were recruited from
Shri Sathya Sai Medical College at Tiruporur and
Madha Medical College and Research Institute at
Kovur in Chennai, Tamil Nadu. Athletes, sports
persons and the ones who were on treatment for
any ailment were not included in the study. In
females, mid follicular phase of menstrual cycle
was chosen for the study. Ethical clearance was
obtained from the institutions. The aim and
essence of the research work were explained to
them and their consent was obtained before
proceeding with the work. They were instructed
to report in Physiology laboratory in the
forenoon after a light breakfast.
The data regarding their age and sex were noted
and the weight and the height of the subject were
measured. The weight was recorded with their
casual clothes on. The height was measured by
using a measuring scale drawn on the wall of the
laboratory. The subjects were resting in a sitting
position with uncrossed legs for five minutes
before proceeding with the experiment.
Systolic blood pressure (SBP), diastolic blood
pressure (DBP) and heart rate (HR) were
measured by using the Automatic BP Monitor
(OMRON, Model HEM-7111). Body mass index
(BMI), Basal Metabolic Rate (BMR) and Body
Fat Percentage (BFP) were measured by using
Body Fat Monitor (OMRON Model HBF-306).
Statistical analysis: Computerized data analysis
was done using SPSS 17.0 and the comparison
was done in Studentst test. Values are
expressed as mean SD, Significance level was
fixed at p < 0.05
Objectives of the study:

RESULTS
1. To screen the college going students

(adolescents) for the prevalence of obesity,
overweight and hypertension
2. If obesity and hypertension are in the
vicinity, which gender is most affected?
Prema et al.,
Anthropometric parameters: The mean age of

male and female subjects was similar (18.73
1.97 and 18.19 0.16 years) (P < 0.077). The
height and weight of the male subjects were
528
significantly greater than that of females (p <

0.000 and 0.001) (Table 2)
BMI, BMR and BFP: The mean BMI was
slightly less in males (21.33 3.70 kg/m2) than
in females (22.18 3.64 kg/m2) but the
difference was not statistically significant (p <
0.275). BMR was more in males (1553 240.82
kcal) than in females (1282.42 205.49 kcal)
with statistical significance (p < 0.000). BFP was
less in males (18.26 5.53%) than in the females
(28.90 6.65%) and the difference was highly
significant (p < 0.000) (Table 3).
Blood pressure : The mean SBP was more in
males (117.97 9.55 mm Hg) than in females

(104.93 9.26 mm Hg) and the difference was
highly significant (p < 0.000). The DBP did not
show any significant difference between the two
groups (p < 0.899) The MAP was slightly more
in males than in females with less statistical
significance (p < 0.034) (Table 4)
Heart rate: HR was significantly less in males
than in females (p < 0.000).
Rate-pressure product: The mean RPP was less
in males than in females (8.91 1.83 and 9. 30
2.11) but it was not statistically significant (p <
0.409) (Table 4)
Table 2. Comparison of anthropometric parameters between males and females
Age (years)
Male (37)
(Mean SD
18.73 1.97
Female (37)
(Mean SD
18.19 0.16
Height (cm)
172.00 7.65
154.45 8.81
p < 0.000
Weight (kg)
62.99 11.04
54.14 10.46
p < 0.001
Parameter
Significance
p < 0.077
Table 3. Comparison of BMI, BMR and BFP between males and females
Male (37)
Female (37)
Parameter
Significance
(Mean SD
(Mean SD
BMI (kg/m2) 21.33 3.70
22.19 3.64
p < 0.275
BMR (kcal)
1553.03 240.8 1282.42 205.49
p < 0.000
BFP (%)
18.26 5.53
p < 0.000
28.90 6.65
BMI Body mass index, BMR Basal metabolic rate, BFP - Body fat percentage
Table.4: Comparison of blood pressure (SBP, DBP & MAP), heart rate (HR), and rate-pressure product
(RPP) between males and females
Parameter
Male (37)
Female (37)
Significance
(Mean SD
(Mean SD
SBP (mm Hg) 117.97 9.55
104.93 9.26
p < 0.000
DBP (mm Hg)
62.87 8.67
62.58 8.41
p < 0.899
MAP (mm Hg)
81.48 7.99
76.72 8.03
p < 0.034
HR (beats/min) 75.15 12.13
88.42 15.91
p < 0.000
RPP
9.30 2.11
p < 0.409
8.91 1.83
SBP Systolic blood pressure, DBP Diastolic blood pressure, MAP Mean arterial pressure, RPP
Rate pressure product
Prema et al.,
529
DISCUSSION
The results of the present study are quite

interesting and reveal the fact that the adolescent
age group (17 and 20 years) is not at risk of
obesity. Though the females showed more fat
content than males (p < 0.000), their BMI was
similar to that of males. However, in both the
genders, BMI was within normal limits (18.5
24.5 kg/m2)) indicating normal weight.
In one of the studies done in undergraduate
students in Nigeria, the mean BMI was found to
be higher in males (25.54 kg/m2) than in females
(23.38 kg/m2) and in both sexes, BMI was found
to be towards the overweight side1. Our results
differ from this in that the males have lower BMI
(21.33 3.70 kg/m2) and females have higher
BMI (22.19 3.64 kg/m2) though it did not show
the statistical significance. Moreover, none of
our subjects were in the danger zone of
overweight or obesity and the mean BMI was
within normal range of 18.6 25 kg/m2 (Table
3). As the mean age of Nigerian students was
more (22 years) and the mean age of our subjects
was less (18.5 years), we thought of the
possibility of age-related influences on BMI.
But according to Kadri and Salako and
Oghagbon etal87, 8, influence of age and gender
difference has got nothing to do with BMI value.
So the slightly increased mean BMI in females of
our study group may be attributed to more fat
content in them than in their male counterparts.
As there is a possibility of further increase in fat
content among females under the influence of
estrogen9 and as the tendency to weight gain is
more in females than in males in the
advancement of age1, there is all chances for
BMI to move towards the morbid side of obesity
in females.
As far as blood pressure (BP) was concerned, in
our study group, it was found to be within
normal limits both in males and females and
there was no report of hypertension. According
to Oghagbon et al8 and Lawoyin et al10,
overweight rather than obesity is more relevantly
Prema et al.,
related to hypertension rather than BMI and fat

content. In our study, higher SBP and MAP in
males may be attributed to the more weight and
height in them than in their female counterparts
whose BMI and fat content were more than in
males.
RPP is the interesting factor coupled with obesity
in the present study. It is the product of SBP and
HR and it has got its own significance because it
represents the myocardial oxygen consumption
(MVO2) that reflects the work load on the
heart11, 12. It is calculated by the formula RPP =
(HR X SBP) /10013. The hemodynamic of RPP,
ie., HR and SBP are under the control of
autonomic nervous system. HR is modulated by
both sympathetic nervous system (SNS) and
parasympathetic nervous systems and SBP is
modulated by sympathetic nervous system.
Lesser RPP indicates more parasympathetic
activity14. Normally it should be 12 or below 12
with the HR ranging 60 120 bpm and SBP
ranging 100 to 140 mm Hg12. In our study, in
both the groups, RPP is well within normal limit.
However, it is slightly less in males (8.91 1.83)
than in females (9.30 2.11). Though the
difference is not statistically significant, yet it
has got its own functional significance because
lesser RPP is an indicator of more PSN activity
and increased parasympathetic tone is believed to
be cardioprotective14. In the present study with
their lower BMI, HR and RPP, males are
armoured
well
against
stress-induced
cardiovascular changes.
Limitations of the study: There are a few
drawbacks in the present study. Admittedly, the
number of the subjects is less. Categorization of
the subjects on their socioeconomic status and
food habits could have been considered which
may throw some light on the status of BMI and
BP. The study is in progress to rectify these
drawbacks and to include different age groups
also.
530
CONCLUSION
BMI was found to be within the normal range

of our subjects.
Though BMI is within normal range, both
groups were towards the higher range
showing susceptibility for obesity.
Females showed higher BMI and BFP than
the males. As overweight and obesity are age
related and as there is possibility of weight
gain in females during advancement of age,
an orientation program becomes mandatory
for the fresh undergraduate students
regarding their health conditions in the form
of a thorough medical check-up including
BP monitoring and recording of BMI and
BFP.
Keeping in mind the modern sedentary
lifestyle, poor nutrition and a lot of stress,
implementation of awareness program
regarding the causes, consequences, control
and prevention of morbid obesity may be
made mandatory for the youngsters.
ACKNOWLEDGEMENT
We would like to appreciate and acknowledge all

the help rendered by the Dean and the Head of
the Department of Physiology at Shri Sathya Sai
Medical College & Research Institute,
Ammapettai,
Tiruporur,
Kancheepuram,
Tamilnadu, for allowing us to proceed with this
research as a collaborative work. We are
indebted to the student volunteers for their
spontaneous willingness to participate in this
research work.
REFERENCES
1. Kenneth EO, Valentine UO, Eze KN, Kevin

EP. Body Mass Index and Blood Pressure
Pattern of Students in a Nigerian University
International Journal of Health Research,
June 2009; 2 (2): 177-182
2. http://www.righthealth.com/topic/Bmi_Chart
_Body_Mass_Index/overview/NaturalStanda
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rd20?fdid=NaturalStandard_19c078281e2d1
932259393604fc1cfba
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obesity WHO 2000
4. Haslam DW, James WP. Obesity. Lancet.
2005;366 (9492): 1197209
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6. Wang Y, Ge K, Popkin BM. Tracking of
body mass index from childhood to
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Am J ClinNutr. 2000; 72: 1018-24
7. Kadiri S, Salako BL. Cardiovascular risk
factors in middle aged Nigerian. East Afri
MED J. 1997; 74(5): 303-6 10
8. Oghagbon EK, Okesina AB, BIiliaminuSA.
Prevalence of hypertension and associated
variables in salaried workers in Ilorin,
Nigeria. Niger J ClinPract 2008;11 (4) 34246)
9. Sembulingam K & Prema Sembulingam.
Essentials of Medical Physiology, 6th ed.
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BROTHERS
MEDICAL
PUBLISHERS (P) LTD, 2013. P 479
10. Lawoyin TO, Asuzu MC, Kaufman J, Rotimi
C, Owoaje E, Johnson L, Cooper R.
Prevalence of cardiovascular risk factors in
an African, urban inner city community.
WestAfr J Med. 2002; 21(3): 208-11
11. VanVliet BN, Montani JP. Baroreflex
stabilization of the double product. Am J
Physiol. 1999; 277: H 1679-89
12. White WB. Heart rate and rate pressure
product as determinants of cardiovascular
risk in patients with hypertension. Am J
Hypertens. 1999; 12-50 S-5
13. Thompson WR, Gordon NF, Pescatello LS,
editors. ACSM's Resource manual for
guidelines for exercise testing and
prescription. 6th ed. Baltimore MD:
Lippincott Williams and Wilkins; 2010.
American College of Sports Medicine.
Adaptations to cardiorespiratory exercise
training; pp. 47688.
531
14. Michael
A
Figueroa,
Ronald
E
DeMeersman,1 and James Manning. The
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Prema et al.,
532
DOI: 10.5958/j.2319-5886.2.3.094

&
Health Sciences
Received: 31st May 2013
Research article

Accepted: 3rd Jul 2013
A COMPARATIVE STUDY OF ARTERIAL STIFFNESS INDICES BETWEEN SMOKERS &

NON SMOKERS
*Prabha V1, Pratima Buhutkar2, Milind Bhutkar3, Sivagami G4
1, 2
Assistant professor, 3 Professor & Head, 4 Post Graduate, Department of Physiology, Vinayaka
Missions Kirupananda Variyar Medical College & Hospitals, Salem, Tamil Nadu, India.
* Corresponding Author Email: prabhavsetty@gmail.com
ABSTRACT
Arterial stiffening is recognized as a critical precursor of cardiovascular disease. Smoking is one of the
modifiable risk factor for cardiovascular disease. Lifestyle modification is clinical efficacious
therapeutic interventions for preventing and treating arterial stiffening. Hence, the current study is
designed to compare the Arterial Stiffness Indices between smokers & non smokers. The study involved
55 non smokers & 55 smokers within the age group of 30-50 years. Peripheral Pulse Wave was recorded
by Digital Volume Pulse in both non smokers & smokers. Arterial stiffness indices were calculated.
Arterial Stiffness Index = Patients Height / Transit time [Transit time Time delay between
systolic peak & Diastolic peak] Reflection Index = Magnitude of Diastolic peak / Magnitude of
Systolic Peak. Arterial Stiffness Index & Reflection Index were highly significant in smokers than
nonsmokers, p<0.001. The increased arterial stiffness indices in smokers suggest that the cigarette
smoke damages the vascular endothelium.
Keywords: Arterial stiffness, Cardiovascular diseases, Digital Volume Pulse, Smoking.
INTRODUCTION
Cardiovascular disease (CVD) is the leading

cause of mortality and morbidity worldwide.1
Arterial stiffness and wave reflection exerts
adverse effects on cardiovascular function.
Arterial stiffening is recognized as a critical
precursor of CVD and is independent predictors
of cardiovascular events. Arterial stiffening is a
major factor in cardiovascular disease because of
the reduced elasticity in blood vessels.2
Therefore, assessment of arterial stiffness is
believed to be useful in the prevention of
cardiovascular disease. Smoking is one of the
modifiable risk factor for CVD.3 Tobacco,
Prabha et al.,
especially cigarette smoking is a major cause of

CVD, responsible for about one third of CVD
deaths. Chronic cigarette smoking has been
shown to be associated with increased arterial
stiffness.4 The risk of CVD deaths increases with
increasing exposure to cigarette smoke, as
measured by number of cigarette smoked daily,
the duration of smoking & the degree of
inhalation & the age of initiation. The relative
risk for CVD is substantially greater in early
adult life than in old age & is associated more
strongly with the cigarette smoke than other
forms of tobacco. The pathophysiological
533
changes in smoking are due to changes in the

vascular endothelium, induction of coronary
vasoconstriction and changes in the basal nitric
oxide (NO) or endothelial nitric oxide synthase
production. Lifestyle modification, aerobic
exercise and sodium restriction in diet appears to
be clinical efficacious therapeutic interventions
for preventing and treating arterial stiffening.
Arterial stiffness can be measured using invasive
and non-invasive methods. Pulse wave analysis
is one of the methods used to assess arterial
stiffness. The most popular non-invasive
methods are based on pletysmographic
principles.5 A Pletysmographic measurement
depends on Boyles law, a principle that
describes the relationship between the pressure &
volume of gas. Pulse wave velocity (PWV) is
known as an established index of arterial
stiffness. But it is difficult, time consuming and
expensive. These factors have fostered the
development of simple methods to record arterial
stiffness. These techniques are much simpler,
non-invasive, economical and easier to apply.
We can also measure Arterial stiffness Indices
from Digital Volume Pulse (DVP) which is
economical, easier, less time consuming, noninvasive method. So the present study is
designed to record Arterial Stiffness Index (SI),
Reflection Index (RI) by using Finger
Photoplethysmography & to compare it with
smokers and nonsmokers.
MATERIALS & METHODS
The study was conducted in a sample of one ten

subjects in Salem. They had been divided into
fifty five non smokers (control group) & fifty
five smokers (study group) within the age group
of 30-50 years. Subjects were selected based on
inclusion and exclusion criteria.
Inclusion criteria: Fifty five normal healthy
nonsmokers between 30 and 50 years were
included in the control group, Fifty five smokers
between the ages 30 and 50 years were included
in test group.
Prabha et al.,
Exclusion criteria : History of Hypertension,

Diabetes Mellitus, Cardio vascular disease,
Peripheral vascular disease,
Other drug
treatment
Methodology: The subjects were selected by a
detailed
history
&
thorough
physical
examination. They were asked to fill a
questionnaire. To assess their smoking habits.
The experimental protocol was fully explained to
the participants to allay apprehension. They were
refrained from smoking for 12 hours before the
test. Informed consent was taken from all the
subjects. The study was approved by the
Institutional Ethical Committee.
Experimental design: Data was collected by
recording the DVP. Subjects weight was
measured using a calibrated weighing machine in
light clothing and bare feet. Height was
measured in meters. All experiments were
performed at room temperature. Baseline pulse
rate, Systolic, Diastolic & pulse pressure was
measured in sitting position after 5 min of rest by
using mercury sphygmomanometer.
Finger Photoplethysmography:
Digital Volume Pulse was measured by an
instrument
known
as
Finger
Photoplethysmography, using Infra-red light with
wave length of 940 nm; placed on the right index
finger of the subject. The signal from the
instrument was digitalized by digital converter
with a frequency of 100 Hz; which was
connected to the computer. The main principle of
this device is conversion of pressure changes to
voltage changes by means of the pressure
transducer. Subjects were initially acquainted
with the instrument and a trial is given before
performing the study. DVP recording was done
with the help of software virtual oscilloscope
which was provided by national instrument
which can be freely distributed for academic
purpose. Pulse wave contour consists of two
main components: the first component is caused
by systolic pressure wave that results from blood
ejected from the left cardiac chamber to aorta
and its consequent distribution to peripheral sites.
534
The second component is formed by pressure

wave reflected back to the aorta.
Analysis: From the DVP recordings, we
estimated arterial stiffness index (SI) &
reflection index (RI). The shape of the pulse
wave is determined by a number of factors, age,
sex, body height, pulse and physical fitness.6
Length of this travelling wave is usually
proportional to the subjects height (h). The time
delay between systolic peak & diastolic peak is
called Pulse transit time (PTT or T), is
inversely proportional to arterial stiffness. The
time difference between the peaks of the two
components, known as the reflection time, is
inversely proportional to arterial stiffness. To
correct for the size of the subject, the reflection
time is divided by the height of the subject.5 The
resultant value is SI, which is expressed in
meters/second. SI is comparable to the definitive
measure of arterial stiffness, the pulse wave
velocity (PWV). RI is a measure of vascular
tone. It is calculated by dividing the amplitude of
the systolic component by the amplitude of the
diastolic component. This ratio is expressed as a

percentage. The parameters and their definitions
are shown in Figure 1. These parameters were
measured by software Image tool.
Statistical analysis: The results were expressed
as mean standard deviation (SD). A p value of
<0.05 was considered statistically significant.
Statistical analysis was performed using the
statistical package for social & sciences. Student
unpairedt test was applied to compare between
the parameters.
RESULTS
Fifty five normal healthy nonsmokers in the age

group of 30 and 50 (36.85 4.99) years and Fifty
five smokers in the age group of 30 and 50
(37.29 4.76) years were subjected to DVP
recording. Arterial stiffness was estimated from
the pulse wave analysis. Both SI (11.74 4.12)
meters/second & RI (75.64 12.35) % in
smokers were significantly higher at 95%
confidence interval than non-smokers SI (5.72
0.28) meters/second & RI (48.19 9.51) %, p <
0.001. The results are shown in the table 1.
Table 1: Comparison of stiffness indices between Smokers & nonsmokers*
Parameters
Non Smokers
Smokers
p value
Stiffness index (m/s)
5.72 0.28
11.74 4.12
< 0.001
Reflection index (%)
48.19 9.51
75.64 12.35)
< 0.001
*Data presented as mean SD

RI = SYSTOLIC PEAK/DIASTOLIC PEAK
Fig:1. Pulse wave contour and definitions of evaluated parameters
Arterial Stiffness Index (SI) = Patients Height (h)/ Transit time (TDVP)
[Transit time (TDVP) Time delay between systolic peak & Diastolic peak]
Reflection Index (RI) = Magnitude of Diastolic peak / Magnitude of Systolic Peak 100
Prabha et al.,
535
DISCUSSION
Measuring arterial stiffness provides good data
on the endothelial condition. Smoking is known
to increase arterial stiffness in adults.7-9 Cigarette
smoke enhances the atherosclerotic changes by
several mechanisms. Endothelial damage is a
central feature in the evolution of vascular
disease induced by cigarette smoking and may
act as a precursor for future atherosclerosis. The
major health effects of cigarette smoke include:
cancer,
noncancerous
lung
diseases;
atherosclerotic diseases of the heart and blood
vessels; and toxic to the human reproductive
system. Despite the damaging effects of tobacco
use; quitting smoking has immediate and long
term health effects such as improved circulation
and fall in heart rate.10 The inhalation of cigarette
smoke results in activation adrenergic
mechanism as the nicotine contained in tobacco
stimulates the sympathetic nerve terminals, with
consequent systemic release of adrenaline and
nor adrenaline. The released catecholamines
bind to 1-adrenergic receptors on vascular
smooth muscle to cause muscle contraction and
thus a reduction in arterial distensibility and
vasoconstriction.8,11 In the healthy adult, who
does not usually smoke, the vasoconstrictor
response is soon counterbalanced by the local
release of vasodilators from endothelium. The
two best characterized endothelial vasodilators
are nitric oxide (NO) and prostacyclin. Nitric
oxide is considered to be the dominant local
regulator of resting vasomotor tone, with packets
of NO being produced at regular intervals.12
Impaired nitric oxide production and endothelial
dysfunction have also been known to play major
roles in altering the mechanical properties of
large arteries.8, 11
Smoking cessation is an important lifestyle
measure for the prevention of cardiovascular
disease, and patients with myocardial infarction
may experience as much as a 50% reduction in
risk of re-infarction, sudden cardiac death.13
Prabha et al.,
Quitting in late in life also has positive effects.

The toxins from cigarette smoke can go
everywhere as the blood flows. Chronic tobacco
smoking is associated with endothelial
dysfunction. Smoking not only accelerates
endothelial dysfunction in the large arteries but it
is also responsible for changes in the physical
properties of arterioles and small arteries.14
Vascular endothelium produces a number of
mediators including nitric oxide (NO) which
regulates arterial wall stiffness. McWeigh et al
showed that cigarette smoking triggers NO
production damage. Basic structural factors
determining arterial stiffness are predominantly
collagen, elastin and transmural pressure.15 The
mechanisms involved in amelioration in arterial
stiffness with smoking cessation may include
lipid-soluble smoke particles,16
endothelial
17
dysfunction,
or vascular inflammation,18
because smoking cessation leads to reduction in
levels of inflammatory markers.19 Although it
may take more than a decade to reverse these
vascular changes, and the effect is relatively
small, smoking cessation helps to reduce
cardiovascular events through amelioration in
arterial stiffening.
Willett et al reported that cigarette smoking
affects cholesterol metabolism, it lowers levels of
the protective high-density lipoprotein (HDL)
cholesterol 20 and Rabkin et al reported smoking
cessation raises HDL cholesterol.21 In animal
models, nicotine can damage the inner lining of
blood vessels, thus enhancing the transfer of lowdensity lipoprotein cholesterol particles across
the arterial wall and into the developing
cholesterol-laden plaque.22 Cigarette smoking
also can affect the blood clotting system,
including adherence of blood platelets to the
lining of arterial blood vessels23 and the
formation of blood clots that block a narrowed
artery. Selley et al reported that Acrolein in
cigarette smoke is partly responsible for its
536
platelet-adhering effects.24 Cigarette smoke also

causes spasm of the coronary arteries.25 Many
chemical components of cigarette smoke have
been found to accelerate the development of
atherosclerotic disease. Nicotine, the major
psychoactive component of smoke, causes
powerful changes in heart rate and blood
circulation. Nicotine appears to cause injury to
the arterial lining.22 Smoking causes tissue injury
induced by oxidative stress. Free radicals in
cigarette smoke, which are highly reactive
oxygen products, are damaging to the heart
muscle cells. Studies have reported dermal
applications of cigarette smoke in laboratory
animals demonstrated chemicals in cigarette
smoke underwent covalent binding with heart
tissue DNA.26 Van Schooten et al reported that
cigarette smokers showed that the heart tissue
contained more DNA adducts than that from
nonsmokers and linear relationship between
DNA adduct levels and daily cigarette
smoking.27 Furthermore, higher DNA adduct
levels were associated with a higher degree of
coronary artery disease.
In our study we used SI which substitutes pulse
wave velocity (PWV). It has been proved that SI
positively correlates with PWV.28 SI values are
mainly influenced by large artery stiffness but it
can be also supported by wave reflection from
peripheral sites as well as from large arteries (28,
29). For smokers we detected significantly higher
values of SI than nonsmokers, p < 0.001, which
indicates increased arterial stiffness. To
determine vascular tone we used the parameter
RI. RI was also significantly higher in smokers
compared to nonsmokers, p < 0.001, indicating
vascular tone is increased.
less time consuming, economical, easier to apply

and non-invasive method. Non invasive
measurements of arterial stiffness will aid the
optimal stratification of CVD risk in an
apparently healthy population. Chronic smoking
is a leading risk factor in development
cardiovascular diseases. DVP can be used to
assess how chronic smoking impairs arterial
elasticity by evaluating SI and RI. Since the
scientific evidences are suggestive of smoking
induction of endothelial dysfunctions, the best
advice to the smokers is stop smoking.
Scope for the study: Additional study including
a detailed evaluation of endothelial factors &
measurement of arterial stiffness by Pulse wave
velocity is needed to clarify whether initial
changes of cardiac impairment exist with early
initiation of smoking.
CONCLUSION
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ACKNOWLEDGEMENTS
I express my feeling of gratitude, respect and

appreciation; I thank my brothers Mr. V. Prasad
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aromatic DNA adduct levels in human right
atrial
tissue. FASEB
Journal. 1998;12(13):140917
29. Woodman RJ, Watts GF, Kingwell BA, Dart
AM. Interpretation of the digital volume
pulse: its relationship with large and small
Prabha et al.,
artery compliance. Clinical Science, 2003;

3:283-285
539
DOI: 10.5958/j.2319-5886.2.3.095

&
Health Sciences
Received: 1st Jun 2013
Research article
PHENOMENOLOGY OF INHALANT ABUSE AMONG ADOLESCENT IN URBAN INDIA.

*Dhoble PL1, Bibra M 2
1
Assistant Professor, Department of Psychiatry, R.D. Gardi Medical College, Ujjain, Madhya Pradesh,
India.
2
Resident, Department of Psychiatry, R. D. Gardi Medical College, Ujjain, Madhya Pradesh, India.
*Corresponding author email: dr_paragdhoble@yahoo.com
ABSTRACT
Introduction: The deliberate inhalation of volatile substance can cause serious harm to psychological,
emotional and neurobiological development. Inhalants are considered to be harmful substance used as it
is linked with high rate of morbidity. Lack of knowledge, expertise in the field of inhalant dependence,
resulted in little research about the subject. Current research is focused on evaluation of the
symptomatology of inhalant intoxication and withdrawal. Methods: This is a prospective cross-sectional
study of inhalant users in 32 cases meeting criteria for inhalant abuse according to DSM-IV-TR in a
tertiary-level multi-specialty hospital. Results and conclusion: The most common inhalant used was
whitener and most common method was sniffing. Among all intoxication symptoms, euphoria was most
common (97%) followed by hallucinations (88%), burning in oropharynx (69%), light headedness
(47%), drowsiness (38%) etc. Common withdrawal features reported were: craving (97%), irritability
(94%), restlessness (88%), insomnia (78%) etc.
Keywords: Inhalants, Intoxication, Withdrawal, Phenomenology
INTRODUCTION
Inhalant abuse is defined as the intentional use of

fumes from different chemicals to produce
altered state of mind. In sniffing user may inhale
fumes directly from a can while in huffing they
would soak the cloth with a chemical substance
and inhale fumes by placing it over the face.
Bagging is another method of inhalant use in
which user inhale fumes directly from a plastic
bag containing chemical 1. Inhalants are a group
of substances which include paints, thinners,
typewriter correction fluid, gasoline, deodorants,
adhesives, dry cleaning fluids etc. 2. Compared to
other substance's effect of inhalant last for a short

duration and user has to inhale it repeatedly to
gain desired effect 3, 4. The inhalation of a
volatile substance is linked with both central
nervous system and different physical side
effects. Death can result from respiratory
depression or cardiac failure. It has long lasting
emotional and psychological adverse effects 5.
Inhalants are among the most harmful forms of
substance as they are linked with high rate of
morbidity and mortality 6, 7.
540
Dhoble et al.,
Int J Med res Health Sci. 2013;2(3):540-544
The scientific literature is lagging as evident in

the brief description of inhalant dependence in
the Diagnostic and Statistical Manual, 4th edition
(DSM-IV) 1. It has included little information
regarding
sociodemographic
features,
epidemiology, prevalence, subtypes, withdrawal,
co morbid medical and mental health conditions.
The literature from India is limited to few case
reports, case series and very few case studies.
This paucity of literature can be attributed to the
fact that there is a lack of awareness among the
general public as well as health care
professionals. Over the last few years our
understanding of the clinical epidemiology of
inhalant abuse has progressed but the larger
phenomenological study may avail us with a
better understanding of underlying mechanisms
and treatment response.
We conducted a cross-sectional study of inhalant

users in 32 patients fulfilling Diagnostic and
Statistical Manual of Mental DisordersIV TR
criteria for inhalant abuse. The study was
conducted in the department of psychiatry of a
hospital attached with a teaching institute. The
subjects were recruited from both indoor and
outdoor unit of the department. Detailed work up
has included a detailed history taking, physical
examination, investigations etc. Patients were
thoroughly assessed using criteria for inhalant
abuse according to DSM-IV1 . For operational
purpose DMS-IV definition was used which
define inhalant dependence as maladaptive
inhalant use which leads to significant
impairment or distress. Patients should meet
three out of seven criteria for a period of at least
12 months. The first three subjects were self
referred and the rest were identified due to
referrals via the initial subjects. Further friends
of the admitted patients when motivated, they
also agreed to participate in the study as well as
treatment.
Inclusion criteria: The patients diagnosed with
inhalant abuse according to DSM-IV TR criteria
were included in the study. For study purpose

definition of adolescence was adopted from the
World Health Organization guidelines which
define adolescence as the period between the age
of 10 and 19 years and patients in the same age
group were included in the study.
Exclusion criteria: Too young i.e. less than 10
years and more than 18 years of age were
excluded from the study. Patients unwilling to
participate and those with poor general medical
condition were excluded from the study.
Consent: The study purpose and procedures
were explained in detail to all the participants.
Considering the non-invasive nature of the study,
patients as well as their relatives consent was
easily obtained. The study was conducted in
accordance with ethical principles, including the
provisions of a World Medical Association
Declaration of Helsinki.
Assessment: Semistructured questionnaires were
used for collection of the data .It had details of
sociodemographic profile, relevant history, drug
exposure, co morbid conditions, family history
and findings of the laboratory investigations
done. The intoxication and withdrawal symptoms
were assessed on separate sheet. Observation of
the nursing staff and house officers were noted to
supplement rating of symptoms.
Data Analyses: The Statistical Package for the
Social Sciences, Windows version 17.0 was used
for data analysis.
RESULTS
A total of 32 patients meeting DSM IV TR

criteria for inhalant abuse were included in the
study of which 31 were males and one was
female. Mean age was 16.4 years (range, 11 to
19years); all of them were adolescents (as per
WHO, in between the age group of 10 to 19
years) and all were unmarried. While 37%
participant were studying, 63%
participants
were engaged in some kind of semiskilled and
unskilled employment activities. Considering the
educational level, nine percent were illiterate,
63% studied till high school, 19% studied till
541
Dhoble et al.,
higher secondary and another nine percent of

participants persuaded graduation. All were of
urban background while 13% were migrants.
Among study group 82% belonged to a nuclear
family while three percent were living alone.
Though most of the respondents were of lower
socioeconomic strata, 16% belonged to middle
class families. History of alcohol dependence
was found in close family member of 63% of
patients.
Figure.1: Different routes of inhalant use.

They began inhalant use at the average age of 14
years and average amount of inhalant used was 4
bottles per day. Curiosity was the commonest
reason for first use (90%) about which they learn
from their colleagues and friends (94%). Of the
32 subjects, 82% met the DSM-IV criteria for
inhalant dependence. Inhalant was the first
psychoactive substance used in case of 43% of
subjects. Only 40% reported it to be the only
substance abused whereas the rest of others used
Fig.2: Type of Inhalent used
it along with two or more other substances. In

65% subjects, inhalants are most preferred
psychoactive substance; in 28% subjects it was
second most preferred substance and in others it
was third or fourth preferred substance.
The most common route used for inhaling was
sniffing which was reported by 53% of the
subjects. Other routes included both sniffing and
huffing (31%), only huffing (3%), and huffing
and bagging (10%). One subject was using a
substance by only bagging (Fig. 1). The most
common inhalant reported was whitener (53%),
whereas 21% reported using typewriter erasing
fluid. For 68% patients reported it to be a most
preferred psychoactive substance while 22 %
reported it to be second most preferred
substance. Other variants included adhesives,
thinners, petrol etc (Fig. 2).
Intoxication features:
Among all intoxication symptoms, Euphoria was
most common (97%) followed by hallucinations
(88%), burning in the oropharynx (69%),
lightheadedness (47%), Drowsiness (38%) etc.
All intoxication features are described in detail in
figure - 3.
Withdrawal features:
Common withdrawal features reported were:
Craving (97%), irritability (94%), restlessness
(88%), insomnia (78%) etc (Fig. 4).
Fig.3: Inhalant intoxication features.

542
Dhoble et al.,
.
Fig 4: Inhalant withdrawal features
DISCUSSION
As in earlier studies most of our cases being male

indicates that inhalant abuse is more prevalent
among males. In our study less involvement of
females may not mean absence of inhalant abuse
but it may be because of lack of awareness and
greater stigmas for female gender 8, 9.
All the cases were from an urban locality which
may indicate that inhalant abuse is an adversity
of urbanization, poor health care awareness and
facilities, easy availability of substance and lack
of regulations10. Initially it was thought that
inhalant abuse is a problem of self employed
unskilled, adolescents of low socioeconomic
strata. But in our study we have found that few of
our patients were from middle class, educated
families with no history of any substance
dependence among family members. This might
suggest the changing pattern of inhalant abuse
among adolescents. Similar to earlier studies
most of our patients were either school dropouts
or irregular to the school8, 9. It may denote the
possibility of cognitive dysfunctions and lower
scholastic performance, especially if the
substance abuse starts early.
As in ethnographic reports, our study displayed
that urban youth consume inhalant to produce
euphoric state and intoxication11,12. The
psychological experiment like conditioning and
laboratory studies has confirm the abuse
potential of inhalants13, 14. Our patients also
reported intoxication that is similar to previously

reported intoxication symptoms 15, 16. Euphoria
was most common intoxication symptom, which
might have act as a reinforcer for subsequent use.
Despite adverse events of intoxication like
burning in eyes and oropharynx, nausea, memory
loss, giddiness etc, most of the users used
inhalants continuously.
Craving reported by most of our cases indicate
that inhalants has great potential of misuse17, 18.
Other common withdrawal features were
irritability, restlessness, anhedonia, etc. The
withdrawal symptoms in our patients were nearly
similar to the ones found by other study19, 20.
During course of clinical practice, practitioners
should be watchful for cases of inhalant abuse.
They should routinely enquire and screen for
inhalant use and intervene early. This can be
effectively done by health education as well as
approaches used for other substance dependence.
Other important action could be supply-side
interventions which have not been widely
practiced in the India. But in countries like
Australia they have included adding bittering
agents to frequently abused inhalant products,
selling substitutes that are not readily abused,
and altering the products so that they are no
longer be used for inhalation22 . Similar
legislations are needed in India to curtail the use
of inhalants among adolescents.
CONCLUSION
Inhalant use can cause serious harm to

psychological, emotional and neurobiological
development of adolescents. Our study has
shown that it has distinct intoxication and
withdrawal features. It would help in formulating
an appropriate treatment strategy like substitution
therapy, aversion therapy, anti-craving therapy
etc. It is also important to introduce supply-side
interventions and legislations in India to curtail
the use of inhalants among adolescents.
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Dhoble et al.,
1. American
Psychiatric
Association.
Diagnostic and Statistical Manual of Mental
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American Psychiatric Press. 2000;257-263
2. Kurtzman TL, Otsuka KN, Wahl RA.
Inhalant abuse by adolescents. J Adolesc
Health.2001; 28: 170180.
3. Bowen SE. Increases in amphetamine-like
discriminative stimulus effects of the abused
inhalant
toluene
in
mice.
Psychopharmacology (Berl).2006; 186: 517
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4. Balster RL, Cruz SL, Howard MO, et al.
Classification of abused inhalants. Addiction.
2009; 104(6):87882.
5. Balster RL. Neural basis of inhalant abuse.
Drug Alcohol Depend.1998; 51: 20714.
6. Dinwiddie SH. Abuse of inhalants: a review.
Addiction. 1994; 89(8):92539.
7. Dinwiddie SH. Psychological and psychiatric
consequences of inhalants. In: Tarter, RE.;
Ammerman RT, Ott PJ. editors. Handbook of
Substance
Abuse:
Neurobehavioral
Pharmacology.New York: Plenum; 1998.
8. Shah R, Vankar GK, Upadhyaya HP.
Phenomenology of gasoline intoxication and
withdrawal symptoms among adolescents in
India: A case series. Am J Addict
1999;8:254-7.
9. Kumar S, Grover S, Kulhara P, Mattoo SK,
Basu D, Biswas P, et al. Inhalant abuse: a
clinic-based study. Indian J Psychiatry
2008;50:117-20
10. Seth R, Kotwal A, Ganguly KK. Street and
working children of Delhi, India, misusing
toluene: an ethnographic exploration. Subst
Use Misuse 2005;40:1659-79.
11. DAbbs P, MacLean S. Volatile substance
misuse: A review of interventions. National
Drug Strategy, Monograph Series No. 65.
Australian Government, Department of
Health and Aging.2008.
12. Howard MO et al. Inhalant use among
incarcerated adolescents in the United States:
Prevalence, characteristics, and correlates of
use. Drug and Alcohol Dependence, 2008;

93(3):197209.
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SL. The last decade of solvent research in
animal models of abuse: mechanistic and
behavioral studies. Neurotoxicol Teratol,
2006; 28: 636647.
14. Giannini AJ. The volatile agents. In: Miller
NS, ed. Comprehensive Handbook of Drug
and Alcohol Addiction. New York, NY:
Marcel Dekker; 1991: 125130.
15. Jaffe JH. Drug addiction and drug abuse. In:
Gilman AG, Rall TW, Nies TW, Taylor P,
eds. The Pharmacological Basis of
Therapeutics. 8th ed. New York, NY:
McGraw-Hill; 1990:522573.
16. Brady M. In: Heavy Metal: The Social
Meaning of Petrol Sniffing in Australia.
Canberra: Aboriginal Studies Press; 1992.
17. National Institute of Drug Abuse. Research
report series: Inhalant Abuse. NIH
Publication Number 05-3818, Revised March
2005.
18. Pahwa M, Baweja A, Gupta V, Jiloha RC.
Petrol-inhalation dependence: A case report.
Indian J Psychiatry 1998;40:92-4.
19. Waraich BK, Chavan BS, Raj L. Inhalant
abuse: A growing public health concern in
India. Addiction 2003;98:1169.
20. Basu D, Jhirwal OP, Singh J, Kumar S,
Mattoo SK. Inhalant abuse by adolescents: A
new challenge for Indian physicians. Indian J
Med Sci 2004;58:245-9.
21. Das PS, Sharan P, Saxena S. Kerosene abuse
by inhalation and ingestion. Am J Psychiatry
1995;149:7-10.
22. Howard M, Bowen S, Garland E, Perron B,
Vaughn M. Inhalant Use and Inhalant Use
Disorders in the United States. Addiction
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544
Dhoble et al.,
DOI: 10.5958/j.2319-5886.2.3.096

&
Health Sciences
Received: 3rd Jun 2013

Research article
MEDIAN ARTERY IN FORMATION OF SUPERFICIAL PALMAR ARCH: A CADAVERIC
STUDY
*Joshi SB1, Vatsalaswamy P2, Bhahetee BH3
1,3
2
Department of Anatomy, B.J.G.Medical College, Pune, Maharashtra,India

Department of Anatomy, Dr. D. Y. Patil medical College and Research centre, Pune, MHS, India
*Corresponding author email: drsheetalbjoshi@rediffmail.com

ABSTRACT
Background: Knowledge of the variations in the arterial supply of hand has reached a point of practical
importance with the advent of microvascular surgery for revascularization, replantation and composite
tissue transfers. Superficial palmar arch has many interesting variations, of them the median artery
contribution is been evaluated in the present study. Method: 100 cadaveric hands of 50 cadavers were
dissected and their formation and pattern was recorded according to Coleman and Anson classification,
1961 and photographed. The present study highlights particularly the median artery contribution in the
formation of superficial palmar arch. Results: In the present study 4% of specimens showed medianoulnar type of incomplete superficial palmar arch. This observation had a unilateral presentation seen in
only right hand of four adult male cadavers. The left hand of these specimens showed ulnar type of
complete arch. Conclusion: The median artery is a transitory vessel that represents the arterial axis of the
forearm during early embryonic life. It normally regresses in the second embryonic month Its
persistence in the human adult has been recorded in different patterns: as a large, long vessel (palmar
type) which reaches the hand is the focus of present study The clinical importance of the persistence of
this artery at wrist level is well documented as a cause of the carpal tunnel syndrome, but it has also
been associated with the `pronator teres syndrome' in cases where the persistent median artery pierces
the median nerve in the proximal third of the forearm.
Keywords: Mediano-unlar arch, Ular arch, Palmar type
INTRODUCTION
A detailed study of the functions of the hand is

the basic requirement of all aspiring hand
surgeons. This is unfortunately a highly complex
matter and though general guidelines can be
given, continued clinical experience and
observations are necessary if treatment
programmes are to be put to the best advantage
to the patient.1
Joshi et al.,
We need to study hand in terms of arterial supply

and the more intimate knowledge, the hand
surgeon is provided with, he can get better
equipped to deal with microvascular and plastic
surgeries.
Knowledge of the variations in the arterial supply
of hand has reached a point of practical
importance with the advent of microvascular
Int J Med Res health sci. 2013;2(3):545-550
545
surgery for revascularization, replantation and

composite tissue transfers.2
The superficial palmar arch is an anastomosis fed
mainly by the ulnar artery. The later enters the
palm with the ulnar nerve, anterior to the flexor
retinaculum and lateral to the pisiform. It passes
medial to the hook of the hamate, and then
curves laterally to form an arch, convex distally
and level with a transverse line through the distal
border of the fully extended pollicial base. About
a third of the superficial palmar arches are
formed by the ulnar alone; a further third are
completed by the superficial palmar branch of
the radial artery and a third by the arteria radialis
indicis, a branch of arteria princeps pollicis or the
median artery.
Four digital arteries arise from the convexity of
the arch and pass to the fingers. The most medial
artery supplies the medial side of the little finger
and the remaining three subdivide into two and
supply the contiguous sides of the little, ring,
middle, and index fingers, respectively. 3
Variation in superficial palmar arches has always
attracted attention of number of researchers.
Many variations have been reported but the focus
of present study is to record involvement of
median artery in the formation of superficial
palmar arch. According to Huelin, Barreiro and
Barcia, antebrachial and palmar are the two types
of termination of median artery. Antebrachial
type shows two variants Atrophic type and
Carpal type.
Palmar or embryonal type also shows two
variants, Long type, which ends in the superficial
palmar arc through small arterioles or supplying
small vases to the subcutaneous cellular tissue;
before reaches the end; the median artery sends
branches which anastomose with the ulnar and
radial arteries at the carpus level. The second
variant is Digital type 4
In present study the palmar type of median artery
is highlighted for its significance in formation o
superficial plmar arch
Aims and objectives: The present study was
conducted to analyse the contribution of median
Joshi et al.,
artery in the formation of superficial palmar arch

in human cadavers.
The aim of present study was to establish the
pattern of the palmar type of median artery in a
large sample of hands in terms of side, and also
to provide a more accurate account of its detailed
morphology and relationships along its course.
The study was carried out in 100 formalin fixed

human hands of 50 cadavers (46 male and 4
female ) during the period 2009 to 2012 at Dr. D.
Y. Patil Medical College, Pune and B. J. Govt.
Medical College, Pune. The dissection was
carried out according to Cunninghams manual
the formation of superficial palmar arch was
observed and recorded. The data was classified
according to Coleman and Anson, 19615
classifications. (Table 1)
Observations: Among the 100 hands of 50
cadavers, 4 male right hands showed the
formation of superficial palmar arch by median
and ulnar arteries where in the two arteries did
not anastomose. According to Coleman and
Anson classification the superficial palmar arch
is broadly categorized into complete type-group I
(contributing
arteries
anastomose)
and
incomplete type-Group II (contributing arteries
do not anastomose). Each category is further sub
classified into types A to type E depending on
the arteries which form the superficial palmar
arch. Refer table 1.
In the present study 4% showed type C where in
superficial palmar arch is Incomplete arch group II , medianoulnar type according to
Coleman and Anson, 1961.5 In all 4 male
cadaveric specimens this type had a unilateral
presentation, observed in the right hand only.
The left hand in these specimens showed ulnar
type of arch where in the arch was completely
formed by superficial palmar branch of ulnar
artery. This type of arch is classified according to
Coleman and Anson, 1961 as type B superficial
palmar arch (Complete arch - group I ) Ulnar
type.
546
Table 1: classified according to Coleman and Anson5
Group
Complete
Arch(I)
(contributing
vessels
anastomose )
Types according to Coleman and Anson 1961.5

A
B
C
Superficial
palmar branch
of radial artery
+ larger ulnar
artery
Superficial
Incomplete
palmar branch
Arch(II)
of the radial
(contributing artery + ulnar
vessels
do artery.
not
anastomose)
Entirely
by Ulnar artery
Radio
ulnar artery
+
enlarged medianomedian artery.
ulnar arch
Ulnar
artery
only (does not
supply
the
thumb and the
index finger).
Fig. 1 Shows incomplete mediao-ulnar superficial

palmar arch. Classified as group(II) type C according
to Coleman and Anson,1961
Superficial
vessels
of
median
+ulnar arteries.
E
Ulnar artery +
large
sized
vessel derived
from
deep
arch.
Superficial
vessels of
Radial
+
median
+ulnar
arteries.
Fig.2: Shows course and relations of median

artery in forearm
M-Median artery, U-Ulnar artery, SU- Superfical palmar branch of ulnar, 1-4- Common plamar digitial
arteries, 5- Proper palmar digital artery, B- Brachial artery, R-Radial artery, MN-Median nerve, AIAAnterior interosseous artery, Encircled area shows median artery piercing median nerve
Joshi et al.,
547
Fig. 3 Shows complete Ulnar type of superficial

palmar arch. Classified Group I type B 5
R- radial artery, U-ulnar artery, SR- superficial

palmar branch of radial
Superficial palmar arch in the right hand of 4
specimens: In four adult male cadavers the right
hand showed superficial palmar arch formed by
superficial palmar branch of ulnar artery(U) and
median artery(M).The contributing arteries did
not show anastomosis, so were termed to have
incomplete type of arch. (Fig.1)
Branches of superficial palmar arch in the right
hand of four specimens: The superficial palmar
branch of ulnar was noted to have given a proper
palmar digital branch to the ulnar side of little
finger (5) and two common palmar digital
arteries which divided into proper palmar digital
arteries (3&4) to supply the adjacent sides of
little, ring, and middle fingers respectively. (Fig.
1)
The median artery in the hand was found to have
given two common palmar digital arteries (1 &
2) which divided into proper palmar digital
arteries to supply the adjacent sides of thumb,
index and middle fingers respectively.
Course of median artery in right forearm of 4
specimens:
Joshi et al.,
normal origin as a terminal branch of brachial

artery in the cubital fossa. To visualize the
median artery the oblique attachment of flexor
digitorum superficialis on the anterior surface of
radius was reflected medially. Another important
and interesting finding of the median artery
which was recorded was that, it pierced the
median nerve (MN) in the upper third of the
forearm and then traversed distally into the hand
deep to flexor retinaculum. (Fig. 2)
Superficial palmar arch in the left hand of 4
specimens: The superficial palmar arch was
formed by superficial palmar branch of ulnar
artery (U) only. The superficial palmar branch of
radial artery (R) was did not contribute to the
formation of the arch on the lateral side, instead
the artery ended in thenar eminence. See fig. 3
Branches of superficial palmar arch in the left
hand of 4 cadavers: The superficial palmar
branch of ulnar was noted to have given a proper
palmar digital branch to the ulnar side of little
finger and four common palmar digital arteries
that divided into proper palmar digital arteries to
supply adjacent sides of thumb, index, middle,
ring and little fingers respectively. Fig 3
Ontogenic basis : According to classic studies of
Caplan and Koutroupas, myogenic areas become
vascular and chrodrogenic areas become clear
and avascular. By 6th week, ulnar artery is
apparent and branches from brachial artery
progressing down the hand plate to form the deep
palmar arch. The radial artery develops later and
is more variable progressing down the preaxial
side of the limb. Eventually, median and
interossesus arteries decrease in size, and median
artery degenerates, providing only some blood
supply to median nerve the small vestige of
interosseous artery terminates in many small
branches (rete system) in the carpus. 6
Arey 1957, 7 is of the view that the anomalies of
blood vessels may be due to;
1. The choice of unusual paths in the primitive
vascular plexuses. 2. Persistence of vessels
normally
obliterated.
3. Disappearance
of vessels
When
the median
artery was traced
in these specim
normally retained. 4. Incomplete development. 5.
548
Fusion and absorption of the parts usually

distinct.
DISCUSSION
Coleman and Anson 1961, 5 Classified the

superficial palmar arch as: Group (I) Complete
Arch (contributing vessels anastomose) Group
(II) Incomplete Arch (contributing vessels do
not anastomose). According to Coleman and
Anson 1961, 5 in the present study the
superficial palmar arches of the right hand in 4
specimens is
classified
into group II
(incomplete) and type C (mediano-ulnar arch),
whereas the superficial palmar arch of the left
hands is classified as group I (complete) and
type B (ulnar arch).
According to Coleman and Anson 1961, (1) the
common palmar digital arteries were recorded to
have 7 different patterns which applied to the
present study and it is noted to be of type 1 in
both hands. This type shows that the 1st common
palmar digital artery which supplies ulnar side of
the thumb and radial side of the index finger. The
rest 3 common palmar digital arteries supply 2nd,
3rd, and 4th inter-spaces
Many studies which comprised recordings
exclusively of median artery and its contribution
to Superficial Palmar Arch have been put forth.
Few of these studies with their percentages are as
follows
Tandler et al, 18875 (16%) Adachi,
19288 (8%), Misra, 19559 (8.4%), Coleman and
Anson, 19615 (9.9%), M. Chimalgi, 199510 14%
The present study reflects 4%. The past studies
had variating sample size so the incidence cannot
be justified.
Lo, Leung, Lau and Young 198611 have observed
that 16% of the patients with Downs syndrome
demonstrate persisting median artery. 76.9% of
the hands with radial or ulnar deficiency
syndromes demonstrated persisting median
artery as put forth by Inoue and Miura, 199112.
Such an association could be due to simultaneous
teratogenic effects.
The unilateral presence of median artery in the
present four cases indicates that, the factors
Joshi et al.,
responsible for these variations could be acting

unilaterally.
Rodrguez-Niedenfhr et al, 199913study also
confirms that the median artery may persist in
adult life in two different patterns palmar and
antebrachial based on their vascular territory the
palmar type which represents the embryonic
pattern is large long and reaches the palm the
antebrachial type which represents a partial
regression of embryonic artery is slender short
and terminates before reaching the wrist.
In the present study only the palmar type of
median artery was taken into consideration
whereas antebrachial pattern was not recorded.
D'Costa et al, 2006 14 conclude that palmar type
of median artery have a higher incidence than the
antebrachial type and that it may be involved in
the pronator teres syndrome, carpal tunnel
syndrome and anterior interosseous syndrome. In
the present study the right hand of all four
specimens showed presence of palmar type of
median artery.
CONCLUSION
The knowledge of frequency of anatomical

variations of arterial pattern of hand is very
important for safe and successful hand surgery.
In the present study in 4% cases the right hand
showed medianoulnar type of superficial
palmar arch and left hand only ulnar type from
which it can be concluded that, in such cases
radial artery harvest for coronary artery bypass
may prove to be less fatal. The study highlights
a palmar type of median artery in the right hand
of 4 specimens which may be involved in the
pronator teres syndrome, carpal tunnel syndrome
and anterior interosseous syndrome.
It is
interesting to note that many authors have tried
to explore the anatomy of hand but very few
report similar results.
ACKNOWLEDGMENT
Dr. V. Arole, Hod and Professor Department of

Anatomy at Dr. D.Y.Patil Medical College and
549
research centre for her support, Mr. Dananjay,

our technician for his photographic skills,
Mr.Bhimprasad Joshi, my husband for labelling
the photographs.
REFERENCES
1. Barron JN, Saad MN. The hand operative

plastic and reconstructive surgery: general
principles. Edinburgh: Churchill Livingstone;
1980. p. 923-9.
2. McCarthy Joseph G. Plastic surgery the hand,
Part 1: Examination of the Hand and
Relevant Anatomy. Philadelphia: W.
B.Saunders Company; 2000:4274-83.
3. Richard SS. Clinical Anatomy for Medical
Students: The Upper Limb. 5th edition.
Boston
N.Y:
Little,
Brown
and
Company;1995:445-52.
4. Slvia Regina Arruda de Moraes, Tmara
Nunes de Arajo, etal. Morphologic
variations of the superficial palmar arc. Acta
Cirurgica
Brasileira
So
Paulo 2003;18(3):15
5. Coleman SS, Anson BJ. Arterial patterns in
the hand based upon a study of 650
specimens. Surgery Gynaecology and
Obstetrics. 1961;113:409-24.
6. Loren J Borud, Stephen J Mathes et al.
Plastic SurgeryThe Hand And Upper Limb,
Part 2,Vol. VIII: Embryology of the upper
limb. 2nd Edition Philadelphia PA: Saunders
Elsevier;2006:3-23.
7. Arey.
Developmental
Anatomy:
Development of the arteries 6th Edition..
Philadelphia: W. B. Saunders Co.;1957:375
77.
8. Adachi B. Das arterien-systemder Japaner,
Kenkyusha, Koyoto 1928;1:365-389.
9. Misra BD. Arteria Mediana. J Anat Soc of
India 1955;4:48.
10. Chimmalgi, Sant SM, Chhibber SR,
Humbarwadi RS. A study of superficial and
deep palmar arches in human hands,
Anatomica Karnataka 2004;1(5):90-97.
11. Lo RN, Leung MP, Lau KC, Yeung CY.
Abnormal Radial artery in Downs
Syndrome. Arch Dis Child (England)
1986;61(9):885-90.
Joshi et al.,
12. Inoue G and Miura T. Arteriographic

findings in radial and ulnar deficiencies. Br J
Hand Surg 1991;16(1):409-12.
13. Rodrguez-Niedenfhr M. Median artery
revisited. Journal of Anatomy 1999; 195(1):
57-63
14. D'Costa, Sujatha, Narayana. Occurrence and
Fate OF Palmar type of median Artery. ANZ
Journal of Surgery. 2006;76(6):484-87.
550
DOI: 10.5958/j.2319-5886.2.3.097

&
Health Sciences
Received: 4th Jun 2013
Coden: IJMRHS Copyright @2013 ISSN: 2319-5886

Research article
STUDY OF VASCULAR SEGMENTS OF LIVER ON COMPUTERISED TOMOGRAPHY IN
SUBJECTS WITH NORMAL LIVER
More Anju B.
Department of Anatomy, Sree Mookambika Institute of Medical Sciences, Kulsekharam, Tamilnadu,
India.
Corresponding author email:as.anju@yahoo.in
ABSTRACT
Liver, the largest gland in the body receives total perfusion of 1500ml per min even in inactive state.
The introduction of Computerised Tomography has made imaging of liver more detailed and safe. The
liver is divided into eight vascular segments. Each of them receives a portal pedicle. The ramifications
of hepatic veins define intersegmental planes. Aims: Pattern of ramification of both portal and hepatic
veins, internal diameter of these vessels and their angulation is measured. Methods and Material: CT
scans of 50 adult patients both male and female for indications other than liver pathology and clinically
normal liver were included in the study. Results: Portal vein divides into three branches, namely Left
branch of portal vein, anterior and posterior segmental vein; branches of right portal vein in 12% of
cases. Patterns of drainage of hepatic veins indicate variable internal architecture. Internal diameter of
vessels and ramification within 1 cm from IVC determine surgical plan. Conclusions: Pattern of internal
architecture is unique for each individual. Preoperative CT scan will help to plan resection along the
intersegmental plane with minimal loss of liver tissue. The liver transplantation is done using cadaver
donor or partial transplantation using live donor. In trauma and malignancy, the affected lobe and
segments of liver can be resected preserving the rest, which can hypertrophy to compensate for the loss.
Keywords: Hepatic vein, Portal vein, Liver, Vascular segments
INTRODUCTION
Prior to World War II, mortality due to liver

injury was approximately 60%. The initial
attempts to control bleeding were by using gauze
packs which was later replaced by omentum as
living pack. The description of segmental
anatomy by Cauniud in 1957 changed the view. 1
This knowledge was used during liver surgeries
for trauma to achieve vascular occlusion.
More
Stephens et al have studied 600 liver

examinations by CT scan and stated the
consistent findings.2 The best pictures are
obtained within 20-40 EMI units range of
attenuation values. 3He has defined the segments
on basis of boundaries formed by intrahepatic
branches of portal vein and hepatic vein.
Nagasue et al have beautifully developed the
technique of segmental and subsegmental
resection in 1985. Anatomic hepatic lobectomy
551
or major segmentectomy involve teasing away of

liver tissue to expose vessels. The nomenclature
of these resections is based on anatomical
description of Cauniaud.1
Initially invasive techniques were used to study
internal architecture of liver.4 Liver surgeries
have become more common as incidence of liver
Ca is raising. The transplantation and resection
are now performed in Indian institutions as well.
The contrast CT gives accurate dimensions of the
intrahepatic vessels, which define the segments.
They also define planes for segmental or lobar
dissection of liver. In western countries data is
available both by CT scan imaging and actual
liver dissection during surgeries.5Since live liver
donation and transplantation are not the routine
procedures in India such data is not available in
Indian population. 6
This study was planned to find the normal
pattern and variation of hepatic vessels that
define the surgical plane. The study will be
helpful to derive the normative dimensions of
these vessels in Indian population. Yet the
branching pattern is unique for each individual.
Recent advances in catheterisation of hepatic
veins to determine the hepatic blood flow,
hepatic venography, panhepatography and
increasing interest in hepatic surgery necessitates
a detailed knowledge of the pattern of the hepatic
vessels.
Ethics: The Institution is a tertiary care centre

with state of art facilities in the Radiology
department.
The study was done after the permission of
Institutional Ethical Committee.
CT scans of 50 adult patients both male and
female for indications other than liver pathology
and clinically normal liver were included in the
study. The data archived in the CT section of
Radiology department at Seth G S Medical
College and KEM Hospital, Mumbai during
1/08/2003 to 31/01/2004 was studied. The livers
were examined in contiguous slices (8-10 mm).
The following measurements taken were on
different levels of cross section:
1. A high section through the liver body, which
demonstrated dome of right lobe surrounded by
lung:
a. the diameter of right , middle and left
hepatic veins.
b. the diameter of Inferior vena cava.
c. Angle between hepatic veins.
2. Section through the main body liver: the
diameter of right and left portal veins.
3. Section at lower level: the diameter of main
portal vein.
Statistics: The data was analysed by using
statistical tests of mean and standard deviation.
RESULT
Table 1: Patterns of division of main portal vein

