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ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)Internationally Indexed,Peer Reviewed, MultidisciplinaryScientific JournalICV: 4.18“Let the Science be your passion”International Journal of Current Research and Review(IJCRR)Section: HealthcareVol 04 / Issue 21 / November 2012Frequency: FortnightlyLanguage: EnglishPublished by:Radiance Research Academy,Nagpur, MH, IndiaAug 2012

IJCRRISSN 0975-5241IC Value of Journal: 4.18“Let the science be your passion”Vol 4 / Issue 21 / Nov 2012Editorial BoardDr. Prof. Dato’ Proom PromwichitMasterskill University, MalaysiaDr. Nahla Salah Eldin BarakatUniversity of Alexandria, Alexandria, EgyptDr. Ann MagoufisAriston College, Shannon, IrelandDr. Pongsak RattanachaikunsoponUbon Ratchathani University, ThailandDr. Chellappan DineshInternational Medical University, MalaysiaDr. R. O. GanjiwaleNagpur University, MH, IndiaDr. Shailesh WaderNagpur University, MH, IndiaDr. Alabi Olufemi MobolajiBowen University, Iwo, Osun-State, NigeriaDr. Joshua Danso Owusu-SekyereUniversity of Cape Coast, Cape Coast, GhanaDr. Okorie Ndidiamaka HannahUniversity of Nigeria Nsukka, Enugu StateDr. Parichat PhumkhachornUbon Ratchathani University, ThailandDr. Manoj ChardeAmravati University, MH, IndiaDr. Shah Murad MastoiLahore Medical and Dental College, Lahore,PakistanDr. Hitesh WadhwaMD University, HY, India1 International Journal of Current Research and ReviewVol. 04 issue 21 Nov 2012

IJCRR“Let the science be your passion”Vol 42 / / Issue 212 / / Nov Dec 2012 2010About International Journal of Current Research and Review (ijcrr)International Journal of Current Research and Review (IJCRR) is one of the popularfortnightly international multidisciplinary science journals. IJCRR is peer reviewedindexed journal which is available online and in print format as well.Indexed in: ScopeMed, Google Scholar, Index Copernicus, Science Central,Revistas Médicas Portuguesas, EBSCO, DOAJ, BOAI, SOROS, NEWJOUR,ResearchGATE, Ulrich's Periodicals Directory, DocStoc, PdfCast, getCITED,SkyDrive, Citebase, e-Print, WorldCat (World's largest network of library contentand services), Electronic Journals Library by University Library of Regensburg,SciPeople.Aims and Scope:IJCRR is a fortnightly indexed international journal publishing the finest peerreviewedresearch and review articles in all fields of Science andTechnology. IJCRR follows stringent guidelines to select the manuscripts on thebasis of its originality, importance, timeliness, accessibility, grace and astonishingconclusions. IJCRR is also popular for rapid publication of accepted manuscripts.Mission Statement:To set a landmark by encouraging and awarding publication of quality research andreview in all streams of Science.About the editors:IJCRR journal management team is very particular in selecting its editorial boardmembers. Editorial board members are selected on the basis of expertise, experienceand their contribution in the field of Science. Editors are selected from differentcountries and every year editorial team is updated. All editorial decisions are madeby a team of full-time journal management professionals.IJCRR Award for Best Article:IJCRR editorial team monthly selects one ‘Best Article’ for award among publishedarticles.IJCRR is official publication of Radiance Research Academy, Nagpur, IndiaAdministrative Office: Radiance Research Academy, 148, IMSR Building, NearNIT Complex, Ayurvedic Layout, Umrer Road, Sakkardara, Nagpur, Nagpur-24,MS, India. editor@ijcrr.com, www.ijcrr.com2 International Journal of Current Research and ReviewVol. 04 issue 21 Nov 2012

IJCRR“Let the science be your passion”Vol 4 / Issue 21 / Nov 2012S.N.HealthcareIndexTitle Authors PageNo.MeenakshiShyamsunder Sable, 57Shyamsunder S.Sable, U.S. Zingade,A. N. Kowale1 Prelimanary Study of Lung Functions inAthletes and Nonathletes in MarathwadaRegion2 Comparitive Study of Conventional andUltrasound-Guided Fine NeedleAspiration Cytology of Thyroid in aTertiary Care Center of North Karnataka3 Physicochemical and BiologicalProperties of Adiantum Capillus-VenerisLinn: An Important Drug of UnaniSystem of Medicine4 Diagnostic Dilemma due to DiversePresentation of Tuberculosis: Series of 3Cases5 Grip Strength and Hand FunctionChanges in Unilateral CervicalRadiculopathy6 A Study on Modified Alvarado ScoringSystem in Diagnosing AcuteAppendicitis7 Role of Fine Needle AspirationCytology in Salivary Gland Pathologyand its Histopathological Correlation: Atwo year Prospective Study in WesternB.R Ashwini,Vernekar Sunita,Kulkarni Mohan H.,T. KiranAjij Ahmed, NasreenJahan, AbdulWadud, HashmatImam,Syeda Hajera, AliaBilalShrivastava Deepti,Patil Vijya, BhuteSindhu, MukherjeeSatarupaMohamed FaisalC.K., NirmalMathew, LawrenceMathias, Ajith S.C.P. Ganesh Babu,E.M.J. Karthikeyan,K. Bharaniraj KumarAgravat Amit H.,Dhruva Gauravi A.,Pujara Krupal M.,Sanghvi Hardik K.India8 Variant Axillary Artery – a Case Report Sharadkumar PralhadSawant, ShaguphtaT. Shaikh, RakhiMilind More6470768291951023 International Journal of Current Research and ReviewVol. 04 issue 21 Nov 2012

IJCRR“Let the science be your passion”S.N.HealthcareIndexTitle Authors PageNo.Hundekari JagdishC., Bondade A.K. 1099 Does Thermal Stress Alters theAutonomic Functions in Men Exposedto Heat?10 Comparison Regarding Knowledge,Attitude and Practice of Blood Donationbetween Health Professionals andGeneral PopulationGunvanti B. Rathod,Pragnesh Parmar 11411 Accessory Spleen – A Case Report Pushpalatha M.,Sujana M.,Sharmada K.L.12 Oxidative Stress and AntioxidantEnzyme Status in Patients with Type 2Diabetes Mellitus with and withoutCoronary Artery DiseaseAl- GhonaimMohammed I.,Ramprasad N,Abdel-GhaffarMamdouh H.13 Antiepileptics and Pregnancy: A Review Sanjay Kumar,Biswa BhusanMohanty, DivyaAgrawal, PramilaNayak, ShantilataPatnaik, JyotsnaPatnaik, SusantaKumar Mahapatra14 Comparison of Post 24 Hours Effect ofCooling and Sustained PassiveStretching as Treatment Techniques forReduction of Spasticity in Hemiplegicsusing H-Reflex15 Lower Respiratory Tract Infection-Bacteriological Profile and AntibiogramPattern121123132Shilpa Khandare,Tushar J Palekar 144Supriya Panda,B. Prema Nandini,T.V.Ramani149Vol 4 / Issue 21 / Nov 20124 International Journal of Current Research and ReviewVol. 04 issue 21 Nov 2012

Meenakshi S. Sable et alPRELIMANARY STUDY OF LUNG FUNCTIONS IN ATHLETES AND NONATHLETES INMARATHWADA REGIONIJCRRVol 04 issue 21Section: HealthcareCategory: ResearchReceived on: 26/08/12Revised on:09/09/12Accepted on:15/09/12PRELIMANARY STUDY OF LUNG FUNCTIONS INATHLETES AND NONATHLETES IN MARATHWADAREGIONMeenakshi S. Sable 1 , Shyamsunder S. Sable 2 , U. S. Zingade 1 , A. N. Kowale 11 Dept. of Physiology, B J Medical College and Sasoon Hospital, Pune, M.S., India2 Dept of Surgery, D Y Patil Medical College and Hospital , Pune, M.S., IndiaE-mail of Corresponding Author: meenakshisable@rediffmail.comABSTRACTAim: The aim of this study was to compare the effect of running training on lung functions of runnersand nonrunners and whether the regular exercise and training given to the runners improve the lungfunctions or not. Methods: The subjects selected for this study were 40 runners and 40 nonrunners ofaged 18-21 years. The mean value of Ht and Wt of runners was 167.52+_6.449 (cm), 56.55+_6.97 (Kg)and that of nonrunners were 161.87+_6.44 (cm), 57.17+_9.129 (Kg). Mean value of Ht in runners wasmore than that of nonrunners due to regular physical activity and training. There was no difference inwt in both groups.The mean values of Forced vital capacity (FVC), Forced expiratory volume (FEV1)at one second and Maximum voluntary ventiliation (MVV) in runners were 3.73+_0.78(L)3.39+_0.78(L) and 120.09+_25.8(L/MIN) respectively and in nonrunners were3.16+_0.59(L),2.98+_0.53(L) and 88.74+_28.74(L/MIN). Results: There were significant increased inFVC, FEV1and MVV in runners than nonrunners may be due to training there is improvement in thelung functions and strengthing of respiratory of musclesKeywords: Athletes NonathletesFVCFEV1MVVINTRODUCTIONAthletics is a great fun and people of all ages canenjoy it.Running is the most natural of athleticsmovements and common aerobic exercise. Andhave a profound effect on lung functions.Severalfactors like Age, Height Weight, heredity,environment, diet, training, hormone status etcalso contribute to the performance of sportsman(1,2).There have been many studies documentingpulmonary change following training.Wassermanet al 1995,Twisk et al 1998 who showed thatfollowing exercise athletes tend to have anincrease in pulmonary capacity when compared tononexercising individuals especially when theexercise is strenuous. This ventilatory adaptationto exercise may differ in different populationssuch as Black and Caucasian subjects suggestedby Cerny 1987 particularly under differentInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 57

Meenakshi S. Sable et alPRELIMANARY STUDY OF LUNG FUNCTIONS IN ATHLETES AND NONATHLETES INMARATHWADA REGIONclimatic conditions that is it may be related toethnic and environmental factors.Lung function test provide quantitative andqualitative evaluation of pulmonary function andare therefore of definitive value in the diagnosisand therapy of patients with cardiopulmonarydisorders as well as those with obstructive andrestrictive lung diseases shown by Belman andMittman 1980,Robinson and kjeldgaard 1982.The parameters used to describe lung function arethe lung volumes and capacities.while the variouslung volumes reflect the individual’s ability toincrease the depth of breathing the capacities issimply a combination of two or more lungvolumes.The aim of present study was to compare thevalues of lung functions in runners and nonrunnersand whether the regular training in the form ofrunning improves the lung functions in runners.MATERIALS AND METHODSThe present study was conducted on 40 Runnersand 40 nonrunners Aged-18-21 years. Runnersselected were taking training under SportsAuthority of India ,Krida prabhodiniHostel,Aurangabad for short and middle distancerunning event .Runners selected for this studywere training themselves by running a distance of2-3 km,two times a day for 45-60 min, 7 days aweek Nonrunners selected for this study were 1 stand 2 nd MBBS students.They were not practicingany athletics event .Informed consent wasobtained from all participants.Clinically examinedto rule out any respiratory diseases .The study wasconducted in Dept of Physiology, GMC,Aurangabad.The lung functions were recorded in Pulmonaryfunction test laboratory by Body Plethysmograph(MEDGRAPHICS) USA, Elite DX-Model.Forcedvital capacity (L), Forced expiratory volume at onesecond (L), and Maximum voluntary ventilation(L/MIN) were recorded.Statistical analysis wasdone for all parameters ‘p’ value was determinedp>o.o5-nonsignificant, p

Meenakshi S. Sable et alPRELIMANARY STUDY OF LUNG FUNCTIONS IN ATHLETES AND NONATHLETES INMARATHWADA REGIONal reported that among male athletes only maleshot putters had a significantly higher vitalcapacity than male nonathletes suggesting thatintensity of sports engaged in by the athletesdetermines the extent of strengthening ofrespiratory muscles with resultant increase in lungvolume and chronic exercise cause an increase inrespiratory function which could be due toincreased development of respiratory musculatureincidental to physical training.Hagberg reported that values for static lungvolume of accomplished marathoners and otherendurance trained athletes were no different fromthose of untrained controls of comparable bodysize. However Cordain 1990 reported larger thannormal static lung volume in swimmers anddrivers when compared to normal nonathletes.Thiswas attributed to strengthening of the inspiratorymuscles as they were against additional resistancecaused by weight of water that compresses thethoracic cage.Reports from other workersOnadeko et al 1976, Bjorstorm 1987 also indicatesa significantly higher vital capacity in athletescompared with nonathletes.The conflicting finding may be due to genetic andethnic factors as suggested by Lakhera and Klain1995 who compared pulmonary function amongstathletes in different Indian populations.The lungfunction parameters were found to vary indifferent settings with results suggesting that thesize of lung is governed by genetic, environmentaland nutritional factors.In our study spirometric measurements i.eFEV1,FVC andMVV were found significantlyhigh in athletes than nonathletes.The proablereason for observation could be that followingtraining there is increased requirement of oxygenin the working muscles which stimulates thechemosensitive area located bilaterally in themedulla in turn stimulating the dorsal group ofnucleus tractus solitaries which send strong signalsto inspiratory group of muscles which causeforceful inspiration and expiration .Repeatedforceful inspiration and expiration cause increasedsecretion of surfactant which decreases tension inalveoli and decreases physiological dead space thisin turn manifest increased lung volume andcapacities in athletes.The purpose of this study is to investigate thepossibility of change/adaption of lung function inathletes who have regular exercise/trained for 2-3hrs a day a 7 day a week and involved in sports formore than 3-4 yrs. Hence results from the presentstudy suggest that the intensity or severity ofsports engaged by athlete probably determines theextent of strengthening of respiratory muscles withresultant increase in lung volume and capacitiesCONCLUSIONThe study validates the physiological adaptions inspirometric functions of respiratory system toregular training programme.The effect ofstrengthening of respiratory muscles resultantincrease in lung volume and capacities withimproved endurance of the body following regulartraining is evident in a significantly increased inFVC, FEV1and MVV in athletes than nonathletes.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 59

Meenakshi S. Sable et alPRELIMANARY STUDY OF LUNG FUNCTIONS IN ATHLETES AND NONATHLETES INMARATHWADA REGIONHighlighting the importance of regular training onrespiratory functions and endurance of the bodyACKNOWLEDGEMENTAuthors are grateful to 2005-2006 first MBBSbatch and second MBBS batch GMC,AUGANGABAD and athletes from SAi hostelAurangabad for their support and enthusiasmREERENCES1. Seidman DS, Solev E, Deuster PA et al:Androgenic response to long term physicaltraining.Jsports Med 1990;421-424.2. Dasgupta PK, Mukhopadhyay AK et al: Astudy of cardiopulmonary Efficiency inDifferent categories in Runners.Indian JPhysiology Pharmac 2000;44(2):220-224.3. Wassreman K, Gift A,Wekel HE:Lungfunction changes and exercise inducedventilator Responses to External RestiveLoads in Normal subjects.Respiration1995;62(4):177-184.4. Twick IW, Staal BJ, Kemper HC et al:Tracking of lung function parameters andLogitudinal Relationship with Lifestyle.Eur.Resp.J. 1998 ; 12(3):627-634.5. Beiman MJ, Miman C.Ventilatory MuscleTraining Improves Exercise capacity in COPDpatients.AM Resp Dis.1980; 121:273-279.6. Robison EP, Kjeldgard JM: Improvement inventilator Muscle function withRunning.J.Appl Physiol.1982; 52:1400-1405.7. Cenry FJ.Breathing pattern during exercise inyoung black and Caucasian subjects.J.Applphysiology. 1987; 62(6):2220-2223.8. Hagberg JM.Pulmonary function in young andolder athletes and untrained men: ZJ ApplPhysiol 1988;65:101-104.9. Cordain L: Lung volumes and maximalrespiratory pressures in collegiate swimmersand runners.Res Exer Sport 1990; 61: 70-77.10. Onadeko BO, Fulase AO: Pulmonary functionstudies in Nigeriansportsman.Atr.J.Med.sci.1976; 5:291-295.11. Bjourstrom R.L: Control of ventiliation inElite synchronized swimmers.1987; 63:1091-1095.12. Lakhera SC, Kain TC: Comparison ofpulmonary function amongst Ladakhi, Delhi,Varanasi and Siddhi boyathletes.J.Physiol.pharmac 1996; 39(3):255-258.13. Odunga AC, Jaja S: Some ventilatorparameters in well trained Nigerialathletes.Nigerian Journal of physiological sci:1989;5:7-16.14. Williams C: Assessment of physicalperformance: ABC of sportsMedicine.Br.Med.j.1994; 309: 180-186.15. Pakkala A, Veerannan.A comparative study ofcardiopulmonary efficiency in athletes andnonathletes.J.Indian Med Assoc.2005;103(10):522-527.16. Leith DE, Bradley M: Ventilatory musclestrength and Endurance Training.J Applphysiol.1976;41: 508-516.17. Lakhera SC, Kain TC: Lung function inmiddle distance AdolescentInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 60

AverageAverageMeenakshi S. Sable et alPRELIMANARY STUDY OF LUNG FUNCTIONS IN ATHLETES AND NONATHLETES INMARATHWADA REGIONRunners.Ind.j.physiol.pharmac.1994;38(2):117-120.18. Martin BJ.Slager JM: Ventilatory Endurancein Athletes and nonathletes.Med.sci.sportsExercise 1981; 13(1):21-26.19. Dasgupta PK, DE AK: Assessment ofcardiopulmonary efficiency in Athletes andNonathletes.Ind J Physiol Pharmac:1991;35(4):245-248.20. DE AK, Debnath pk, RoY DC et al: Acomparison of physical efficiency betweenIndian physical education and Medicalstudents.Brit.j .sports Med.1978; 12: 93-96.RESULT : Standard statistical analysis tests were applied in terms of mean &SD, For comparison ‘Z’ test appliedTable 1: Comparison of age in runner and non runner groupParameter Runner Non runner Z Value P ValueMean ± SD Mean ± SD(n=40) (n=40)Age (Yrs) 19.07 ± 0.99 19.12 ± 0.96 0.22 >0.05Multiple bar diagram showing comparison of age in runner and nonrunner group20181614121086420Age (Yrs)RunnerNon runnerTable 2: Comparison of FVC in runner and non runner groupParameter Runner Non runner Z Value P ValueMean ± SD(n=40)Mean ± SD(n=40)FVC (Lit) 3.73 ± 0.78 3.16 ± 0.59 3.65

Meenakshi S. Sable et alPRELIMANARY STUDY OF LUNG FUNCTIONS IN ATHLETES AND NONATHLETES INMARATHWADA REGIONInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 62

AverageAverageMeenakshi S. Sable et alPRELIMANARY STUDY OF LUNG FUNCTIONS IN ATHLETES AND NONATHLETES INMARATHWADA REGIONTable 5: Comparison of height in runner and non runner groupParameter Runner Non runner Z P ValueMean ± SD(n=40)Mean ± SD(n=40)ValueHeight 167.52 ± 6.44 161.87 ± 7.04 3.75 0.05>0.05-Not significantMultiple bar diagram showing comparison of weight in runner andnon runner group6050403020100Weight (Kg)RunnerNon runnerMedgraphics Body Plethysmograph MachineInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 63

B.R. Ashwini et alCOMPARITIVE STUDY OFASPIRATION CYTOLOGYKARNATAKACONVENTIONAL AND ULTRASOUND-GUIDED FINE NEEDLEOF THYROID IN A TERTIARY CARE CENTER OF NORTHCOMPARITIVE STUDY OF CONVENTIONAL AND ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION CYTOLOGY OF THYROID IN ATERTIARY CARE CENTER OF NORTH KARNATAKAIJCRRVol 04 issue 21Section: HealthcareCategory: ResearchReceived on: 08/08/12Revised on:19/08/12Accepted on:30/08/12B.R Ashwini 1 , Vernekar Sunita 2 , Kulkarni Mohan H 3 , T. Kiran 41 Department of Pathology, Bangalore Medical College and Research Institute,Bangalore, K.A., India2 Karnataka Institute of Medical Sciences, Hubli, K.A., India3 Consultant Pathologist, Adhyapaknagar, Hubli, K.A., India4 Department of Gen Surgery, Rajarajeshwari Medical College and Research Institute,Bangalore, K.A., IndiaE-mail of Corresponding Author: dr_ashwinibr@yahoo.co.inABSTRACTFine needle aspiration cytology (FNAC) is a minimally invasive and cost effective technique. Howeversome of the deep seated lesions may have occult carcinomas which could be missed on conventionalFNAC of a multinodular goitre or non–palpable nodules. Ultrasound guidance is helpful in directingthe needle to solid portions of the cystic or mixed nodules and reduce the need for repeat FNAs butadds to cost and turn-around time of patient. Objectives: The study was conducted to compare theresults of conventional FNAC with Ultrasound (USG)-guided FNAC and correlate with histopathologyto evaluate the sensitivity, specificity and diagnostic accuracy of both types of FNAC. Materials andMethods: The study was conducted on 140 patients who underwent conventional FNAC in thedepartment of Pathology and subsequently USG-guided FNAC in department of Radiology. Smearswere prepared from both the FNA and were reported separately by the same pathologist. StatisticalIndices used in the present study for both conventional and USG-guided FNAC with histopathology asgold standard are Sensitivity, specificity, and diagnostic accuracy. Comparison of the FNAC resultswith histopathology showed that there were five false negative results in conventional FNAC and twofalse negative results in USG-guided FNAC. Results: The sensitivity and diagnostic accuracy were77.8%, 92.9% on USG-guided FNAC and 44.4%, 82.1% on conventional FNAC. In conclusion, USGguidedFNAC improved the cytological diagnostic accuracy, sensitivity and reduced the false-negativerates in comparison to conventional FNAC especially in case of multinodular goitre.Keywords: Conventional FNAC, USG-guided FNAC, Histopathological correlation, Sensitivity,Diagnostic accuracy.INTRODUCTIONFine needle aspiration cytology (FNAC) of thyroidis a simple, cost effective method in themanagement of palpable thyroid lesions 1 . Somecases have more than one lesion co-existing inthyroid which could be missed on conventionalFNAC. Multiple revision surgeries are notpossible on thyroid due to its location. Ultrasound(USG) simulates the gross appearance of thyroidin the patient. However USG alone cannot be usedas gold standard as there are over lapping featuresbetween benign and malignant lesionssonographically. An accurate diagnosis isnecessary to obtain results with surgery. USGguidedFNAC has advantage of both specialitiesbut add to cost and turn around time to patients.The study was conducted in Department ofPathology at our institute with the aim ofidentifying whether USG-guided FNAC issignificantly better in identifying the neoplasiathan conventional FNAC. With this objective thediagnostic accuracy of USG-guided FNAC andInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 64

B.R. Ashwini et alCOMPARITIVE STUDY OFASPIRATION CYTOLOGYKARNATAKACONVENTIONAL AND ULTRASOUND-GUIDED FINE NEEDLEOF THYROID IN A TERTIARY CARE CENTER OF NORTHconventional FNAC were compared withhistopathology as the gold standard.MATERIALS AND METHODSThe study was conducted from 1st October 2007to 31st march 2009, during which 417 thyroidFNAC were done in the department of Pathology.Among them, 140 patients gave the consent for thestudy and underwent both conventional and USGguidedFNAC. All patients included in the studywere referred for FNAC with complaints ofthyroid swelling. No age and sex criteria wereincluded in the study.Conventional FNAC was done in the Departmentof Pathology. Subsequently USG was done withhigh frequency probe (5 to 12MHz transducer) inthe department of Radiology, at our institution.The number of nodules, size and echogenecitypatterns were noted. FNAC was then repeated onthe patients under USG-guidance on arepresentative or suspicious area. In both themethods, FNAC was done under asepticprecautions using 22-gauze needle fitted to 5mlsyringe without aspiration with patient in supine orsitting posture with neck extended. The materialcollected in the bore by capillary action. In somecases aspiration technique was used. The aspiratewas then expressed on the clean glass slide andfixed with 95% alcohol and by air dry technique.A minimum of four slides were smeared with theaspirate. The smears were then stained withHematoxylin and Eosin (H&E), and Wright’sstain. The slides prepared from conventionalFNAC and USG-guided FNAC were reportedseparately by the same pathologist. Smears withatleast four clusters of follicular cells wereconsidered adequate for reporting. Among 140cases, twenty-eight patients underwent surgery andthus histopathological correlation was obtained inthem.Histopathological results were correlated withresults of conventional FNAC and USG-guidedFNAC. Statistical Indices used in the present studyfor both conventional and USG-guided FNACwith histopathology as gold standard includeSensitivity = TP/ (TP+FN) X100, Specificity =TN/ (TN+FP) X100, PPV= TP/ (TP+FP) X100,NPV= TN/(TN+FN) X100, FPER =FP/total no ofcases X 100, FNER = FN/Total no cases X 100,Diagnostic accuracy = TP+TN/TP+TN+FP+FNX100 in order to evaluate their sensitivity,specificity and diagnostic accuracy. (TP = TruePositive, FP = False positive, TN = True Negative,FN = False Negative, PPV= Positive predictivevalue, NPV=Negative predictive value,FPER= false positive error rate, FNER= falsenegative error rate)RESULTSThe thyroid aspirations were done on patients withan age range of two to seventy years with meanage of 33.8 yrs. Majority of them were femalesaccounting for 124 cases (88.6%) out of 140. Malewere 16 (11.4%). Aspiration was unsatisfactory inthree cases (2.2%), on conventional FNAC and inone case (0.7%) on USG-guided FNAC. Nonneoplasticlesions were more common in thepresent study on both conventional and USGguidedFNAC.The various lesions found on conventional andUSG-guided FNAC were as in table 1. Differenceswere found in the number of nodular goitre andneoplastic lesions in both FNAC. Nodular goitrewas the commonest lesion found on bothconventional and USG-guided FNAC. Figure 1showing clear correlation between cytologicalfindings and USG features of nodular goitre. Outof 140 cases histopathology was available in 28cases. Histopathology showed 16 cases of nodulargoitre, one Hashimoto’s thyroiditis, two primaryhyperplasia, five papillary carcinomas, threefollicular adenomas and one Hurthle cell adenoma.The results of conventional FNAC and USGguidedFNAC were correlated withhistopathological diagnosis to know theirsensitivity, specificity and diagnostic accuracy ashistopathology forms the gold standard.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 65

B.R. Ashwini et alCOMPARITIVE STUDY OFASPIRATION CYTOLOGYKARNATAKACONVENTIONAL AND ULTRASOUND-GUIDED FINE NEEDLEOF THYROID IN A TERTIARY CARE CENTER OF NORTHNineteen non neoplastic lesions and nineneoplastic lesions were reported onhistopathology. In comparison, out of 28 cases,conventional FNAC showed 24 non-neoplasticlesions with 21 cases of nodular goitre, twoprimary hyperplasia and one Hashimoto’sthyroiditis. There were four neoplastic lesions withthree papillary carcinoma and one Hurthle cellneoplasm. USG-guided FNAC showed 21 nonneoplasticlesions with 18 cases of nodular goitre,two primary hyperplasia, one Hashimoto’sthyroiditis and seven neoplastic lesions with fourpapillary carcinomas, two follicular neoplasms,and one Hurthle cell neoplasm. Oncomparing theresults of conventional and USG-guided FNACwith histopathology, differences were found infive cases as showed in table 2. There were nofalse positive results in our study. The correlationof conventional FNAC and USG-guided FNACwith histopathology showed four true positives, 19true negatives and five false negatives onconventional FNAC. USG-guided FNAC showedseven true positives, 19 true negatives and twofalse negatives. The statistical evaluation withvarious parameters showed 44.4% sensitivity,100% specificity, 100% PPV, 79.2% NPV and82.1% diagnostic accuracy on conventional FNACand 77.8% sensitivity, 100% specificity, 100%PPV, 90.4% NPV and 92.9% diagnostic accuracyon USG-guided FNAC.DISCUSSIONIt is a well-known fact that FNAC is safe, rapid,inexpensive and reliable in the diagnosis ofthyroid nodules 2 . It is possible to classify nonneoplasticand neoplastic lesions with the help ofFNAC and subtype them. However, some of thedeep seated lesions may have occult carcinomaswhich could be missed on conventional FNAC ofa multinodular goitre or non–palpable nodules. Inclinical practice, it is recommended that USGguidanceshould be sought after a failedconventional FNA, in small nodules, in nonpalpablenodules, in lesions that are located indifficult-to-access locations, in nodules withextensive cystic change, fibrosis or calcification.USG-guidance is also helpful in directing theneedle to solid portions of the cystic or mixednodules and reducing the need for repeat FNAC 3 .The present study was undertaken to compare theresults of conventional and USG-guided FNACwith histopathology as gold standard to determinetheir diagnostic accuracy.The inadequacy rate of 2.2% was seen inconventional FNAC and 0.7% in USG-guidedFNAC. The inadequacy rate was not statisticallysignificant in our study in comparison to otherstudies 4,5 . Majority of the cases were females with124 cases. Among them 113 cases (80.7%) hadnon neoplastic lesions and eleven (7.9%) hadneoplastic lesions. Both neoplastic and nonneoplastic lesions were more commonly seen infemales comparable with other studies 6,7 . Therewere five false negative cases on conventionalFNAC and two on USG-guided FNAC. The falsenegative error rates of 17.9% on conventionalFNAC and 7.1% on USG-guided FNAC werecomparable with several other studies 8,9 . Thecytological criteria for diagnosis of the lesions arewell defined but there can be overlappingcytological features, making the diagnosis of thelesions and further more distinction between theneoplastic and non-neoplastic lesions difficult.USG show various patterns due to echogenicvariations in the lesions. These patterns includecyst with avascular colloidplug, blocksofhyperechogenicity separated by bands ofhypoechogenicity,uniform hyperechogenicity,intense hypervascularity, hypoechogenicity,isoechogenicity with or without halo, or noduleswith intense peripheralvascularity.The absence offeatures like calcification, halo, hypoechogenecity,isoechogenecity and increased peripheralvascularity favors benignity. These patterns aresensitive in predicting the neoplastic lesions withvarying specificity 10 . However in cases withoverlapping cytological features these USGpatterns help in differentiating and providing moreInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 66

B.R. Ashwini et alCOMPARITIVE STUDY OFASPIRATION CYTOLOGYKARNATAKACONVENTIONAL AND ULTRASOUND-GUIDED FINE NEEDLEOF THYROID IN A TERTIARY CARE CENTER OF NORTHaccurate cytological diagnosis of some of thelesions. There were two false negative results onconventional FNAC due to overlappingcytological features particularly between nodulargoitre and follicular neoplasm as seen in otherstudies 11 . Figure 2 shows a case with features ofboth nodular goitre and follicular neoplasmcytologically and USG showing features offollicular adenoma supporting the diagnosis offollicular neoplasm. Histopathology confirmed adiagnosis of follicular adenoma in this case.Cellular microfollicular patterns are seen inhyperplastic microfollicular nodule of amultinodular goitre, Hashimoto’s thyroiditis,microfollicular adenomas and a well differentiatedfollicular carcinoma and are the most challengingones in diagnosing cytologically 12 . In our studyfeatures of nodular goitre was seen onconventional FNAC in a patient in whom USGexamination showed a single hypoechoic area inleft lobe of thyroid. Aspiration from this areaunder USG-guidance showed features of papillarycarcinoma as in figure 3. Histopathologicaldiagnosis of micropapillary carcinoma was madein this case. The results obtained in our studyshowed that the sensitivity and the diagnosticaccuracy of USG-guided FNAC was more than theconventional FNAC and was comparable withother study 13 .In conclusion, thyroid is an organ where multiplerevision surgeries are not possible and it is alsodifficult to obtain the patient’s consent for thesame. The cytological criteria for identification ofa lesion are well defined. But some cases showoverlapping cytological features of differentlesions. USG-guided FNAC as an addedadvantage of a multi-modality approach and aidsin providing a more accurate diagnosis of thelesion or the lesions in thyroid. In our study USGguidedFNACreduced the false-negative rates inthe diagnosis of the neoplastic lesions, incomparison to conventional FNAC and improvedthe sensitivity and diagnostic accuracy especiallyin cases of multinodular goitre and therebyreducing the turnaround time in the accuratemanagement of the patient.ACKNOWLEDGEMENTDr G C Patil (Professor and Head), Department ofRadiodiagnosis, Karnataka Institute of medicalsciences, Hubli. The authors acknowledge theimmense help received from the scholars whosearticles are cited and included in references of thismanuscript. The authors are also grateful toauthors/editors/publishers of all those articles,journals and books from where the literature forthis article has been reviewed and discussed.REFERENCES1. Klemi PJ, Joensuu H. FNAC in the diagnosisof the thyroid nodules. ActaCytol1991;35:434-382. Cappel RJ, Bouvy ND, Bonjer HJ,Muiswinkel JM, Chadha S. Fine needleaspiration of thyroid nodules: How accurate itis and what are the causes of discrepant cases?Cytopathology 2001;12:399-4053. TamasSolymosi, GyulaLukacsToth,MiklosBodo. Diagnostic accuracy of FineNeedle Aspiration Cytology of Thyroid.Impact of Ultrasound andUltrasonographically Guided Aspiration.ActaCytol 2001;45:669-744. Izquierdo R, Arekat MR, Knudson PE, KartunKF, KhuranaK,et al. Comparison of palpationversus ultrasound guided FNAB of thyroidnodules an outpatient endocrinology practice.EndocrPract 2006;12:609-145. Cai XJ, Valiyaparambath N, Nixon P,Waghorn A, Giles T, et al. Ultrasound-guidedfine needle aspiration cytology in thediagnosis and management of thyroid nodules.Cytopathology 2006;17:251-56.6. Martinek, J.Dvorackova, M.Honka, J.Horacek,Klvana. Importance of Guided FNA for theDiagnosis of thyroid nodules-Ownexperiences. Biomed Pap MedInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 67

B.R. Ashwini et alCOMPARITIVE STUDY OFASPIRATION CYTOLOGYKARNATAKACONVENTIONAL AND ULTRASOUND-GUIDED FINE NEEDLEOF THYROID IN A TERTIARY CARE CENTER OF NORTHFacUnivPalacky Olomouc Czech Repub2004;148:45-50.7. Lin JD, Hsueh C, Chao TC, Weng HF, HuangBY. Thyroid Follicular Neoplasms Diagnosedby High-Resolution Ultrasonography withFine Needle Aspiration Cytology. ActaCytol1997;41:687-91.8. Suen KC, Abdul-Karim FW, Kaninsky DB,Layfield LJ, Miller TR et al. Guidelines of thePapinicoloau Society of Cytopathology for theexamination of Fine Needle AspirationSpecimen from Thyroid Nodules. Mod pathol1996;9:710-15.9. John Boey, C.Hsu, Robert J.Collins. Falsenegative errors in Fine needle aspirationbiopsy of dominant thyroid nodules: Aprospective follow up study. World J Surg1986;10:623-3010. John A. Bonavita, Jason Mayo, James Babb,Genevieve Bennett, ThairaOweity et al.Pattern Recognition of Benign Nodules atUltrasound of the Thyroid: Which NodulesCan Be Left Alone? AJR Am J Roentgenol2009;193:207-1311. H. R Harach, Silvia B. Zusman, E. SaraviaDay. Diagnostic Dilemma. Nodular goiter: Ahisto-cytological study with some emphasis onpitfalls of fine-needle aspiration cytology.DiagnCytopathol 1992;8:409-1912. Nugen GK, Lee MW, Ginsberg J, Wragg T,Bilodeau D. Fine Needle Aspiration OfThyroid: An Overview. Cytojournal 2005;2:1213. Danese D, Sciacchitano S, Farsetti A,Andreoli M, Pontecoryi A. Diagnosticaccuracy of conventional versus sonographyguidedfine-needle aspiration biopsy of thyroidnodules. Thyroid 1998;8:15-21.Table 1: Table showing various lesions obtained on both conventional and USG-Guided FNACLesions Conventional FNAC USG-Guided FNACNodular Goitre 91 (65%) 88 (62.9%)Hashimoto’s thyroiditis 27 (19.3%) 29 (20.7%)Primary Hyperplasia 5 (3.7%) 5 (3.7%)Dyshormonogenic goitre 2 (1.4%) 2 (1.4%)Acute thyroiditis 1 (0.7%) 1 (0.7%)Follicular neoplasm 3 (2.1%) 5 (3.6%)Papillary carcinoma 6 (4.3%) 7 (5.0%)Anaplastic carcinoma 1 (0.7%) 1 (0.7%)Hurthle cell carcinoma 1 (0.7%) 1 (0.7%)Inadequate sample-no opinion 3 (2.1%) 1 (0.7%)Table 2: Table showing cases with a false negative results on conventional and USG-guided FNACDiagnosis onDiagnosis on US-No of casesHistopathology DiagnosisConventional FNAC Guided FNAC2 Nodular goitre Follicular neoplasm Follicular adenoma1 Nodular goitreMicropapillaryCarcinomaMicropapillary Carcinoma1 Nodular goitre Nodular goitre Follicular adenoma1 Nodular goitre Nodular goitre Micropapillary CarcinomaInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 68

B.R. Ashwini et alCOMPARITIVE STUDY OFASPIRATION CYTOLOGYKARNATAKACONVENTIONAL AND ULTRASOUND-GUIDED FINE NEEDLEOF THYROID IN A TERTIARY CARE CENTER OF NORTHFig 1: [A]: Mixed echoic lesion with specks ofcalcification in thyroid. [B]: Gross showing colloidfilled nodules with specks of calcification on thesepta. [C& D]: FNAC from different area showingclusters of follicular cells with cyst macrophages.Wright’s stain 10x.Fig 3: [A]: Arrow showing 0.5 cm hypoechoic areain left lobe of thyroid [B]: Gross of correspondingarea showed gray-white areas. [C,D]: US-GuidedFNAC from hypoechoic area showed features ofpapillary carcinoma with INC † . Wright’s stain 40x. †Intra nuclear inclusionFig 2: [A]: Single well circumscribed hypoechoiclesion. [B]: Gross of corresponding area showed wellcircumscribed grey white area. [C]: FNAC showedmicrofollicles. Wright’s stain 10x [D]: Anisocytosiswith honeycomb pattern. Wright’s stain 10x.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 69

Ajij Ahmed et alPHYSICOCHEMICAL AND BIOLOGICAL PROPERTIES OF ADIANTUM CAPILLUS-VENERIS LINN:AN IMPORTANT DRUG OF UNANI SYSTEM OF MEDICINEIJCRRVol 04 issue 21Section: HealthcareCategory: ReviewReceived on: 06/09/12Revised on:15/09/12Accepted on:23/09/12PHYSICOCHEMICAL AND BIOLOGICAL PROPERTIES OFADIANTUM CAPILLUS-VENERIS LINN: AN IMPORTANT DRUG OFUNANI SYSTEM OF MEDICINEAjij Ahmed 1 , Nasreen Jahan 1 , Abdul Wadud 1 , Hashmat Imam 2 ,Syeda Hajera 3 , Alia Bilal 11 Dept. of Ilmul Advia, National Institute of Unani Medicine, Kottigepalya, MagadiMain Road, Bangalore, K.A., India2 Dept. of Tahaffuji Wa Samaji Tib, National Institute of Unani medicine,Kottigepalya, Magadi Main Road, Bangalore, K.A., India3 Dept. of Obs. and Gynaecology, Govt. Nizamia Tibbi College, Charminar,Hyderabad, K.A., IndiaE-mail of Corresponding Author: aziznium@gmail.comABSTRACTThe aim of the present paper is to provide information regarding the therapeutic uses and scientificstudies carried out on Adiantum capillus-veneris Linn. The key words used for the literature searchwere Adiantum capillus-veneris, Parsioshan, physico chemical, phytochemical and pharmacologicalstudy. The search was carried out through Unani classical books, ethno botanical literature and Googlescholar. The drug is popularly known as “Parsiaoshan” in Unani and used to treat a number of diseases.It is traditionally used as a diuretic, resolvent, antipyretic, demulcent, emmenagogue, expectorant anddeobstruent. It is also useful in the treatment of hair fall and skin diseases. Chemical analysis ofParsioshan shows that it contains triterpenoids, flavonoids and various other constituents. Researchstudies have shown that it possesses anti fungal, anti inflammatory, anti bacterial, hypoglycemic andlithotriptic activities. An extensive review of ancient literature of Unani medicine revealed that the drughaving numerous therapeutic actions, several of which have been established scientifically which mayhelp the researchers to set their minds for approaching the utility, efficacy and potency of Adiantumcapillus-veneris.Key Words: Adiantum capillus-veneris, Parsioshan, Physico Chemical, Phytochemical andPharmacological studyINTRODUCTIONAs folk medicine, the pteridophytes whichconstitute ferns and fern allies have been known toman for more than 2000 years and also have beenmentioned in ancient literature. It has beenobserved that pteridophytes are not infected bymicrobial pathogens, which may be one of theimportant factors for the evolutionary success ofpteridophytes and the fact that they survived formore than 350 million years 1 .Fern and fern allies, also known as botanicalsnakes or plant reptiles, have always been in thecenter stage of attraction to botanist, horticulturistsand nature lovers since ancient times. Thisfascinating group of pteridophytes is distributed inthe Himalaya, Western Ghats, and Vindhya, hillyareas of Bihar, Orissa and Madhya Pradesh as wellas in the Aravalli, particularly in Mount Abu inRajasthan 2 . Adiantum capillus-veneris Linn is agraceful delicate fern of damp places, foundchiefly in the western Himalayas, ascending to analtitude of 2,400 m, and extending into Manipur. Itis common in Punjab, Bihar, Maharashtra, andsouth India. It grows among rocks and on walls 3, 4 .Theophrastus (327-287B.C.) and Dioscorides(100A.D.) have referred to medicinal attributes ofcertain ferns. Adiantum capillus-veneris Linn isInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 70

Ajij Ahmed et alPHYSICOCHEMICAL AND BIOLOGICAL PROPERTIES OF ADIANTUM CAPILLUS-VENERIS LINN:AN IMPORTANT DRUG OF UNANI SYSTEM OF MEDICINEone such fern whose medicinal values have longbeen mentioned by Sushrata and Charaka 5 .Taxonomical Classification 6Kingdom : PlantaeDivision : PteridophytaClass : PteridopsidaOrder : PteridalesFamily : AdiantaceaeGenus : AdiantumSpecies : cappilus- venerisVernaculars 7Arabic : Shairuljin, Shaar-ul-jibal, Shaar-ularzAyurvedic : Hansaaraja, hansapadiEnglish : Maiden hair fern, Maria’s fern, OurLady’s hairGujarati : HanspadiHindi : Hansraj, Mubaraka, PurshaKannada : HansrajPersian : SirsiapeshaneTamil : SeruppadaiKashmir : DumtuliUrdu : Persia – ushanUnani : Barsioshan, Kazbaratul BerHistoryAs early as in 100 A.C. Dioscorides describedAdiantum capillus-veneris by the name ofAdiavrov for having leaves serrated at the top likecoriander. The Western Arabs, however, appear touse Adiantum capillus-veneris, as they call theplant Kuzburat-el bir or “coriander of the wall”,indicating a habitat where A. venestum is notfound. Other Arabic names for the genusAdiantum are shaar-el-jinn i.e. “fairies hair”,shaar-el-jibal i.e. “hair of the mountains”; shaarel-fuali.e. “hair of omens”; sak-el-aswad i.e.“black stem” and Nasif-el-aswad i.e. “black veil,”Ibn Sina and other medical writers describe thedrug under the name of Barsiawashan, which isthe Arabic form of its Persian nameParsiawashan. It is considered to be deobstruentand resolvent, useful for clearing the primaviae ofbile, and phlegmatic humors; also, expectorant,diuretic, emmenagogue, and alexipharmicproperties are also ascribed to it. Used as a plaster,it is considered to be discutient, and is applied tochronic tumours of various kinds. Theophrastusmentions two kinds of Adiantum, “white” and“black,” used in making hair oil. Greek synonymsfor the plant are polytrichon, calitrichon,trichomenis, and ebinotrichon 8 .Geographical DistributionA native of tropical America Adiantum capillusvenerisLinn found throughout the world in moistand shady places. In India it is distributed in TamilNadu up to 1800 meter on the mountains,Himalaya and in north India 9 .Botanical DescriptionAdiantum capillus-veneris is a delicate gracefulfern. Stipes is blackish, 10-23 cm long 10 . Frondsbipinnate with short terminal pinna and numerouserect patent lateral ones on each side, the lowestbeing slightly branched; segments cuneate, 1.5-2.5cm broad; sori borne at the roundish sinuses of thecrenations, obreniform or rounded 4,5 .Pharmacological Actions and Uses in UnaniLiteratureIt has Dafe humma (antipyretic), Mulattif(demulcent), Munaffise balgham (expectorant),Mudire baul (diuretic), Mudirre haiz(emmenagogue), Muhallil (resolvent) and Mujaffif(siccative) properties 11, 12 . The whole herb is usedas medicine in various forms like decoction,powder, paste, oil etc. in different aliments. Thewhole plant is used as a hair tonic. Decoction inwine is given in cases of hard tumors of spleen,liver and other viscera. The fronds are powderedand given with honey against bad cold. It is alsouseful in splenic pain and jaundice. It expels thestone from the kidneys and bladder. It istherapeutically used to promote diuresis. Due to itsmucilaginous, pectoral and expectorant properties,Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 71

Ajij Ahmed et alPHYSICOCHEMICAL AND BIOLOGICAL PROPERTIES OF ADIANTUM CAPILLUS-VENERIS LINN:AN IMPORTANT DRUG OF UNANI SYSTEM OF MEDICINEits decoction is used in breathing difficulties,bronchitis, and cough. Along with vinegar andolive oil it is useful in alopecia and with the oil ofHabbul Aas it is useful in maintenance of haircolour and hair loss. It is also useful in insect anddog bite 9, 11, 12, 13, 14 .Ethnomedicinal UsesIt is used as demulcent, expectorant, astringent,antitussive, diuretic, and emmenagogue, febrifugeand also as a hair tonic 5, 15, 16, 17 . In Punjab, thefronds are given with pepper as a febrifuge;pounded with honey, they are administered incatarrhal affections. They are smoked to relivecold. The dried fronds are used as a substitute fortea. The herb is used as a pectoral, and also incatarrhal affections. It is reported to be used as ahair tonic. The fern is boiled in wine or mead, anddrunk in case of hard tumors in the spleen, liverand other visceras 4 . Its decoction is also used toremove dandruff. Fresh leaves are boiled in wateralong with sugar; one cup of this decoction istaken orally twice a day for a week to treatjaundice and hepatitis 15 . The fronds are chewed forthe treatment of mouth blisters. Frond extractmixed with honey is used as an eye ointment 18 .Physico Chemical Studies 9Study of the powdered drugThe powder is fine and a bit fluffy in texture. It isdark brownish green in colour and has no taste.The powder after being cleaned in charcoalhydrate, when observed under microscope,showed mostly fragments of leaves and petiolesmostly with no distinguishing character. A veryfew isolated pieces of sporangial wall withcharacteristic transverse thickening were alsovisible. Occasional triangular spore tetrads werealso present. Reaction of chemicals with crudepowdered drug and fluorescence analysis (Table 1)are as follows:Reaction of chemicals with crude powdereddrugChemicalsObservationsPowder treated with An emulsion formedwaterPowder shaken in a testtube with waterPowder treated with 5%NaOHPowder treated with66% H 2 SO 4Powder pressed betweentwo filter papersNo frothing, floatspartiallyTurns dark chocolatebrownTurns dark blakishbrownNo oily stain appearsIdentity, purity, strength and assayForeign organic matter NilPurity 100%Physico chemical constants (%)Loss on drying at 105ºC 7.36Solid contents 74.48Ash valuesTotal ash 7.81Acid insoluble ash 4.42Water soluble ash 0.42Successive extractive values (%)Pet. Ether (60-80º) 4.49Chloroform 3.03Acetone 4.60Ethanol 9.27Distilled water 14.07Phytochemical Studies 19Nine new compounds were identified in thetwenty-two isolated triterpenoids, from the freshfronds of Adiantum capillus-veneris Linn collectedin Japan. The plant of Chinese and Egyptian originwere also identified with the two new triterpenoidseach as 4a -hydroxyfilican- 3-one and fern-9 (11)-en-12b –o and oleanane triterpenoids; olean-12-en-3-one and olean-18-en-3-one 19 .Four triterpenoidal compounds belonging toadiantane and filicane groups, isoadiantone;Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 72

Ajij Ahmed et alPHYSICOCHEMICAL AND BIOLOGICAL PROPERTIES OF ADIANTUM CAPILLUS-VENERIS LINN:AN IMPORTANT DRUG OF UNANI SYSTEM OF MEDICINEisoadiantol-B; 3-methoxy-4-hydroxyfilicane and3,4-dihydroxyfilicane, from the hexane fractionand three flavonoids from the ethyl acetatefraction as: quercetin , quercetin-3-O-glucosideand quercetin-3-O-rutinoside (rutin) wereidentified in Chromatographic fractionation of thealcoholic extract of the dried fronds of Adiantumcapillus-veneris Linn. The identification of theisolated compounds has been established throughtheir physical, chemical and spectroscopicmethods including IR,1 H NMR,13 C NMR,HSQC, HMBC, NOESY and MS 23 .Scientific ReportsAntifungal ActivityThe water extracts and extracted phenols fromgametophytes and different parts of sporophytesof, Adiantum capillus-veneris L. was investigatedfor its antifungal activity and found to be bioactiveagainst Aspergillus niger and Rhizopus stolonifer.Antifungal activity was found to be higher ingametophytes. Among the different parts ofsporophytes, immature pinnule possesses highestfungi static property 20 .Antioxidant activityAntioxidant potential of leaf extract of Adiantumcapillus-veneris Linn was studied in vitro by AnilKumar, against H 2 O 2 induced oxidative damage inperipheral blood lymphocytes. Pre treatment withplant leave extract for 18 hours could effectivelyinhibited lipid peroxidation and enhanced theactivities of antioxidant enzymes and glutathionecontent significantly. The results indicate that itmight be due to its direct action in scavenging freeradicals and thereby modulating the antioxidantdefence system 21 .Antibacterial activityPradeep investigated the in vitro antibacterialactivity of twelve important pteridophytes plantsby disc diffusion method. The aqueous andalcoholic leaves extract of Adiantum capillusvenerisLinn were found to be effective againstAgrobacterium tumefaciens, Escherichia coli,Salmonella arizonae, Salmonella typhi andStaphylococcus aureus strains of Bacteria.Anti inflammatory activityAlcoholic extract of A. capillus-veneris and itshexane fraction showed a significant antiinflammatoryactivity against formalin inducedinflammation. The hexane fraction and compounds3, 4 showed topical anti-inflammatory activityafter 6 h and continued for 30 h in croton oilinducedinflammation 23 .The ethyl acetate fraction of the ethanolic extractof A. capillus-veneris showed significantinhibition of hind paw oedema induced bycarrageenan when evaluated for its antiinflammatoryactivity 24 .Analgesic activityThe analgesic activity of the ethanolic extract of A.capillus-veneris and its fraction has been carriedout by tail flick method and writhing test resultshowed significant analgesic activity withinsignificant ulceration as compared to thestandard drug 24 .Hypoglycemic activityThe alcoholic extract of A. capillus-venerisshowed a significant hypoglycaemic effect inOGTT using rabbit model. Started after 30 minand continued for 4 hours 23 .Lithotriptic activityIn vitro antilithiasic activity of hydro alcoholicextract of Adiantum capillus-veneris wasevaluated by crystallization, aggregation andnucleation assays. The result showed significantinhibition of crystallization and aggregation whichwas further confirmed by in vivo study againstEthylene glycol (0.75%) and ammonium chloride(1%) induced Urolithiasis in male Sprague Dawleyrats. Urine microscopy showed significantreduction in the number of crystals in test groups25 .DISCUSSIONThe present review reveals that Adiantum capillusvenerisLinn is used in treating various ailments.Recent ethno botanical, phytochemical andInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 73