Pattern of division
Present study
Gupta et al (1977)
Cases
%
Cases
percentage
Right and left portal vein
42/50
84
75/85
88
Left branch of portal vein and anterior 8/50
16
10/85
12
and posterior segmental vein
Right portal vein is absent if portal vein directly divide into segmental veins.
More
552
Table 2. Measurements of diameter
Vessel
Main portal vein
Right portal vein
Left portal vein
Inferior vena cava
Right hepatic vein
Left hepatic vein
Middle hepatic vein
Common trunk
Internal diameter (mm)

18.48 0.47
9.87 0.20
9.33 0.19
27.74 0.53
6.65 0.24
6.82 0.21
6.22 0.37
13.95 4.96
Table 3. Various patterns of drainage of three major hepatic veins and their radicle into the IVC
Mode of termination
Present study
Cases
Incidence
out of (%)
50
*
+
**
Separate opening of LHV , MHV , and RHV
27
54%
Left common trunk formed by union of LHV 14
28%
and MHVs, separate opening of RHV
Left common trunk formed by union of superior 2
4%
and inferior radicals of LHV and MHVs,
separate opening of RHV
Separate opening of superior and inferior 2
4%
radicals of LHV, MHV, and RHV
Separate opening of right and left radicals of 1
2%
MHV,RHV and LHV
Left radical of MHV joins with LHV to drain 1
2%
into IVC; Separate openings of right radicle of
MHV and RHV
Left common trunk formed by union of right 1
2%
and left radical of MHV and LHV; separate
opening of RHV
Separate opening for RHV, MHV, LHV and left 1
2%
superior vein
Left common trunk formed by union of right 1
2%
and left radical of MHV and inferior radical of
LHV; Separate opening for RHV and superior
radical of LHV
Single common trunk formed by union of LHV, Nil
Nil
MHV, and RHV
Gupta et al (1979)
Cases
Incidence
out of 95 (%)
Right common trunk formed by union of RHV Nil

and MHV; separate opening of LHV
More
Nil
10
60
10.53
63.16
6.32
5.26
6.32
1.05
Nil
Nil
Nil
Nil
Nil
Nil
4.21
3.15
553
Where *=Left hepatic vein, +=Middle hepatic vein,**= Right hepatic vein
Table 4: Morphology of common trunk
Type 8
I
II
III
IV
Percentage
Present Study
24
10
6
62
Wind et al (1999)
32.81
43.78
7.81
15.63
Table 5. Ramification within 1 cm from IVC
Vesse
l
RHV
LHV
MHV
No of ramifications cases (percentage)

3
2
1
Zero
1(2%) 3(6%) 6(12%)
40(80%)
2(4%) 3(6%) 7(14%)
33(66%)
5(10%) 8(16%) 1(2%)
33(66%)
The vessel itself is absent

Present study
Gupta et al (1979)
Nil
Nil
5/50(10%)
11/95(11.5%)
3/50(6%)
7/95(7.3%)
RHV= Right Hepatic Vein; [LHV] =Left Hepatic Vein; [MHV] =Middle Hepatic Vein
Table 6. Angle between major radicals of hepatic veins
Between
RHV &LHV
RHV &MHV
LHV &MHV
Angle
103.13+30.82
48.59+22.36
70.78+29.27
RHV= Right Hepatic Vein; [LHV] =Left Hepatic Vein; [MHV] =Middle Hepatic Vein
Fig.1: R- Right portal vein
Fig. 2: L-Left portal vein
Fig. 3: Three hepatic veins; R-Right, M-Middle, Fig. 4: C-common trunk formed by union of
More
554
L-Left hepatic vein, I-Inferior vena cava
middle and left hepatic vein
DISCUSSION
Liver is divided into two functional lobes with

right and left division of portal vein. They are
further divided by three major hepatic veins into
four segments and eight subsegments.1 These
intersegmental fissures contain hepatic veins.
Usually no major tributary cross this plane and
thus provide a relatively avascular plane during
surgery. But occasionally, such plane could be
traversed by a relatively large vein and demands
extra precaution. Each sector is fed by portal
pedicle accompanied by hepatic artery and bile
duct. These vessels define segments of liver
which are useful during liver surgery for trauma,
malignancy, resection and transplantation. CT
scan is less operator dependent and more
reproducible. It combines better resolution with
excellent spatial orientation.2
Liver has homogenous architecture supported by
reticular meshwork. Blunt dissection is required
to expose the blood vessels.4 Portal vein divides
directly into left portal vein and anterior and
posterior segmental veins; tributaries of right
portal vein only in 12 to16 % of cases.7 The
significance of internal diameters of the major
vessels is underlined by Gupta et al 1979 but
they have not given the values. These normative
derivations can help to label small or large
caliber vessels during diagnostic procedures and
surgery.
All the three hepatic cranial veins; right, middle
and left drain independently into inferior vena
cava. But it is not unusual for them to join as
they approach IVC forming various patterns.8
The different patterns observed in the present
study are compared with the findings of Gupta et
al (1979). The following two patterns were not
encountered during present as well as reference
study.
1. Left common trunk formed by union of LHV
and right and left radical of MHV; separate
opening for RHV.
More
2. Right common trunk formed by union of RHV

and right radical of MHV; separate opening for
LHV and left radical of MHV.
As the hepatic veins approach IVC they or their
tributaries may join to form a common trunk and
then drain into it. Such common trunk was
observed in 19 of the 50 cases studied. The
internal diameter is measured when present. The
diameter and length of such pedicle will dictate
the type of anastomosis feasible between the
donor and recipients vessel.9 Following
classification is designed and used by Wind et al
in their study.
Morphologic criteria:8
I- No branch within 1cm of the common trunk
from its entry into the IVC. No branches
empting directly into IVC.
II- One or more branches within 1cm of the
common trunk from its entry into the IVC.
No branches empting directly into IVC.
III- One or more branches opening directly into
IVC irrespective of the common trunk.
IV- No common trunk.
Ramification of hepatic vessels within 1cm from
IVC makes it less useful as a pedicle for both
resection and transplantation.10 Gupta et al
(1979) have discussed the significance of this
branching pattern in their study. But they have
not classified the data into number of
ramifications; 3, 2, 1 and zero.RHV is always
present. LHV and MHV may be absent due to its
tributaries joining with other vein to form
common trunk or when these tributaries drain
directly into IVC.
The angulations between major radicles of
hepatic veins are expressed in terms of mean and
standard deviation. This may help to plan surgery
as indentations on liver surface do not
correspond to the fissures during resection, either
segmentectomy or lobectomy; the glissons
capsule is cut with a knife. Then the liver tissue
555
is teased away either with blunt end of knife or a

small sucker. The prior knowledge of placement
of hepatic veins with respect to each other will
help in deciding the plane of dissection.11The
blood supply of caudate lobe is not included in
this study. Since they have small caliber of
0.8mm to pinhole; the resolution during routine
abdominal CT used in the present study does not
show these vessels.
CONCLUSION
The architecture varies from person to person so
we only get to know range of variations that can
be expected from such a study. Study of internal
architecture with CT scan followed by dissection
on same cadaveric liver specimen will stipulate
the accuracy and advantage of CT as
preoperative mapping tool for liver surgeries.
ACKNOWLEDGEMENTS
gross anatomy of liver. American Journal of

Roentgenology. 1983;141:711-18.
5. Kreel L. Computerised tomography and the
liver. Clin Radiol. 1997; 28(6):571-81.
6. Gupta SC, Gupta CD, Arora AK. .
Intrahepatic branching patterns of portal
vein- A study by corrosion cast.
Gastroenteology. 1977; 72: 621-24.
7. Gupta SC, Gupta CD, Arora AK.
Subsegmentationof the human liver. J Anat.
1979; 124:413-23.
8. Wind P, Douard R, Cugnence PH, Chevallier
JM. Anatomy of the common trunk of the
middle and left hepatic veins-Application to
liver transplantation.Surg Radiol Anat.1999;
21:17-21.
9. Gupta SC, Gupta CD, Gupta SB.
Hepatovenous segments in the human liver. J
Anat. 1981; 133(1): 1-6.
10. Nakamura S, Tsuzuki T. Surgical anatomy of
the hepatic veins and the IVC. Surg Gynecol
Obstet.1981;152(1):43-50.
The present article is part of dissertation

submitted for the degree of M.S. (Anatomy) of
the University of Mumbai. I would like to
express my sincere gratitude to my respected
Guide and Institution.
REFRENCES
1. Cauniaud In: Williams PL, Warwick R,
Dyson M, Bannister LH, editors. Grays
Anatomy. 38th edition. Churchill Livingstone;
1995:1795-809.
2. Stephens DH, Sheedy PF II, Hattery RR,
MacCairty RL.Computed tomography of the
liver. Roentgenology. 1977; 128:579-90.
3. Hounsfield In Boyd DP, Parker D, Computed
tomography of the body. In: Moss AA,
Gamsu G, Genant HK, editors. Basic
principles of computed tomography. B
Saunders company;1983: 1-22.
4. Sexton CC and Zeman RK. Correlation of
computed tomography, sonography, and
More
556
DOI: 10.5958/j.2319-5886.2.3.098

&
Health Sciences
Revised: 3rd Jul 2013
Accepted: 5th Jul 2013
Research Article
ATTENUATION OF CARDIOVASCULAR RESPONSES TO LARYNGOSCOPY AND

INTUBATION BY DILTIAZEM AND LIGNOCAINE: A COMPARATIVE STUDY
*Mohan K1, Mohana Rupa L2
1
Department of Anaesthesia, 2Department of Pharmacology, Sri Sathya Sai Medical College & Research
Institute, Tiruporur, Guduvancherry, Ammapettai, Sembakkam, Tamilnadu, India.
*Corresponding author email: koyeedoctor@gmail.com
ABSTRACT
The study has been designed to investigate the attenuation of cardiovascular responses to laryngoscopy
and intubation by diltiazem and lignocaine. Endotracheal intubation is often associated with a
hypertension and tachycardia. This response is primarily because of sympatho-adrenal stimulation,
associated with laryngoscopy and endotracheal intubation. The rise in the heart rate (HR) and blood
pressure increases the myocardial oxygen demand. This increase is tolerated well by normal healthy
individuals. However, in patients with Ischemic heart disease (IHD), Hypertensive heart disease and
cerebrovascular disease, this sudden rise of heart rate and blood pressure can produce deleterious effects,
in the form of myocardial ischemia, pulmonary oedema and cerebral haemorrhage. Many methods, like
beta-blockers, deep inhalational anaesthesia, intravenous lignocaine, calcium channel blockers and
direct acting vasodilators, have been tried to blunt these harmful pressor responses associated with
laryngoscopy and endotracheal intubation. Intravenous lignocaine is a popular method of blunting this
response, because of its ability to depress the myocardium and membrane stabilization effect. Diltiazem,
a calcium channel blocker can blunt these responses because of its direct acting vasodilating properties
and negative chronotropic effect. In view of it, the present study was undertaken to compare the effects
of 1.5 mg/kg lignocaine IV given 3 minutes before laryngoscopy and intubation, Diltiazem 0.2 mg/kg
IV given 60 seconds before laryngoscopy and intubation and combination of 0.2 mg/kg of diltiazem IV
and 1.5 mg/kg of lignocaine IV given 60 seconds before laryngoscope and intubation on laryngoscopic
reactions. It was noted that,both lignocaine and diltiazem attenuated the pressor response to
laryngoscopy and endotracheal intubation compared to control group. However, the combination of
lignocaine and diltiazem gave better protection against the laryngoscopic reaction than when either of
the drugs was given alone.
Keywords: Laryngoscopy, tracheal intubation, cardiovascular response, Lignocaine, Diltiazem
Mohan et al.,
557
INTRODUCTION
Direct laryngoscopy and endotracheal intubation
following induction of anaesthesia is always
associated with hemodynamic changes due to
reflex sympathetic discharge caused by
epipharyngeal
and
laryngopharyngeal
1
stimulation. This increased sympatho-adrenal
activity may result in hypertension, tachycardia
and arrhythmias. 2, 3 This increase in blood
pressure and heart rate are usually transitory,
variable and unpredictable. Hypertensive patients
are more prone to have significant increases in
blood pressure, whether they have been treated
before hand or not. 4 Transitory hypertension and
tachycardia are probably of no consequence in
healthy individuals but either or both may be
hazardous to those with hypertension,
myocardial insufficiency or cerebrovascular
diseases. This laryngoscopic reaction in such
individuals may predispose to development of
pulmonary oedema, 5 myocardial insufficiency 6
and cerebrovascular accident. 7 At least in such
individuals there is a necessity to blunt these
harmful laryngoscopic reactions.
Many pharmacological methods have been
devised to reduce the extent of hemodynamic
events including high dose of opioids, 8 local
anaesthetics like lignocaine, 9 alpha and beta
adrenergic blockers 10, 11 and vasodilatation drugs
like nitroglycerine. 12 Topical anaesthesia with
lignocaine applied to the larynx and trachea in a
variety of ways remains a popular method used
alone or in combination with other techniques. 13
Intravenous lignocaine with its well established
centrally depressant and anti-arrhythmic effect
was found to be a more suitable alternate method
to minimize this pressor response. 14, 15 Recently
several studies have shown that calcium channel
antagonist like diltiazem, with its direct
vasodilation and direct negative chronotropic and
dromotropic properties are also effective. 4, 16
Hence the present study was undertaken to
compare the effect of Intravenous lignocaine and
intravenous diltiazem on blunting the
haemodynamic responses to endotracheal
Mohan et al.,
intubation. An attempt is also made to study the

effect of combination of these two drugs on
haemodynamic response to endotracheal
intubation. The advantage of combining
diltiazem and lignocaine are considered to be
based on their different mechanism of activity
and their efficacy when used alone. 4
Objectives of the study: The main objectives of
the present study are:
1. To study the effect of laryngoscopy and
intubation on changes in the heart rate (HR),
Systolic blood pressure (SBP), Diastolic
blood pressure (DBP), Mean arterial blood
pressure (MAP) and Rate pressure product
(RPP)
2. To study the effect of diltiazem 0.2 mg/kg,
lignocaine 1.5 mg/kg and combination of
diltiazem 0.2 mg/kg i.v. and lignocaine 1.5
mg/kg i.v, on hemodynamic responses to
laryngoscopy and endotracheal intubation.
METERIALS AND METHODS
A study was undertaken in Sri Sathya sai medical

college & research institute during the year
February 2011 to January 2012. The study design
was approved by the Institutional ethics
committee and informed consent obtained from
all the patients prior to the experiment. One
hundred and twenty (120) patients were included
in the study. The patients were normotensive
with age varied from 18 to 60 years with both
sex. The patients were selected at random.
Patients having any significant systemic
disorders, IHD, Hypertensive heart disease,
Diabetes Mellitus, Bronchial asthma, patients
with previous Myocardial infarction and patients
with cerebrovascular insufficiency or associated
with any co-morbid diseases were excluded from
the study. The study populations were divided
into four (4) sub groups with 30 patients in each
group.
Control Group: Received normal saline as a
placebo and served as control (n=30).
558
Group I: Received 0.2 mg/kg of Diltiazem i.v. 60

seconds before laryngoscope & intubation (n=30)
Group II: Received 1.5 mg/kg of Lignocaine i.v.
3 minutes before laryngoscopy & intubation
(n=30)
Group III: Received combination of 0.2 mg/kg of
Diltiazem and 1.5 mg/kg of Lignocaine i.v. 60
seconds before laryngoscopy and intubation (n
=30).
Pre-an aesthetically the following investigations
were done in all patients; Hemoglobin
estimation, Urine examination for albumin, sugar
and
microscopy,
Standard
12lead
electrocardiogram, X-ray chest/ Screening of
chest , Blood sugar, FBS/PPBS, Blood urea and
hypersensitivity reaction to local anaesthetics.
All the patients included in the study were
premedicated with Tab. Alprazolam 0.5 mg, Tab.
Ranitidine 150 mg orally at bed time the
previous day and Inj. Midazolam 1 mg iv and inj.
Pentazocine 15 mg i.v given to all the patients
before induction of anesthesia as premedication.
On the arrival of the patient in the operating
room, an 18-gauge/20-gauge intravenous cannula
was inserted and an infusion of Dextrose with
normal saline was started. The patients were
connected to Siemens SC-7000, multichannel
monitor which records Heart rate, non-invasive
blood pressure (NIBP), end-tidal carbon dioxide
concentration, and continuous ECG monitoring,
MAP and oxygen saturation. The baseline blood
pressure and heart rate were recorded from the
same non-invasive multichannel monitor and
cardiac rate and rhythm were also monitored
from a continuous visual display of

electrocardiogram from lead II.
Induction of Anaesthesia : Anaesthesia was
induced with inj. Thiopentone 5 mg/kg as 2.5%
solution and endotracheal intubation was
facilitated with Succinylcholine 1.5 mg/kg
administered one minute prior to laryngoscopy
and intubation. The patients were intubated using
appropriate sized cuffed endotracheal tubes.
After confirming bilateral equal air entry, the
endotracheal tube was secured.
Anaesthesia was maintained using 66% nitrous
oxide and 33% of oxygen. After the patients
recovered
from
Succinylcholine
further
neuromuscular blockade was maintained with
non-depolarizing muscle relaxants. At the end of
the procedure patients were reversed with
neostigmine 0.05 mg/kg IV and atropine 0.02
mg/kg IV.
Monitoring : The following cardiovascular
parameters were recorded in all the patients
Heart rate (HR) in beats per minutes (bpm)
Systolic blood pressure (SBP) in mm Hg
Diastolic blood pressure (DBP) in mm Hg
Mean arterial pressure (MAP) in mm Hg
Rate Pressure Product (RPP) calculated by
multiplying the SBP and HR
The above cardiovascular parameters were noted
as below one, three, five minute after
laryngoscopy and intubation
The data were expressed as Mean SEM and
analyzed by using studentt test comparing
between the groups and within the group. P
Value < 0. 05 were considered as significant.
RESULTS
Table.1: Table showing changes in mean heart rate(bpm)

Groups
Control
Group I
Group II
Basal
83.00 5.86
81.63 9.38
77.20 8.10
Pre-Induction
90.73 7.62
87.33 11.60
80.70 7.66
Intubation: 1 Min 118.53 6.89
94.47 11.90*
96.17 8.61*
3 Min 114.40 9.72
92.30 11.38*
90.50 9.38*
5 Min 99.03 5.40
89.37 9.34*
83.93 7.60*
Data were expressed as Mean SEM, *P Value < 0. 05 significant
Mohan et al.,
Group III
77.97 10.42
78.53 10.32
85.43 11.08*
77.37 10.57*
76.07 10.43*
559
Table.2: Table showing changes in mean systolic blood pressure (mmHg)

Control
Group I
Group II
Basal
120.40 9.36
132.90 14.91
132.73 12.97
Pre-Induction
117.57 10.41
135.87 13.90
132.70 13.85
Intubaion 1 Min
164.47 10.41
138.43 19.22* 147.40 11.33*
3 Min
150.83 13.34
136.40 17.50* 141.63 10.89*
5 Min
134.70 11.62
132.40 12.93* 137.60 11.18*
Group III
138.13 15.04
130.47 14.65
140.27 18.31*
129.57 17.31*
122.53 17.05*
Table .3: : Table showing changes in mean diastolic blood pressure (mmHg)
Control
Group I
Group II
Basal
73.57 6.69
80.83 6.75
79.63 9.37
Pre-Induction
73.43 6.30
81.63 8.70
78.97 8.42
83.60 9.12*
85.57 8.75*
3 Min 88.03 5.01
83.57 10.88*
81.57 8.61*
5 Min 82.37 3.96
83.73 9.92*
77.43 8.46*
Group III
78.23 8.60
75.73 8.11
81.07 4.89*
75.90 8.39*
74.90 7.25*
Table.4:Table showing changes in the mean arterial pressure (mmHg)

Control
Group I
Group II
Basal
88.93 6.64
98.07 9.01
99.70 12.29
Pre-Induction
87.77 6.80
99.43 10.32
99.10 12.54
101.27 13.41* 104.33 13.32*
3 Min 108.57 7.05
100.83 13.13* 98.47 11.94*
5 Min 99.37 5.50
101.10 10,07* 97.97 9.60*
Group III
97.10 10.68
93.50 10.22
100.63 8.44*
92.03 9.55*
92.77 9.66*
Table.5: Showing changes in mean rate pressure product (RPP)

Control
Group I
Group II
Basal
9,983.93
10,872.27
10,261.10
Pre-Induction
10,670.47
11,900.77
10,733.93
Intubation: 1 Min 19,483.20
13,175.13*
14,195.00*
3 Min 17,264.80
12,675.27*
12,827.43*
5 Min 13,325.80
11,874.10*
11,556.17*
Group III
10,825.43
10,249.83
12,027.87*
10,037.77*
9,367.83*
DISCUSSION
General anaesthesia has almost become

synonymous with endotracheal anaesthesia. As a
matter of fact, the rapid studies made in the
speciality of anaesthesia can directly be
attributed to our ability to manage the airway.
The hemodynamic responses to laryngoscopy
and endotracheal intubation have been a topic of
Mohan et al.,
discussion right since 1940. When Reid et, al 17

found that stimulation of upper respiratory tract
provoked an increase in vagal activity. A year
later Burstein et al 18 totally contradicting Reids
statement, found that the pressor response
occurring at laryngoscopy and endotracheal
intubation was due to augmented sympathetic
560
response, provoked by stimulation of epipharynx

and laryngopharynx. These factors were further
confirmed by Prys-Roberts 3.
These responses are transitory, variable and may
not be of much significant in otherwise normal
healthy patients. But in patients with
cardiovascular compromise like Ischemic heart
disease (IHD) and Hypertension, patients with
cerebrovascular diseases and in patients with
intracranial aneurysms, even these transient
changes can result in potentially deleterious
effects like left ventricular failure, 5 pulmonary
oedema, myocardial ischemia 6 and ventricular
dysrhythmias 3 and cerebral haemorrhage.7
In early sixties, inhalational anaesthetic agents
were used to attenuate the laryngoscopic
reactions. But inhalational anaesthetic agents had
their own demerits, for example myocardial
depression
and
arrhythmogenicity
with
halothane, nephrotoxicity with methoxyflurane
coronary steal with Isoflurane. Among the
pharmacological agents used for blunting the
hemodynamic responses, opioids were found to
be effective but they caused respiratory
depression, chest wall rigidity and prolong the
recovery time. 8, 19 Adrenergic blockers were
employed by Devault et al., 10 and direct acting
vasodilators was employed by Robert K,
Stoelting. 20 Both these agents were found to be
effective in suppressing hemodynamic responses
to laryngoscopy and endotracheal intubation.
However, adrenergic blockers had long duration
of action which outlasted the transient intubation
response and caused intraoperative hypotension.
Direct acting vasodilators also had the
disadvantage of producing reflex tachycardia.
Lignocaine which avoids these problems has
been successfully used to blunt the hemodynamic
responses to intubation, Hamil et al. 21 studied the
effect of lignocaine on endotracheal intubation
when given by laryngotracheal route and
intravenous route and came to a conclusion that
intravenous lignocaine is the preferred route for
administering lignocaine prior to endotracheal
intubation.
Mohan et al.,
Recently Mikawa et al., 16 have reported that

calcium channel antagonists like Nicardipine and
Diltiazem are also effective in controlling the
hemodynamic responses to laryngoscopy and
intubation in normotensive as well as in
hypertensive patients. A good correlation has
been demonstrated between the cardiovascular
responses to intubation and changes in plasma
catecholamine concentrations. Calcium ions
exert a major role in the release of
catecholamines from the adrenal gland and
adrenergic nerve endings, which affects plasma
concentrations of catecholamines in response of
sympathetic stimulation. Animal experiments
have shown that calcium channel antagonists
inhibited catecholamine release from the
sympathetic nerve endings by electrical
stimulation. In a study in healthy volunteers, the
blocker inhibited the increase in plasma
adrenaline induced by exercise. These
observations suggest that calcium channel
antagonists interfere with catecholamine release
after tracheal intubation. Yashitoka Fuji et al 22
noted that between diltiazem and Nicardipine,
diltiazem was found to be superior to Nicardipine
in attenuating the hemodynamic response to
laryngoscopy and intubation. G. Godet et, al., 23
noted that diltiazem prevents intraoperative
myocardial ischaemia during non-cardiac
surgery.
In view of these advantages of lignocaine and
diltiazem the present study was carried out to
evaluate the efficacy of these two drugs in
blunting the hemodynamic response. An attempt
was also made to study the effect of combination
of these two drugs on the hemodynamic response
to laryngoscopy and intubation.
In the present study also we noticed that though
both diltiazem and lignocaine partially attenuated
the pressor response to laryngoscopy the results
of the combination group were superior to either
of the drugs when given alone. This is reflected
by RPP changes. In diltiazem group RPP
increased by an average of 2302, while in
lignocaine group it increased by 3933. However,
561
in combination group it increased by only 1488.

The difference in rise of RPP between the three
groups is statistically significant.
Thus overall, from the present study it was seen
that pressor response to laryngoscopy without
any drugs employed for attenuation results in
marked rise of HR, SBP, DBP MAP and RPP.
Both diltiazem 0.2mg/kg IV given 60 seconds
before intubation and intravenous lignocaine 1.5
mg/kg given 3 minutes before intubation,
significantly attenuates the pressor response to
laryngoscopy. The results of diltiazem 0.2 mg/kg
were superior to intravenous lignocaine 1.5
mg/kg.The combination of diltiazem and
intravenous lignocaine given 60 seconds earlier
to intubation very significantly attenuates the
increase in HR, SBP, DBP, MAP and RPP
associated with laryngoscopy and intubation.
However, this combination may sometimes in
small percentage of patients may produce
significant fall of blood pressure. Caution should
be taken when using this combination against the
development of hypotension. However this
hypotension was easily manageable and did not
produce any untoward effects on the patients.
CONCLUSION
From the present study it can be concluded that,

marked rise in the HR, SBP, DBP, MAP and
RPP occur one minute following laryngoscopy
and intubation, when no drug is employed to
attenuate the pressor response to intubation. This
cardiovascular reaction persists for about 5
minutes after which they return towards baseline
values. Diltiazem in the dose of 0.2 mg/kg IV
given 60 seconds earlier to intubation blunts the
cardiovascular response to intubation. The
effects of diltiazem are more marked on the
blood pressure changes than on the heart rate.
Intravenous lignocaine 2 % in the dose of 1.5
mg/kg given 3 minutes before laryngoscopy and
intubation is also helpful in attenuating the
cardiovascular response to intubation. The effect
of lignocaine is also more marked on the blood
pressure changes rather than the heart rate
Mohan et al.,
changes. Combination of lignocaine 1.5 mg/kg iv

and diltiazem 0.2 mg/kg iv given 60 seconds
earlier to intubation effectively blunts the HR,
SBP, DBP, MAP and RPP associated with
intubation. Combination of diltiazem and
lignocaine is more effective than diltiazem or
lignocaine, when given alone in blunting the
pressor response.
REFERENCES
1. Reema Goel, Raka Rani, Singh OP, Deepak

Malviya, Arya SK. Attenuation of
cardiovascular responses to laryngoscopy and
intubation by various drugs in normotensive
patients, Hospital Today. 2000; 9.
2. Robert K. Stoelting MD. Blood pressure and
heart rate changes during short-duration
laryngoscopy for tracheal intubation.
Influence of viscous or intravenous lidocaine.
Anaesthesia Analgesia. 1978; 57: 197-99.
3. Prys-Roberts, Greene LT, Meloche R and
Foex P. Studies of anaesthesia in relation to
hypertension-II.
Haemodynamic
consequences of induction and endotracheal
intubation. British Journal of Anaesthesia.
1971; 43: 541-47.
4. Yoshitaka Fujii, Yuhji Saitoh, Shinji
Takahashi, Hidenori Toyooka. Diltiazemlidocaine combination for the attenuation of
cardiovascular
responses
to
tracheal
intubation in hypertensive patients. Canadian
Journal of Anaesthesia. 1998; 45: 935-37.
5. Elisabeth J Fox, Garry S Sklar, Constance H
Hill, Raymond Villanueva, Benton D King.
Complication related to the pressor response
to endotracheal intubation. Anaesthesiology.
1977; 47: 524-25.
6. Dalton B and Guiney T. Myocardial
ischaemia from tachycardia and hypertension
in coronary heart disease Patients
undergoing anaesthesia. Ann. Mtg. American
Society of Anaesthesiologists, Boston. 1972;
pp. 201-02.
562
7. Donegan MF and Bedford RF. Intravenously

administered lignocaine prevents intracranial
hypertension during endotracheal suctioning.
Anaesthesiology, 1980; 52:516-18.
8. Forbes AM and Dally FG. Acute
hypertension during induction of anaesthesia
and endotracheal intubation in normotensive
man. British Journal of Anaesthesia. 1970;
42: 618-22.
9. Stoelting RK. Circulating responses to
laryngoscopy and intubation with or without
prior oropharyngeal viscous lidocaine.
Anaesthesia Analgesia. 1977; 56: 618-21.
10. Devault M, Greifenstein FE and Harris JR.
Circulatory responses to endotracheal
intubation in light general anaesthesia; the
effect of atropine and phentolamine.
Anaesthesiology. 1960; 21: 360-62.
11. Prys-Roberts C, Foex P, Biro GP and Roberts
JG. Studies of anaesthesia in relation to
hypertension
Adrenergic beta-receptor
blockade. British Journal of Anaesthesia.
1973; 45: 671-80.
12. Dich J Nielson. The effect of intranasally
administered nitroglycerine on the blood
pressure response to laryngoscopy and
intubation in patients undergoing coronary
artery
bypass
graft
surgery.
Acta
Anaesthesiologica Scandinavia. 1986; 30: 2327.
13. Mounir-Abou-Madi, Hugo Keszler and Odile
Yacoub. A method for prevention of
cardiovascular responses to laryngoscopy and
intubation. Canadian Anaesthetic Society
Journal. 1975; 22(3):316-29.
14. Stanley Tam, Frances Chung and Michael
Campbell. Intravenous lignocaine: optimal
time for injection before tracheal intubation.
Anaesthesia. Analgesia. 1987; 66: 1036-38.
15. Mounir-Abou-Madi, Hugo Keszler and Joseh
M Yacoub. Cardiovascular reactions to
laryngoscopy and tracheal intubation
following small and large intravenous dose of
Mohan et al.,
lidocaine. Canadian Society Anaesthesia

Journal. 1977; 24(1):12-18.
16. Mikawa K, Nishina K, Maekawa N and H.
Obara. Comparison of nicardipine, diltiazem
and
verapamil
for
controlling
the
cardiovascular
responses
to
tracheal
intubation. British Journal of Anaesthesia.
1996; 76: 221-26.
17. Reid LC and Bruce DE. Initiation of
respiratory tract reflexes and its effects on
heart. Surgy. Gynae. Obstretrics. 1940; 70:
157.
18. Burstein CL, Lo Pinto FJ and Newman W.
Electrocardiographic
studies
during
endotracheal intubation 1, effects during
usual routine techniques. Anaesthesiology.
1950; 11:224.
19. Bedford RF and Lt Marshal K.
Cardiovascular responses to endotracheal
intubation during four anaesthetic techniques.
Acta Anaesthesiologica Scandinavia. 1984;
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20. Robert RK Stoelting. Attenuation of blood
pressure responses to laryngoscopy and
tracheal
intubation
with
sodium
nitroprusside. Anaesthesia Analg. 1979;
58(2): 116-19.
21. Churchill-Davidson HC. A practice of
anaesthesia, 5th Edition, P.G. Publishing
Limited: New Delhi, 1984.
22. Yoshitaka Fujii, Hiroyoshi Tanaka, Yuhji
Saitoh, Hidenori Tayooka D. Effects of
calcium channel blockers on circulatory
response
to
tracheal
intubation
in
hypertensive patients: Nicardipine versus
Diltiazem. Canadian Journal of Anaesthesia.
1995; 42(9): 785-88.
23. Richard S Himes, Cosmo A, Difazio et al.
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563
DOI: 10.5958/j.2319-5886.2.3.099

&
Health Sciences
Coden: IJMRHS Copyright @2013 ISSN: 2319-5886

Revised: 7rd Jul 2013
Research article
EFFECTS OF HAND WASH AGENTS: PREVENT THE LABORATORY ASSOCIATED
INFECTIONS
*
Singh Gurjeet, Urhekar AD, Raksha.
Department of Microbiology, MGM Medical College and Hospital, Sector-18, Kamothe, Navi Mumbai,
Maharashtra, India.
*
Corresponding author email: gurjeetsingh360@gmail.com
ABSTRACT
Background: The aim of this study was to find out the prevalence of bacteria and their antimicrobial
susceptibility pattern in hands of the laboratory workers. Laboratory associated infections are an
occupational hazard for laboratory workers in the microbiology laboratory. The workers can expose to
infection if they do not properly wash their hands before taking food. Materials: Swabs from 35
laboratory workers was taken before and after applying the different disinfectants. The swabs were
directly inoculated onto blood agar, MacConkey agar and nutrient agar. Inoculated plates were
incubated at 37C for 24 hours. The antibiotic sensitivity testing was done by Kirby Bauer disc diffusion
method according to CLSI guidelines. Results: This study detects the major pathogenic bacteria in
hands i.e. Staphylococcus aureus (40.58%), CoNS (21.74%), Klebsiella oxytoca and Pseudomonas
aeruginosa (8.70%) were isolated. Conclusion: This study helps to minimize the infections by proper
hand washing and also minimizing the spread of infection from one person to others.
Keywords: Hand hygiene, Disinfectants, Laboratory workers, Staphylococci, antibiotic sensitivity test.
INTRODUCTION
Hand washing is an easiest and simplest method

to prevent the laboratory acquired infections
(LAI) among workers. Proper hand washing can
minimize the infections in clinical and
nonclinical settings.1
Laboratory associated infections (LAI) is a
documented occupational hazard for laboratory
workers in microbiology laboratory 2. Most
studies have emphasized the prevention of
airborne or droplet acquisition. There is scanty
information on the risks of bacterial
contamination of laboratory surfaces, many of
which are not easily amenable to surface
Gurjeet et al.,
decontamination with disinfectants 3. Similarly,

there are few data to document the transfer of
bacteria to the hands of laboratory technicians
while processing and observing bacterial cultures
4
. Contamination of hands of laboratory workers
can pose health risk to self and to other
laboratory staff and contaminate cultures if
proper care of hand is not followed.
Hand washing with soap and water is a
universally accepted practice for reducing
bacterial burden and transmission of potentially
pathogenic microorganisms. Use of soap cake is
already discontinued in health care facilities.
564
Liquid soap can become contaminated with

bacteria during storage and poses a recognized
health risk factor. 5 Similarly drying of hands
with a towel is to be avoided and hot air dryers
have been recommended.
To provide such evidence, we studied the
dynamics of bacterial contamination of the hands
of laboratory staff. Study findings should help
identify situations associated with high
contamination levels and ultimately improve
hand-cleansing practices 6-8.
A good amount of work on hand hygiene and
disinfection is available for health care workers
dealing with patients, however less studies have
done for laboratory staff.
This prospective study was carried out at

Department of Microbiology, MGM Medical
College and Hospital, Navi Mumbai, from
September 2012 to February 2013.
The total 36 laboratory workers were selected for

this study. Exclusion criteria: Skin disorder or
any wounds persons are excluded from the study.
The 36 laboratory workers were divided into 3
groups in each12. Group A was Technician,
Group B - PG students and Group C - laboratory
attendants Swab was moistened with sterile
saline and swabbing the over the hand and space
between the fingers before and after applying the
different disinfectants. Each hand rub was rubbed
into the hands until dry. The swabs were directly
inoculated onto blood agar, MacConkey agar and
nutrient agar. Inoculated plates were incubated at
37C for 24 hours. The isolated bacteria were
identified by standard Microbiological methods.
All isolated Staphylococcus aureus were tested
for MRSA by disc diffusion method. The
antibiotic sensitivity testing was done by Kirby
Bauer disc diffusion method according to CLSI
guidelines 12.
RESULTS
Table 1: shows group wise distribution of laboratory workers.

Groups
Growth rate of microorganism (%)

Before hand wash After hand wash
Lab technicians
PG students
Lab attendants
Total
7 (100)
24 (100)
4(100)
45
2(14.29)
11(78.57)
1(7.14)
14(100)
Table 2: bacteria isolated from hands before and after cleaning with disinfectants.
Isolated bacteria
Staphylococcus aureus (MSSA)
Coagulasenegative staphylococci
Diphtheroids
Klebsiella oxytoca
Micrococcus
Acinetobacter baumannii
Staphylococcus aureus (MRSA)
Total
Total No. (%)

28 (40.58)
15(21.74)
7 (10.14)
6 (8.70)
6 (8.70)
4 (5.80)
02 (2.90)
01 (1.45)
69 (100)
565
Gurjeet et al.,
Table 3: Antibiotic sensitivity pattern Gram positive cocci in hands.

Isolated bacteria
A/S (%)
COT (%)
TE (%)
25 (100)
CIP
(%)
25(100)
GEN
(%)
25(100)
RO
(%)
4(16)
L
(%)
19 (76)
(MSSA) n=25
25(100)
8 (32)
CoNS (n=15)
15 (100)
4 (26.6)
15 (100)
15(100)
15(100)
7(46.6)
15(100)
(MRSA) n=1
1(100)
1(100)
1(100)
Abbreviations-A/S=Ampicillin/Sulbactam,
COT=Co-Trimoxazole,
CIP=Ciprofloxacin, GEN=Gentamicin, RO=Roxithromycin, L=Lincomicin.
TE=Tetracycline,
Table 4: Antibiotic sensitivity pattern Gram negative bacteria in hands.

Isolated bacteria
Klebsiella oxytoca
n=6
AK
(%)
6
(100)
CPZ
(%)
6
(100)
OF
(%)
6
(100)
CIP
(%)
6
(100)
GEN
(%)
6
(100)
PF
(%)
6
(100)
AMC
(%)
0
n=6
Acinetobacter baumanii
n=2
6
(100)
2
(100)
6
(100)
2
(100)
6
(100)
2
(100)
6
(100)
2
(100)
6
(100)
1
(50)
AbbreviationsAK=Amikacin,
CPZ=Cefoperazone,
GEN=Gentamicin, PF=Pefloxacin, AMC=Augmentin.
OF=Ofloxacin,
CIP=Ciprofloxacin,
DISCUSSION
Total 35 swabs were taken from the laboratory
workers hands before and after applying
disinfectants. Out of this 7 samples were taken
from laboratory technicians, it showed 100%
growth in before applying and 14.29% after
applying disinfectants, 24 samples from
postgraduate students it showed 100% growth in
before applying and 78.57% after applying
disinfectants and 4 samples were from laboratory
attendants it showed 100% growth in before
applying and 7.14% after applying disinfectants
(Table 1).
A study reported on hands of 16 volunteers was
contaminated with Serratia marcescens. Hand
rub A (85% ethanol), hand rub B (60% ethanol),
hand rub C (62% ethanol), and hand rub D (61%
ethanol) were applied as blinded formulations,
each in single applications of 2.4 or 3.6 mL.
Hibiclens (4% chlorhexidine gluconate) served
as the reference treatment. The general trend

toward alcohol-based hand rubs should not
overlook evidence of significant differences in
efficacy that appear to be related primarily to a
products overall concentration of alcohol 9.
In our study major bacteria were isolated
Methicillin sensitive Staphylococcus aureus from
28 samples (40.58%), Coagulase negative
staphylococcus from 15 samples (21.74%),
Diphtheroids from 7 samples (10.14%),
Klebsiella oxytoca and Pseudomonas aeruginosa
from 6 samples (8.70%) each, Micrococcus from
4 samples (5.80%), Acinetobacter baumanii from
2 samples (2.90%) and Methicillin resistant
Staphylococcus aureus from 1 sample (1.45%).
(Table 2)
A study reported on food safety as very
important were less likely to test positive for S.
aureus on hands (P < .05). S. aureus on post566
Gurjeet et al.,
handling chicken, cutting board and salad was

positively associated with S. aureus on
participants' hands (P < .05). Meal preparer's
hands can be a vehicle of pathogen transmission
during meal preparation 10.
Another study reported that under laboratory
conditions using liquid soap experimentally
contaminated with 7.51 log10 CFU/ml of
Serratia marcescens, an average of 5.28 log10
CFU remained on each hand after washing, and
2.23 log10 CFU was transferred to an agar
surface. Additionally, the mean number of Gramnegative bacteria transferred to surfaces after
washing with soap from dispensers with sealedsoap refills (0.06 log10 CFU) was significantly
lower than the mean number after washing with
contaminated bulk-soap-refillable dispensers
(0.74 log10 CFU; P < 0.01). Contaminated soap
from bulk-soap refillable dispenser can increase
the number of opportunistic pathogens on the
hands and may play a role in the transmission of
bacteria in public settings 5.
Patient care activities independently (P<.05 for
all) associated with higher contamination levels
were direct patient contact, respiratory care,
handling of body fluid secretions, and rupture in
the sequence of patient care. Contamination
levels varied with hospital location; the medical
rehabilitation ward had higher levels (49 CFUs;
P=.03) than did other wards. Furthermore,
because hand antisepsis was superior to hand
washing, intervention trials should explore the
role of systematic hand antisepsis as a
cornerstone of infection control to reduce crosstransmission in hospitals 11.
Our study showed that major isolated bacteria
were sensitive to Gentamicin, Ciprofloxacin,
Amikacin and Tetracycline and resistant to
Roxithromycin, Lincomicin.
A study showed increasing the wash time from
15 to 30 second. The transfer of E. coli to plastic
balls following a 15-second hand wash with
antimicrobial soap resulted in a bacterial on balls
handled by hands washed with non-antimicrobial
soap. This indicates that non-antimicrobial soap
was less active and that the effectiveness of

antimicrobial soaps can be improved with longer
wash time and greater soap volume. 1.
CONCLUSION
We conclude that the laboratory associated

infections can be minimizes by the simple hand
washing procedure before taking the food and
before and after the work completed. Our study
showed that the effect of any disinfectants on
hands is satisfactory and it will be better if the
procedure repeat twice. In this study many
organism isolated out of which many are drug
resistant bacteria which can cause the serious
infections.
ACKNOWLEDGEMENT
Author thankful to Dr. Anahita V. Hodiwala

(Professor) and Dr. S.A. Samant (Associate
Professor), Department of Microbiology, MGM
Medical College, Navi Mumbai for their valuable
suggestion and support. Also acknowledge to all
staff of Microbiology Department and Post
Graduate students and laboratory technicians for
their practically support. Last but not the least I
want to sincerely acknowledge my father Mr.
Dalveer Singh and mother Mrs. Munna Kaur for
their love, encouragement and for giving me the
life which I ever dreamed.
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Gurjeet et al.,
DOI: 10.5958/j.2319-5886.2.3.100

&
Health Sciences
th
Received: 12 Jun 2013

Research article
Coden: IJMRHS
Copyright @2013
th
Revised: 10 Jul 2013
ISSN: 2319-5886
DISTRIBUTION PATTERN OF HCV GENOTYPES AND ITS SIGNIFICANCE WITH VIRAL

LOAD
*Ismail Mahmud Ali 1, Amirthalingam R2
1
Hospital Director, Head, Assistant Professor, Department of Surgery, 2Specialist Department of

Molecular biology, Ibn Sina Teaching Hospital, Sirt University, Libya. P.O.Box 705
*Corresponding author email: amrith2002@rediffmail.com
ABSTRACT
Background &Aim: Hepatitis C virus (HCV) is the most important causative agent of hepatitis
infection and leading high risk for progression of liver cirrhosis and hepato-cellular carcinoma. HCV
Genotyping and quantification of RNA in infected patients is compulsory for designing the remedial
strategies. Therefore, the current study is intended to find out the distribution pattern of HCV genotypes
in HCV infected patients and their significance with the viral load. Materials &Methods: There are one
hundred fifteen HCV infected patients RNA samples were included in this study. HCV genotypes was
analyzed by linear array the Roche method after that through viral load measurement was analyzed by
Cobas Amplicor Roche. Results: The genotype 4 was observed in 78/115 (67, 82%) patients followed
by genotype 1 was observed in 21/115 (18.26%) patients; genotype 2 was observed in 9/115 (7.82%)
patients; genotype 3 was observed in 7/115 (6.08%) patients and genotypes 5& 6 were not detected
among one hundred fifteen patients. Genotype 4 was found to be the most predominant and significantly
higher viral load as compared to genotypes 1, 2&3. Conclusion: The current study identified that HCV
genotype 4 and then genotype1 accounted for approximately 87% of the HCV infection in Sirt region of
Libya. Genotype 4 was associated with more harshness of liver diseases as compared to other genotypes.
This may be due to more capable viral replication of genotype 4 than other types and this study might be
continue for antiviral therapy among Libyan population in feature.
Keywords: Genotypes-hepatitis C virus-RT-PCR viral load-linear array
INTRODUCTION
Hepatitis C virus is a hepatotropic virus of the

family Flaviviridae and genus Hepacivirus
having single stranded RNA of positive polarity
as genomic material. There are different types of
genotypes have been identified along with
hepatitis C virus isolate from different part of the
world. At present, there are six main groups of

sequence variants have been distinguished
subsequent to genotypes 1-6 and every genotypes
having a number of more closely related
subtypes(a,b,c etc)1.
569
Ismail Mahmud Ali et al.,
Infectivity of Hepatitis C virus is the important

root of chronic liver diseases worldwide2.
Chronic stage of hepatitis C is one of the
foremost causes of liver cirrhosis and final-stage
liver disease, resulting in liver malfunction,
hepatocellular carcinoma, liver transplantation
and early death. Gratitude to antiviral therapy,
there are about 50% of patients with progressive
hepatitis can be cured if the infection is
diagnosed in right time and management is
available3. Hepatitis C virus infection (HCV) are
epidemic with a universal incidence of up to
3%4,5.There are 130-170 million people infected
with hepatitis C virus (HCV), and 2.3 to
4.7million new infections per year have been
reported by WHO5.HCV chronic infection is well
known after exposure of six months and there is
an extremely low down of natural clearance.
Most of the HCV infected patients with chronic
diseases are asymptomatic or contain only mild
nonspecific symptoms as long as cirrhosis is not
present and most frequent complaint is tiredness,
vomiting, weakness, muscle pain, and joint pain
and weight loss6. Chronic liver diseases (CLD)
consist of ranges of diseases such as chronic
hepatitis, liver cirrhosis, and hepato cellular
carcinoma7. It is responsible for over 1.4 million
deaths yearly and is distinguished by everlasting
inflammatory processes that predispose to liver
cancer5. The liver cirrhosis can be present at the
time of diagnosis or may extend for the duration
of 5 to 10 years. On the other hand, the survival
of healthy HCV carriers showing patiently
normal serum alanine transaminase (ALT) values
and least changes in liver histology has been
reported. For the reason that, these patients are
thought to have better long time prognosis, the
ability to distinguish which patients take an
indolent course or ultimately extend Hepato
cellular carcinoma is an essential medical
problem8.
In that condition, observing the rate of
progression from chronic hepatitis to cirrhosis
and hepatocellular carcinoma is most beneficial
with advanced clinical and laboratory technique.
Latest molecular technology like quantitative real

time polymerase chain reaction allow to measure
the hepatitis C virus (HCV) RNA as viral load
and it has become pivotal role in the assessment
of patients with chronic hepatitis C infection9.
Quantification of viral load is well established in
HCV patients with chronic hepatitis C and the
response to alpha interferon therapy is associated
with serum HCV RNA levels before the disease
management10, 11, 12. A very low viral load (< 2x
106 RNA copies/ml) is a strong predictor of a
continual response to therapy. In addition, the
latest studies have publicized that the period of
combination therapy may be customized
according to pretreatment viral load and HCV
genotypes, advocated a longer duration of
therapy in patients with a high viral load (>2x106
RNA copies/ml) who are infected with HCV
genotype 1.Hence, the assessment of viral load is
helpful for monitoring antiviral therapy.
Therefore, the measurement of serum HCV RNA
levels must to be specific, correct and
reproducible, and identical in order to present an
accurate estimation of treatment response and
comparisons between the clinical issues13, 14,
15.
The present study was decided to investigate
the distribution of pattern of HCV genotypes in
patients with chronic infection and their
importance with viral load.
Patients: This prospective study was included

forty four females (44) and seventy one (71)
male patients. A total of one hundred fifteen
patients (115) have been randomly selected with
clinical history of hepatitis C virus infection,
who attended the medical outpatient department
and wards of Ibn Sina Teaching Hospital, a
tertiary care hospital in Sirt Region of Libya,
during the year of 2010 to 2011. The ethics panel
and internal review board of the organization
approved the procedure. Informed consent was
obtained from individual patients.
Serum Collection: Five milliliter blood sample
was collected from each patient. Serum sample
570
were separated immediately (within1hour) to

prevent viral RNA degradation and each serum
sample was then dispensed into screw capped
vials and stored at 80C. This sample was
utilized for detection of anti-HCV antibodies;
HCV-RNA detection and subsequent genotyping
analysis. Statistical analysis was performed using
Microsoft office excel2007.
The Cobas Amplicor HCV test v. 2.0 is based
on Five Major Processes
HCV RNA Extraction: HCV RNA was
extracted16 by adding 400l of working lyses,
100l control and 100l serum sample;
incubated at 60C for 10 minutes, added 500l of
100% isopropyl alcohol; allowed for room
temperature; centrifuged at 15000rpm for 15
minutes, removed supernatant as much as
possible; added 1 ml of 70% Ethanol for
extracting thread like nucleic acid, centrifuged
for 5 minutes, and supernatant aspirate without
any residual ethanol and diluted the pellets in
1ml of dilution buffer for further
PCR
amplification and genotypes analysis.
Reverse Transcription: Reverse transcription of
the target RNA to generate complementary DNA
(cDNA). The processed specimens are added to
the amplify reaction mixture in amplification
tube (A-tubes) in which both reverse
transcription and PCR amplification occur. The
downstream or antisense primer is biotinylated at
the 5`end, the upstream or sense primer is not
biotinylated. The reaction mixture is heated to
allow the downstream primer to anneal
specifically to the HCV target RNA and the
HCV internal control target RNA. In the
presence of Mn+2 and excess deoxynucleotide
triphosphates (dNTPs).
Target Amplification: PCR amplification of
target cDNA using HCV specific complementary
primers as well as amplification of internal
control. The HCV internal control has been
added in the Cobas Amplicor HCV test, v 2.0 to
permit the identification of processed specimens
containing substance that may interfere with
PCR amplification. The HCV quantitation

standard is a non infectious 351 nucleotide in
vitro transcribed RNA molecules with primer
binding regions identical to those of the HCV
target sequence and it generates a product of the
same length and base composition as the HCV
target RNA. These features were selected to
ensure equivalent amplification of the HCV
internal control and the HCV target RNA.
Hybridization: Hybridization of the amplified
products to oligonucleotide probes specific to the
target. Following PCR amplification, the
analyzer automatically adds denaturation
solution to the A-tubes to chemically denature
the HCV amplicon and the HCV internal control
amplicon to form single-stranded DNA. An
oligonucleotide probe specific for HCV amplicon
or HCV internal control is added to the
individual. The biotin labeled HCV and HCV
internal control amplicon are hybridized to the
target-specific oligonucleotide probes bound to
the magnetic particles. This hybridization of
amplicon to the target-specific probes increases
the overall specificity of the test.
Detection: Detection of the probe bound
amplified products. Following the hybridization
reaction, the Cobas Amplicor analyzer washes
the unbound material and then adds Avidinhorseradish peroxidase conjugate which binds
the biotin-labeled amplicon hybridized to the
target-specific oligonucleotide probes, then
washing step occurs. After that, a substrate
solution containing hydrogen peroxide and tetramethyl-benzidine (TMB) is added to form a
colored complex measured at wave length 660
nm by Cobas Amplicor photometer.
Genotypes Assay: Hybridization Reaction:
Following PCR amplification, the Cobas
Amplicor analyzer automatically adds 100 l
denaturation solutions to the A-tubes to
chemically denature the HCV amplicon and the
HCV internal control amplicon to form single
strand DNA. Added 100l denatured amplicon
manually to the proper well of the typing tray
that contains 4ml of hybridization buffer and
571
reserved a single linear array HCV genotyping

strip in tray, which was coated with a series of
oligonucleotide probe specific for various HCV
genotypes (Roche Molecular System, USA).The
biotin-labeled HCV amplicon will hybridize to
the genotypes-specific oligonucleotide probe
only if the amplicon contains the matching
sequence of the genotype-specific probe.
Genotypes Detection: After the genotypes
hybridization reaction was completed, the linear
array HCV genotyping strip was washed several
times
to
remove
any
unbound
amplicon.Streptavidin-Horseradish Peroxidase
Conjugate is then added to the genotypes linear
array strip and its binds to the biotin-labeled
amplicon hybridized to the genotype specific
oligonucleotide probe on the genotypes strip. The
genotypes strip was washed to remove any
unbound streptavidin-horseradish peroxidase
conjugate and then a substrate solution
containing hydrogen peroxide and 3, 3, 5, 5,tetramethylbenzidine (TMB) were added to each
genotypes strip. The streptavidin-horseradish
peroxidase catalyses-the oxidation of TMB to
form a blue colored complex, which precipitates
at the probe positions where hybridization
occurs. The linear array HCV genotyping strip
has then interpreted visually by comparing the
pattern of positive (blue) and faint bands to a
reference table of genotypes patterns (Fig.1).
RESULTS
The study has been designated to test one

hundred fifteen patient samples (confirmed cases
by PCR) with 15 kits control. All the cases and
the controls have been distributed in accordance
to different factors in addition to the molecular
study. All HCV RNA viral load samples were
subjected to genotypes analysis. The study
discovered the presence of HCV genotypes 1, 2,
3, & 4 by HCV linear array method. The HCV
genotype 4 was observed in 78/115(67, 82%)
patients. Of these, 49 male patients were showed
high viral load (1.14 x 105 to 9.81x107), 29
female patients were showed moderate viral load
(3.24x102 to 3.31x 10 4).Genotype 1 was
observed in 21/115(18.26%) patients. Of these,
14 male patients were showed high viral load
(1.47x105 to 5.60x106), 7 female patients were
showed moderate viral load (5.38x103 to 5.72 x
10 4).Genotype 2 was observed in 9/115(7.82%)
patients. Of these, 4 male patients were showed a
high viral load (1.50X105 to 1.21x106), 5 female
patients were shown moderate viral load
(2.74x103 to 4.66x 103).Genotype 3 was
observed in 7/115(6.08%) patients. Of these, 4
male patients were showed high viral load
(6.24x105 to 2.06x106), 3female patients were
shown moderate viral load ((2.74x103 to 4.66x
103) (Fig.2).
Fig: 2 Genotypes Pattern of Libyan Population

Fig:1 HCV Genotypes pattern-Linear Array
Strip1-GT1; Strip 2-GT2; Strip3 GT3; Strip 4

GT4 , Strip 5; reference table (from left to right
side)
HCV RNA quantification was carried out in all

115 positive patients and it was compared
between the four genotypes. The genotypes 4 and
then genotype 1 having high viral load and then
572
it was significantly higher than average viral load

of the HCV patients infected with 2 and 3
genotypes
(Table-1).The
study
results
highlighted that the 49 male HCV genotype 4
patients had severed chronic hepatitis and 29
female HCV genotype patients were confirmed
as acute and some chronic hepatitis cases
according to the viral load. However, HCV
genotype 1, genotype 2 and genotype 3 patients

were detected and there were chronic and acute
cases also. These results have been shown
relationship with earlier study that HCV
genotype 4 was more predominant in the Middle
East and Egypt where it account for >80% all
chronic hepatitis cases (>34 million people)17.
Table. 1: HCV RNA viral load-Genotypes

Viral
Load(IU/mL)
High
load
Low
load
Genotype1 (18.26%)
14male+7female (21)
1.47x105to 5.60x106
Genotype2 (7.82%)
4male+5female (9)
1.50X105to 1.21x106
Genotype3 (6.0%)
4male+3female (7)
6.24x105 to 2.06x106
Genotype4 (68%)
49male+29female (78)
1.14x105 to 9.81x107*
viral 5.38x103 to 5.72 x10 4
2.74x103to 4.66x 103
5.0x103 to 1.80x104
3.24x103 to 3.31x 10 4*
viral
DISCUSSION
HCV genotypes distribution varies according to

the geographical region. It has been isolated and
reported in different part of country. Genotypes
1-3 are generally dispersed all over the world18-19
.Genotype 1a is widespread in North and South
America, Europe, and Australia20.Genotype 1b is
prevalent in North America and Europe21, and is
also found in parts of Asia . Genotype 2 is
present in most developed countries22, although it
is extremely lower than genotype 1.Genotype 3a
is more common in specific risk group like
intravenous drug user (IVDU) 23. Genotype 4a is
a single types circulating in all over the Middle
East, Egypt and South Africa with subtype
5a24.Genotypes 6 was mostly found in SouthEast Asia25.
Current data showed that genotype 4 (67.82%) to
be the most predominant genotype circulating in
patients with chronic hepatitis C. The present
studies confirmed the results of previous review
(35.7%) from Libya, which have conclude that
genotype 4 is the most predominant genotype in
Libya26. Likewise in Egypt 4a is predominant27,
4e, 4c, and 4d common in Sudan28, types 4 in
Saudi Arabia29, and in Dubai and Qatar30 is most
predominant genotypes 4, 3 and 1.This analysis
finding the distribution pattern of genotype

appear to be comparable to the genotypes pattern
which was reported from Middle East24, 17 but
different from other countries like Asia, Europa,
America, where genotype 1 is predominant
circulating in their population 20,21. The present
studies were not able to isolate even single
genotypes of 5 and 6 from any infected patients
that understood to be absent in Libya, and it is
the most prevalent HCV genotypes in South
Africa and South-East Asia, respectively24,25 and
it may be missing or very rare in the other part of
the world.
HCV genotype is the toughest prediction matter
for persistent virological response as patients
with the dissimilar HCV genotype act in
response in a different way to antiviral treatment.
For this reason, as well as quantification of HCV
RNA and genotyping has become gradually more
significant in a routine diagnostic laboratory for
decision making in antiviral treatment.
Measurement of viral load seems to be a precious
prognostic sign for the result of antiviral therapy
since ALT levels do not usually enlighten the
disease activity. Indeed, patients with elevated
viral load present a poor response to interferon
573
therapy than those with very low-level viral

copy. The possibility of a reversion after
termination of therapy is higher in patients with
high HCV RNA viral load prior to therapy .The
relationship between HCV genotypes and viral
load residue debatable; in a number of studies
have high titer viral load was associated with
highly developed liver stage31though others
found no relationship with either, viraemia,
histology or aminotransferase enzymes activity3233
.In current study, the HCV RNA viral load
(1.14 x 105 to 9.81x107) in patients with
genotype 4 was significantly higher than persons
with genotypes 1, genotype 2and genotype 3.
This may be due to more capable of viral
replication of genotype 4 as compared to the
others genotypes in this region. The only
restriction of this study is the detection of a
limited number of samples with untypable
genotypes. All of the samples were HCV RNA
positive, had a standard viral load and thus might
be genotyped by sequencing method to choose
the accurate genotype, therefore, we were not
able to sequence these samples due to lack of
sequencing facility in our center.
CONCLUSION
The present study adorned that genotype 4 is the

predominant circulating genotype in the Sirt
Region of Libya and then by genotype1.
However, the harshness of liver disease was
more in genotype 4 and then 1 as assessed by
elevated viral load.HCV genotypes, regular viral
load and management of antiviral response could
provide information for supervision of
personalized treatment in feature among the
Libyan population.
ACKNOWLEDGEMENT
The authors are thankful to Laboratory technical

staffs of
Ibn Sina Teaching Hospital, Sirt,
Libya, for helping in this study.
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DOI: 10.5958/j.2319-5886.2.3.101

&
Health Sciences
Accepted:13th Jun 2013
Research Article
A STUDY OF SEXUAL DIMORPHISM IN HUMAN STERNA

*Adhvaryu Ankit V, Adhvaryu Monika A, Rathod Suresh P, Chauhan Pradip R, Joshi Hemang G
Department of Anatomy, P.D.U. Medical College, Rajkot, Gujarat, India
*Corresponding author email: ankit_adhvaryu@yahoo.co.in
ABSTRACT
In the present study, 100 human, dry adult sterna, 45 male and 55 female, from various medical colleges
of Saurashtra region of Gujarat were measured for length of manubrium, length of mesosternum and
combined length of manubrium and mesosternum. The data was statistically analysed for mean, standard
deviation and p value. The Rule of 136 given by Ashley (1956) was applied to determine the sex of
sterna and to determine the number of male and female sterna obeying the rule. Statistically significant
difference in mean values of length of manubrium, length of mesosternum and combined length of both
sexes was observed. Rule of 136 determined 34 male and 66 female sterna, while 71.11% (32) of
male sterna and 96.34% (53) of female sterna obeyed the rule. It concluded that of all the three
parameters measured, combined length of manubrium and mesosternum was the best discriminating
parameter of sex and Rule of 136 was helpful in determination of sex.
Keywords: Human Sternum, Combined length of manubrium and mesosternum, Rule of 136
INTRODUCTION
Sex determination from unknown human skeletal

remains or decomposed bodies is an important
initial step in forensic investigation1. Experts are
always facing a problem in identifying whether
the skeletal remains are human or not as well as
estimation of correct age and sex of specimen
available2. Accurate determination of skeletal sex
has been a critical issue in medicolegal cases and
the accuracy depends on the nature of material
available and methods applied1.
The human sternum is a flat elongated shield of
bone that forms the middle of anterior part of
thoracic cage forming a and protects the inner
vital organs1.
Ankit et al.,
Various studies have been carried out by various

workers by using Sternum as an individual
parameter of the determination of age and sex.
The first work was done in 1788 by Wenzel3,
who studied the ratio between the length of
manubrium and that of mesosternum in both the
sexes.
Wenzels work lead to enunciation of Hyrtls law
(1788)4 which stated that the Manubrium-Corpus
Index also now known as Sternal Index (M/B
100) exceed 50 in females while it is less than
50 in males. This was followed by works to
correlate the total length of Manubrium and
mesosternum (M+B) with sex. Dwight (1890)5
concluded from his study that combined length
577
of sternum is more reliable and accurate. Further

Ashley (1956)6 studied the combined length in
both sexes in European population. He forwarded
rule of 149, according to which if the
combined length is more than 149mm than it was
male and it the value is less than 149 it was
female sternum, but its application on African
population was not conclusive; so he forwarded
rule of 136(1956)6 for African Population.
Recent works on Combined length of Sternum
includes the works of Inder Jit (1980)7, Dahipale
et al.(2002)8, Gautam et al. (2003)2, Mahajan et
al.(2009)9 and Puttabandthi et al. (2012)1.
2. Length of Mesosternum (B)

3. Combined length of sternum (M+B)
Data obtained was analyzed statistically to find
out mean, standard deviation, p value. The z
test was applied to determine the significance of
sexual difference obtained in means of above
parameters. Data was analysed for the
overlapping zone for all the three parameters to
determine their reliability in determination of
sex.
Rule of 136, given by Ashley (1956)6 was
applied, which states that if the combined length
is more than 136 mm than it was male and it the
value is less than 136 it was female sternum. The
results were obtained in two forms, one, as the
number of male and female sterna determined by
the rule and second, as the number of actual male
and female sterna obeying this rule. The data was
analysed for its statistical significance by using
chi-square test.
The present study, material consisted of 100

normal, dry, human adult sterna (45 male and 55
female) obtained from skeletal collection of
Anatomy department of various medical colleges
of Saurashtra region. Random sampling was
done and sterna were measured with help of
Vernier Caliper. Measurements were taken in
millimetres according to technique described by
Dahipale et al (2002)8.
1. Length of Manubrium (M)
RESULTS
Various observations of the present study are

presented in table I and table II
Table: 1. Measurements of sternum of both sexes
PARAMETER
SEX
RANGE
MEANSD
Length of manubrium
(M) (in mm)
Length of mesosternum
(B) (in mm)
Combined length
(M+B) (in mm)
M
F
M
F
M
F
39.61 - 58.2
33.90-53.30
67.78 116.78
62.20 - 94.20
107.39 - 173.1
103.81 143.69
48.954.25
44.034.21
92.119.55
78.287.59
141.0610.64
122.319.38
Table: II. Statistical analysis of sterna of both sexes

Male
P VALUE
P<0.001
P <0.001
P<0.0001
Actual sample size
45
55
P value
-------
BY RULE OF 136
No. of Specimen obeying Rule of 136
34
32 (71.11%)
66
53 (96.34%)
P>0.05
P >0.05
Ankit et al.,
Female
No.&%
of
overlapping
specimen
39 (86.66)
52 (94.54)
28 (62.22)
52 (94.54)
29 (64.44)
52 (94.54)
578
DISCUSSION
The observations of various workers regarding

the sexual dimorphism in length of manubrium,
length of mesosternum and combined length are
presented in table III.
Length of Manubrium : In the present study,
mean length of manubrium In male and female
sterna is 48.95 mm and 44.03 mm respectively,
in accordance with the observations of Dahipale
et al. (2002)8 and Jit et al (1980)7. The difference
in mean length of manubrium of male and female
sterna is 4.92 mm which is statistically highly
significant (P <0.001) and in accordance with the
value of Gautam et al (2003)2 and Dahipale et al.
(2002)8, but the parameter is not so useful in
determination of sex of individual specimen
because 91% specimens lie in overlapping zone.
This is in accordance with Ashley (1956)6, Jit et
al. (1980)7 and Dahipale et al. (2002)8.