Ajij Ahmed et alPHYSICOCHEMICAL AND BIOLOGICAL PROPERTIES OF ADIANTUM CAPILLUS-VENERIS LINN:AN IMPORTANT DRUG OF UNANI SYSTEM OF MEDICINEpharmacological studies have reported themedicinal values of Adiantum capillus and itsactive constituents. This review provides evidencebased scientific validation to some of thetherapeutic uses and actions described forParsioshan in classical texts of Unani medicine. Itis popularly used as diuretic and for the treatmentof kidney stone in Unani system of medicine sincelong. Its pharmacological activities like antioxidant 21 , anti bacterial 22 , anti-inflammatory 24 ,lithotriptic activities 25 clearly justify its therapeuticefficacy in nephrolithiasis. It is further suggestedthat phytochemical and pharmacological studieson some of the less known or controversial Unanidrugs may be taken up on priority basis not only toscientifically validate therapeutic uses , but revivethe faith and confidence of Unani practitioners inits actions to serve the large strata of the ruralsociety.CONCLUSIONThis article briefly reviews the traditionalknowledge and ethno medicinal reports ontherapeutic activities of the plant Adiantumcapillus-veneris Linn. The physicochemical,phytochemical and pharmacological studies of thisplant provide a scientific basis for its therapeuticuse.ACKNOWLEDGEMENTAuthors acknowledge the immense help receivedfrom the scholars whose articles are cited andincluded in references of this manuscript. Theauthors are also grateful to authors/editors/publishers of all those articles, journals and booksfrom where the literature for this article has beenreviewed and discussed.REFERENCES1. Singh M, Singh N, Khare PB, Rawat AKS.Antimicrobial activity of some importantAdiantum species used traditionally inindigenous systems of medicine.Pharmacognocy and Ethno pharmacologyDivision, Lucknow: National botanicalresearch institute, India.2. Sharma NK. Ethno medicinal Studies on Fernsand Fern Allies of Hadoti Plateau, SouthEstern Rajasthan. Zoo’s Print Journal 2002;17(3): 732-4.3. Anonymous. The wealth of India. Volume- I:A. New Delhi: National institute of ScienceCommunication and Information Resources(CSIR); 2003. p. 79-804. Chatterjee A, Pakrashi SC. The treatise onIndian medicinal plants. Vol 1. New Delhi:National institute of Science Communicationand Information Resources(CSIR); 2005.p. 85. Parihar P, Leena p. Some pteridophytes ofmedicinal importance from Rajasthan. NaturalProduct Radiance 2006; 5(4): 297-3016. www.usda.gov/java/namesearch (naturalresource conservation service, USA Dept. ofAgriculture. (Cited on 13-4-2012)7. Kirtikar KR, Basu BD. Indian medicinalplants with illustration. 2 nd edi. Vol-11 th .Dehradun: International Book Distributors;2003. p. 3747-498. Dymock W, Warden CJH, Hooper D.Pharmacographia Indica vol- III. New Delhi:Srishti book Distributors; 2005. p. 624-259. Standardisation of single drugs of Unanimedicine, part II. New Delhi: CCRUM; 1992;p.240- 47.10. Narayan DP, Purohit S, Arun K. Sharma,Tarun K. A hand book of medicinal plants, acomplete source book Jodhpur: AgrobiosIndia; 2009. P. 1711. Abu Sayeed BAM. Kitab al fatah fi al – tawdi(Urdu translation). I st edi. New Delhi: JamiaHamdard; 2007. p. 6612. Hakim IHB. Kitabul mukhtarat fil Tib (Urdu).Published by New Delhi: CCRUM; 2005. VolII, p.77 Vol III. p.321-2513. Hakim MK. Ilmul Advia Nafisi. New Delhi:Aijaz Publishing House; 2007. p. 255-56.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 74

Ajij Ahmed et alPHYSICOCHEMICAL AND BIOLOGICAL PROPERTIES OF ADIANTUM CAPILLUS-VENERIS LINN:AN IMPORTANT DRUG OF UNANI SYSTEM OF MEDICINE14. Central council of research in Unani Medicine.Qarabadin Sarkari. 2 nd edi. New Delhi:CCRUM; 2006. p. 3015. Arsahd MA, Khan MA, Ahmad M, Zafar M,Khan H, Muhammad N et al., Medicinalplants used for the treatment of jaundice andhepatitis based on socio-economicdocumentation. African Journal ofBiotechnology 2009 April 20; 8 (8): 1643-5016. Khare CP. Indian medicinal plants anillustrated dictionary. New York: SpringerScience Media; 2007. p.19-2017. Ambasta SP. The useful plants of India. NewDelhi: National Institute of ScienceCommunication and Information ResourcesCouncil of scientific and industrial research;2006. p. 1518. Upreti K, Jewan SJ, Tewari LM, Joshi GC,Pangtey YPS, Tewari G. Ethno medicinal usesof pteridophytes of Kumaun Himalaya,Uttrakhan, India. Journal of American Science2009; 5(4): 167-7019. Takahisa N, Yoshiko M, Hideharu E, Yoko A,Kazuo M, Akihito T et al., fern constituents:Triterpenoids from Adiantum capillus-veneris. Chem. Pharm. Bull. 2002; 50 (9): 1273-7520. Piyali G, Mukhopadhyay R, Gupta K.Antifungal activity of the extracts andextracted phenols from gametophytes andsporophytes of two species of Adiantum.Taiwania, 2005; 50 (4): 272-83.21. Pourmorad F, Hosseinimehr SJ, ShahabimajdN. Antioxidant activity, phenol and flavonoidcontents of some selected Iranian medicinalplants. African Journal of Biotechnology 2006June; 5 (11): 1142-45.22. Pradeep P, Leena P, Bohra Achaleshwar. Invitro antibacterial activity of fronds (leaves) ofsome important pteridophytes. Journal ofMicrobiology and Antimicrobials 2010March; 2 (2): 19-2223. Ibrahim ZZ, Ahmed AS, Gouda YG.Phytochemical and biological studies ofAdiantum capillus-veneris L. SaudiPharmaceutical Journal 2011 January 7; 1-1024. Haider S, Nazreen S, Alam, MM, Gupta A,Hamid H, Alam MS. Anti-inflammatory andanti-nociceptive activities ofhdroalcoholicextract and its various fractionsfrom Adiantum capillus veneris Linn. Journalof Ethnopharmacology 2011; 138: 741-74725. Ahmed SA. Antilithiasic activity ofParsiaoshan in experimental models[dissertation]. Nationa Institute of UnaniMedicine: RGUHS, Bangalore; 2012.Table 1: Fluorescence analysis of the powdered drugObservation underUltra violetTreatmentOrdinary lightlightPowder as such Dark dull green colourlessPowder treated with 1NDark brown colourlessNaOH in methanolPowder treated with 1NDark brown colourlessNaOH in waterPowder treated with 1N Hcl Brown colourlessPowder treated with 50% HNO 3 Dark cherry brown colourlessPowder treated with 50% H 2 SO 4 Dark brownish green colourlessPowder mounted in nitro cellulose in amyl acetate Almost black colourlessPowder treated with 1N NaOH in methanol, dried and then mountedin nitrocellulose in amyl acetatePowder treated with 1N NaOH in water, dried and then mounted innitrocellulose in amyl acetateDark chocolatebrownDark browncolourlesscolourlessInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 75

Shrivastava Deepti et alDIAGNOSTIC DILEMMA DUE TO DIVERSE PRESENTATION OF TUBERCULOSIS: SERIES OF 3CASESDIAGNOSTIC DILEMMA DUE TO DIVERSE PRESENTATIONOF TUBERCULOSIS: SERIES OF 3 CASESIJCRRVol 04 issue 21Section: HealthcareCategory: Case ReportReceived on: 29/08/12Revised on:07/09/12Accepted on:17/09/12Shrivastava Deepti, Patil Vijya, Bhute Sindhu, Mukherjee SatarupaDepartment of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College,AVBRH, DMIMS Sawangi, Meghe, WardhaE-mail of Corresponding Author: deepti_shrivastava69@yahoo.comABSTRACTTuberculosis is still a common culprit for illhealth in India, particularly in rural areas. For infertilityand other gynaecological disorders we routinely rule out any possibility of it but less stress is given forits co-incidental association in obstetric patients High degree of suspicion remains the only tool insome cases .We are hereby presenting 3 cases of tuberculosis presented altogether differently, alongwith obstretic conditions.Key Words: Tuberculosis, Infertility, Gynaecological disordersINTRODUCTIONTuberculosis is the leading infectious disease inthe world. In developing countries and certainareas of industrialized countries, rates oftuberculosis are highest among women and men ofchildbearing age. Tuberculosis (TB) andpregnancy are two different types of stressesexperienced by women. Their simultaneouspresence affects them both physically andmentally. India accounts for 30% of the burden ofall TB cases in the world 1 .A early diagnosis of TBinfection in a pregnant woman is important asInfant and maternal mortality are between 30%and 40% in untreated active TB cases.However, unfortunately the diagnosis of TBduring pregnancy is usually delayed (for 2–30weeks) because of its non-specific symptoms andprotean manifestation. Up to 20% of pregnantwomen with TB are asymptomatic or have onlyatypical symptoms 2 . Here we are presenting 3cases of tuberculosis with different presentations.CASE REPORTSCase 1A 23 year old primigravida attended the antenatalclinic with history of amenorrhea since 2 monthswith 4-5 episodes of vomiting per day. She wasmarried since 3 months with her menstrual cyclesbeing regular with scanty flow. On examination,she was thin built. Her other findings and routineantenatal investigations were within normal limits.Ultrasound showed single live intrauterinepregnancy of 7.5 weeks gestation with goodcardiac activity. She was prescribed folic acid anddoxylamine tablets. She returned back after 2 dayswith increasing episodes of vomiting, her generalcondition appeared poor, hence was advisedadmission, but as patient was not willing foradmission, she was prescribed oral hydration withglucose supplements and anti-emetics, after urineketone examination revealed negative. Shereturned again after 2 days with uncontrolledvomiting and severe abdominal pain. Her generalcondition was further poor and tenderness over theabdomen was present with mild distention.Ultrasound was repeated which suggesteddistended bowel loops with intrauterine pregnancyof 8 weeks with absent cardiac activity. Surgeons‟opinion was obtained and on abdominal x-ray,multiple gas-fluid levels were seen. Laparotomyalong with D& E was planned. Resectionanastomosis of small intestine was done due toInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 76

Shrivastava Deepti et alDIAGNOSTIC DILEMMA DUE TO DIVERSE PRESENTATION OF TUBERCULOSIS: SERIES OF 3CASESstricture present at terminal ileum along withmultiple fibrous adhesions, which later onconfirmed as Koch‟s abdomen on histopathologyand microbiology of resected part of ileum wheretypical caseating granulomas were present. Herintra and post operative period was uneventfuland later on she responded very well to antituberculartreatment as per advice of TB-Chestphysician .She was not having any evidence ofpulmonary tuberculosis and diagnosed as extrapulmonary, category1-case of TB and drugs givenwere 2H 3 R 3 Z 3 E 3 + 4H 3 R 3 as per RNTCP norms 7 .Case 2A 25 years old lady G4A3 of good socioeconomicstatus was admitted on 29 th of may2008, during emergency hours with amenorrheasince 8 months, with complaints of fever andcough since 20 days, with haemoptysis since 4hours and dyspnea. She was not a booked case ofour institute but admitted in some private nursinghome of nearby peripheral town since 7 days forfever and cough. On general examination, she wasof average built, pale, temperature of 100 degreeFahrenheit, pulse- 90 beats per minute, bloodpressure was 130/80mmHg. On examination of therespiratory system, basal crepitations and rhonchiwere present on the left side. Abdominalexamination revealed a fundal height of 32 weeks,with cephalic presenttion, FHS was 140/min,regular and uterus was relaxed. On internalexamination, cervical os was 1 cm. dilated, 50%effaced, membrane was present, station was at -2and pelvis was adequate for baby size. Routineinvestigations revealed Hb of 6 gm%, TLC-16,400. peripheral smear showed microcytic,hypochromic blood picture. Blood group wasO+ve . Her other investigations were withinnormal limits. Ultrasound suggested single liveintrauterine fetus of gestational age of 34 weeks,placenta was fundoposterior. Ultrasound suggestedleft sided pleural effusion of 40-50cc fluid. X-raychest suggested left upper lobe consolidation andsuspicious of Koch‟s abdomen .Her mother gavehistory of receiving AKT 10 years back. Opinionof Chest physician was sought, all 3 samples ofsputum AFB were negative. She was diagnosed asCategory1, seriously ill, smear negativepulmonary tuberculosis 7 hence Along with broadspectrum Antibiotics, Ethamsylate,2H 3 R 3 Z 3 E 3 +4H 3 R 3 regimen, patient was shifted toTB ward. She still had persistent haemoptysis, onand off, received 5 units of whole bloodtransfusion and after 20 days, she was back atlabour ward and delivered a near term male babyof weight 2.7kg. Baby did not exhibit anysigns/symptoms of congenital tuberculosis butprophylactic Isoniazide 5mg/kg body weight wasstarted to him along with Vitamin K. After 7 daysof delivery, she had sudden collapse of leftlung[Fig-1] due to blood clots in left bronchus,which was diagnosed and removed by rigidbronchoscopy[Fig-2]. Later on after 7 days,patient was totally asymptomatic and discharged.Anti tubercular treatment was given to bothmother and baby. Baby was on mixed feeds offormula and breast milk, as in between mother wasnot able to feed him properly due to her poorgeneral condition. Patient was discharged in astable condition with exclusive breast feeding andto be followed up at the local TB center for directobservation therapy. No further episode ofhemoptysis was reported at follow up after 6weeks of delivery at our OPD and baby gainedadequate weight and was on total breast feeding.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 77

Shrivastava Deepti et alDIAGNOSTIC DILEMMA DUE TO DIVERSE PRESENTATION OF TUBERCULOSIS: SERIES OF 3CASESFig. 1 Showing Complete left lung collapse.Fig. 2 : Clot in the left bronchusCase 3A 36 year old primigravida was referred from aperipheral centre, during emergency hours, withhistory of amenorrhea since 9 months withpremature rupture of membrans since 2 days andnon-progress of labour. Patient had a history ofspontaneous conception 15 years after hermarriage. Her general examination was withinnormal limits. On per abdomen-uterus was fullterm size, cephalic presentation, FHS was present,being 110 beats/min, irregular in nature. On pervaginum, cervix was 3 cm. dilated, 25% affected,caput was present with head being at station -3.She underwent Emergency LSCS in view ofPROM with fetal distress. A male baby of wt.3.2kg was delivered with mild birth asphyxia. Shewas started on liquid diet from 2 nd post- operativeday and catheter was removed on 3 rd day. Fromday 3 rd post-op she started developing high gradedfever, associated with chills. TLC count was21,000 along with features of septicemia. Toxicgranules were present on peripheral smear; otherinvestigations were within normal limits. Woundwas healthy, high vaginal swab, urine for cultureand sensitivity and blood culture was sent, whichlater on showed sterile. She was having spikes of102-103 degree Fahrenheit temperature,intermittently, hence injection chloroquine alongwith broad spectrum antibiotics were continued.Her fever subsided on day 6 th post-op. she wastaking full oral diet and bowel/bladder habits werenormal. Her sutures were removed on day 8 andshe had rise of temperature the next day. On herabdomen examination, mild ascites was suspected,hence ultrasound directed fluid aspiration wasdone and samples were sent for routine andmicroscopic examination along with culture andsensitivity. Abdominal wound was absolutelynormal without any discharge or induration. Toour surprise report of ascitic fluid was positive forAFB staining, Her endometrial sampling was sentfor histopathology and microscopy but not positivefor AFB. Baby did not show any signs/symptomsof congenital TB but prophylactic Isoniazidetherapy was started to him along with injectablevitamin K. Although during LSCS intestines,omentum and peritoneal fluid appeared normal butpresence in peritoneal fluid made it to think asprimary peritoneal disease only. She had history ofprimary infertility but endometrial tissue wasnegative for it and she had conception without anytreatment. She was Categorised as CAT-1 , extrapulmonary tuberculosis and , 2H 3 R 3 Z 3 E 3 +4H 3 R 3regimen was prescribed. Patient was dischargedwithout any fever or ascitis on 15 th postoperativeday on continued AKT with DOT centre.Here H= Isoniazide, R=Rifampicine,Z=Pyrizinamide and E=Ethambutol.All our caseswere weighing between 30-60 kilogram hencedosage were H-600mg, R-450mg,Z-1500mg andE-1200mg. all these drugs are safe in pregnancyand during breast feeding .The important drugwhich is contraindicated is Streptomycin. 7Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 78

Shrivastava Deepti et alDIAGNOSTIC DILEMMA DUE TO DIVERSE PRESENTATION OF TUBERCULOSIS: SERIES OF 3CASESDISCUSSIONM. tuberculosis is transmitted by airborne dropletnuclei, which may contain fewer than 10 bacilliand humans are the only known reservoir for M.tuberculosis. Individuals at high risk for M.tuberculosis infection in industrialized countriesinclude close contact a patient with infectious TB,IV drugs abusers, migrant farm workers orhomeless persons and individuals who may haveoccupational exposure to TB; individuals withimmune-suppressing conditions like HIV ormedication use, individuals with a history ofinadequately treated TB, and infants. Chances thatan individual acquires infection depend on theinfectiousness of the index case, duration of theexposure, environment (crowding, poorventilation), and virulence of the organism. 3,4,5Atypical presentations and slow confirmation byculture often delay the diagnosis and treatment ofpatients with TB. Other reasons include an underuse of tuberculin skin tests, misinterpretation ofunusual chest X-rays, and waiting for cultureresults in patients with AFB-negative smears 2,5 .Pregnancy is not thought to change the course oftuberculosis, however, tuberculosis poses a risk tothe pregnant woman and her fetus. 1 Diagnosisduring pregnancy is delayed because the disease isfrequently extrapulmonary with few symptoms.Although sites reported are pulmonary as well aslaryngeal, pleural, cerebral, miliary, peritoneal,ileocaecal, skeletal or dermal. 1,2,3,4,5 Diagnosis isusually require high degree of suspicion becauseof similarities of symptoms between TB andpregnancy like tachycardia, anaemia, raised ESRand low serum albumin level, as well as dissimilarparameters (like increase in weight duringpregnancy and decrease due to TB, hypertensionin the former and hypotension in the latter etc.)Under RNTCP, sputum examination done as peran algorithm is the preferred method for diagnosisof pulmonary TB. A chest skiagram (performedafter shielding the abdomen) is done if all the 3sputum smears are negative and symptoms persistdespite giving antibiotics for 1-2 weeks. Thepresence of suggestive radiographic abnormalitiesand a medical officer‟s decision to treat with ATTlabels the patient as a „smear-negative‟ TB case 7 .A pregnant woman with extra-pulmonary TB hasconstitutional and organ-affection symptoms.Routine haematology and Mantoux test (notcommonly advocated in programme) along withinvestigations specific for the site are carried outfor the establishment of specific diagnosis 1 .Many patients with suspected pulmonary TB donot produce sputum spontaneously or are smearnegativefor AFB. We could not obtain sputumsample positive in our patient even withhemoptysis. With the use of PCR, nucleic acidsequences unique to M. tuberculosis can bedetected directly in clinical specimens with betteraccuracy and urgency than AFB smear andculture, respectively. Probes are used for rapididentification and maximizing cost effectiveness.Used alone or in combination with otheridentification methods, they serve as a substitutefor biochemical testing and are also more accurate.Molecular tests in combination with “classic tests”can enhance the diagnostic ability particularly inpauci-bacillary infections and in patients withatypical presentations like ours. 5 If proper andadequate chemotherapy is given to pregnantwomen with TB, they are not a higher risk thannon-pregnant women with TB. Neither the diseasenor chemotherapy is threatening to mother ornewborn. However, today the ominouscombination of human immunodeficiency virus,due to the influence of HIV, drug resistant TB andpatient compliance and pregnancy poses a newchallenge to obstetrocians 1,3,5,6The incidence of TB is around 1-2% amongsthospital deliveries, especially in the underprivileged sections of the society. 6 . Treatmentshould also be initiated when the probability ismoderate-to-high. Although the drugs in the initialtreatment regime cross the placenta, theseInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 79

Shrivastava Deepti et alDIAGNOSTIC DILEMMA DUE TO DIVERSE PRESENTATION OF TUBERCULOSIS: SERIES OF 3CASESconcentrations do not appear to have harmfuleffect on the fetus 1,5,6. Pregnant women with TBshould also be tested for HIV as there is a higherincidence of extrapulmonary TB and multidrugresistantTB (MDR TB) in this set of patients.Though none of our patients were HIV positive.Effective methods for prevention and treatment ofthe disease are available and inexpensive but stillare not used appropriately in most parts of thedeveloping world. The clinician caring forpregnant women should be aware of the riskfactors for tuberculosis infection and disease andshould test women and families according to risk. 5Patient compliance has to be good to ensure thesuccess of the DOTS strategy. DOTS haveemerged as one of the most reassuring tool toimprove the challenging situation of pregnancywith TB. 6Early diagnosis and prompt treatment ofTuberculosis during pregnancy would give betterresults. Drug therapy in appropriate dosage has nomajor adverse effects on the offspring. Breastfeedingshould be actively encouraged. Early ANCregistration, intensive intrapartum monitoring andpost partum surveillance, adequate rest andnutrition are crucial.Breast feeding should not be discouraged inwomen being treated with first-lineantituberculosis drugs because the concentrationsin the breast milk are subtherapeutic and too lowto produce toxicity in the nursing new born. Theeffect would likely be much lower if the motherbreast feeds before taking the medication.Similarly, breast milk is also inadequate as atreatment option for TB or latent TB infection innewborns 5 . Close follow up of patients is essentialsince current therapy for TB infection is long andsuboptimal .Role of Bacillus of Calmette-Guérin(BCG) vaccine in preventing TB in adults isdebatable due to its variable efficacy (0–80%) 1,5 .Its efficacy in prevention of tuberculousmeningitis and miliary TB in young children hasbeen easier to document than in adults or in theprevention of pulmonary TB in both children andadults 4 . In our as well as opinion of other authors 2 ,the most crucial step in managing TB in pregnancyis an early diagnosis. Obstetricians should be alertto this “old disease” in their daily practice.Screening of TB should be considered for thefollowing groups of pregnant women: (A) patientswith symptoms suggestive of TB (B) patients withHIV infection (C) women who were in closecontact with infectious TB patients, who visitedhigh TB-prevalent areas recently without beingscreened for TB previously (D) patient havinghistory of infertility.CONCLUSIONA high index of suspicion and awareness of therapid advances and innovations made in thediagnosis is required to recognize the changingface and disease spectrum of tuberculosis andinitiate treatment for better outcomes. Atypicalpresentation may lead to misdiagnosis or a delayin diagnosis. Also the absence of systemicsymptoms does not rule out TB. Radiologicalimaging, sputum smear, and PPD only aid in thediagnosis but a high degree of suspicion isrequired to ascertain an accurate diagnosis.Establishing an early diagnosis of TB infectionand disease in a pregnant woman is important as itaffects the health of both mother and infant.ACKNOWLEDGEMENTWe are extremely thankful to Dr Sameer Singhal,Associate Professor, Deptt of Chest and TB for hisvaluable guidance and support in management ofall these cases and making this article possible.REFERENCES1. Arora V K and Gupta R :TUBERCULOSISAND PREGNANCY : Ind J Tub, 2003, 50, 132. GAO Xue-lian, Gyaneshwar R. An unusualpresentation of tuberculosis in pregnancyInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 80

Shrivastava Deepti et alDIAGNOSTIC DILEMMA DUE TO DIVERSE PRESENTATION OF TUBERCULOSIS: SERIES OF 3CASESChinese Medical Journal, 2007, Vol. 120 No.15 : 1378-13803. Song J Y , Park CW , Kee SY , Choi WS ,Kang EY , Sohn JW. DisseminatedMycobacterium avium complex infection in animmunocompetent pregnant woman, BMCInfectious Diseases 2006, 6:1544. Llewelyn M, Cropley I, Wilkinson RJ,Davidson RN. Tuberculosis diagnosed duringpregnancy: a prospective study fromLondon.Thorax. 2000 Feb;55(2):129-325. Maddineni M and Panda M ;PulmonaryTuberculosis in a Young Pregnant Female:Challenges in Diagnosis and treament , InfectDis Obstet Gynecol. 2008; 2008: 6289856. Rao S B, Dalal SJ, Badhwar VR, Patil M;Tuberculosis in Pregnancy and the Impact ofDirectly Observed Therapy - Short Course(Dots) Bombay Hospital Journal. Volume 48No. 02, April 20067. Revised National Tuberlosis ControlProgramme; PPM Training Module forMedical Practitioners. Central TB Division,Directorate General of Health Services,October 2006 page 22.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 81

Mohamed Faisal et alGRIP STRENGTH AND HAND FUNCTION CHANGES IN UNILATERAL CERVICALRADICULOPATHYGRIP STRENGTH AND HAND FUNCTION CHANGES INUNILATERAL CERVICAL RADICULOPATHYIJCRRVol 04 issue 21Section: HealthcareCategory: ResearchReceived on: 05/09/12Revised on:19/09/12Accepted on:02/10/12Mohamed Faisal C.K. 1 , Nirmal Mathew 1 , Lawrence Mathias 3 , Ajith S. 11 Nitte Institute of Physiotherapy, Nitte University, Mangalore, KA,India2 Department of Orthopaedics, K.S.Hegde Medical Academy, Nitte University,Mangalore, KA, IndiaE-mail of Corresponding Author: faisal77mpt@gmail.comABSTRACTBack Ground and Objective: This study was to know and compare the extent of ill effect of cervicalradilculopathy in upper limb, by measuring the hand grip strength and hand functions comparing withthe normal or unaffected side. Materials and Method: It was a retrospective covariance study, where30 subjects were selected who satisfied the inclusion and exclusion criteria with a mean age group of45. All the subjects were explained about the procedures and an informed written consent wasobtained. The 30 patients were assessed for grip strength by hand dynamometer and hand function byJebsen – Taylor hand function test. The assessments were taken three times with an adequate intervalof five minutes and the average values were taken. Results: The grip strength and hand functions ofthe affected side were compared with the unaffected or normal side. Paired and independent t test wasused for the analysis of data. High significance was seen in hand grip strength with P = 0.028 P< 0.05between affected and unaffected side. Hand function data was analyzed by independent t test for theseven sub tests, in which five tests showed very high significance with P= 0.000, 0.015, 0.000,0.000,0.043 P < 0.05. Interpretation of Results: Hand grip strength and hand functions were significantlyreduced in patients with cervical radiculopathy. There was significant reduction in the hand gripstrength and hand function in the patients with unilateral cervical radiculopathy when compared withthe unaffected side.Keywords: Cervical radiculopathy, Hand Grip Strength, Hand function, Jebsen Taylor Test, HanddynamometerINTRODUCTIONCervical radiculopathy is as condition caused bycompression of a nerve root in the cervical spine.It is generally from a herniated disc or a bone spurthat is pressing against an inflamed nerve root [1].Nerve roots compression may lead to weakness,numbness and pain where the nerve travels. Thepain may be felt as deep, dull and achy or mayhave sharp shooting pain along the path of thenerve. Muscles controlled by the affected nerveroot may also be weakened [2].Degenerative disc disease (DDD) is extremelycommon, occurring in up to 5% of women and13% of men during the 3 rd decade, more than 90%of adults over the age of 50 years and almost100% by 70 years [3]. Isolated root pathology iscommonly caused by protrusion of a disc,although chronic degenerative arthritic changes orabnormalities of the superior facet region may alsoplay a role. The most commonly affected level isC 5 - C 6, with 86% of specimens having observableabnormalities. The C 6 – C 7 level is the next mostfrequently affected site in the cervical region.Finally, involvement of the 8 th cervical nerve rootby a herniated C 7 –T 1 disc produces a significantweakness of the intrinsic musculature of the hand.This involvement can lead to rapid atrophy of theinterosseous muscles. Loss of the interrossei leadsInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 82

Mohamed Faisal et alGRIP STRENGTH AND HAND FUNCTION CHANGES IN UNILATERAL CERVICALRADICULOPATHYto significant loss in fine hand motion. The mostcommon areas of the disc herniation are C 6 – C 7and C 5 – C 6 [4].The existing treatments for these conditions aremedications, surgical management andphysiotherapy [5]. The physiotherapy managementfor the condition includes; educating the patient,teaching the natural history of Osteoarthritis of thecervical spine, heating modalities like SWD,ultrasound, TENS, infrared lamps, hydrocollatorpacks, hydrotherapy, stretching of the neckmuscles and range of motion exercises.Intermittent cervical spine traction, Specialpillows, cervical massage, relaxation techniques torelieve the emotional stress that aggravates thesymptoms and cervical manipulation and manualtraction are also found to be effective [6].Functional tests assess a broad spectrum of handand upper extremity function including ADLs,gross and fine motor abilities, tool usage,manipulations, dexterity, grasp and release ofobjects and unilateral and bilateral hand use andsensibility [7]. Power is a good indicator of handfunction, and its measurement must be included asthe part of any hand assessment. The mostcommonly measured aspects of hand functionsinclude grasp, lateral pinch and opposition pinch.The hand function tests are often timed and usedto analyze patterns of grip and form a problemindex. They are particularly useful in anassessment situation where the therapist has nothad the opportunity to observe the patient usingthe hand. The hand function test may be used toanalyze and evaluate treatment outcomes [8].Measurement of handgrip strength is an importantcomponent of hand rehabilitation because itassesses the patients’ initial limitation as comparedwith norms. Its utility continues throughout thetreatment process because it provides a quickreassessment of the patient’s progress. Without theability to grasp, a person ceases to be functionallyindependent and is unlikely to be able to work orplay. Measuring the strength of hand muscles withdynamometer is frequently used as a parameter toasses hand function [9, 10].Jebsen-Taylor hand function test consist of 7subtests. Each test is timed, and there arepublished standardized times against which toevaluate the performance of the patient. It hasbeen widely used to evaluate hand functions in anumber of medical and surgical conditions. Itevaluates unilateral grasp and prehension patterns.Although this test cannot be purchasedcommercially, the therapist can assemble itinexpensively. It is fast and easy to administer too[11].Since cervical radiculopathy can decrease thehandgrip strength and the associated functions,there are chances of alternate functionalimpairment during unilateral cervicalradiculopathy, towards the affected side. This canbe assessed by using the hand dynamometer forgrip strength and Jebsen-Taylor test for functionalactivity. So this study is to know the extent of theeffect of cervical radiculopathy in grip strengthand hand functions and to compare the extent ofthe ill effects of cervical radiculopathy by gripstrength and hand functions with the normal sideor unaffected side.MATERIALS AND METHODSThe study included a sample of 30 subjects withage group between 30 to 60 years who werediagnosed with unilateral cervical radiculopathy ofthe right side, based on their clinical findings,irrespective of their sex. The diagnosed cases wererecruited from the Department of Orthopaedicsand Neurology of K S Hegde Hospital, Mangalore.Methods of Data CollectionThis study was a retrospective covariance study.The subjects were explained about the condition,experimental procedures, and outcome measures.Formal written consent was obtained from eachsubject and ethical clearance was obtained fromthe Institutional Ethical Committee.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 83

Mohamed Faisal et alGRIP STRENGTH AND HAND FUNCTION CHANGES IN UNILATERAL CERVICALRADICULOPATHYInclusion Criteria• Diagnosed cases of unilateral cervicalradiculopathy of the right hand dominant side,where the patients were under control of pain.• Age group between 30 to 60.• Both males and femalesExclusion Criteria• Subjects who have any other musculo skeletaldisorders• Neurovascular Impairment• Bilateral cervical radiculopathy• Cervical Myelopathy• Acute cases of cervical radiculopathyMaterials required• Jamar Hand Dynamometer• Jebsen Taylor Hand Function KitMETHODOLOGYThe hand dynamometer measures cylinder gripstrength and it is widely available to handtherapist, has a standardized method of use, hasnormative values established for its use, and iswidely accepted by hand therapist. The normativevalues are particularly useful when it is necessaryto compare the patient against norms.The patients were seated in a chair with shoulderadducted, neutrally rotated, elbow flexed at 90degree, forearm neutral, wrist between 0 degreeand 15 degree dorsiflexion and 0 degree and 15degree ulnar deviation. Hold the dynamometerlightly around readout dial. Then the patient hasinstructed to hold the handle and “squeeze” ashard as possible and then “Relax”. Same techniquewas repeated with same instructions for the secondand third trial. Both the right and left hand hasbeen tested in the second handle position. Thepeak reading of the three trials was noted andaverage was taken [9].The Jebsen-Taylor hand function test is composedof seven subtests that represent various handactivities. The seven subtests include; (1) Writing,(2) Turning over 3 by 5- in cards (which simulatespage turning), (3) Picking up small commonobjects (4) Simulated feeding, (5) Stackingcheckers, (6) Picking up and placing large emptyobjects, (7) Picking up and placing large heavyobjects.The examiner reads the directions to the patientand records the time that the patient requires tocomplete each subtest with the non dominant andthen the dominant hand. The results are comparedwith normative data available relative to genderand age. Seven subtests were chosen to provide abroad sampling of hand function. Each of thesubtests was designed to be administered inprecisely the same manner to each subject. Theresults measured objectively using a stop watch.Each subject was seated in a chair of 18-inchheight at a desk of 30-inch height in a well –lighted room. Questions were answered after theinstructions were given to be certain that theinstructions were understood. The subtests werealways presented in the same sequence and werealways performed with the non dominant handfirst.SUBTEST 1: WritingProcedure: The subject is given a black ball pointpen and for 8-by-11 inch sheets of un ruled whitepaper fastened one on top of the other, to a clipboard. The sentence to be copied has 24 letters.The sentence is typed in all capital letters andcentered on a 5-by-8 inch index card. The card ispresented with the typed side faced down on abook stand. After the articles are arranged to thecomfort of the subjects the card is turned over bythe examiner with an immediate command tobegin. The item is timed from the word “go” untilthe pen is lifted from the page at the end of thesentence. The item is repeated with the dominanthand using a new sentence.SUBTEST 2: Card turning (simulated pageturning)Procedure: Five 3 X 5 inch index cards ruled onone side only, are placed in a horizontal row 2inches apart on the desk in front of the patient.Each card is oriented vertically five inches fromthe front edge of the desk. Timing is from theInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 84

Mohamed Faisal et alGRIP STRENGTH AND HAND FUNCTION CHANGES IN UNILATERAL CERVICALRADICULOPATHYword “go” until the last card is turned over. Noaccuracy of placement after turning is necessarythe item is repeated with the dominant hand.SUBTEST 3- Picking up small common objectsProcedure: An empty 1 pound coffee can is placeddirectly in front of the subject, five inches from thefront edge of the desk. Two 1 inch paper clipsoriented vertically, two regular sized bottle capseach 1-inch in diameter placed with inside of thecap facing up and two coins are placed in ahorizontal row to the left of the can. The paperclips are to the extreme left and the coin nearestthe can. The objects are two inches apart. Timingis from the word “go” until the sound of the lastobject striking the inside of the can is heard. Theitem is repeated with the dominant hand.SUBTEST 4- Simulated feedingProcedure: Five kidney beans of approximately 5X8 inch length are placed on the desk in front of thesubject 5 inches from the front edge of the desk.The beans are oriented to the left of the centre 2inches apart. An empty 1 pound coffee can isplaced centrally in front of the patient. A regularteaspoon is provided. Timing is from the word“go” until the last bean is heard hitting the bottomof the can. The item is repeated with the dominanthand, the beans being placed to the right of thecentre.SUBTEST 5 –Stacking checkersProcedure: Four standard sized red woodencheckers are placed in front of the subject, fiveinches from the front edge of the desk. Thecheckers are oriented two on each side of thecentre in a 0000 configuration. Timing is from theword “go” until the fourth checker makes contactwith the third checker. The fourth checker neednot stay in place .The item is repeated withdominant hand.SUBTEST 6- Picking up large light objectsProcedure: Five empty cans are placed in front ofthe subject five inches from the front edge of thedesk. The cans are spaced two inches apart withthe open end of the can facing down. Timing isfrom the word “go” until the fifth can has beenreleased. The item is repeated with dominant hand.SUBTEST 7-Picking up large heavy objectsProcedure: Five full 1 pound cans are placed infront of the subject with five inches from the frontedge of the desk. The cans are spaced two inchesapart. Timing is from the word “go” until the fifthcan has been released. The item is repeated withthe dominant hand [12].RESULTSThirty patients were taken with unilateral cervicalradiculopathy of the dominant right side. Theaverage ages of the patient were 45 +\- 8.75. Outof 30 patients, 18 were males and 12 werefemales. The analysis was done using Paired andindependent t-test.The data were compared to check whether there isany significant difference in handgrip strengthbetween the affected and the unaffected side andthe statistical analysis shows in hand grip of thetotal 30 subjects, there was a mean difference of -1.87 with t-value of -2.34 with P-value 0.028,where is P

Mohamed Faisal et alGRIP STRENGTH AND HAND FUNCTION CHANGES IN UNILATERAL CERVICALRADICULOPATHYdifference in the card turning on the affected sidewhen compared to the normal.The statistical analysis shows that in picking upsmall objects, there was a mean difference of –1.02 with t-value of 1.23 with P-value 0.105,which is P>0.05. It shows there is a non significantdifference in picking up small objects on theaffected side when compared to the normal.The statistical analysis shows that in simulatedfeeding, there was a mean difference of 0.866with t-value 2.49 with P- value 0.015,which isP

Mohamed Faisal et alGRIP STRENGTH AND HAND FUNCTION CHANGES IN UNILATERAL CERVICALRADICULOPATHYmajority of the subtests of the Jebsen-Taylor handfunction test in those patients with radiculopathy.The evaluation of handgrip strength and functionalactivities of hand are useful to provide anobjective index for the functional integrity of theupper extremity. Grip strength is an importantprerequisite for good performance of the upperlimb and checking the normal activities of handfunction also plays a major role in upper extremityassessment. Hence it is not only the painassessment, but also the assessment of hand gripstrength and hand function should also be a part ofthe evaluation in patients with radiculopathy whocome for the rehabilitation program.In the current study we had included only the rightside dominant radiculopathy patients to avoid anybias because the study done by Crosby et al [13] tofind out normal hand strength value withdynamometer concluded that the right-sidedsubjects were 10% stronger in grip strength on thedominant side. In the left-handed subjects, themean grip was the same for both hands and a studydone by Petersen et al [14] to find out the effect ofgrip strength and hand dominance concluded that10% rule was valid for right dominant handedpersons and for left handed persons, grip strengthshould be considered equivalent in both the hands.And in a study by Ozcan et al, suggested that in aright- dominant handed subjects, the dominanthand was significantly faster with the timeperform test [15].In this study we have used the Jamar handdynamometer to assess the grip strength which ishaving a high intra and inter tester reliability andreference values for checking the hand gripstrength, according to Peolsson A et al. Thereliability studies showed that handgrip strengthmeasured with the Jamar dynamometer is areliable method (ICC values 0.85 –0.98) and canbe recommended for using in clinical practice. Thereference values for hand strength improve thepotential for objective evaluation of patients witharm / hand disorders caused by cervicalradiculopathy [16].And to check the grip strength we have adoptedthe method suggested by Joseph A. Balogun et al[9], where they found that grip strength wassignificantly higher (p

Mohamed Faisal et alGRIP STRENGTH AND HAND FUNCTION CHANGES IN UNILATERAL CERVICALRADICULOPATHY4. Friendenberg ZB, Ediken J, Spenser N.Degenerative changes of the cervical spine.Journal of Bone Joint Surg Am. 1959; 41: 61.5. Rubin D. Cervical radiculitis - Diagnosis andtreatment. Archives of Physical MedicineRehabilitation. 1960; 41 (l):175.6. John Ebenezer. Essentials of Orthopaedics forPhysiotherapists. 1 st Ed. Jaypee BrothersMedical Publishers; New Delhi; 2003: pg:223.7. Apfel E. Preliminary Development ofStandardized Hand function Test. Journal ofHand Therapy. 1990; 3 (4): 191.8. Maureen Salter, Lynn Chesire. Hand TherapyPrinciples And Practice. 1 st Ed. Butterworth-Heinemann Publishers, Oxford; 2000; pg:40,53.9. Joseph Balogun. A, Charles Akomolafe.T,Lateef Amusa O. Grip Strength: Effects oftesting posture and elbow position. Archivesof Physical Medical Rehabilitation. 1991;April; 72:280-283.10. Annemike J. Videler, Anita Beelen. Handstrength and fatigue in patients withhereditary motor and sensory neuropathy(Types 1 and 2). Archives of Physical MedRehabilitation. 2002 Sept; 83: 1274-1278.11. Barbara G. Stanely, Susan M. Tribuzi.Concepts in Hand Rehabilitation. F.A.DavisCompany. Philadelphia; 1992; pg: 5, 7.12. Robert Jebsen, Neal Taylor. An Objective andStandardized test of Hand function. Achievesof Physical Med Rehabilitation. 1969 June:311-319.13. Crosby CA, Wehbe MA. Hand strength:normative values. American Journal of HandSurgery. 1994 July; 19(4): 665-70.14. Petersen P, Petrick M. Grip strength and handdominance: challenging the 10% rule.American Journal of Occupational Therapy.1989 July; 43(7): 444-7.15. Ozcan A, Tulum Z. Comparison of Pressurepain threshold, grip strength, Dexterity andTouch pressure of Dominant and Nondominant hands with in right and left handedsubjects. Journal of Korean Med Science.2004 Dec;19(6): 874-816. Peolsson A, Hedlund R. Intra and inter-testerreliability and reference values for handstrength. Journal Rehabilitation Medicine.2001 Jan; 33(1): 36-41.17. Bravo G, Hebert R. Impact of elbow positionon grip strength of elderly men. Journal ofHand Therapy. 1995 Jan-Mar; 8(1):27-30.Table 1: Mean, standard deviation and standard error of the hand functionVariableAFFECTEDNORMATIVEMEAN SD SE MEAN SD SEWriting speed 22.8 8.01 1.46 16.32 2.09 0.38Card turning 4.4 1.16 0.21 5.2 0.39 0.07Small objects 5.6 1.42 0.26 6.6 0.29 0.05Simulated feeding 8.3 1.8 0.34 7.5 0.24 0.04Stacking checkers 5.06 1.2 0.21 3.9 0.04 0.009Large light objects 4.6 1.2 0.23 3.4 0.09 0.01Large heavy objects 4.1 1.37 0.25 3.5 0.09 0.01Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 88

MeanMohamed Faisal et alGRIP STRENGTH AND HAND FUNCTION CHANGES IN UNILATERAL CERVICALRADICULOPATHYTable 2: Comparison of hand function between the affected and the normalVariable MEAN DIFFERENCE T-VALUE P-VALUE RESULTWriting speed 6.4 4.28 0.000 P0.05 NSSmall objects -1.02 1.23 0.105 P>0.05 NSSimulated feeding 0.866 2.49 0.015 P

MeanMohamed Faisal et alGRIP STRENGTH AND HAND FUNCTION CHANGES IN UNILATERAL CERVICALRADICULOPATHYGraph 2: Comparison of hand function between the affected and the normalcomparison of hand function between the affected andthe normal2522.82016.32151054.45.25.66.68.37.55.063.94.64.13.4 3.501 2 3 4 5 6 7SubtestsAffectedNormalInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 90

C.P. Ganesh Babu et alA STUDY ON MODIFIED ALVARADO SCORING SYSTEMAPPENDICITISIN DIAGNOSING ACUTEA STUDY ON MODIFIED ALVARADO SCORING SYSTEM INDIAGNOSING ACUTE APPENDICITISIJCRRVol 04 issue 21Section: HealthcareCategory: ResearchReceived on: 14/09/12Revised on:21/09/12Accepted on:29/09/12C.P. Ganesh Babu, E.M.J. Karthikeyan, K. Bharaniraj KumarDept. of General Surgery, MAPIMS, Melmaruvathur.E-mail of Corresponding Author: ganeshvanicp@yahoo.co.inABSTRACTAim: To study the role of Modified Alvarado scoring system in diagnosing acute appendicitisin clinical practice. Materials and Methods: A prospective study was conducted on 250patients admitted with abdominal pain suggestive of acute appendicitis and were operated, fromJanuary 2008 to December 2009 in AVMC&H and MAPIMS. Both males and females patientsfrom 8 years to 60 years of age were included.Preoperative modified Alvarado score was used in all, and the results were compared withoperative finding and biopsy. Results: 155 patients were identified to have score of 8 or more. 149patients were confirmed by biopsy. 91 patients have score 5 -7 and 66 were confirmed by biopsy.Conclusion: This scoring system is a reliable and diagnostic modality to increase the accuracyin diagnosing appendicitis.Keywords: Alvarado. Scoring system. Acute appendicitisINTRODUCTIONAcute appendicitis is one of the most commonsurgical emergency. Its lifetime prevalence is 1 in7, incidence is 1.5 to 1.9 / 1000 in male andfemale population. Surgery for acuteappendicitis is the most frequent operationperformed in all emergency.The diagnosis of acute appendicitis is purelybased on history, clinical examination andlaboratory investigations. Negativeappendicectomy rate is 15 to 40% as perliteratures. Delay in diagnosis definitelyincreases the morbidity, mortality and cost oftreatment. Early diagnosis is a primary goal toprevent morbidity and mortality.(1)Alvarado in 1986 introduced a criterion forthe diagnosis of acute appendicitis which waslater modified to accommodate additionalparameters along with original Alvaradoscoring system.( 2- 5).The aim of the study is to evaluate thesensitivity of modified Alvarado scoringsystem in the diagnosis of acute appendicitis,to reduce the rate of negative appendicectomyand to reduce the complications of acuteappendicitis.MATERIALS AND METHODSA total number of 250 cases of clinicallysuspected acute appendicitis were studied fromthe period of January 2008 to December 2009in AVMC&H in pondy and MAPIMS . Dataincluding age , sex, symptoms, physical sighsand laboratory findings such as white bloodcells total and differential count were recordedin modified Alvarado form. (Table 1). (6)In addition, urine for routine examination wasdone for all cases. ultra sonogram of abdomenwas performed when diagnosis was doubtful,especially in female patients to excludegynecological diseases.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 91

C.P. Ganesh Babu et alA STUDY ON MODIFIED ALVARADO SCORING SYSTEMAPPENDICITISIN DIAGNOSING ACUTEThe score of each patient was correlated with theclinical, operative and histopathological findings.RESULTSAge of the patients ranged from 7 years to 60years with the majority of the patients in thethird decade (46%) followed by second decade(25%). (Table 2).Out of 250 patients, 155(62%) were males and95 (38%) were female. clinically males weremore susceptible than females. (Table 3).All the specimen were sent to laboratory forhistopathological examination. The reportsshowed features of acute appendicitis in 215(86%) cases and 35 (14%) patients did nothave acute appendicitis. (Table 4).In this series, patients with score of 8- 10, 5– 7, and 1- 4, had 96%, 72.5%, and 0%sensitivity respectively. (Table 5).Patients with score 8 and above, thesensitivity is 98.04% in male and 92.45% infemales.(table 6).Patients with score less than 8, the sensitivityis 79.24% in male and 57.15 % in females andoverall is 68.72.%. (Table 7).DISCUSSIONResults of this study shows acute appendicitiswas most common in the 21 – 30 years(46%).Next most common group was 11 -20 (26%). Allthe studies have shown that appendicitis ismore common in 10- 30 years of age .(7)Males more susceptible than females .(8)A negative rate of appendicectomy of 20-40% is not unusual finding in literature (9) .Negative appendicectomy in this study is 15.75%,male (8.4%), females (23.1%). The percentageof normal appendicectomy in varies seriesvaries from 8 to 33%. In this era manysurgeons accept 15 to 20% negativeappendicectomy (10) .From this study it was found that the higherthe score, more of its sensitivity. Patientswith the Alvarado score ranges 8 -10, 5 – 7and 1 – 4 have accuracy of 96%, 72.5% and0% respectively. Fengo at al reported asensitivity of 90.2% and others reported asensitivity of 73% with negative laparotomyrate 17.5% .(11)In this series, the sensitivity of the patientswith the score 8 and above was 98,04% inmales and 92.45% in females and combinedsensitivity is 95.45% whereas the sensitivitywith score less than 7 was 79.24% in males,57.15% in females and combined sensitivity is68.75%.This study also reveals that scoring systemwas more helpful in male patients by showinghigh accuracy rate as compared to femalepatients.Lower values in female patients were due topresence of diseases in genital system (i.e.)ovaries, salpinges (4, 12) . In females, additionalinvestigations are required. Different literaturesalso support these observations (13).However there are no signs , symptoms orlaboratory test that are 100% reliable in thediagnosis of acute appendicitis. In this studymodified Alvarado scoring system showed thatthe accuracy of the diagnosis was verydependable and acceptable in higher scores butpatients with lower scores should be observed.Patients with score 8 to 10 are almost certainto have appendicitis and they should undergooperation immediately. Patients with a score 5 to7 indicate probable appendicitis. they should beobserved and evaluated every 4 to 6 hrs, ifthe score remains the same or increases afterthis, reevaluation is required and patients withthe score of 4 or less are very unlikely butnot impossible to have appendicitis and theycan be discharged from hospital after givinginitial conservative treatment.CONCLUSIONIn the diagnosis of acute appendicitis, themodified Alvarado score is a fast, simple,reliable, noninvasive repeatable and safeInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 92

C.P. Ganesh Babu et alA STUDY ON MODIFIED ALVARADO SCORING SYSTEMAPPENDICITISIN DIAGNOSING ACUTEdiagnostic modality without extra expense andcomplication. It can be very useful for juniordoctors provided it is applied purposefully andobjectively in patients. The application of thisscoring system improves diagnostic accuracyand consequently reduces negativeappendicectomy and this reduces complicationrates.Table 1: Modified alvarado scoresymptoms Migratory rt. Iliac fossa painAnorexiaNausea / vomitingsigns 1) Tenderness in rt. Iliac fossa2) rebound tenderness3) elevated temperature4) extra signs eg: cough testand or rovsing sign and orrectal tendernesslaboratory leucocytosis 21112111Total score 10Interpretation:Score 1- 4: acute appendicitis very unlikelyScore five -7: acute appendicitis probableScore eight -10: acute appendicitis definitive.Table 2Age Groups (yrs) No of patients PercentageUp to 10 5 2%11 - 20 65 26%21 - 30 115 46%31 - 40 35 14%41 - 50 25 10%51 - 60 05 2%Total 250 100Table 3: Distribution of patients as per sexSex No. of patients PercentageMale 155 62%Female 95 38%Total 250 100%Table 4: Peroperative FindingsInflammation 128 60%Suppuration 65 30%Gangrenous 13 06%Perforation 09 04%Total 215Table 5: Sensitivity of different score rangeNo. of Acute NormalScoresensitivityPt appendicitis appendix8 -10 155 149 6 96%5 - 7 91 66 25 72.5%1 -4 04 00 04 00%Table 6: Sensitivity of modified alvarado score > 8No. of Acute NornalSexsensitivityPt appendicitis appendixMale 102 100 2 98.03%Female 53 49 4 92.45%Total 155 149 6 95.5%Table 7: Sensitivity of modified alvarado score

C.P. Ganesh Babu et alA STUDY ON MODIFIED ALVARADO SCORING SYSTEMAPPENDICITISIN DIAGNOSING ACUTEappendicitis in children. Ann R Coll SurgEngl 1997; 79: 203 -205.6. Al-Fallouji MAR, Postgraduate surgery, thecandidates Guide. Oxford: Butterworth-Heinemann; 1998: 388- 389.7. Addiss DG, Shaffer N, Fowler BS, et al. Theepidemiology of appendicitis andappendicectomy in united states. Is JEpidemiology 1990: 132: 910 -25.8. Williams NS, Bulstrode CJK, O’ConnellPR, Bailey and love’s short practice ofsurgery. 25 th Ed. London. Hodder Arnold,2008; 1205- 1206.9. Al Qahatani HN, Muhammed AA,Alvarado score as an admission criterionfor the suspected appendicitis in adults.Saudi J Gastroenterology 2004: 10: 86- 91.10. Jones PF, suspected acute appendicitis ,trend in management over 30 years. B JSurg 2001; 88: 1570 – 1577.11. Fengo G, Lindberg G, Blind P, Enochsson L,Oberg A. Diagnostic decision in suspectedacute appendicitis : validation of simplifiedscoring system. Eur J Surg 1997: 163; 831– eight.12. Baber MD, Mclarn J, Rainay JB. Recurrentappendicitis. Br J Surg 1997: 84: 110 -112.13. Shrivastona UKJ, Gupta A, Sharma D ,Evaluation of the Alvarado score in thediagnosis of acute appendicitis. TropGastroenterol 2004; 25:184-6.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 94

Agravat Amit H. et alROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN SALIVARY GLAND PATHOLOGY AND ITSHISTOPATHOLOGICAL CORRELATION: A TWO YEAR PROSPECTIVE STUDY IN WESTERN INDIAIJCRRVol 04 issue 21Section: HealthcareCategory: ResearchReceived on: 13/09/12Revised on:20/09/12Accepted on:29/09/12ROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN SALIVARYGLAND PATHOLOGY AND ITS HISTOPATHOLOGICALCORRELATION: A TWO YEAR PROSPECTIVE STUDY IN WESTERNINDIAAgravat Amit H., Dhruva Gauravi A., Pujara Krupal M., Sanghvi Hardik K.Department of Pathology, P.D.U. Government Medical College, Rajkot, Gujarat, IndiaE-mail of Corresponding Author: dr.amit.patho@gmail.comABSTRACTBackground and objectives: Salivary gland lesions account for 2-6.5% of all the neoplasm of the headand neck. Fine needle aspiration cytology (FNAC) is being increasingly used in the diagnosis ofsalivary gland lesions. The objective of this study was to evaluate the diagnostic accuracy and thesensitivity and specificity of FNAC in various salivary gland lesions in correlation with theirhistopathology, which helps in the appropriate therapeutic management.Methods: A total of 120 FNACs were done on salivary gland tumors from July 2010 to June 2012 inthe Department of Pathology, P.D.U. Government Medical College, Rajkot (Gujarat, India). Formalinfixed (10%), surgically resected specimens were received, they were processed and slides wereprepared for histopathological diagnosis. The stained cytological and histopathological slides werestudied, analyzed and correlated.Results: The cytomorphological features were studied and analyzed and the following lesions wereobserved: Pleomorphic adenoma (88), Warthin’s tumor (2), Cystic lesion (4), Mucoepidermoidcarcinoma (6), Acinic cell carcinoma (2), Primary lymphoma (2), Carcinoma EX pleomorphicadenoma(4), metastatic malignancy deposits (2), benign parotid tumor (8) and malignant tumor(unspecified)(2). A histopathological correlation was available in 78 cases. Out of these, 71 cases weretrue positive, 1 was false positive, 2 were false negative and 4 were true negative.Interpretation and conclusion: The overall sensitivity, specificity and the diagnostic accuracy were97%, 80% and 92% respectively. Hence, the appropriate therapeutic management could be plannedearlier. This study documents that FNAC of the salivary gland tumors is accurate, simple, rapid,inexpensive, well tolerated and harmless for the patient.Keywords: Salivary gland tumors, FNAC, Diagnostic accuracy, Sensitivity, Specificity, Benign,Malignant.INTRODUCTIONFine needle aspiration cytology (FNAC) isaccurate, simple, rapid, inexpensive, well toleratedand harmless for the patient (1),(2),(3),(4),(5).Although salivary gland tumors are rare and theyaccount for 2-6.5% of all the head and necktumors, their superficial location, easyaccessibility and high diagnostic accuracy makesFNAC a popular method for evaluatingthem (6),(7),(8).Among the primary epithelial tumors, 64-80%occur in the parotid glands, 7-11% occur in thesub-mandibular, less than 1% occur in thesublingual and 9-23% occur in the minor salivaryglands (1),(9),(10). In the files of the ArmedForces Institute of Pathology, about 1/3rd of themajor gland and half of the minor gland tumorsare malignant (10). The ratio of the malignant tothe benign tumor is the greatest (>2.3:1) in thesub-lingual gland and in the minor salivary glandsInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 95