Length of Mesosternum: In the present study,
mean length of mesosternum In male and female
sterna is 92.11 mm and 78.28 mm respectively,
in accordance to the observations of other Indian
workers, Jit et al (1980)7, Dahipale et al. (2002)8,
Gautam et al. (2003)2 and Puttabanthi et al.
(2012)1. The difference in mean length of
mesosternum of male and female sterna is 13.83
mm which is statistically highly significant
(P<0.001) and in accordance with the value of
Ashley (1956)6 and Jit et al. (1980)7. Dahipale et
al (2002)8 found the length of mesosternum
extremely useful in determining the sex, but in
the present study 80% specimens lie in
overlapping zone, so not useful in determination
of sex of individual specimen.
Table.3: Observations of various workers regarding measurements of various parameters of sternum

NAME
WORKER
OF
Sex
No.
MANUBRIUM (M)
(in mm)
Mean
Difference
M
F
30
26
51.8
46.7
142
53.7
86
49.4
310
52
126
47.3
4.7
91
12.70
-----
Ashley (1956)6
African
M
F
85
13
45.9
44.2
1.7
96.5
82.9
13.60
142.6
127.1
Ashley (1956)6
European
378
52.2
F
M
168
312
47.9
51.73
88
48.42
3.3
78.60
16.75
127.02
20.06
M
F
98
55
57.86
46.96
10.90
115.19
93.85
21.34
173.05
140.82
32.23
Gautam et al
(2003)2
56
53
44
48
Dahipale et al
(2002)8
96
48.42
47
43.78
Puttabanthi et al
(2012)1
57
47.48
22
21.68
45
48.95
55
44.03
Dwight (1881)10
Dwight (1890)5
Paterson(1904)11
JIT et al (1980)7
Mahajan
(2009)9
et
al
PRESENT STUDY
Ankit et al.,
SPECIMEN
5.1
MESOSTERNUM (B)
(in mm)
Mean
Difference
COMBINED (M+B)
(in mm)
Mean
Difference
105.9
89.4
---------
16.50
110.4
4.3
91.9
164.1
18.50
103.7
4.3
104.7
90.8
95.35
95
5.00
76
25.80
70.19
13.90
19.00
24.23
78.28
156.9
138.7
147.08
-15.50
18.20
149
124
25
113.87
29.32
139.55
3.41
92.11
4.92
22.80
142.20
92.36
88.95
141.3
-----
94.43
4.64
--
110.64
28.91
141.06
13.83
122.31
18.75
579
Combined length of manubrium and

mesosternum ; In the present study, mean
Combined length of manubrium and
mesosternum In male and female sterna is
141.06 mm and 122.31 mm respectively, in
accordance to the observations of other Indian
workers, Jit et al (1980)5, Dahipale et al. (2002)8
and Gautam et al. (2003)2. The difference in
mean combined length of manubrium and
mesosternum of male and female sterna is 18.75
mm which is statistically highly significant (P
<0.0001) and in accordance with the value of
Ashley (1956)6 and Jit et al. (1980)7. Puttabanthi
et al (2012)1 found combined length as the best
discriminator of sex. They had 100% accuracy
to sex female and 68.42% to sex male. In the
present study 81% specimens lie in overlapping
zone, so the parameter is not useful in
determination of sex of individual sex.
Of all the three parameters, the combined length
of manubrium and mesosternum is the most
reliable parameter for determination of sex with
p value less than 0.0001 which is agreement
with previous literature authors.
Rule of 136: This rule was given by Ashley
(1956)6 for the population of East Africa. It
states that combined length of manubrium and
mesosternum is more than 136 mm for male and
less than 136 for female. But he found a co
extensive range of 126 mm to 171 mm and
therefore any sternum of unknown sex having
combined length within this range cannot be
sexed with certainity.
Jit et al (1980)7 found the combined length
extremely helpful in determination of sex of
North Indian sterna. He applied Rule of 136 ,
by which they determined the sex of 86% male
and 78% female, but individually they cant say
if any particular sternum given is definitely
male of female.
In the present study, Rule of 136 was applied
and it was observed that 32 (71.11%) male and
53 (96.34%) female sterna obeyed the rule.
Ankit et al.,
Total numbers of male and female sterna sexed

by the rule were 34 and 66 respectively, while
the actual sample size was 45 male and 55
female. On applying chi-square test, P value
was more than 0.05, so the difference in
observation from the Rule of 136 was not
statistically significant. So The Rule of 136
was considered reliable in determination of sex.
CONCLUSION
Following conclusions were drawn based on

present study.
If the length of manubrium was less than 39.61
mm then it was of female and if it was more
than 53.30 mm then it was of male.
If the length of mesosternum was less than
67.78 mm then it was of female and if it was
more than 94.20 mm then it was of male.
If the combined length of manubrium and
mesosternum was less than 107.39 mm then it
was of female and if it was more than 143.69
mm then it was of male.
Of all the above three parameters, Combined
length of manubrium and mesosternum was the
most reliable parameter for determination of sex
(P <0.0001). Rule of 136 for combined length
was obeyed by 71.11% of male and 96.34% of
female sterna, hence considered helpful for
determination of sex.
REFERENCES
1. Puttabanthi S, Velichety S, Padi TR, Boddeti

RK, Priyanka JR. Sexing of unknown adult
human sterna by metrical analysis.
International Journal of Biological and
Medical Research. 2012;3(2):1516-1519.
2. Gautam RS, Shah GV, Jadav HR, Gohil BJ.
The human sternum as an index of age & sex.
Journal of the Anatomical society of India.
2003;52(1):20-23.
3. Wenzel, J. (1788): Quoted by Ashley 1956;
A comparison of human and anthropoid
580
mesosterna. American Journal of Physical

Anthropology. 1956;3:449-461.
4. Hyrtl J. Handbuch der Topographischen
Anatomic percentage 1893 BD. 1 , S. 348.
Quoted by Ashley GT, (1956).Armitage P.
Statistical methods in medical research.
Oxford and Edinburgh: Blackwell Scientific
Publications; 1971.pp.332-35.
5. Dwight T. The sternum is an index of sex,
height and age. Journal of Anatomy.
1890;24:527-35.
6. Ashley GT. Typing of the human sternum
the influence of sex and age on its
measurement. Journal of Forensic Medicine.
1956; 3:27-43.
7. Jitindar I, Jhingan V, Kulkarni M. Sexing the
human sternum. American Journal of
Physical Anthropology. 1980;53:217-24.
8. Dahiphale VP, Baheete BH, Kamkhedkar
SG. Sexing the human sternum in
Marathwada Region. J. Anat. Soc. India;
2002;51(2): 162-67.
9. Mahajan A, Batra APS, Khurana BS, Sharma
SR. Sex determination of human sterna in
north Indians. Journal of Punjab Academy of
Forensic
Medicine
And
Toxicology.
2009;9(1):12-15.
10. Dwight T. The sternum as an index of sex
and
age,
Journal
of
Anatomy.
1881;15(3):327-30.
11. Paterson A.M. The Human Sternum.
Williams And Norgate, London: University
Press of Liverpool 1904:36-37 and 77.
12. Armitage P. Statistical methods in medical
research. Oxford and Edinburgh: Blackwell
Scientific Publications; 1971.pp.332-335.
Ankit et al.,
581
DOI: 10.5958/j.2319-5886.2.3.102

&
Health Sciences
Revised: 9th Jul 2013
Research article
ALERT!!! BEWARE OF MOBILE PHONES!!! HAS A GREAT ROLE IN DISEASE
TRANSMISSION, CLEAN THEM UP!!!! SAFE TO HANDLE...
Sue Elizabeth Shajan, Mohammed Faisal Hashim, Michael A
PhD Student, School of life Sciences, Karpagam University, Coimbatore, Tamil Nadu, India,
Department of Microbiology, Al Mana General Hospital, Al Jubail, Saudi Arabia
Department of Medicine, Al Mana General Hospital, Al Jubail, Saudi Arabia
Department of Microbiology, PSG College of Arts& Science, Coimbatore, Tamil Nadu, India
*Corresponding author E-mail id: sueshajan@yahoo.com, sueshajan@gmail.com
ABSTRACT
Introduction: Socially and professionally mobile phones are indispensable and are used in an
environment of high microbial flora. This study is alerting to Beware of Mobile Phones!!! has a great
role in disease transmission. Aims and Objectives: This study deals with the spread of both hospital
and community associated microbial infections from the unavoidable mobile phones.Materials and
Methods: Sterile samples were obtained from 255 mobile phones and divided into 5 categories of
people as follows: Group I Market vendors, Group II Public workers, Group III Teachers, Group
IV Office Staffs, Group V Healthcare workers. Samples were cultured aerobically, anaerobically
and for fungus. The resulting isolates were biochemically identified and subjected to antimicrobial
sensitivity tests by Standard procedures. Results and Discussions: The result revealed a very high
percentage (83%) of microbial contamination with 15 bacterial and 5 fungal isolates. Mobile phones in
Group I had the highest rate of colonization (54, 25.5%), Followed by Group II (52, 24.6%), Group III
(48, 22.7%), Group IV (42, 19.9%), and Group V (15, 7.1%). Acinetobacter baumanii was the most
prevalent bacterial agent from mobile phones in Group V (33.3%) and least from Group IV
(9.5%).There was no statistical significance difference (P<0.05) in the occurrence of Acinetobacter
baumanii a soil opportunistic pathogenic bacterial agent most frequently isolated from the mobile
phones of all the study groups. Conclusion: The colonization rate of mobile phones may serve as a
reservoir, immediate source and spread of both hospital and community associated microbial
infections. Hence mobile phone users are strict adherence of infection control, such as hand washing
and good hygienic practices is advocated. To prevent the health care associated infections (HCAI) in
hospitals, the use of mobile phones during working hours should be strictly prohibited.
Keywords: Mobile phones, Health care associated infections (HCAI), Health Care Workers (HCWs)
INTRODUCTION
Healthcare associated infections increase day

by day and such infection causes significant
Sue et al.,
rate of mortality and morbidity. The etiological

agents of hospital infections may spread
582
through the hands of healthcare workers

(HCWs),
thermometers,
stethoscopes,
1
computers, and mobile phones . Mobile phones
continue to have an increasing presence in
almost every aspect of our occupational,
recreational, and residential environments. In
the higher school, university environment,
teachers, and students have indicated that 100%
have access to computers and mobile phones,
92.1% regularly use the internet, and 73.3%
regularly use e mail.
The mobile phones are the indispensable
accessories of professional and social life used
in hospitals, laboratories, and intensive care
units when dealing with severe illness. In the
present study alerting to Beware of mobile
phones has a great role in disease
transmission, 20 isolates of microorganisms [15
bacterial and 5 fungal] was conducted to
determine that the mobile phones of various
groups and healthcare workers (HCWs) are act
as the vehicles of health care associated
infections.3 A strict hygienic practices as an
effective preventive measure 4,5 The first study
of bacterial contamination of mobile phones
was conducted in a teaching hospital in Turkey
6.
In a study conducted in New York were
found to isolate pathogenic microorganism 7. In
this study the frequent use of mobile phones is
common so microorganisms are likely high,
such as in market vendors (fish, poultry, animal
slaughter areas), school teachers, public
workers, office staffs and there was a gross
reduction in HCWs due to the use of alcohol
based hand rub and the prohibition of mobile
phones during working hours. Therefore, the
present study was conducted to determine
whether mobiles phones could play a role in the
transmission of microbial pathogens and to
strictly adhere to the control of infections
reservoir or mode of transmission of infection.
A total of 255 mobile phones were randomly

sampled. The surface samples were obtained
Sue et al.,
from the following study groups for two

months between October and November 2011,
the work was done in the Microbiology lab in
Al Mana General Hospital, Saudi Arabia.
Group.1:55 market vendors, Group.2: 58 public
workers, Group.3:52 teachers, Group.4: 55
office staff and Group.5: 35 Healthcare
workers. The users of these mobile phones were
adult volunteers. The concept of the study was
explained to all respondents and their consent
sought. Respondents were also asked to answer
question regarding disinfection practice like How frequently they cleansed their phones,
Cleansing agent used, Washing hands before
and after using the mobile phones, etc.
Sample collection and Bacteriological
Analysis: The local research ethics committee
reviewed the protocol and confirmed. Consent
was obtained from the respondents after the
goal of the study was explained to them, and
they were told that participation was voluntary
and responses would be confidential. The
samples collected aseptically by using swabs
moistened with sterile normal saline, was rolled
over all exposed outer surfaces of the mobile
phones. From each location those collected
samples were inoculated into Amies transport
medium. Sampled swabs were streaked over
blood agar, Mac-conkey agar and Thioglycolate
medium (Oxoid) for the characterization of
aerobic bacteria, the plates were incubated
aerobically at 37C for 24-48 hours. For the
anaerobic bacteria Neomycin blood agar with
Metronidazole5 g disc at the center of the
streaked area were incubated anaerobically at
37C for 48 hours. A Saboraud Dextrose Agar
plate for fungus isolation.
Culture reading and interpretation was done by
presumptive identification methods10. Other
tests like production of coagulase enzyme by
Staph aurex kit (Latex agglutination testOxoid,
U.K)
and
utilization
of
oxidation/fermentation (OF) glucose and
mannitol. Gram positive catalase negative cocci
were tested using a Streptex kit (Latex
583
agglutination test- Oxoid, U.K). Identification

of gram negative bacilli were tested using API
20E system and API 20 NE system for
Enterobacteriaceae and non-enteric Gram
negative rods (Biomerieux, Marcy l Etoil,
France). Neomycin Blood agar with
Metronidazole (5g) sensitive isolate further
identified by (Mast Diagnostic Method)
Anaerobic Identification kit and API 20A test
(Biomerieux, Marcy l Etoil, France). All
Staphylococcus aureus and Enterococcus
faecalis strains were screened for oxacillin and
vancomycin resistance.
Susceptibility
Testing:
The
identified
organisms are tested for susceptibility
according to Clinical Laboratory Standards
Institute (CLSI) antibiotic disc susceptibility
testing guidelines.11
The following antibiotic agent were tested for
the
isolates:Amoxicillin
(10g),
Augmentin(30g),Cefepime(30g),Ceftazidime
(30g),Cefuroxime(30g),Cephalexin(30g),Ci
profloxacillin(5g),
Clindamycin
(2g),
Colistin
(30g),
Erythromycin(15g),
Gentamycin(10g),
Imipenim(10g),
Metronidazol(5g), Oxacillin(1g), Pencillin
(10Units),
Piperacillin(100g),
Tazocin(110g), Trimethoprim(1.25g) and
Vancomycin (30g). The diameters of the
zones of inhibition were measured with a ruler
and compared with a zone-interpretation
chart11. Escherichia coli ATCC 25922,
Pseudomonas aeruginosa ATCC 27853
Staphylococcus aureus ATCC 25923 and
Streptococcus faecalis ATCC 29212 strains
were used as the control.
RESULTS
Out of the 255 samples 211 mobile phones with

bacterial growth and 44 samples showed no
growth. The result of this study revealed a high
percentage (83%) were contaminated with 15
Polymicrobials and 5 fungal isolates. From the
five groups (I-V) studied, 1st Group [market
vendors] had the highest rate of contamination
Sue et al.,
(54, 25.5%). IInd Group [public workers] had

the next highest (52, 24.6%); IIIrd Group
[teachers] (48, 22.7%) the next highest and the
IVth Group [office workers] (42, 19.9%) the last
highest. Vth Group [Health care workers] had
the lowest rate of contamination (15, 7.1%)
(Figure1).
Fig.1: Mobile Phone Contamination in Hospital

and Community Settings
Specifically, Acinetobacter baumanii (47) was

the most frequently isolated aerobic bacterial
agent from the mobile phones of 33.3%, 27.7%,
23.0%, 22.9% and 9.5%, of Groups V, I, II, III
and IV in an order. These results were followed
closely by Coagulase Negative Staphylococci
(31),Nonfermenting Gramnegativebacilli (29),
Chryseomonas
luteola(15),
Klebsiella
pneumonia(13),Enterococcus
faecalis
(13),Enterobacter
cloacae(10),Pseudomonas
aeruginosa
(10),
Micricoccus(9),
Bacillusspp(9), Diptheroids(9),Staphylococcusaureus(7), Escherchia coli(4), Clostridium
spp(3) and Anaerobic Bacteroides fragilis (2)
(Figure 2).
There was no statistical significance difference
(P<0.05) in the occurance of Acinetobacter
baumanii, a soil opportunistic pathogenic
bacteria isolated from the mobile phones of all
the study groups. Many of the community
associated organisms were isolated from the
hand to mobile phones of the public workers
and market vendors. The wide spread fungal
isolates(5) were found in the mobile phones of
the Group I market vendors are Candida
584
albicans, Aspergillus spp, Fusarium spp,

Mucor and Rhizopus (Figure- 3).
%, 44, 07%, 38, 86%) (Figure-4).

Metronidazole was found to be effective against
anaerobic Bacteriodes fragilis.
Fig.2:Frequency distribution of bacterial isolates

Fig.4: Percentage of Antibiotic Susceptibility of
Identifed Bacterial Contamination of Mobile
Phones.
DISCUSSION
Fig.3: Fungal isolates from market vendors
Multi drug resistant pathogens isolated from

the mobile phones of all five groups in this
study
include
Vancomycin
resistant
Enterococcus fecalis(2) from Group II and III;
Gentamycin
resistant
Pseudomonas
aeruginosae(5) from Group I and II;
and[Extended Spectrum Beta-lactmase -ESBL]
ESBL Escherichia coli(2), ESBL Klebsiella
pneumonia(3) were isolated from the Group I,
II, IV.
Antimicrobial susceptibility tests for the
isolates revealed that Ciprofloxacin and Third
generation Cephalosporins were sensitive for
most aerobic isolates (66, 35%, 55, 45%, 54, 50
Sue et al.,
For a better healthy life microbiological

standards in hygiene are necessary. In the
developed world the health care workers
[HCWs] use their mobile phones excessively
while in the hospital and the community. The
threat of highly infectious pathogens is a
concern. Many studies found that one third of
the phones were cross contaminated through
inanimate devices from HCWs to patients
(Singh et al; 8Borer et al;9 Goldglatt et al;7
Karabay et al;6 Jayalakshmi et al;4and Sham
S.Bhat et al)13 All these research shows that an
average cell phone carries more germs than a
public toilet seat, and most phones are covered
with nasty creatures like Vancomycin resistant
Enterococcus fecalis, Gentamycin resistant
Pseudomonas
aeruginosae
and
ESBL
Escherichia coli, ESBL Klebsiella pneumonia,
Acinetobacter baumanii, Coagulase Negative
Staphylococci, Non fermenting Gram negative
bacilli, Chryseomonas luteola, Klebsiella
pneumonia,
Enterococcus
faecalis,
585
Enterobacter
cloacae,
Pseudomonas
aeruginosa, Micricoccus, Bacillus spp,
Diptheroids,
Staphylo coccus aureus,
Escherchia coli, Clostridium spp, Anaerobic
Bacteroides fragilis, Candida albicans,
Aspergillus spp, Fusarium spp, Mucor, and
Rhizopus [ These organisms
shown in
(Figure2).] these organisms not only make you
sick, but also, in severe cases, can be deadly12.
In this study, 83% of 255 mobile phones were
contaminated by microbial agents. Isolation of
these from electronic devices such as mobile
phones, computers, key boards, have shown
that these devices acts as a spread of hospital
associated infection1. Out of the five groups (IV) studied, Group I (54.25.5%), had the highest
rate of bacterial contamination followed Group
II (52, 24.6%), Group III (48, 22.7%), Group
IV (42, 19.9%) and Group V (15, 7.1%). The
high prevalence of bacterial agents isolated
from the mobile phones of Group I, could be
due to the poor hygienic and sanitary practices
associated with the low level of education
among markets vendors, especially those
involved in handling raw meats and vegetables,
compared to staffs working in a hospital
environment, Group V where there is a regular
disinfection. The health care workers
contamination is less compared to all other
groups; It reveals that in a developing countries
like Saudi Arabia the frequent hand washing
and disinfection with 70% alcohol rub is
mandatory in this hospital and the use of mobile
phones during working hours also strictly
prohibited specially in the areas like
Radiology, laboratory, ICU and OR.4-7
Mobile phones have a great role in disease
transmission such as diarrhoea, respiratory
infections, fungal infections like Non invasive
Candidiasis,
Otomycosis,
disseminated
Aspergillosis and Zygomycosis (MucorRhizopus) and viral Hepatitis A, B, C, and D all
these infections are widely spread through hand
to mouth, nose, ears etc. 83% of this
contamination reveals that our hands are the
best source of contamination. This study has
Sue et al.,
made it essential that frequent hand washing be

accomplished and maintained 3. Wide use of
mobile phones are hazardous to the persons
health, hearing loss, neck pain and constant use
lead to numbness due to radiation effects 4. In
this study, the use of mobile phones from five
different groups of people highly contaminated
with drug resistant bacteria it can be gradually
transmitted to any areas of the human groups
from the market place in public, teachers, office
staff, and health care workers. Acinetobacter
baumanii (47, 22.2%) was the most prevalent
bacterial isolate among the gram negative
bacilli. It is interesting to note that there was no
statistical significant difference (P >0.05) in the
occurrence of Acinetobacter baumanii the
pathogenic bacterial agent isolated in the
mobile phones of all the study groups (Figure2). This finding corroborates with the findings
from a study from Israel, where Acinetobacter
was the predominant isolate recovered from cell
phones Borer et al;9. When exposed to sunlight
most of the bacterial agents die due to
dehydration, but Acinetobacter and
S. aureus are survive for weeks and multiply
rapidly in a warm environment Kramer et al;14.
A similar study in Israel identified a multi drug
resistant Acinetobacter baumanii on the hands.
Cell phones of health care workers and patients
in hospital, especially in ICU, OR, other areas
banned the use of mobile phones. It could
reduce miscommunication, medical errors and
transmission of infectious agents. A recent
randomized controlled trial found that the
unrestricted visiting hours on an intensive care
unit did not reduce the risk of infections.
Antimicrobial sensitivity testing revealed that
over 66% of the isolates were susceptible to
Ciprofloxacin, third and fourth- generation
Cephalosporins. Other antibiotics evaluated in
this study ranged between 29.38% to 38.38%
efficacy (Figure-4). However the vancomycin
resistant Enterococci, Gentamycin resistant
Pseudomonas aeruginosae, ESBL E.coli and
ESBL Klebsiella pneumoniae of public workers,
586
market vendors and teachers had been

documented.
xIn Saudi Arabia, being a developing country,
disinfections guidelines are widely used and
practices are strictly followed in hospitals and
shopping malls. Bacteria is likely high such as
hospitals, lecture halls, animal slaughter areas,
canteens, shopping malls, toilets, and other
public places is difficult and are hence advised
to use of antimicrobial. But especially in
hospital premises a strict adherence to infection
control, such as hand washing with good
hygienic practice is advocated. (Site: Mobile
Hygiene.org).
CONCLUSION
In this study reveals the cleaning of mobile

phones was much effective in reducing the
microbial contamination to avoid cross
infections. More and more studies are required
to improve the adherence and the practice of
hygienic
methods.
The
non-corrosive
antibacterial products should be introduced; it
will encourage everyone to wipes the mobile
phones when visibly soiled. In this data we
found 20 bacterial and fungal isolates, further
such viral studies surely will help the
community or hospitals alert the use of mobile
phones which is in close contact. In hospitals
the use of mobile phones during working hours
should be strictly prohibited.
Conflict of Interest: The authors declare that
they have no conflict of interests.
Acknowledgements: The authors are grateful
to the members in the department of
Microbiology, Al Mana General Hospital,
Saudi Arabia, the assistance of Ranjit D and
Ansa Simson the student volunteers for their
support.
REFERENCES
1. Glenn Anderson, Enzo A. Microbial

contamination of computer keyboards in a
Sue et al.,
university settings. Palombo. American

Journal of Infect Control 2009,37:507-9
2. Manoharan G, Dharmarajan S. Mobile
phone communication and health system
strengthening: A Pilot study of telephonic
Warm line Consultation in HIV Care and
Support in South India. Journal of
international Association of Physicians
AIDS Care (Chic) 2012, Feb 21. DOI:
10.1177/ 1545109711428010
3. Singh S, Acharya S, et al. Mobile phone
hygiene: Potential risks posed by use in the
clinics of an Indian dental School. Journal
of Dental Education 2010; 74 (10)1153-58
4. Jayalakshimi J, Appalaraju B, Usha S. Cell
phone as reservoirs of nosocomial
pathogens. Journal of the Association of
Physicians of India 2008; 56: 388 389
5. Dinah J. Gould. Intervention to improve
hand hygiene compliance in patient care.
The Cochrane Effective Practice and
Organisation of Care Group. 2010 Sep 8
DOI : 10.1002 / 14651858.CD 005186.pub3
6. Karabay O, Kocoglu E, Tahtaci M. The role
of mobile phones in the spread of bacteria
associated with nosocomial infections.
Journal of Infection in Developing
Countries 2007; 1: 72 -73
7. Goldblatt JG, Krief I, Klonsky T et al. Use
of cellular telephones and transmission of
pathogens by medical staff in New York
and Israel. Infection Control Hospital
Epidemiology 2007; 28:500-03.
8. Singh D, Kaur H, Gardner WG, Treen LB.
Bacterial contamination of hospital pagers.
Infection Control Hospital Epidemiology
2002; 23: 274-76.
9. Borer A, Gilad J, Smolyakov R, et al. Cell
phones and Acinetobacter transmission.
Emerging Infectious Disease 2005; 11:
1160 61.
10. Lynne S.Garcia; Henry D. Isenberg.
Clinical Microbiology Procedures Hand
book Vol I , Vol II.(2009):pg875
11. Franklin R. Cockerill III, Matthew A.
Wikler, Jeff Alder. Performance Standards
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for Antimicrobial Susceptibility Testing;

22nd Informational Supplement. Clinical
and
Laboratory
Standard
Institute.
2012;32(3):M100-S22;
12. Mobile Hygiene.org, The mobile hygiene
movement: Raising Awareness about
bacteria
on
Cell
Phones.
www.mobilehygiene.org.
13. Sham S. Bhat, SK Hegde, S Salian.
Potential of Mobile Phones to serve as a
Reservoir in Spread of Nosocomial
Pathogens. Journal of Health and Allied
Sciences. 2011;10(2):14
14. Kramer A. Schwebke I, Kampf G. How
long do nosocomial pathogens persist on
inanimate surfaces? A Systematic review.
BMC infectious Diseases 2006; 6:130
Sue et al.,
588
DOI: 10.5958/j.2319-5886.2.3.103

&
Health Sciences
Research Article

IMPACT OF EARLY COLLEGE EDUCATION AMONG POLYTECHNIC STUDENTS

*Suganya N1, Raja Kantham G1, Chandhrasekar M2, Nappinnai Seran3, Punitha.C4
1
Third year MBBS,2Department of Physiology, 3Department of Psychiatry, 3Department of Community

Medicine, Meenakshi Medical College, Kanchipuram, Tamilnadu, India.
*Corresponding author email Sugan.Niya93@gmail.com
ABSTRACT
Emotional Quotient (EQ) and Personality plays a vital role in every ones life and paves way for a
successful future. Emotional quotient and Personality assessment were conducted among polytechnic
students through questionnaires and subjects with psychiatric problem were excluded.
Method: A study was done in a polytechnic college from melmaruvathur, kanchipuram district among
423 students of age ranging from 16 to 21 years. Results: There was a significant difference among
personality of the polytechnic students when they reach final year and their emotional quotient remains
the same till final year.
Key words: Emotional intelligence, Personality.
INTRODUCTION
Since many years there have been studies going

on through emotional intelligence (the
measurement of which is known as emotional
quotient) because an individual with high
emotional intelligence can have a better
personality. Many researchers have been
working on it till the date from 1930s. In 1930s
Edward Thorndike, 1940s David Wechsler,
1950s Abraham Maslow, 1975 Howard Gardner,
1985 Wayne Payne, 1987 Keith Beasley, 1990
Peter Salovey and John Mayer and the concept of
emotional intelligence have been popularised by
Daniel Goleman in 19951. Emotional quotient is
the measure of ones own emotional intelligence.
As the name suggest emotional intelligence
means applying our intelligence towards our
Suganya et al.,
emotions at a perfect time, place and with a

respective person.
Personality is the uniqueness of a person which
comprises ones own pattern of thoughts,
feelings and behaviours2. Gordan Willard
Allport, American psychologist was one of the
first people to focus the study on personality. A
study conducted by Paul.T.Costa3and McCrae
(1987) says personality has five major domains
namely (NEO 5 FACTOR or BIG 5
PERSONALITY, Neuroticism Extroversion
Openness Agreeableness Conscientiousness)3
N- Negative emotional stability like sadness,
depression,E- Sociable, lively, active, friendly
and excitable, O- Imaginative, independent and
has a preference for variety,A- Good-natured,
589
helpful, cooperative and trusting, C- Organized,

self-disciplined, careful and responsible.
High Emotional Intelligence signifies that the
person is good enough in having control over
their emotions. Among the five dimensions of
personality only neuroticism convey negative
emotional stability so when its value increases it
implies low emotional intelligence. When EOAC
value is higher it denotes the person is friendly,
independent, good-natured and responsible
towards their work, whereas when it is low it
express the individual is reserved, dependant,
harsh and careless towards their work.
In this study Emotional Quotient and Personality
were studied because both play a major role in
career which goes hand in hand. A person with
high emotional intelligence can be a better
personality and a person with good personality
would be high in emotional intelligence. This
study was targeted among polytechnic college
students so as to make out any difference among
their emotional intelligence and personality as
they start their college life two years earlier4.
Normally one enters into college when they are
18years after completing 12th standard whereas
polytechnic students enter into college by
16years after completing 10th standard.
Schutte et al scale (1998) was used for measuring

emotional intelligence which has 33 questions
and comprises score of 1 to 5 for each question5.
NEO 5 FACTOR by Paul.T.Costa and McCrae
(1992)3 revised comprised of 60 questions was
used to measure personality. Raw scores were
calculated for the 5 dimensions of personality
and converted to T-scores based on the normal
data for male and female population. T-scores
are often categorized into one of five categories
to summarize an individuals personality on each
dimension6.
A study was done among 423 polytechnic
students after getting ethical clearance and it was
ethically approved out of which 100 were drop
outs. Study was conducted in polytechnic college
in Melmaruvathur, Kanchipuram district by the
month of June to July 2012. Only normal
subjects were included in the study whereas an
individual with any psychiatry problems were
excluded.
Study results were analyzed using SPSS, CHI
SQUARE the test for significance was applied to
know the sequel of the study (p value less than
0.05 considered as significance).
RESULTS AND DISCUSSION

Table.1: Outcome of their personality level (first year of academic year)
High
Average
Low
Neuroticism
63.97%
31.18%
4.83%
Extroversion
57.51%
31.18%
11.28%
Openness
14.51%
51.61%
33.86%
Agreeableness
18.27%
23.65%
58.05%
Conscientiousness
12.36%
38.70%
48.91%
Table.2: Outcome of their personality level (final year of academic year)
High
Average
Low
Suganya et al.,
Neuroticism
64.22%
29.19%
6.56%
Extroversion
65.68%
24.81%
9.47%
Openness
28.45%
48.17%
23.34%
Agreeableness
16.04%
25.54%
58.38%
Conscientiousness
21.88%
38.68%
39.40%
590
Table.3: Outcome of emotional quotient
First year
High
87.63%
Moderate
12.37%
(All the values are in percentage. Significant value of
conscientiousness 0.004)
There was a significant difference among
openness, conscientiousness and agreeableness
of personality with respect to their higher
academic year. Study result showed that there
was increase in openness and conscientiousness
as they go on to final year. Likely the reason
would be, until school ones life is very concise,
its just made up of family, school, and friends
and is always under the care of parents. But in
contrast, college life is where they get chance to
interact with more people which in turn provides
them to experience many things. Here age and
exposure plays a major role for change in
personality.
Also the sequel of the study showed there was
decrease in agreeableness as they reach final
year. As they interact with more people, they
keenly observe everyone and start reflecting
according to that, without knowing what is right
and wrong more over students are left free after
coming to college and it became a starting point
for change in character and behaviour which
makes them less disagreeable person.
In the previous study done by Paul.T.Costa3 and
McCrae says that personality doesnt change, it
is unique for every person and remains constant
throughout ones life, only the situation makes us
to change but in depth our personality is same
but the study conducted by Sanjay Srivastava
says that personality changes with age and the
present study supports Sanjay Srivastava7.
CONCLUSION
Generally agreeableness increases with age and

experience8. In this fast paced world youngsters
are provided with vast exposure and gets
opportunity to interact with more people at
Suganya et al.,
Final year
90.51%
9.49%
openness 0.005, agreeableness 0.001,
different age groups which make them to

understand different things. As a result they face
rewards and punishments out of which they learn
new things and try to correct their negatives.
Once when an individual undergoes this phase
their activities and thoughts become mature in
the future.
ACKNOWLEDGEMENT
I deeply thank my parents and my professors

Dr.M.Chandrasekar, Dr.Nappinnai, Dr Punitha
C, and Ambareesh who did help me throughout
the study.
REFERENCES
1. Daniel Goleman, Emotional Intelligence:

Why It Can Matter More Than IQ, first
edition 1996, Bloomsbury Publishers: 1995,
page number 154
2. Lenore Thomson, Personality Type, 1998,
Shambhala Publications, chapter 1 This
Door Is Not the Door; page number 3, 4 and
chapter 4 The First Type Category:
Extraversion or Introversion; page number 27
to 29.
3. Robert R McCrae and Paul T Costa, Jr, 2006,
A division of Guilford Publications, New
York.
4. Emotional Intelligence vs. Personality, a
study by Drs. Eric Rossen and John Kranzler
available at http://eiinsider.wordpress. com/
2009/02/26/emotional-intelligence-vspersonality/
5. Schutte. Scale which was used for measuring
emotional intelligence is available at
http://www.google.co.in/url?sa=t&rct=j&q=
&esrc=s&source=web&cd=4&ved=0CEkQFj
591
AD&url=http%3A%2F%2Fwww.csun.edu%
2F~mrm03408%2FPSY%2520150%2Fhand
outs%2FEmotional%2520Intelligence%2520
Handout.doc&ei=8M_jUbjuHo6nrAfm9YGo
Dw&usg=AFQjCNEv8VPKSRUhQtqL8bES-cYp7OUlA&bvm=bv.48705608,
d.bmk
6. Scores for personality is available at http://
www.webpages.uidaho.edu/klocke/neo_scori
ng.htm
7. Personality changes with age is available at
http://webcenters.netscape.compuserve.com/
news/package.jsp?name=fte/personalitytraits
/zpersonalitytraits
8. Personality changes in men and women older
than 30 were demonstrated in a study
conducted at the University of California,
Berkeley, and published recently in the
Journal
of
Personality
and
Social
Psychology.2003;l34(7):1012-18
9. Personality questions were taken from
http://www4.parinc.com/Products/Product.as
px?ProductID=NEO-PI-3 and http://www.
sigmatesting.com/information/ffnpq.htm
10. Scores for emotional intelligence is available
athttp://www.statisticssolutions.com/
academic-solutions/resources/directory-ofsurvey-instruments/schutte-self-reportemotional-intelligence-test-sseit/
Suganya et al.,
592
DOI: 10.5958/j.2319-5886.2.3.104

&
Health Sciences
www.ijmrhs.com
Volume 2 Issue 3 July - Sep Coden: IJMRHS
th
Research article

Accepted: 12nd Jul 2013
TO STUDY THE EFFECT OF THE BODY MASS INDEX AND WAIST HIP RATIO ON
BLOOD PRESSURE IN PRE- AND POST-MENOPAUSAL WOMEN
*Parvatha Rani.N, Neelambikai. N
Department of Physiology, Coimbatore Medical College, Coimbatore, TamilNadu, India.
*Corresponding author email: parvatharani91@gmail.com.
ABSTRACT
Background: Menopause is the transient period of declined ovarian activity and decreased oestrogen
level associated with increased chances of obesity and increased comorbidities like hypertension, hypercholestrelemia, impaired cognitive function and cardio vascular dysfunction. Hypertension is one of the
major cardiovascular risk factor for the excess mortality and morbidity in postmenopausal females. Aim
& Objective: To study the effect of Body Mass Index and Waist Hip Ratio on Blood Pressure in Preand Post-Menopausal Women. Participants: Fifty premenopausal women in the age group of 40 to 45
years and fifty postmenopausal women in the age group of 50 to 55 years. Methodology: Standardised
measurements of weight, height, waist circumference, hip circumference and Blood Pressure were done.
Results were analysed by student t test. Statistical analysis was performed to find the association
between Blood Pressure, BMI and WHR of premenopausal and post-menopausal women. Results: Postmenopausal women had higher BMI, (p<0.05), had a higher waist and hip circumference (p<0.05) as
compared with the pre-menopausal women; p<0.05. When compared with WHR, the result shows that
there is no significance difference between pre- menopausal and post-menopausal; p>0.05. Blood
pressure is elevated among postmenopausal women when compared with Pre -menopausal women
p<0.01. Conclusion: These findings suggest that obesity has significant impact on Blood Pressure and
obese post menopausal women are at increased risk of developing Cardio vascular complications when
compared with pre-menopausal women.
Keywords: Menopause, Body Mass Index, Waist Hip Ratio, Blood Pressure.
INTRODUCTION
Cardio vascular disease is the leading cause of

mortality and morbidity in the post-menopausal
woman. Women tend to gain weight and prone
to develop hypertension as age advances and
the importance of high blood pressure as a
Parvatha Rani et al.,
risk factor in cardio vascular diseases is well

established6.
Menopause is the transient period of declining
ovarian function and hormones as a part of
ageing and it has an impact on health and sense
of wellbeing. Menopause is unique in mammals
Int J Med Res Health Sci. 2013;2(3); 593-596
593
and only human beings have a longer life span

after menopause. The declining
ovarian
function starts as early as 40 years of age but it is
insidious and asymptomatic often but abrupt and
symptomatic mostly. As estrogen acts as a
shield of protection, women are protected from
cardiovascular dysfunction during reproductive
phase and the chances are equal after
menopause due to structural and functional
changes involving cardiac muscles and valves.
Prevalence of obesity in women rises in each
decade but 20% weight gain occurs within 3years
of menopause. Obesity in Post menopausal
women are multi factorial like reduced physical
activity, resting metabolic rate, stress etc. The
pattern of weight distribution like more on
abdominal girth or more on hips and buttocks is
also a predictor of coronary events. The altered
hormonal status precipitate central adiposity
which inturn leads to non communicable diseases
like diabetes,
dyslipidemia,
hypertension,
cardiovascular dysfunction and decline in
cognitive function.
The body mass index is commonly used as an
index to assess the degree of body fat and various
studies shown that with normal body BMI with
increased waist hip ratio have two fold increases
in cardiovascular dysfunction. WHR is a better
predictor to assess the risk of development
of CVD in women compared to BMI2. The
measurement of WHR, BP is easy and aid as
non-invasive and effective tool to assess the
health status of women. Hence the purpose of
this study is to establish the relationship of
BMI, WHR and BP and to identify their
effectiveness to screen the postmenopausal
women.
age group of 50-55 years. The study was

explained to the subjects and written consent was
obtained. Institutional Ethical Committee
Clearance also obtained. Women who were
diabetics, hypertensive, and smokers, alcoholic,
amenorrhoeic due to surgical removal of uterus
were excluded from the study.
Anthropometric Measurements: Weight in
(kg) was measured with the calibrated weighing
scale and height in meters was determined with
the stadio meter. The BMI was calculated using
the Quetelets formula BMI= weight in kg /
height in m2.as a measure of relative weight.
Using the flexible meter tape the waist
circumference was measured at a point midway
between lowest rib and iliac crest1. Hip
circumference was measured at the widest level
on the greater trochanter4. The Waist to hip
ratio was calculated using the formula WHR=
waist circumference (cm)/ hip circumference
(cm). All anthropometric were taken using
standard techniques.
Physiometric Measurements: This includes
measurement of systolic and diastolic blood
pressure. Two consecutive values were recorded
and averages were used. The measurements were
taken using mercury sphygmomanometer in a
sitting position after a minimum of 10-15
minutes rest with the right fore arm were placed
horizontally on a table5. Three consecutive BP
were recorded and the mean value was used for
analysis
Statistical Analysis: The results were tabulated
and T-test statistical analyses were performed to
find the association between blood pressure, BMI
and WHR in pre-menopausal and postmenopausal women.
MATERIALS AND METHODOLOGY
RESULTS
This Cross sectional study was conducted in

Research Laboratory, Department of Physiology,
Coimbatore Medical College after the between
June 2012 to October 2012. Study involved 50
pre-menopausal women in the age group of 4045 years and 50 post menopausal women in the
Post- menopausal women are obese (Mean BMI

26.340.40) when compared with the premenopausal women (24.390.12); p<0.05. The
post-menopausal women had a higher waist
(91.14) and hip circumference (84.64); p<0.05
as compared with the pre-menopausal women
594
(84.64 and 98.06 respectively); p<0.05. When

compared with WHR, there is no significance
difference between pre- menopausal (0.8618)
and post-menopausal (0.8724); p>0.05. Postmenopausal women
had increased Blood
Pressure, when compared with pre-menopausal
women p<0.01.
Table.1: Anthropometric data of pre and post
menopausal women
Parameter
Mean
Age
(years)
BMI
Waist circum-ference (cm)
Hip circum-ference (cm)
Systolic BP
(mmHg)
Diastolic BP
(mmHg)
W H R (%)
Pre
menopausal
Post
Menopausal
P
value.
42.510.60
49.380.65
24.390.12
26.340.40
P<0.05
84 .360.14
91.140.22
P<0.05
78.160.18
84.640.24
P<0.05
108.421.32
124.101.62
P<0.01
74.621.10
82.461.12
P<0.01
0.86
0.87
P<0.05
BMI: Body mass index; BP: Blood pressure;

WHR: Waist Hip ratio
DISCUSSION
During the transition period from pre menopause

to post menopause, most of the women
experience loss of lean mass, gain in weight, fat
mass and central obesity. The BMI of the
postmenopausal women was higher and in the
overweight range (Mean BMI 26.4)p <0.05. Only
11.37% of the post menopausal women were
normal BMI, 89.63% were overweight. Similar
findings were observed in a study of post
menopausal women in Zaria, Nigeria where
BMI of 25.96 were determined1. The waist
circumference and hip circumference of the
study group (91.141.20cm) was higher than
that of the control (84.631.10cm) p<0.05.
More fat deposition around the abdomen in
the reproductive age
present as greater
(3)
WHR . The identification of menopausal
women at risk of hypertension
based on
WHR supports
the
study
on three
population groups of Punjab by Divya Bishnol
et al2 and and Tesfaye F et al11. In this present
sample, 93.25% (p<0.01) of post menopausal
women were with elevated blood pressure
suggested that BP rises after menopause
appear to be more due to increased BMI 5. The
results of the present study shows that the BMI,
WHR and BP were elevated among postmenopausal women and the association between
BMI, WHR and BP were studied. Biological
changes as a result of cessation of estrogen
secretion and aging leads to obesity.
Obesity in post menopausal women is
multifactorial like reduced resting metobolic
Rate, reduced physical activity, increased
appetite and eating habits, emotional stress. The
significant increase in body parameters and BP in
post menopausal women due to lesser amount of
estradiol as compared to pre menopausal women
and suggested careful management at right time
like healthy habits and regular exercise can make
this phase comfortable7. The BMI, WHR and BP
had a positive correlation with each other11 and
stressed that the decreased estrogen secretion
among post menopausal women resulting in
agglomeration of abdominal fat12.
CONCLUSION
The results of this study demonstrates there is a

linear association between BP and central
adiposity and post menopausal women are at
risk of weight gain . Obesity, more of visceral
obesity precipitates atherosclerotic changes
and increases the risk of Hypertension and
cardio vascular dysfunction. In this study we
observed an association between Body Mass
Index and Blood pressure . Weight gain and
increased WHR in menopausal period can be
prevented by Life style modification.
595
ACKNOWLEDGEMENT
I am thankful to all the subjects participated

in this study and grateful to our Prof & HOD
Dr. N. Neelambikai. M.D., for
valuable
guidance and support.
REFERENCES
1. Achie LN, Olorunshola KV, Toryila JE,.