Agravat Amit H. et alROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN SALIVARY GLAND PATHOLOGY AND ITSHISTOPATHOLOGICAL CORRELATION: A TWO YEAR PROSPECTIVE STUDY IN WESTERN INDIAavailable for 6 and all were diagnosed as PA.Among 4 cases of cystic lesions, all werehistopathologically correlated. Of these, 2 werediagnosed as mucocele and the other 2 as benignlymphoepithelial cysts.Among 4 cases of carcinoma ex PA, 2 wereavailable for histopathological correlation, whichwere diagnosed as MEC. Among 4 cases of MEC,2 were concordantly diagnosed by histopathology.Two cases were reported as acinic cell carcinomas,both of which were not available forhistopathological correlation. There were 2cytologically diagnosed cases of primarylymphoma of the parotid, both of which wereconcordantly diagnosed by histopathologically asnon-Hodgkins lymphoma- diffuse large B celltype. Two cases were cytologically diagnosed asmetastatic squamous cell carcinomas, both ofwhich were not available for histopathologicalcorrelation.In the above cyto-histopathological correlationstudy, the sensitivity, specificity and the diagnosticaccuracy were 97%, 80% and 96%.DISCUSSIONSalivary gland neoplasm are rare and they accountfor 2 to 6.5% of all the neoplasm of the head andneck (1). Among all the parotid gland tumors, 15-30% was malignant, in contrast to about 40% inthe submandibular gland, 50% in the minorsalivary gland and 70-90% in the sublingualglands. The likelihood that a salivary gland tumorbeing malignant is inversely proportional to thesize of the gland.Salivary gland tumors usually occur in adults, but5% can occur in children who are younger than 16years of age. FNAC of the salivary gland tumors isadvantageous for both the patients and theclinicians because of its immediate results,accuracy, lack of complications and economy (8).Many studies have revealed the high diagnosticaccuracy of FNAC when it was used for salivarygland tumors (13), (14), and (15).Pleomorphic AdenomaPA is the most common tumor which accounts for60-70% of all the salivary gland tumors. Thesetumors occur in the middle age group and they canbe bilateral in 5-6% of the cases. They have astriking sex difference, with 85-90% of the casesoccurring in the male population. The reliability ofFNAC in diagnosing PA has been reported as 90-97% (13). Among the 120 cases of salivary glandtumors in the present study, 88 cases (73.3%) werediagnosed as PA cyto-logically. Sixty four of themwere available for histopathological correlation,out of which 52 were concordantly diagnosed. Thecommonest changes which were observed wereepithelial and mesenchymal like elements with awide variety of patterns within the tumor. Thecommonest elements that were seen includedfibrous, mucinous, myxochondroid and chondroidtissues.Out of the 64 cases which werehistopathologically correlated, 2 were discordantlydiagnosed as basal cell adenomas and 2 asmyoepitheliomas. In both these cases, the FNACslides were reviewed; both showed highly cellularsmears with scanty stromal elements and weremistakenly diagnosed as PA. From the practicalperspective, this confusion was of minorimportance, since the surgical treatment wassimilar in both the cases. Two cases werediscordantly diagnosed as Warthin’s tumor. Thereviewed FNAC slides showed an oncocyticchange, which we suspected as epithelial cellswith metaplastic change. The lymphoidcomponent was not present in the FNAC slidesdue to a sampling error.There were 2 cases of false negative diagnoses inour study, which were diagnosed asmucoepidermoid carcinomas histopathologically.This erroneous diagnosis was due to a samplingerror. This can occur when the malignantcomponent is small and it can be resolved with awider sampling of the tumor, in order to obtainsmears from the malignant transformation. Manystudies showed similar findings [13-15]. ThereInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 97

Agravat Amit H. et alROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN SALIVARY GLAND PATHOLOGY AND ITSHISTOPATHOLOGICAL CORRELATION: A TWO YEAR PROSPECTIVE STUDY IN WESTERN INDIAwere 4 cases which were diagnosed as sialadenosishistopathologically. The FNAC slides werereviewed, which showed increased cellularity withepithelial components and fibrocollagenous tissue,which were mistaken as chondromyxoid stromalfragments.Warthin’s Tumor (WT)WT is the second most common benign salivarygland tumor (5-6%) and a majority of these canoccur in the parotid or periparotid area. Thesetumors are bilateral in 5-6% of the cases, they maybe multiple and may occur in the older agedgroups, and with the striking sex difference that85-90% of the cases occurs in males. Acombination of oncocytes, lymphoid tissues andcystic macrophages help in the diagnosis.Among the 120 cases in the present study, 2 caseswere diagnosed as WT by FNAC. Both of thesewere not available for histopathologicalcorrelation.Salivary CystsSmall cysts (mucoceles or mucus retention cysts)which arise from minor salivary glands are notuncommon. The favored sites are in the submucosaof the oral cavity of the lower lip, thecheeks, the dorsal surface of the tip of the tongueand the floor of the mouth.The cysts in the salivary gland can occur in someneoplasm like PA, WT, MEC, acinic cellcarcinomas and squamous cell carcinomas. In thepresent study, out of the 120 cases, there were 4cases of cysts, which were diagnosed by FNAC.All the 4 cases were available forhistopathological correlation. Two wereconcordantly diagnosed as mucocele and the other2 as benign lymphoepithelial cysts. The FNACslides were reviewed, which showed plenty of cystmacrophages and degenerated epithelial cellsagainst a myxoid background. There were nolymphoid components in the smear. This may bedue to a sampling error where the needle mighthave hit only the cystic area.Mucoepidermoid CarcinomaMECs comprise 5-10% of all the salivary glandtumors and 9/10th of these tumors occur in theparotid gland (15). Zajicek et al. reported a DA of37% when all the 3 cellular components(epidermoid cells, intermediate cells and mucouscells) were present. Cellular smears from welldifferentiated MECs usually pose no problem intheir diagnosis. However, the high grade, poorlydifferentiated tumors may be difficult to recognizeas MECs and they may be misdiagnosed as poorlydifferentiated squamous cell carcinomas. Whenthe tumor is cystic and the aspiration yields onlymucous material, a diagnosis of MEC may bemissed.In our study, out of 120 cases, there were 6 casesof MEC, which were diagnosed by FNAC. Thesmear showed 3 types of cells, epidermoid cells,intermediate cells and mucus cells against a dirtynecrotic background. Two cases were available forhistopathological correlation, which wereconcordantly diagnosed.Acinic Cell Carcinoma (ACC)ACCs comprise 1% of the salivary gland tumorsand 95% of them occur in the parotid glands,accounting for about 2.5-4% of all the parotidtumors.Among the 120 cases in the present study, 2 casesof ACCs were reported cytologically in a 60 yearold male and another was reported in a 52 year oldfemale, both presenting with hard parotid masses.The patients were not available for further followup since they were referred to higher centers forfurther management.Carcinoma ex pleomorphic adenoma (CA exPA) and malignant mixed tumorThe incidence of CA ex PA is 1.5-6.5%.Among the 120 cases in the present study, 4 werediagnosed as CA ex PA cytologically. The smearswhich were studied showed epithelial cell clusterswhich revealed a prominent nuclear enlargementand atypia with clusters of benign epithelial cellsand myxoid stroma.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 98

Agravat Amit H. et alROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN SALIVARY GLAND PATHOLOGY AND ITSHISTOPATHOLOGICAL CORRELATION: A TWO YEAR PROSPECTIVE STUDY IN WESTERN INDIAOne case was available for histopathologicalcorrelation, which was concordantly diagnosed asMEC.Primary lymphoma of the salivary gland:Lymphoma of the salivary gland accounts for 5%of the cases of extra nodal lymphomas and 10% ofall the malignant salivary gland tumors (16). Amajority of the salivary gland lymphomas (70-80%) arise in the parotid gland and most of themare low-grade non-Hodgkin’s lymphomas. Amongthe 120 cases in the present study, two cases (48and 64 year old male patients) were diagnosed asprimary lymphomas cytologically, who presentedwith the bilateral enlargement of the parotidglands. There was no associated lymphadenopathyor organomegaly. Both the cases wereconcordantly diagnosed by biopsy as high gradenon-Hodgkin’s lymphomas (Diffuse large B celllymphomas) and were referred to higher centersfor further management.Metastatic DepositsMetastatic carcinoma and melanoma may involveeither the salivary glands or the lymph nodeswhich are adjacent or within the gland. Thecommonest primary tumor is cutaneous squamouscell carcinoma of the head and neck. Among the120 cases in the present study, two cases ofsquamous cell carcinoma metastatic deposits werediagnosed cytologically in 2 60 and 75 year oldmale patients with a history of bilateralsubmandibular gland enlargement. Both presentedwith hoarseness of the voice and directlaryngoscopy revealed ulceroproliferative growthsin their vocal cords. The smears showedpleomorphic squamous epithelial cells in clustersand singles, tadpole cells and keratin pearls againsta dirty background. Both the patients were referredto higher centers for further management andhence a histopathological correlation was notpossible. The malignant tumors spread by thedirect and the haematogenous routes. Interestingly,20% of the parotid glands, 34% of thesubmandibular glands and 14% of the minorsalivary glands will have cervical lymph nodemetastases at presentation, especially due to highgrade MEC (39%) and malignant mixed tumors(32%).In our study, benign tumors were more commonthan malignant tumors, which was similar to thefindings in all other studies (12), (13), (14). Theparotid gland was very commonly involved,whereas PA and MEC were the commonest benignand malignant tumor respectively, which wassimilar to that which was found in other studies(14), (15). The diagnostic accuracy (DA) was92%, the sensitivity was 97% and the specificity80%, which were similar to that which was seen inother studies (13), (14), and (15).CONCLUSIONFNAC offers valuable information which is notobtained by any other means. FNAC of thesalivary gland tumors is advantageous for both thepatients and the clinicians because of itsimmediate results, accuracy, economy, and lack ofcomplications. Although FNAC of the salivarygland tumors has a high diagnostic accuracy (92%in the present study), it can further be improved bya wider sampling and ultrasound guidedaspirations.Awareness of the therapeutic implications andlimitations of the cytological interpretationamongst both the clinicians and thecytopathologists should enable FNAC to its bestadvantage.ACKNOWLEDGMENTWe acknowledge the immense help received fromthe scholars whose articles are cited and includedin references of this manuscript. We are alsograteful to authors / editors / publishers of all thosearticles, journals and books from where theliterature for this article has been reviewed anddiscussed.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 99

Agravat Amit H. et alROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN SALIVARY GLAND PATHOLOGY AND ITSHISTOPATHOLOGICAL CORRELATION: A TWO YEAR PROSPECTIVE STUDY IN WESTERN INDIAREFERENCES1. Fernandes GC, Pandit AA. Diagnosis ofsalivary gland tumors by FNAC. BombayHospital Journal 2000; 42:108-11.2. Crystallini EG, Stafano A, Raffaelle F,Liberati F, Maccio T, Peciarolo A, et al. Fineneedle aspiration biopsy of the salivary gland,1985-1995. Acta Cytol 1997; 41:1412-20.3. Eveson JW, Cawson RA. Salivary glandtumors. A review of 2410 cases with particularreference to the histological types, sites, ageand sex distribution. J Pathol 1985; 146:51-58.4. Kline TS, Merriam JM, Shapshay SM.Aspiration biopsy cytology of the salivarygland. Am J Clin Pathol 1981; 76:263-69.5. Lindberg LG, Akerman M. Aspirationcytology of salivary gland tumors: Diagnosticexperience from six years of routinelaboratory work. Laryngoscope 1976; 86:584-94.6. Mavec P, Eneroth CM, Franzen S, MobergerG, Zajicek J. Aspiration biopsy of salivarygland tumors. Acta Otolaryngol 1964; 58:471-84.7. Persson PS, Zettergren L. Cytologicaldiagnosis of salivary gland tumors byaspiration biopsy. Acta Cytol 1973; 17:351-54.8. Cohen MB, Fisher PE, Holly EA, Ljung BM,Lowhagen T, Bottles K. Fine needle aspirationbiopsy diagnosis of mucoepidermoidcarcinoma. Statistical analysis. Acta Cytol1990; 34:43–49.9. Qizilbash AH, Sianos J, Young JE, ArchibaldSD. Fine needle aspiration biopsy cytology ofthe major salivary glands. Acta Cytol 1985;29:503-12.10. Spiro RH. Salivary neoplasms- An overviewof 35 years of experience with 2807 patients.Head Neck Surg 1986; 8:177-84.11. Stewart CJ, MacKenzie K, McGarry GW,Mowat A. Fine-needle aspiration cytology ofthe salivary gland: a review of 341 cases.Diagn Cytopathol 2000; 22:139-46.12. Zbaren P, Nuyens M, Loosli H, Stauffer E.Diagnostic accuracy of fine-needle aspirationcytology and frozen sections in primaryparotid carcinoma. Cancer 2004; 100: 1876-83.13. Layfield LJ, Tan P, Glasgow BJ. Fine-needleaspiration of salivary gland lesions.Comparison with frozen sections andhistological findings. Arch Pathol Lab Med1987; 111:346-53.14. Hood IC, Qizilbash AH, Salama SS,Alexopoulou I. Basal-cell adenoma of theparotid. Difficulty in the differentiation fromadenoid cystic carcinoma on aspiration biopsy.Acta Cytol 1983; 27:515-20.15. Matsushita I, Takeda T, Tadao Kobayashi TK,Tanaka B, Sawaraqi I. Mucoepidermoidcarcinoma of the salivary gland in pleuralfluid. A case report. Acta Cytol 1983; 27:525-28.16. Agale SV, D’Costa GF, Hastak MS, ShedgeRT. Primary non-Hodgkin’s lymphoma of thesalivary gland: A spectrum oflymphoepithelial sialadenitis and low-grade B-cell lymphoma of the mucosa-associatedlymphoid tissue with transformation to highgradelymphoma. Indian J Pathol Microbiol2010; 53:364-67.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 100

Agravat Amit H. et alROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN SALIVARY GLAND PATHOLOGY AND ITSHISTOPATHOLOGICAL CORRELATION: A TWO YEAR PROSPECTIVE STUDY IN WESTERN INDIATable 1 : Age and sex crosstabulationAgeSexMaleFemaleTotalBelow 10 Count 2 2% within sex 2.9% 1.7%11-20 Count 8 8 16% within sex 11.4% 16.0% 13.3%21-30 Count 16 14 30% within sex 22.9% 28.0% 25.0%31-40 Count 12 10 22% within sex 17.1% 20.0% 18.3%41-50 Count 6 12 18% within sex 8.6% 24.0% 15.0%51-60 Count 12 6 18% within sex 17.1% 12.0% 15.0%61-70 Count 12 12% within sex 17.1% 10.0%71-80 Count 2 2% within sex 2.9% 1.7%Total Count 70 50 120% within sex 100% 100% 100%Table 2 : Frequency of cases diagnosed on FNACDiagnosis Frequency PercentPleomorphic Adenoma 88 73.3%Benign Parotid Tumor 8 6.7%Warthin’s Tumor 2 1.7%Cystic Lesion 4 3.3%Mucoepidermoid Carcinoma 6 5.0%Acinic Cell Carcinoma 2 1.7%Primary Lymphoma 2 1.7%Carcinoma ex Pleomorphic Adenoma 4 3.3%Metastatic deposits 2 1.7%Malignant Tumor (Unspecified) 2 1.7%TOTAL 120 100%Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 101

Sharadkumar P. Sawant et alVARIANT AXILLARY ARTERY – A CASE REPORTVARIANT AXILLARY ARTERY – A CASE REPORTIJCRRVol 04 issue 21Section: HealthcareCategory: Case ReportReceived on: 14/08/12Revised on:28/08/12Accepted on:10/09/12Sharadkumar Pralhad Sawant, Shaguphta T. Shaikh, Rakhi Milind MoreDepartment of Anatomy, K. J. Somaiya Medical College, Somaiya Ayurvihar,Eastern Express Highway, Sion, Mumbai, M.S., IndiaE-mail of Corresponding Author: dr.sharadsawant@yahoo.comABSTRACTDuring routine dissection for the undergraduate medical students, we observed the variations in thecourse and distribution of axillary artery in the right upper limb of a 80 years old donated embalmedmale cadaver in the Department of Anatomy, K. J. Somaiya Medical College, Sion, Mumbai, India. Inthe present case the axillary artery, 1cm distal to the outer border of first rib divided into superficial anddeep brachial arteries. The superficial brachial artery continued as brachial artery proper and divided atthe level of neck of radius into radial and ulnar arteries. The deep brachial artery performed the role ofaxillary artery in the axilla. It gave rise to all branches which are usually given by the axillary artery.The deep brachial artery first gave superior thoracic, thoracoacromial, lateral thoracic artery & articularbranch to the shoulder joint. It then divided into anterior & posterior divisions. The anterior divisiongave anterior circumflex humeral, posterior circumflex humeral and profunda brachii artery. Theposterior division continued as the subscapular artery and it gave rise to the circumflex scapular andthoracodorsal arteries. The deep brachial artery giving rise to all branches which are normally given byfirst, second and third part of axillary artery is very rare and not found in literature. The profundabrachii artery arising from anterior division of deep brachial artery is also very rare and not found inliterature. The axillary vein was on medial side of superficial brachial artery in the arm. The cords ofbrachial plexus were around the superficial and deep brachial artery. The origin, course and distributionof axillary artery was normal on the left side of the same male cadaver. The photographs of thevariations of axillary artery were taken for proper documentation and for ready reference.Conclusion: Topographical anatomy of the normal and abnormal variations of the axillary artery isclinically important for surgeons, orthopaedicians and radiologists performing angiographic studies onthe upper limb. The appropriate diagnostic interpretation and therapeutic intervention can be achievedon the basis of knowledge of such variations.Key words: Axillary Artery, Superficial Brachial Artery, Deep Brachial Artery, Anterior & PosteriorDivision Of Deep Brachial Artery, Angiographic Studies, Radiologists, Orthopaedicians, ShoulderJoint.INTRODUCTIONThe axial artery of the upper limb is derived fromthe lateral branch of the seventh cervicalintersegmental artery. This axial artery becomesaxillary, brachial, radial and ulnar arteries onfurther development. At the level of the outerborder of the first rib the subclavian arterycontinues as the axillary artery. The axillaryartery ends at the level of the lower border of theteres major muscle and continues downwards asthe brachial artery. The brachial artery is the mainartery of the arm. During the course of theaxillary artery the pectoralis minor muscle crossesit anteriorly and divides the course of artery intoInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 102

Sharadkumar P. Sawant et alVARIANT AXILLARY ARTERY – A CASE REPORTthree parts; proximal to the pectoralis minormuscle is the first part, posterior to the muscle issecond part and distal to the muscle is the thirdpart of the axillary artery. The first part of axillaryartery gives one branch i.e. superior thoracic arterywhich is arising at the level of the lower border ofsubclavius muscle. The superior thoracic arterymay arise from the thoraco acromial artery.The second part of axillary artery gives twobranches i.e. thoraco acromial artery and lateralthoracic artery. The thoraco acromial artery iscovered by the pectoralis minor muscle. It comesout from the medial border of the pectoralis minormuscle and pierces the clavipectoral fascia. Itdivides into pectoral, acromial, clavicular anddeltoid branches of which the pectoral branch isthe largest branch. The lateral thoracic arterycomes out from the lateral border of the pectoralisminor muscle. It is large in females and has lateralmammary branches which supply the breast. Thethird part of axillary artery gives three branchesi.e. subscapular, anterior and posterior circumflexhumeral arteries. The subscapular artery is thelargest branch arising from the lower border of thesubscapularies muscle. In the lower part it isaccompanied by the thoracodorsal nerve (C6, 7,8). The subscapular artery terminates into largercircumflex scapular and smaller thoracodorsalarteries. The circumflex scapular artery during itscourse interrupts the origin of teres minor muscleand appears into the upper triangular space, whichis bounded above by subscapularis muscle, belowby teres major muscle and laterally by long headof triceps brachii muscle. The circumflex scapularartery gives two important cutaneous branches, theupper (scapular) and the lower (parascapular).The scapular flap (upper cutaneous or scapularbranch) and the parascapular flap (lower cutaneousor parascapular branch) are used forreconstructions in the areas of missing tissues. Thethoracodorsal artery runs along the lateral(axillary) border of scapula and enters the deepsurface of the latissimus dorsi muscle along withthe nerve to latissimus dorsi. The anteriorcircumflex humeral artery orginates at the lowerborder of sub scapularis muscle from the lateralside of the third part of the axillary artery as asmaller branch. It runs around the surgical neck ofthe humerus anteriorly and anastomoses with theposterior circumflex humeral artery. It gives anascending branch which supplies the head of thehumerus and the shoulder joint. The posteriorcircumflex humeral artery is the larger branchoriginating at the same level of the anteriorcircumflex humeral artery. It runs along withaxillary nerve (C5, 6) in the quadrangular space.The quadrangular space is bounded above by teresminor muscle, below by the teres major muscle,medially by the long head of triceps brachiimuscle and laterally by the surgical neck of thehumerus. It runs round the neck of the humerusand supplies the shoulder joint. It anastomoseswith anterior circumflex humeral artery. It gives adescending branch which anastomoses with theascending branch of the profunda branchii artery(1). The branches of subclavian and axillaryarteries show extensive collateral circulationaround the scapula so that the sound knowledgeof neuromuscular variation is important forsurgeons who remove the axillary lymph nodes, toanaesthesiologist and orthopaedic surgeonsconsidering the frequency of procedures done inthis region. Sometimes many of the branches mayoriginate from a common stem or arise separately(2). These variation, are well documented inliterature. The second part of axillary artery maygive rise to a third branch i.e. alar thoracic artery.The second part of the axillary artery may giveonly one branch i.e. the thoraco-acromial arteryand the second branch i.e. the lateral thoracicartery may be absent. Variations are common inthe branching pattern of the third part of theaxillary artery. A common arterial trunk may giverise to the scapular artery and the posteriorcircumflex humeral artery or it may give rise tosubscapular, anterior and posterior circumflexhumeral and profunda brachii arteries. Theprofunda brachii artery rarely gives the posteriorInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 103

Sharadkumar P. Sawant et alVARIANT AXILLARY ARTERY – A CASE REPORTcircumflex humeral artery which will pass belowthe teres major musle and not through thequadrangular space. The axillary artery may giverise to high origin of radial and ulnar arteries andrarely the anterior interosseous artery may arisefrom axillary artery.Case Report:During routine dissection for the undergraduatemedical students, we observed the variations in thecourse and distribution of axillary artery in theright upper limb of a 80 years old donatedembalmed male cadaver in the Department ofAnatomy, K. J. Somaiya Medical College, Sion,Mumbai, INDIA. In the present case the axillaryartery, 1cm distal to the outer border of first ribdivided into superficial and deep brachial arteries.The superficial brachial artery continued asbrachial artery proper and divided at the level ofneck of radius into radial and ulnar arteries. Thedeep brachial artery performed the role of axillaryartery in the axilla. It gave rise to all brancheswhich are usually given by the axillary artery. Thedeep brachial artery first gave superior thoracic,thoracoacromial, lateral thoracic artery & articularbranch to the shoulder joint. It then divided intoanterior & posterior divisions. The anteriordivision gave anterior circumflex humeral,posterior circumflex humeral and profunda brachiiartery. The posterior division continued as thesubscapular artery and it gave rise to thecircumflex scapular and thoracodorsal arteries.The deep brachial artery giving rise to all brancheswhich are normally given by first, second andthird part of axillary artery is very rare and notfound in literature. The profunda brachii arteryarising from anterior division of deep brachialartery is also very rare and not found in literature.The axillary vein was on medial side of superficialbrachial artery in the arm. The cords of brachialplexus were around the superficial and deepbrachial artery. The origin, course and distributionof axillary artery was normal on the left side of thesame male cadaver. The photographs of thevariations of axillary artery were taken for properdocumentation and for ready reference.Figure 1: Photograph representation of the axillaryartery of right upper limb divided into superficialbrachial and deep brachial arteries.Figure 2: Photograph representation of thesuperficial brachial artery continued in the armwithout giving any branches. The deep brachialartery divided into anterior & posterior division.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 104

Sharadkumar P. Sawant et alVARIANT AXILLARY ARTERY – A CASE REPORTFigure 3: Photograph representation of the deepbrachial artery first gave superior thoracic,thoracoacromial, lateral thoracic artery & articularbranch to the shoulder joint.Figure 4: Photograph representation of the anteriordivision of deep brachial artery gave rise toanterior circumflex humeral, posterior circumflexhumeral and profunda brachii artery.Figure 5: Photograph representation of theposterior division of deep brachial arterycontinued as subscapular artery gave rise tocircumflex scapular and thoracodorsal artery.DISCUSSIONVariations in the arterial pattern of the upper limbare commonly found in literature. Bergman R.A.et al, Rodriguez - Baeza A. et al and TountasC.H.P.et al have reported variations in thebranching pattern of the axillary artery (3, 4, 5).According to Jurjus A. et al the variations andanomalies of the arterial system of the upper limbcan be best explained on the basis of embryologicdevelopment of the vascular plexuses of the limbbuds (6). Senior H. D. and Singer E. haveproposed the model of development of the arteriesof upper limb. According to them arterialdevelopment begins with the appearance of anaxial artery followed by other branches. The axialartery forms axillary artery, brachial artery andanterior interosseous artery. The median arterybranches from the anterior interosseous artery. Theulnar artery arises from the brachial artery. Theaxillary artery gives a superficial brachial arterywhich continues as the radial artery (7, 8).According to Tan C.B. et al the variations in theorigin, course and distribution of the axillaryartery are not common (9). Jurjus A. R. et al statedthat the axillary artery is the axial artery of upperInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 105