Tende JA. The Body Mass Index, Waist
Circumference and blood pressure of
Postmenopausal Women in Zaria, Northern
Nigeria.. Curr. Res. J. Biol. Sci. 2012;4 (3)
329-32.
2. Divya Bishnoi, Tanveen Kaur, Badaruddoza.
Predictor of cardiovascular disease with
respect to BMI, WHR and lipid profile in
females of three population groups. Biology
and medicine.2010;2(2):32-41
3. Colombel1 A, Charbonnel B. Weight gain
and cardiovascular risk factors in the postmenopausal woman. Human Reproduction
12(1):134 -45
4. Abdoljalol Marjani, Sedigheh Moghasemi.
The
Metabolic
Syndrome
among
Postmenopausal
Women
in
Gorgan.
International Journal of Endocrinology, 2012
Article ID 953627 6 Pages.
5. Renata Cifkova, Jan Pitha, Magdalena
Lejskova, VeraLanska and Silvia Zecova.
Blood pressure around the menopause: a
population study. Journal of hypertension
2008,26:1976-82
6. Badaruddoza, Navneet Kaur and Basnti
Barna. Inter-relationship of waist-to-hip ratio
(WHR), body mass index (BMI) and
subcutaneous fat with blood pressure among
university-going Punjabi, sikh and Hindu
females.IJMMS.2010;2(1):5-11
7. Sargun Singh and Kawaljit Kaur. Association
of age with obesity related variables and
blood pressure among women. Annals of
Biological Research,2012,3(7):3633-37
8. Feldstein CA. Akopian M, Olivieri AO,
Kramer AP. Nasi M, Garrido DA.
comparison of body mass index and waistto- hip ratio as indicators of hypertension
risk in an urban Argentine population:a
hospital-based study. Nutr Metab Cardiovasc
Dis.2005;15(4):310-5
9. Omoyemi Olubunmi, Ogwumike, Article

submitted at 9th WCPT Africa Region
Congress and meeting in Nairobi, Kenya
from 6th to 9th June 2012. Physical activity
level and pattern of Blood pressure and
Hypertension in Nigerian Postmenopausal
women.
10. Reddy KSN, Reddy KK and Sudha G.
Overall and Abdominal Adiposity on Blood
pressure: Consistency and Evaluation of
their Association in an Adult Indian
Population. J Life Sci:2010;2(2);117-25
11. Hongwei Wang et al Blood pressure, body
mass index and risk of cardiovascular disease
in Chinese men and women. BMC Public
Health 2010, 10:189
12. Tesfaye F. Association between body mass
index and blood pressure across three
populations in Africa and Asia.BMC Public
Health 2010,10:189
13. Mohammad Faheem. Does BMI affect
cholesterol, sugar and blood pressure in
general population?. J Ayub Med Coll
Abbotabad 2010;22(4);74-76.
596
DOI: 10.5958/j.2319-5886.2.3.105

&
Health Sciences
Research article

EFFECT OF SLOW DEEP BREATHING (6 BREATHS/MIN) ON PULMONARY FUNCTION

IN HEALTHY VOLUNTEERS
Shravya Keerthi G1, Hari Krishna Bandi2, Suresh M3, Mallikarjuna Reddy N1*
1
Department of Physiology, Narayana Medical College, Nellore, Andhra Pradesh, India

Department of Physiology, JIPMER, Puducherry.
3
Dept of Physiology, Meenakshi Medical College Hospital & Research Institute, Kancheepuram, Tamilnadu.
2
*Corresponding author email: res.publications@gmail.com

ABSTRACT
Objective: We designed this study to test the hypothesis that whether 10 minutes of slow deep breathing
have any effect on pulmonary function in healthy volunteers. The main objective was to study the
immediate effect of slow deep breathing on Forced vital capacity (FVC), Forced expiratory volume in
the first second (FEV1), Forced expiratory volume percent (FEV1/FVC%), Peak expiratory flow rate
(PEFR), Forced expiratory flow 25-75%(FEF25-75%), Maximum voluntary ventilation (MVV), Slow vital
capacity (SVC), Expiratory reserve volume (ERV), Inspiratory reserve volume (IRV) and Tidal volume
(TV). Methodology: Following 5 minutes sitting rest in the lab, Forced vital capacity (FVC), Forced
expiratory volume in the first second (FEV1), Forced expiratory volume percent (FEV1/FVC%), Peak
expiratory flow rate (PEFR), Forced expiratory flow 25-75% (FEF25-75%), Maximum voluntary
ventilation (MVV), Slow vital capacity (SVC), Expiratory reserve volume (ERV), Inspiratory reserve
volume (IRV) and Tidal volume (TV). The same parameters were recorded following Regular
Spontaneous Breathing (RSB) and Slow Deep Breathing (6 breaths/min). Results and Conclusion:
There was significant increase in FVC (p<0.0059), FEV1 (p<0.026), PEFR (p<0.02), FEF25-75%
(p<0.0006), SVC (p<0.002), ERV (p<0.033), IRV (p<0.025) and TV (p<0.0001) after practicing SDB
compared to RSB. Slow deep breathing may be used as a non-pharmaco therapeutic and safe modality, it
can be used as an effective lifestyle adjunct to medical treatment to reduce drug dosage and improve
quality of life of the patients.
Key words: Pulmonary function, Regular Spontaneous Breathing (RSB), Slow Deep Breathing (SDB).
INTRODUCTION
Yoga has been originated in 5000 BC, it is an

ancient philosophical and religious tradition.
Because of increasing incidence of lifestyle
diseases such as obesity, hypertension,
cardiovascular diseases, and diabetes mellitus
Shravya et al.,
due to urbanization and faulty lifestyle and

psychological stress, yoga is incorporated into
modern medicine since few decades 1.
Pranayama is the science of breathing2. As it is a
form of physiological stimulus, the regular
597
practice of Pranayama is a form of adaptation to

a repeated stimulus. Breathing is the only
autonomic function that can be consciously
controlled. It helps in bringing the involuntary
nervous system i.e; sympathetic and the
parasympathetic nervous system into harmony3.
The practice of breathing exercise increases
parasympathetic tone, decreases sympathetic
activity, improves cardiovascular and respiratory
functions by affecting oxygen consumption,
metabolism and skin resistance4,5.
Slow deep breathing like pranayama reduces
dead space ventilation, renews air throughout
lungs, in contrast with shallow breathing which
renews air only at the base of the lungs.
Pranayama, the fourth step of astang yoga is an
important component of yoga training6. Training
effect of different pranayama techniques and
deep breathing on pulmonary functions has been
reported extensively. Pranayama is a method of
breathing and chest expansion exercise, which
has been reported to improve respiratory function
in health and respiratory disease7. The literature
search through PUBMED central and other
search engines showed scanty data on
acute/immediate effects of deep breathing and
pranayama on pulmonary functions. Even a few
successive episodes of deep breathing may
influence the lung dynamics. The role of deep
breathing on release of surfactant and consequent
change in pulmonary compliance, and other lung
functions has been extensively studied both in
cultured pulmonary epithelial cells, in isolated
and intact lungs of many different animals8 . But
whether the same phenomenon occurs in human,
and whether that can alter any of the parameters
of pulmonary function has not been studied in
detail.
In our literature search, we found only effects of
at least a short term practice extended over a
period of a few days to weeks of pranayama
rather than acute effects of pranayama. The
pulmonary function test (PFTs) is a valuable tool
for evaluating the respiratory system and is a
simple screening procedure which can be
Shravya et al.,
performed by using standardized equipment to

measure the lung function. Keeping this in mind
the present study was designed to test the
hypothesis that whether 10 minutes of slow deep
breathing have any effect on pulmonary function
in healthy volunteers. The main objective was to
study the immediate effect of slow deep
breathing on Forced vital capacity (FVC), Forced
expiratory volume in the first second (FEV1),
Forced
expiratory
volume
percent
(FEV1/FVC%), Peak expiratory flow rate
(PEFR), Forced expiratory flow 25-75%(FEF2575%), Maximum voluntary ventilation (MVV),
Slow vital capacity (SVC), Expiratory reserve
volume (ERV), Inspiratory reserve volume (IRV)
and Tidal volume (TV).
This is a cross-sectional study undertaken by the

Department of Physiology, Pulmonary Function
Testing Laboratory, Narayana medical college
(NMC), Nellore (A.P), India. After obtaining
approval of the Institutional Ethics Committee
(IEC), pulmonary function tests were conducted
in 30 healthy volunteers.
Inclusion criteria: Age group of 18 to 40 years;
age , BMI matched students and residents of
NMC. The subjects of both genders were
included.
Exclusion criteria: Subjects with a past history
of smoking, hypertension, respiratory diseases,
chest wall injuries, congestive cardiac failure,
kyphoscoliosis and who are already trained in
yoga and exercise were excluded from the study.
Methodology: The volunteers were properly
explained about the objectives, methodology,
expected outcome and implications of the study
and written informed consents were obtained
from them. They were instructed to report to PFT
lab of Physiology department at about 9 A.M.
Volunteers are trained to Slow deep breathing
(SDB) by experienced yoga teacher from
Narayana Yoga and Naturopathy college, and
volunteers also get familiarized with our research
lab and procedure of pulmonary function testing.
598
Following 5 minutes sitting rest in the lab, their

pulmonary functions were assessed by
computerized spirometer (Spirowin Version 2.0
of Genesis Medical systems pvt Ltd) which gives
ERS-93 predicted values at BTPS conditions9.
After preliminary trials, a baseline reading was
taken followed by a reading after practicing
regular spontaneous breathing (RSB) for 10
minutes. Volunteers followed the instructions
given by qualified and experienced yoga teacher
for slow deep breathing of 6 breaths/min for 10
mins. After practicing slow deep breathing (6
breaths/min) for 10 min, the test was performed
three times and the best reading was considered.
The tests were performed with subjects in the
standing position10,11.(Explanation: A sitting
position was used at the time of testing to prevent
the risk of falling and injury in the event of a
syncopal episode, the PFT can also be performed
in the standing position.The test is performed in
standing position as the ventilatory capacities are
greater in standing position than in sitting or
lying posture, change in posture will change the
ability to carry out physical effort and ventilatory
capacity of the lungs. As the procedure of these
tests are effort dependent the subjects are asked
to perform the test in standing position because
the diaphragm descends and the capacity of
thoracic cage increases in erect posture). During
the procedure, the subjects inhaled deeply and
then exhaled with maximum effort as much as
possible into the mouthpiece for FVC test. The
subjects inhaled deeply and exhaled slowly and
completely as much as possible, this was
repeated for 3-4 times followed by normal

respiration for SVC test. The following
parameters were recorded: Forced vital capacity
(FVC), Forced expiratory volume in the first
second(FEV1), Forced expiratory volume
percent(FEV1/FVC%), Peak expiratory flow
rate(PEFR), Forced expiratory flow 2575%(FEF25-75%),
Maximum
voluntary
ventilation(MVV), Slow vital capacity(SVC),
Expiratory reserve volume (ERV), Inspiratory
reserve volume (IRV) and Tidal volume (TV).
RESULTS
The data were expressed as mean SD, were

analyzed using the GraphPad Instat Version3.0
for Windows, GraphPad Software. The Gaussian
distribution
was
determined.
Normally
distributed data were tested by the one way
ANOVA and post-hoc analysis was done with
Tukey. Non-normally distributed data were
tested with Krusukal-Wallis and post-hoc
analysis was done with Dunn. A Pvalue of
P<0.05 was considered significant.
Table 1 shows the anthropometric parameters of
the subjects. Table 2 shows the respiratory
variables like lung capacities, volumes and flow
rates at baseline (BL), after Regular spontaneous
breathing (RSB) and after Slow deep breathing
(SDB). There was a significant increase in FVC
(p<0.0059), FEV1 (p<0.026), PEFR (p<0.02),
FEF25-75% (p<0.0006), SVC (p<0.002), ERV
(p<0.033), IRV (p<0.025) and TV (p<0.0001)
after practicing SDB compared to RSB and BL
values.
Table 1. Anthropometric parameters

Parameter
Age (Yrs)
Weight (Kgs)
Height (m)
BMI (kg/m2)
BSA ( m2)
Shravya et al.,
Mean + SD
20.8 4.41
54.6 11.8
1.62 0.09
20.6 3.28
1.563 0.20
599
Table 2. Comparison of Respiratory variables between BL, RSB and SDB

Parameter
Mean + SD
P value
BL
RSB
SDB
FVC(L)
2.25 0.45 2.52 0.56
2.72 0.62
0.0059*
FEV1(L)
1.92 0.54 2.17 0.52
2.30 0.54
0.026*
FEV1/FVC%
86.53 .16
86.23 9.89
85.05 8.14
0.80
PEFR(L/S)
3.85 1.29 4.16 1.38
4.53 1.07
0.02*
FEF25-75% (L/S) 2.05 0.70 2.52 0.69
2.73 0.64
0.0006*
SVC (L)
3.39 1.77 4.09 2.58
5.36 3.11
0.002*
ERV (L)
1.16 1.14 1.54 1.48
2.17 2.13
0.033*
IRV (L)
1.69 1.42 2.36 2.24
3.11 2.74
0.025*
TV (L)
0.66 0.40 0.96 0.45
1.22 0.45
0.0001*
MVV (L)
67.6420.82 73.99 23.22
81.16 22.9
0.069
BL: Baseline, RSB: Regular spontaneous breathing, SDB: Slow deep breathing, FVC: Forced Vital
capacity, FEV1 : Forced Expiratory Volume in 1 sec, PEFR: Peak Expiratory Flow rate, FEF25-75% :
Forced Expiratory Volume, SVC: Slow vital capacity, ERV: Expiratory Reserve Volume, IRV:
Inspiratory Reserve Volume, TV: Tidal Volume and MVV: Maximal Voluntary Ventilation. * signifies
p< 0.05 which shows values are statistically significant.
DISCUSSION
As yoga aims at the perfection of the body and

mind, it is natural to ask whether the progress
towards
perfection
reflects
objective
reproducible changes in physiological variables.
Breathing is the only autonomic function that can
be consciously controlled and it is the key in
bringing the sympathovagal harmony.
From the results (table 2) it is evident that
immediate effect of slow deep breathing showed
significant improvement in FVC, FEV1, PEFR,
FEF 25-75%, MVV, SVC, ERV, IRV and TV.
FEV1 is the volume of air that is exhaled in the
first second during FVC manoeuvre. It is useful
to detect generalized airway obstruction.
FEV1/FVC% is the volume of air expired in the
first second, expressed as percentage of FVC. It
is a more sensitive indicator of airway
obstruction, than FVC or FEV1 alone. FEF25-75%
is the average flow rate during middle 50% of
FVC. It indicates patency of the small airways.
FEF25-75% depends on non-bronchopulmonary
factors like, neuromuscular factors and
Shravya et al.,
mechanical equipment factors of inertial

distortion of the lungs. PEFR and FEF2575% are
the first parameters to decline on many
respiratory diseases. Any practice that increases
PEFR and FEF2575% is expected to retard the
development of COPDs. The immediate effect
of slow deep breathing practice also alleviates
PEFR and FEF2575% and other lung function
parameters .
Our findings are consistant with Bal et al.,
Upadhyay et al., Nayar et al., Joshi et al. And
subbalakshmi et al12-16. Most of the study results
are based on the practice of slow deep breathing
for a few weeks to months but the immediate
effect of it is less studied.
Physiological changes occurring during
different phases of SDB are:
Inspiration phase14, 16:
During the inspiration the lungs are expanded
considerably and the walls of alveoli are
stretched maximum. After a particular degree of
stretching, the stretch receptors situated in the
alveolar walls are stimulated. In normal
600
breathing, during this stage or even before this,

the inhibitory impulses would be sent to the
inspiratory center and the phase of exhalation
would have been started in a reflex. But as we
continue the phase of inspiration with strong
voluntary control, the normal stretch reflex is
inhibited, no exhalation is possible. The chest
continues to expand under neural control. The
stretch receptors are thus trained to withstand
more and more stretching. During this phase the
intra-pulmonary pressure is also raised and the
diaphragm does not move freely. Therefore the
alveoli in the lung apices are filled with air.
Inspiratory capacity is used for this phase. This
has a beneficial effect on the gaseous exchange,
as it works efficiently throughout the day. This is
not just a mechanical prolongation of inspiration
but it is done with full concentration.
Expiration phase14,16:
This phase is a voluntary controlled expiration as
compared to normal. The duration, force,
ventilation and the flow of air are controlled. The
expiratory force is reduced and the air is allowed
to escape slowly. This helps in prolongation of
expiration, reduce the force of outgoing air. This
phase has utilized ERV for expiring completely
before initiating the next cycle. In this phase the
intra-pulmonary pressure slowly reduces and the
alveoli are gradually deflated. By this time when
one is expiring slowly, the percentage of carbon
dioxide is still increasing in the blood and the
chemo receptors in the medulla are trying to
inhibit expiration and to start inspiration phase
by stimulating the inspiratory center. The
peripheral chemo receptors also try to bring
about inspiration in a reflex manner as they are
sensitive to the lower oxygen concentration in
the blood.
Slow, deep breathing also resets the autonomic
nervous
system
through
stretch-induced
inhibitory signals and hyperpolarization currents
propagated through both neural and non-neural
tissue which synchronizes neural elements in the
heart, lungs, limbic system, and cortex4. It is
Shravya et al.,
thought that voluntary deep breathing

dynamically modulates the autonomic nervous
system by generation of two physiologic signals:
1) SDB increases frequency and duration of
inhibitory neural impulses by activating stretch
receptors of the lungs during inhalation above
tidal volume (as seen in the Hering Breuers
reflex). 2) SDB increases generation of
hyperpolarization current by stretch of
connective tissue (fibroblasts) localized around
the lungs. It is recognized that inhibitory
impulses, produced by slowly adapting receptors
(SARs) in the lungs during inflation, play a role
in controlling typically autonomic functions such
as breathing pattern, airway smooth muscle tone,
systemic vascular resistance, and heart rate. The
stretch of connective tissue fibroblasts is capable
of affecting the membrane potential of nervous
tissue4. Both hyperpolarization and inhibitory
impulses generated by a stretch of neural and
non-neural tissue of the lungs are the likely
agents of the autonomic shift during slow deep
breathing4, 5. Synchronization within the
hypothalamus and the brainstem is likely
responsible for inducing the parasympathetic
response during breathing exercises. The
strongest cardiorespiratory coupling which is a
parasympathetic phenomenon occurs when there
is decreased breathing frequency. Stretch of lung
fibroblasts likely contributes to the generation of
the slower wave brain activity and the
parasympathetic autonomic shift during slow
deep breathing exercises4.
CONCLUSION
Slow deep breathing may be used as a nonpharmaco therapeutic and safe modality, it can
be used as an effective lifestyle adjunct to
medical treatment to reduce drug dosage and
improve quality of life of the patients.
ACKNOWLEDGMENT
We kindly aknowledge
Mr.Sukumar BV,
Technical Supervisor, Pulmonary Function
601
Testing Laboratory, Naryana Medical Colllge

(NMC) for his technical support, students and
residents of NMC, who have participated in the
study and led to complete the study successfully.
REFERENCES
1. Roopa B. Ankad, Anita Herur, Shailaja

Patil, G.V. Shashikala, and Surekharani .
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and Meditation on Cardiovascular Functions
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3. Sukhdev Singh. Effects of a 6 week nadishodhan
pranayama
training
on
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Physical Education and Sports Management
2011; 2 (4): 44-47.
4. Shankarappa V, Prasanth P, Nachal
Annamalai, Varunmalhotra. The short term
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JCDR, 2012; 6(1):27-30.
5. Ravinder Jerath, John WE, Vernon A.
Barnes, Vandna Jerath. Physiology of long
pranayamic breathing: Neural respiratory
elements may provide a mechanism that
explains how slow deep breathing shifts the
autonomic nervous system. article in press2006.
6. Pal GK, Velkumary S and Madanmohan.
Effect of short-term practice of breathing
exercises on autonomic functions in normal
human volunteers. Indian J Med Res.
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pranayamas
on
reaction
time
and
cardiorespiratory variables. Indian J Physiol
Pharmacol 2005; 49(3): 313- 18.
8. Madanmohan. Effect of six week yoga
training on weight loss following step test,
respiratory pressures, handgrip strength and
handgrip endurance in young
healthy
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subjects. Indian J Physiol Pharmacol 2008;

52 (2): 164-70.
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breathing for a short duration (2 10 min) on
pulmonary functions in healthy young
volunteers. IJPP 2011; 55 (2): 154-59.
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test system, User Manual, (Hyderabad :
Genesis Medical Systems Pvt. Ltd, 2006).
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Madden. Pulmonary Function Tests. Ulster
Med J 2011;80(2):84-90.
12. GK Pal and Pravati Pal. In: Effect of posture
on vital capacity. Text book of practical
physiology, University press; 3rd ed: 142-44.
13. Chanavirut R. Yoga exercise increases chest
wall expansion and lung volumes in young
healthy thais. Thai journal of Physiological
sciences 2008; 19(1): 1-7.
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and Urban JA, DSouza. Immediate effect of
nadi -shodhana pranayama on some
selected parameters of cardiovascular,
pulmonary, and higher functions of brain.
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Damodara Gowda KM. Effect of selected
breathing techniques on respiratory rate and
breath holding time in healthy adults.
IJABPT. 2011; 2(3): 225-229.
16. Baljinder Singh Bal. Effect of anulom vilom
and bhastrika pranayama on the vital capacity
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602
DOI: 10.5958/j.2319-5886.2.3.106

&
Health Sciences
Research article
CORRELATION BETWEEN THE RETINAL NERVE FIBRE LAYER (RNFL) PARAMETERS
MEASURED USING STRATUS OPTICAL COHERENCE TOMOGRAPHY AND GDx VCC
(SCANNING LASER POLARIMETRY) IN ESTABLISHED GLAUCOMA PATIENTS IN
SOUTH INDIAN POPULATION
*Elangovan Suma, Puri K Sanjeev
Department of Ophthalmology, Meenakshi Medical College and Research Institute, Enathur, Kanchipuram,
Tamilnadu, India
*Corresponding author email: elangovansuma@hotmail.com

ABSTRACT
Purpose: Optical Coherence Tomography and Scanning LASER polarimetry (GDx) are investigatory
modalities used to evaluate the structural changes in the optic nerve and retina in glaucoma patients.This
study aims to evaluate the correlation between the Retinal Nerve Fibre Layer (RNFL) parameters
measured using Stratus-OCT (optical coherence tomography) and GDx VCC(scanning laser
polarimetry) in established glaucoma patients in South Indian Population. Materials and methods:
Prospectively planned cross sectional study of 67 eyes of 34 established glaucoma patients on medical
management The mean age of patients was 46.911 years (SD+13.531). A complete ophthalmic
examination, automated perimetry with octopus interzeag 1-2-3 perimeter, retinal nerve fiber analysis
with GDx VCC and Stratus OCT was done. Correlation coefficients between the parameters of OCT and
GDx VCC were calculated. Results: Statistically significant positive correlations were observed
between GDx VCC and OCT parameters in the respective areas. Conclusion: The RNFL thicknesses
measured by two different investigatory modalities OCT and GDx are well correlated despite the
differences in values of RNFL thickness.
Keywords: Retinal nerve fibre layer, OCT, GDx
INTRODUCTION
Glaucoma is defined as a disturbance of the

structural and functional integrity of the optic
nerve that can usually be arrested or diminished
by adequate lowering of the intraocular
pressure1.
Glaucoma is a type of progressive
optic neuropathy in which there is a
morphological change in the optic nerve head
and retinal nerve fibre layer with visual field
Suma et al.,
loss2. Visual field analysis by automated static

perimetry is both sensitive and specific to detect
field loss and is currently the most widely used to
evaluate and to monitor disease progression.
However it is prone to variability as it is highly
subjective 3. It has been documented that up to
40 percent of the RNFL may be lost before a
field defect is detectable4,5. Studies have shown
603
that structural changes of the ONH6-8and NFL 5,911

may precede field loss.
Stereoscopic photographs of the optic disc and
RNFL were the objective methods utilized to
diagnose and monitor glaucoma. But the
interpretation of photographs remains subjective,
and variations in assessment among even
experienced observers are well documented12-14
Confocal scanning laser ophthalmoscopy (HRT),
scanning laser polarimetry with fixed and
variable corneal compensator (GDxVCC),
optical coherence tomography (OCT) and the
retinal thickness analyzer (RTA) have become
available that provide quantitative reproducible,
and objective measurements of RNFL thickness.
The purpose of this study is to evaluate the
relationship
between
structural
changes
evaluated by OCT and GDX VCC in established
glaucomatous eyes.
This was a cross sectional study, prospectively

planned. 67 eyes of 34 glaucoma patients
attending glaucoma clinic were included in this
study after getting clearance from the ethical
committee. Informed consent was obtained from
all the patients.
Inclusion and exclusion criteria: Primary open
angle glaucoma patients on medical treatment
and routine follow up were chosen for the study.
The patients were diagnosed as glaucomatous by
the following criteria: at least three or more
occasions of elevated intra ocular pressure >21
mm Hg now on medical control and significant
optic nerve head changes with or without visual
field defects. The patients had a best corrected
visual acuity of 6/12 or better. The refraction of
these patients were as follows: Hyperopia <
+2.50D, Myopia -3.00 D , Astigmatism+2.00
D.
All patients who had Closed angles /narrow
angles, secondary glaucomas, juvenile and
congenital glaucomas, media opacities that may
prevent good RNFL assessment and coexistent
Suma et al.,
retinal pathology or neurological problems were

excluded. Primary open angle glaucoma patients
who had undergone surgical or laser therapy for
glaucoma were also excluded.
All subjects underwent a
complete
ophthalmologic examination including Slit lamp
biomicroscopy for anterior segment evaluation
and fundus examination with +90 D lens,
gonioscopy, intra ocular pressure measurement
using Goldmann applanation tonometry and also
direct ophthalmoscopy.
Glaucomatous
appearance of the Optic disc was defined as an
increased C: D ratio, asymmetry of the C:D ratio
of >0.2 between the two eyes, neuro retinal rim
thinning , disc haemorrhage , notching and
excavation. Visual field analysis was performed
with Octopus Interzeag1-2-3 perimeter.
RNFL analysis with Optical coherence
tomography: Retinal nerve fibre layer
measurements were obtained with Stratus OCT
(Zeiss) version 4.0.1. All scans were performed
by well trained technicians who were unaware of
the patients diagnosis. The OCT parameters
analyzed in this study were Total average nerve
fibre layer thickness (OCT T Avg), superior
average (OCT S Avg) and inferior average
thickness (OCT I Avg).
RNFL analysis with GDX VCC: The GDX
VCC (Version 5.2.3) is a scanning laser
polarimeter that measures RNFL thickness using
polarized light. The disc margin on the image
was established by marking with an ellipse by
the same experienced technician who was
masked to the patients diagnosis. A series of
RNFL parameters were generated by the
software for this study. The parameters TSNIT
average thickness, Superior Average thickness,
Inferior average thickness and Nerve Fibre
Indicator (NFI) were considered.
All these investigating modalities were carried
out within a period of 3 weeks to obtain the best
cross sectional comparison and to nullify the
effect of any temporal lag.
Statistical analysis was carried out using SPSS
software. Correlation analysis was done by
604
Pearsons correlation coefficient and the

statistical significance ascertained by two tailed
significance test.
Table.1: RNFL parameters obtained by OCT
OCT parameters
(microns):
RESULTS
GDX RNFL parameters: The GDX VCC

RNFL analysis parameters studied were the
TSNIT average (TSNIT Avg), superior
(GDXSAvg) and inferior averages (GDXIAvg)
and the nerve fibre indicator (GDX NFI).The
mean values of the parameters are tabulated in
table :2.
Correlational analysis was carried out
between RNFL parameters as obtained by
OCT and GDXVCC: The OCT parameters
correlated were the Total average nerve fibre
layer thickness (OCT T Avg) , superior
average(OCT S Avg) and inferior average
thickness (OCT I Avg) with the GDX VCC
parameters TSNIT average (TSNIT Avg),
superior (GDXSAvg) and inferior averages
(GDXI Avg) respectively. A high positive
correlation was obtained with a p value < 0.01significant at 1% level. (table:3).Scatter plots
showing the positive correlation between the
parameters are shown in figures 1,2 and 3.
Suma et al.,
Total
average
87.7422.218 20
thickness
Superior average
112.8032.32 0
Inferior average
103.5032.67 34
129
164
159
Table: 2, RNFL parameters as obtained with

GDXVCC:
Primary open angle glaucoma
GDX parameters: (N=67)
(microns)
MeanSD
Min
Max
TSNIT average
thickness
Superior average
Inferior average
Nervefibre
indicator
48.219.02
24.16
64.7
58.4213.28
54.4711.62
23.80
26.86
79.2
73.3
32.4625.36
98
Table.3: Correlational analysis between RNFL

parameters as obtained by OCT and GDXVCC:
Correlation between
N=67
0.7925
OCT T Avg& GDX TSNIT r
Avg
p
0.000**
r
0.8123
OCT S Avg & GDXS Avg
p
0.000**
r
0.7341
OCT I Avg & GDXI Avg
p
0.000**
r = Pearsons correlation coefficient; p = p value,
*p<0.05 (0.01 to 0.05) significant at 5% level
**p< 0.01- significant at 1% level
140
120
OCT Total Average
67 eyes of 34 established Primary open angle

glaucoma patients were analysed in this study.
The mean age of the patients of this study was
46.911(13.531) .The ages of these patients
ranged from 26 to 70 years. Out of the 34
patients, 10 patients were females accounting for
about 29.41%.
Optical
coherence
tomography RNFL
parameters: The Retinal nerve fibre layer
thickness was analysed by Optical coherence
tomography and the parameters which were
obtained were total average nerve fibre layer
thickness (OCT T Avg) , superior average(OCT
S Avg) and inferior average thickness (OCT I
Avg). Analysis of the OCT parameters are shown
in table:1
Primary
open
angle
glaucoma (N=67)
MeanSD
Min Max
100
80
60
40
20
0
20
30
40
50
60
70
GDX - TSNIT Average
Fig.1: Scatter plot showing the positive correlation

between the total average nerve fibre layer thicknesses
(in microns) obtained with GDx and OCT.
605
OCT - Superior Average
200
175
150
125
100
75
50
25
0
20
30
40
50
60
70
80
GDX - Superior Average
Fig2: Scatter plot showing the positive correlation

between the superior average nerve fibre layer
thicknesses (in microns) obtained with GDx and
OCT.
OCT - Inferior Average
160
140
120
positive correlation was obtained with a p value

< 0.01- significant at 1% level(table:4,Figures
1,2,3).In a recent study by Chen et al21, the
RNFL thickness measured by both Stratus OCT
and GDX VCC were well correlated in early
glaucoma and poorly correlated in ocular
hypertensive and glaucoma suspect eyes.
We obtained Correlation coefficients (r) 0.7925
for TSNIT average/average thickness, 0.8123 for
superior average, and 0.7341 for inferior
average(table:3). Similar results were brought
out in studies by Leung et al 22 and Chung et al23
.They demonstrated the significant positive
correlations between GDx VCC and StratusOCT
RNFL measurements even though there were
substantial differences in RNFL thickness.
100
CONCLUSION
80
60
40
20
20
30
40
50
60
70
80
GDX - Inferior Average
Fig. 3: Scatter plot showing the positive

correlation between the inferior average nerve
fibre layer thicknesses (in microns) obtained with
GDx and OCT
Outcomes of the study: The RNFL thicknesses

measured by two different investigatory
modalities OCT and GDx are well correlated in
established glaucoma patients. The newer
instruments are valuable tools that have become
available to provide quantitative reproducible
and objective measurements of RNFL thickness.
ACKNOWLEDGEMENT
DISCUSSION
The purpose of the study was to compare the

results obtained by these two methods (OCT and
GDX VCC) for
assessing the RNFL in
established glaucomatous eyes in south Indian
population. We have compared the two methods
in a single population . The limiting factor in this
study is the smaller sample size.
The diagnostic accuracy with different modalities
of imaging in glaucoma has been demonstrated
in various studies15-20.
In this study when the OCT parameters, the Total
average nerve fibre layer thickness (OCT T
Avg), superior average (OCT S Avg) and inferior
average thickness (OCT I Avg) were correlated
with the GDX VCC parameters TSNIT average
(TSNIT Avg), superior (GDXSAvg) and inferior
averages (GDXIAvg) respectively, a high
Suma et al.,
The authors would like to thank Prof. V.

Velayutham for his guidance and support in
carrying out this study.
REFERENCES
1. Stamper RL, Lieberman MF, Drake MV.

Becker -Shaffers diagnosis and therapy of
glaucoma, Ed 7, St. Louis, 1999, Mosby.
2. Lan Y-W Henson DB, Kwartz AJ. The
correlation between optic nerve head
topographic measurements, peripapillary
nerve fibre layer thickness, and visual field
indices in glaucoma, Br. J. Ophthalmol.
2003;87: 1135
3. Guedes, V. Schuman JS, Hertzmark et al:
Optical coherence tomography measurement
of macular & nerve fibre layer thickness in
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normal
and
glaucomatous
eyes,
Ophthalmology.2003;110(1):177-17
4. Son P, Sibota R, Tewari HK, Venkatesh P,
Singh R. Quantification of the RNFL
thickness in normal Indian eyes with OCT,
Indian J. Ophthalmology.2004;52:303-09
5. Quigley HA, Addicks EM, Green WR. Optic
nerve damage in human glaucoma ischemic
neuropathy,
papilledema
and
toxic
neuropathy, Arch Ophthalmol; 1982;100:
135-46
6. Sommer A, Pollackk I, Maumenee AE. Optic
disc parameters and onset of glaucomatous
field loss I methods and progressive changes
in disc morphology. Arch Ophthalmol 1979;
97 (8): 1444-8.
7. Pederson J, Anderson D. The mode of
progressive disc cupping in ocular
hypertension
and
glaucoma.
Arch
Ophthalmol 1980; 98: 490-5.
8. Quigley HA, Katz J. Derick RJ. An
evaluation of optic disc and nerve fibre layer
examination in monitoring progressive of
early glaucoma damage. Ophthalmology
1992: 99 (1): 19-28.
9. Sommer A, Miller NR, Pollack I. The nerve
fiber layer in the diagnosis of glaucoma
Arch Ophthalmol 1977; 95(12): 2149-56.
10. Summer A, Quigley HA, Robix AL.
Evaluation of nerve fibre layer assessment.
Arch Ophthalmol. 1984; 102 (12): 1766-71.
11. Sommer A, Katz J, Quigley HA.Clinically
detectable nerve fibre atrophy procedure the
onset of glaucomatous field loss. Arch
Ophthalmol 1991;109 (1): 77-83.
12. Lichter PR. Variability of expert observes in
evaluating the optic disc .Trans AM
ophthalmolSoc 1976;74: 532-72.
13. Tielsch JM, Katz J, Quigley HA, Miller NR,
Sommer A. Intraobserver and interobserver
agreement in measurement of optic disc
characteristics. Ophthalmology. 1988; 95:
350-6.
Suma et al.,
14. Varma R, Steinmann WC, Scott IU. Expert

agreement in evaluating the optic disc for
glaucoma. Ophthalmology 1992;99:215-21.
15. Medeiros FA, Zangwill LM, Bowd C.
Comparison of the GDx VCC scanning laser
polarimeter, HRT II confocal scanning laser
ophthalmoscope, and Stratus OCT optical
coherence tomography for the detection of
glaucoma. Arch Ophthalmol. 2004;122:82737.
16. Bowd C, Weinreb RN, Wiliam JM. The
retinal nerve fiber layer thickness in ocular
hypertensive, normal and
glaucomatous
eyes with optical coherence tomography.
Arch Ophthalmol. 2000;118:22-26.
17. Zangwill LM, Bowd C, Berry CC.
Discriminating between normal and
glaucomatous eyes using Heildelberg Retina
Tomograph,GDx Nerve Fiber Analyzer, and
Optical Coherence tomograph. Arch
Ophthalmol. 2001;119:985-93.
18. Greaney MJ, Hoffman DC, Garway-Heath
DF. Comparison of optic nerve imaging
methods to distinguish normal eyes from
those with glaucoma. Invest Ophthalmol Vis
Sci.2002;43:140-45.
19. Chen HY, Huang ML. Discrimination
between normal and glaucomatouseyes using
Stratus optical coherence tomography in
Taiwan Chinese subjects. Graefes Arch
ClinExpOphthalmol.2005;243:894-902.
20. Chen HY, Huang ML, Tsai YY. Comparing
glaucomatousoptic neuropathy in primary
open angle and primary angleclosure
glaucoma eyes by scanning laser
polarimetry- variable corneal compensation.
J Glaucoma. 2008;17:105-10.
21. Chen, Hsin-Yi, Huang, Mei-Ling, Wang, IJong, Chen, Wen-Chi. Correlation between
Stratus OCT and
GDX VCC in early
glaucoma,
ocular
hypertension
and
glaucoma suspect eyes. J Optom. 2012;5:2430.
22. Leung CK, Chan W, Chong KKL.
Comparative study of retinal nerve fiber
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layer measurement by stratus OCT and GDx

VCC. I. Correlation analysis in glaucoma.
Invest Ophthalmol VisSci. 2005;46:321420.
23. Yun Suk Chung,
YongHoSohn. The
Relationship between Optical Coherence
Tomographyand
Scanning
Laser
Polarimetry Measurements in Glaucoma.
Korean J Ophthalmol. 2006;20(4):105-10
Suma et al.,
608
DOI: 10.5958/j.2319-5886.2.3.107

&
Health Sciences
th

Research article
Coden: IJMRHS
th
Revised: 12 Jul 2013
Copyright @2013
ISSN: 2319-5886
GENDER AND SEGMENTAL STUDY OF ARSENATE UPTAKE BY THE EVERTED GUT

SACS OF MICE
*Latha R1, Prakasa Rao J2
1
Department of Physiology, Sri Venkateswara Medical College Hospital and Research Centre, Ariyur
Puducherry, India.
2
Department of Physiology, Kasturba Medical College, Manipal, India.
*Corresponding author email: lathaphysio@yahoo.co.in
ABSTRACT
Background: Humans are exposed to both inorganic and organic arsenic through environmental,
medicinal and occupational situations. The main source of arsenic exposure is drinking water with high
levels of arsenic. Aim: This study was undertaken to investigate the gender and segmental difference in
arsenate (As V) uptake by everted gut sacs of mice. Materials & methods: By using the everted gut
sac technique, the serosal and mucosal uptake of Arsenate (2 mM) in both sexes of mice was studied in
the intestinal segments. The Arsenate in the samples of fluid present in serosal and mucosal
compartments of everted gut sacs was estimated by Hydride-Generation Atomic Absorption
Spectrophotometer. Results: There was a steady increase in both serosal and mucosal uptake of
Arsenate in both duodenum and ileum with a rise in the initial Arsenate concentration of the incubation
medium. The mucosal uptake of Arsenate was significantly higher in duodenum than ileum (P<0.001).
Both serosal and mucosal uptakes were elevated in the duodenal segment of male mice when compared
to female mice except mucosal uptake in ileum. Conclusion: These results indicate that there is a gender
and segmental difference in the uptake of AS (V), which can be explored pharmaceutically to reduce the
arsenic toxicity in population at risk.
Keywords: Arsenic transport, Everted gut sacs, Arsenic toxicity.
INTRODUCTION
Arsenic, a ubiquitous element present in various

compounds, is mainly transported in the
environment by water. Arsenic can exist in four
valency states1. The predominant form of
inorganic arsenic in aqueous and aerobic
environments is arsenate (As V) whereas arsenite
(As III) is more prevalent in anoxic
environments. Humans are exposed to inorganic
or organic arsenic through environmental,

medicinal and occupational situations. The main
source of arsenic exposure for the general
population is drinking water with high levels of
arsenic2,3. The food contains both organic and
inorganic arsenic, whereas drinking water
contains primarily inorganic forms of arsenic. A
variety of adverse health effects e.g., skin and
Latha etal.,
609
internal cancers, cardiovascular and neurological

effects have been attributed to arsenic exposure,
primarily from drinking water.
Arsenic can be absorbed from the gastrointestinal
tract after ingestion of arsenic containing food,
water, beverages or medicines, or as a result of
inhalation and subsequent mucociliary clearance.
The concentration of arsenic in unpolluted
ground water is in the range of 1-10 g/ L. In
many parts of the world - India 4, Bangladesh 4,
Chile 5, North Mexico 6 , Argentina 7 and Taiwan
8
the arsenic concentrations (> 1 mg As/ L) in
groundwater was found to be elevated. Though
various chelators are available for acute arsenic
toxicity, so far there is no known drug available
to prevent the absorption of arsenic at the
intestinal level. The preventive measures are
mainly aimed at reducing the levels of arsenic in
the drinking water 9. Since the gut remains the
main portal of entry of this metal into the human
body and the inorganic arsenicals like
pentavalent and trivalent forms are rapidly and
extensively absorbed from the gastrointestinal
tract 10,11, it was decided to study the effect of
varying the Arsenate concentration in the
incubation medium on Arsenate transport in all
segments of intestine using the everted gut sacs
of both the sexes of mice.
Chemicals and Reagents: Sodium arsenate

(Na2HAs5O4 7H2O; molecular weight 312.01)
and other analytical laboratory chemicals and
reagents were procured from Sigma Aldrich
Chemicals (St. Louis, MO.USA).
Animals: After the approval by Institutional
Animal Ethical Committee (IAEC) of
SVMCH&RC. Healthy adult male (40) and
female (40) Swiss albino mice, weighing
approximately 25-31 g were used for present
study. Mice were acclimatized for 7 days to light
from 06:00 to 18:00 h, alternating with 12 h
darkness, maintained under controlled conditions
of temperature (25 2C), humidity (50 5%)
and a 12-h lightdark cycle. Mice were allowed

standard laboratory commercial feed obtained
from Gold Mohur Animal Feeds (Bangalore,
India) throughout the experiment and water ad
libitum.
All animals maintained compliance with the
guidelines of the Committee for the Purpose of
Control and Supervision of Experiments on
Animals (CPCSEA).
Tissue preparation: This was assessed by usage
of everted gut sacs prepared from the mice.
Under anaesthesia the intestine was excised
carefully and fat and mesenteric attachments
were removed. Everted sacs of 6 cm length were
prepared from the duodenum according to the
method described by Wilson and Wiseman 12.
The distal end of the sac was tied with a ligature
(000 Ethilon Black braided nylon). A ligature
was placed loosely around the proximal end.
After weighing, the empty sac was filled with 0.5
ml of the desired incubation medium (serosal
compartment) using a micro syringe (Gas tight
syringe 1750, Hamilton Company, USA) fitted
with a blunt needle. The filled sacs were slipped
off the needle carefully and the loose ligature on
the proximal end was tightened. After weighing,
the distended sacs were placed in 5 mL of the
same incubation medium contained in a 25 mL
Erlenmeyer (siliconized) flask. After gassing for
1 min with 100% oxygen, the flasks were tightly
stoppered and incubated at 37C for 1 h in a
metabolic shaker bath (Techno India Ltd, Pune,
India) at a frequency of 90-110 shakes/ min. At
the end of the 1 h incubation period, the sacs
were removed from the flasks, blotted and
weighed again. The incubation medium
contained (in mM) NaCl (135), KCl (11) and
CaCl2 (0.04) dissolved in phosphate buffer of the
desired concentration (KH2PO4 and Na2HPO4) at
pH 7.4. Sodium arsenate was added to give a
final concentration of 2 mM.
Estimation of Arsenate: After incubation in a
water bath at 37C with shaking for varying
periods, the sacs were emptied and samples of
fluid from the mucosal and serosal compartments
610
Latha etal.,
were collected. The final Arsenate concentrations

of mucosal and serosal fluids were determined.
The amounts of Arsenate removed from these
fluids were calculated and characterized as
mucosal uptake and serosal uptake
respectively. These were expressed as mol/ gm
tissue wet weight/ hr. Arsenate was estimated by
using Hydride Generation-Atomic Absorption
Spectrophotometer (HG-AAS, GBC Instruments
Pvt. Ltd., Australia, Model-916)13.
Enterocyte Viability Test: Enterocytes were
isolated by mechanically vibrating the emptied
gut sacs at the end of 90 min incubation. The
cells were then incubated with 0.2% trypan blue
solution at 37C to check the viability14. The
sample was taken into consideration only if 80%
or more of mucosal cells excluded the dye
showing their viable nature.
Statistics
Data were expressed as mean SEM. One-way
ANOVA test and Students unpaired t-test was
performed. P < 0.05 was considered to be
significant.
RESULTS
Effect of varying arsenate concentration in the
incubation medium on arsenate transport of
duodenum: From fig 1. it is seen that the
mucosal uptake of Arsenate was increased with
the rise in the initial Arsenate concentration of
the incubation medium, reaching a maximum
value at a medium concentration of 6 mM. From
then on, the serosal uptake remained fairly steady
whereas a slight decline is noted in the mucosal
uptake. The mucosal uptake at this point is about
thrice the value obtained with a concentration of
2 mM. The serosal uptake on the other hand
reached a maximum value at 6 mM and showed a
mild insignificant decline at higher initial
Arsenate concentration in the medium.
Effect of varying Arsenate concentration in
the medium on Arsenate transport of ileum:
From Fig 2, it is seen that the mucosal uptake of
Arsenate increased with a rise in the initial

Arsenate concentration of the incubation medium
but reaching a maximum value at a medium
concentration of 4mM. From then a decline in
Arsenate uptake was noted at higher initial
concentration in the medium. The mucosal
uptake at this point is about thrice the value
obtained with a concentration of 2mM. The
serosal uptake reached a maximum value at 6mM
followed by a mild insignificant decline. The
serosal and mucosal uptake at different Arsenate
concentrations between duodenum and ileum are
significant except the serosal uptake at 6mM and
8mM Arsenate concentration.
Time study: Fig 3. The serosal and mucosal
Arsenate uptake steadily increases with time. The
serosal uptake when expressed as a percentage
over mucosal uptake tends to remain at 37% and
decreases to about 22% at the end of 60 minutes.
At the end of 90 min of incubation, the serosal
uptake becomes 31% .The drained sacs at the end
of 90 minutes were tested for viability using
trypan blue test ; 80% - 90% of the mucosal cells
showed an exclusion of the stain showing their
viable nature.
Gender and Segmental Study
The Arsenate transport in various segments of
intestine namely duodenum, jejunum and ileum
was studied successively in male and female
mice and are represented by Fig 4 and 5. It is
apparent that Arsenate transport is maximal in
the proximal segment for males whereas the
terminal segment of the female mice gave the
maximal Arsenate transport. It tended to plunge
to a low value in the second segment of both the
groups. From there a steady increase was noted
in successive segments of the intestine. Both
serosal and mucosal uptakes were elevated in
male when compared to female mice except
mucosal uptake in ileum.
611
Latha etal.,
Fig.1: Effect of varying arsenate concentration in the medium on arsenate transport by proximal intestinal sac
Fig.2: Effect of varying arsenate concentration in the medium on arsenate transport by distal intestinal sac
Fig.3: Time course of arsenate transport by everted proximal intestinal sacs of male mice
612
Latha etal.,
Fig.4: gender and segmental study of serosal arsenate uptake in evereted mice intestinal sac
Fig.5: Gender and segmental study of mucosal arsenate uptake in the everted mouse intestinal sacs
DISCUSSION
Our results clearly showed that both the serosal

and mucosal uptakes of Arsenate in both
duodenum and ileum were found to be linearly
increased at varying Arsenate concentrations in
the incubation medium. The observations of this
study goes in agreement with the previous
studies where the
intestinal absorption of
Arsenate in chick by means of in-situ ligated
duodenal loop technique showed that, it is
rapidly and completely absorbed (80-95%) from
the lumen at the Arsenate concentration up to 5
mM, declining to about 50% absorption at

50mM. The total mucosal accumulation of
Arsenate increases in a linear logarithmic fashion
from 0.05 to 5 mM 14,15.
In KB oral epidermoid carcinoma cells, the
cytotoxicity and intracellular accumulation of
Arsenate were dramatically enhanced, equaling
those of As III when cells were grown in
phosphate -free medium and Arsenate uptake
was dose-dependently inhibited by phosphate 16.
The previous studies have shown that the cellular
Latha etal.,
613
uptake of arsenite is four times higher than for

Arsenate17. In KB (cell line) oral epidermal
carcinoma cells, the uptake of arsenite were
linearly
correlated
with
extracellular
concentrations suggesting that arsenite uptake is
accomplished through simple diffusion through
aquaglyceroporins 10.
The absorption of Arsenate by the rat small
intestine was investigated, where intestinal
absorption of Arsenate appeared to be carried out
by a saturable transport process. The inorganic
phosphate (Pi) produces a pronounced decrease
in the intestinal absorption of As V. These results
suggest that Arsenate shares a common transport
system with phosphate which is an active
secondary carrier mediated system depending on
Na+ and H+ gradients 18.
Studies by Borowitz and Granrud 19 showed that
Pi absorption appeared to decrease with age, as
the 12 week old rabbits contained Na-Pi cotransporters only in duodenum and proximal
jejunum compared with young animals. The
significant increase in Arsenate uptake in
duodenum could be attributed to the increase in
the number of Na-Pi co-transporters in the
duodenum.
REFERENCES
We are thankful to Dr. S. Govindaraju, Professor

of statistics for helping us in doing the statistical
analysis.
1. Tamaki S & Frankenberger WT Jr.

Environmental biochemistry of arsenic. Rev
Environ Contam Toxicol. 1992;124: 79-110.
2. WHO (1981). Environmental health criteria.
18: World Health Organization, Switzerland.
3. ATSDR (2000). Toxicological Profile for
Arsenic (update). Atlanta, GA, Agency for
Toxic Substances and Disease Registry, U.S.
Department of Health & Human Services.
4. Rahman MM, Chowdhury UK, Mukherjee
SC, Mondal BK, Paul K, Lodh D et al.
Chronic arsenic toxicity in Bangladesh and
West Bengal, India--a review and
Commentary. J Toxicol Clin Toxicol. 2001;
39(7):683-700.
5. Borgoo JM, Vicent P, Venturino H, Infante
A. Arsenic in the drinking water of the city of
Antofagasta: epidemiological and clinical
study before and after the installation of a
treatment plant. Environ Health Perspect.
1977; 19:103-5
6. Cebrian ME, Albores A, Aguilar M, Blakely
E. Chronic arsenic poisoning in the north of
Mexico. Hum Toxicol 1983; 2(1): 121-33.
7. De Sastre MSR, Varillas A, Krischbaum P.
Arsenic content in water in the north west
area of Argentina, arsenic in the environment
and its incidence on health (International
seminar proceedings), 1992, Universidad de
Chile (Santiago). pp 91-99
8. Tseng WP. Effects and dose-response
relationships of skin cancer and blackfoot
disease with arsenic. Environ. Health
Perspect.1977; 19, 109119
9. Newsletter of Indian Training Network and
All India Institute of Hygiene and Public
Health, Kolkata. 1996;3:112.
10. Wang C, Chen G, Jiang J, Qiu L, Hosoi K,
Yao C. Aquaglyceroporins are involved in
uptake of arsenite into murine gastrointestinal
tissues. J Med Invest 2009; 56(Suppl):34346.
Latha etal.,
CONCLUSION
The difference in the As V uptake by both sexes

of mice observed in our study correlates well
with the previous studies 20 indicating a clear sex
difference in phosphate transport of duodenum in
mice. Since As V is transported by the same
transport protein, it is natural to see such
difference in As V transport also. Hence, Na-Pi
co-transporters in the duodenum may be used for
further pharmaceutical exploration with a view to
reduce the arsenic toxicity in population at risk.
ACKNOWLEDGEMENT
614
11. Calatayud M, Gimeno J, Vlez D, Devesa V,

Montoro R. Characterization of the intestinal
absorption of arsenate, monomethylarsonic
acid, and dimethylarsinic acid using the
Caco-2 cell line. Chem. Res. Toxicol 2010;
23 (3): 547556.
12. Wilson TH , Wiseman G. The use of sacs of
everted small intestine for the study of
transference of substances from the mucosal
to the serosal surface J Physiol
1954;123:116-25.
13. Jimenez de Blas O, Vicente Gonzalez S,
Seisdedos Rodriquez R & Hernandez
Mendez J. Determination and speciation of
arsenic in human urine by ion-exchange
chromatography / flow injection analysis
with hydride generation / atomic absorption
spectroscopy. J AOAC 1994; 77(2): 441-5.
14. Karsenty G, Lacour B, Ulmann A, Pierandrei
& Drueke T. Early effects of vitamin D
metabolites on phosphate fluxes in isolated
rat enterocytes. Am J Physiol 1985; 248(1 Pt
1): G40-5.
15. Fullmer CS & Wasserman RH. Intestinal
absorption of arsenate in the chick. Environ
Res 1985; 36(1): 206-17.
16. Huang RN & Lee TC. Cellular uptake of
trivalent arsenite and pentavalent arsenate in
KB cells cultured in phosphate-free medium.
Toxicol Appl Pharmacol 1996; 136(2): 2439.
17. Bertolero F, Pozzi G, Sabbioni E, Saffiotti E.
Cellular uptake and metabolic reduction of
pentavalent and trivalent arsenic as
determinants
of
cytotoxicity
and
morphological
transformation.
Carcinogenesis 1987; 8(6): 803-8.
18. GonzalezMJ, AguilarMV, Martinez-Para
MC. Gastrointestinal absorption of inorganic
arsenic (V) : The effect of concentrations and
interactions with phophate and dichromate.
Vet Hum Toxicol 1995; 37(2): 131-36.
19. Borowitz SM, Granrud GS. Ontogeny of
intestinal phosphate absorption in rabbits.
Am J Physiol 1992; 262 (5 Pt 1): G847-53.
20. Mary PL & Rao JP. Phenol red inhibits

uptake of phosphate by the everted gut sacs
of mice. Kobe J Med Sci 2002; 48(1-2): 5962.
615
Latha etal.,
DOI: 10.5958/j.2319-5886.2.3.108

&
Health Sciences
st

Research article
Coden: IJMRHS
Copyright @2013
th
ISSN: 2319-5886
IN VITRO ANTIOXIDANT ACTIVITY ASSESSMENT ON ALCOHOLIC EXTRACT OF

CYANOBACTERIA CULTURES FROM SPIRULINA PLATENSIS
*Senthilkumaran Jagadeesh J1, Jaiganesh K2, Somasundaram G3
1
Deparetment of Pharmacology, Sree Balaji Medical College and Hospital, Tamil Nadu, India
Department of Physiology, Mahatma Gandhi Medical College and Research Institute Pillaiyarkuppam,
Pondicherry, India.
3
Department of Pharmacology, Mahatma Gandhi Medical College and Research Institute
Pillaiyarkuppam, Pondicherry, India.
2
*Corresponding author email:jagadeesh.j@gmail.com

ABSTRACT
The antioxidant supplementation such as vitamin C, E, A and beta carotene etc, has proven to prevent
the process of ageing caused by free radicals. Antioxidants either prevent free radical production or
counteract the impeding damage by doing so they are involved in the protection and prevention of
cellular damage which is the common pathway for cancer, aging and much disease. The cyanobacteria is
a blue green micro algae believed to be a rich antioxidant source, found in abundance in Spirulina
platensis is evaluated for antioxidant potential by modern in vitro techniques. METHODS the alcoholic
extract of cyanobacteria is studied by in vitro Lipid Peroxidation inhibition assay (LPO) , The nitric
oxide (NO)free radical scavenging activity and the determination of the DPPH (one, 1-diphenyl-2picrylhydrazil) radical scavenging activity in concentrations which ranged from 1.95 g/mg to 500 g/mg
in a geometric progression using spectrophotometer Results: The IC-50 % inhibition value of
cyanobacteria by LPO is 102.70 mcg/ml, DPPH is 63.35 mcg/ml and by NO is 8.80 mcg/ml
CONCLUSION The alcoholic extract of corynebacterium culture from Spirulina platensis exhibited
potent NO free radical scavenging activity with mild activity on DPPH and LPO inhibition assay.
Keywords: Spirulina platensis, Cynabacteria, Anitoxidant activity
INTRODUCTION
In vitro studies in biomedical research is far

more advanced, these studies permits a more
detailed, reproducible and convenient analysis
that can be done with whole organism1. Day to
day free radicals production in the body causes
oxidative damage to the system which are
responsible for various diseases. These damages
are counteracted often by exogenous substance

or nutrients which are now identified as
antioxidants. These antioxidants scavenges free
radicals thus prevent damage to the body2.
Hence there is a great need to identify the rich
exogenous source of antioxidant which would
prevent and repair damage caused by free
616
Jagadeesh etal.,
radicals3. Cyanobacterium is a blue green algae

found in aquatic and terrestrial habitat. In the
present study the antioxidant potential of
cyanobacterial isolates from Spirulina platensis
has been evaluated against the in vitro
scavenging of the NO radical activity, Lipid
Peroxidation (LPO) inhibition and the 1Diphenyl-2-Picrylhydrazil (DPPH) inhibition
antioxidant assays.
This study was done on February 2013 at the

Department of Pharmacology and physiology at
Mahatma Gandhi Medical College and research
Institute Pillaiyarkuppam, Pondicherry, India.
Spirulina platensis were collected from
department
of
marine
biotechnology,
Bharathidasan university, Tiruchirapalli. The
cyanobacteria isolates were extracted from mid
log phase culture of S.platensis, 1gm weight of
cyanobacteria were homogenized with 75%
alcohol using mortar and pestle. The clear extract
was separated and dried using flash vacuum
concentrator. The alcoholic extract was then
subjected to in vitro scavenging of the NO
radical activity4, Lipid Peroxidation (LPO)
inhibition5 and 1-Diphenyl-2-Picrylhydrazil
(DPPH) inhibition antioxidant assays6 analyzed
by spectrophotometer.
Statistical Analysis
All the in vitro experiments were performed in
triplicate. The IC50 values were calculated by
linear regression analysis using an experimental
software multiplex
IC50 = 63.35mcg/ml
Fig.1: DPPH-1,1-diphenyl-2-picrylhydrazil radical
% inhibition of Cynobacterium
IC-50 = 102.70 mcg/ml

Fig.2: LPO - Lipid peroxidation % inhibition of
Cynobacterium
RESULTS
In the present study, the percentage inhibition of

the cyanobacteria extract was analyzed by the in
vitro Lipid Peroxidation inhibition assay (LPO) ,
The nitric oxide (NO)free radical scavenging
activity and by the determination of the DPPH
(one,
1-diphenyl-2-picrylhydrazil)
radical
scavenging activity in various concentrations
which ranged from 1.95 g/mg to 500 g/mg in a
geometric progression
IC-50 = 8.80 mcg/ml.

Fig.3: NO - Nitric oxide %
Cynobacterium
inhibition of
617
Jagadeesh etal.,
Table.1: Inhibition % of antioxidant activity

Method Corynebacterium
(IC-50 mcg/ml)
Vitamin-E (IC50 mcg/ml)
LPO
102.70
27
DPPH 63.35
14.4
NO
8.80
18.5
DPPH - 1,1-diphenyl-2-picrylhydrazil radical,
LPO - Lipid peroxidation, NO - Nitric oxide
DISCUSSION
Cyanobacteria
is
a
prokaryotic
and
photosynthetic organism which has recently
caught attraction world wide as a model
organism for research exploration7. In the present
study Spirulina platensis a common source of
cyanobacteria available as food is believed to be
an excellent source of antioxidant activity is
assessed by modern scientists in vitro techniques.
The in vitro analysis by lipid peroxidation assay
and DPPH assay revealed to minor activity when
compared to that of Vitamin E whereas the nitric
oxide free radical scavenging activity is superior
with IC 50 values of 8.80 mcg/ml compared to
that of vitamin E IC-50 values 18.85mcg/ml. The
micro algae by its significant free radical
scavenging action minimize the production of
pro-inflammatory cytokines which would release
from macrophages and spllenocytes by NF-kB
pathway8. the role of free radicals induced
oxidative stress has been implicated in various
pathological conditions and ageing9. The
imbalance in antioxidant and free radical cause
disease conditions by two ways, one by
mitochondrial oxidative stress and second by
inflammatory oxidative condition10. In the recent
years the synthetic flavanoids has come to
limelight as potent antioxidants but still along
with its positive biological effects some
flavanoids also exhibited toxic effects like breast
cancer (oestrogenic effects), liver disease,anemia
and dermatitis11. The cyanobacteria is a
microalgae with rich polyunsaturated fatty acids,
proteins, vitamins and minerals12. The present
study has proved the presence of another rich
biological activity of micro algae cyanobacteria

as a potent antioxidant.
CONCLUSION
For the current generation strenuous life style

and food habits, its doubtless that antioxidant
supplementation is ideal. At the same time it is
important to understand that free radical
generation and counteracting antioxidant
production should be in balance. The availability
of modern synthetic antioxidants could be
deleterious, hence as far as possible dietary
source of antioxidants with reduction in exposure
to free radical source (pesticides, pollution etc,.)
Spirulina for generations has provided such
benefit, the present study has scientifically
proven the micro algae cyanobacteria from
Spirulina has antioxidant activity.
REFERENCES
1. James E Polli. In Vitro Studies are some

times better than conventional human
pharmacokinetic In vivo studies in assessing
bioequivalence of immediate-release solid
oral dosage forms AAPS J.2008; 10(2) 28929
2. Cerutti, P. A.. Oxidant stress and
carcinogenesis. European Journal of Clinical
Investigation, 1991 21:1-11.
3. Pratt, D. E.. Natural antioxidants from plant
material, Phenolic compounds. In: Food and
their effects on health. American Chemical
Society, Washington, (ACS Symposium
Series, 507): 1992; 54-71.
4. Green LC, Wagner DA, Glogowski J,
Skipper PL, Wishnok JS, Tan nenbaum SR.
Analysis of the nitrate in biological fluids.
Anal Bio chem. 1982; 126:131-35
5. Ohkawa H, Ohishi N, Yagi K. An assay on
the lipid peroxides in animal tissues by the
thio
babituric
acid
reaction.
Anal
Biochem.1979; 95: 346- 51.
6. Koleva I, Van Beek TA, Linssen JPH, DeGroot A, Evstatieva LN. Screening of plant
extracts for their antioxidant activities: A
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comparative study on three testing methods.