Sharadkumar P. Sawant et alVARIANT AXILLARY ARTERY – A CASE REPORTlimb derived from the the lateral branch of theseventh cervical intersegmental artery (10).Hamilton W. J. et al documented that the arterialvariations in the upper limb are due to the defectsin the embryonic development of the vascularplexus of the upper limb bud. This may be due toarrest at any stage of development, showingregression, retention, or reappearance and maylead to variations in the arterial origins and coursesof the major upper limb vessels (11). According toCavdor et al the axillary artery is having twodistinct variations one is the high origin of thesuperficial brachial artery which emerges from theaxillary or brachial artery and continues in theforearm as the radial artery. Second is thesuperficial brachial artery may or may not be abrachial artery terminating in to radial and ulnararteries. The incidence of such superficial brachialartery is around 0.1- 3.2% as available in theliterature (12). De Garis C.F. has observed thedivision of the axillary artery into superficial anddeep brachial arteries more frequent in blackpersons (13.4%) than in white persons (4.6%)(13). In the present case the axillary artery dividesin to superficial brachial artery and deep brachialartery. The superficial brachial artery has notgiven any branches during its course in the arm. Itterminated in to the radial and ulnar arteries andthe arterial arches of the hand were normal. Thedeep brachial artery giving rise to all brancheswhich are normally given by the axillary artery isvery rare and no such case report is available inliterature. The deep brachial artery first gavesuperior thoracic, thoracoacromial, lateral thoracicartery & articular branch to the shoulder joint. Itthen divided into anterior & posterior division.The anterior division gave rise to anteriorcircumflex humeral, posterior circumflex humeraland profunda brachii artery. The posteriordivision i.e. subscapular artery gave rise tocircumflex scapular and thoracodorsal artery.According to Charles et al there are 7 types oforigins for profunda brachii artery. In Type I theprofunda brachii artery is the branch of brachialartery, Type Ia the profunda brachii arteryoriginates by 2 separate branches, Type Ib theprofunda brachii artery originates by 3 separatebranches, In Type II the profunda brachii arteryarises as a common trunk with superior ulnarcollateral artery, In Type III the profunda brachiiartery arises at lower border of teres major so canbe considered to be arising from axillary orbrachial, In Type IV profunda brachii artery is thebranch of 3rd part of axillary artery. In Type Vprofunda brachii artery arises as a common trunkwith posterior circumflex humeral. In Type VIprofunda brachii artery arises as a common trunkwith subscapular and both circumflex humeralsfrom axillary artery and in Type VII profundabrachii artery is absent (14). In the present case theprofunda brachii artery arises from the anteriordivision of the deep brachial artery along withanterior circumflex humeral and posteriorcircumflex humeral arteries which is rare and notfound in literature. The arterial variationsdocumented in the present case are due to thedefects in the embryonic development of thevascular plexus of the upper limb bud. This maybe due to arrest at any stage of development,showing regression, retention, or reappearance andmay lead to variations in the arterial origins andcourses of the major upper limb vessels (11). Theembryological correlation of the variations of thecourse and distribution of axillary artery seen inpresent case may be by the persistence,disappearance, incomplete development fusionand absorbtion of vessels and the selection ofunsual path by primitive vascular plexuses (15).According to Decker G.A. G. the knowledge ofsuch variations are important while operating onchronic dislocation of the shoulder joint. Theorthopaedicians must take precautions whiletaking transverse incision in order to avoid injuryto the deep brachial artery and its branches (16).Yoshinaga K. et al in his study on “A rarevariation in the branching pattern of the axillaryartery.” concluded that an accurate knowledge ofthe normal and variant arterial pattern of theInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 106

Sharadkumar P. Sawant et alVARIANT AXILLARY ARTERY – A CASE REPORThuman upper extremities is important both forreparative surgery and for angiography (17).According to Samuel L. the presence of deepbrachial artery and its branches must be kept inmind during the surgical repair of brachial plexusinjury in order to prevent bleeding (18).CONCLUSIONThe arterial variations of the upper limb have beenimplicated in different clinical situations. Thevariations in the origin and course of principalarteries are clinically important for surgeons,orthopaedicians and radiologists performingangiographic studies on the upper limb. Thesevariations are compared with the earlier data & itis concluded that variations in branching pattern ofaxillary artery are a rule rather than exception.Therefore both the normal and abnormal anatomyof the region should be well known for accuratediagnostic interpretation and therapeuticintervention.Competing Interests:The authors declare that they have no competinginterest.Authors' contributions:SPS wrote the case report, performed the literaturereview & obtained the photograph for the study.RMM performed the literature search and assistedwith writing the paper. STS conceived the studyand helped to draft the manuscript. All authorshave read and approved the final versionmanuscript.ACKNOWLEDGEMENTAuthors also acknowledge the immense helpreceived from the scholars whose articles are citedand included in references of this manuscript. Theauthors are also grateful to authors / editors /publishers of all those articles, journals and booksfrom where the literature for this article has beenreviewed and discussed. All the authors arethankful to Dr. Arif A. Faruqui for his support.Authors are also thankful to Mr. M. Murugan forhis help in typing the manuscript.REFERENCES1. Standring S. Gray’s Anatomy: TheAnatomical Basis of Clinical Practice. 40thEd. 2008. Churchill-Livingstone: Elsevier.ISBN 978-0-443-06684-89.2. Hollinshed W.H. Anatomy for surgeons ingeneral surgery of upper limb. The backand limbs. A Heber Harper Book, New York,1958. pp- 290-300.3. Bergman RA, Thomson SA, Afifi AK,Saadeh FA (1988).Compendium of humananatomic variations. Urban andSchwarzenberg. Baltimore Munich.4. Rodriguez - Baeza A, Nebot J and Ferreira Bet al (1995).An anatomical study andontogenic explanation of 23 cases withvariations in the main pattern of the humanbrachio-antebrachial arteries. J Anat 187;473-479.5. Tountas CHP, Bergman RA (1993) Anatomicvariations of the upper extremity . ChurchillLivingstone, New York pp196-210.6. Jurjus A, Sfeir R, Bezirdjian R (1986).Unusual variation of the arterial pattern of thehuman upper limb. Anat Rec 215;82-83.7. Senior H. D. (1926) A note on thedevelopment of the radial artery .Anat Rec32:220-221.8. Singer E (1933) Embryological patternpersisting in the arteries of the arm.AnatRec.55;403-409.9. Tan C.B., Tan C.K. An unusual course andrelations of the human axillary artery.Singapore Med J 1994; 35: 263-264.10. Jurjus A.R., Correa-De-Aruaujo R., BohnR.C. Bilateral double axillary artey:embryological basis and clinical implications.Clin Anat 1999; 12: 135-140.11. Hamilton W.J., Mossman H.W.Cardiovascular system. In: HumanInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 107

Sharadkumar P. Sawant et alVARIANT AXILLARY ARTERY – A CASE REPORTembryology. 4th ed. Baltimore: Williams andWilkins, 1972: 271-290.12. Cavdar S., Zeybek A., Bayramicli M. Rarevariation of the axillary artery. Clin Anat2000; 13: 66-68.13. De Garis C.F., Swartley W.B. The axillaryartery in white and Negro stocks. Am J Anat1928; 41: 353.14. Charles, C.M.; Pen, L; Holden, H.F; Miller,R.A. & Elvis, E.B. (1931): The origin of thedeep brachial artery in American White &American Negro males. Anatomical Record.50: pp 299-302.15. Arey L. B. Development Anatomy in :Development of the arteries , 6 th edition.Philadelphia: W.B. Saunders Co; 1957. pg.375-77.16. Shoulder joint. In: Decker G.A.G., du plessisD.J. Lee Mc Gregor’s Synopsis of SurgicalAnatomy. 12th ed. Mumbai: K.M. Varghesecompany, 1986: 451.17. Yoshinaga K., Kodama K., Kameta K.,Karasawa N., Kanenaka N., Kohno S. &Suganuma T. A rare variation in thebranching pattern of the axillary artery.Indian J. Plast. Surg., 39:222-223, 2006.18. Cervicobrachial region. In: Samuel L.Turek’s orthopaedics: Principles and theirApplications: Vol 2. 4th ed. New Delhi:Jaypee brothers, 1989:913.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 108

Hundekari jagdish C. et alDOES THERMAL STRESS ALTERS THE AUTONOMIC FUNCTIONS IN MEN EXPOSED TO HEAT?DOES THERMAL STRESS ALTERS THE AUTONOMICFUNCTIONS IN MEN EXPOSED TO HEAT?IJCRRVol 04 issue 21Section: HealthcareCategory: ResearchReceived on: 12/09/12Revised on:19/09/12Accepted on:24/09/12Hundekari Jagdish C., Bondade A.K.Department of Physiology, MIMER Medical College, Talegaon D. Pune, M.S., IndiaE-mail of Corresponding Author: jchundekari_31@yahoo.co.inABSTRACTAim and objectives: The aim of the study was to evaluate the relationship between exposure to heat(stressful stimuli) and indicators of autonomic functions in workers of thermal power station. Materialand method : 133 male workers were selected out of whom 65 workers were exposed to heat (40 0 C to45 0 C) emitted by boiler in boiler section for 8 hrs daily and 6 days in a week for estimation of plasmacatecholamines and blood pressure. The control group consists of office workers and staff who werenot exposed to extreme heat. Depending on age, they were divided into four groups. Estimation ofplasma adrenaline and nor-adrenaline was carried out by HPLC method with flurimetre detection andblood pressure by mercury sphygmomanometer between cases and controls to observe the effect ofheat stress on autonomic functions. Results: It was observed that there is highly significant increase inplasma level of the adrenaline and nor-adrenaline in workers. Systolic and diastolic blood pressure rosesignificantly in workers. Conclusion : The general hypothesis to emerge is that automatically mediatedcardiovascular reactions to stressful stimuli (heat) may initiate progression towards sustainedhypertension and coronary heart disease (CHD) in susceptible individualsKeywords: adrenaline, nor-adrenaline pressure, diastolic blood, systolic blood pressure, thermalstress.INTRODUCTIONStress is the reaction of body to stimuli that disturbits normal physiological equilibrium orhomeostasis. In our daily lives, some stressprepares us to meet certain challenges. Theproductive stress is called Eustress while the otherharmful stress is called Distress 1 . Stress causesmental, emotional and physical responses inhumans. When stressed, an organism firstexperiences arousal of the sympathetic nervoussystem, followed by activation of themusculoskeletal, cardiovascular and endocrinesystems. The outcome of this process is a series ofnon-specific psycho-physiologic changes such asan increase of certain neurotransmitters in thebloodstream, and results in adverse effectsassociated with the negative aspect of stress. 2Several kind of mental stress are associated withtemporary rise in blood pressure. In animalexperiments, it has been shown that repeatedexposure to stressful stimuli can cause permanentrise in blood pressure. Such a relationship betweenrepeated stressful stimuli and a permanent rise inblood pressure is obviously not so easy to establishin man, partly due to the fact that environmentalstress is difficult to measure and quantitate. 3Over the past decade, due to the view that stressfulstimuli may influence the onset and progression ofnumber of disorders in human beings leading tohypertension, stroke, depression etc. There isconsiderable evidence that heightened autonomicnervous system activity may be present early inthe aetiology of hypertension. It has become clearover recent years that autonomic regulation of theInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 109

Hundekari jagdish C. et alDOES THERMAL STRESS ALTERS THE AUTONOMIC FUNCTIONS IN MEN EXPOSED TO HEAT?cardiovascular system is not confined to the brainstem cardiovascular centres, but it is organisedlongitudinally within the central nervous systemwith higher cortical and sub cortical regionshaving an important influence. The generalhypothesis to emerge is that automaticallymediated cardiovascular reactions to psychologicalchallenges may initiate progression towardssustained hypertension in susceptible individuals. 4Effect of different stresses on autonomic changeshas been studied widely, but occupationalexposure to heat stress is least studied part of thesubject.MATERIAL AND METHOD:The subjects were 133 workers from thermalpower plant in the age group of 30-50yrs. Thisstudy group was divided into control (68) andexperimental groups (65) based on their exposureto heat.Selection criteriaCases - Only those workers were selected whowere exposed to heat emitted by boiler in “Boilersection”. The workers were exposed for 8 hrs dailyand 6 days a week and temperature to which theyare exposed is in between 40 0 c to 45 0 c.Control -The control group consists of officeworkers and staff who were not exposed toextreme heat.In the present study, each subject was madefamiliar with the procedure to alleviate any fear orapphrension and before starting the procedure,they were asked to relax for five minutes.Screening of each volunteer was done with thehelp of proforma. After Screening, followingvolunteers were excluded from the study. Thosehaving major cardiovascular illness or Diabetesmellitus in the past or present, with the H/Oconsumption of tobacco, alcohol, smoking, historyof any systemic illness, history of drug treatment.METHODOLOGYCollection of blood sample: Venous plasmaadrenaline and nor-adrenaline concentration wereused as a indices of adreno-medullary andsympathoneural regulation respectively. 5ml bloodsample was collected in supine position (30mins)from anti-cubital vein of the non-dominantforearm for determination of plasma adrenalineand noradrenaline concentration. The bloodsamples were centrifuged at 4 0 C andcatecholamines were assayed by means of HPLCwith flurimetre detection after isolation fromplasma by a specific liquid/ liquid extractionmethod. 5Blood pressure measurement: Because largevariations in blood pressure have been shown toexist with a given subject, it is difficult to detectdifferences between groups may lead tomisclassification of individuals. Therefore,multiple blood pressure measurements usingstandard procedures were implemented in thisinvestigation. Their blood pressure was recordedin supine position using mercurysphygmomanometer. Three readings were taken10minutes apart and mean was taken as bloodpressure.Statistical analysis: For statistical analysis wehave applied t-test to compare cases with controls.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 110

Hundekari jagdish C. et alDOES THERMAL STRESS ALTERS THE AUTONOMIC FUNCTIONS IN MEN EXPOSED TO HEAT?RESULTSTable 1:- Comparision of plasma adrenaline (pg/ml) in supine (30mins) between cases and control belongingto different age groupGroups 31-35yrs 35-40yrs 41-45yrs 46-50yrs(Group-I) (Group-II) (Group-III) (Group-IV)Control Cases Control Cases Control Cases Control CasesNo. of Cases 17 16 18 16 20 21 13 12Mean 9 12 11 18 26 34 43 47±SD 3 5 5 9 15 16 16 19t- test P < 0.05 P < 0.001 P < 0.001 P < 0.05Significant S H.S. H.S. STable no. 1 shows highly significant increase in plasma adrenaline level in workers exposed to heat in Group II andIII while significal increase in Group I and IV.Table 2:- Comparision of plasma noradrenaline (pg/ml) in supine (30mins) between cases and controlbelonging to different age groupGroups 31-35yrs 35-40yrs 41-45yrs 46-50yrs(Group-I) (Group-II) (Group-III) (Group-IV)Control Cases Control Cases Control Cases Control CasesNo.of Cases 17 16 18 16 20 21 13 12Mean 159 163 226 234 416 422 386 390±SD 44 47 45 47 108 114 86 91t- test P < 0.05 P < 0.001 P < 0.05 P < 0.05Significant S H.S. S STable no. 2 shows significant increase in plasma nor-adrenaline level in workers exposed to heat as compared tocontrols in Group I, III and IV while highly significant increase in Group II.Fig. 1:- Comparision of Systolic blood pressure (mm of Hg) between cases and control belonging to differentage groupsystolic bloodpressure (mmof Hg)130128126124122120118116114112110Group-I (21-30yrs )p

Hundekari jagdish C. et alDOES THERMAL STRESS ALTERS THE AUTONOMIC FUNCTIONS IN MEN EXPOSED TO HEAT?Fig. 2:- Comparison of Diastolic blood pressure (mm of Hg) between cases and control belonging to differentage group908886diastolic bloodpressure (mm ofHg)84828078casescontrols767472Group-I (21-30yrs )p

Hundekari jagdish C. et alDOES THERMAL STRESS ALTERS THE AUTONOMIC FUNCTIONS IN MEN EXPOSED TO HEAT?significant increase in systolic and diastolic bloodpressure. It can also be concluded that prevalenceof hypertension, CHD and its risk is higher inworkers exposed to heat stress as compared tocontrols.ACKNOWLEGEMENTAuthors acknowledge the immense help receivedfrom the scholars whose articles are cited andincluded in references of this manuscript. Theauthors are also grateful to authors / editors /publishers of all those articles, journals and booksfrom where literature for this article has beenreviewed and discussed.REFERENCES1. R. Archana et al. The effect of acute noisestress on neutrophil functions. IJPP.1999;43(4) : 491-4952. Young-Hee Lee et al. The effects of heat andmassage application on Autonomous NervousSystem. Yonsei Med Journal .2011 ;52(6) :982-9893. Anders Jonsson et al. Prolonged exposure to astress stimuli (noise) as a cause of raisedblood pressure in man. Lancet.1977 ; January8: 186(7)4. Andrew Steptoe. Stress mechanism inhypertension. Postgraduate medicaljournal.1986; 62: 697-699.5. Davies CL et al. Routine determination ofplasma catecholamines using HPLC withelectrochemical detection. J Chromatography.1982; 231:41-51.6. Dimsdale J E et al. Plasma catecholamine instress and exercise. JAMA 1980; 243: 340-3427. Fibiger W et al. Relationship betweencatecholamines in urine and physical andmental stress. Int. journalPsychophysiology.1984; 1: 325-3338. Lefur C et al. Urinary epinephrine increasesduring mental stress.1999 ;489. Shinji Y. Amamoto et al. Evaluation of theeffect of heat exposure on the autonomousnervous system by HRV and urinarycatecholamines. Journal Occupational Health.2007;49 : 199-20410. Milakofsky L et al. Effect of repeated stresson plasma catecholamine and taurine inyoung and old rats. Neurobiology aging. 1993; 14(4) : 359-36611. De Turck KH et al. Factors influencingplasma catecholamines during rest and mentalstress: effect of posture. Pharmaco BiochemBehaviour. 1980; 13(1) : 129-1312. .Nagraja H.S. et al. Effect of different typesof stress on selected cardiovascularparameters in rats. IJJP. 1999 ; 43(3) : 296-30413. Kulkarni S et al. Stress and hypertension.WMJ. 1998; 97(11) : 34-814. Saha S et al. Effect of noise stress on somecardiocascular parameters and audiovisualreaction time. IJPP. 1996; 40(1) : 35-40.15. Parvizpoor D et al. Noise exposure andprevalence of high blood pressure amongsweaver in Iran. J. occupational medicine.1984; 18 : 730-116. Talbott et al. Occupational noise exposure,noise induced hearing loss and theepidemiology of high blood pressure.American J. of epidemiology. 1985; 120(8) :501-51417. Jian Cui et al. Heat stress attenuates theincrease in arterial blood pressure during thecold pressor test. J. applied physiology. 2010; 109 : 1354-135918. Mathew F et. Acute cholesterol responses tomental stress and change in posture. 1995;152 : 775-780Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 113

Gunvanti B. Rathod et alCOMPARISON REGARDING KNOWLEDGE, ATTITUDE AND PRACTICE OF BLOOD DONATIONBETWEEN HEALTH PROFESSIONALS AND GENERAL POPULATIONIJCRRVol 04 issue 21Section: HealthcareCategory: ResearchReceived on: 08/09/12Revised on:13/09/12Accepted on:18/09/12COMPARISON REGARDING KNOWLEDGE, ATTITUDE ANDPRACTICE OF BLOOD DONATION BETWEEN HEALTHPROFESSIONALS AND GENERAL POPULATIONGunvanti B. Rathod 1 , Pragnesh Parmar 21 Department of Pathology, Mahatma Gandhi Medical College and Research Institute,Pillaiyarkuppam, Pondicherry, India2 Department of Forensic Medicine, Mahatma Gandhi Medical College and ResearchInstitute, Pillaiyarkuppam, Pondicherry, IndiaE-mail of Corresponding Author: neempath@gmail.comABSTRACTObjectives: The objectives of this study are to assess the knowledge, attitude and practice regardingblood donation among various categories of health professionals and comparing them with that of thegeneral population. Material and method: A cross sectional descriptive study was carried out atPondicherry. Total 150 individuals were interviewed including doctors (n=25), nurses (n=25),technicians (n=25) and general population of Pondicherry (n=75). All were interviewed with the helpof a pretested and semi-structured questionnaire. Results: There was a significant difference inknowledge pertaining to blood donation between health professionals and the general population. Onthe other hand there was no difference of attitude of the two groups. There was no difference inknowledge and attitudes according to gender but most of the donors were males.Conclusion: There is a need to increase the awareness and attitude among the paramedical staff and ingeneral population. There is also need to motivate females for blood donation. There is also need tocreate awareness about blood safety in paramedical staff and general population.Keywords: Attitude, Blood donation, General population, Health professionals, Knowledge, Practice.INTRODUCTIONBlood is the most donated tissue in medicalpractice and a veritable tool in many life savingsituations when used judiciously. In spite of therapid and remarkable conquest and breakthroughof medical science today, there is still no idealsubstitute. Blood is manufactured by only humanbeings and human donation is the only way ofacquiring blood to meet emergency requirementsin cases of road traffic accidents, complications ofpregnancy and childbirth, various anaemicdisorders and surgical emergencies. Blooddonation is the act of giving one's blood, so it canbe transfused into another for therapy. It is safeand advantageous to the donor, recipient,community and the blood transfusion service.Blood can save millions of life and young peopleare the hope and future of a safe blood supply inthe world. [1]The World Health Organization (WHO) estimatedthat donation by 1 % of a country population is theminimum blood required to meet a nation’s mostbasic needs for blood. [2] India needs about 6 to7.5 million units of blood annually and every yearthere is gradual increase in this demand. [3] Thereasons for increase in demand are because of therise in human life expectancy and theimplementation of new and aggressive surgicaland therapeutic methods requiring large quantitiesof blood and blood products. [4] Donor bloodprocurement from voluntary, non-remunerateddonor has been adjudged the safest source ofblood. Even though Indian law forbiddencollection of blood from paid donors, many timeshealth care facilities forced to accept blood fromInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 114

Gunvanti B. Rathod et alCOMPARISON REGARDING KNOWLEDGE, ATTITUDE AND PRACTICE OF BLOOD DONATIONBETWEEN HEALTH PROFESSIONALS AND GENERAL POPULATIONpaid donors as there are scarcity of voluntaryblood donors. [5] Hence the World HealthOrganization has adopted a policy aimed at 100 %voluntary, non-remunerated donor bloodprocurement by the year 2020. [6] It is a wellknown fact that in developing countries more than50 % of blood donations are made by paid andvoluntary donors. [7, 8] Ignorance, fear and wrongconcepts about blood donation and lack ofvoluntary blood donation organizations are majorconstraints in many developing countries tofacilitate voluntary blood donation. The study wasdesigned to determine the behaviour of themedical and paramedical persons and generalpopulation towards blood donation by theirknowledge, attitude and blood donation practicealong with factors influencing blood donation andtheir willingness to donate the blood voluntarily.MATERIAL AND METHODThis cross sectional study was conducted amonghealth professionals and general population ofSouth India. Total 25 doctors, 25 nurses, 25technicians and general population (75) ofPondicherry were included as study population. Awell structured validated and self administeredquestionnaire was used to assess the knowledge,attitude and practice about blood donation. Thequestionnaire was pretested and verified for errors.Questionnaire consists of three sections: practice,knowledge and attitude. Blood donation practicewas assessed through six questions addressing thenature of donation, frequency of donation, reasonsfor not donating blood etc. Knowledge partcontains 6 questions; knowledge on blooddonation was assessed through questions coveringbenefits, requirements and restrictions of blooddonation. The attitude for blood donation wasassessed through 6 questions with ‘yes’ and ‘no’options. A scoring mechanism was used tounderstand overall knowledge level; a score of onehas given for each correct response and zero forwrong response. Respondents with all correctresponse get a maximum of 18 points, higherpoints indicate good knowledge. Based on totalscore, knowledge level on blood donation wascategorized into poor (≤8 points), average (9 -14points) and good (≥15 points). The participation tosurvey was on voluntary basis. All participantswere given a briefing about objective of the studyand assured confidentiality in collection ofpersonal data.RESULTSTable – I showed details of the demographics ofrespondents. The response was gathered from atotal of 150 respondents voluntarily participated inthe survey. The age of the respondents rangedbetween 17 to 54 years. The study sampleconsisted of 93 males (62 %) and 57 females (38%). The mean age of males was 37 years and themean age of females was 26 years. Thedemographics showed the mean age of therespondents to be 32 years.There was significant difference in knowledgepertaining to blood donation between healthprofessionals and general population. More thanhalf 42 (56 %) of the general population had pooroverall score regarding knowledge, attitude andpractice of blood donation as per Table – II whichshowed overall score comparison of therespondents.Total 68 (45.33 %) of the respondents had goodknowledge about blood donation. About onequarter 43 (28.67 %) had poor knowledge on whatblood donation entails. Total 62 (41.33%)respondents had poor knowledge about the healthconditions that would require blood transfusion,only 46.67% could state correctly some of thehealth conditions like anaemia, trauma, road trafficaccidents, sickle cell anaemia and surgery. Total112 (74.67 %) said they can donate bloodvoluntarily as per Table – III which showedknowledge of respondents on blood donation.More than half of the respondents, total 94 (62.67%) had never donated blood; only few of therespondents, total 61 (37.33 %) had ever donatedblood. Among those that had ever donated, malesInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 115