Phytochemical Analysis.2002; 13: 8-17
7. Yu B, Wang J, Suter PM, Russell RM,
Grusak MA, Wang Y, et al. Spirulina is an
effective dietary source of zeaxanthin to
humans". British Journal of Nutrition
2012 108 (4): 61119
8. Ku CS, Pham TX, Park Y, Kim B, Shin M,
Kang I, Lee J. Edible blue-green algae reduce
the production of pro-inflammatory cytokines
by inhibiting NF-B pathway in macrophages
and splenocytes. Biochimica et Biophysica
Acta (BBA) - General Subjects 2013.
9. Dalle-Donne I, Rossi R, Colombo R,
Giustarini D and Milzani A. Biomarkers of
oxidative damage in human disease. Clin
Chem. 2006;52:601-23.
10. Harman D. Aging- A theory based on freeradical and radiation-chemistry. J Gerontol.
1956 11: 298-300
11. Valko M, Morris H, Mazur M, Rapta P and
Bilton RF. Oxygen free radical generating
mechanisms in the colon: Do the
semiquinones of Vitamin K play a role in the
aetiology of colon cancer? Biochim Biophys
Acta. 2001;1527:161-66
12. Christaki E, Florou-Paneri P, Bonos E.
Microalgae: A novel ingredient in
nutrition". International Journal of Food
Sciences and Nutrition 2011;62 (8): 79499
619
Jagadeesh etal.,
DOI: 10.5958/j.2319-5886.2.3.109

&
Health Sciences
Research article
Coden: IJMRHS Copyright @2013

ISSN: 2319-5886
STUDY OF PREHILAR BRANCHES OF SPLENIC ARTERY BY DISSECTION METHOD

*Veeramalla Linga Swamy1, Suseelamma D2, Jadhav Surekha D1, Zambare Balbhim R1, Potuganti
Mithil N1, Krishna Chaitanya2.
1
2
Department of Anatomy, P D V V P Fs Medical College, Ahmednagar, Maharashtra, India

Department of Anatomy, K I M S, Sreepuram, Narketpally,Nalgonda,AndhraPradesh,India.
*Correspondence email:viveklingaswamy06@yahoo.com
ABSTRACT
Background: Spleen is a large lymphoid organ which is supplied by splenic artery. It is commonly
injured in blunt abdominal trauma. The treatment of splenic injury has been changed in the past 2-3
decades. Depending upon the severity of injury, either total or partial splenectomy is done. However,
total splenectomy is avoided to prevent the risk of postsplenectomy sepsis or avoid the resulting
decrease in immunity and hematological functions. Now a days partial splenectomy is preferred, as it is
followed by rapid regeneration of splenic tissue. During partial splenectomy, segmental branch of that
affected segment is ligated. These branches show the variation as they originate from the prehilar
branches of splenic artery which shows variation. Aim: Aim of this work was to observe the prehilar
branches of splenic artery and polar arteries supplying spleen. Methods and Material: Sixty spleens of
unknown sex were studied by dissection method. All spleens were cleaned by washing them under tap
water. Then, we carefully removed the unwanted tissue around the splenic artery and its branches.
Results: Splenic artery was divided into two primary branches at hilum in 66%, in 17% into three, and
in 17% into four terminal branches. Superior and inferior polar arteries were present in 41.6 %, and
25% spleen respectively and both were present in 16.6%.Conclusions: Precise knowledge of prehilars
and polar arteries is very important because now a days, during surgery, surgeons try to remove only
affected tissue. Findings reported by us will be helpful to surgeons while performing surgical procedures
on spleen.
Keywords: Spleen, Prehilar branches, Splenic artery, Partial splenectomy, Polar arteries.
INTRODUCTION
Spleen is a large lymphoid organ which is

supplied by splenic artery. Near the hilum,
usually it divides into two i. e. superior and
inferior terminal branches. However, in some
cases, middle terminal artery may be present.
Lingaswamy etal.,
The terminal branches further undergo several

subdivisions which are the segmental intrasplenic
branches. The branches of the splenic artery
entering into spleen through the poles of the
spleen are called polar arteries i.e. superior and
620
inferior polar arteries1. The human spleen is

divided into two or three main arterial segments
and these segments are separated by a definite
avascular plane2. Each main segment is
subdivided, usually in to two to four secondary
segments which are not constant. The
architecture of these segments and the avascular
planes between them are very variable3. Also,
the polar segments are separated from the
remaining of the organ by constant avascular
plane1, 4.
Spleen is commonly injured in blunt abdominal
trauma or during automobile or bicycling
accident, in which internal hemorrhage occurs.
Depending upon the severity of injury, either
total or partial splenectomy is done. However,
total splenectomy is avoided to prevent the risk
of postsplenectomy sepsis or avoid the resulting
decrease in immunity and hematological
functions. Now a days partial splenectomy is
preferred, as it is followed by rapid regeneration
of splenic tissue. During partial splenectomy,
segmental branch of that affected segment is
ligated. These branches show the variation as
they originate from the prehilar branches of
splenic artery which shows variation 2, 5,6.
Kehila and Abderrahim did the partial
splenectomy in cases of major trauma, after the
splenic vessel ligation7. While performing
splenic surgery, precise knowledge of the
terminal and polar ateries is essential because
avascular plane of the spleen and its segmental
pattern which mainly depends on the number of
terminal and poar arteries6. The aim of this study
was to accurately identify the pre hilar branches
of the splenic artery and polar arteries supplying
spleen. The aim of this work was to observe the
prehilar branches of splenic artery and polar
arteries supplying spleen.
Department of KIMS, Narketpally, Nalgonda,

Andhra Pradesh, India. This study was approved
by the Institutional Ethical Committee of KIMS.
For this study, sixty spleens of either sex were
studied by dissection method. Spleens which
showed perisplenic adhesions or marked
pathological changes were rejected.
Spleens were removed from abdomen by
detaching their various attachments and by
cutting the splenic vessels of minimum 5-6 cm in
length. All spleens were cleaned by washing
them under tap water. Then, we carefully
removed the unwanted tissue around the splenic
artery and its branches. We dissected all spleens
carefully along the course of the branches of the
splenic artery. Then, we noted the number of
terminal and the polar branches of the splenic
artery and their variations were noted.
RESULT
Splenic artery was originated from the celiac

trunk in all spleens. Splenic artery was divided
into two primary i.e. superior and inferior
branches, at the hilum in 66% (40 out of 60). In
17% (10 out of 60) spleen it was divided into
three, superior, middle and inferior branches
(Fig. 1) and in 17% (10 out of 60) spleen it was
divided into four terminal branches (Fig.2). All
polar arteries were originated from splenic trunk.
In 50 spleens polar arteries were present (83.3%).
Superior polar arteries were present in 41.6 %
(25), inferior polar in 25% (15) and both (Fig. 3)
were present in 16.6% (10). According to this
branching pattern the spleen had two lobes, when
there were superior and inferior branches and
three lobes, when there were superior, middle
and inferior terminal branches. Additional lobes
were present, when there were polar arteries.
Thus the splenic lobes could vary from 2-4 in
numbers.
The present work was carried out in the Anatomy
Lingaswamy etal.,
621
DISCUSSION
Fig.1: Showing Three branches of Splenic artery

and two polar arteries (i.e. superior and inferior)*
Fig.2: Showing Four branches of splenic

artery*
Figure.3: Showing Superior and Inferior

polar arteries*
*SA-Splenic Artery, SPB-Superior Primary
Branch,IPB-Inferior Primary Branch,MPBMiddle Primary Branch IPoA-Inferior Polar
Artery, SPoA-Superior Polar Artery
Lingaswamy etal.,
Spleen is highly vascular and friable organ and

therefore it cannot be sutured6. However, it has
two or three main arterial segments and these
segments are separated by a definite avascular
plane2, 4, 8, 9. Each main segment is subdivided,
usually in to four less secondary segments which
are not constant. The architecture of these
segments and the avascular planes between them
are very variable. Also, the polar segments are
separated from the remaining of the organ by
constant avascular plane. During the partial
splenectomy, a particular segmental branch of
the injured tissue is ligated. So, precise
knowledge of the prehilar and further branches of
the splenic artery is essential while performing
splenectomy1, 4.
In the present study, the primary and the polar
branches of the splenic artery (Fig. 1, 2, 3) were
observed. Two primary branches were found in
66%, three in 17% and four in 17% four. When
we compared our results (Table 1) with earlier
studies done by various workers, we obtained
different percentage pattern. We observed four
primary branches of the splenic artery (Fig. 2) in
17% but no other researcher observed four
branches (Table 1).
We observed superior and inferior polar branches
of the spleen which were arising from the
splenic artery. Incidence of superior polar artery
was in accordance with Chaware et al 10, but we
observed lower percentage of inferior polar
artery. Superior and inferior polar arteries were
present in 16.6 % spleen which was on the higher
side when compared with other researches
percentage obtained by them (Table 1). Prehilar
branching of splenic artery and polar arteries of
spleen shows variations which may be because of
differences in sample size and population from
where spleens were obtained. This knowledge of
vascular pattern helps in identification of lobes or
segmentation in spleen, which is important in
partial splenectomy and surgical repair of spleen
injuries11.
622
Table 1- Showing the comparison of percentage of division of splenic artery studied by different
authors.
Author
Percentage of Division of Splenic Artery
Two
Three Four
Polar Arteries
Superior Inferior Both
2
Gupta et.al (1976)
84
16
8
Michail (1979 )
77
23
12
50
12
4
Katritisis et al. (1982)
85.7
14.3
3
Chakravarthi. et al (2003)
56
27
10
Chaware et al. (2012 )
85
14.42
40.53
54.06
11
Londe et al. (2013)
90
10
33
54
12.6
Present study
66
17
17
41.6
25
16.6
CONCLUSION
In the present study, we observed that splenic

artery divides into two to four branches at hilum.
Also it gives polar branches to it. These branches
divide the spleen into definite arterial segments
which are separated by an avascular plane. It is
interesting to note down that, we observed four
primary branches of splenic artery in 17% but no
other researcher observed four branches. Precise
knowledge of prehilars and polar arteries is very
important because nowadays, during surgery,
surgeons are trying to remove only affected
tissue. Finding reported by us will be helpful to
the surgeons while performing surgical
procedures on spleen.
REFERENCES
1. Susan standring. In: Grays Anatomy 40th

edition.Churchill Livinstone, 2008; 1193.
2. Gupta CD, Gupta SC, Arora AK, Jeya SP.
Arterial segments in the human spleen. J.
anat. 1976; 121: 613-16.
3. Chakravarty S, Shamal, S, Pandey SK.
Avascular Zone in the Human Spleen A
Sex Difference. J Anat. Soc. India.2003: 52;
150-51.
4. Katritsis, E, Parashos A, Papadopoulos N.
Arterial segmentation of the human spleen by
postmortem angiograms and corrosion casts.
Lingaswamy etal.,
Journal of Vascular Diseases.1982; 33: 72027.

5. Cullingford GL, Watkins DN, Watts AD,
Mallon DF. Severe late postsplenectomy
infection. Br J Surg 1991; 78:71621.
6. Cooper MJ, Williamson RCN. Splenectomy;
indications, hazards and alternatives. Br. Jr.
Surg. 1984; 71: 173-80.
7. Kehila M, Abderrrahim, T. Partial
splenectomy which required ligation of the
splenic vessels Appropos of 40 cases.
Annales Chirr. 1993; 47: 433-35.
8. Michel NA. The variational anatomy of the
spleen and the splenic artery. Am. Jr. Anat.
1942; 70: 21-72.
9. Melnikoff A. Uber extra organ und
intraorgan liegende Geffass kollateralen.
Archiv Klin Chir.1923; 125: 120-43.
10. Chavare PN, Belsare SM, Kulkarni R, Pandit
SV, Ughade JM. Anatomy of the Segmental
Branches of the Splenic Artery. JCDR. 2012;
6 :336-38.
11. Londhe SR. Study of vascular pattern in
human spleen by corrosion cast method. Al
Ameen J Med Sci. 2013; 6: 167-69.
623
DOI: 10.5958/j.2319-5886.2.3.110

&
Health Sciences
st

Research article
Coden: IJMRHS
th
Copyright @2013
ISSN: 2319-5886
HEPATITIS B AND C VIRAL INFECTIONS AMONG BLOOD DONORS AT BAHIR DAR,

ETHIOPIA
*Abate Assefa1, Biniam Mathewos2, Abebe Alemu3, Zelalem Addis2, Meseret Alem2, Mucheye
Gizachew1
1
Department of Medical Microbiology, 2Department of Immunology and Molecular Biology,

3
Department of Medical Parasitology, School of Biomedical and Laboratory Sciences, College of
Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
*Corresponding Author e-mail: abezew@gmail.com
ABSTRACT
Background: Hepatitis B virus and hepatitis C virus are the major public health problem world wide
that affects billions of people. In the study area, there is lack of available information on this issue.
Aims: the aim of the study was to assess seroprevalence of HBV and HCV among blood donors.
Method: A cross sectional study was conducted among blood donors attending Bahir Dar Felege Hiwot
Referral Hospital. Five milliliters of blood samples were collected and screened with ELISA tests for
detecting hepatitis B surface antigen and anti hepatitis C virus antibody. Chi-squared and fisher exact
tests were used for the analytical assessment. Results: Out of 2384 blood donors examined, 108(4.5%)
were seropositive for at least one of the two Hepatitis diseases markers of which five were co-infected.
The prevalence of HBs Ag and anti-HVC was 4.11% and 0.63%, respectively. High seropositivity of
HBV (8.3%) was noticed among >45 years old and HBV positivity were significantly higher among
males (4.4%) than females (1.45%) (P =0.04). HCV prevalence was significantly higher in >45 years
old (2.5%, p=0.01). Conclusion: The prevalence of HBV and HCV were high and the diseases were still
major health problem in elderly people in the study area, which alerts public health intervention as soon
as possible.
Keywords: Ethiopia, Hepatitis B virus, Hepatitis C virus, Seroprevalence, Blood donors
INTRODUCTION
Hepatitis B virus (HBV) and hepatitis C virus

(HCV) are the main causes of serious liver
disease, like hepatocellular carcinoma (HCC)
and life threatening disorders of liver disease.
Globally there are about 360 million chronic
HBV infections and 5.7 million HBV related
cases.1 Cirrhosis, liver failure and hepatocellular

carcinoma develop in 1540% of chronically
infected hepatitis B virus individuals.2
Approximately 3% of the world's population was
infected with HCV and of which higher
prevalence reaching 4% to 6% found in some
624
Abate et al.,
parts of Africa. Over 80% persists as HCV

chronic infection. 3 In Ethiopia, report indicated
that the prevalence of anti-HCV among patients
with chronic hepatitis, cirrhosis of the liver and
HCC was found to be 21%, 36% and 46%
respectively. Furthermore, about 50% of healthy
individuals had at least one of HBV marker by
the age of 2024 years old.4, 5
Blood transfusion, vertical transmission during
pregnancy and sexual or nosocomial exposure
are risk factors for HCV and HBV infections and
they remain considerable risk for transfusion
transmissible infection.6 Even though now a days
the risk of blood transfusion transmitted
infections is lower than ever, providing safe
blood
products
remains
subjected
to
contamination with many human pathogens.7
Hepatitis B virus and HCV are the major concern
of blood transmissible infections because of their
prolonged viraemia and carrier state.8 Hepatitis B
virus is highly contagious and relatively easy to
transmit from infected individual to another by
blood transfusion and in tropics there is
relatively higher HBV prevalence.9, 10
Accurate estimate of the prevalence of these
viruses in a particular population is very
important to monitor the safety of the blood
supply and plan effective preventive strategies.
In Ethiopia, especially in the study area there is
lack of available information on this issue.
Therefore, the aim of the study was to assess the
seroprevalence of HBV and HCV infections
among blood donors in two years at Bahir Dar
Felege Hiwot Referral hospital, North West
Ethiopia.
METHODS
Ethics: The study was reviewed and approved

by the Institutional Review Board of the School
of Biomedical and Laboratory Sciences,
University of Gondar and official permission was
obtained from Bahir Dar Felege Hiwot Referral
Hospital. Written informed consent was taken
from each prospective blood donor recruited into
the study. Individual records was coded and
accessed only by the research team.The collected

data of the study were analyzed anonymously.
Individuals confirmed as seropositive for one or
both of HBV and HCV infections were evaluated
and managed according to the current standard of
care in Ethiopia.
Study Design and Area: A cross sectional study
was conducted at the blood bank of Bahir Dar
Felege Hiwot Referral Hospital from January
2007 to December 2008. The hospital is located
at Bahir Dar town in North West Ethiopia. The
Hospital is a referral hospital serving a
population of about 7 million people in North
West Ethiopia.
Sample Size and Sampling Technique: All
(2384) blood donors who donated blood at Bahir
Dar Felege Hiwot Referral Hospital between
January 2007 and December 2008 were eligible
for this study. Individuals who satisfy the blood
donation screenings criteria: age between 18 and
65 years, body weight over 50 kg, normal body
temperature, hemoglobin level, blood pressure
and absence of signs of an acute infections, no
history of infectious and chronic diseases, donate
blood. Those blood donors who did not meet the
criteria for blood donation stated in the inclusion
criteria were excluded from the study. Therefore,
all study participants recruited in this study were
without any history of known or noticeable risk
factor.
Data collection and processing: Data from
each study participant were collected after taking
written informed consent.
Structured
questionnaire based interviews of the study
participant was used to collect necessary sociodemographic information of blood donors,
gender, age, and residence, types of donor,
occupation and marital status. From each blood
donor about 5ml of blood sample was collected
from the collection bag using a sterile capped
tube. The blood was centrifuged and plasma was
separated and stored at -20 oC until tested.
Samples were brought to room temperature prior
to testing. All blood samples were screened for
Hepatitis B surface antigen (HBsAg) and anti625
Abate et al.,
HCV antibodies based on established screening

procedures
according
to
manufacturers
recommendations at the Blood bank laboratory
of Bahir Dar Felege Hiwot Referral Hospital.
Each plasma sample was tested for HBsAg and
anti-HCV antibodies using enzyme linked
immunosorbent assay (ELISA) kits. For each
run of the test internal quality controls was
performed.
Statistical Analysis: Data were manually
cleaned, categorized, coded and entered and
analyzed using SPSS version 20 software. A

descriptive analysis was used to determine
demographic characteristics and seroprevalence
of HBV and HCV. The differences in
proportions of risk factors associated with the
seroprevalence of HBV and HCV were tested by
the chi-square test and fisher exact test.
Significance levels were chosen at 0.05 level
with a two-tailed test.
RESULTS
Table1: Sociodemographic characteristics of blood donors recruited at Bahir Dar
Frequency
(%)
Variable
Male
Female
18-25
26-35
Age in years
36-45
>45
Urban
Residence
Rural
Volunteer
Type of blood Commercial
donor
Relative of recipient
Daily laborer
Farmer
Occupation
Student
Employed
Merchant
House wife
Single
Marital
status
Married
Gender
2177
207
1233
758
272
121
1632
752
3
1356
1025
1356
739
132
78
18
61
1514
870
91.3
8.7
51.7
31.8
11.4
5.0
68.4
31.6
0.1
56.9
43.0
56.9
31.0
5.5
3.2
0.7
2.5
63.5
36.5
Table.2: Serological test result blood donors recruited at Bahir Dar
Variables
HBsAg
Anti HCV antibody
Co-infected
Total
Status
Positive
Negative
Positive
Negative
Positive
Positive
Negative
Number (%)
98 (4.11)
2286(95.9)
15(0.63)
2369(99.4)
5(4.6)
108(4.5)
2276(95.5)
626
Abate et al.,
significant (2=4.074, p=0.04). However, there

was no statistical significant association between
seroprevalence of HCV infection and gender
(p=0.63). The highest seroprevalence of HCV
was observed in blood donors aged greater than
45 years old (2.5%) followed by 18-25 years old
donors (0.8%). The difference of seroprevalence
of HCV among different age groups was
statistically significant (2 =10.57, P=0.01).
However, age distribution and seroprevalence of
HBV was not significantly associated (2 =7.3,
P=0.06). In case of occupation of the blood
donors the higher seroprevalence of HBV was
observed in day laborers 62(4.6%) followed by
farmers 28(3.8%), and students 4 (3.1%).
Nonetheless, this differences in the proportion of
the seroprevalence of HBV among donors
occupations was not statistically significant (2
=2.67, P=0.75).
Moreover, there was no
significant association between residence, types
of blood donors, occupations and marital status
and seroprevalence of HBV and HCV (table 3).
The seroprevalence rate of HBV infection was

4.11% where 95 (4.4%) out of 2177 males and
three (1.45%) of the 207 females were having
HBV infections. The overall prevalence rate of
HCV infection in the study was 0.63% and all
were males. The highest seroprevalence of HBV
was observed in blood donors whose age is
greater than 45years old (8.3%) followed by 3645 years old donors 14 (5.9%). Similarly, high
seroprevalence of HCV 3(2.5%) was observed in
age groups of whose age is greater than 45.
Among blood donors whose residence was from
urban, the seroprevalence of HBV and HCV
were 68(4.1%) and 10(0.6%) respectively.
Among 1356 commercial blood donors,
62(4.6%) for HBV and 10(0.7%) for HCV were
seropositive (table 3).
Associated risk factors for seropositivity of
HBV and HCV: The difference in proportions
of seroprevalence of HBV 95(4.4%) in male
versus 3(1.4%) in female was statistically
Table 3. Seroprevalence and associated risk factors of HBV and HCV among blood donors
HBV sero-positive
2
P
HCV sero-positive
Varia N (%)
ble
Yes (%) No (%)
Yes(%) No (%)
Male
Female
18-25
Age in 26-35
year
36-45
>45
Reside Urban
nce
Rural
Types
Volunteer
of
Commercial
blood
Relative of
Donor recipient
Occup Day laborer
ation
Farmer
Student
Employed
Merchant
Housewife
Marit
Single
al
Married
Gende
r
2177(91.3)
207 (8.7)
1233(51.7)
758 (31.8)
272 (11.4)
121 (5)
1632(68.4)
752 (31.6)
3 (0.1)
1356(56.9)
1025 (43)
1356(56.9)
739 (31)
132 (5.5)
78 (3.2)
18 (0.7)
61 (2.5)
1514(63.5)
870 (36.5)
95 (4.4)
3 (1.45)
43(3.5)
31(4.1)
14(5.9)
10(8.3)
68(4.1)
30(3.4)
0(00)
62(4.6)
36(3.5)
2082(95.6)
204 (98.6)
1190(96.5)
727(95.9)
256(94.1)
111(91.7)
1564(95.9)
722(96.6)
3(100)
1294(95.4)
989(96.5)
62(4.6) 1294(95.4)
28(3.8) 711(96.2)
4(3.1)
128(96.9)
2(2.6)
76(97.4)
0(00)
18(100)
2(3.2)
59(96.8)
64(4.2) 1450(95.8)
34(4.0) 832(96)
4.07
0.04
7.3
0.06
0.04
0.83
1.79
0.41
2.67
0.75
0.06
0.80
15 (0.7)
0.00
10(0.8)
1(0.2)
1(0.4)
3(2.5)
10(0.6)
5(0.66)
0(00)
10(0.7)
5(0.5)
2162(99.3)
207(100)
1223(99.1)
757(99.8)
10.57
271(99.6)
118(95.5)
1622(99.4)
747(99.4)
3(100)
1346(99.3)
0.6
1020(99.50
10(0.7)
5(0.7)
0
0
0
0
11(0.7)
4(0.5)
1346(99.3)
734(99.3)
132(100)
78(100)
18(100)
61(100)
1503(99.3)
866(99.9)
P
0.63
0.01
1.00
0.74
2.11
0.83
0.27
0.6
status
627
Abate et al.,
DISCUSSION
In the present study, 4.11% and 0.63% of

subjects were positive for HBsAg and HCV
antibodies respectively. A higher (6%)
seropositivity of HBV was reported previously
from Ethiopia, December to February 2003.11
This implies that there has been appreciable
change in the seroprevalence of HBV in the area
over the last decade. When the finding of the
current study were compared with results
reported from similar study subjects of other
countries, a comparable prevalence of HBV has
been reported such as in Kosovo (4.2%) 12 and
Egypt (4.3%).13 The prevalence of HBsAg in this
study was lower than the findings reported from
Nigeria ((14.3%).14 Nevertheless, this finding is
higher than the seroprevalence rate reported in
India (2.2%), 15 Turkey (1.38% and 1.8%), 16, 17
Libya (1.28%),18 and Iran (1.07%).19 The sociocultural difference may be the possible factors
for these differences.
Regarding HCV infection, the overall prevalence
of HCV antibody was 0.63% in the present
study, which was significantly lower as
compared with reports from Tunisia (1.4 %),20
Egypt (2.7%),13 and Senegal (0.8%).21 The
seroprevalence of anti-HCV antibodies was
comparable with findings reported among blood
donors from Libya (0.69%)17 and India (0.7%), 15
but this result was higher as compared with
findings in Kosovo (0.3%)12 and Turkey
(0.35%). 16 In the present study, despite the large
number of female donors tested (207 subjects),
none was positive for HCV antibodies.
Regarding co-infection, low prevalence was
found (five cases out of 2384 blood donors
tested) which indicated that HBV positive donors
in this study do not have much risk of exposure
to HCV infection. The hepatitis co-infection
pattern was higher among blood donors whose
age is greater than 45 years compared to other
age categories.
The demographic analysis of the 98 blood donors
who were seropositive for the HBV infections
indicated that it had significantly higher in males

(4.4%) as compared to females (1.45%)
(p=0.04). A recent study which was done in
Southwest Ethiopia showed a statistically
significant difference in the seroprevalence of the
HBsAg between the male and the female donors
(2.5% in males vs. 0.8% in females).22 Similarly,
in the general population from Addis Ababa
Ethiopia the prevalence of HBsAg in males
(8.6%) was significantly higher than in females
(4.6%). 5 We found an increasing prevalence of
HBsAg and anti HCV antibody with the
increasing age of blood donors, which was
similar to the findings, anti-hepatitis B core
antibody, of the study which was reported from
Vietnam,25 this might be due to as age increases
the risk of exposure to HBV and HCV increases
in parallel. Therefore, this finding can suggest
that HBV and HCV infections may enhance
susceptibility to gender due to risk-behavior
differences by gender as well as the raising in
age with time.
Other important findings we observed were high
occurrence of HBsAg (4.6%) and HCV
antibodies (0.74%) among commercial blood
donors and HBsAg (4.6%) in daily laborers as
compared to other type of blood donors. The
prevalence of HBsAg and HCV among the
commercial blood donors in this study is
comparable with figures reported from previous
studies in Gondar Ethiopia24 but lower than result
reported from Nigeria in which the prevalence of
HBV was11%.25 In the present study only three
volunteers (0.1%) donated blood in the study
period. This implies that there is lack of
knowledge or awareness about blood donation in
the community.
CONCLUSIONS
The seroprevalence of HBV and HCV were

considerably high among blood donors in our
study and male blood donors are more affected
628
Abate et al.,
than females. Moreover, the seroprevalence of

HBV and HCV were higher among elderly
people and commercial blood donors. Since there
were significant proportions of HBsAg and HCV
antibody positive blood donors, strict blood
donor selection should be considered. Promoting
and awareness creation to the community
regarding volunteer donation of blood should be
considered rather than using commercial blood
donors.Therefore, health care associated risk
prevention and health education among
population should be considered as the main
interventions that might help reducing the spread
of these blood-borne infections.
ACKNOWLEDGEMENT
We gratefully acknowledge all participants,

staffs of the Blood Bank of Bahir Dar, Felege
Hiwot Referral Hospital for participating in and
facilitation of this study. Our great thanks go to
University of Gondar for providing the grant of
this research.
REFERENCES
1. Schmidt M, Nbling CM, Scheiblauer H,

Chudy M, Walch LA, Seifried E et al. The
anti-HBc screening of blood donors: a
comparison of nine anti-HBc tests. Vox
Sanguinis. 2006; 91:23743.
2. Lok AS. Chronic hepatitis B. N Eng J Med.
2002; 346:16823.
3. Darwish MA, Raouf TA, Rushdy P,
Constantine NT, Rao MR, Edelman R. Risk
factors associated with a high seroprevalence
of hepatitis C virus infection in Egyptian
blood donors. Am J Trop Med Hyg. 1993;
49:4407.
4. Tsega E. Epidemiology, prevention and
Treatment of viral hepatitis with emphasis on
new developments. Review article. Ethiop
Med J. 2000; 38:13141.
5. Abebe A, Nokes DJ, Dejene A, Enquselassie
F, Messele T, Cutts FT. Seroepidemiology of
hepatitis B virus in Addis Ababa, Ethiopia:
transmission patterns and vaccine control.

Epidemiol. Infect. 2003; 131:75770.
6. Schreiber GB, Busch MP, Kleinman SH and
Korelitz JJ. The risk of transfusion
transmitted viral infections. N Engl J Med.
1996; 334:168590.
7. Bihl F, Castelli D, Marincola F, Dodd RY,
Brander
C.
Transfusion-transmitted
infections. Journal of Translational Medicine.
2007;5:25
8. UNAIDS. Report on the global AIDS
epidemic. Geneva, Joint United Nations
program on HIV/AIDS. 2002.
9. Fasola FA, Otegbayo IA. Post-transfusion
hepatitis in sickle cell anaemia; retrospectiveprospective analysis. Nig J Clin Pract. 2002;
5:1619.
10. Drosten C, Nippraschk T, Manegold C,
Meisel H, Brixner V, Roth WK, et al.
Prevalence of Hepatitis B virus DNA in antiHBC
positive/H
BsAg- negative sera correlates with HCV but
not HIV serostatus. J Clin Virol. 2004;
29:5968.
11. Gelaw B, Mengistu Y. The prevalence of
HBV, HCV and Malaria parasites among
blood donors in Amahra and Tigray regional
states. Ethiop.J.Health Dev. 2007; 22:37.
12. Hajrullah F, Skender T. Prevalence of HBV
and HCV among blood donors in Kosovo.
Virology Journal. 2009; 6:21.
13. El-Gilany AH, El-Fedawy S. Bloodborne
infections among student voluntary blood
donors in Mansoura University, Egypt. East
Mediterr Health J. 2006; 12:7428.
14. Uneke CJ, Ogbu O, Inyama PU, Anyanwu
GI, Njoku MO, Idoko JH. Prevalence of
hepatitis-B surface antigen among blood
donors and human immunodeficiency virusinfected patients in Jos, Nigeria. Mem Inst
Oswaldo Cruz, Rio de Janeiro. 2005;
100:1316.
15. Pahuja S, Sharma M, Baitha B, Jain M.
Prevalence and trends of markers of HBV,
HCV and HIV in New Delhi blood donors a
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hospital based study. India, Jph J infec Dis.

2007; 60:38991.
16. Afsar I, Gungor S, Sener AG, Yurtsever SG.
The prevalence of HBV, HCV and HIV
infections among blood donors in Izmir,
Turkey. Indian J Med Microbiol. 2008;
26:28889.
17. Karaosmanoglu HK, Aydin OA, Sandikci S,
Yamanlar ER, Nazlican O. Seroprevalence of
hepatitis B: Do blood donors represent the
general population? J Infect Dev Ctries.
2012; 6:18183.
18. Khmmaj A, Habas E, Azabi M. Frequency of
hepatitis B, C, and HIV viruses among blood
donors in Libya. Libyan J Med. 2010;
5:5333.
19. Ghavanini AA, Sabri MR. Hepatitis B
surface antigen and anti-hepatitis C
antibodies among blood donors in the Islamic
Republic of Iran. East Mediterr Health J.
200; 6:111416.
20. Mastouri M, Ben othman S, Bouzgarrou N,
Hassin M, Pozzetto B, Trabelsi A, et al .
Virus de l'hpatite C chez les donneurs de
sang dans la rgion de Monastir (Tunisie):
Prvalence et facteurs de risque. MHA. 2004;
16:5962.
21. Etard JF, Colbachini P, Dromigny JA.
Hepatitis C antibodies among blood donors
in Senegal. Emerg Infect Dis. 2001; 9:1492
93.
22. Alemeshet Y, Fissehaye A, Alima H.
Hepatitis B and C Viruses Infections and
Their
Association
With
Human
Immunodeficiency Virus: A Cross-Sectional
Study Among Blood Donors In Ethiopia.
Ethiop J Health Sci. 2011; 21:6775.
23. Viet L, Lan NTN, Ty PX, Bjorkvoll B, Hoel
H, Gutteberg T, et al. Prevalence of hepatitis
B and hepatitis C virus infections in potential
blood donors in rural Vietnam. Indian J Med
Res. 2012; 136:7484.
24. Rahlenbeck SI, Yohannes G, Molla K,
Reifen R, Assefa A. Infection with HIV,
syphilis and hepatitis B in Ethiopia: a survey
in blood donors. Int J STD AIDS. 1997;

8:2614.
25. Oronsaye FE, Oronsaye JI. Prevalence of
HIV-positives and hepatitis B surface
antigen-positives among donors in the
University of Benin Teaching Hospital,
Nigeria. Trop Doct. 2004; 34:15960.
630
Abate et al.,
DOI: 10.5958/j.2319-5886.2.3.044

&
Health Sciences
th

Review article
Coden: IJMRHS
rd
Copyright @2013
ISSN: 2319-5886
Accepted: 29th Apr 2013
PERIODONTAL DISEASE AND SYSTEMIC HEALTH: A REVIEW

Ameet Mani1, Shubhangi Mani2, Neha Kaur Sodhi3, Raju Anarthe4, Rajiv Saini4
1
Reader, 3PG student, 4Senior lecturer, Dept. of Periodontology and Oral Implantology, 2Reader, Dept.
Of Orthodontics, Rural Dental College, PIMS, Loni.
*Corresponding author E-mail: nea4sam@gmail.com
ABSTRACT
Periodontal disease is an infectious disease. However, certain factors like environmental, physical, social
and host stresses may affect and modify disease expression. Certain systemic disorders affecting the
neutrophil, monocyte/macrophage and lymphocyte function result in altered production or activity of
host inflammatory mediators which may affect the initiation and progression of gingivitis and
periodontitis. Evidence has also shed light on the converse side of the relationship between systemic
health and oral health i.e. the potential effects of periodontal disease on a wide range of organ systems
like the cardiovascular, endocrine, reproductive and the respiratory system. This article sheds light on
the effects of periodontal disease on different systemic conditions, the possible mechanisms involved
and the role of periodontal therapy on systemic outcomes.
Keywords: Periodontal medicine, Systemic diseases, Pregnancy, Osteoporosis, Alzheimers.
INTRODUCTION
The periodontal diseases are a family of chronic

inflammatory diseases, including gingivitis and
Periodontitis, which involve the periodontium
(the bone and soft tissues that support the teeth in
the jaws). Gingivitis, an inflammation of the
gums, is a very common condition. Periodontitis
is also common and is a more severe condition
that causes loss of bone that supports the teeth.
Research over the last 30 years has described the
role of bacterial plaque in causing periodontal
disease, and controlled clinical trials suggest that
periodontal treatment (such as scaling and
cleaning of teeth) usually stabilizes the condition
and improves periodontal health.1,2 Thus,

periodontal management, with an emphasis on
bacterial plaque control, is an evidence-based
intervention with established health outcomes.
A wide range of systemic conditions, ranging
from the hormonal changes of puberty and
pregnancy to disease entities involving immune
dysfunction, connective tissue disease and
malignancy, have manifestations in the mouth.
The dynamics of the periodontium are a product
of its circulation, hormonal changes and immune
response mechanisms. Changes in systemic
health that affect any of these factors can be
631
Ameet et al.,
Int J Med Res Health Sci. 2013;2(3);631-635
reflected in changes in periodontal health. While

this is well known, the main concerns of
periodontics remain focused on oral causes, oral
risks and oral remedies. Indeed, dental education,
management and research have been limited by
the dualistic notion that the oral cavity is separate
from the rest of the body.
However, recent research suggests that
periodontal diseases can influence systemic
health through two mechanisms. The first is
direct, by the pathogenic action of dental plaque
bacteria that enter the bloodstream (bacteraemia).
The second is indirect, by the distant effect of
inflammatory mediators, such as cytokines,
prostaglandins and serum antibodies that are
induced by periodontal disease.
Focal infection theory : In1900s, William
Hunter, a British physician, first developed the
idea that oral microorganisms were responsible
for a wide range of systemic conditions that were
not easily recognized as being infectious in
nature.3 He claimed that gingivitis, periodontitis
and carious teeth with periapical infections as
foci of infection. Hence, he advocated the
removal of teeth with sepsis to improve the
overall systemic health.
Fig1:The most significant areas identified to date

to have a suspected oral-systemic connections
Current era: The Focal infection theory fell into

dispute in the 1950s when widespread extraction
failed to reduce or eliminate the systemic
conditions. The theory, had been based on very
little, if any, scientific evidence. In 1989, a
landmark publication ushered, Mattila and
colleagues4 reported that when patients presented
to the emergency room with a cardiac arrest, they
were more likely to have a high index of oral
disease, which included gingivitis, periodontitis,
and endodontic problems.
[Fig.1]
A. Periodontal diseases and cardiovascular
diseases:
The risk factors for cardiovascular diseases
(CVDs)
such
as
hypertension,
hypercholesterolaemia, and smoking do not
account for all the variations in the incidence and
severity of CVD. Certain unrecognised risk
factors may also play a role in the pathogenesis
of the same. Bacteraemia as caused due to eating,
flossing, brushing is a particular risk for people
with damaged heart valves, prosthetic valves and
various cardiac anomalies that may develop
bacterial endocarditis if bacterial vegetations
form in parts of the heart with turbulent blood
flow. Another possible mechanism is that
periodontal
infection
can
cause
hypercoagulability state by an increase in
fibrinogen, C- reactive protein, white blood cell
count and von Willebrand factor causing
ischemic heart disease. Clinical studies have
found that people with periodontal diseases are
almost twice as likely to suffer from coronary
artery disease as those without periodontal
diseases.5 CVD and periodontal diseases may
share a similar causative pathway through a
hyper-inflammatory
phenotype.
Moreover,
periodontal diseases may also exacerbate existing
heart conditions. Patients at risk for infective
endocarditis may require antibiotic cover prior to
dental procedures likely to cause bacteraemias.
People diagnosed with acute cerebrovascular
ischaemia, particularly non-haemorrhagic stroke,
632
Ameet et al.,
were found to be more likely to have a

periodontal infection.6 Here, the periodontal
disease may contribute directly to the
pathogenesis by providing a persistent bacterial
challenge to the arterial endothelium resulting in
the narrowing of the vessel lumen.
B. Periodontal disease and diabetes mellitus:
Although the relationship between periodontal
disease, inflammation and overall health has
been suspected, numerous studies are providing
more comprehensive evidence for this link. In
this context, diabetes predisposes oral tissues to
greater periodontal destruction but several
studies have now identified that periodontal
disease leads to poor glycemic control. It was
hence predicted that there exists a two-way
relationship between periodontal disease and
diabetes mellitus.7 Although diabetes is a
metabolic disorder and periodontitis is an
infectious disease, the relationship occurs
through the ability of both conditions to induce
an inflammatory response
leading to the production of inflammatory
mediators. These proinflammatory cytokines
such as Interleukin-6 impair the glucosestimulated release of insulin from the pancreas.
Infact, periodontal disease has been considered
as the sixth complication of diabetes.8
Periodontal
therapy, on the other hand, can stabilize glycemic
control and reduce complications from unstable
blood sugar levels.
C. Periodontal
disease
and
adverse
pregnancy outcomes:
The adverse pregnancy outcomes associated with
periodontal disease are pre term low birth
(PTLBW) weight and pre-eclampsia. Preterm
low birth weight is a significant cause of infant
morbidity and mortality. There are a number of
risk factors associated with adverse pregnancy
outcomes including low socioeconomic status,
the mothers age, race, multiple births, smoking,
alcohol abuse, systemic maternal infection,
genitourinary tract infections and bacterial
vaginosis.9 It was hypothesized that periodontal
infection which serves as a reservoir for

anaerobic bacteria and inflammatory mediators
may be a potential threat to the foetal -placental
unit by provoking an inflammatory response
producing prostaglandin production resulting in
pre term labor.10 Offenbacher and colleagues
found that the risk of PLBW was 7.5-fold greater
if the mother had evidence of periodontal disease
compared to those with no periodontal disease.11
These findings support the theory that bloodborne bacteria can reach the foetus and thus
induce an immunologic response.
Pre-eclampsia is a common disorder of
pregnancy that is characterized by hypertension
and the presence of protein in the urine. A casecontrol study carried out in Colombia showed a
consistent link between exposure to periodontal
disease and subgingival pathogens and preeclampsia in pregnant women.12
D. Periodontal disease and pulmonary
infections.
To date there have been two systematic reviews,
both of which concluded that there was evidence
of an association between periodontal disease
and two respiratory conditions, bacterial
pneumonia and chronic obstructive pulmonary
disease (COPD). Bacterial pneumonia is either
community-acquired or hospital acquired
(nosocomial). The main cause of the first type is
aspiration of bacteria that reside on the oropharynx. Oropharynx being the primary site of
potential respiratory pathogens can lead to
pneumonia with subsequent aspiration. The most
important established risk factor for COPD is a
history of prolonged cigarette smoking. There
were some reports of an association between
COPD and poor oral hygiene.13
Though
conflicting results have been obtained regarding
the link between periodontitis and acute
respiratory infections, it can be concluded that
improvement of oral hygiene and professional
oral health care are vital for reducing the
occurrence of pneumonia among high-risk
elderly adults especially those living in nursing
homes.
633
Ameet et al.,
E. Periodontal disease and

rheumatoid
arthritis:
The two diseases share some basic
characteristics: both, diseased gingival tissues
and joints affected by rheumatoid arthritis (RA)
produce similar cytokines and growth factors
that promote the dissolution of bone, a problem
shared by both diseases. This suggests the
presence of a common underlying inflammatory
mechanism. Levels of antiCCP antibodies (anticyclic citrullinated peptide antibody) are
considerably higher in RA patients with
periodontal disease,
Suggesting that periodontitis may
be a
contributing factor in the pathogenesis of RA.
Coincidently, P.gingivalis produces an enzyme
that
induces
citrullination
of
various
14,15
autoantigens.
F. Periodontal disease and osteoporosis:
The common factor between osteoporosis and
periodontal disease is the excessive osteoclastic
activity and bone loss initiated through chronic
inflammatory conditions. This shared chronic
inflammatory
response
may
predispose
individuals with periodontitis to osteoporosis.
Estrogen modulates cytokines that regulate bone
metabolism and the host inflammatory response.
Lack of estrogen increases the number of
osteoclasts causing an imbalance in bone
metabolism and a reduction in bone density.
Periodontitis also activates the inflammatory
response
and
the
osteoclasts.
Many
investigations have found a significant
correlation between periodontal disease and
estrogen deficiency. These two risk factors,
working together, can induce osteoporosis.16
Further, risk factors such as age, smoking and
estrogen deficiency are the same for both,
periodontal disease and osteoporosis.
G. Periodontal disease and
Alzheimers
disease:
There is evidence that periodontal disease may
be a risk factor for dementia through the bacterial
and viral infections commonly found in
periodontal disease. Periodontal infections may
result in elevating the systemic inflammatory

response which in turn may contribute to existing
brain and vascular pathologies that would
impact brain function.17 Hence, timely treatment
of periodontal infections that reduces oral
pathogens would also reduce the risk of systemic
infection.
CONCLUSION
The emerging field of periodontal medicine

offers new insights into the concept of the oral
cavity as one system interconnected with the
whole human body. The potential link between
periodontitis and systemic conditions is now the
focus for a wide range of research around the
world. The potential for periodontal pathogens to
gain access to the systemic circulation through
ulcerated pocket walls is certainly present.
Biologically plausible mechanisms support the
role of periodontal infection in these conditions,
but periodontal infection should not be presented
as the cause but a readily modifiable risk factor
for such systemic diseases and conditions.
However, in order to show cause between
periodontal disease and systemic condition, the
need for more studies is greatly advocated by
physicians and dentists. In general, larger and
more randomized populations and better
controlled clinical trials will be required to
substantiate the correlation of periodontal disease
to these systemic conditions.
REFERENCES
1. Axelsson P, Lindhe J. Effect of controlled

oral hygiene procedures on caries and
periodontal disease in adults. J Clin
Periodontol. 1978; 5: 133-51.
2. Suomi JD, Greene JC, Vermillion JR. The
effect of controlled oral hygiene procedures
on the progression of periodontal disease in
adults: Results after third and final year. J
Periodontol 1971; 42: 152-60.
3. Newman HN. Focal infection. J Dent
Res.1996;75:1912-19
634
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4. Mattila KJ, Pussinen PJ, Paju S. Dental

infections and cardiovascular diseases: A
review. J Periodontol. 2005;76:208588.
5. Beck J, Garcia R, Heiss G, Vokonas PS,
Offenbacher S. Periodontal disease and
cardiovascular disease. J Periodontol. 1996;
67:112337.
6. Genco RJ, Le H. The role of systemic
conditions and disorders in periodontal
disease. Periodontol 2000 1993;2:98-116.
7. Matthews DC. The relationship between
diabetes and periodontal disease. J Can Dent
Assoc.2002;68:16164.
8. Le H. Periodontal Disease. The sixth
complication of diabetes mellitus. Diabetes
Care 1993; 16: 32934.
9. Scannapieco FA. Systemic effects of
periodontal diseases. Dent. Clin. North Am.,
2005;49, 533-50
10. Collins JG, Windley HW, Arnold RR,
Offenbacher S. Effects of a Porphyromonas
gingivalis infection on inflammatory
mediator response and pregnancy outcome in
hamsters. Infect. Immun, 1994; 62, 4356-61.
11. Offenbacher S, Katz V, Fertik G, Collins J,
Boyd D, Maynor G. et al. Periodontal
infection as a possible risk factor for preterm
low birth weight. J.Periodontol., 1996;
67:1103-13.
12. Contreras A, Herrera JA, Soto JE, Arce RM,
Jaramillo A, Botero JE. Periodontitis is
associated with preeclampsia in pregnant
women. J.Periodontol., 2006;77, 182-88.
13. Scannapieco
FA,
Papandonatos
GD,
Dunford, RG. Associations between oral
conditions and respiratory disease in a
national
sample
survey
population.
Ann.Periodontol.1998; 3:251-56.
14. Mercado F. Marshall RI, Klestov AC,
Bartold PM. Is there a relationship between
rheumatoid arthritis and periodontal disease?
J Clin Periodonto. 2000;27:267- 72
15. Berthelot JM, LeGoff B. Rheumatoid

arthritis and periodontal disease. Joint Bone
Spine. 2010;77:537-41
16. Kim J, Amar S. Periodontal disease and
systemic
conditions:
a
bidirectional
relationship. Odontology.2006; 94(1):10-21
17. Watts A, Crimmin EM, Gatz M.
Inflammation as a potential mediator for the
association between periodontal disease and
Alzheimers
disease.
Neuropsychiatric
Disease and Treatment. 2008;4(5):865-76
635
Ameet et al.,
DOI: 10.5958/j.2319-5886.2.3.045

&
Health Sciences
Review article
MEASURING INAPPROPRIATE PRESCRIPTIONS
OVERVIEW OF VARIOUS SCREENING TOOLS
IN
GERIATRIC
POPULATION:
*Karandikar Yogita S1, Dhande Priti P2

1
Assistant Professor, 2Associate Professor, Department of Pharmacology, Bharati Vidyapeeth Deemed

University Medical College, Dhankawadi, Pune 411043
*Corresponding author email:karandikar_yogita@yahoo.com
ABSTRACT
In this era of growing research, a plethora of effective therapeutic agents has been made available to
treat chronic disorders that often accompany advancing age. However, medications often act as a
double edge sword. Instead of medications being a cure, frequently they cause problems. Thus,
managing the medications in elderly patients is truly a challenge for all health professionals. The use of
a medication is generally considered appropriate if the expected benefits of the medication outweigh the
potential risks. Because older adults are more sensitive to any adverse effects of medications, various
lists of medications have been created for guiding clinicians to avoid certain drugs in elderly people.
Various screening tools based on explicit (criterion-based) or implicit (judgment-based) prescribing
indicators have been devised to detect inappropriate prescriptions of such drugs. The purpose of this
evidence-based guideline or screening tool is to improve medication management practices for older
adults. In this review we have discussed various methods of finding out inappropriate prescriptions in
the elderly which can be referred by health care providers of this population. Therefore, regular
application of such inappropriate prescription screening tools should hypothetically reduce the
prevalence of adverse drug events, their related morbidity and health care cost.
Keywords: Geriatric population, inappropriate prescriptions, explicit criteria, implicit criteria
BACKGROUND
Rational drug therapy, though important at all

ages, becomes more relevant in elderly. Aging is
defined as progressive, universal decline first in
functional reserve and then in function that
occurs in organisms over time.1 According to the
WHO, generally accepted age is >65 years. Older
people often experience multiple co-morbidities
and are prescribed multiple medications thereby
increasing the risk of adverse drug events, drug
drug, and drugdisease and drug-food
Yogita etal.,
interactions.2 This risk is heightened by agerelated physiological changes, which influence

pharmacokinetics and pharmacodynamics.3,4
Adverse effects of medications and drug related
problems can have profound medical, safety and
economic consequences for older adults. As
population demographics is changing worldwide
and there has been a rise in the aging population,
inappropriate prescribing in older people is
becoming a global health care concern. The
636
percentage of elderly in the world population is

expected to increase rapidly from 9.5 in1995 to
20.7 in 2050 to 30.5 in 2150.5
The purpose of this review is to discuss the
various methods of finding out Inappropriate
Prescriptions (IP) in elderly, so that appropriate
measures can be taken. The intentions of the
criteria are to improve the selection of
prescription drugs by clinicians; educate them on
proper drug usage; and evaluate health outcomes, cost, and utilization data.
Inappropriate prescriptions: It is defined as
overuse of drugs; irrational choice of drugs
and/or under use of appropriate drugs.6 IP
encompasses the use of medicines that pose more
risk than benefit, particularly where safer
alternatives exist. IP also includes under
prescribing (failure to prescribe drugs that are
needed), overprescribing (prescribing more drugs
than are clinically needed) and misprescribing
(incorrectly prescribing a drug that is needed).7
IP is associated with many risk factors like older
age, polypharmacy and multiple attending
physicians and pharmacists. IP also relates to
increased morbidity, mortality and health care
cost, largely because of an increased prevalence
of adverse drug events (ADEs).
Measures of appropriateness of prescribing:
Appropriateness of prescribing can be assessed
by a process or outcome measures that are
explicit (criterion-based) or implicit (judgmentbased).8 They assess whether the prescription
accords with accepted standardsthey are direct
measures of performance.
Explicit indicators: Explicit indicators are
usually developed from published reviews,
expert opinions, and consensus techniques.
Expert opinion is usually needed in geriatric
medicine because evidence-based aspects of
treatments are frequently absent.9 These
measures are usually drug-orientated or diseaseoriented, and can be applied with little or no
clinical judgment. Explicit criteria used with
prescription data alone or with clinical data are
commonly used to detect inappropriate
Yogita etal.,
prescribing. Most criteria constitute a floor of

quality below which no patient should go.
However all these Explicit criteria were followed
drawbacks:
1) These criteria might not take into account all
factors that define high quality health care for the
individual.10
2) They generally do not address the burden of
co morbid disease11 and patients preferences.
3) Consensus approaches have little evidence of
validity and reliability.
4) The inclusion of some drugs in the list is
subject to controversy, and there is insufficient
evidence to support inclusion of several drugs.
5) This approach sometimes identifies
appropriate prescribing as inappropriate (poor
specificity).
Implicit indicators: In implicit approaches, a
clinician uses information from the patient and
published work to make judgments about
appropriateness.12 The focus is usually on the
patient rather than on drugs or diseases. These
approaches are potentially the most sensitive and
can account for patients preferences.
Drawbacks: 1) They are time-consuming 2)
These depend on the users knowledge and
attitudes
3) They have low reliability.
There is no ideal measure, but the strengths and
weaknesses of both approaches should be
considered.
Tools to measure inappropriate prescriptions
(IP): Due to the potentially serious consequences
of inappropriate prescribing, researchers have
designed screening tools (implicit and explicit
criteria) to detect prescribing that is potentially
inappropriate. Theoretically, the routine clinical
application of these explicit or implicit
prescribing criteria could represent an
inexpensive and time efficient method to
optimize prescribing practice. However, IP
criteria must be sensitive, specific, have good
inter-rater reliability and incorporate those
medications most commonly associated with
ADEs in older people. To be clinically relevant,
637
use of prescribing appropriateness tools must

translate into positive patient outcomes, such as
reduced rates of ADEs.2 To accurately measure
these outcomes, a reliable method of assessing
the relationship between the administration of a
drug and an adverse clinical event is required.
IPs can be identified by several instruments
described
as
below:
I]
Medication
13-16
Appropriateness Index (MAI)
Initially
developed by Dr. Joseph Hanlon and colleagues,
the Medication Appropriateness Index (MAI) is
an implicit tool which measures prescribing
appropriateness according to ten criteria
including indication, effectiveness, dose, correct
directions, practical directions, drug-drug
interactions,
drug-disease
interactions,
duplication, duration, and cost. Out of these ten
criteria, three criteria indication, effectiveness,
and duplication can be used to detect
unnecessary polypharmacy and potentially
inappropriate medications (PIM) prescribing.
Each criterion has operational definitions that
instruct the evaluator to rate a medication as
appropriate, marginally appropriate, or
inappropriate.
The
measure
of
inappropriateness for each medication, ranges
from 0 to 18 that is, a medication that fulfills all
10 criteria of inappropriateness receives the
maximum score of 18. A total score for each
patient is obtained by combining the weighted
MAI scores across all medications.
The major advantages of MAI as a tool to
evaluate PIM prescribing are: i) been tested in
both the inpatient and ambulatory settings, ii)
exhibits excellent intra-rater and inter-rater
reliability, and iii) has face and content validity.
It addresses multiple components of prescribing
appropriateness, and can be applied to every
medication in the context of patient-specific
characteristics. However, the tool is more timeconsuming to complete (~10 minutes per drug
assessed) and does not assess under-prescribing
(untreated indications). Most studies using the
MAI have been performed in a single setting.
Clinical expertise is required to apply some of
Yogita etal.,
the criteria, resulting in variable inter-rater

reliability.
II] Assessment of Underutilization (AOU)17:
Under prescribing can be detected with the
Assessment of Underutilization of Medication.
The assessment needs a health professional to
match a list of chronic medical disorders to the
prescribed medications to establish whether there
is an omission of a needed drug. The evaluator
requires a list of established medical conditions
and concurrent medications to apply one of three
ratings for each condition: A = no omission, B =
marginal omission (patient preference, changing
therapeutic goals, discontinuation of medications
to focus on palliation, or other documented
relative contraindication), and C = omission of
an indicated medication without absolute or
relative contraindication. The outcome measure
is the proportion of patients with at least one
medication omission detected by the AOU.
III] Assessing Care Of the Vulnerable Elder
(ACOVE) project : This quality indicator (QI)
set was developed in the year 2000 by Rand
Healthcare and the UCLA as a comprehensive
method for assessing the quality of care of
vulnerable elderly patients.18 Iterative expert
panel meetings with review of the relevant
evidence were used to generate a set of indicators
to assess the quality of the process of care, rather
than outcomes. It consists of 68 (29%) indicators
refer to medication.19 The ACOVE indicators
have several merits: i) geriatric conditions (eg,
dementia, falls) are included, ii) indicators
pertain to treatment, prevention, monitoring,
education, and documentation, and they
encompass overprescribing, misprescribing, and
under prescribing and iii) most indicators are
applicable to people with advanced dementia and
poor prognosis.20
IV] IPET (Improved Prescribing in the
Elderly Tool) Referred to as the Canadian
Criteria, the IPET consists of a list of the 14
most prevalent prescription errors identified from
a long list of inappropriate prescription instances
drawn up by a panel in 1997 (list by McLeod et
638
al).21 Few of the drawbacks of this criteria are: i)

it only cites 14 instances of inappropriate
prescribing, three of which relate solely to
tricyclic antidepressants (TCAs), which are
infrequently used in todays medical practice, ii)
it can be said as outdated because it recommends
against the use of beta-blockers in heart failure
contrary to current guidelines and published
evidence and iii) it mainly considers
cardiovascular drug use, psychotropic drug use
and Nonsteroidal anti-inflammatory drugs
(NSAID) use and is not organized in any
particular order or structure.22 It has not been as
widely used in published research studies. But
IPET was easier to apply as it had fewer criteria
and hence user friendly.
V] Beers criteria- The best known screening
tool is a Beers criteria which are American
based. Beers criteria were originally developed
in 1991 and contained an explicit list of 30
medicines that should not be used in elderly
patients regardless of diagnosis. This set of
criteria was originally compiled primarily with
nursing home patients in mind.23
The 1991 criteria were updated and expanded in
1997 to make the criteria more applicable to the
general elderly population and to determine the
severity of an adverse advent due to potential
inappropriate prescribing. The guidelines
consisted of two different explicit lists one
considering diagnosis (CD) and one independent
of diagnosis (ID) that define potentially
inappropriate prescribing in the elderly. Doses or
frequencies of administrations that should not be
exceeded were also listed.
The 1997 criteria were revised and updated again
in 200324 and recently in 201225.The new criteria
lists 48 medicines ID and 20 medicines CD, total
68 medicines that should be avoided. The 2003
criteria included new conditions that were not
listed in the previous versions e.g. depression,
anorexia and obesity. Each of these versions of
Beers criteria has been used in several studies to
identify rates of inappropriate prescribing in the
elderly population
Yogita etal.,
Updated 2012 AGS Beers Criteria- The

previous Beers Criteria was updated recently
through the support of the American Geriatrics
Society (AGS) and the work of an
interdisciplinary panel of 11 experts in geriatric
care
and
pharmacotherapy
using
a
comprehensive, systematic review and grading of
the evidence on drug-related problems and
adverse drug events (ADEs) in older adults.25
The 2012 AGS Beers Criteria are intended for
use in all ambulatory and institutional settings of
care for populations aged 65 and older in the
United States..
These updated criteria are supported by Quality
of evidence (High, Moderate, Low) and Strength
of recommendation (Strong, weak and
insufficient). The final updated criteria consist of
53 medications, which are divided into three
categories:
a) PIMs and classes to avoid in older adults
(Independent of diagnosis)- includes 34
potentially inappropriate medications.
b) PIMs and classes to avoid in older adults with
certain diseases and syndromes that the drugs
listed can exacerbate (considering diagnosis)includes 19 drugs.
c) Medications to be used with caution in older
adults- consists of 14 medications.
Beers criteria have some limitations: i) even
being the largest consumers of medication, older
adults are often underrepresented in drug trials.25
ii) it does not address other types of potential
PIMs that are not unique to aging (e.g., dosing of
primarily renally cleared medications, drugdrug
interactions, therapeutic duplication) and iii) it
does not comprehensively address the needs of
individuals receiving palliative and hospice care,
in whom symptom control is often more
important than avoiding the use of PIMs.
VI] Zhan criteria26 The Zhan criteria focus only
on drugs that should generally be avoided in
elders, without consideration of drug dosages,
drug-disease
interactions,
or
drug-drug
combinations. The Zhan criteria categorize drugs
into one of three categories: i) drugs that should
639
always be avoided (e.g., meperidine), ii) drugs

that are rarely appropriate (e.g., diazepam), and
iii) drugs that are sometimes appropriate but
often misused (e.g., amitriptyline). Zhan created
a modified Beers criteria for a study of
potentially inappropriate medication use in
community-dwelling elderly and reported the
results.
VII] STOPP and START 27,28 As a result of the
shortfalls with all the above tools and the
importance of prescribing appropriately, a more
organized, up-to-date tool that also considers the
acts of prescribing omissions has been
developed. This has been given the acronym
STOPP START (screening tool of older
peoples prescriptions [STOPP] and screening
tool to alert doctors to the right treatment
[START]).
STOPP comprises 65 indicators that pertain
primarily to important drugdrug and drug
disease interactions (potentially leading to side
effects such as cognitive decline and falls) and
therapeutic duplication. These criteria are
arranged according to relevant physiological
systems for ease of use, as is the case in most
drug formularies. Each criterion is accompanied
by a concise explanation as to why the
prescription is potentially inappropriate.
START
incorporates
22
evidence-based
indicators of common prescribing omissions.
VIII] Phadkes criteria29,30: Phadke's criteria is
a method to assess a prescription for rationality
as a whole and assign the status as rational,
semirational or irrational to it. It is based on a 30point scale comprising of 20 points for main
drug/s and 10 points for complementary drug/s.
Half of the points (10 and 5 respectively) for
each of these two categories are allotted to the
drug chosen for the condition and remaining half
for the correctness of the dose given, including
route and frequency of administration and the
duration of therapy. If more than two drugs are
needed to be given in a condition, the points
allocated are subdivided accordingly. For
deciding the correctness of the selection of a
Yogita etal.,
drug, its dose, route, frequency of administration

and duration of therapy, the evidence base is
searched and applied. In computing the final
score (out of 30), when necessary, negative
points are assigned as under 30
a. Irrational drug or irrational drug
combination: 5 for each drug/formulation.
b. Unnecessary drug or injection: 5 for each
drug/formulation
c. Hazardous
drugs:
10
for
each
drug/formulation.
d. Unnecessary injection: 5 for each
injection.
CONCLUSION
A screening tool by definition must be shown to
improve outcome. Randomized control trials are
needed to test the true benefit of these tools to
patients in terms of morbidity and mortality, and
also in terms of health resource utilization.
Timely inputs from geriatrician and review by
pharmacists can improve drug appropriateness in
older people but it is not feasible, in most health
services, for a geriatrician to assess all older
patients. Hence such screening tools can be used
in a time-efficient manner by all disciplines
involved in the care of older patients. For the
success of these drug utilization screening tools,
proper training of medical students, doctors,
pharmacists and nursing staff in appropriate
pharmacotherapy for the elderly is very
important.
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1. Caruso LB, Sulliman RA, Fauci EAS.

Geriatric Medicine in Harrisons Principles of
Internal
Medicine 17th edition, Mc Graw
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2. Hamilton HJ, Gallagher PF and Mahony DO.
Inappropriate prescribing and adverse drug
events in older people. BMC Geriatrics
2009, 9:5-10
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3. Sloan RW. Principle of drug therapy in

geriatric patients. Am Fam Physician 1992
Jun; 45(6):270918
4. Petrone K, Katz P. Approaches to
Appropriate Drug Prescribing for the Older
Adult Prim Care Clin Office Pract. 2005;32
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5. Shah RR. Drug development and use in the
elderly: search for the right dose and dosing
regimen. British Journal of Clinical
Pharmacology; 2004:136525.
6. Chaurasia RN, Singh AK, Gambhir IS.
Rational Drug Therapy in Elderly. Journal of
The Indian Academy of Geriatrics, 2005; 2:
82-88
7. Spinewine A, Schmader KE, Barber N,
Hughes C, Lapane KL, Swine C, Hanlon JT.
Appropriate prescribing in elderly people:
how well can it be measured and optimised?
Lancet 2007; 370: 17384
8. Brook RH. Qualitycan we measure it. N
Engl J Med 1977; 296: 17072
9. Campbell SM, Cantrill JA. Consensus
methods in prescribing research. J Clin
Pharm Ther 2001; 26: 514
10. Anderson GM, Beers MH, Kerluke K.
Auditing prescription practice using explicit
criteria and computerized drug benefi t
claims data. J Eval Clin Pract 1997; 3: 283
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11. Boyd CM, Darer J, Boult C, Fried LP, Boult
L, Wu AW. Clinical practice guidelines and
quality of
care for older patients with
multiple comorbid diseases: implications for
pay for performance. JAMA 2005; 294:
71624
12. Page RL, II, Linnebur SA, Bryant LL, Ruscin
JM. Inappropriate prescribing in the
hospitalized
elderly patient: Defining the
problem, evaluation tools and possible
solutions. Clin Interv Aging. 2010; 5: 7587
13. Hanlon JT. A method for assessing drug
therapy appropriateness. J. Clin. Epidemiol
1992;45:104551
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14. Volume CI, Burback LM, Farris KB.

Reassessing the MAI: elderly people's
opinions about medication appropriateness.
Int J Pharm Pract 1999; 7:129-37
15. Samsa GP, Hanlon JT, Schmader KE,
Weinberger M, Clipp EC, Uttech KM et al. A
summated score
for the medication
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including content validity. J Clin Epidemiol
1994; 47(8):891-96
16. Ct I, Farris K, Olson K, Wiens C,
Dieleman S. Assessing the usefulness of the
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in a
community setting Institute of Health
Economics Working Paper 03-01
17. Gallagher PF, OConnor MN, OMahony D.
Prevention of Potentially Inappropriate
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Clinical
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18. Askari M, Wierenga PC, Eslami S, Medlock
S, de Rooij SE. Assessing Quality of Care of
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Appropriateness of quality indicators for
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21. McLeod PJ, Huang AR, Tamblyn RM,
Gayton DC. Defining inappropriate practices
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Development and validation of an improved
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23. Beers MH, Ouslander JG, Rollingher I,

Brooks J, Reuben D, Beck JC. Explicit
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642
DOI: 10.5958/j.2319-5886.2.3.046

&
Health Sciences
th
Received:20 May 2013

Review article
Coden: IJMRHS
rd
Revised: 23
Copyright @2013
Jun 2013
ISSN: 2319-5886
MECHANICAL DEVICES IN PELVIC ORGAN PROLAPSE

*Raja AM1, Seema SR2
1
2
Department of Obstetrics and Gynaecology, Sri Devaraja Urs Medical College, Tamaka, Kolar, India.
Department of Anatomy, ESIC MC&PGIMSR, Bangalore, India.
*Corresponding author email:drrajabellary@yahoo.co.uk

ABSTRACT
Pelvic organ prolapse (POP) is a common condition, up to 50% of women will have some degree of
prolapse and many are asymptomatic. The pessaries are intended to decrease the symptoms of prolapse
and are valid options for patients with stress incontinence. Generally pessaries are safe to use. There are
two types of pessaries, support type and space occupying type. Ring pessary is very commonly used, as
it is easy to insert and remove. Pessaries can make a significant difference in the quality of life of the
patients and even can differ surgical management. As the aging population is increasing in developed
and developing countries, pessaries can be of considerable help in managing the pelvic organ prolapse.
Keywords: Pelvic organ prolapse; vaginal pessary; Urinary incontinence
INTRODUCTION
Pelvic organ prolapse (POP) is a common
condition with an overall incidence of more than
10% in the western world1, the mean prevalence
of pelvic organ prolapse was 19.7% in the Indian
subcontinent2. Up to 50% of women will have
some degree of prolapse and many are
asymptomatic. Prolapse is managed either by
mechanical devices, conservative techniques or
by surgery 3.
The pessaries are aimed to decrease the
symptoms of prolapse or delay the need for
surgery. Pessaries are a valid option for patients
with stress incontinence worsened by strenuous
physical activity 4. Zeelha Abdool et, al., in their
study found, one year after the treatment of
symptomatic POP either with mechanical devices
or surgical methods, women had similar

improvement in both the groups with respect to
urinary, bowel, sexual function, and quality of
life parameters5. However there was little
evidence from controlled trials on which to judge
whether their use is better than no treatment.
There was also insufficient evidence in favour of
one device over another and little evidence to
compare mechanical devices with other forms of
treatment6. Varieties of pessaries are available
for this purpose.
The word pessary comes from a Greek word
pessos meaning an oval stone. Oval stones
were inserted into the uteruses of saddle camels
using a hollow tube, to prevent conception
during long desert voyages. This practice was
643
Raja et al.,
widespread in both Arabia and Turkey and would

have translated to apply to all intrauterine
devices in later periods 7.
Different techniques are being used since many
years to manage prolapse. Egyptians have
documented pessary use, suggesting that
mechanical devices have been used to restore the
prolapse since many years. Hippocrates used the
technique of suspending a woman upside down
using a ladder in an attempt to reduce the
prolapse3. He also described reduction of vaginal
prolapse by placing a halved pomegranate
soaked in wine into the vagina8. Modern day
pessaries are made up of silicone or inert plastic.
Incidence of prolapse: Kumari S et al., in their
screening study found, 7.6% of women had
symptoms of uterine prolapse. Out of which 57%
had not taken any treatment. The prevalence of
prolapse was significantly higher in women with
higher parity. It is difficult to estimate the exact
number of women using pessaries. Only small
numbers of women were using ring pessary9.
Indications for insertion of pessary: The most
common indication for pessary use is POP.
Pessaries are generally offered for women who
desire nonsurgical management, have early-stage
prolapse or patients who are not fit for surgery.
In addition pessaries are better options for
women having stress incontinence, pelvic pain,
and back ache or in the presence of pressure
symptoms due to POP4.
Contraindications: Generally pessaries are safe
to use, patients who are allergic to silicon or
latex should not be recommended to use the
pessaries made of these materials. Their insertion
should be suspended in presence of active
vaginitis and pelvic inflammatory disease. But
can be inserted after the clearance of infection.
May not be recommended for non-compliant
patient4.
Types of pessaries: Pessaries are usually made
of silicone or inert plastic materials and they do
not absorb vaginal secretions and they prevent
odours, In addition silicone pessaries can be
autoclaved. There are two types of pessaries,
support type and space occupying type. In First
and second degree prolapses the supporting type

of pessaries are used and in third degree prolapse
the space occupying type of pessaries are used,
sexual intercourse is not possible in space
occupying type of pessaries.
First degree prolapse is defined as within the
vagina, second degree is up to the introitus; third
degree is decent outside the intoritus2. Ring
pessary is most commonly used pessary in India.
Keisha A Jones et.al. descried many types of
available pessaries. Commonly used ones are
(A) Ring,(B) Ring with diaphragm (C) Hodge
with support, (D) Gehrung, (E) Risser, (F)
Hodge, (G) Smith, (H) Cube, (I) Shaatz, (J)
Rigid Gellhorn, (K) Flexible Gellhorn, (L)
Incontinence ring, (M) Inflatoball, (N) Donut
and (O) Shelf pessary4.
Selection of pessaries: Ring pessary [Fig.1] is
usually the first-line pessary, as it is easy to
insert and remove, the types of ring pessaries are
those with and without support, and those with a
knob for concomitant stress urinary incontinence.
The size of pessary is determined by objective
assessment of the size of the vagina by vaginal
examination. Index and middle fingers are
inserted into the vagina with middle finger
reaching the posterior fornix as high as possible,
and then a point is marked on the base of the
index finger that is performing the vaginal
examination just below the pubic arch. The
distance between the two points is measured and
1 to 1.5 cms is deducted to allow soft tissues.
The outer diameter of the ring should be
approximately equal to this calculated distance 3.
Fig.1: Ring pessary
644
Raja et al.,
Fitting of the ring pessary : The ring needs to

be lubricated and the outer diameter of the ring is
squeezed at the middle so that it assumes the
dumbbell shape and it is inserted into the vagina
in such a way that its leading point is behind the
cervix and the opposite end is behind the pubic
arch. The longitudinal axis of the pessary is kept
in the anteroposterior direction of introitus. After
insertion, pessary is released slowly so that it is
placed in the correct position; the ring is palpated
all along the outer margin to check for pressure
points. The largest pessary that fits comfortably
is to be selected by trial and error basis 3.
Before sending the patient home with pessary in
situ, she is encouraged to pass urine and walk
around to ensure that there is no difficulty in
micturition and no undue pressure symptoms.
Patient is advised to come back to the hospital, if
the pessary is too tight or uncomfortable or if it
drops out and that a different size will be
inserted. The Gellhorn pessary [Fig. 2] is suitable
for more advanced-stage prolapse, or in a patient
who is sexually not active. Removal and
insertion of this pessary is technically more
difficult and cannot be done by the patient
herself and needs trained personnel.
Gellhorn pessary has a concave portion attached
to a stem that faces into the vagina. To insert the
pessary it is folded in half with the use of
lubricant on the leading edge to ease insertion.
Once the pessary is behind the pubic symphysis,
it will expand and rest against the leading edge of
prolapse, forming suction. To remove the
Gellhorn, the knob is grasped and rotated to
release the suction and then the pessary is pulled
downward, folded, and removed.
Fig.2: Gellhorn pessary
Fig.3: Donut pessary
The donut pessary [Fig. 3] can be used to relieve

the symptoms of a cystocele or rectocele and for
second or third-degree uterine prolapse. It is hard
to compress, so is difficult to insert and remove.
The cube pessary is flexible silicone and may be
used in III and IV degree prolapse. The pessary
has a string on one end for easy removal. The
cube pessary is compressed and inserted into the
vagina it forms suction with the leading edge of
prolapse and very often the secretions in the
vagina are trapped resulting in malodorous
discharge. So it is usually used as last option4.
It is difficult to select the ideal pessary as there is
insufficient evidence in favour of one device
over another and little evidence to compare
mechanical devices with other forms of
treatment6.
Complications of pessaries
The newer pessaries are made of inert materials
and need minimal care for maintenance, but can
cause vaginal excoriations, ulcerations and
impaction, vaginal discharge. Rarely they can
cause vaginal actinomycosis, bacterial vaginosis,
vesicovaginal fistula and rectovaginal fistulas.
Unusual complications are cervical entrapment,
small bowel incarceration, hydronephrosis and
vaginal cancer have also been reported.
Neglected pessaries can be removed safely and
sometimes cause fibrosis resulting in regression
of the prolapse. Local application of estrogen and
regular follow up of patients can minimise the
complications associated with pessaries. Pelvic
floor muscle training can reduce severity and
symptoms of prolapse for women with stage I to
III prolapse4, 10.
645
Raja et al.,
Inter course and pessaries: Sexual inter course

is possible with ring pessary. The newer
pessaries made of silicone are soft and user
friendly. Patients can also be taught to remove
them, clean and reinsert them after the
intercourse. How aver the space occupying
passers like Shelf pessary and Gellhorn
peassaries act like a mechanical barrier for sexual
intercourse.
Follow up: Patients who are asymptomatic and
who do not have vaginal wall ulcerations on
examination, the pessary can be changed every 6
months. Peassaries should be removed and not to
be reinserted if there are ulcerations or erosions.
So that they are allowed to heal. If the ulcers are
persistent and non-healing, biopsy is justified to
rule out any underlying pathology. If vaginal
mucosa is atrophic, application of topical
oestrogen cream is to be considered and pessary
is changed more frequently (every 3 to 4
months). Procidentia with non-healing ulcers
may need in patient admission for reduction of
prolapse and vaginal packing; this in turn reduces
the tissue oedema and help in healing of the
ulcers.
There is no reliable data on various issues like
indications for different types of peassaries, who
can fit the pessary, how often it needs to be
changed, should it be used along with hormone
replacement therapy and or pelvic floor
exercises4. Cochrane study did not find any
evidence from randomised controlled trials to
recommend peassaries as a mode of management
for pelvic organ prolapse.
CONCLUSION
Usefulness of Pessaries, for non-surgical

management of prolapse is time tested and is
effective. Minimal investment is needed for
understanding and incorporating the use of
pessaries and can make a significant difference in
the quality of life of the patients and even can
differ surgical management.
Pessaries are effective options for women who
are not fit for surgery, who have not completed
their families or those who decline surgery. Very

few side effects are associated with pessaries
which can be minimised by regular follow up. As
the aging population is increasing even in
developing countries, pessaries can be of
considerable help.
REFERENCES
1. Zoltan Nemeth, Johannes Ott. Complete

recovery of severe postpartum genital
prolapsed after conservative treatment a
case report. International Urogynecology
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2. Godfrey JA Walker, Prasanna Gunasekera.
Pelvic organ prolapse and incontinence in
developing countries: review of prevalence
and risk factors. International Urogynecology
Journal. February 2011; 22 (2): 127-35.
3. Yalanadu Narendra Suresh, Rotimi AK
Jaiyesimi. Mechanical devices for genital
prolapse. Trends in Urology Gynaecology &
Sexual Health. 2009; 14(2): 22-24.
4. Keisha A Jones, Oz Harmanli, MD. Pessary
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5. Zeelha Abdool, Ranee Thakar, Abdul H.
Sultan, Reeba S. Oliver. Prospective
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DOI: 10.5958/j.2319-5886.2.3.047

&
Health Sciences
www.ijmrhs.com
st
Coden: IJMRHS
Copyright @2013
th
ISSN: 2319-5886
Review article
EXCITOTOXINS: THEIR ROLE IN HEALTH AND DISEASE

*Tadvi NA1, Qureshi SA2, Naveen Kumar T3, Shareef SM4, Naidu CDM5, Venkata Rao Y6
1
Associate Professor, 4Assistant Professor, 5Professor, 6Professor and Head of Department,

Pharmacology, Kamineni Institute of Medical Sciences, Narketpally.
2
Post Graduate Student, Physiology, Kamineni Institute of Medical Sciences, Narketpally.
3
Associate Professor, Pharmacology, Apollo Institute of Medical Sciences, Hyderabad.
*Corresponding author email: nasertadvi@yahoo.co.uk
ABSTRACT
Background : Excitotoxins are a class of substances usually amino acids or their derivatives that
normally act as neurotransmitters in brain but in excessive amounts lead to over excitation of neurons
leading to a state of exhaustion & death. Over 70 types of excitotoxins have been identified so far and
many have a free access to our body in form of taste enhancing food additives like monosodium
glutamate, aspartame, sodium casienate etc. They have been implicated for the development of a wide
variety of neurological disorders like Alzheimer`s disease, Huntingtons disease, Parkinsons disease,
amyotrophic lateral sclerosis, and even for early ageing. Objective: The purpose of this review is to sort
out truth about extent of involvement of excitotoxins in neurodegeneration from the massive propaganda
against them wherein they have been implicated in almost all disorders of unknown etiology. Method:
A comprehensive search strategy was developed incorporating both the peer reviewed, non peer
reviewed literature and electronic databases like Medline. These were scrutinized and relevant research
papers were examined. Conclusion : There is considerable evidence based research pertaining to the
neurodegenerative effect of excitotoxins to the human brain. Yet the autonomous food regulating bodies
like FDA refuse to recognize the immediate and long term danger to the public caused by the use of
such excitotoxic food additives. Thus only means of protecting oneself from such type of neurological
damage is to consume only unprocessed, fresh, whole, organic foodstuffs.
Keywords: Excitotoxins,Health Disease
INTRODUCTION & OVERVIEW
Excitotoxins refer to those substances which are
capable of inducing excitotoxicity. The term
excitotoxicity was coined by Dr. John Olney in
the year 1969 to describe the neuronal injury that
results from presence of excess glutamate in
brain.1 The histological appearance of
excitotoxicity includes massive swelling of

neuronal bodies & dendrites consistent with
somatodendritic location of glutamate receptors
and excitatory synapses2. They have been
implicated in wide variety of neurological
disorders like Alzheimers disease3 , Parkinsons
648
Tadvi NA et al.,
disease4 , Amyotropic lateral sclerosis5 ,

olivopontocerebellar degeneration , Multiple
sclerosis6 etc and also for the injury caused in
status epilepticus7 after cerebral ischaemia8 &
after traumatic brain injury8.
Many of these substances are abundantly found
in the body as well as in the environment both in
animal and plant kingdom. For example in the
body within the normal limits excitatory amino
acids like glutamate have a crucial role in
development of learning, memory9, perception of
pain, immune function and functioning of
various special senses10. But if their levels
exceed it leads to excitatory damage11. Over 70
types of excitotoxins have been identified so far
& many have a free access to our body in the
form of taste enhancing additives like
monosodium glutamate, aspartame, sodium
casienate etc. They also exist as variety of toxins
in nature. In presence of associated risk factors
long term exposure to excitotoxins has been
proved in etio pathogenesis of neurodegenerative
disorders3-6. In fact, glutamate & aspartate
toxicity are also thought to be responsible for
memory loss, confusion , mild intellectual
disorientation that frequently late middle age or
old age12.There is substantial evidence that
shows that excitotoxic damage is related to
neuronal death associated after cerebral ischemia
, stroke , status epileptics and head trauma.8
It is the purpose of this review to consolidate
available information about excitotoxins and to
segregate fact from fiction as regards to their role
in etio-pathogenesis in wide variety of disorders
especially neurodegenerative diseases.
MECHANISM
EXCITOTOXINS
OF
ACTION
OF
Excitotoxins along with other factors especially

ageing alter the metabolic capacities of neurons.1
Ageing is an associated strong risk factor as with
ageing there is progressive accumulation of
mutations in mitochondrial genome decreasing
the capacity of neurons to handle oxidative
metabolism.1 Moreover, altering the oxidative
metabolism of neurons leads to increased
production of reactive oxygen metabolites.

Natural antioxidant defenses fail to tackle this
excessive free radicals and as a result the
membrane potential is altered in such a way that
the magnesium block of NMDA glutamate
receptors is lifted up. This makes the receptor
channel highly sensitive to even low levels of
glutamate present around and leads to massive
calcium influx1. Increased calcium influx
causes,increased water influx & osmotic damage
to mitochondria13,Stimulation of phospholipase
A214, stimulation of nitric acid synthase15,
production of platelet activating factor(PAF)16,
generation of free radicals12 ,Activation of other
enzymes like endonucleases , proteases esp
calpain, phosphatases17,18, Stimulation of
phospholipase A2 causing production of
arachidonic acid metabolites 19-21 leading to
potentiation of NMDA evoked currents leading
to sustained activation of glutaminergic receptors
and inhibition of absorption of glutamate into
astrocytes & neuron via EAAT 2 (Essential
Amino Acid Transporter 2). Stimulation of nitric
oxide synthase (esp NO synthase II of
oligodendrocytes)
generates
more
nitric
oxide(NO) furthur increasing free radical
production22.
Constant sustained activation of glutaminergic
receptors inhibits cysteine transport decreasing
the intracellular levels of beneficial reducing
agents in form of sulphydryl groups 23reduction
of sulphydryl groups further potentiates free
radical production.
Free radicals along with endonucleases cause
DNA fragmentation and induce apoptosis17,18. If
the damage is severe enough there is rupture of
lysosomes and extracellular release of intact and
enzymatically modified cellular organelles
causing inflammation and necrosis17,18.
Neurons become more susceptible to glutamate
toxicity in presence of astrocytes. In fact,
concentrations of glutamate required to produce
neurotoxicity in absence of astrocytes was 100
times more than that required in presence of
astrocytes24. These results confirmed that there
was a soluble factor released by neurons which
649
Tadvi NA et al.,
signaled astrocytes of their presence and

astrocytes increase the sensitivity of neurons to
glutamate25.
DISTRIBUTION OF EXCITOTOXINS
Endogenous excitotoxins: They are naturally

present in body and in appropriate amounts are
actively involved in physiological process related
to survival of the organism. Important among
this group are excitatory neurotransmitters
glutamate and aspartate which are present
throughout central nervous system.26
Glutamate : The human body contains about
10g of free glutamate brain 2.3g muscle 6g , liver
0.7g , kidneys 0.7g & blood 0.04g27. The most
abundant molecular component of glutamate
system is N- acetyl aspartyl glutamate
(NAAG)26. Glutamate is produced from
ketoglutarate an intermediate in the krebs
cycle.Once released it is taken up from synaptic
cleft by both neurons & glia. Astrocytes convert
it to glutamine by enzyme glutamine synthase.
Glutamine then diffuses back into neurons which
hydrolyze it back to glutamate by enzyme
glutaminase28. It has 2 subtypes of receptors
called as ionotropic ( iGluR) and metabotropic
(m GluR) receptors. Ionotropic are ligand gated
ion channels that open in response to a various
agonists like kainate (ka) , NMDA (N methyl D
aspartic acid) , AMPA ( amino 3 hydroxy 5
methyl
4
isoxalopropionic
acid).Kainate
receptors are simple ion channels when open
permit Na influx and K efflux. AMPA has two
population one leads to only Na influx & the
other both Na & Ca influx. NMDA receptors are
facilitated by binding of glycine which on
opening allows large amount of calcium in. It
also has a Mg+ion block at resting membrane
potential & it gets removed only when the
neuron containing the receptor is partially
depolarized by some other receptors like AMPA
etc.29
Metabotropic glutamate receptors operate via G
protein mediated second messenger system.
Based on sequence homology they have been

divided in 3 groups30,
Group
mGluR1 , mGluR5
Group
mGluR2 , mGluR3
Group
mGluR4 , mGluR6 , mGluR7
Group stimulate Phospholipase C & eventually
increase intracellular calcium and Group ,
Group are coupled to inhibition of adenyl
cyclase31.Activation of mGluR causes the
production of inositol triphosphate which in turn
activates receptors on nedoplasmic reticulum that
open calcium permeable channels. Glutamate is
excitatory at ionotropic receptors & modulatory
at metabotropic receptors28. Another important
function of mGluR is to modulate the function of
other receptors by changing the synapse
excitability32,33.Glutaminergic neurons form an
extensive network throughout the cortex ,
hippocampus , striatum , thalamus ,
hypothalamus , cerebellum , visual & auditory
system & are essential for cognition , memory ,
movement & sensations like taste , sight &
hearing11.NMDA receptors bring about long term
potentiation. They are pivotal in developing fetal
brain for differentiation & migration of neurons
mainly via calcium influx.34 Blockade of NMDA
receptos during prenatal period with ethanol can
induce apoptosis in vulnerable neurons leading to
fetal alcohol syndrome.35,36
Aspartate: It is also an excitatory as glutamate
usually seen at synapses of pyramidal projection
neurons of cortex in layers 3 , 4 & 6 along with
glutamate. Excitatory stellate interneurons in
layer 4 of cortex also use it as neurotransmitter2.
Exogenous excitotoxins: Although glutamate &
other endogenous excitotoxins are present in the
body. They are highly prevalent in the
environment especially plants & animals either
in free form or bound to peptides. In fact
Glutaminergic system is present in nearly all
species of organisms including plants37,38.
1. Dietary glutamate: It has been estimated
that an average adult man has a daily
glutamate intake of 28g and daily turnover of
48g from diet and breakdown of gut
650
Tadvi NA et al.,
proteins26. Out of that only 2.5% of dietary

protein escapes digestion & absorption, rest
all is taken in29. The process of digestion
breaks protein into aminoacids & smaller
peptides which are taken in very efficiently
by active transport. At least 7 different amino
acid transporters have been identified so far
five of which require Na and two require Cl
ions and rest are uniport mechanisms29.
Using these mechanism dietary L glutamate
thus enters circulation & reaches blood brain
barrier. Although tight junctions of cerebral
capillaries prevent proteins from entering
brain tissue , there are amino acid
cotransporters present at those sites which
allow acidic amino acids to enter inside29.
2. Monosodium Glutamate(MSG): It is the
sodium salt of glutamate responsible for fifth
taste sensation i.e. the umami taste. In 1909
Professor Ikeda and Saburosuke Suzuki
discovered taste enhancer called MSG. It is
very commonly used as a food additive or a
taste enhancing agent in almost all processed
foodstuffs like readymade soups , curries ,
sauces , salad dressings , potato chips , all
types of Chinese cuisine in form of ajinomoto
& even baby foods. Many of the times it is
present disguised under the labels of natural
flavouring, malt extract , whey protein
concentrate etc. Since, 1948 the rate of
addition of MSG to readymade food products
is doubling per decade39. The food additive
called as hydrolysed protein is more
dangerous as it contains aspartate along with
glutamate in very large amounts.
Extensive research has been done to study the
effects of MSG on body in experimental
animal models & have shown definitive
effects like, neuronal cell death40, substantial
deficit
in
hippocampal
long
term
41
potentiation , learning disabilities &
behavioral deficits42,43, delayed co ordination
in newborns44, retinal damage45, hepatic and
renal toxicity.46 As the consumption of MSG
is increased because of increased uptake of
processed food products , the extrapolation of

these results to human beings is very much
possible.
The general mechanism of action of MSG is
very similar to excess of endogenous
glutamate in form of NMDA receptor
induced cation influx ultimately resulting in
cellular injury in form of apoptosis or
necrosis with associated inflammation17. The
determinant as to whether glutamate stress
will lead to apoptosis or necrosis depends
upon degree of damage to mitochondria
where minor damage causes apoptosis &
severe causes necrosis17,18
3. Aspartame :Aspartame is an artificial
sweetener used extensively in variety of
products like low calorie sugar substitute ,
diet soft drinks , low calorie confectionaries
,weight
loss
supplements
,
sports
supplements, ready made low calorie sweets
for diabetics etc. It is found in more than
6,000 products, including soft drinks,
chewing gum, candy, yoghurt, tabletop
sweeteners and some pharmaceuticals such as
vitamins
and
sugar-free
cough
47
drops .Dietary surveys, performed among
APM consumers, have shown that the
average APM daily intake in the general
population ranged from 2 to 3 mg/kg b.w.
and was even more in children and pregnant
women The Acceptable Daily Intake (ADI)
both 50 to 40 mg/kg 481.In rodents and
humans, APM is metabolised in the
gastrointestinal tract into three constituents:
aspartic acid,phenylalanine and methanol
49
.And aspartic acid is an excitatory
neurotransmitter whose metabolism is very
similar to glutamate.However, a recent study
found that female rats fed aspartame
developed more lymphomas and leukemias
than controls, in a dose-dependent manner,
starting from a dose that may be relevant to
human intake as low as 20 mg per kg body
weight50,51.
4. Domoic acid (DMA): It is an glutamate
analog and an agonist of ionotropic glutamate
651
Tadvi NA et al.,
5.
6.
7.
8.
receptors like AMPA & NMDA52,53. It is

found in marine algae and filter feeder
organisms like shell fish accumulate them in
their bodies . As these shell fish are
consumed DMA reaches human being it
leads to increase calcium influx via sustained
activation of iGluR 54causes seizure activity
esp of limbic system &direct excitotoxic
damage to CA3 cells of cerebral cortex.
Lesions produced are extensive neuronal loss
in bilateral hippocampus , dentate gyrus ,
amygdale , thalamus , insula & subfrontal
cortex. In fact, experimental administration
of AMPA antagonist like 2,3dihydroxy-6nitro7sulphamoylbenzoquinoxaline
dione
(NBQX) can prevent all its effects except of
CA3 cell damage55.
-N-oxalylamino-L-alanine (BOAA): It is
found in chickpeas called kesar dal and is a
selective agonist of AMPA receptors. It is
found to be responsible for Neurolathyrism
which is a paralytic disorder characterized by
loss of upper motor neurons specifically in
malnourished people.56 However,BOAA does
not cause disease in healthy people as is
evidenced from animal studies54. Later it was
found that it causes pathology in man only
when
associated
with
multivitamin
deficiencies that impair mitochondrial
metabolism and render neurons vulnerable
for it.
methylamino l-alanine (BMAA): It is
found in fruits of cycad plant that grows in
Guam region and is responsible for a disorder
called as Amyotropic lateral sclerosis of
Guam57. The toxin becomes active only in
presence of bicarbonate ions and the exact
mechanism is not known.58
Malonate : It is a mitochondrial toxin which
impairs electro transport chain in neurons and
makes them sensitive to even low doses of
endogenous excitotoxins.
3 -Nitropropionic acid (3NPA): It is a
secondary metabolite of fungi of Arthirium
sp. which grows on sugarcane. It inhibits
succinate dehydrogenase and impairs

electron transport chain. It alters the
membrane potential and brings about reversal
of Mg ion block causing increased
susceptibility of neurons to glutamate esp in
striatum producing lesions very similar to
Huntingtons disease.59
9. Methyl mercury and ammonia: Their
mechanism of action is not clear but involves
disruption of interactions between neurons
and oligodendrocytes.60,61
10. Casein : There are several geneticallydetermined variants of -casein, the protein
which constitutes about 25-30% of cows
milk proteins. One variant, A1 -casein, has
been implicated as a potential etiological
factor in type 1 diabetesmellitus (DM-1),
ischaemic
heart
disease
(IHD),
schizophrenia, and autism.Studies show that
antibodies against A1 -casein are increased
in patients with DM-162.It was also
demonstrated that the relationships between
milk protein consumption and IHD mortality
rates were much stronger63. The hypothesis
that links neurological disorders such as
schizophrenia and autism to A1 -casein is
that, in genetically susceptible individuals,
dietary components like casein and gluten are
cleaved in the gut to produce peptide
fragments
with
opioid
characteristics(gluteomorphines
and
64
casomorphines) . These compounds enter
the circulation, cross the blood brain barrier
and influence neurological functioning.
EVIDENCE
OF
INVOLVEMENT
OF
EXCITOTOXINS IN NEURODEGENERATIVE
DISORDERS:
1. Amyotropic lateral sclerosis (ALS): Anti

glutamate strategies like use of drug called
Riluzol slows the disease and decreases the
mortality65. Two fold increase in CSF
glutamate levels were found in patients of
ALS66. The CSF of ALS patients induced
apoptosis in cultured spinal motor neurons.66
652
Tadvi NA et al.,
AMPA receptors on spinal motor neurons

cause increase in calcium influx and are
involved in their excitotoxic degeneration67
AMPA antagonist GYK1 52466 prevents
increased glutamate induced degeneration of
cultured spinal motor neurons.68,69
2. Huntingtons disease (HD): Expansion of
CAG repeat sequence is found in first exon
on the gene of chromosome 4p16.3 coding a
protein called as Huntington70 in the genome
of patients effected. CAG is a codon for
glutamate and the normal range of glutamate
in a polyglutamate tract is between 6 to 34
whereas in HD cases it is more than 4071.
Huntington protein interferes with binding of
a scaffold protein PSDP-95 which has
guanylate cyclase activity at special areas
called as PDZ domains on NMDA receptors
& KaGluR that normally plays a pivotal role
in synaptogenesis and regulation of synaptic
plasticity72 ultimately making NMDA
receptors hypersensitive to glutamate which
increase calcium influx & cause apoptosis of
neurons via stimulation of MLK2 gene
transcription73,74.
3. Addisons disease (AD): Physiologically,
NMDA receptors serve as gating switch for
the modification of major forms of synaptic
plasticity
involved
in
learning
&
consolidation of short term memory to long
term memory75. Neuronal damage due to
excitotoxic effects of glutamate via NMDA
receptors caused by increased glutamate
levels due to dysfunction of cystineglutamate antiporter is seen in cases of AD.76
Memantine a weak glutamate antagonist
increases learning and memory in animal
models & in patients of AD77.
4. Multiple sclerosis (MS): Local elevated
concentrations of glutamate are found in MS
patients.78 Glutamate antagonist amantadine
reduces the relapse rate in patients of MS.79
Malfunctioning
of
astrocytes
and
downregulation of enzymes which bring
down the level of glutamate like glutamate
dehydrogenase & glutamate synthase causing
axonal and oligodendrocyte damage is seen

in such patients80
5. Parkinsons disease (PD): There is a
mitochondrially encoded defect in complex I
of electron transport chain enhancing the
susceptibility of neurons for excitotoxic
damage81 Substantia nigra pars compacta
neurons have NMDA receptors & sustained
activation of which via increased calcium
influx coexistent with impaired energy
metabolism leads to PD.82 Studies have
shown 3-NPA & malonate via NMDA
receptors loss of dopaminergic neurons in
mesenchephalic neuronal cultures.83
6. Cerebral ischaemia & traumatic brain
injury: Positive modulation of NMDA
receptor activity by group I receptors
mGluR1,5
potentiates
neuronal
excitotoxicity84-86 Group
II receptors
(mGluR2/3)
exert a protective effect
possibly through presynaptic inhibition of
Glutamate release87,88. NMDA and AMPA
receptor antagonists have been shown to be
powerful neuroprotective agents in animal
models of stroke89 In permanent or reversible
occlusion of the middle cerebral arteries,
these antagonists consistently reduce the
volume of cortex that is infarcted90.91. AMPA
receptor antagonists reduce cortical and white
matter damage in vitro and in vivo92. AMPA
antagonist if given close to the time of onset
of
the
ischemia
gives
optimum
neuroprotection
against
excitotoxic
93
damage .
Glutamate
excitotoxicity,
oxidative stress, and acidosis are primary
mediators of neuronal death during ischemia
and reperfusion& astrocyte are critical
determinant of neuronal survival in the
ischemic penumbra94,95.
7. Epilepsy & status epilepticus: Brain
damage from repeated seizures can occur
independent of cardiopulmonary &systemic
metabolic changes suggesting that local
factors in brain can lead to neuronal death.2
Excitatory glutamatergic mechanisms are
involved during both acute,transient, evoked
653
Tadvi NA et al.,
seizures and long-term, adaptive cellular

plasticity associated with seizure activity as
in chronic epilepsy animal models such as
amygdala-kindled rats or rats with
spontaneous, recurring seizures after an
episode of induced status epilepticus96.
NMDA and AMPA receptor antagonists are
powerful anticonvulsants in a wide range of
animal models ofepilepsy97. Astrocytes have
a direct role in the regulation of synaptic
strength and neuronal excitability98,99.and a
dysfunction in glial cells, and not in neurons
or synapses is the initiating cause of
epilepsy100& robust reactive gliosis is
necessary to induce posttraumatic epilepsy101.
SUMMARY AND CONCLUSION
Specific excitotoxins like DMA, MOAA, BMAA

, 3NPA are found in specific foodstuffs and can
be easily avoided by not eating marine shellfish ,
cycad fruit , chickpea , fungated sugarcane.
However, the other exogenous excitotoxins like
MSG, aspartame are being consumed in large
amounts under the disguise of appetizing,
processed food products and if co existent with
genetic predisposition or ageing or any other
factor causing oxidative metabolic stress
inevitably, lead to an auto stimulatory
glutaminergic vicious cycle causing apoptosis
and necrosis of specific neurons and
development of neurodegenerative disorders. It
should also be appreciated that the effects of
excitotoxic food additives generally are not
dramatic and are subtle and develop over a long
period of time. But they certainly can precipitate
these disorders and worsen their pathology.
Likewise, foodborne excitotoxins may be
harmful to those suffering from strokes, head
injury and HIV infection, and certainly should
not be used in a hospital setting.
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DOI: 10.5958/j.2319-5886.2.3.049

&
Health Sciences
Short communication
FACEBOOK AND OCCUPATIONAL THERAPY PROFESSION
*
Koushik Sau, Guruprasad V
Department of Occupational Therapy, SOAHS, Manipal University, Karnataka, India

*
Corresponding author email: koushiksau@gmail.com
INTRODUCTION
Social media is any web or mobile based

platform thats enables an individual or agency to
communicate interactively and enables exchange
of user generated content1. Facebook is the most
powerful social media 2 and India is the third 3 in
world in terms of active user. So Indian
occupational therapist can use Facebook
effectively for professional growth
Dos
Manage your Facebook image in professional
manner 5 and plan before posting anything.
Response if it is relevant to you1. know your
organization policies 5 and maintain your ethical
responsibility
regarding
privacy
and
2
confidentiality as occupational therapist .
Benefits
Dons
It helps to connect, collaborate with 1. Provides

stage for developing diverse, low density
networks free of charge and with reduced cost in
terms of time and efforts 4. It can be used to
communicate public messages with a click any
time from any place. Enhance one to one
communication with clients. It can be used for
marketing and promoting2 to clients.
Uploading video or photo of client or yours in a

clinical setup5. Posting of any thing which can be
used for identification and break the privacy5.
Post any unfavourable message about your
organizations, clients and employers5.
Risk
Though it is recommended for use by
occupational therapist2 but they should consider
the privacy and confidentiality of patient and
profession otherwise it may land you in prison 6.
REFERENCES
1) Draft framework & guidelines for use social

media for government organization by
department of electronics and information
technology.
Available
at:
http://negp.gov.in/pdfs/Social%20Media
%20Framework%20and%20Guidelines.pdf
Accessed 05/04/2013.
2) BAOT/COT
Social
Media Guidance
available at http://www.cot.co.uk/strategic660
Sau et al.,
3)
4)
5)
6)
plans/social-media-strategy-guidance
Accessed 05/04/2013
India Facebook statistics. Available at
http://www.socialbakers.com/facebookstatistics/india Accessed 05/04/2013.
Bodell S, Hook A. Using Facebook for
professional networking: a modern day
essential,. British Journal of Occupational
Therapy, 2011;74 (12), 588-590.
Practice guideline ethical and responsible use
of social media technologies. Available at
http://www.nanb.nb.ca/downloads/Practice%
20Guidelines-%20Social%20Media-E(1).pdf
Accessed on 05/04/2013
Now, leaking health information may land
you
in
prison.
Available
at:
http://www.indianexpress.com/news/nowleaking-health-information-may-land-you-inprison/809389 Accessed 04/04/2013
661
Sau et al.,
DOI: 10.5958/j.2319-5886.2.050

&
Health Sciences
rd

Case report
Coden: IJMRHS
Copyright @2013
rd
Accepted: 1st May 2013
STRONGYLOIDES STERCORALIS HYPERINFECTION

IMMUNOSUPPRESSED PATIENT: A CASE REPORT
ISSN: 2319-5886
IN
AN
IATROGENICALLY
Shafiq Syed1, Ramathilakam B2, Prakash, Geetha3, Devipriya G4

1
DM Resident, 2Professor and HOD, Department of Medical Gastroenterology,

3
Professor and HOD, 4Postgraduate student, Department of Pathology, Meenakshi Medical College and
Research Institute, Enathur, Kanchipuram
*Corresponding author email: syed.dr.s@gmail.com
ABSTRACT
We report a case of Strongyloides stercoralis infection of the stomach in an elderly male patient who
was on corticosteroids for six months. The patient presented with epigastric pain associated loss of
appetite and loss of weight. The patient underwent upper endoscopy, and his gastric antral biopsy
showed superficial ulcerations of the gastric mucosa with adult worms of Strongyloides stercoralis in the
crypts of the gastric antrum. Stool sample showed the larval forms of Strongyloides. The patient was
treated with Ivermectin in a dose of 200g/kg/day PO for two days, same treatment was repeated after
two weeks. Prednisone was tapered and stopped.
Keywords: Strongyloides stercoralis, ivermectin, prednisone
INTRODUCTION
Strongyloides stercoralis is an intestinal

nematode endemic in tropical and subtropical
countries of Asia and Africa. It is estimated that
30 to 100 million people worldwide are infection
with Strongyloides stercoralis.1-3 It remains as an
asymptomatic infection in a majority of those
infected with it but is capable of producing
hyperinfection with dissemination throughout the
body when the host immunity is compromised.
The Strongyloides life cycle is unique and more
complex than that of other nematodes with its
alternation between free-living and parasitic
cycles and its potential for autoinfection and
multiplication within the host. Hyperinfection or
Shafiq et al.,
disseminated infection occurs usually in

immunocompromised patients, most often in
patients on corticosteroid treatment. The
diagnosis is based on a high index of suspicious
a diagnosis of Stronglyloides can be made for
certain by identifying the worm in stool samples.
Eosinophilia can be helpful but it is most often
absent in patients with disseminated disease.
Ivermectin is a highly effective drug against
strongyloidosis, but eradication of the worm is
difficult to ascertain based on stool examination
alone. Thiabendazole and albendazole are the
other alternative drugs.
662
CASE REPORT
A 62 year old male patient was being seen in the

department of Dermatology for eczema since two
years.
He was referred to Medical
Gastroenterology for complaints of epigastric
pain associated with loss of appetite since 3
months along and loss of weight with early
satiety. According to the patient and his
attenders, he had lost 6 Kgs over the last 3
months. There was no history of fever or cough.
He denied melena or hematochezia. No history
of altered bowel habits. No history of passing
worms in stool.
The patient was on oral prednisone therapy on
and off, and most recently he has been on
steroids therapy for as long as six months for his
skin condition, prescribed by his dermatologist.
On examination, vital signs were normal. There
was no pallor, clubbing, or palpable
lymphadenopathy. Systemic examination was
likewise normal except for skin showing some
Fig.1: Gastric antral biopsy showing adult

Strongyloides stercoralis worm in the gastric crypts
dry scaly lesions, mainly over his extremities and

neck.
His labs showed a Hb of 13.0 gm%, TC of
11,700 cells/cubic mm with differential showing
eosinophils of 7%. HIV testing was negative. His
random sugar was 75 mg/dl.
Patient was subjected to upper GI scopy which
showed antral gastritis with duodenitis. Antral
biopsies were taken and submitted for HPE. The
pathology specimen was reported as gastric
mucosa showing superficial ulcerations and adult
worms of Strongyloides stercoralis were seen
within the gastric crypts.
Patients stool was sent for ova and parasite, and
it showed rhabditiform larvae of Strongyloides
stercoralis. The patient was treated with a course
of ivermectin in a dose of 200 mcg/kg/day orally
for 2 days, and this was repeated after 14 days.
The patients prednisone was tapered and
stopped.
Fig.2: Stool specimen showing rhabditiform larva

of Strongyloides stercoralis
DISCUSSION
Strongyloides stercoralis is a free-living

nematode endemic in tropical and subtropical
countries infecting more than 100 million people
worldwide.1 A distinctive feature of this parasite
is its ability to persist and replicate within a host
for decades producing minimal or no symptoms
but being capable of causing life-threatening
Shafiq et al.,
infection by way of hyperinfection or

dissemination in an immunocompromised host
with a mortality rate as high as 80%.2
The life cycle of Strongyloides stercoralis is
rather complex and unique among the intestinal
nematodes. It has two types of life cycles - a
free-living life cycle (rhabditiform larvae) and a
663
parasitic life cycle (filariform infective larvae) with 3 developmental stages: adult, rhabditiform
larva, and filariform larva.
The free-living life cycle allows for development
of nonparasitic adults, both males and females, in
the soil, which can indefinitely maintain
infestation of the soil.
The second type of life cycle, which is the
parasitic cycle, allows noninfective larvae to
molt in the human host into infective filariform
larvae. These infective larvae then penetrate the
intestine and set up a new cycle, the
hyperinfective or autoinfective cycle. Unlike
other intestinal nematodes infecting humans,
these larvae can increase in numbers without
reinfection from outside.
The clinical manifestations of Strongyloides
infection depends on the burden of worm
infection and the host immune response.
Majority of the infected patients remain
asymptomatic and are only discovered as a
serendipitous incidental finding. Risk factors for
dissemination include patients who have
suppressed cell mediated immunity with patients
on high-dose corticosteroids and those infected
with HTLV-I being the highest risk groups.3,4 It
is postulated that corticosteroids act directly to
promote development of infective filariform
larvae.
Fulminant infection can complicate
patient with HIV and AIDS. The other at risk
groups
being
patients
who
are
on
immunosuppressive drug therapy, patients with
hematologic malignancies, renal and bone
marrow transplant recipients.
Diagnosis is made with certainity by the presence
of larva in the stool. Peripheral eosinophilia is
found in half of those infected but is usually
absent in hyperinfection. Patients with increased
peripheral eosinophilia appear to have a better
prognosis.5 There are several methods to identify
larvae in stool with Baermann funnel technique
being regarded at the gold standard. Other
methods used for diagnosis are duodenal
aspiration, immunodiagnostic tests (viz., IFA,
IHA, ELISA, etc.), direct smear of feces in
Shafiq et al.,
saline-lugol iodine stain, and the use of these

diagnostic tests depends on the local availability
of resources and expertise.
Strongyloides infection can be successfully
treated with ivermectin which is the drug of
choice.6,7 Thiabendazole and albendazole can
also be used as alternatives.8 A single dose of
ivermectin 200 mcg/Kg body weight/day orally
for two days is the drug of choice in
uncomplicated strongyloidosis. This dose can be
repeated after two weeks. Tribendimidine is an
investigational drug showing promise in the
treatment of strongyloidiasis.9 Patients with
hyperinfection or dissemination are at risk of
sepsis and meningitis with gram-negative
organisms and hence also require a broad
spectrum antibiotic along with the above
antihelminthic treatment.
The diagnosis of strongyloidiasis requires the
clinicians to have a high index of suspicion as
patients with the infection present with no
distinctive clinical features, and the laboratory,
imaging, and endoscopic findings are often
nonspecific. Immunocompromised patients are
at high risk of dissemination with high mortality,
and there have been multiple reports of fatal
outcomes in patients being treated with steroids10
Hence the need of identifying patients at risk for
strongyloidosis and performing appropriate
diagnostic
tests
before
beginning
immunosuppressive therapy is of utmost
importance.
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J.
Severe
strongyloidiasis in corticosteroid-treated
patients: case series and literature review. J
Infect. Jan 2007;54(1):18-27.
4. Neefe LI, Pinilla O, Garagusi VF, and Bauer
H. Disseminated strongyloidiasis with
cerebral involvement: a complication of
corticosteroid therapy. The American
Journalof Medicine.1973; 55(6): 83238
5. Jamil SAand Hilton E. The Strongyloides
hyperinfection syndrome. N. Y. St. J.
Med.1992; 92:6768.
6. Gann PH, Neva FA, and Gam AA. A
randomized trial of singleand two-dose
ivermectin versus thiabendazole for treatment
of
strongyloidiasis.
J.
Infect.
Dis.
1994;169:107679.
7. Guzzo CA, Furtek CI, Porras AG. Safety,
tolerability, and pharmacokinetics of
escalating high doses of ivermectin in healthy
adult subjects. The Journal of Clinical
Pharmacology. 2002;42(10): 112233.
8. Datry A, Hilmarsdottir I, MayorgaSagastume R, Lyagoubi M, Gaxotte P,
Biligui S, et al. Treatment of Strongyloides
stercoralis
infection
with
ivermectin
compared with albendazole: results of an
open study of 60 cases. Trans R Soc Trop
Med Hyg. 1994;88(3):344-45.
9. Steinmann P, Zhou XN, Du ZW, Jiang JY,
Xiao SH, Wu ZX, et al. Tribendimidine and
albendazole for treating soil-transmitted
helminths, Strongyloides stercoralis and
Taenia spp: open-label randomized trial.
PLoS Negl Trop Dis. 2008;2(10):322
10. Boulware DR, Stauffer WM, HendelPaterson BR, Rocha JL, Seet RC, Summer
AP. Maltreatment of Strongyloides infection:
case series and worldwide physicians-intraining survey. Am J Med. Jun
2007;120(6):545-8
Shafiq et al.,
665
DOI: 10.5958/j.2319-5886.2.3.051

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Health Sciences
Revised: 2nd May 2013
Case report
CERVICAL LYMPHADENOPATHY IN A YOUNG FEMALE: A CASE REPORT
Shafiq Syed
Assistant Professor, Department of General Medicine, Meenakshi Medical College and Research
Institute, Enathur, Kanchipuram, Tamilnadu, India.
Corresponding author email: syed.dr.s@gmail.com
ABSTRACT
Kikuchi-Fujimoto disease is a rare disease of unknown etiology and characterized by benign selflimiting cervical lymphadenopathy. It is an extremely rare disease with higher prevalence amongst
Japanese and other Asiatic individuals. Its recognition is important because it can be mistaken for
immunologic, infective, and even lymphomas, and the patient may be subjected to inappropriate and
costly diagnostic workup and treatment. A 21-year-old female presented to the clinic with chief
complaint of swelling over the left neck with fever since 10 days. On examination, patient was febrile,
and she had multiple small enlarged cervical lymph nodes, that were mildly tender. Other system
examination was normal. Her laboratory investigations were normal. FNAC of the cervical lymph node
was suggestive of necrotizing lymphadenitis. Patient was started on a course of ciprofloxacin. Her
lymph node biopsy confirmed Kikuchis disease. Immunohistochemistry further confirmed the
diagnosis. The patient has been free of symptoms and in remission on followup after six months.
Keywords: Kikuchi-Fujimoto disease, necrotizing lymphadenitis, immunohistochemistry
INTRODUCTION
Kikuchi-Fujimoto disease, otherwise called

histiocytic necrotizing lymphadenitis, is an
idiopathic, rare disease generally presenting as
cervical lymphadenitis. It was first described in
Japan in the year 1972. It is reported to be more
common in the Japanese and Asiatic individuals.
The male to female ratio is reported to be around
1:4
CASE REPORT
A 21-year-old unmarried female presented to the

clinic with a history of fever and multiple neck
swellings and with generalized myalgias and

arthralgias of 10 days duration. There was no
other significant past medical history. The
patient denied any history of previous Kochs or
contact with any patient with Kochs. Her
physical examination was significant in that she
was febrile with a temperature of 100.8 degrees
Fahrenheit. Her neck exam showed multiple,
small lymph nodes, which were mobile and
tender on the left side of the neck, the largest of
which measured and 1.5 x 1.5 cm. There were
no other lymph nodes palpated elsewhere in the
666
Shafiq
body. Her throat exam was normal with no

pharyngitis or tonsillitis or tonsillar hypertrophy.
Her cardiovascular, respiratory, and per abdomen
exams were likewise normal. Patients routine
blood investigations including ESR were normal.
She had normal electrolytes, liver function tests,
and renal function tests. Mantoux did not show
any induration. Her chest x-ray and abdominal
ultrasounds were reportedly normal. She had
ANA and anti dsDNA antibodies checked which
were negative. USG of neck showed cervical
lymphadenopathy involving the left upper and
mid cervical nodes, the largest of which was 1.8
x 2.1 cms.
Patient was then subjected for FNAC of the
cervical lymph node which was reported as
showing necrotizing lymphadenitis, to rule out
Kikuchis disease. A lymph node biopsy was
done which confirmed the diagnosis of KikuchiFujimotos disease, which was further confirmed
with immunohistochemistry. The patient was
treated symptomatically with ciprofloxacin and
nonsteroidal anti-inflammatory drugs with
resolution of her symptoms, and she has
remained in remission after two years of follow
up.
Fig.1: Smear from cervical lymph node showing

reactive lymphoid cells with scattered crescentric
histiocytes. Background shows necrosis with
numerous tingible body macrophages.
DISCUSSION
Kikuchi-Fujijmotos
disease
remains
an
enigmatic condition of unclear etiology and one
that is rare except in the Japanese and Asiatic

individuals and often leads to unnecessary
investigations and potentially harmful treatments.
The disease often presents with tender cervical
lymphadenopathy in a female aged between 20 to
30 years. Though the etiology is still to be
elucidated, viral infections with Herpes simplex
virus, Epstein Barr virus, Parvovirus B19, and
HTLV1 have been suggested, but this is
controversial
and
not
convincingly
1
demonstrated . Other infectious agents which
have been implicated in Kikuchis disease
include Brucella, Yersinia, Bartonella, and
Toxoplasma. There are reports suggesting an
association between Kikuchis disease and SLE.
It has been suggested by some authors that
Kikuchis disease may represent a self-limited
autoimmune process which is induced by virusinfected transformed lymphocytes in a
genetically susceptible individual2.
Cervical lymphadenopathy is almost always the
most common symptoms which bring the patient
to physicians. The other less common symptoms
include anorexia, nausea, vomiting, arthralgias,
night sweats, and skin rash. It has also been
reported as a cause of PUO3. Leukopenia and
atypical lymphocytes are demonstrated in about
25% to 30% of the cases.
No specific laboratory tests are available;
although some patients may have an elevated
ESR Fine needle aspiration cytology has an
overall diagnostic accuracy of around 56% 4.
Diagnosis is established by histopathologic
findings of lymph node biopsy.
The
characteristic histopathologic findings include
irregular paracortical areas of coagulative
necrosis with abundant karyorrhectic debris,
which distorts the nodal architecture, and large
number of different types of histiocytes at the
margin of the necrotic areas. The karyorrhectic
foci are formed by different cellular types,
predominantly histiocytes and plasmacytoid
monocytes but also immunoblasts and small and
large
lymphocytes.
Neutrophils
are
characteristically absent and plasma cells are
667
Shafiq
either absent or scarce. Of note, atypia seen in

the reactive immunoblastic component is not
uncommon and can be mistaken for lymphoma.
The differentiation of KFD from SLE can
sometimes pose problems because both can show
similar clinical and histological features.
Furthermore, KFD has been reported in
association with SLE. Antinuclear antibodies
(ANA) and anti-DNA antibodies were done in
our patient and were negative.
The
immunophenotype of Kikuchis disease is
primarily composed of mature CD8-positive and
CD4-positive T lymphocytes with very few Blymphocytes. High rates of apoptosis are seen
among lymphocytes and histiocytes. The
histiocytes express histiocyte-associated antigens
such as lysozyme, myeloperoxidase (MPO) and
CD68
which
can
be
detected
by
immunohistochemistry. Plasmacytoid monocytes
are also positive for CD68 but not for
myeloperoxidase5.
KFD usually follows a self-limited course with a
possible recurrence rate of 3% to 4% reported in
literature.3 Treatment is generally supportive
since no specific treatment is available for
Kikuchis disease.
Nonsteroidal antiinflammatory drugs (NSAIDs) are used to
alleviate the tender lymphadenitis and fever.
Corticosteroids have been recommended if the
patients manifest with severe extranodal or
generalized disease, but this is of unproven
efficacy6. Limited success has been reported
with the use of intravenous immunoglobulin7
REFERENCES
1. Sousa Ade A, Soares JM, de Sa Santos MH,

Martins MP, Salles JM. Kikuchi-Fujimoto
disease: three case reports. Sao Paulo Med J.
2010;128(4):232-35.
2. Imamura M, Ueno H, Matsuura A, Kamiya
H, Suzuki T, Kikuchi K, Onoe T: An
ultrastructural study of subacute necrotizing
lymphadenitis. Am J Pathol 1982, 107:29299
3. Kapadia Y, Robinson BA, Angus HB.
Kikuchis disease presenting as fever of
unknown origin. Lancet.1989;2:1519-20.
4. Tong TR, Chan OW, Lee KC. Diagnosing
Kikuchi disease on fine needle aspiration
biopsy: a retrospective study of 44 cases
diagnosed by cytology and 8 by
histopathology. Acta Cytol. 2001;45:953-57.
5. Bosch X, Guilabert A. Kikuchi-Fujimoto
disease. Orphanet J Rare Dis. 2006;1: 18.
6. Jang YJ, Park KH, Seok HJ. Management of
Kikuchi's disease using glucocorticoid. J
Laryngol Otol 2000;114:709-11.
7. Noursadeghi M, Aqel N, Gibson P, Pasvol G.
Successful treatment of severe Kikuchi's
disease with intravenous immunoglobulin
Rheumatology 2005;45:235-39
CONCLUSION
Kikuchis disease must be considered in the

differential
diagnosis
of
cervical
lymphadenopathy in a young female in order to
avoid laborious investigations and potentially
harmful
treatments
for infectious and
lymphoproliferative diseases.
668
Shafiq
DOI: 10.5958/j.2319-5886.2.3.052

&
Health Sciences
Coden: IJMRHS
Copyright @2013
ISSN: 2319-5886
th
nd
th
Revised: 2 May 2013
Accepted: 5 May 2013
Case report
A RARE SHOULDER DISEASE OF PRIMARY SYNOVIAL CHONDROMATOSIS

Lakhkar Dilip1, *Athawale Kedar2, Deochake Prasanna3, Pawar Khushal 4
1Professor and Head of Department, 2Assistant Professor, 3Senior Resident, 4Resident, Dept of
Radiodiagnosis and Imaging, Padmashree Dr. Vithalrao Vikhe Patil Medical College & Hospital, Near
Govt. Milk Dairy, Vilad Ghat, Ahmednagar, Maharashtra.
*Corresponding author email: kedarathawale@gmail.com
ABSTRACT
Primary synovial chondromatosis is a rare, benign condition which affects the synovial membranes. It
commonly involves knee, elbow and hip in young adults but is rare in shoulder. We reviewed a rare case of
synovial chondromatosis of the shoulder. A young female came to our hospital with pain and swelling at right
shoulder joint. Radiograph, ultrasound and MRI with contrast were obtained. It helped to make a diagnosis of
synovial chondromatosis. The shoulder was operated and multiple oval loose bodies measuring up to 8 mm were
removed. Partial synovectomy was done.
Keywords:Synovial chondromatosis, Shoulder
INTRODUCTION
Primary synovial chondromatosis affecting the

shoulder joint is a rare orthopaedic problem of no
known aetiology. It is characterized by the presence
of multiple cartilaginous nodules within the joint
1
cavity or are attached to the synovium . Typically

it affects one of the bilateral joints. Knee joint is the
most commonly affected one.2,3 Other joints such
as the shoulder, elbow, hip, ankle and
4,5
temporomandibular joints are also affected .

Males are the more to be affected predominantly
1,6,7
ranging from the third to fifth decade . A preexisting primitive embryonic rest has been
postulated to be the etiological basis of the
disease2. In cultures of fourteen surgical specimens
obtained by Jeffreys in 1967, no growth of
organism occurred. Trauma has been implicated as

the precipitating factor for the development of this
disease. Neoplastic etiology is considered to be the
cause of the cartilaginous metaplasis by some.
However a few isolated cases of malignancy have
been reported. We here describe an unusual
presentation of synovial chondromatosis in the
shoulder joint.
CASE REPORT
A twenty four years old female came to

orthopaedic OPD with pain in right shoulder. She
had pain for 6 months which had precipitated with
history of fall. No investigations were obtained
after the fall. The pain gradually increased over 6
months. She also had swelling over the shoulder
669
Lakhkar Dilip etal.,
with restricted movements for 2 months.