Gunvanti B. Rathod et alCOMPARISON REGARDING KNOWLEDGE, ATTITUDE AND PRACTICE OF BLOOD DONATIONBETWEEN HEALTH PROFESSIONALS AND GENERAL POPULATION(85.71 %) were more than females (14.29 %).More than half, total 30 (53.57 %) of the blooddonated by the study population was for relationsand total 19 (33.93 %) donated for friends. Veryfew, only 11 (7.33 %) of the total respondents hadvoluntarily donated blood. Total 17 (30.35 %)donated for emergency situations, 28 (50 %)donated to replace blood units borrowed from theblood bank as per Table – IV which showed blooddonation practice among the respondents.DISCUSSIONEscalating demand for safe blood and itsavailability in our country can be only ensuredthrough enhancing voluntary blood donations.Role of general population in voluntary blooddonation is crucial to meet the demand of safeblood and more over health professionals having abetter understanding on healthcare requirements ofour country should come in forefront. Thereforeunderstanding the various factors contributing toknowledge, attitude and practice of blood donationamong health professionals and general populationis important.This study revealed that the respondents had goodknowledge about blood donation; however, it didnot find any significant relationship between age,ethnic group and literacy level with knowledgeabout blood donation. Even though therespondents had a good knowledge of blooddonation, poor blood donation practice wasobserved in this study as 37.33 % had everdonated and only 7.33% had voluntarily donatedblood in the past. This finding agrees with thestudy in Mmabatho where only 17.5 % had everdonated blood. [9] The results of this study alsorevealed that almost more than two third of males(85.71 %) while only 14.29 % of female haddonated blood, which is comparable to the studyby Olaiya where female donors compared to maleswere abysmally low (1%). [10]It is important to note that majority of therespondents 112 (74.67 %) participated in thisstudy shown positive attitude towards voluntaryblood donation. Hossain et al. has reported similarresults, 82 % of participants showed a positiveattitude towards voluntary blood donation. [11]The negative attitude towards paid blood donationreported in other studies [8, 11, 12] was alsoreported in this study. However in this study, only7.33 % of the respondents had actually donatedblood voluntarily. Therefore, the findings of thisstudy would suggest that greater knowledge aboutblood donation does not necessarily lead to actualblood donation practice, probably because of themythical beliefs and wrong perceptions aboutblood donation still held by people. In this study,large number of male and female respondentsexpressed their willingness to donate blood if theylearn more about the importance of blooddonation.Blood donations among the respondents in thisstudy were mostly for beneficial reasons as therecipients were mostly friends (33.93 %) andrelatives (53.57 %) and the majority claimedreplacement from the blood bank compelled themto donate blood. The voluntarily donated bloodwas scarce (7.33 %) and about two thirds of thosewho had donated voluntarily, did so duringorganizations' activity. This agrees with thefindings of Olaiya that voluntarily donated bloodwas donated during religious week and clubactivities. [10] Hence the need to explore theunions and departmental activities of tertiaryinstitutions in the country as a means of voluntaryblood donation drive.The reasons given by the respondents for notdonating blood include lack of opportunity (26.59%) and inaccessibility of blood bank facilities,inadequate information about the benefits ofvoluntary blood donation to the donor, recipientand community (9.57 %) as well as the fear (14.89%) that the process is harmful to the health of thedonor. Additionally, other inhibitory factors (18.08%) that would deter them from blood donationwere inadequate information about the blooddonation process, fear of exposure to HIV/Hepatitis infection and fear of fainting. This showsInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 116

Gunvanti B. Rathod et alCOMPARISON REGARDING KNOWLEDGE, ATTITUDE AND PRACTICE OF BLOOD DONATIONBETWEEN HEALTH PROFESSIONALS AND GENERAL POPULATIONthe wrong perception still held by people of thetransmission of HIV infection. The same findingwas seen in Mwanza, Tanzania where donors wereafraid of being infected with HIV. [13] This wasalso a deterrent amongst the Scottish population asit adversely affected their blood donation practice.In Australia, a study conducted among the collegestudents showed that the reluctance was mostlydue to fear, contracting possible illness afterwardand inconveniences of giving blood. [14] Anotherstudy in Mexico also found that non donation wasmainly due to the fear of getting dizzy after blooddonation.A study in Baltimore also found that the donorswould be encouraged to donate if specificincentives were offered; the highest response wasfor future blood credits and medicaltesting. [15] Another study in Texas alsoconcluded that individuals donate in order toreduce medical risks and that earning future bloodcredits would be a primary motivator. [16] A studyamongst the adults in Mwanza Region, Tanzania,also noted a positive attitude towards voluntaryblood donation but the majority of the people willdo so only for an incentive. [13] In Nigeria, theNational blood transfusion service is making aneffort to retain its voluntary donors by givingincentives such as free blood tests (blood group,haemoglobin genotype, HIV/ hepatitis) to donors,allowing the immediate family of volunteers to useblood without replacement and giving gift itemssuch as certificates, T-shirts, haematinics,refreshments and badges. [17] When assessingdonor incentives and enablers, the study foundthat, in general, people are focused primarily onmotivational tools, rather than rewards. This iscritical in beginning to change the blood donationculture from replacement to that ofvolunteerism. [18, 19]CONCLUSIONThe findings of this study revealed that althoughthe majority of respondents had good knowledgeof blood donation, only a few had donated bloodin the past. There is prime need to increase theawareness and attitude among the paramedicalstaffs & general population. Blood donoreducation and sensitization should begin atsecondary school by blood donor organizers. It isalso needed to motivate females for the blooddonation and to create awareness about bloodsafety in paramedical staffs and generalpopulation. Healthcare institutions should take allnecessary steps to create more awareness programon blood donations among entire community.Incentives and gift items such as T-shirts, wristbands, haematinics and certificates can motivatean altruistic spirit among the people.ACKNOWLEDGEMENTAuthors acknowledge the immense help receivedfrom the scholars whose articles are cited andincluded in references of this manuscript. Theauthors are also grateful to authors / editors /publishers of all those articles, journals and booksfrom where the literature for this article has beenreviewed and discussed.REFERENCES1. Dhingra N., World blood donor day: Newblood for the world, World HealthOrganization., Available onhttp://www.who.int/mediacentre/news/releases/2010/blood_donor_day_20100613/en,Assessed on 15-08-2012.2. Gillespie TW, Hillyer CD, Blood donors andfactors impacting the blood donation decision,Transfusion Medicine Reviews, 2002; 16:115–130.3. National AIDS control Organization (NACO),India. Voluntary blood donation programme -An operational Guideline, 2007. Availablefrom:http://www.nacoonline.org/upload/Policiesand Guidelines/29, voluntary blooddonation.pdf, Assessed on 15-08-2012.4. Riley W, Schwei M, McCullough J., TheUnited States potential blood donor pool:Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 117

Gunvanti B. Rathod et alCOMPARISON REGARDING KNOWLEDGE, ATTITUDE AND PRACTICE OF BLOOD DONATIONBETWEEN HEALTH PROFESSIONALS AND GENERAL POPULATIONEstimating the prevalence of donor exclusionfactors on the pool of potential donors,Transfusion 2007; 47: 1180–1188.5. Dixit JV, Mahale AR, Kulkarni AP, et al.,Impact of blood donation awareness campaignby National Service Scheme of GovernmentMedical College, Nanded., Indian Journal ofCommunity Medicine, Jan-Mar 2001; 26(1):12-15.6. Blood safety and donation: Fact sheet No. 279.Jun, 2008. Available from:http://www.who.int/mediacentre/factsheets/fs279/en/. Assessed on 15-08-2012.7. Wake D, Cutting W., Blood transfusion indeveloping countries: Problems, priorities andpracticalities, Tropical Doctor, 1998; 28: 4-8.8. Alam M, Masalmeh BE, Knowledge, attitudeand practices regarding blood donation amongthe Saudi population, Saudi MedicalJournal, 2004; 25(3): 318-321.9. Mwaba K, Keikelame MJ, Blood donationbehaviour and belief among a sample of highschool students in Mmabatho, Curationis,1995; 18: 2-3.10. Olaiya MA, Alakya N, Ajala A, et al.,Knowledge, attitude, belief and motivationstowards blood donation among blood donorsin Lagos, Nigeria, Transfusion Medicine,2003: 13-17.11. Hossain GM, Anisuzzaman M, Begum A.,Knowledge and attitude towards voluntaryblood donation among Dhaka Universitystudents in Bangladesh, East African MedicalJournal, September 1997; 74(9): 549-553.12. Wiwanitkit V., Knowledge about blooddonation among a sample of Thai Universitystudents, Vox Sang, August 2002; 83(2): 97-99.13. Jacob B, Berege ZA., Attitudes and beliefabout blood donations among adults inNwanza Region, Tanzania, East AfricanMedical Journal, 1995; 72: 345-348.14. Namgay S, Ranabir P, Subhabrata S.,Behaviour disparities toward blood donationin Sikkim, India, Asian Journal of TransfusionScience, 2008; 2: 56-60.15. Sanchez AM, Ameti DI, Schreiber GB, et al.The potential impact of incentives on futureblood donor behaviour, Transfusion Journal,2001; 41: 172-178.16. Burnett JJ., Examining the profiles of thedonor and non donor through a multiplediscriminated approach, Transfusion Journal,1982; 22: 138-142.17. Federal Ministry of Health in Nigeria. FederalMinistry of Health, Policy on blood donation.Nigeria: Federal Government of Nigeria Press,Abuja, Nigeria, 2007.18. Okpara RA., Attitudes of Nigerians towardsblood donation and blood transfusion,Tropical and Geographical Medicine, 1989;41: 89-93.19. Ottong JG, Asuquo EE, Olaniran NS, et al.Community mobilization for blood donationin Cross-River state, Nigeria, InternationalJournal of Gynaecology and Obstetrics, 1997;59: 119-125.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 118

Gunvanti B. Rathod et alCOMPARISON REGARDING KNOWLEDGE, ATTITUDE AND PRACTICE OF BLOOD DONATIONBETWEEN HEALTH PROFESSIONALS AND GENERAL POPULATIONTable 1: Details of the demographics of respondents.Variables Frequency (%)Age (years)50 16 10.67Total 150 100GenderFemale 57 38Male 93 62ReligionHindu 94 62.67Islam 37 24.67Christianity 19 12.67OverallscoreTable 2: Overall score comparison of the respondentsDoctors Nurses Technicians General populationFrequency % Frequency % Frequency % Frequency %Good 17 68 10 40 08 32 18 24Fair 08 32 11 44 10 40 15 20Poor 00 00 04 16 07 28 42 56Total 25 100 25 100 25 100 75 100Table 3: Knowledge of respondents on blood donationVariables Frequency %What is blood donation?Good 68 45.33Fair 39 26Poor 43 28.67Any health problem after blood donation?Yes 41 27.33No 109 72.67Indications for blood transfusion?Good 70 46.67Fair 18 12Poor 62 41.33Can females donate blood?Yes 98 65.33No 52 34.67Would you donate blood voluntarily?Yes 112 74.67No 38 25.33Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 119

Gunvanti B. Rathod et alCOMPARISON REGARDING KNOWLEDGE, ATTITUDE AND PRACTICE OF BLOOD DONATIONBETWEEN HEALTH PROFESSIONALS AND GENERAL POPULATIONTable 4: Blood donation practice among the respondents.Variables Frequency %Ever donated blood?Yes 56 37.33No 94 62.67Total 150 100Ever donated blood?(by gender) (N=56)Male 48 85.71Female 08 14.29Types of blood donationVoluntarily 11 7.33Non voluntarily 45 30Non donor 94 62.67Reasons for blood donation (N=56)Emergency 17 30.36Replacement 28 50Organizationactivity07 12.5Free will 04 7.14Reasons for non-donation (N=94)No opportunity 25 26.59No knowledge 09 9.58Fear 14 14.89Other reasons 17 18.08Unfit 29 30.86Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 120

Pushpalatha M. et alACCESSORY SPLEEN – A CASE REPORTACCESSORY SPLEEN – A CASE REPORTIJCRRVol 04 issue 21Section: HealthcareCategory: Case ReportReceived on: 17/09/12Revised on:28/09/12Accepted on:05/10/12Pushpalatha M., Sujana M., Sharmada K.LDepartment of Anatomy, Bangalore Medical College and Research Institute,Bangalore, IndiaE-mail of Corresponding Author: mpushpalatha145@gmail.comABSTRACTAccessory spleen is a common congenital anomaly. There are currently no endoscopic ultrasoundcriteria for the diagnosis or differentiation of this benign splenic anomaly from pathologic disordersincluding neoplasms. Accessory spleen and splenic lobulation can be misinterpreted as neoplasm byendoscopic ultrasound. Although homogenous, they can be hyperechoic or hypoechoic [1]. Accessoryspleen has been known to rupture [2].Keywords: Endoscopic ultrasound, neoplasms, pathologic disorders.INTRODUCTIONAn accessory spleen is a small nodule of splenictissue found apart from the main body of thespleen. Accessory spleens are found inapproximately 10% of the population [3]. They aretypically around 1 centimeter in diameter. Theyform either by the result of developmentalanomalies or trauma. They may result ininterpretation errors in diagnostic imaging [4]. Themost common locations for accessory spleens arethe hilum of the spleen and adjacent to the tail ofthe pancreas. They may be found anywhere alongthe splenic vessels, in the gastrosplenic ligament,the splenorenal ligament, the walls of the stomachor intestine, the pancreatic tail [5], the greateromentum, the mesentry or the gonads and theirpath of descent [6].Case reportDuring routine dissection for 1 st year medicalundergraduate students in Anatomy Department inBMCRI. During the routine dissection of stomachand its relations along the greater curvature in thegreater omentum a splenic tissue about 3cm indiameter was oval in shape. It was 7cm distal tothe cardiac end of the stomach. It was receivingthe blood supply from small branches arising fromthe left Gastro epiploic artery. Spleen was normalin its position and gastrosplenic ligament waspresent.Fig: 1DISCUSSIONAnatomy text books tend to mention theinfrequent presence of accessory spleens as ananatomic fact devoid of pathological significance.The Accessory spleen is an anomaly which is dueto development abnormalities in the embryo [7].Ten patients with the mean age of 58 years wereevaluated 9 for pancreaticobiliary disease and 1Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 121

Pushpalatha M. et alACCESSORY SPLEEN – A CASE REPORTfor gastric sub mucosal mass of which 8 had anaccessory spleen [1].The developing spleen formsnear the urogenital ridge from which the gonadsdevelop. The gonads may pick up some tissuefrom the spleen and as they descend through theabdomen they can produce either a continuous or abroken line of deposited splenic tissue [6].The typical size is approximately 1 centimeter, butsizes ranging from a few millimeters up to 2-3 cmare not uncommon [6].Fig: 2CONCLUSIONThus the presence of accessory spleen is rarefindings providing knowledge for surgeons andradiologists. They are medically significant in thatthey may result in interpretation errors indiagnostic imaging [4]. It may lead to continuedsymptoms after therapeutic splenectomy [3].REFERENCES1. Barawi M, Bekal P, Gress F. Division ofGastroenterology and Hepatology, Winthrop-University Hospital, State University of NewYork at Stony Brook, Mineola, New York11501, USA. 2000 Dec;52(6):769-72.2. Kumar, R.: A Case of Traumatic Rupture ofan Accessory Spleen, Arch Dis Child. 1962Apiril;37:227.3. Moore, Keith L. Clinically Oriented Anatomy3 rd ed. Baltimore: Williams &Wilkins.1992;p.187.4. Grayer G; Zissin R, Apter S, Atar E, PortnoyO, Itzchak Y. CT findings in congenitalanomalies of the spleen. British Journal ofRadiology. 2001 Aug;74(884):767-772.5. Kin SH; Lee JM, Hun JK, Lee JY, Kim KW,Cho KC, Choi BI. “Intrapancreatic AccessorySpleen: Findings on MR Imaging, CT, US andScintigraphy, and the Pathologic Analysis”.Korean J Radiology. 2008 Apirl;9(2):162-174.6. Chen S-L; Kao Y-L, Sun H-S, Lin W-L.Splenogonadal Fusion. Journal of theFormosan Medical Association. 2008Nov;107(11):892-5.7. Settle, E.B.: The Surgical Importance ofAccessory Spleens, Amer J Surg. 1940Oct;50:22-26.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 122

Al- G. Mohammed et alOXIDATIVE STRESS AND ANTIOXIDANT ENZYME STATUS IN PATIENTS WITH TYPE 2DIABETES MELLITUS WITH AND WITHOUT CORONARY ARTERY DISEASEIJCRRVol 04 issue 21Section: HealthcareCategory: ResearchReceived on: 10/09/12Revised on:17/09/12Accepted on:23/09/12OXIDATIVE STRESS AND ANTIOXIDANT ENZYME STATUSIN PATIENTS WITH TYPE 2 DIABETES MELLITUS WITHAND WITHOUT CORONARY ARTERY DISEASEAl- Ghonaim Mohammed I., Ramprasad N., Abdel-Ghaffar Mamdouh H.Medical Laboratory Science Department, College of Applied Medical Sciences,Shaqra University, Al- Quwayiyah, Kingdom of Saudi ArabiaE-mail of Corresponding Author: ramprasad4u7@gmail.comABSTRACTBackground: Diabetes Mellitus (DM) is the most common disorder characterized by metabolicabnormalities and long term complications. Patients with type 2 diabetes mellitus are more prone toCoronary Artery Disease (CAD). Although oxygen free radicals are known to contribute to thedevelopment of CAD and diabetes. Oxidative stress occurs as a result of increased level of lipidperoxides and free radical intermediates, as well as the decreased in total antioxidant capacity.Aim: In the present study, our aim was to investigate the lipid peroxidation, lipid profile andantioxidant enzymes in diabetic patients with and without CAD. Materials and Methods: The studywas carried out in 62 patients suffering from diabetics, 59 patients suffering from diabetes with CADand 78 healthy controls were randomly selected. Various parameters like serum lipid profile,Malondialdehyde used as an index of oxidative stress, antioxidant enzymes like Glutathione peroxidase(GPx), Superoxide dismutase (SOD), and Paraoxonase (PON) were measured and compared. Results:Increased levels of MDA concentration, total cholesterol, triglycerides, LDL-cholesterol, whiledecreased levels of HDL- cholesterol, GPx, SOD and PON were significantly low (p

Al- G. Mohammed et alOXIDATIVE STRESS AND ANTIOXIDANT ENZYME STATUS IN PATIENTS WITH TYPE 2DIABETES MELLITUS WITH AND WITHOUT CORONARY ARTERY DISEASEdevelopment of atherosclerosis is closelyassociated with risk factors such as hypertension(HTN), obesity; smoking, dyslipidemia andmainly diabetes have been identified [4].Oxidative stress is defined as the interruption ofbalance between oxidants and reductants withinthe body due to the excess production of peroxidesand free radicals. This imbalance will causedamage to cellular components and tissues in thebody leading to oxidative stress and as well as thedecrease in total antioxidant capacity [5].Hyperglycemia, a hallmark of diabetic depletesnatural antioxidant and facilitates the productionof reactive oxygen species (ROS) which has theability to react with all biological molecules likelipids, proteins, carbohydrates, DNA etc and exertcytotoxic effects on cellular components. Thus asincreased ROS and impaired antioxidant defensecontribute for the initiation and progression ofmicro and macro vascular complications indiabetes [6].DM is characterized by hyperglycemia togetherwith biochemical alternations of glucose and lipidperoxidation. Lipid peroxidation is a free radicalrelated process, which is potentially harmfulbecause its uncontrolled, self-enhancing processcauses disruption of membranes, lipids and othercell components. A lot of oxygenated compounds,particularly aldehydes such as Malondialdehyde(MDA) are produced during the attack of freeradicals to membranes, lipoprotein andpolyunsaturated fatty acids [7]. Thus lipidperoxidation in the blood provides usefulinformation for the prognosis of diabetes in whichsecondary disorders are often fatal.Serum Paraoxonase (PON) synthesized in the liverand it is High density lipoprotein cholesterol(HDL-C) associated enzyme that preventsoxidative modification of Low density lipoproteincholesterol (LDL-C). Serum PON is responsiblefor the antioxidant activity of HDL- C [8].Sufficient levels of antioxidants are important tolive with healthy condition for human beings andmost important for the prevention of chronicdiseases such as cancer, diabetes and CAD. Lowplasma levels of antioxidant as well as low intakeof dietary antioxidants have been associated withan increased risk of atherosclerotic heart disease[9]. Enzymatic Glutathione peroxidase (GPx),Superoxide Dismutase (SOD) and PON play animportant role in alleviating tissue damage due toformation of free radicals. Morever, the bodydefense mechanism would play an important rolein the form of antioxidants and try to minimize thedamage adapting itself to the above stressfulsituation.Hence a systemic approach has been made in thepresent study to focus on the Diabetes andCoronary artery disease. Oxidative stress wasmeasured by the serum levels of MDA, which iswidely used as an index of the extent of oxidativedamage, stress related enzymes such as GPx, SODand PON were measured and compared in type 2diabetic subjects with and without CoronaryArtery Disease along with normal healthysubjects.MATERIALS AND METHODSThe study was case controlled in design. We haveselected the patients as they are presented. Thestudy was only male oriented. Patients included inthe present study were all admitted to the medicineunit or attending the Out Patient Department(OPD) of medicine and some patients wereadmitted to the intensive coronary care unit(ICCU) of Al- Quwayiyah Government GeneralHospitals, Shaqra University, Kingdom of SaudiArabia, during the period from October 2011 toAugust 2012 were included in the study.Consecutive 121 patients with type 2 diabetesmellitus, admitted to hospital were selected for thestudy and they were between 40- 65 years. Theywere further classified into two groups. 62 patientswere diabetes mellitus without CAD and anothergroup of 59 patients were diabetes mellitus withCAD. The criteria for the diagnosis of type 2diabetes was fasting blood glucose >126.0 mg/dl[10] and glycated hemoglobin (HbA1c) 6.2% [11].Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 124

Al- G. Mohammed et alOXIDATIVE STRESS AND ANTIOXIDANT ENZYME STATUS IN PATIENTS WITH TYPE 2DIABETES MELLITUS WITH AND WITHOUT CORONARY ARTERY DISEASEThe criteria for the diagnosis of CAD was madeon the basis of clinical history, history ofmyocardial infarction, 12 leads electrocardiogram(ECG) and coronary angiography findings.Smoking was defined as regular smoking ofcigarettes / Beedies (a local type of tobacco).Those patients whose body mass index (BMI) >25were considered as obese. Controls had 78 healthyage matched, non diabetes, non myocardialinfarction, non smoking and non alcoholic healthyindividuals.All diabetic patients selected for this study wereon irregular treatment for diabetics and none of thestudy subjects was an antioxidant supplementationor lipid lowering drugs. Subjects suffering fromrenal, hepatic disease and any chronic or acuteinflammatory illness were excluded from thestudy.All participants gave written informed consent andthis protocol was approved by the ethical andhuman research committee of College of AppliedMedical Sciences, Shaqra University, Al-Quwayiyah, Kingdom of Saudi Arabia.Fasting venous blood samples were collected fromall the study subjects after an overnight fast.Fasting glucose levels were estimated byenzymatic methods [12]. Glycemic control wasassessed by measuring glycated hemoglobin by theresin-ion exchange method [13]. The lipid profilewas done by fully auto analyzer (ERBA-XL-300).The concentration of serum Cholesterol wasestimated by CHOD- PAP method [14],Triglycerides level was estimated by GPO(trinder) method [15], while HDL-C estimationwas done by Phosphotungestic method [16] andLDL-C levels were estimated by enzymaticmethods [17]. Serum levels of MDA, a marker oflipid peroxidation were measured by thiobarbutricacid (TBA) method [18]. The haemolysateprepared from the red cells was used for theestimation of antioxidant enzyme activities. GPxwas measured by the method of Paglia andValentine [19]. SOD estimation was based on thereaction between superoxide radicals and 2-4-iodophenyl 3-4- nitrophenol- 5-phenyl tetrazoliumchloride to form a red formazon dye [20]. PONactivity was estimated by using 5.5 Mm p-nitrophenyl acetate (sigma chemicals Co.,) as asubstrate. The change in the absorbance at 412 nmdue to the formation of p- nitro phenol wasmeasured by using ELICO spectrometer [21].STATISTICAL ANALYSISAll values are expressed as mean ±SD. Student t-test was used to estimate the significant differencebetween the groups. Pearson’s correlation analysiswas used to test the correlation between variousparameters and considered significant whenp

Al- G. Mohammed et alOXIDATIVE STRESS AND ANTIOXIDANT ENZYME STATUS IN PATIENTS WITH TYPE 2DIABETES MELLITUS WITH AND WITHOUT CORONARY ARTERY DISEASEpositively correlated with HbA1c levels indiabetics without CAD and diabetics with CAD asshown in Table IV.DISCUSSIONType 2 (Non-Insulin-Dependent) Diabetes isassociated with a marked increase in the risk ofcoronary heart disease. It has been debatedwhether patients with diabetes who have not hadmyocardial infarctions should be treated asaggressively for cardiovascular risk factors aspatients who have had myocardial infarctions[22].Although it has been apparent for some time thatcoronary heart disease (CHD) is the major causeof morbidity and mortality in patients with type 2diabetes. Framingham study demonstrated a directassociation between diabetes and heart failure[23]. CAD occurs due to a number of factors indiabetics; both insulin resistance and elevated lipidlevels, common in diabetics primarily triggersatherogenic injury. It is also suggested thatendothelium in diabetic arteries is more prone toatherogenic injury due to decreased production ofendothelial nitric oxide, known to beantiatherogenic, and increased production ofplasminogen activator inhibitor [24].Tobacco Smoking is one of the most powerfulmodifiable risk factor for the development of CADand diabetes patients [25]. Our data showed thatprevalence of smoking was significantly higher indiabetes with CAD patients as compared tocontrols. Like other studies [26, 27] in our studyalso, hypertension and obesity was found to besignificantly high in diabetic patients and furtherincreased in diabetic with CAD patients.Atherosclerosis is a process for which there issubstantial evidence of a role for oxidative stress.Hypercholesterolemia and triglyceridemia areindependent risk factor that alone or together canaccelerate the development of CAD andprogression of atherosclerotic lesions. HDL maybe protective by reversing cholesterol transport,inhibiting the oxidation of LDL and byneutralizing the atherogenic effects of oxidizedLDL [28].MDA is a natural product of lipid peroxidation andreflects the oxidant status of the biologicalsystems. It has been demonstrated that high MDAlevels are associated with high oxidative stress indiabetes mellitus and CAD [29]. Several authorshave reported increased levels of lipidperoxidation in diabetic patients [30, 31] while afew could not find any significant increase in lipidperoxidation in diabetes [32, 33]. Few authorshave reported increased levels of MDA in CADpatients [6, 34]. In our study also, increased levelsof MDA in diabetic patients and further increasedin diabetic with CAD patients compared tocontrols, because at a time two diseases have a stillgreater degree of oxidative stress.Earlier studies on the relationship between thelipid peroxides and glycemic controls have yieldedconflicting results. Kesavulu et al [35] and Losadaet al [36] have shown a positive correlationbetween MDA and the measure of blood glucosecontrol such as HbA1c, while several authorscould not [37]. Similarly, positive correlationbetween the MDA concentrations versus HbA1clevels was observed in the present study. Theestimation of lipid peroxidation in the diabetes andCAD patients is very useful as it may serve as auseful monitor to judge the prognosis of thepatients.Free radicals scavenging enzymes such as GPxand SOD are the first line of cellular defenseagainst oxidative injury, which are involved in thedisposal of superoxide anions and hydrogenperoxide [28]. One of the most importantantioxidant enzymes found in the humans is GPx;it protects the cell damage by catalyzing thereduction of lipid hydroperoxides and also protectsthe heart from damage by oxidative stress due tooxygen free radicals through its antioxidant effect[38]. A few authors have reported increased GPxactivity in the RBC of type 2 diabetes [39]. Incontrast, some reports have described a decreasedactivity of erythrocyte GPx in diabetic patientsInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 126