Radiographs for shoulder were normal. No fracture
or dislocation was seen on the radiograph.
Ultrasonography study showed moderate fluid at
the shoulder joint with multiple well-defined
echogenic rounded lesions measuring up to 8 mm
within the effusion. There was thickening of the
synovium noted. The rounded nodules and
thickened synovium showed increased vascularity
on Doppler study. The rotator cuff appeared normal
with no tear. MRI with contrast revealed moderate

shoulder joint effusion with thickened synovium
and multiple enhancing nodules of varying sizes in
the joint. The nodules appeared hypointense on
T1W and T2W MRI images. Moderate
homogenous contrast enhancement of the
thickened synovium and nodules was seen. No
erosion of the articular surfaces was seen. The
rotator cuff appeared intact. Bones showed normal
signals.
Fig 5: T1W axial MRI image shows multiple hypointense

Fig.6: Contrast enhanced T1W axial MRI image shows
nodules with moderate joint effusion. The articular margins
enhanced hypertrophied synovium and nodules.
appear regular.
670
DISCUSSION
Synovial chondromatosis is a rare benign condition

affecting large joints. Cartilaginous nodules are
seen in the synovium of joints, tendon sheaths, and
bursae. No history of trauma or infection is noted in
majority of the cases. As the disease progresses,
the loose bodies may ossify and can be identified
radiographically as rounded dense lesions8-11.
Males are affected more than females by synovial
chondromatosis. Out of three affected individuals
{synovial chondrosarcoma} is made when there is

a large, lobulated synovial lesion with extraarticular invasion on imaging studies like MRI or
ultrasound. The histological sections show
numerous multinucleated cartilage cells having
bizarre hyperchromatic nuclei.
Acute primary synovial chondromatosis can be
cured adequately by removing the loose bodies and
the affected synovium.
2,11
two are males and one if female
. It is usually
6,7
identified in the third to fifth decades of life . The

synovial chondromatosis can be differentiated into
a primary and secondary form. The primary form
occurs in a normal joint unaffected by any other
disease4. It is characterised by undifferentiated
stem cell proliferation in the stratum synoviale.
Metaplasia of the synovial cells is considered to be
the pathological process. Trauma is commonly
thought of as an inciting stimulus however no
statistical relationship has been reported in the
literature. It has been concluded via
immunostaining
that
primary
synovial
chondromatosis has as metaplastic etiology12. The
nodules attached to the synovium may get detached
as the disease progresses. These form loose bodies
in the joint. These loose bodies may continue to
grow which are nourished by the synovial fluid.
Some of these nodules may calcify and it is called
as osteochondromatosis. Secondary condition is
said when a joint affected by some other disease
also shows changes of synovial chondromatosis. It
is thought to be caused by irritation of the synovial
13
tissue . The cartilage fragments get detached from

articular surface and become embedded in the
synovium to form nodules.
Malignant degeneration is worrying and this has
produced recent interest in the diagnosis. Although
the change to malignant condition is rare, the
patients diagnosed should be monitored3. In a 1998
study examining primary synovial chondromatosis,
a relative risk of 5% for malignant degeneration
was reported14. The diagnosis of malignant change
CONCLUSION
The shoulder joint of a female is one of the rare

joints to be affected and hence this case is reported.
Histological diagnosis plays an important role in
finding out the malignant change if radiographic or
MR imaging are inconclusive.
REFERENCES
1. Bennett OA. Reactive and Neoplastic

Changes in Synovial Tissues. Proc. Inst. Med.
Chicago. 1950;18: 26-37
2. Fisher AGT. A Study of Loose Bodies
Composed of Cartilage or of Cartilage and Bone
Occurring in Joints. With Special
Reference to Their Pathology and
Etiology. British J. Surg. 1921;8:493-23
3. Jones HT. Loose Body Formation in
Synovial Osteochondromatosis with Special
Reference to the Etiology and Pathology. J.
Bone and Joint Surg. 1924;6:407-58.
4. Mussey RD Jr. and Henderson MS.
Osteochondromatosis. J. Bone and Joint Surg.
1949; 31:619-27
5. Murphy FP, Dahlin DC and SullivanCR.
Articular Synovial Chondromatosis. J.
Bone and Joint Surg. 1962;44:77-86
6. Nixon JE, Frank GR and Chambers G.
Synovial Osteochondromatosis. With
Report of Four Cases, One Showing
Malignant Change. U.S. Armed Forces Med.
J.1960;11:1434-45.
7. B l o o m
R
and
Pattinson
J
N . Osteochondromatosis ofthe Hip Joint. J.
671
Bone and Joint Surg. 1951;33: 80-84

8. Jeffreys TE. Synovial Chondromatosis. J.
Bone and Joint Surg.,1967; 49;530-34
9. Wee GC, Torres AU, Gustinjack LD et al.
Synovial Chondromatosis of the Ankle. Case
Report. Missouri Med. 1971;68:781-84.
10. Bonnin JG. Internal Derangements of the Knee
Joint and Allied Conditions. In Modern
Trends in Orthopedics. Vol. 2. pp. 182-188.
Edited by Sir Harry Platt. New York. Paul B.
Hoeber, Inc., 1956.
11. Jaffe HL. Tumors and Tumorous
Conditions of the Bones and Joints, pp. 558566. Philadelphia. Lea and Fehiger, 1958.
12. Ackerman LV, Ros AI, JUAN. Surgical
Pathology. St. Louis, The CV Mosby Co.1974.
Ed. 5. pp. 1086-88.
13. Peh WCG, Shek TWH, Davies AM,
Wong
JWK,
Chien
EP.
Osteochondroma secondary synovial
osteochondromatosis. Skeletal Radiol
1999;28:169-74.
14. Davis RI, Hamilton A, Biggart JD.
Primary synovial chondromatosis: A
clinicopathologic
review
and
assessment of malignant potential.
Human
Pathology 1998:29(7):68388.
672
DOI: 10.5958/j.2319-5886.2.3.053

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Health Sciences
Revised: 23rd May 2013
Case report
PANCREATITIS SECONDARY TO ASCARIS LUMBRICOIDES: A CASE SERIES ANALYSIS
*Ab hameed Raina1, Ghulam Nabi Yattoo2, Feroz Ahmad Wani3, Reyaz Ahmad Para1, Khaild Hamid
Changal1, Arshed Hussain Parry4
1
Post graduate, Department of Internal Medicine, 2Professor, Department of Gastroenterology, 3Post

graduate, Department of Community Medicine, 4Post graduate, Department of Radiodiagnosis, Sher-iKashmir Institute of Medical Sciences, Soura (J&K) India.
*Corresponding author email: rainahameed@gmail.com
ABSTRACT
Ascaris lumbricoides infestations are endemic in tropical countries. Ascaris lumbricoides is the second
most common intestinal parasite world-wide and, although the infection can be asymptomatic, in some
cases it can present with complications, such as acute pancreatitis. Pancreatitis secondary to ascaris is
more common in females. We describe three cases who presented with Ascaris lumbricoides-induced
acute pancreatitis and all of them were females and were diagnosed on ultrasonography. In two patients
the sphicterotomy was done while in third patient the worm came out after two days of conservative
management.
Keywords: Pancreatitis, Ascaris Lumbricoides, Ultrasonography, Tropical countries
INTRODUCTION
Infestation with gastrointestinal parasites is well
known in Asian countries and is associated with
a well recognized spectrum of biliary and
pancreatic complications. In the Indian
subcontinent, ascariasis is highly endemic in
Kashmir (70%), Bangladesh (82%), and central
and southwest India (20-49%) 1.
These parasites are transmitted via the faeco-oral
route. Their eggs hatch in the small intestines and
the larvae migrate through the gut wall into the
bloodstream and to the alveoli. They
subsequently move up the respiratory tract to the
trachea and are swallowed. The larvae mature in
the small intestines, deriving nutrients from
Raina et al.,
ingested food. Poor sanitation is usually the most

important risk factor for infection, and women
are more affected because progesterone plays a
role in inducing Oddis sphincter relaxation,
allowing the nematode to access the biliary duct
2
. Ascaris lumbricoides is the second most
common intestinal parasite world-wide and,
although the infection can be asymptomatic, in
some cases, it can present with complications,
such as acute pancreatitis 3.
CASE REPORTS
Our first case was a 27 year old female with 4

months pregnant who presented with pain upper
abdomen which was severe in intensity,
673
continuous type, radiating to back, aggravated by

lying supine and multiple episodes of vomiting.
Examination was normal except tenderness over
epigastrium with 16 weeks of gestational age.
Fetal heart sounds present with FHR of 130 beats
/min. Investigation revealed Hb 9.5 mg/dl, total
leucocyte count 14.8 103 /ul, DLC showed
neutrophils 82.6% and lymphocytes 16.7%,
platelets 98 103 /ul, MCV 88.9 fl, MCH 26.3
pg, urea 26 mg/dl, creatinine 1.1 mg/dl, sodium
145 meq/L, potassium 3.0 meq/L, pH 7.50, pO2
73 mmHg, amylase 1886 IU/L (repeat amylase
1379 IU/L), bilirubin 0.28 mg/dl , ALT 19
IU/ml, ALP 41 IU/ml, proteins 6.26 g/dl and
albumin 3.4 g/dl. Ultrasonography of abdomen
showed a large linear shadow extending from
mid body to tail in the main pancreatic duct
(MPD) (Fig. 1). Initially a diagnosis of acute
mild pancreatitis with BISAP score of 1/5 was
made. Patient was put on intravenous fluids and
analgesics but there was no response instead pain
got
aggravated.
Urgent
esophagogastroduodenoscopy (EGD) was done
which was normal ruling out worm across papilla
which may cause so severe pain. Next morning
she was subjected to endoscopic retrograde
cholangiopancreatography (ERCP) [shield was
used in view of pregnancy] which confirmed the
presence of ascaris worm in main pancreatic duct
(Fig. 2). Attempts to remove the worm from the
duct failed. Hence patient was continued on
conservative management and pyrantel pamoate
(safe in pregnancy) 750 once a day for 7 days to
which she responded. MRCP on follow up

revealed no worm in MPD (Fig. 3).
Second case was a 13 year old female student
presented with sudden onset pain upper abdomen
which was radiating to back and aggravated on
lying down. Pain was associated with profuse
bilious vomiting. On examination there was
tenderness epigastrium and right hypochondrium
with
mild
guarding
of
abdomen.
Ultrasonography showed bulky pancreas with
hypoechoic linear shadow and double lumen sign
suggestive of worm in the MPD (Fig. 4). Serum
amylase was 2000 IU/ml. EGD showed worm
across papilla hence sphincterotomy was done.
Repeat USG after two weeks was normal.
Our third case of pancreatitis secondary to
ascaris was a 45 year old female presented with
pain upper abdomen which was severe in
intensity, radiating to back, continuous, non
colicky and relieved by analgesics. Nausea was
associated with the pain. There was no history of
vomiting, passage of worms, icterus or bleeding
from any site. Examination of the patient was
normal except for mild epigastric tenderness.
Ultrasonography showed bulky pancreas and
hypoechoic elongated focus suggestive of worm
in main pancreatic duct (MPD) (Fig. 5). There
was also a well defined perifollicular cyst 4.4
3.1 cm in right adnexial region. Serum amylase
in this patient was 3400 IU/ml while rests of the
investigations were normal. Patient was managed
conservatively and USG on second day showed
no worm in MPD.
Fig.1: ultrasound of a 27 year old pregnant woman Fig. 2: ERCP of the same patient showing worm
showing worm in main pancreatic duct (W)
in MPD (arrow)
Raina et al.,
674
Fig. 3: MRCP of the same patient on follow up.

No worm in MPD (arrow)
Fig. 4: Ultrasound of a 13 year old girl showing

worm in MPD (arrow)
Fig. 5: Ultrasound of a 45 year old female showing worm in MPD (W)

DISCUSSION AND CONCLUSION
Ascaris lumbricoides is a common parasitic

infestation that is known to infect more than a
billion people worldwide4. Endemic areas
include tropical and subtropical countries. The
warm and humid climate is appropriate for the
growth and development of the larva.
Ascaris lumbricoides infestation is acquired
through ingestion of eggs in raw vegetables. The
human is the definitive host. Ingested larvae
penetrate the intestinal lymphatic and venous
vessels and through the portal vein reach the
right heart, pulmonary circulation and the
alveoli. After alveolar rupture they pass into the
trachea and the pharynx, are then swallowed;
after about 2 months they reach maturity. In the
bowel nematodes can perforate the intestinal
wall, be ejected from the mouth or anus and
Raina et al.,
penetrate the biliary ducts or the airways. The

infestation can present as a wide range of
symptoms: intestinal perforation or occlusion,
cholangitis,
obstructive
jaundice,
acute
pancreatitis or appendicitis, pneumonia and
respiratory failure and allergic reactions to the
ascaris antigen. In most cases, however, patients
present with unspecific symptoms and sometimes
the diagnosis is incidental2.
Common clinical manifestations of this parasite
include malnutrition, symptoms of intestinal
obstruction and also pneumonitis, if the larvae
load is high. The adult worm can invade the
biliary or pancreatic ducts, or both, and cause
complications such as biliary duct obstruction,
cholecystitis, cholangitis and acute pancreatitis.
Invasion of the pancreatic duct is rare because of
675
its narrow caliber. Pancreaticobiliary ascariasis

commonly occurs with a background history of
cholecystectomy and sphincterotomy.5
Ascaris lumbricoides causes pancreatitis due to
obstruction of papilla of Vater, invasion of
common bile duct, or invasion of pancreatic duct.
Ascension of the parasite into the pancreatic
ducts and calcified worm and ova remains are
implicated in pancreatitis. The worm enters the
pancreatic duct only as a result of abnormal
migration. The clinical diagnosis of Ascaris
pancreatitis requires a high degree of suspicion.
While intestinal obstruction is more common in
children, pancreatic ascariasis, unlike in adults, is
rare. The hepatobiliary duct network in children
is smaller and thus more difficult for worm entry.
The mean age of patients who present with
hepatobiliary and pancreatic ascariasis (HPA) is
35 years (range, 4 to 70 years), with a female-tomale ratio of nearly 3:1 6. Pregnant women and
patients with ahistory of biliary tree surgery who
are infected with ascaris are at an especially
heightened risk for contracting HPA7. There is a
postulated female preponderance for biliary
ascariasis due to the ampullary smooth muscle
relaxing effect of the hormone progesterone.
Ascaris related clinical disease is not just
restricted to patients with a heavy worm load8
but may be seen with a single worm lodged in
the biliary tract and negative parasitic tests in the
stools9. Pain is sudden in onset but may be
gradual, the epigastrium being the commonest
location. Other accompanying symptoms are
vomiting, nausea and anorexia8, jaundice with
fever being a sign of associated biliary tract
involvement.
In the biochemical evaluation, the sensitivity of
amylase in pediatric acute pancreatitis is less
than in adults. Even then, it remains the most
widely used single test in acute pancreatitis. The
serum level rises within 2 to 12 hours. Some
studies claim that stool examination lacks
sensitivity and specificity10. Ultrasonography of
the biliary system is the investigation of choice
to reveal the aetiology of pancreatitis. It is
capable of detecting stones and has been shown
Raina et al.,
to be able to detect ascariasis4. Ultrasonography

is also the gold standard technique for follow-up.
A case of a 64-year-old lady with acute
pancreatitis was reported by Price et al11 in 1988,
in which pancreatic duct ascariasis was
diagnosed based on the characteristic
ultrasonographic appearance known as the fourlines sign.
Sandouk et al5 reviewed 300 patients with
pancreatic ascariasis in Syria and showed that
ultrasonography, together with clinical findings,
are the mainstay of diagnosing pancreatic
ascariasis5. Diagnostic ultrasonography is a
simple, non-invasive test with a sensitivity of
50% to 86% for worms in the biliary tree; but the
sensitivity for detecting worms in the pancreatic
duct is unknown10,12. The two major sonographic
findings are:
1) Increased bulk and decreased echogenicity of
pancreas.13
2) Long, linear, echogenic strips in the pancreatic
duct that may show acoustic shadowing9.
A CT scan can also be useful but has a lower
sensitivity than ultrasonography5. Endoscopic
retrograde cholangiopancreatography is the gold
standard method for identifying and removing
the nematode from the duodenal, biliary or
pancreatic tract2.
Anthelmintic therapy with piperazine is preferred
though mebendazole or albendazole is effective
in eradicating ascariasis in 84% to 100% of
cases12. Feedings should be restarted when
abdominal tenderness has disappeared, any ileus
has resolved, and urinary amylase clearance has
become normal. The prognosis of ascarisinduced pancreatitis is excellent if the patient is
diagnosed and treated early. It requires prompt
recognition
and
treatment
to
prevent
5
complications . Wait and watch protocol should
be followed as there are high chances that worms
come out with conservative management only.
ACKNOWLEDGEMENT
We acknowledge the support of teachers at our

institute and patients who were actively involved
in the case study.
676
REFERENCES
1. Khuroo MS. Hepatobiliary and pancreatic

ascariasis.
Indian
J
Gastroenterol.
2001;20:C2832.
2. Misra SP, Dwivedi M. Clinical features and
management of biliary ascariasis in a nonendemic area. Postgraduate medical journal,
2000;76:2932.
3. Al-Qurashi A, Maklad KM, Al Abdulwahed
O. Pancreatitis due to ascaris lumbricoides, a
case report. J Egypt Soc Parasitol
2003;33:657-62.
4. Clinch CR, Stephens MB. Case description
of Ascariasis. Arch Fam Med 2000; 9:11934.
5. Sandouk F, Haffar S, Zada M, Graham DY,
Anand BS. Pancreatic-biliary ascariasis:
experience of 300 cases. Am J Gastroenterol
1997; 92:2264-7.
6. Khuroo MS: Ascariasis. Gastroenterol Clin
North Am 1996; 25:553-577
7. Sridhar V. Basavaraju, Peter J. Hotez. Acute
GI and surgical complications of ascaris
lumbricoides infection. Emedicine 2003;
available
at
http://www.medscape.com/
viewarticle/ 451597
8. Jordan SC, Ament ME. Pancreatitis in
children and adolescents, J Pediatr 1977; 91:
211-216
9. Shad JA, Lee YR. Pancreatitis due to
Ascaris Lumbricoides: second occurrence
after 2 years. South Med J 2001;94(1):78-80
10. Khuroo MS, Zargar SA, Yatoo P, et al:
Ascaris-induced acute pancreatitis. Br J Surg
1992; 79:1335-1338
11. Price J, Leung J.W.C.Ultrasound diagnosis of
Ascaris lumbricoides in the pancreatic
duct:the four-linessign. Br J Radiol.
1988;61:4113.
12. Larrubia JR, Ladero JM, Mendoza JL, et al:
The role of sonography in the early diagnosis
of biliopancreatic Ascaris infestation. J Clin
Gastroenterol 1996; 22:48-50
Raina et al.,
13. Fleischer AC, Parker P, Kirchner SG, et al.

Sonographic findings of pancreatitis in
children. Radiology. 1983; 146:151-55.
677
DOI: 10.5958/j.2319-5886.2.3.054

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www.ijmrhs.com
th
Coden: IJMRHS
Copyright @2013
th
ISSN: 2319-5886
Case report
BILATERAL VARIATIONS OF RENAL VASCULATURE : A CASE REPORT

Praveen Kumar Doni R1, Janaki CS1, Vijayaraghavan V1, Usha Kothandaraman1, Chandrika Teli1,
Ambareesh2
1
Department of Anatomy, 2Department of Physiology, Meenakshi Medical College & R.I., Enathur,
Kanchipuram,Tamilnadu,India.
*Corresponding author email: sudprav@gmail.com.
ABSTRACT
During routine dissection, an uncommon variation was found in the renal vessels of a male cadaver.a
Each kidney was found to have two renal veins and the branches of the renal artery lie outside the hilum.
In the present scenario, it has become imperative for the surgeons understand the abnormalities of renal
vasculature, as the utility of laparoscopic renal surgeries grew considerably. Otherwise such surgeries
may be hampered by these anatomical variations. The presence of these abnormalities is also
accountable in radiological Imagings, renal transplant, selective segmental clamping during partial
Nephrectomy. Hence, this case report will throw light in the understanding of renal vasculature and its
anatomical, embryological variations.
Key words: Kidney, Renal vessels, Laparoscopic procedures, Nephrectomy
INTRODUCTION
The renal arteries are the lateral branches of

abdominal aorta just below the origin of superior
mesenteric artery. And these paired renal arteries
are considered as end arteries and it takes 20%
cardiac output. The right renal artery is longer
and higher than the left renal artery. In 70%
individuals a single renal artery is present but it
often varies in disposition. The left renal vein
(7.5cm) is three times longer than the right renal
vein (2.5cm) 1. And for this reason, the left
kidney is the preferred side for live donor
nephrectomy. Left renal vein is may be doubled
and sometimes referred to as persistence of the
renal collar. However renal vessels variations
are very common. Variations are reported by
many researchers2,3,4. These variations useful in

radiological imagings, renal transplant, renal
artery embolization, renovascular hypertension,
radical renal surgery5. During conservative
surgical procedures, these Renal arterial lesions
may develop the Hypertension6.
Praveen et al.,
CASE REPORT
During routine conventional dissection in a male

cadaver approximately 65 years, unusual
dispositions of the renal vessels were found.
Variations were found both sides, the presence of
unexpected blood vessels to and from the kidney
was observed.
678
Variations
Renal arteries: The anterior division of the renal
artery divided into three segmental arteries
before entering hilum on left kidney (Fig1) and
on the right kidney (Fig2) is divided into two
segmental arteries.
Renal veins
Right kidney: Additional renal vein is found on

the right side (Fig2), which drained into the
inferior venacava with the renal vein separately.
Left Kidney: Two tributaries of the left renal
vein (Fig1) were also found lying outside the
Hilum of the left kidney which joined to form a
single vein that eventually drained into the
inferior vena cava.
Figure 1. Left renal artery (LT.RA) 1,2,3 shows Segmental arteries Left renal vein (LT.RV) 1,2 Tributaries of
left renal vein Superior mesenteric artery (SMA) Left ureter (LT.URETER), Left gonadal vein (LT.GONADAL
VEIN)
Figure 2. Right renal artery (RT.RA) Renal vein1 (RV1) Renal vein (RV2) Inferior vena cava( IVC)
Fig.3: Right kidney (RT. KIDNEY) 1(Renal vein1), 2 (Renal vein2) Right renal veins (RT. RV) Right ureter (
RT. URETER) (Left Kidney (LT.KIDNEY) Left renal vein (LT.RV) 1,2 ( Tributaries of left renal vein) Left
gonadal vein (LT. GONADAL VEIN) Left ureter (LT. URETER) Superior mesenteric artery (SMA)
679
Praveen et al.,
Fig.4: Right renal vein (RV1) Right renal vein (RV2) Right renal artery ( RT.RA) Inferior venacava (IVC)
DISCUSSION
The vascular patterns of the kidneys are

inevitable to understand in order to perform
various procedures for treatment. Graves7first
described the vascular segments of the kidneys
into five: apical, superior, inferior, middle and
posterior. Each segment receives blood supply by
the branches from the main renal artery.
Embryological explanation of these variations
are discussed by Keibel and Mall8. During
development the mesonephric arteries are present
between the 6th cervical to the 3rd lumbar
segments and classified into three groups:
i) Cranial Group consists of 1st and 2nd arteries
located cranial to the coeliac trunk
ii) Middle group Consists of 3rd to 5th arteries
that pass through the suprarenalbody.
iii) Caudal group consists of 6th to 9th arteries.
The gonads, mesonephros and metanephros are
supplied by arterial segments from rate
arteriosum urogenital which is the network
formed by mesonephric arteries, later some of
the roots of this network degenerate and blood
supply and blood supply to the area are replaced
by the neighbouring root. This describes why the
segmental branches have variation in their point
of origin.
The occurrence of variations of renal vein can be
explained on the basis of embryologic
development. The development of the veins is a
part of a complex developmental process of the
inferior vena cava. The processes start of the 4th

week and ends at the 8th week of conception.
Three pairs of parallel veins formed initially,
they are posterior cardinal vein, sub cardinal vein
and supracardinal vein.
Renal veins are formed by the anastomoses of
sub cardinal and supracardinal veins. Initially
two renal veins formed i.e. Dorsal and ventral
vein. The dorsal vein usually degenerates, ventral
vein forms the renal vein. Around the 8thweek,
the bilateral cardinal venous system converts into
unilateral right sided inferior venacava. At this
time, two renal veins are present on each side,
one on ventral plane and another dorsal to it.
With further development, there is a confluence
of two tributaries producing a single vessel. The
persistence of these two veins results in the
additional renal vein on the right side.
In this case, the renal vein on the right side falls
under the category of type IA and on the left side
it is type III of the classification of Sathyapal et
al9.
CONCLUSION
A detailed knowledge of variations of renal

vessels is obligatory for the safe performance of
endovascular procedures, clamping of vessels
during partial nephrectomy and abate the
complications in various surgical procedures.
680
Praveen et al.,
REFERENCES
9.
Susan standaring Grays Anatomy. The

Anatomical Basis of Clinical practice.39th
Edition
London,
Elseiver
Churchil
Livingstone Publishers. 2005; 1274 -75.
Shakeri AB, Tubbs RS, Shoja MM, Pezeshk
P. Farahani RM. Khaki AA, Ezzati F,
SeyednejadF. Bipolar supernumerary renal
artery. Surg Radio Anat. 2007, 29(1):89-92.
Rao M, Bhat SM, Venkataramana V,
Deepthinath R, Bolla SR. Bilateral prehilar
multiple branching of renal arteries: A case
report and literature review, Kathmandu
University Medical journal. 2006, 4(3):345348.
Satypal KS, Haffejee AA, Singh B,
Ramsaroop L, Robbs JV,Kalideen JM.
Additional renal arteries incidence and
Morphometry,
Surg
Radiol
Anat,2000,23(1):33-38.
Fernandes RMP, Conte FHP, Favorito LA,
Abidhu-Figueredo M, BabinskiMA. Triple
renal vein: an uncommon variation. Int J
Morphol.2005;23:231-33.
Harrison LH, Flye MW, Seigler HF.
Incidence of anatomical variants in renal
vasculature in the presence of normal renal
function. Ann Surg 1978;188(1):83-9.
Graves FT. The anatomy of the intra renal
arteries and its Application to Segmental
Resection of the kidney. Br J Surg
1954;42:132-39.
Keibel F, Mall FP,eds.,Manual of human
Embryology.
Vol.2.Philadelphia,
J.B.Lippincot 1912;820-825.
Satyapal
KS,
Rambiritch
V,PilaiG.
Additional Renal veins:incidence and
morphometry. Clin Anat. 1995;8:51-55
681
Praveen et al.,
DOI: 10.5958/j.2319-5886.2.3.055

&
Health Sciences
Revised: 31st May2013
Case report

Accepted: 3rd Jun 2013
OSLER-WEBER-RENDU SYNDROME: A RARE CAUSE OF UPPER GI BLEED

*Komaranchath AS1, Arun Abhilash 1, Anilakumari 2, Praveen M 3, Abdul Kareem MM4
1
Intern, 2Postgraduate trainee, 3 Senior Lecturer,

Government Medical College, Calicut, India.
Professor, Department of Internal Medicine,
*Corresponding Author e-mail: komaranchath@gmail.com

ABSTRACT
The causes of upper gastrointestinal bleed are manifold with the most common being peptic ulcers and
oesophageal varices. We present a rare cause of upper gastrointestinal bleeding due to Hereditary
Hemorrhagic Telangiectasia presenting with hematemesis and malaena due to bleeding from
telangectatic lesions in the stomach and duodenum. The patient also had typical mucosal and nail
manifestations of the disease which aided in the diagnosis of the condition.
Keywords: Osler Weber Rendu, Hereditary Hemorrhagic telangectasia, Upper GI Bleed
INTRODUCTION
Hereditary Hemorrhagic Telangiectasia (HHT)1,2

is a disorder characterized by multiple
telangiectasias in the gastrointestinal tract,
central nervous system and lungs. The criteria to
be satisfied for the diagnosis of HHT3 are
epistaxis, mucocutaneous telangiectasias, and a
positive family history. We report a typical case
of HHT who presented to us with history of
bleeding from oral and nasal cavity since several
decades and recent onset of hematemesis and
malaena. There was positive family history of
epistaxis as well. Diagnosis was delayed as the
patient did not seek tertiary level care for her
complaints for several years and it was only the
distressing complaint of blood stained vomiting
which prompted her to seek an expert opinion.
CASE SUMMARY
Komaranchath etal.,
A 65 year old female was brought to the

Medicine Casualty with a history of hematemesis
and melaena. She had recurrent epistaxis since
30 years of age, 2 episodes of bleeding from the
tongue 20 years ago, recurrent episodes of
melaena for the past 20 years and one episode of
bleeding from the nails five years ago. Two of
her siblings had epistaxis in the past. Her
youngest son has epistaxis for past 2 years. On
examination, she was pale, with no icterus,
clubbing, or pedal oedema. Her vitals were
stable. She had multiple telangiectasias in the
nail bed (Fig. 1) and multiple telangiectasias in
the oral cavity and tongue ( Fig. 2). She had no
hepatosplenomegaly or ascites. Her respiratory
and central nervous system were within normal
limits.
Cardiovascular
system
revealed
cardiomegaly. With the history of mucosal bleed.
A positive family history, and multiple mucosal
682
telangiectasias, a diagnosis of Hereditary

Hemorrhagic Telangiectasia (HHT) was made.
function, with no regional wall motion

abnormality. Ultrasound showed fatty changes in
her liver with prominent hepatic veins and no
splenomegaly or ascites. Her portal vein size was
10.8mm.
Endoscopy
showed
multiple
hemorrhagic spots in fundus, body, and antrum
of stomach (Fig. 3). She was managed with
blood transfusion and supportive measures. She
had no bleeding from other sites.
Fig. 1: Nail telangiectasias
Fig. 3: Endoscopy showing multiple telangiectasias

in the gastric fundus.
DISCUSSION
Fig.
2:
Tongue
telangiectasias.
And
Palatte
showing
Investigations
Laboratory investigations revealed hemoglobin

of 6.5g/dL , total count of 6600/mm3 ,
differential count of 84 % neutrophils, 12%
lymphocytes, and 4 % eosinophils , red cell
count of 3.3 million/mm3, haematocrit of 20%,
mean corpuscular hemoglobin of 16.3pg, mean
corpuscular volume of 62.5fl, a platelet count of
2.77 lakhs/mm3, and erythrocyte sedimentation
rate of 55 mm/hr. Peripheral smear confirmed
microcytic hypochromic anemia. Her bleeding
time and clotting time were 3mts and 6 mts
respectively. Her prothrombin time was 16s
(control 14s). Antinuclear antibody was negative.
Her blood group was O positive. Chest X ray
revealed cardiomegaly, with aortic knuckle
calcification. ECG showed ST depression in the
lateral leads. Echo-cardiogram showed good LV
Komaranchath etal.,
Heriditary Hemorrhagic Telangectasia or HHT

was first described by Legg in 18764. Later it
was described separately by Rendu. Weber, and
Osler5. 80 % of cases have a positive family
history. There is increased frequency of HHT in
blood group O which happens to be the blood
group of our patient as well. The criteria for
diagnosis
are
epistaxis,
mucocutaneous
telangiectasia, and a positive family history. The
earliest sign of this disease is epistaxis. Epistaxis
and mucocutaneous lesions are constant features.
Pulmonary involvement is seen in 30 % of cases,
70 % of which are in the lower lobes and 10 %
seen
bilaterally.
The
patient
becomes
symptomatic if the arteriovenous malformation
(AVM) is more than 2 cm. The most common
complaint being dyspnoea, followed by
hemoptysis and bruit over the chest. Clubbing
and cyanosis occurs in some cases due to right to
left shunt in the lung. CT thorax and angiography
can diagnose the lesions. In the gastrointestinal
683
tract, AVMs is seen most commonly in the

stomach and small bowel. Hepatic involvement
occurs in 10 % of cases which is characterized by
high output cardiac failure, portal hypertension
and biliary tract disease6. Upper GI endoscopy,
angiography and Doppler aids in the diagnosis.
Central nervous system manifestations include
cerebral abscesses and embolism due to right to
left shunt, and cerebral AVMs. Cerebral AVMs
are seen in 10% of cases which are detected on
MRI and MR Angiogram.
HHT is an autosomal dominant disease with two
loci7. Depending upon the genetic mutation HHT
is divided into two types - HHT 1 & HHT 2. The
genetic locus of HHT 1 is an Endoglin gene on
9q3 and codes for TGF binding protein expressed
on endothelial cells7. There is increased
incidence of pulmonary AVMs in HHT 1. The
genetic locus of HHT 2 is ALK 1 gene on
chromosome 12 which encodes a member of
TGF B receptor family7. The telangiectasias are
angiodysplastic with insufficient smooth muscle
contractile element and perivascular connective
tissue weakness. There is increased circulating
tissue plasminogen activator leading to the
impaired thrombus formation. There is increased
incidence of DIC, Factor IX deficiency and type
2 Von Willebrand's disease. Skin and digestive
tract lesions can be managed by NdYAG laser
ablation2. Pulmonary and central nervous system
AVMs are tackled using interventional radiology
techniques3,8. Gastrointestinal lesions can be
treated by Epsilon Amino Caproic Acid9,
Estrogen and Progesterone10, and endoscopic
ablation. Liver AVMs are significantly harder to
treat and liver transplantation may be the only
curative therapy which can be offered11.
Experimental treatments with anti-angiogenesis
drugs have been evaluated in small clinical trials
and have found have beneficial effects.
Bevacizumab, an anti-VEGF antibody was found
to reduce number and severity of episodes of
epistaxis12,13 and Thalidomide, another drug with
anti-angiogenic properties was also found to be
effective 14.
Komaranchath etal.,
REFERENCES
1. Govani FS, Shovlin CL. "Hereditary

haemorrhagic telangiectasia: a clinical and
scientific review". Eur. J. Hum. Genet.
2009;17 (7): 86071
2. Dupuis-Girod S, Bailly S, Plauchu H. J.
Thromb.
Hereditary
hemorrhagic
telangiectasia (HHT): from molecular
biology to patient care. Haemost. 2010; 8 (7):
144756
3. Faughnan ME, Palda VA, Garcia-Tsao G, et
al. International guidelines for the diagnosis
and management of hereditary hemorrhagic
telangiectasia". J. Med. Genet. 2009;48 (2):
7387
4. Legg W. A case of haemophilia complicated
with multiple naevi. Lancet.1876; 2 (2781):
85657
5. Alan E, Guttmacher, Douglas A, Marchuk,
Robert I, White Jr. Hereditary Hemorrhagic
Telangiectasia. N Engl J Med. 1995;
333:918-24
6. Garcia-Tsao, Korzenik JR, Young C. Liver
disease in Pts with HHT. NEJM.2000;
343:931
7. Azuma H. Genetic and Molecular
Pathogenesis of HHT. J.Med.Invest.2000;
47:81
8. Friedlander
RM.
Clinical
practice.
Arteriovenous malformations of the brain. N.
Engl. J. Med. 2011;354(26): 270412
9. Sabu HI, Morelli GA, Logrono LA.
Treatment of bleeding in HHT with EACA.
NEJM; 1995;330:1789
10. Van Cutsam E, Rut Geerts P, Geboes K et al.
Progesterone Rx in HHT. Journal of GE;
1988;10:676
11. Buscarini E, Plauchu H, Garcia Tsao G, et al.
Liver involvement in hereditary hemorrhagic
telangiectasia: consensus recommendations.
Liver Int. 2006;26 (9): 10406
12. Chandler D. Pulmonary and Cerebral AVE in
MIT. Arch. Intern. Med. 1965;116:277
684
13. Dupuis-Girod S. Bevacizumab in patients

with hereditary hemorrhagic telangiectasia
and severe hepatic vascular malformations
and high cardiac output. JAMA. 2012;307:
94855
14. Franchini M, Frattini F, Crestani S, Bonfanti
C. Novel treatments for epistaxis in
hereditary hemorrhagic telangiectasia: a
systematic review of the clinical experience
with thalidomide. JThromb. Thrombolysis.
2012 {Online First} DOI 10.1007/ s11239012-0840-5
Komaranchath etal.,
685
DOI: 10.5958/j.2319-5886.2.3.056

&
Health Sciences
Received:14th May 2013
Case report

HISTOMORPHOLOGICAL PATTERNS OF BREAST CARCINOMA : CASE REPORTS

Sandhya Panjeta Gulia*1, Lavanya M2 ,Madhusudan Chaudhury3, Arun Kumar SP3
1
Associate Professor , 2Assistant Professor, 3Professor, Dept. Of Pathology, Sri Venkateshwaraa Medical
College Hospital and Research Centre, Ariyur , Pondicherry
*
Corresponding author email :sandhya_path@yahoo.com
ABSTRACT
Breast carcinoma is the most frequent cancer in women worldwide. Diagnosis is made by triple
assessment of clinical, radiological and pathological correlation. Of all the types of breast carcinoma
diagnosed, infiltrating duct carcinoma constitutes about 75% , invasive lobular carcinoma 5 -15%,
medullary carcinoma 1-7%, secretory carcinoma ( rare type ) <1% .
Keywords : Breast carcinoma , Infiltrating duct carcinoma , Triple assessment
INTRODUCTION
Women worldwide with 1.05 million new cases

of Breast Carcinoma every year represent over
20% of all malignancies1. It has a complex
etiology with the interplay of the many causal
factors including hormonal , genetic and
environmental2. Diagnosis is made by triple
assessment which includes clinical, radiological

and pathological correlation. According to the
study conducted by Saxena et al , the commonest
age group of incidence was 4554 years (31.8%).
Nearly 22% of cases were below 40 years while
16% of cases were above the age of 65 years3.
Table 1: CASE REPORTS - Breast Carcinoma

Case
No.
Age
Gross
findings
Biopsy report
1.
2.
3.
43
40
70
7.553 cm
642 cm
321cm
4.
42
32 2cm
IDC *
IDC
IDC with neuroendocrine focal
papillary and cribriform patterns
IDC with intraductal component
5.
84
2.521.5cm
IDC with neuroendocrine

differentiation
Axillary
Lymph node
metastasis
Positive
-
Hormone
receptor status
(ER/PR)
Negative
Weakly positive
Negative
ER > 90%
PR > 90%
ER 75%
PR 85%
686
Sandhya etal.,
Case
No.
Age
Gross
findings
Biopsy report
6.
\\7.
46
52
1144cm
643cm
IDC with focal papillary pattern

ILC#
Axillary
Lymph node
metastasis
Positive
Positive
Hormone
receptor status
(ER/PR)
Negative
Negative
8.
71
3.532cm
Medullary carcinoma
Positive
Negative
9.
50
54.53cm
Secretory carcinoma
Negative
(*) IDC - Infiltrating Ductal Carcinoma ;( ) ILC Infiltrating Lobular Carcinoma ; ( ) ER/PR Estrogen and Progesterone Receptor
CASE I : 6 case of IDC with similar gross
morphology of the irregular firm to hard mass,
cut section - gray white was reported.
Microscopy showed neoplastic ductal epithelial
cells with moderate nuclear pleomorphism
arranged in solid sheets, nests, tubules, alveoalar
and trabecular patterns infiltrating into the fibro
fatty stroma of breast. One case had features of

the intense desmoplastic reaction. Neuroendocrine pattern with rosette like formations
was seen in 1 case; metastasis to axillary lymph
nodes was seen in 2 cases. Tumor grades were 12. Two cases were positive for ER/PR receptors.
(Figure 1 & 2)
Figure. 1: (a) Gross appearance of Infiltrating Duct Carcinoma c/s : infiltrative grayish white mass(b)
Low power view (10 X,H&E) of Infiltrating Duct Carcinoma (c) Low power view(10X,H&E) of
Scirrhous carcinoma showing intense desmoplasia. (d) High power view(40XH&E) of Infiltrating Duct
Carcinoma with neuroendocrine differentiation.
Figure. 2: (a) Estrogen and (b) Progesterone Receptor strong positivity in Infiltrating Duct Carcinoma
687
Sandhya etal.,
CASE 2 : ILC presented as an irregular gray

white mass 2 cm away from the surgical margin.
Sections of the tumor
shows dyscohesive
malignant cells with relatively uniform round
nuclei. Neoplastic cells were seen infiltrating in

single file pattern.3 lymph node were positive
for metastatic deposits . Surgical margins were
free from tumor infiltration.(Figure 3)
Figure.3: (a) Gross appearance of Infiltrating Lobular Carcinoma of breast -ill defined gray white mass.
(b) Low power (10X,H&E) view of Lobular Carcinoma with Indian file pattern
CASE 3 : Secretory carcinoma presented as gray
white to solid mass in a thick walled 54.5cm
cyst, the wall of which was reddish brown ,
granular and contained blood clots and necrotic
material. Microscopy showed infiltrating sheets
and clusters of tumor cells with mild nuclear
pleomorphism, surrounding microcystic spaces
filled with eosinophilic secretions. The tumor

cells also formed tubular and papillary pattern
with fibrovascular core in sclerotic stroma.
Margins were infiltrated by the tumor cells. The
tumor was negative for hormone receptors
(Figure 4)
Figure. 4: (a) Gross appearance of Secretory Carcinoma with cystic cavity. (b) Low power (10X, H&E)
view of Secretory Carcinoma with microcystic spaces filled with eosinophilic secretions, papillary
pattern and solid sheets.
688
Sandhya etal.,
CASE 4 : Grossly Medullary carcinoma was a

gray brown mass with haemorrhagic and necrotic
cut surface. Microscopy showed pleomorphic
cells with hyperchromatic and vesicular nuclei
with prominent nucleoli, tumor cells arranged in
sheets, syncytial masses and compact nests
separated by fibrous stroma showing intense
lympho-plasmacytic infiltration.
Extensive
tumor necrosis, atypical mitoses and numerous
giant cells were present. Surgical margins were
free of infiltration. Metastasis to 6 axillary lymph
nodes was positive. The tumor was negative for
ER/PR. (figure 5)
Figure. 5: (a) Gross appearance of Medullary Carcinoma - gray brown tumor mass. (b) High power
view (40X,H&E) of Medullary Carcinoma with lymphoplasmacytic infiltrate, tumor giant cells and
mitotic figures.
DISCUSSION
IDC constitutes about 75% of breast carcinoma 4.

There is general agreement that patients with
ISC have significantly better prognosis than
those with IDC or
ILC5. According to the Nottingham modification
of Scarff Bloom Richardson grading scheme,
score is assessed : scores 3,4,5-low grade tumors
, scores 6,7-intermediate grade and scores 8 & 9
are
high grade tumors 6. Assessment of
histological grade is an important determinant of
breast cancer prognostication and should be
incorporated in algorithms to define therapy for
patients with breast carcinoma 7.
ILC represents 5-15% of all breast carcinomas4.
Tumor mass being ill defined,
lobular
carcinomas are difficult to detect clinically and
by diagnostic mammography. The tumor has a
characteristic dyscohesive cell population of low
nuclear grade arranged in a single file pattern.
Metastasis can occur to retroperitoneum,
gastrointestinal tract, orbit, leptomeninges and

genitourinary tract8.
Medullary carcinoma comprises 1-7% of all
invasive breast carcinomas4. Most are hormone
receptor negative and Her 2 negative 4. ER/PR
status did not appear to be related to the relative
risk of mortality among women with medullary
carcinoma 9. Their prognosis is more favourable
than that of other invasive breast carcinomas 9. It
has been found that the extensive presence of
plasma cells and lymphocytes helps to keep the
medullary carcinoma in check preventing it from
growing and spreading early 10. A division of
medullary carcinoma into typical and atypical
subtypes has prognostic significance and doesnt
modify treatment options 11. A cancer can be
termed as classic medullary only if all five
features of syncytial growth pattern in 75% of
the areas examined , microscopic circumscription
, high nuclear grade , lympho-plasmacytic
689
Sandhya etal.,
infiltrate and absence of tubular differentiation

and intraductal component 12,13.
Secretory carcinoma, being reported in a 50 year
old lady who presented as a case of breast
abscess is one of the rare types and accounts for
<1% of all breast cancers 14. Our case had a
mixed architectural pattern of solid , cribriform ,
tubular and papillary patterns with intra and
extracellular secretory material showing PAS
positivity. Favourable prognostic features are :
tumor size <2cm , age <20 years at the time of
diagnosis and tumor with circumscribed
margins15.
Metastasis to axillary lymph node is the single
most predictive of treatment failure
and
recurrence in patients with breast carcinoma 16.
ER/PR positivity has a better prognosis because
of responding to hormone therapy 17. Women
with tumors lacking ER / PR expression have an
estimated 1.5-2 fold higher risk of death 18.
CONCLUSION
A series of 9 consecutive breast carcinoma cases

are reported. Triple assessment comprising of
clinical, radiological and pathological assessment
should be made mandatory in high risk groups
after self examination in view of the increasing
incidence of carcinoma of the breast. The
morphologic spectrum of carcinoma is wide
with invasive ductal carcinoma constituting the
majority in our study . ER/PR studies must be
done in all cases as it has prognostic implication.
REFERENCES
1. ParkinDM , Bray F , Ferlay J, Pisani P.

Estimating the world cancer burden :
Globocon 2000. Int J Cancer 2001,94:153-56
2. SunitaSaxena, Bharat Rekhi, AnjuBansal,
Ashok Bagga, Chintamani and Nandagudi S
Murthy. Clinico-morphological patterns of
breast cancer including family history in a
New Delhi hospital , India A crosssectional study. World Journal of Surgical
Oncology 2005;3:67
3. Sunita Saxena, Bharat Rekhi, Anju Bansal,

Ashok Bagga1, Chintamani,Nandagudi S
Murthy. Clinico-morphological patterns of
breast cancer including family history in a
New Delhi hospital, India-A cross-sectional
study.World Journal of Surgical Oncology
2005;3:67
4. R.Yerushalmi, K.A.Gelmon, M.M.Hayes.
Breast carcinoma rare types : review of the
literature. Annals of Oncology 2009;20:176370
5. S Toikkanen, L Pylkkanen, H Joensuu.
Invasive lobular carcinoma of the breast has
better short- and long-term survival than
invasive ductal carcinoma.British Journal of
Cancer 1997;76(9):1234-1240
6. Leslie W Dalton et al. Histologic Grading of
Breast Cancer:Linkage of Patient Outcome
with level of Pathologist Agreement. Mod
Pathol. 2000;13(7):730-35
7. Rakha et al. Breast cancer prognostic
classification in the molecular era:the role of
histological grade. Breast Cancer Research
2010;12:207
8. Yousef et al. Invasive lobular carcinoma of
the breast presenting as retroperitoneal
fibrosis : a case report. Journal of Medical
Case Reports. 2010;4:175
9. Li Cl, Uribe DJ, Daling JR. Clinical
characterstics of different histologic types of
breast cancer. Br J Cancer 2005;93:1046-52
10. Kuroda H,TamaruJ,Sakamoto G, Ohnisi K,
Itoyama
S.
Immunophenotype
of
lymphocytic infiltration in Medullary
Carcinoma of the breast. Virchows
Arch.2005;446:10-14
11. Erum Asma. Medullary Cancer of Breast
with Atypical Features A case study. J Pak
Med Stud 2012;2(1):21-25
12. Ridolfi RL, Rosen PP, Port A, Kinne D,
Mike V. Medullary Carcinoma of the breast :
a clinicopathologic study with 10 year follow
up. Cancer. 1977;40:1365-85
13. Rumack CM, Wilson SR ,Charboneau JW.
Diagnostic Ultrasound. St Louis.1991;1:81221
690
Sandhya etal.,
14. Arce C, Cortes D, Padilla, Huntsman DG,

Miller MA, Duennas Gonzalez et al.,
Secretory Carcinoma of the breast containing
the ETV6 NTRK3 fusion gene in a male :
case report and review of the literature.
World Journal of Surgical Oncology
2005:3:35
15. Tavassoli FA, Norris HJ. Secretory
carcinoma
of
the
breast.
Cancer
1980;45:2404-13
16. Bonadonna G. Karnofsky memorial lecture:
conceptual and practical advances in the
management of breast cancer. J ClinOncol
1989;7:1380-97
17. American Cancer Society Breast Cancer
Facts and Figures 2011-2012. Atlanta :
American Cancer Society , Inc.
18. Dunwald LK, Rossing MA, Li Cl. Hormone
receptor status, tumor characteristics and
prognosis: A prospective cohort of breast
cancer patients. Breast Cancer Res
2007;9(1):6
691
Sandhya etal.,
DOI: 10.5958/j.2319-5886.2.3.057

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Copyright @2013
ISSN: 2319-5886
th
th
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Revised:10 Jun 2013
Case report
BILATERAL VARIATIONS OF ABDUCTOR POLLICIS LONGUS AND EXTENSOR

POLLICIS BREVIS: SURGICAL SIGNIFICANCE
*Gurude PV, Bahetee BH
Department of Anatomy, BJGMC, Pune, Maharashtra, India.
* Corresponding author email: chinmaydev@yahoo.co.in
ABSTRACT
Background: Abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscles are known to
exhibit numerous variations. Aims: We would like to put across an accidental unusual finding of APL
and EPB muscles. Materials and Methods: During routine cadaveric dissection of a 52 year old female
cadaver, we found an unusual APL and EPB muscles variations bilaterally. Results: Duplication of
APL tendon was noted, one showing normal attachment and the additional one on trapezium. EPB
muscle had an unusual insertion with one of the tendons of APL muscle going onto the base of the first
metacarpal. Conclusion: Such variations are important for clinicians and surgeons while performing
surgical decompression of De Quervains syndrome.
Keywords: abductor pollicis longus, extensor pollicis brevis, variations, de Quarvains syndrome.
INTRODUCTION
Variations in the anatomy of the first extensor

compartment have been associated with the
development of de Quervains syndrome.1,2 This
syndrome involves stenosing tenosynovitis of
abductor pollicis longus (APL) and extensor
pollicis brevis (EPB) tendons which comprise the
first extensor compartment of the wrist. So, their
variations have always been an area of
anatomical interest.
The APL muscle takes origin from the posterior
surface of radius, ulna and the interosseous
membrane. It is inserted into the first metacarpal
and may have an additional attachment to
trapezium bone.3 EPB muscle takes origin from
the posterior surface of radius and interosseous
membrane and is inserted into the base of

proximal phalynx.3
Anatomical knowledge of such variations may be
clinically important for surgeons performing
surgeries in the dorsolateral region of the hand.
During routine cadaveric dissection in the

department of anatomy, we found variations in
APL and EPB muscles in a 52 year old female
cadaver bilaterally. The APL and EPB muscles
were studied in detail with regard to its origin,
insertion, and innervations.
692
Gurude et al.,
RESULTS
Fig.1:Dorsolateral view of hand showing

anomalous abductor pollicis longus and extensor
pollicis brevis
EPB-Extensor pollicis brevis
APL1-Abductor pollicis longus inserted into base
of first metacarpal
APL2-Abductor pollicis longus inserted into
trapezium
EPL-Extensor pollicis longus
APB-Abductor pollicis brevis
The origin of APL and EPB muscle was found to
be normal. But near wrist APL muscle splits into
two tendons, out of which one was found to be
inserted into the base of the first metacarpal and
other on trapezium. EPB muscle had a single
tendon and was found to be unusually inserted
along with one of the tendons of APL muscle
into the base of the first metacarpal. The
innervation of both muscles was found to be by
posterior interosseous nerve.
DISCUSSION
Way back in 1951, Stein AH 4 observed that
variations in the first extensor compartment of
the wrist were involved in the etiology of the
Quervains syndrome. An incomplete knowledge
of such variations can lead to inadequate surgical
decompression of de Quervains syndrome.5
Okazaki Katsushi6 found that APL muscle had
two to four tendons and interestingly EPB
muscle had an additional insertion mainly into

the distal phalynx of thumb. Whereas in present
case report, we noted two tendons of APL
muscle and for the first time, unusual insertion
site of EPB muscle onto the base of the first
metacarpal. Teerawat Kulthanan7 studied wrists
of the cadavers and wrists of patients with de
Quervains syndrome and found that number of
fibroosseous tunnels and multiple compartments
in the first extensor compartment may be
associated with a predisposition to De
Quervains syndrome.
It may be stated that it is exceptional to find a
single tendon or the insertion of APL muscle. 8
In accordance to this fact great variability was
observed in the arrangement of tendons and their
insertions by many workers. Duplication and
triplication of APL has been frequently
reported9,10 and maximum 9 tendons have been
reported by Dil Islam Mansur.11 The presence of
multiple tendons of APL muscle may be
important for surgeons performing reconstructive
surgeries in a dorsolateral compartment of hand.
CONCLUSION
The prior knowledge of anatomical variations of

APL and EPB muscles may be helpful for
surgeons while treating de Quervains syndrome
and also during reconstructive surgeries of
traumatized hand.
REFERENCES
1. Gonzalez MH, Sohlberg R, Brown A,

Weinzweig N. The first dorsal extensor
compartment: an anatomic study. J Hand
Surg (Am). 1995;20:657-60.
2. Yuasa K, Kiyoshige Y. Limited surgical
treatment of de Quervains disease:
decompression of only the extensor pollicis
brevis subcompartment. J Hand Surg (Am).
1998;23:840-43.
3. Standring Susan. Grays Anatomy The
Anatomical Basis of Clinical Practice.39th ed.
693
Gurude et al.,
Elsevier Churchill Livingstone, New

York;2005;881.
4. Stein AH. Variations of the tendons of
insertion of the abductor pollicis longus and
the extensor pollicis brevis. Anat Rec.
1951;110:49-55.
5. Giles KW. Anatomical variations affecting
the surgery of De Quervains disease. J. Bone
Joint Surg. 1960;42:352-355.
6. Okazaki Katsushi. Anatomical studies on the
abductor pollicis longus and extensor pollicis
brevis muscles in Japanese. J. Aichi Med
Univ.Association. 2002;30:65-73.
7. Teerawat Kulthanan, Boonsong Chareonwat.
Variations in abductor pollicis longus and
extensor pollicis brevis tendons in the
Quervain syndrome: A surgical and
anatomical study. Scand J Plast Reconstr
Surg Hand Surg. 2007;41(1):36-38.
8. Coleman SS, Mcafee DK, Anson BJ. The
insertion of the abductor pollicis longus; an
anatomical study of 175 specimens. Q. Bull.
Northwest. Univ. Med School. 1953;27:117122.
9. Lacey T 2nd, Goldstein LA, Tobin CE.
Anatomical and clinical study of the
variations in the insertions of abductor
pollices longus tendon, associated with
stenosing tendo-vaginitis. J Bone Joint Surg
Am. 1951;33(2):347-350.
10. Baba MA. The accessory tendon of the
abductor pollicis longus muscle. Anat
Rec.1954; 119(4):541-547.
11. Dil Islam Mansur, Ashwin Krishnamurthy et
al. Multiple tendons of abductor pollicis
longus.
International
J
Anatomical
Variations. 2010;3:25-28.
694
Gurude et al.,
DOI: 10.5958/j.2319-5886.2.3.058

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Health Sciences
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Received: 15
Case report
2013
Coden: IJMRHS
th
Revised: 5 Jun 2013
Copyright @2013
ISSN: 2319-5886
ABDOMINAL ACTINOMYCOSIS PRESENTING AS SIMPLE ACUTE APPENDICITIS

Anita Harry
Professor, Department of surgery, Meenakshi Medical College & Research Institute, Kanchipuram,
Taminadu, India
Corresponding author email: omnarayana05@yahoo.com
ABSTRACT
Actinomycosis is an uncommon chronic infection. It usually occurs in the cervicofacial, thoracic and
abdominopelvic region. In abdominopelvic actinomycosis the ileum, ceacum and appendix is involved
usually as a mass. In our case, there was no mass clinically or radiologically. He had tenderness right
lower quadrant of abdomen, clinical diagnosis of acute appendicitis was made and appendicectomy
done. Histopathological report showed bacterial colony or sulphur granules surrounded by acute and
chronic inflammatory cells.
Keywords: Abdominal actinomycosis, Acute appendicitis
INTRODUCTION
Abdominopelvic actinomycosis is a rare

condition caused by Actinomyces israeli 1 Most
of the cases reported, describe localized forms
demonstrating
masses, pseudotumors or
abscesses during radiological studies or
surgeries 2. We report a case in which this
disease
presented
as
simple
acute
appendicitis, and the etiology, actinomycosis 1
was proved only in the histopathological report 3.
There was no mass in the abdomen clinically or
radiologically 4
CASE REPORT
A male, 22 years old, came to our hospital

with complaint of abdominal pain for two
days, vomiting one day and fever one day.
On examination he was febrile 101 F,
tachycardic 102/min. Examination of abdomen

revealed rebound tenderness over the right
lower quadrant, no guarding, no rigidity, no
mass palpable. Blood investigations were
normal except for an elevated leucocyte
count of 16,600 cells/cu.mm with 70%
neutrophils, ESR of 110mm in the first hour.
Test for HIV was non-reactive. Ultrasound of
the abdomen was suggestive of acute
appendicitis, no mass. A preoperative diagnosis
of acute appendicitis was made. Patient was
taken up for emergency appendicectomy under
spinal anesthesia. The appendix was turgid and
inflamed with tip perforated. Caecum and
distal ileum was normal, no mass. Appendix
was sent for histopathological examination.
695
Anita Harry
Fig.1: Photomicrograph shows the central

abscess with bacterial colony or sulfur granules
surrounded by acute and chronic inflammatory
cells. Rudimentary appendicular mucosa .
Post operative period was uneventful, sutures
were removed on the 7th post operative day.
He was treated with crystalline penicillin 30
lacs intravenously 6th hourly for 6 weeks and
discharged with Amoxicillin for another 6
months. Patient was doing well when he was
followed up 3 months later.
DISCUSSION
Actinomycosis is a rare granulomatous

disease caused by an anaerobic gram positive
bacterium, generally Actinomyces Israelii1 and
affects mainly cervical and thoracic regions.
One fifth of the cases have an abdominal
localization simulating other conditions 5
Actinomyces species are considered part of
normal flora found in the oral cavity,
gastrointestinal and genital tracts. 2 They are
considered opportunistic pathogens, since they
take advantage of the anaerobic environment
produced and when the mucosal barrier is
broken, it penetrates the mucosa, starting up
a
granulomatous
and
suppurative
6,7
inflammation.
Common symptom and sign
include fever and leukocytosis.8 Histopathology
confirms the diagnosis showing granulomas
and focal sulphur granules the characteristic
lesion of actinomycosis. All cases reported
about abdominal actinomycosis describe

localized
forms
demonstrating
masses,
pseudotumors or abscesses during surgeries or
radiographic studies.2 There are very few
reports about acute appendicitis caused by
actinomycetes. The most common organisms
involved in gangrenous and perforated
appendicitis are E.coli, Peptostreptococcus,
bacillus fragilis and Pseudomonas species.
Rarely actinomyces species is involved in this
process.
Preoperative
diagnosis
of
abdominal
actinomycosis is difficult. An accurate
diagnosis is always obtained by histological
or microbiological examination. Recognition
is important because successful treatment
requires combined surgery and prolonged
penicillin treatment. 3,5
REFERENCES
1. Russo TA. Agents of actinomycosis. In:

Mandal GL, Bennett JE, Dolin R. Principles
& practice of infectious diseases. New York
Churchill Livigstone; 2005p. 2924-34
2. Erdel Karagulle, Hale Turan , Emin Turk ,
Halil Kiyici, ErkanYildirum, Gokhan Moray.
Abdominal actinomycosis mimicking acute
appendicitis. Can J Surgery October 2008;
51(5): 109- 10
3. Yigiter M, Kiyici H, Arda IS, HIC Sonmez
A. Actinomycosis : a differential diagnosis
for appendicitis. A case report and review of
literature. J Pediatric surgery 2007; 42(6):236
4. Liu V, Val S, Kang K, Velcek F. Case report:
actinomycosis of the appendix - an unusual
cause of appendicitis in children. J.
Peadiatrics 2010;45(100):2050-52
5. Benhoff DF. Actinomycosis: diagnostic &
therapeutic considerations and a review of 32
cases. Can J Surgery October 2008; 51(5):
155-158
6. Berardi RS. Abdominal actinomycosis Surg
Gynecol obstet. 1979; 149: 257-66
696
Anita Harry
7. Brown JR. Human actinomycosis. A study of

181 subjects. Hum pathol 1973; 4:319-30
8. Sang-Yunhee, Hee Jin Kwaon, Jin Han
Cho,Jon Young Oh, Kyun Jin Nam, Jin
Hwahee, Seong Kuk Yoon, Myong Jin Kang,
Jin Sook Jeong:Actinomysis mimicking
appendiceal tumour:Acase report. Worid J
Gastroenterol 2010 Jan 21;16(3):395-97
697
Anita Harry
DOI: 10.5958/j.2319-5886.2.3.059

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Coden: IJMRHS
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ISSN: 2319-5886
th
th
th
Case report
COLORECTAL ADENOMAS: A CASE SERIES OF 5 CASES

Aisha Tabassum1, *Mohammad Shahid Iqbal1, Veeragandham Satyanarayana2
1
Assistant Professor, 2Professor & Head, Department of Pathology, Kamineni Institute of Medical
Sciences, Narketpally, Nalgonda, Andhra Pradesh, India
*Corresponding author email: drshahidkbn@yahoo.com
ABSTRACT
Adenomatous colorectal polyps are known to be precursor lesions for colorectal cancer. Colorectal
adenomas are usually classified into two categories:tubular and villous. A mixed (tubulovillous)
phenotype is also recognized. The aim of the study was to study the prevalence and pathological features
of adenomatous polyps. We studied five cases of adenomas. Three were diagnosed as tubular adenomas
and two were diagnosed as villous adenomas. Most of the significant polyps were identified in patients
aged 50 years or older. In case of villas adenoma, the incidence of dysplasia rose with an increase in
size. Conclusion: It is advisable that all polypoidal lesions should be removed for definitive histological
examination.
Key words: Adenoma, Polyp, Colorectal cancer
INTRODUCTION
The adenoma is a circumscribed, benign

epithelial neoplasm with potential for malignant
change 1 .The prevalence of large intestinal
adenomas varies in different parts of the world.
Adenomas are common in westernized cultures
and uncommon in developing countries 2. Many
studies have linked age, gender, smoking, family
history, and other factors, with risk of adenoma
occurrence3. The incidence of adenomas parallels
the incidence of colorectal cancer, and countries
with high rates of colorectal cancer also have
high rates of colorectal adenoma4. The frequency
of adenomas increases with age, so that there is a
50% incidence in patients who are 60 80 years
of age. They are commonly found in the
ascending colon, transverse colon, sigmoid colon

and rectum5. Adenomas may be categorized as
conventional, flat or serrated. Depending on their
predominant growth pattern conventional
adenomas are the most common5. Adenomas are
uncommon before the age of 40 years. Autopsy
surveys have also shown that adenomas are
relatively evenly distributed along the length of
the large intestine. However, adenomas are more
likely to occur in the ascending colon with
increasing age.1
Grossly, adenomas assume one of the three
major growth patterns.
(a) Pedunculated (b) Sessile, or (c) flat or
depressed
698
Aisha etal.,
Adenomatous polyps are segregated into three

subtypes on the basis of the epithelial
architecture :
1. Tubular adenomas : tubular glands
2. Villous adenomas : villous projections
3. Tubulovillous adenoma : a mixture of the
above 6 .
CASE REPORT
Here we report a case series of five cases of

colorectal adenomas diagnosed in our institute.
Three cases were diagnosed as tubular adenomas
and two cases were diagnosed as villous

adenomas4. Cases were received as a biopsy
specimen while 1 was a resected specimen. Age
of the patient ranged from 25 years to 68 years
with a mean age of 47 years. Of the 2 villous
adenomas, one was pedunculated measuring 4.5
x 2.5 cm with a stalk of 1 cm, and the other was
sessile measuring < 0.5 cm. Two tubular
adenomas were pedunculated and one was
sessile. The size of the tubular adenoma ranged
from <0.5 cm to 1.5 cm.
Table.1: Details of cases
Case No.
1
2
3
4
5
Age (Years)
68
25
28
59
50
Sex
M
M
M
M
M
Site
Rectum
Rectum
Rectum
Rectum
Rectum
Fig.1: Tubular adenoma showing dysplastic

epithelium (40X)
Histologically tubular adenomas showed tubular

architecture with back to back gland arrangement
having stratification of lining epithelium with
hyperchromatic nuclei, mitosis and mucin
depletion. The nuclei are crowded, elongated and
stratified. All the three tubular adenomas were of
low grade (Fig.1). The villous adenomas showed
elongated finger like non branching fronds and
dysplastic epithelium showing stratification of
the lining epithelium with hyperchromatic nuclei
and
mitoses.
Considerable
architectural
abnormality present in the form of crowding and
Aisha etal.,
Size (cm)
1.5
< 0.5
2.5 x 1
4.5 x 2.5
< 0.5
Type
Tubular adenoma
Tubular adenoma
Tubular adenoma
Villous adenoma
Villous adenoma
Fig.2: Villous adenoma showing dysplastic

epithelium (60X)
back to back gland arrangement was present.

Nucleoli were prominent in the larger villous
adenoma.(Fig.2)
DISCUSSION
Tubular adenomas are more frequently

pedunculated lesions. They represent the
majority of adenomatous polyps, accounting for
nearly two-thirds of lesions identified.
Histologically,
these
lesions
have
a
predominantly tubular configuration with glands
embedded in the lamina propria and infolding of
Int J Med Res Health Sci.2013;2(3):698-701 699
tubules. While the percentage of specific tubular

versus villous elements required to define
adenoma type is subject to individual definition,
it is generally accepted that tubular adenomas
must contain greater than 75% tubular features to
meet criteria 7 .Villous adenomas are the least
common type of adenomatous polyp, comprising
only 5% to 10% of all adenomas. They are more
often sessile than other polyps and commonly
appear multilobated and friable with a
cauliflower -like appearance. Histologically,
epithelial fronds that may be single or branched
are characteristic. Relative to other adenomatous
polyp, villous lesions have the most pronounced
association
with
carcinoma.
Importantly
sampling error with endoscopic biopsy may
occur, particularly with larger lesions, and all
villous adenomas should be removed completely
because of the high rate of associated cancer 7
.Distinction of villous structures from elongated
separated tubules is sometimes problematical.
Villous architecture is defined arbitrarily by the
length of the glands exceeding twice the
thickness of the normal colorectal mucosa8
Tubulovillous adenomas are characterized by a
combination of both tubular and villous
elements. These lesions occur less frequently
than tubular adenomas7. Microscopically, there is
an increase in the number of glands and cells per
unit area compared to the normal mucosa. The
cells
are
crowded,
contain
enlarged
hyperchromatic nuclei, and have an increased
number of mitoses, some of which may be
atypical. Focal areas of villous configuration are
not infrequent in adenomatous polyps9. The
degree of atypia seen in adenomatous polyps is
related to increasing age, number of polyps per
patient, size of the polyps and presence of villous
changes. It can be graded into mild, moderate
and severe; the latter is equivalent to carcinoma
in situ9. Sometimes, clusters of atypical glands in
an adenomatous or villoglandular polyp are seen
beneath the muscularis mucosae and may lead
to a mistaken diagnosis of
malignant
10,11
transformation
.
Aisha etal.,
Our study showed a male preponderance. In the

national polyp study, adenoma occurred more
frequently in men than women, with 61.6% cases
in men and 38.4% cases in women 11. In our
study, three cases were seen in individuals above
50 years of age and two cases were seen in
individuals < 40 years of age. William et al has
reported 45% of the cases in the age range of 5165 years 12. An adenoma less than 1 cm has a 0.2
% chance of being malignant, adenoma 1.0
2.0cm has a 4.2 % chance and an adenoma > 2.0
cm, a 27% chance 12 .Morphological features that
determine the malignant potential of an adenoma
are size, growth pattern and grade of dysplasia.
The majority of colorectal adenomas are small,
with roughly 95% less than 2cm in greatest
diameter. However, there is a correlation
between the degree of villous component and
polyp size at diagnosis. Adenomas smaller than 5
mm confer almost no risk of harboring cancer,
while increasing size and villous component
have positive linear relationships with invasive
capacity 7 . The classification of adenomas into
those with a predominantly tubular pattern, those
with a mainly villous pattern and those with a
mixture of tubular and villous areas
(tubulovillous adenoma) has shown that in
general, the adenoma with a villous pattern has a
higher malignant potential than one with a
tubular pattern. The reported risk factors for
recurrence include multiple adenomas, a large
adenoma, severe dysplasia, a tubulovillous /
villous adenoma, and an adenoma in the
proximal colon 13 To conclude, adenomas are
usually asymptomatic. Larger adenomas may
bleed and this may be tested by occult blood
testing. Most adenomas show mild dysplasia and
least
common
are
severe
dysplasia.
Demonstration across the line of muscularis
mucosae is a precondition for diagnosis of
invasive carcinoma. Innocent displacement
(pseudoinvasion) through the muscularis mucosa
to the submucosa must be distinguished. It is
advisable that all polypoidal lesions should be
removed for definitive histological examination.
700
REFERENCES
1. Jass JR. Editor. Tumors of Small and large

intestine including the anal region. Chapter 9.
In : Fletcher CDM. Diagnostic histopatholo
gy of tumors ,Churchill Livingstone Vol.1,
2nd ed. p. 379-411
2. Cooper HS. In: Mills SE, Carter D, Greenson
JK, oberman HA, Renter V, Stoler MH,
Stenbergs Diagnostic surgical pathology.
Intestinal neoplasms. 4th ed. Vol.1,
Philadelphia : Lippincott Williams and
Wilkins; 2004:p.1413-67.
3. Onega T, Goodrich M, Dietrich A, Butterly
L. The influence of smoking, gender, and
family history on colorectal adenomas. J
Cancer Epidemiol. 2010;3:1-6
4. Gastrointestinal
and
liver
pathology.
Christine A Locobrizio-Denalu, Elizabeth A.
Montgomery. A volume in the series:
Foundation in diagnosticpathology. Churchill
Livingstone, Philadelphia, 2005:p.367-394.
5. Odze RD, Noffsinger AE.Neoplastic diseases
of the small and large intestines. Chapter 27.
In: Silverberg SG, Debellis RA, Frable WJ,
Livolsi VA, Wick MR. Editors. Silverbergs
principles and practice of surgiocal pathology
and cytopathology. Vol 24th ed.Churchill
livingstone 2006.p1418-1464
6. Lui C, Crowford JM. Editors : The
gastrointestinal tract. Chapter 17. In: Robbins
& Cotran. Pathologic basis of disease. 7th ed.
Saunders, New Delhi. p797-875.
7. Weinberg D, Sigudrome, Lewis N, Meyers.
Adenoma / Adenocarcinoma (excluding
adenomatous polyposis). Chapter 23 In:
Wexner SD, Stollman N. editors. Diseases of
colon. Information health care, Newyork,
p.477-515
8. Hamilton SR, Aaltonen LA, editors : WHO
classification of tumors. Pathology and
genetics of tumors of the digestive system.
IARC press Lyon. 2000:p103 -142.
Aisha etal.,
9. Large bowel. Chapter 11, In: Rosai and

Ackermans surgical pathology 9th ed.
Mosby 2004;1:776-885.
10. Makinen MJ, George SMC, Jernvall P,
Makela J, Vihko P, Karttunen TJ. Colorectal
carcinoma associated with serrated adenoma
prevalence, histological features, and
prognosis. J Pathol 2001;193:286 -294.
11. Epithelial neoplasms of the colon. Chapter
14. In : Fenoglio-preiser CM, Noffsinger AE,
Stemmermann GN, Lantz PE, Issacson PG.
Gastrointestinal pathology. An Atlas and
Text. 3rd ed. Wolters Kluwer / Lippincott
Williams and Wilkins. 2004. P899-1035
12. Webb WA, Medaniel L, Leroy RN, Jones
MT. Experience with 1000 colonoscopic
polypectomies Ann Surg. 1998;201(5):62630
13. Ji JS, Choi KY, Lee WC, Lee BI, Park SH,
Choi H et al. Endoscopic and histopathologic
predictors of recurrence of colorectal
adenoma on lowering the miss rate. Korean J
Intern Med 2009;24:196-202
Int J Med Res Health Sci.2013;2(3):698-701 701
DOI: 10.5958/j.2319-5886.2.3.060

&
Health Sciences
Received: 2nd May 2013
Case report
GASTRIC DUPLICATION CYST: AN UNCOMMON CAUSE OF PAIN ABDOMEN IN AN
ADULT
*Shafiq Syed1, Ramathilakam B2
1
DM Resident, 2Professor and HOD, Department of Medical Gastroenterology. Meenakshi Medical

College and Research Institute, Kancheepuram, Tamilnadu, India
*Corresponding author email: syed.dr.s@gmail.com
ABSTRACT
Duplication cysts are rare congenital developmental anamolies of the gastrointestinal tract, the etiology
of which is not completely understood. Multiple theories have been proposed to explain their existence
including partial twinning, in utero ischemic events, and abnormal endoderm and notochord
separation. Complications including infection, intussusception, and perforation can occur. Rarely,
these duplications cysts may undergo neoplastic changes. In this report, we present the case of a 40year-old male with a gastric duplication cyst who presented with vague postprandial dull-aching
epigastric pain. Gastric duplication cyst was diagnosed with upper GI endoscopy and CT scan. The
cyst was removed by simple excision and patient has remained symptom-free on follow up.
Keywords: Gastric duplication cyst, Volvulus, Intussusception, simple excision.
INTRODUCTION
A duplication cyst is one of the rarest congenital

abnormality involving the gastrointestinal tract.
The wall of these duplication cysts is contiguous
and they tend to derive a common arterial
supply from the GI organ from which they
arise1. Duplication cysts usually present in the
pediatric age group, but some may remain
asymptomatic and may present later in life.2 In
this report, we present a middle aged male
patient with uncomplicated gastric duplication
cyst.
A 40-year-old male patient presented with
history of recurrent episodes of postprandial

dull aching, nonradiating abdominal pain,
localized in the epigastrium and around the
umbilicus for 6 months. There was no history
of hemetemesis, melaena, hematochezia, loss of
appetite, or weight loss. There was no history of
diabetes mellitus or hypertension. His past
medical, surgical, and social history was
unremarkable. Physical examination revealed
him to be afebrile with stable vital signs. His
systemic examination was noncontributory
including per abdomen examination. His
laboratory investigations including complete
hemogram, RBS, RFT, LFT were unremarkable
Shafiq et al.,
702
CASE HISTORY
as was a chest x-ray and USG abdomen. Upper

GI endoscopy showed a soft cystic mass causing
an extraneous impression over the fundus of
stomach with normal overlying mucosa (Figure
1). Duodenum revealed mild duodenitis in its
first part. The rest of the endoscopy was normal.
CT plain and contrast of the abdomen showed a
well-defined cystic lesion measuring 4.2 x 3.6 x
4.0 cm adjacent to gastroesophageal junction
and fundus of the stomach causing extraneous

impression on it with no enhancement of the
lesion, suggestive of distal esophageal/gastric
duplication cyst (Figure 2 and 3). The patient
was treated by simple excision of the
duplication cyst. Microscopic examination
revealed a cyst lined with gastric type mucosa
consistent with a gastric duplication cyst.
Fig.1: Retroflexed endoscopic view showing a soft cystic mass arising in the fundus of the stomach with
normal overlying mucosa
DISCUSSION
Duplication cysts arise due to a congenital

developmental
abnormality
within
the
gastrointestinal tract, the etiology of which is
not completely understood. The first description
of duplication of the gastrointestinal tract was
described by Calder1 in 1733. A gastrointestinal
duplication cyst can occur anywhere along the
GI tract. Gastric duplication cysts represent
approximately 20% of all gastrointestinal cysts.
They are often a missed by the clinicians due to

the rarity of their occurrence and the vague
complaints with which the patients present.
With advances in diagnostic techniques, they
are now being diagnosed before the patient is
subjected to surgery in a majority of the cases.
Multiple theories have been proposed to explain
their existence including partial twinning, in
utero ischemic events, abnormal endoderm and
Shafiq et al.,
703
notochord separation, abnormal recanalization

theory by Bremmer, etc., have been described to
explain their occurrence. Although each of these
theories offers an explanation for the formation
of duplication cysts, none of them adequately
and satisfactorily explains the occurrence of
these duplication cysts.
A duplication cyst can rarely present in the adult
age group and is usually an incidental finding
during endoscopy done for vague abdominal
complaints of palpable mass, signs and
symptoms suggesting GI tract obstruction, or
gastrointestinal hemorrhage. The cyst may
sometimes contain ectopic pancreatic mucosa
and mimic acute pancreatitis. A majority of the
duplication cysts occur in females regardless of
age3,4. About half of the cases were reported to
have associated congenital abnormalities5 the
commonest being concurrent duplications
elsewhere in the GIT with vertebral anomalies
being the second most commonly linked
abnormality4,5.
Gastric duplication cysts are located contiguous
with the stomach, generally along the greater
curvature of the stomach. If the lumens are
contiguous, then it is defined as tubular, and if
they are completely separate, then it is described
as cystic6,7 and a majority of them are of the
later variant. In our case, gastric duplication was
located on greater curvature of the stomach, was
cystic in nature, and of the non-communicating
variant.
The clinical features of gastric duplication cysts
depend on the size, the location, and the
communicating structure (if any). Rare though
reported complications include torsion of
pedunculated cysts, neoplastic transformation,
hemorrhage,
and
pancreatitis4,8.
These
duplication cysts have a definite although
limited malignant potential, and three cases of
Shafiq et al.,
malignancy arising from these duplication cysts

have been reported in literature9.
Ultrasound abdomen, upper GI endoscopy,
contrast studies of the GI tract, CT scan, and
MRI may demonstrate these lesions.
Simple surgical excision is considered the
optimal therapy (6). When a complete excision
of these cysts is not possible, debulking,
cystogastrostomy, or partial gastrectomy is
done.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
Calder J. Duplication of the stomach.

Medical essays obser 1733; 1 : 205
Rowling JT. Some observations on gastric
cysts. Br J Surg 1959;46:441-5
Kim DH, Kim JS, Nam ES, et al. Foregut
duplication cyst of the stomach. Pathol Int
2000;50:142-5
Gupta S, Sleeman D, Alsumait B.
Duplication cyst of the antrum: a case
report. Can J Surg 1998;41:248-50.
Wieczorek RL, Seidman I, Ranson JH.
Congenital duplication of the stomach: case
report and review of the english literature.
Am J Gastroenterol 1984;79:597-602.
Bartels RJ. Duplication of the stomach.
Case report and review of the literature. Am
Surg 1967;33:747-52.
Wang JY, Huang TJ, Hsieh JS. Gastric
duplication cyst: report of a case.
Kaohsiung J Med Sci 1998;14:121-5
Sasaki T, Shimura H, Ryu S. Laparoscopic
treatment of a gastric duplication cyst:
report of a case. Int Surg 2003;88: 68- 71.
Blinder G, Hiller N, Adler SN. A double
stomach in the adult. Am J Gastroenterol
1999;94:1100-2
704
DOI: 10.5958/j.2319-5886.2.3.61

&
Health Sciences
Coden: IJMRHS
st
Case report

COMPRESSION OF LEFT MAIN BRONCHUS WITH COLLAPSE OF LEFT LUNG BY A

LARGE DESCENDING THORACIC AORTIC ANEURYSM: A CASE REPORT
*
Khushal N. Pawar1, Dilip L. Lakhkar2, Sushil Nemane3, Sandeep Shinde 3
Senior Resident, 2Professor and Head, 3Senior Resident, Department of Radiodiagnosis and Imaging,
Padmashree Dr.Vithalrao Vikhe Patil Foundations Medical College & Hospital, Ahmednagar,
Maharashtra, India
*Corresponding author email: pawar.khushal@gmail.com
ABSTRACT
We report a case of 60 years old female who presented with a history of progressive breathlessness over
a period of one year. CECT thorax revealed a large aneurysm of descending thoracic aorta which was
causing compression of left main bronchus with resultant complete collapse of left lung. There was a
contralateral shift of the trachea and mediastinum.
Keywords: Large aneurysm, descending thoracic aorta, left main bronchus
INTRODUCTION
The origin of term, aneurysm is from the

Greek word, Aneurusma, which means
widening. 1 In general an aneurysm is defined
as a permanent and irreversible localized
dilatation of a blood vessel.1 Morphologically
the, fusiform or saccular aneurysm can be
defined, when the aneurysm involves the whole
or partial circumference, respectively.1 Computed
tomography (CT), is a standard modality for
evaluating an aortic aneurysm as it provides
morphology and
its relationship with the
2
adjacent structures.
In this article we are presenting a case of thoracic
aortic aneurysm with compression of left main
bronchus which was diagnosed on CECT.
CASE REPORT
A 60 year old female presented with a history of

progressive breathlessness over a period of one
year. A radiograph of chest showed opaque left
hemithorax with contralateral shift of
mediastinum and curvilinear calcification [Figure
1]. CECT thorax showed severe fusiform
dilatation of entire thoracic aorta commencing
approx. 1.5 cm distal to origin of left subclavian
artery and extending inferiorly up to T11
vertebra. Non enhancing intraluminal hypodense
thrombus was seen with peripheral calcifications.
The entire lesion measured 12.4 x 11.6 x 18.0
cms in its antero-posterior, transverse and craniocaudal dimensions respectively [Figure 2 & 3].
There was contralateral shift of trachea and
mediastinum. Significant extrinsic compression
of left main bronchus was noted with resultant
705
Khushal Pawar etal.,
complete collapse of left lung [Figure 4]. The

lesion also causesd compression of mid
esophagus with proximal dilatation. Scalloping
of the adjacent left ribs was noted due to chronic
pressure effect. Incidentally, aberrant right subclavian artery was seen [Figure5]. Small quantity
of left pleural and pericardial effusion was seen
[Figure2&3].
Fig.3: Coronal CECT image showing cranio
caudal extent of the aneurysm
Fig.4: Axial CECT Arrow shows compression of

left main bronchus
Fig.1: X- ray chest
Fig.5: Axial CECT image, arrow showing

aberrant right subclavian artery
DISCUSSION
Fig.2: Axial CECT image showing large an
aneurysm of descending thoracic aorta with
peripheral hypodense thrombus
An aortic aneurysm defined as an abnormal focal

dilatation of blood vessels. Computed
tomography (CT) angiography is commonly used
for the diagnosis of thoracic aortic aneurysm (3).
The diameter of the descending thoracic aorta
should not be more than 3 cm3,4. The thoracic
706
aorta consists of aortic root, ascending aorta,

aortic arch and descending thoracic aorta. The
ascending aorta is from the root of the aorta to
the origin of the right brachiocephalic artery. The
aortic
arch
extends
from
the
right
brachiocephalic artery to the attachment of the
ligamentum arteriosum. The descending thoracic
aorta extends from the ligamentum arteriosum to
the aortic hiatus in the diaphragm5.
Thoracic aortic aneurysm can be classified as
true
aneurysm
or
false
aneurysm
(pseudoaneurysm). True aneurysms consist of all
the three layers i.e.
intima, media, and
adventitia. Fusiform dilatation is commonly seen
with atherosclerosis3. Out of the various causes
of aneurysm, atherosclerosis is the most common
cause accounting for approximately 70% of all
thoracic aortic aneurysm6.
Pseudoaneurysms are not lined by all the three
layers and are contained by the an adventitia or
periadventitial tissue. They are typically saccular
having a narrow neck, and the common causes
are trauma, penetrating atherosclerotic ulcers, or
infection (mycotic aneurysms)6.
CT accurately gives assessment of thrombus
morphology and the patent contast filled lumen.
The extent and the location of the calcification is
also better evaluated on CT scan. The mass effect
of thoracic aortic aneurysms like compression of
adjacent structures is also clearly seen with the
help of CT scan3.
2. Macura KJ, Corl FM, Fishman EK, Bluemke

DA. Pathogenesis in acute aortic syndromes:
aortic aneurysm leak and rupture and
traumatic aortic transaction. AJR Am J
Roentgenol 2003;181: 303-7.
3. Prachi P. Agarwal, Aamer Chughtai,
Frederick RK. Matzinger, Ella A. Kazerooni,
MD, MS; Spectrum of CT Findings in
Rupture and Impending Rupture of
Abdominal
Aortic
Aneurysms.
RadioGraphics 2009; 29:53752
4. Aronberg DJ, Glazer HS, Madsen K, Sagel
SS. Normal thoracic aortic diameters by
computed tomography. J Comput Assist
Tomogr 1984;8:24750.
5. Rajagopalan S, Sanz J, Ribeiro VG,
Dellegrottaglie S. CT angiography of the
thoracic aorta with protocols.In: Mukherjee
D, Rajagopalan S. CT and MR angiography
of the
peripheral circulation: practical
approach with clinical protocols. London,
England: Informa Healthcare, 2007; 91110.
6. Lesko NM, Link KM, Grainger RG. The
thoracic aorta. In: Grainger RG, Allison D,
eds. Diagnostic radiology: a textbook of
medical imaging. 3rd ed. Edinburgh,
Scotland: Churchill Livingstone. 1997:
1;854857.
CONCLUSSION
CT with its post processing advantages such as

maximum
intensity
projection,
volume
rendering, and multiplanar reformatting provides
valuable information regarding morphology of
the aortic wall, adjacent structures structure and
helps in the planning of the treatment.
REFERENCES
1. Sakalihasan N, Limet R, Defawe OD.

Abdominal
aortic
aneurysm.
Lancet
2005;365:1577-89.
707
DOI: 10.5958/j.2319-5886.2.3.062

&
Health Sciences
th

Case report
Coden: IJMRHS
Copyright @2013
rd
ISSN: 2319-5886
CASE REPORT OF VON RECKLINGHAUSENS DISEASE

*Archana S , Shefali Singhal, Muruganandam TV, Hamedullah, Thilak S, Meera G, Shilpa Reddy,
Chandramani
Department of Dermatology Meenakshi Medical College Hospital & Research Institute, Kanchipuram,
Tamil Nadu, India
*Corresponding author email: catcharch.samynathan5@gmail.com
ABSTRACT
Neurofibromatosis type -1 is a familial tumour syndrome belonging to genodermatosis group of

disorders. It is genetically transmitted by autosomal doiminance with variable penetrance. The disorder
is characterized by benign growths of the peripheral nerve sheaths,neurofibromas and caf au lait
macules. A45 year old male came with complaint of multiple asymptomatic swelling all over his body
since birth. They were continuously progressing in size,one of which on the back, weighed 2.5 kgs ,
causing dragging pain. No constitutional on systemic symptoms were present. Patient was completely
evaluated. Neuofibroma was confirmed with a biopsy. The results being normal. The plexiform lesion
was excised. The patient is on regular follow up.
Keywords:Neurofibroma, Lischs nodules, Genodermatosis, Schwann cells, Neurofibrin.
INTRODUCTION
Neurofibromatosis type -1
was formerly
reffered to as von Reckling Hausens disease
after Friedrich Daniel von Recklinghausen,who
first described it. It is a distinct genetic disorder
characterised by benign growths of peripheral
nerve sheaths,neurofibroma,and Caf au lait
macules. Also is associated with a repertoire of
other cutaneous and systemic manifestations.the
disease is classified under familial tumour
syndromes,a group of Genodermatosis.
Krishna murthy a 45 year old male, an

astrologer by occupation came with complaints
of multiple swellings all over the body since
childhood and dragging pain due to a solitary

swelling on his back. The swellings began as
small papules and
nodules,
gradually
progressed to present size.A solitary swelling on
the back progressed to present size of 10*20
cms weighing 2.5 kgs over 6 years. H/O
headaches, dull aching, intermittent in
occurrence.No H/O pain in other swellings ,
pruritis,secondary changes on the overlying
skin,
learning
disabilities
,visual
impairment,seizures,
hearing
abnormalities,bleeding tendencies, burning
micturation, constipation . Not a known case of
TB, DM, HTN, not undergone any surgical
procedure. He is the last born of 11 siblings,out
Archana etal.,
708
CASE REPORT
of nonconsanguinous marriage. None of the

other siblings are affected.Chews beetle leaf and
nut, non smoker, non alcoholic.
the palm(left).
Axillary freckling
present(Crowes sign). Patrick-Yesudian sign
positive . Hair changes: none. Nail changes:
none. Mucosa: oral and genital : normal
Fig.1: Multiple swellings
Fig-3 Caf-au-liat macule

Systemic examination: CVS: S1, S2 heard, no
murmurs. RS: Normal vesicular breath sounds
heard , no added sounds. CNS: Clinically
sound. Abdomen: Soft, no organomegaly, bowel
sounds heard.
Investigations:Haemoglobin:15.4g, Neutrophils
: 57%, Eosinophils:6%, BT: 2 mins 3 secs.
ESR1/2 hr, CT: 4 mins,Lymphocytes
37%,Platelets:3.85 lakhs/cumm, X-ray(A-P):
normal.ECG: Normal. USG: Normal study,
MRI BRAIN: Few small ill defined lesions
showing hyper intense signal in
both
cerebellar hemispheres & right cerebellar
peduncle representing white matter lesions.
Physical Examination: A 45 yr old male

poorly built & nourished . Conscious and
oriente.Pallor,
Icterus, Clubbing- absent,
Cyanosis , Lymphadenitis,Pedal Edema- absent.
No
obvious
skeletal
abnormalities.
Macroglossia present. Vitals are stable and
normal.
Dermatological Examination:
Multiple swellings(fig-1&2) present all over the
body ranging from 2cm to 5cm in diameter.Soft
to firm in consistency , pedunculated and sessile
in nature. No vascular prominence.
Fig.2: Button hole sign - positive.

Caf-au-lait macules(fig-3) present,>6 in
number. Two plexiform swellings present over
the back.One of which is 510 cm, approx 2 kgs
weight (insitu), bag of worms feel,overlying
skin is normal. Another plexiform swelling on
Archana etal.,
Fig.4:
Biopsy:
neurofibroma(40X)
concomittant
with
709
Slit lamp examination: Lischs nodules present.

ENT audiometry: normal. This patient
underwent reduction surgery by plastic surgeon.
Fig:5 Plexiform neurofibroma ( excised surgically)
DISCUSSION
Type 1 neurofibromatosis is also called Von

Recklinghausens disease. It is a multifactorial
Autosomal Dominantly inherited disorder with
variable penetrance. The
incomplete or
monosymptomatic form is commom 5.Random
spontaneous de novo mutation of Neurofibrin
gene on
the chromosome2
17q11
6
occurs.Neurofibrin
(GTPase
activating
enzyme) is a tumor suppressor gene which
inhibits P21 RAS oncoprotein. RAS encodes
membrane associated guanosine nucleotide
binding protein involved in regulation of cell
differenciation, proliferation & learning.Has
variable expressivity.Affects cells of the neural
crest(schwann cells, endoneural fibroblasts,
melanocytes). 82% of affected chilren develop
lesions by the age of one1.
Pathology : Derived from peripheral nerves and
supporting tissues. Arborising Schwann cells in
collagenous interstitial tissue.Giant pigment
cells in epidermal cells and melanocytes.
Types: Type 1-Von Recklinghausens, Type
2-Acoustic, Type 3-Mixed, Type 4-Variant,
Type 5-Segmental(non familial),
Type 6CALM, Type 7- Late onset(manifestations
beyond 20 yrs),
Type 8-Not otherwise
specified
Archana etal.,
RICCARDI Diagnotic criteria3,6:(any two)

1. Two or more neurofibroma cutaneous or
subcutaneous on or under the Skin, one
plexiform neurofibroma.
2. Intertrigous Freckling - axilla(Crowes sign)
3. Six or more Caf-Au-Lait7 spots >5mm in
diameter in pre pubertal & >15mm in post
pubertal individuals.
4. Skeletal
abnormalities-Sphenoid
wing
dysplasia, kyphoscoliosis, thinning of long
bones, with or without pseudoarthrosis.
5. On slit lamp examination-Lischs nodules4
(vascular hamartomas of the iris).
6. Tumors of the optic pathway(gliomas).
7. A first degree relative with NF 1 by the
above criteria.
Frequent associations aiding diagnosis:
1. Macrocephaly in 30% -50% of pediatric
population(without hydrocephaly).
2. Epilepsy.
3. Juvenile posterior lenticular opacity.
Differential diagnosis: Caf-au- lait7 macules
may be present in normal individuals in 10%20% of cases1. Tuberous sclerosus,Bloom
syndrome
,Cowdens
disease
,Fanconi
anaemia,Watson
syndrome,Silver-Russel
syndrome may also show caf-au liat macules.
In children the presence of Plexiform lesions
may stimulate congenital melanocytic naevus
due to pigmentation and hypertrichosis.
Complications: Skeletal deformities-scoliosis
may lead to nerve root compressions ,spinal
cord injury, osteomalacia, osteoporosis, short
stature,Plexiform
lesions
may
turn
sarcomatous.
Pheochromocytoma
(most
common). CML, Juvenile Xanthomatosis.
Rhabdomyosarcoma, GIT stromal tumor,
Somatostatinoma. Vasculopathy- renal stenosis
with HTN, Cerebral infarct, bleeding
aneurysms, intermittent claudication. Endocrine
abnormalities: Acromegal, Addisons disease,
precocious puberty, gynaecomastia, hyper
parathyroidism.
Subnormal
Intelligence,
Learning disabilities, attention deficits. Visual
perceptional disabilities, UTI, constipation,
pulmonary HTN.Speech impediments.
710
Neurological8
manifestations-intra
cranial
solitary tumors(optic nerve glioma, astrocytoma,
schwannomas), Malignant peripheral nerve
sheath
tumors
(MPNST).
Wilmstumor
Malignantmelanoma, Retinoblastoma.
Treatment modalities: Caf-au-Lait spots
causing cosmetic disfigurements can be treated
with LASER(Carbondioxide1, Ruby,YAG).
Cutaneous Neurofibromas can be surgically
excised( gamma knife surgeries are an option)
Plexiform neurofibromas
are excised
14
Surgically, Pirfenidone (antifibrotic agent),
PEG interferon, INF- 2b methotrexate and
vinblastine combination are bein studied for
use.
Prenatal diagnosis:Embryo-genetic testing/
counselling.Fetus -amnioscopy , chorionic
villous sampling, Fetoscopy can be done to
plan the course of pregnancy.
CONCLUSION
5.
6.
7.
8.
Hwang ST, Maloney ME, Paller AS.

Advances in
dermatology.Vol 20.
Philadelphia:Mosby;2004.p.75-115.
Huson SM,Clark P,Compston DAS. A
genetic study of von Reckling Hausens
disease neurofibromatosis in South East
Wales , I: prevalence, fitness, mutation rate,
and effect of parental transmission on
severity. J Med Genet 1989;26:704-11.
Wolkenstein P, Freche B, Zeller J,
Usefullness of screening investigations in
neurpfibromatosis type 1. A study of 152
patients. ARCH Dermatol,1996;132-:133336.
Landau M,Krafchik
BF.The diagnostic
value of caf-au-liat macules .J Am Acad
Dermatol. 1999;40:877-90.
Ruggeri M, Huson SM, The clinical and
diagnostic implications of mosaicism in the
neurofibromatosis.
Neurology.2001;56;1433-43.
This is a characteristic case of von Reckling

Hausens disease with 4 out of the 7 diagnostic
criterias fulfilled.the patient had no systemic
manifestations.
REFERENCES
1. Harper JL,Trembath RC, Genetics,and

genodermatosis. In : Burns T, Breathnach
S,Cox N,,Griffiths C, editors, Rooks
textbook of dermatology.7th edition.
Oxford:Blackwell Science;2004.p-12.1-85.
2. 2.Irvine
AD,Mc Lean
WHI. The
moloecular
genetics
of
the
genodermatosis;progress to date and future
directions. Br J Dermatol.2003;148:1-13.
3. Riccardi VM, Neurofibromatosis: clinical
heterogeneity. Curr Probl Cancer.1982;7:334.
4. ListernickR, Charrow J. Neurofibromatosis1 in childhood.In:James WD,Cockrell CJ,
Archana etal.,
711
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Case report
A CASE REPORT OF MOLLUSCUM CONTAGIOSUM INFECTION IN AN HIV INFECTED
INDIVIDUAL
*Shefali Singhal, Archana S, Shilpa Reddy, Murugnantham TV, Hamedullah A
Department of Dermatology, Meenakshi Medical College Hospital & Research Institute, Kanchipuram,
India
*Corresponding author email: shefali.porqupine@gmail.com
ABSTRACT
Molluscum contagiosum is a viral disease caused by mollusci pox virus (DNA virus).Seen commonly as
disease in children and immunocompromised adults. Infection transmitted by direct skin to skin contact,
fomites or sexual contact. A 27 year old male with pearly umblicated skin coloured papules and nodules
over whole face with history of weight loss (10 kg in 3 months) along with history of sexual contact. On
investigation HIV ELISA was positive and biopsy report showing Henderson Peterson bodies,
conforming molluscum contagiosum. Patient was diagnosed as MCV in HIV. Patient was treated with
HAART and topical imiquimod 5% cream and he responded well to treatment.
Keywords: Molluscum, HIV, Umblicated, sexual contact, biopsy, ELISA, HAART
INTRODUCTION
Molluscum contagiosum (MC) is a common viral

disease1 caused by mollusci pox virus (DNA
virus). It is commonly seen in children. The virus
forms part of normal flora in the
immunocompetent people. It presents as disease
in immunocompromised adults. Molluscum
contagiosum infection in HIV patients may
present with pearly skin coloured umblicated
papules (Fig. 1,2). Giant molluscum and
widespread or numerous small miliaria like
lesions are more commonly seen in HIV.2
However lesions that are large confluent and
predominantly facial are characteristic of
advanced HIV (AIDS).
Shefali et al.,
CLINICAL FEATURES
A 27 year old male patient, textile merchant by

occupation,
presented
with
numerous
asymptomatic, umblicated, pearly, skin coloured
papules and nodules over whole face causing
cosmetic disfigurement. (Fig. 1,2) Patient gave
history of weakness, malaise, anorexia and
weight loss 10 kgs in 3 months. No history of
fever, cough, sore throat, diarrhoea, vomiting,
nausea was present. No history of itching or
burning. History of contact exposure with CSW
2 years ago was elicited. No lympadenopathy
present. On needling of a lesion, it was hard and
thick not like typical molluscum lesions
712
Fig.1: Numerous skin coloured papules & nodules

on forehead
blood sugar, VDRL, TPHA, HBs Ag, ANTIHCV Ab, HIV ELISA (1&2) and skin excision
biopsy.
According to the clinical manifestations we made
these differential diagnosis :-Lymphomatoid
papulosis,
Molluscumcontagiosum,
Crypto
coccosis, Coccidiomycosis, Histoplasmosis,
Penicillinosis, Syringomas, Epidermal inclusion
cyst,
Sebaceous
cyst,
keratoacanthoma,
Arthropod infection , Squamous cell carcinoma ,
Basal cell carcinoma
Diagnosis; On investigation reports patient was
detected positive for HIV ELISA test. VDRL
was negative.RBS was normal.
Histopathologic examination with H&E staining
reveals a hypertrophied and hyperplastic
epidermis. Above the basal layer, enlarged cells
containing large intracytoplasmic inclusions
(Henderson Peterson bodies) can be seen. There
is increase in size of cells as the cells reach horny
layer.(FIGURE 3&4)
Fig.2: Numerous skin coloured papules & nodules

on left side of face
Fig. 4: Histopathology of Skin biopsy (40X)

Patient
was
diagnosed
as
Molluscum
Contagiosum and HIV based on investigations.
DISCUSSION
Fig.3: histopathology of Skin biopsy (10X)
DIFFERENTIAL DIAGNOSIS
Investigations: Patient was investigated for

complete and differential blood count, Random
Shefali et al.,
Molluscum contagiosum (MC) is a common

viral1 disease caused by mollusci pox virus(DNA
virus). It is commonly seen in children. The virus
forms part of normal flora in the
immunocompetent people. It presents as disease
713
in immunocompromised adults. Infection is

transmitted by direct skin to skin contact or
indirectly by means of fomites1. Disease very
rare in infants due to maternally transmitted
immunity and long incubation period8.MC
reported even in 1 week old child3.Genital
lesions in adults if present are mostly transmitted
through sexual contact4. MCV is difficult to
grow in usual established cell cultures, but has
been
propagated
in
human
foreskin
2,5,6
xenografts
.Outbreaks are seen with poor
hygiene, low socio economic status, crowded
living conditions and household10. MC more
common in atopic children7,8. Genital lesions in
children are common even without sexual abuse
but lesions with sexual abuse in children are
possible12.MCV has four subtypes (MCV1&2
common in UK9,10) and (MCV 1&3 common in
Japan while MCV2 &4 are rare)11. No
relationship is seen between viral subtypes,
morphology or
anatomical
distribution4.
Cutaneous markers in HIV when CD4 counts are
<100 cells/cubic mm. classical lesions of MC are
discrete, dome shaped, umblicated, waxy papules
which are either skin coloured or white. Lesions
are usually distributed on axillae, lower
abdomen, sides of trunk, thighs and face.
Uncommon sites are scalp, lips, tongue, buccal
mucosa membrane and soles12. Rarely seen on
scars17 and tattoos too (transmitted in the
pigment13). Small lesions may sometimes
coalesce to form plaques (agminate form).
Molluscum contagiosum infection in HIV
patients may present with pearly skin coloured
umblicated papules (Fig.1,2). Giant molluscum
and widespread or numerous small miliaria like
lesions are more commonly seen in HIV14-18.
However lesions that are large confluent and
predominantly facial are characteristic of
advanced HIV(AIDS). Atypical lesions are
common and may resemble folliculitis, abscess,
warts, furuncles and cutaneous horns without
characteristic umblication. In HIV infected
individuals, molluscum infection tends to be
Shefali et al.,
progressive, persistent refractory to treatment

and recurrent.
TREATMENT METHODS
Electrofulguration with repeated curettage is

found to be effective for multiple large and
confluent lesions. Lesions usually resolve
spontaneously in 6-9 months. Rarely lesions
persist for several years. Lesions mostly heal
without a scar but sometimes atrophic scars may
be present. Resolution is heralded by
inflammation, suppuration and crusting of
lesions. Eyelids if involved may lead to toxic
conjunctivitis. Similarly hair follicle involvement
leads to molluscum folliculitis. For cases
refractory to standard therapies topical
imiquimod 5% cream may be effective in both
children and adults. Topical cidofovir, a
nucleotide analogue with activity against several
DNA viruses, is reported to be efficacious.
Cryotherapy with liquid nitrogen is effective but
a painful procedure.Its repeated at 3-4 weekly
intervals until all lesions disappear. Diathermy
can be done for large lesions. For recalcitrant
lesions pulse dye laser has also been used
effectively. Topical application of phenol and
cantharidin 0.9% without spreading to periphery
is used effectively in the destruction of lesion.
Application of silver nitrate paste 40% or
salicylic acid 15-20 % in collodion or acrylate
base once or twice weekly will speed clearance.
Potassium hydroxide 10 % solution used
topically everyday also gives good results.
CONCLUSION
This case is an atypical presentation of MCV

infection seen in HIV patient. He was clinically
suspected as lymphomatoid papulosis& then
investigated. On biopsy it was detected to be
MCV infection. Due to atypical presentation of
MCV, we suspected HIV and investigated for it.
Patient came positive for ELISA (along with
contact history) and was diagnosed as MC in
HIV. He did not have any spontaneous resolution
714
unlike most typical molluscum contagiousum

lesions. Patient was started on HAART(highly
active anti retro viral therapy). He was prescribed
topical imiquimod for molluscum lesions on
alternate days for 4 weeks (6-10 hours of contact
period). Patient was advised to abstain from
contact sports, swimming pools, avoid sharing
towels, clothes, bedsheets and communal baths
to prevent transmission to others. Patient was
advised to get his spouse fully investigated for
HIV and Molluscum infection. Patient responded
well to treatment. He did not develop any
scarring or crusting.
REFERENCES
1. Esposito JJ, Fenner F. Poxviruses. In: Knipe
DM, Howley PM. Fields virology. 4th ed.
philadelphia:
Lippincott
Williams
&
Wilkins;2001. p. 2886-2921
2. Buller RML, Burnett J, Chen W, Kreider J.
Replication of molluscumcontagiosum virus.
Virology .1995;213:655-59
3. Fife KH, Whitfield M, Faust H. Growth of
molluscumcontagiosum virus in a human
foreskin
xenograft
model.
Virology.
1996;226:95-101
4. Scholz J, Rosen-Wolff A, Bugert K.
Epidemiology of molluscumcontagiosum
using genetic analysis of viral DNA. J Med
Virol. 1989;27:87-90
5. Smith KJ, Yeager J, Skeleton H.
Molluscumcontagiosum:
Its
clinical
histopathological, and immunohistochemical
spectrum. Int J Dermatol. 1999;38:664-72.
6. Porter CD, Archard LC. Characterization by
restriction mapping of three subtypes of
molluscumcontagiosum virus. J Med
Virol.1992;38:1-6
7. Nakamna J, Arao Y, Yoshida M. Molecular
epidemiologic
study
of
molluscum
contagiosum virus in two urban areas of
western Japan by the in gel endonuclease
digestion method .Arch Virol.1992;125:33945
Shefali et al.,
8. Kaplan KM, Fleischer GR, Paradisc JE.

Social relevance of genital herpes simplex in
children Am J Dis Child.1984;138:872-74
9. Mandel MJ, Lewis RJ. Molluscum
contagiosum of the newborn.Br J Dermatol.
1970;84:370
10. Sterling JC. Virus infections. In: Burns T,
BreathnachS,
CoxN,
GriffithC,editors.
Rooks Textbook of dermatology.7thed
.Oxford: Blackwell Publishing ;2004.p.25.125.83
11. Brown TJ, Yen-Moore A, Tyring SK. An
overview of sexually transmitted diseases:
Part ii. J Am AcadDermatol. 1999;41:511-32
12. Bergamen H. Is molluscumcontagiosum
acutaneous manifestation of sexual abuse in
children?
J
Am
Acad
Dermatol.
1986;14:847-9
13. Hellier FF. Profuse mollusc contagiosa of
face induced by corticosteroids. Br J
Dermatol. 1971;85:398
14. Roscubery EW, Yusk JW. Molluscum
contagiosum : Eruption following treatment
with prednisolone and methotrexate .Arch
Dermatol.1970;101:439-41
15. Goerz G, Ilgner M. Disseminated molluscum
contagiosum in mycosis fungoides during
combined glucocorticoid -antineoplastic
therapy. Hautarzt. 1972;23:37-40
16. Cotton DWK, Cooper C,Barrett DF. Severe
atypical molluscumcontagiosum infection in
immunocompromised
host.
Br
J
Dermatol.1987;116:871-6
17. Isaac F. Molluscumcontagiosum limited to a
scar. ermatologica. 1980;160:351-3
18. Foulds ES. Molluscumcontagiosum: an
unusual complications of tattooing. BMJ.
1982;285:607
715
DOI: 10.5958/j.2319-5886.2.3.064

&
Health Sciences
th
Coden: IJMRHS
th
Revised: 4
Jul 2013
Copyright @2013
ISSN: 2319-5886
Research article
INTRA-PAROTID NEUROFIBROMA OF FACIAL NERVE : A CASE REPORT

*Amit Kumar1, Rajeev Ranjan1, Sushil Kumar1, Shrinivas Radder2, Ranveer singh rana1, Saketan
Bhagat1
1
Department of Surgery,2Department of Radiology, Rajendra Institute of Medical Sciences, Ranchi
*Correpsonding author email: drrajeevsingh1982@gmail.com

ABSTRACT
A 45-year-old male presented with a painless slowly growing mass in the region of the left parotid
gland over a period of 4 years. The swelling was nontender, measuring 8cm*6cm and it was hard in
consistency. Facial function was normal. At surgery, a bulky, lobular tumor was found in the parotid
gland. Identification of the facial nerve was not possible and eventually the mass, which was seen to
be incorporating one of the peripheral branches of the nerve, was identified as a facial nerve tumor.
Due to the size and local expansion of the tumor, complete tumor resection was done. A mass
measuring 8*6*4cm was excised and a superficial parotidectomy was performed. Failing to dissect
the tumor from the nerve, the nerve portion involved in the tumor mass was inevitably sacrificed.
Histopathologically the tumor was found to be a neurofibroma. Postoperatively, the patient suffered
from an incomplete facial palsy.
Keywords: Intraparotid, Neurofibroma, Nontender Facial nerve, Superficial Parotidectomy
INDRODUCTION
Both benign and malignant tumors can affect the

facial nerve1. It can originate from the facial
nerve itself or from a contiguous structure or a
metastatic disease. Actually, extrinsic tumors are
far more common than intrinsic tumors Benign
tumors of the nerve sheath are of 2 types:
schwannoma and neurofibroma,. Intraparotid
location of benign tumors of the facial nerve
sheath is considered a rare event compared with
intratemporal location.
CASE REPORT
A 45-year-old male presented with a painless

Amit et al.,
slowly growing mass in the region of the left

parotid gland over a period of 4 years. The
swelling was nontender, measuring 8cm*6cm
and it was hard in consistency. Facial function
was normal. At surgery, a bulky, lobular tumor
was found in the parotid gland(fig.1).
Identification of the facial nerve was not
possible and eventually the mass, which was
seen to be incorporating one of the peripheral
branches of the nerve, was identified as a facial
nerve tumor. Due to the size and local expansion
of the tumor, complete tumor resection was
done. A mass measuring 8*6*4cm was excised
716
along with the incorporated branch of the facial

nerve(fig.2 &3) and a superficial parotidectomy
was performed. Failing to dissect the tumor from
the nerve, the nerve portion involved in the
tumor mass was inevitably sacrificed.
Histopathologically the tumor was found to be a

neurofibroma(fig.4). Postoperatively, the patient
suffered from an incomplete facial palsy.
DISCUSSION
The estimated incidence of parotid tumors of

facial nerve origin ranges from 0.2% to 1.5% 2.
More specifically, 79 cases have been reported
in the literature involving the intraparotid
segment of the facial nerve3. The most common
presenting symptom is a painless slow-growing
parotid mass, while 3.9% of these tumors will
finally be diagnosed as malignant3. Preoperative
diagnosis is extremely difficult due to the
variation in clinical presentation and its
dependency upon the nerve site involved4
Intraparotid facial nerve neurofibroma are quite
rare by Brettau et al. Kavanaugh & Panj, and
almost half of these tumors involve the main
trunk of the nerve.5-8 Such cases may present with
or without pain, tenderness, facial spasm or
paralysis. Our patient presented without any pain or
facial weakness. Fine needle aspiration cytology is
typically non-diagnostic as there is extreme
Amit et al.,
difficulty in obtaining positive cytology in

neurogenic neoplasms. The rarity of positive
cytology may be secondary to the adhesive nature
of the cells in such tumors.7 Neurofibromas may
occur most commonly as a part of the syndrome of
Von Recklinghausens disease, as solitary
neurofibromas or as multiple
neurofibromas
without Von Recklinghausens disease .5,9 Grossly,
neurofibroma is nonencapsulated and frequently
multiple.
Axons
pass
directly
through
neurofibromas.
Histologically,
they
are
characterized by relatively scant, haphazard
arrangement of delicate spindle cells among a
loosely textured collagenous matrix. Malignant
transformation of neurofibromas is uncommon but
does occur; it has been reported to be 10-15% in
plexiform
neurofibromas.
Sarcomatous
transformation is commoner in NF1 associated and
deeply seated neurofibromas5,10 Management of
717
neurogenic tumors of the intraparotid facial nerve is

controversial. Schwannomas tend to displace
nerves and thus allow for nerve preservation
procedures. Neurofibromas, however, incorporate
nerves and are generally resected en bloc with the
involved nerve. En bloc resection with cable
grafting is recommended when nerve fibres are
tenuous and interspersed within the tumor
capsule6,9. Preoperative facial nerve function is
central to the treatment of benign neurogenic facial
nerve neoplasms. But the rare malignant tumor
require surgical removal, and every parotid mass
associated with facial nerve weakness or paralysis
should be biopsied. However there is controversy in
the treatment of benign tumors with intact facial
nerve function. Some authors state that the results
with facial nerve reconstruction are better when
there is no preoperative facial weakness rather than
in the presence of a long standing palsy .5 However,
others recommend that resection not be performed
when all clinical parameters suggest a benign
neuroma: intraoperative tumor appearance,
inseparability from the facial nerve, and facial
movement elicited by electrical stimulation of the
tumor.11 In such cases, the option of following
benign
neurogenic
lesions
with
serial
electroneurography and computerized tomography appears feasible. Such an approach may be
quite palatable for elderly patients who continue to
have good facial function; and may have a greater
opportunity to defer resection for patients in whom
progressive degeneration is unlikely5
literature review and classification proposal.

J Laryngol Otol. 2007; 121:707-712
4. Salem E, Archilli V, Naguib M, Taibah AK,
Russo A, Sanna M, et al. Facial nerve
neuromas: diagnosis & management. Am J
Otol. 1995; 16:521-526
5. Sullivan MJ, Babyak JW, Kartush JM.
Intraparotid
facial
neurofibroma.
Laryngoscope 1987; 97:219-223.
6. Conley J, Janecka I. Neurilemmoma of the
facial nerve. Plast Reconstr Surg 1973;
52:55-60.
7. Brettau P; Melchiors, H. & krogdahl A.
Intraparotid
neurilemmomma.
Acta
Otolaryngol. 1983;95(3-4):382-84,
8. Conley JJ, Neurilemmomma of the facil
nerve. In: Salivary glands and the facial
nerve. New York, Grune and Stratton, 1975.
pp.103-5.
9. Kavanaugh KT, Panje WR. Neurogenic
neoplasms of the seventh clinical nerve
presenting as a parotid mass. Am. J.
Otolaryngol. 1982; 3(1):53-56
10. Mcguirt WSr, Johnson PE, Mcguirt WT.
Intraparotid facial nerve neurofibrommas.
Laryngoscope,.2003;113(1):82-84
11. May M. Tumors involving the facial nerve.
In: The Facial Nerve. New York, Thieme
Inc., 1986. pp.455-67.
REFERENCES
1. Facial Nerve Tumor, Facial Nerve Centre,

Massachusetts Eye and Ear
infirmary,
www.facialnervecentre.org
2. Chiang CW, Chang YL, Lou PJ.
Multicentricity of intraparotid facial nerve
schwannomas. Ann Otol Rhinol Laryngol.
2001; 110:871-874
3. Marchioni D, Alicandri CM, Presutti L.
Intraparotid facial nerve schwannoma:
Amit et al.,
718

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DOI: 10.5958/j.2319-5886.2.2.

International Journal of Medical Research

Volume 2 Issue 3 July - Sep

Received: 3 Apr 2013

Revised: 2 May 2013

Accepted: 15th May 2013

LEARNING STYLES OF FIRST YEAR MEDICAL STUDENTS STUDYING PHYSIOLOGY IN

Physiology is being taught to medical students in

Suzanne Maria Dcruz et al.,

Int J Med Res Health Sci. 2013;2(3):321-327

College, when they are as it is struggling with

a sensory modality preference assessment that

Suzanne Maria Dcruz et al.,

Int J Med Res Health Sci. 2013;2(3):321-327

scenario in India where many curricular reforms

subtraction would result in 3 a). By convention,

Table 1 Strength of learning style preferences of first year medical students.

Suzanne Maria Dcruz et al.,

Int J Med Res Health Sci. 2013;2(3):321-327

This study was done to determine the learning

dimension and sensory/intuitive dimension.

Suzanne Maria Dcruz et al.,

Int J Med Res Health Sci. 2013;2(3):321-327

written in PowerPoint slides, overhead projector

Suzanne Maria Dcruz et al.,

Int J Med Res Health Sci. 2013;2(3):321-327

preferentially perceives external information

performance in Physiology and attendance; and

Suzanne Maria Dcruz et al.,

Int J Med Res Health Sci. 2013;2(3):321-327

Our study done to assess the learning styles of

1. Felder RM, Brent R. Understanding Student

from: http://www.vark- learn.com/english/

13. Shenoy UG, Kutty K, Shankar VMS,

Suzanne Maria Dcruz et al.,

Int J Med Res Health Sci. 2013;2(3):321-327

International Journal of Medical Research

Volume 2 Issue 3 July - Sep

Received: 10 Mar 2013

Revised: 23 Apr 2013

Accepted: 30th Apr 2013

In recent decades, most of the pathogenic

importance due to their multidrug resistance1, 2.

Int J Med Res Health Sci. 2013;2(3):328-333

survey indicated that a high percentage of

This study was conducted in the department of

Antibiotic susceptibility pattern

Out of 112 Enterococcal isolates consists of 98 E

Int J Med Res Health Sci. 2013;2(3):328-333

Table .1: Specimen wise distribution of Enterococcus

Tracheal aspirate (1)

Ascitic fluid (1)

Table.2: Basic data of patients with Enterococcus infection

Table.3: Pattern of Enterococcus isolation

Enterococcus+ Staphylococcus aureus

Enterococcus+ CONS+ Candida species

Table.4: Virulence characteristics of Enterococcus

Int J Med Res Health Sci. 2013;2(3):328-333

Table-5 Antimicrobial susceptibility pattern of Enterococcus

High level gentamicin

Fig.1: Sensitivity pattern of Enterococcus species

The Enterococcus species have now emerged as

Enterococcal infections were common in males

Int J Med Res Health Sci. 2013;2(3):328-333