Al- G. Mohammed et alOXIDATIVE STRESS AND ANTIOXIDANT ENZYME STATUS IN PATIENTS WITH TYPE 2DIABETES MELLITUS WITH AND WITHOUT CORONARY ARTERY DISEASE[35] and CAD patients [40]. Similarly in thepresent study also, it was found significantlydecreased activity of GPx in diabetic patients dueto decreased activity of glucose-6- phosphatedehydrogenase in erythrocytes [28]. Howeverhypercholesterolemia is also one of the reasons forthe decreased GPx activity in CAD patients. Sowe have observed further decreases in diabeticwith CAD patients. Another one of the importantantioxidant enzymes present in human body isSOD. Some studies reported reduced levels ofSOD activity in diabetes [41] and Suresh Chari etal [42] says decrease in the activity of SOD inCAD patients. On the other hand jain et al [43]reported on increased levels of SOD in diabetesand MM Kesavulu et al [44] revealed that there isno change in the activity SOD in CAD patients,but Sree hari babu et al [45] says decreased levelsof SOD activity in diabetic patients, Whereas inthe present study decreased activity of erythrocyteSOD was observed in diabetic without CADpatients and further decreased in diabetic withCAD patients because of superoxide is the mainreactive oxygen species which react with nitricoxide radical and forms peroxynitrite therebycausing oxidative stress, cellular damage and alsoincreased levels of lipid peroxidation andconjugated dienes [46]. This would seemunexpected because in a disease with elevatedoxidative compounds, a compensatory increase inantioxidant enzymes would be desirable.It was tested whether there was a correlationbetween HbA1c levels and SOD, GPx activity andour results showed a significant negativecorrelation between HbA1c versus GPx and SODlevels, which suggest that the enzymes could beglycated. Similarly Faure et al [47] and Nath et al[48] revealed that there was a significant negativecorrelation between HbA1c versus SOD and GPxlevel.In recent studies, reduced serum PON activity hasbeen reported to be associated with increased riskof insulin resistance [49]. Mackness et al [21] andLeviev et al [50] reported the PON activity wassignificantly lowered in patients with diabetesmellitus and CAD. Lower serum PON activity hasbeen associated with increased susceptibility toatherosclerosis, neuropathy, retinopathy and othercomplications in diabetic population comparedwith healthy controls. In the present study also, adecreased PON activity was observed in diabetesand this further decreased in diabetes with CADpatients. Thus there was a significant negativecorrelation between HbA1c and serum PONactivity.There were some limitations in the present study,sample size was small and it was a hospital basedstudy, so can’t represent whole population. Thereis need to perform such studies on larger andcommunity based population.CONCLUSIONIt is very clear from this study that there areabnormalities in lipid profile, lipid peroxide levelsand antioxidant enzymes in diabetic patients withand without CAD. We hypothesized that reducedantioxidant enzyme activities and increased MDAlevels may contribute to the increasedsusceptibility for the development of insulinresistance and CAD in patients with NIDDM. Thepresent study illustrates that reduced consumptionof alcohol, smoking, animal saturated fat andincreased consumption of n-3 fatty acids, intake offruits and vegetables, tree nuts, natural ofantioxidants, supplementation of trace elements,physical activity and maintenance of healthy bodyweight and secondary measures like control ofhyperglycemia and HTN are the measures tomitigate the devastating consequences of diabeteswhich further may lead to cardiovascular diseases.Thus, further investigations of therapeuticstrategies to prevent or delay the progression ofdiabetic cardiovascular complications are needed.ACKNOWLEDGEMENTWe thank the Deanship of Scientific Research,College of Applied Medical Sciences, Al-Quwayiyah, Shaqra University, Kingdom of SaudiInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 127

Al- G. Mohammed et alOXIDATIVE STRESS AND ANTIOXIDANT ENZYME STATUS IN PATIENTS WITH TYPE 2DIABETES MELLITUS WITH AND WITHOUT CORONARY ARTERY DISEASEArabia. Authors acknowledge the immense helpreceived from the scholars whose articles are citedand included in references of this manuscript. Theauthors are also grateful to authors / editors /publishers of all those articles, journals and booksfrom where the literature for this article has beenreviewed and discussed.REFERENCES1. King H, Aubert RE and Herman WH. Globalburden of diabetes, 1995-2025. Prevalence,numerical estimates and projection. Diabetescare 1988; 21: 1414- 1431.2. Taylor SI. Deconstructing type 2 diabetes.Cell 1999; 97: 9- 12.3. Srikrushna Mahaptra, Kashinath Padiary,Trinath Kumar Mishra, et al. Study on BodyMass Index, Lipid Profile and LipidPeroxidation status in Coronary ArteryDisease. J Indian Med Assoc 1998; 96: 2: 40 -42.4. Enrique Z Fisman, Alexander Tenenbaum. Acardiologic approach to Non- insulinantidiabetic Pharmacotherapy in patients withheart disease. Cardiovascular Diabetology2009; 10: 1186: 1475- 2840- 8- 38.5. L. E. Pavlova, V. M. Savov, H. G. Petkov, andI. P. Charova. Oxidative stress in patients withBeta Thalassemia major. Prilozi 2007; 28: 1:145- 154.6. Shivaprakash T.M, Purnima Dey Sarkar,Tripti Sharma, Ramprasad. N and R.Maheshwari. Oxidative Stress andParaoxonase status for Coronary ArteryDisease in NIDDM patients. BiomedicalResearch 2007; 18: 2: 19- 23.7. Mahbood, M .F and Rahman P.G. Serum lipidPeroxidation and antioxidant enzyme levels inmale and female diabetic subjects. SingaporeMed J 2005; 46: 322- 324.8. Ikeda Y, Suehiro T, Nakauchi Y, Morita T andArii K. Serum PON activity and itsrelationship to diabetic complications inpatients with non insulin dependent diabetesmellitus. Metab 1998; 47: 598- 602.9. MS Van der Gaag, R Van den Berg, H Vanden berg et al. Moderate consumption of Beer,red wine and spirits has counteracting effectson plasma antioxidants in middle- aged men.Eur of Clin Nutrition 2000; 54: 586- 591.10. Trinder P. Blood sugar estimation by GOD-POD method. Ann Clin Biochem 1969; 6: 24-27.11. Trivelli, LIA.et al Glycosylated Hemoglobinestimation by Ion Exchange Resin Method.New Eng J Med 1971; 284:353.12. Hayvarinen, A. and Nikkila, E. Specificdetermination of blood glucose with orthotoluidine.Clin Chim Acta 1962; 7:140- 143.13. Eross, J., Kreutzmann, D., Jimenez, M., Keen,R., Rogers, S., Colwell .C et al. Colorimetricmeasurement of Glycosylated protein in wholeblood red cells, plasma and dried blood. AnnClin Biochem 1984; 21: 519-522.14. Richmond W. Preparation and properties ofcholesterol oxides from nocardia sp. and itsapplication to the enzymatic assay of totalcholesterol in serum. Clin Chem 1973;19:1350-6.15. McGowan MW, Artiss JD, Strandbergh DR,Zak B. A peroxidase-coupled method for thecolorimetric determination of serumtriglycerides. Clin Chem 1983; 29: 538-42.16. Rifal N, Warnick GR editors. Laboratorymeasurement of lipids, lipoproteins andapolipoproteins. Washington DC: AmericanAssociation of Clinical Chemistry (AACC)press; 1994 p. 21 – 42.17. Pissani T, Gebski CP, Leary ET, et al.Accurate direct determination of low densitylipoprotein cholesterol using an immuneseparation reagent and enzymatic cholesterolassay. Arch Pathol Lab Med 1995; 119: 1127-1135.18. Yagi K. Lipid peroxides and Human diseases.Chem Phys lipids 1987; 45: 337-351.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 128

Al- G. Mohammed et alOXIDATIVE STRESS AND ANTIOXIDANT ENZYME STATUS IN PATIENTS WITH TYPE 2DIABETES MELLITUS WITH AND WITHOUT CORONARY ARTERY DISEASE19. Paglia DE, Valentine WN. Studies in thequalitative and quantitative characterization oferythrocytic glutathione peroxidase. J LabClin Med 1967; 70: 158- 169.20. Arthur JR, Boyne R. Superoxide dismutaseand glutathione activities in neutrophils fromselenium deficient and copper deficient cattle.Life sciences 1985; 36: 1569- 1575.21. Mackness MJ, Harty D, Bhatnagar D,Winocour PH and Arrol S. Serum PONactivity in familiar hypercholesterolemia andinsulin dependent Diabetes mellitus.Atherosclerosis 1991; 86: 193- 198.22. Steven. M. Haffner, M.D SeppoLehto, M. D.,et al. Mortality from Coronary Heart diseasein subjects with and Type 2 diabetes and innon diabetic subjects with and without priorMyocardial infraction. N Eng J Med 1998;339: 229- 234.23. Saxena KK. Congestive Heart Failure inDiabetes. Cardiology Today 2002; 2: 71- 76.24. Purnima dey Sarkar, Shivaprakash. T. M, B.Madhusudhan. Association between PONactivity and Lipid levels in patients withpremature coronary artery disease. ClinicaChimica Acta 2006; 373: 1:2: 77- 81.25. Pias P, Pogue J, Gstein H et al. Risk factorsfor AMI in Indians: a case- control study.Lancet 1996; 348: 358- 363.26. Chen L, Chester M, Kaski JC. Clinical factorsand angiographic features associated withpremature coronary artery disease. Chest1995; 108: 364- 49.27. Zimmerman FH, Cameron A, Fisher LD.Myocardial infraction in young adults:angiographic characterization, risk factors andprognosis. J Am Coll Cardiol 1995; 26: 654-61.28. K. Kaviarasan, M.M. Arjunan, K.V.Pugalendi. Lipid Profile, oxidant- antioxidantstatus and glycoprotein components inhyperlipidemic patients with/ without diabetes.Clin Chim Acta 2005; 362: 49- 56.29. Jung HH, Choi DH, Lee SH. SerumMalondialdehyde and Coronary artery diseasein hemodialysis patients. Am J Nephrol 2004;24: 537- 542.30. Mooradian AD. Increased serum conjugateddienes in elderly diabetic patients. J AmGeriatric Soc 1991; 39: 571- 574.31. Griesmacher A, Kindhauser M, Andert SE,Schrenier W, Toma C, et al. Enhanced serumlevels of thiobarbituric acid reactivesubstances in diabetic mellitus. Am J Med1995; 98: 469- 475.32. Velazquez E, Winocour PH, Kesteven P,Alberti KG and Laker MF. Relation of lipidperoxides to macrovascular disease in type 2diabetes. Diabet Med 1991; 8: 752- 758.33. Sklodowska M, Gromadzinska J andWasowicz W. Lipid peroxidationconcentration, selenium level and glutathioneperoxidase activity in blood of type 2 diabeticelderly people. J Clin Biochem Nutr 1989; 7:35- 41.34. Sharma Anitha, Sharma Ashish, AgarwalApurva. Correlation of Homocysteine withMDA and Lipid parameters in CAD patients.IJCRR 2012; 4: 14: 44- 48.35. Kesavulu MM, Giri R, kameshwara Rao B andApparao C. H. Lipid peroxidation andantioxidant enzyme levels in type 2 diabeticswith microvascular complications. Diab Metab2000; 26: 387- 392.36. Losada M and Alio JL. Malondialdehydeserum concentration in type 1 diabetes withand without retinopathy. Doc Opthalmol1996- 97; 93:223- 229.37. Freitas JP, Filipe PM, and Rodrigo FG. Lipidperoxidation in type 2 normo lipdemicdiabetic patients. Diabet Res Clin Prac 1997;36: 71- 75.38. Q. Shazia, Z H Mohammad, Taibur Rahman,and Hossain Uddin Shekar. Correlation ofoxidative stress with Serum Trace ElementLevels and Antioxidant Enzyme Status in BetaThalassemia major patients: A Review of theInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 129

Al- G. Mohammed et alOXIDATIVE STRESS AND ANTIOXIDANT ENZYME STATUS IN PATIENTS WITH TYPE 2DIABETES MELLITUS WITH AND WITHOUT CORONARY ARTERY DISEASELiterature. Anemia 2012; Hindawi PublishingCorporation: Article ID 270923: 7 pages: doi:10.1155/ 2012/ 270923.39. Rema M, Mohan V, Bhaskar A, andShamugasundram KR. Does oxidative stressplay a role in diabetic retinopathy?. Ind JOpthalmol 1995; 43: 17- 21.40. Purnima Dey Sarkar, Ramprasad N, IndranilDey Sarkar, and Shivaprakash TM. Study ofoxidative stress and trace element levels inpatients with Alcoholic and Non AlcoholicCoronary Artery Disease. Indian J PhysiolPharmacol 2007; 51: 2: 141- 146.41. Vucic M, Gavella M, Bozikov V, Acroft SJand Rocic B. Superoxide dismutase activity inlymphocytes and polymorphonuclear cells ofdiabetic patients. Eur J Clin Chem Biochem1997; 35: 517- 521.42. Suresh Chari and Madhur Gupta. Proxidantand Antioxidant status in patients of type 2diabetes mellitus with IHD. Ind Jour ClinBiochem 2006; 21: 2: 118- 122.43. Jain AP, Mohan A, Gupta OP, Jajoo UN andKalantri. SP. Role of oxygen free radicals incausing endothelial damage in diabetesmellitus and its microvascular complications. JDiab Assoc India 1998; 38: 51- 54.44. MM Kesavulu, B Kameswara rao, R Giri, JVijaya, G Subramanyam, et al. Lipidperoxidation and antioxidant enzymes status intype 2 diabetics with Coronary Heart Disease.Diab Res and Clin Prac 2001; 53: 33- 39.45. B. Sree Hari Babu, D. Lakshmi Lalitha, P.KBehera, D.S.S.K Raju. Study of serumAdenosine deaminase as an effector ofoxidative stress in diabetes mellitus type 2.IJCRR 2012; 4: 16: 108- 115.46. S. Filiz, O. Gulyuz, K. Sabri, E. Deniz, and H.Alev. “Oxidant and Antioxidant status in betaThalassemia major patients”. Journal ofAnkara University faculty of Medicine 2005;58: 1: 34-38.47. Faure P, Benhamou PY, Petard A, Halini Sand Roussel AM. Lipid peroxidation in insulindependent diabetic patients with early retinadegenerative lesions: effects of an oral zincsupplementation. Eur J Clin Nutr 1995; 49:282- 288.48. Nath N, Chari and Rathi B. Superoxidedismutase in diabetic polymorphonuclear indiabetic polymorphonuclear leucocytes.Diabetes 1984; 33: 586- 589.49. Polat Dursun, Ezgi Demirtas, Ahmet Baayrakand Hakan Yarali. Decreased serumParaoxonase 1 activity: an additional riskfactor for atherosclerotic heart disease inpatients with PCOS?. Human Reproduction2006; 21: 104- 108.50. Leviev I, Kalix, Brulhart, Meynet MC, andJames RW. The PON 1 promoterpolymorphism C (-107) T is associated withincreased serum glucose concentration in nondiabetic patients. Diabetol 2001; 44: 1177-1183.Table 1. Clinical details of the study subjectsParticulars Controls(n=78)Mean ±SDDiabetes without CAD(n= 62)Mean ±SDDiabetes with CAD(n= 59)Mean ±SDAge (yrs) 47.6 ± 7.9 50.2 ± 12.3 53.8 ± 11.4 *BMI (kg/m 2 ) 22.7 ± 8.1 25.2 ± 3.5 28.0 ±4.2 *HTN % 7 % 59 % 70 % *Smokers % 9 % 62 % 72 % ** P

Al- G. Mohammed et alOXIDATIVE STRESS AND ANTIOXIDANT ENZYME STATUS IN PATIENTS WITH TYPE 2DIABETES MELLITUS WITH AND WITHOUT CORONARY ARTERY DISEASETable 2: Biochemical details of study subjectsParametersControls(n=78)Mean ±SDDiabetes withoutCAD(n= 62)Mean ±SDDiabeteswith CAD(n= 59)Mean ±SDFasting Blood Glucose (mg/dl) 90.3 ± 13.5 189.0 ± 17.9 * 223.0 ± 21.2*HbA1c % 5.1 ± 0.6 7.9 ± 0.8* 8.2 ± 0.7*Total Cholesterol (mg/dl) 146.0 ± 17.5 181.0 ± 18.4* 287.0 ± 28.1*Triglycerides (mg/ dl) 111.2 ±15.8 122.0 ±16.3* 230.0 ±22.2*HDL-C (mg/ dl) 50.1 ±5.0 46.0 ±5.3* 32.2 ±5.9*LDL-C (mg/ dl) 72.0 ±21.8 90.0 ±24.2* 192.0 ±30.2** P

Sanjay Kumar et alANTIEPILEPTICS AND PREGNANCY: A REVIEWANTIEPILEPTICS AND PREGNANCY: A REVIEWIJCRRVol 04 issue 21Section: HealthcareCategory: ReviewReceived on: 1/09/12Revised on:13/09/12Accepted on:25/09/12Sanjay Kumar 1 , Biswa Bhusan Mohanty 2 , Divya Agrawal 2 , Pramila Nayak 1 ,Shantilata Patnaik 1 , Jyotsna Patnaik 1 , Susanta Kumar Mahapatra 31 Dept. of Pharmacology, IMS and SUM Hospital, SOA University, Bhubaneswar, India2 Dept. of Anatomy, IMS and SUM Hospital, SOA University, Bhubaneswar, India3 Dept. of O and G, IMS and SUM Hospital, SOA University, Bhubaneswar, IndiaE-mail of Corresponding Author: dska27@yahoo.co.inABSTRACTEpilepsy in a pregnant woman is a serious and potentially life-threatening condition for both motherand child. Most pregnant women with epilepsy will need to take at least one antiepileptic drug. Thegoal for all concerned is a healthy, seizure-free mother and an undamaged child. However, epilepsy aswell as antiepileptic drugs cause some serious effect on the fetus. So, for epileptic women it isimportant to obtain appropriate information about possibility to have children and about risksconnected with their pregnancy. Every physician should be informed about risk to the fetus that isassociated with seizures and drugs used for treatment during pregnancy. Drugs used in girls and youngwomen should be chosen with the respect to the future reproduction, because the use of antiepilepticdrugs (AED) in women with epilepsy is in fact a balance between seizure control and adverse effects ofdrugs. The purpose of this review is to provide an update on management of Women with Epilepsy(WWE) prior to and during epilepsy.Keywords: Epilepsy, antiepileptic drugs, pregnancy, women with epilepsy (WWE)INTRODUCTIONEpilepsy is the tendency to have recurrentunprovoked seizures. It is universal, with no age,sex, geographical, social class or racialboundaries. Epilepsy imposes a large economicburden on health care systems of countries. Thereis also a hidden burden associated with stigma anddiscrimination against the patient and even his/herfamily in the community, workplace, school andhome. Many patients with epilepsy suffer severeemotional distress, behavioral disorders andextreme social isolation.Epilepsy is one of the most common chronicillnesses encountered by obstetricians, affectingaround 1 in 200 women attending antenatalclinics. Epilepsy itself is associated with a risk ofgiving birth to a malformed child around 25%higher than for pregnant women generally (inwhom the risk is 2-3%) and, for women withepilepsy who are taking anti-epileptic drugs, theincreased risk is around three-fold. The babies ofwomen with epilepsy (WWE) are also atincreased risk of neonatal problems, includinghemorrhagic disease of the newborn and„abstinence syndrome‟ In addition to these effectsof epilepsy and anti-epileptic medication on theprogress of pregnancy, the pregnancy may alsoinfluence the progress of epilepsy, with anincrease in seizure frequency in around a third ofwomen and altered metabolism of anti-epilepticdrugs. During pregnancy, the clinician faces thedual challenge of maintaining seizure control, yetminimizing teratogenic risk.What is epilepsy?Epilepsy can be defined as “the occurrence oftransient paroxysms of excessive or uncontrolleddischarges of neurons, which may be due to anumber of different causes leading to epilepticseizures”. The actual presentation ormanifestation differs among individuals,Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 132

Sanjay Kumar et alANTIEPILEPTICS AND PREGNANCY: A REVIEWdepending upon the location of the origin of theepileptic discharges in the brain and their spread.A person should only be diagnosed as having“epilepsy” if there are recurrent manifestations i.e.there should be at least two or more unprovokedsimilar episodes in 24 hours. Hence, the firstepisode of a seizure is called “single seizure” andnot epilepsy.Prevalence of epilepsyApproximately 50 million people are affected byepilepsy globally. About 40 million or 80% areassumed to live in developing countries. Multiplestudies worldwide indicate that the prevalence ofepilepsy globally is in the range of 5 to 8 per onethousand populations.Risk factors for epilepsyThere are well recognized risk factors for thedevelopment of epilepsy. Febrile seizure occur in2% to 4% of otherwise healthy children youngerthan age 5 years; however a history of a complexfebrile seizure or a neurodevelopmentalabnormality or a family history of epilepsy mayincrease the risk of developing epilepsy by 2% to4% (1) . A history of significant head trauma also isa risk factor. Studies of Vietnam War veteransshowed a risk of 50% after a penetrating headtrauma(2) . Head trauma with loss ofconsciousness, amnesia or a skull fractureincreases the 5 year risk to approximately 2%;however the risk is increased with severe headinjuries, with 12% of survivors developingepilepsy (3) . Vascular lesions are a significantcause of epilepsy.Epilepsy develops in 6% to 44% of individualswith arteriovenous malformations (4) . Cavernousmalformations commonly present as seizures (5)and cerebrovascular disease is the major cause ofepilepsy in elderly (6) . Brain tumours account forapproximately 4% of cases of epilepsy (1) andseizures is often the presenting feature of braintumours. CNS infections can also increase the riskof developing epilepsy, particularly in childrenand in elderly. The risk is further increased withcertain types of infection and if there aresymptomatic seizures early in the course ofinfection. For example, in patients with viralencephalitis and early seizures, the risk ofepilepsy is 10% by 5 years and 20% by 10 years(7) . Degenerative CNS diseases are associated withan increased risk of epilepsy. Alzheimer‟s diseaseincreases the risk by 10 fold and 10% of long termAlzheimer‟s disease survivors eventually developepilepsy (6) . Up to 5% of patients with multiplesclerosis develop epilepsy (8) . Mental retardation(MR) and cerebral palsy (CP) are important riskfactors for the development of epilepsy in childrenand young adults. Prematurity and birthcomplications are risk factors for both CP andMR, but pre or perinatal events themselves are notindependent risk factors for epilepsy whenchildren with CP or MR are excluded (9) . Finally,patients with a first degree relative with epilepsyhave a twofold to four fold risk of developingepilepsy (10) .Reproductive function and fertility in WWEIncreased rates of sexual dysfunction are reportedamong both men and WWE. This may arise fromboth neuroendocrine disturbances related toseizure activity, as well as the alteration ofendogenous sex steroid metabolism in thepresence of enzyme-inducing AEDs(11) .Hypothalamic amenorrhoaea, hyperprolactinemiaand premature menopause are over-representedamong WWE, thought partly because ofinterference with normal hypothalamic andpituitary function by tempero-limbic dischargescommonly involved in epilepsy (12) . An increase inanovulatory cycles and polycystic ovariansyndrome (PCOS) has also been observed inWWE (12, 13) . While this may partly relate todisturbance of the Hypothalamic-pituitary-adrenal(HPA) axis, AEDs may also play a role in this (13) .Enzyme-inducing (EI) AEDs increase serum sexhormone binding globulin (SHBG) levels,resulting in decreased levels of biologically activeestradiol and testosterone. In addition, valproicacid (VPA) is associated with an increased rate ofhyperandrogenism, ovulatory dysfunction andInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 133

Sanjay Kumar et alANTIEPILEPTICS AND PREGNANCY: A REVIEWPCOS, particularly among young (

Sanjay Kumar et alANTIEPILEPTICS AND PREGNANCY: A REVIEWmephenytoin in utero who had microcephaly, cleftpalate, a speech defect and an IQ of 60 (26) . Infantsof mothers with epilepsy after exposure to AEDsin utero are twice as likely to have birth defects asinfants not exposed to these drugs. Meador et alreported that the rate of total congenitalmalformations was significantly higher forpolytherapy (9.84%; 95% CI = 7.82, 11.87) thanfor monotherapy (5.3%; 95% CI = 3.51, 7.09) (27) .In addition to the direct effect of AEDs, there maybe contribution from toxic AED metabolites,reduced folate availability, hypoxic injuryassociated with seizures and geneticpredisposition(28) . Malformation rates in thegeneral population range from 2-3 %. Reports ofmalformation rates in various population ofexposed infants range from 1.25% to 11.5% (29- 36) .The precision of risk estimation with anyindividual AED is imperfect as there is a paucityof controlled data, and an uncertain impact ofpotential confounders, such as type of epilepsy,seizure frequency, and family history of birthdefects, socio-economic factors, nutrition andexposure to additional teratogens (37) .Valproic Acid (VPA) – Valproate has beenassociated with a distinctive pattern of anomaliescalled “Fetal Valproate Syndrome”. This involvespoor growth, small head circumference,characteristic facial features, heart defects, cleftlip/palate, and limb anomalies (particularly absentradius). A variety of developmental issues havealso been reported, including developmentaldelay, decreased IQ scores, hyperexcitability,behavior problems, autism spectrum disorders andneurological dysfunction. Numerous small studieshave suggested cognitive and languageimpairment and an increase in autistic spectrumdisorder in children who have been exposed toantiepileptic drugs in utero (38) . Recent reportssuggest that these problems may be highest inchildren who have been exposed to valproate.Valproate should therefore be avoided inreproductive women wherever possible. When itis unavoidable, the lowest effective dose shouldbe used. It should not exceed 1000 mg/day individed doses. Breastfeeding is consideredcompatible with valproate therapy. Valproateconcentrations in breastfed babies are low.Phenytoin - The primary site of action appears tobe the motor cortex where spread of seizureactivity is inhibited. It promotes sodium effluxfrom neurons and tends to stabilize the thresholdagainst hyperexcitability caused by excessivestimulation or environmental changes capable ofreducing membrane sodium gradient. Thisincludes the reduction of post tetanic potentiationat synapses. Loss of post tetanic potentiationprevents cortical seizure foci from detonatingadjacent cortical areas. Phenytoin reduces themaximal activity of brain stem centers responsiblefor the tonic phase of tonic-clonic (grand-mal)seizures. The use of phenytoin during pregnancyhas been associated with a 2-3 fold increased risk(6-15%) for malformations, including heartdefects, microcephaly and cleft lip and palate. Acharacteristic pattern of abnormalities, called“Fetal Hydantoin Syndrome”, has been reportedin about 10% of infants born to women who tookphenytoin during pregnancy. Features of thissyndrome include a unique facial appearance,abnormalities of fingers, toes and nails, growthdelay and developmental delay/disability. Also itproduces cardiac anomalies such as atrial septaldefects and ventricular septal defects.Diazepam - Diazepam is prescribed as atranquilizer, muscle relaxant, preoperativemedication, and as an adjunct to anticonvulsanttherapy. There is a no consistent pattern ofmalformations observed in infants exposed todiazepam. Some neonatal behavior problems havebeen noted in exposed infants.Phenobarbital - Chronic use of phenobarbitallate in pregnancy has been associated withtransient neonatal sedation or withdrawalsymptoms in infants. Features seen in theseinfants include hyperactivity, irritability andtremors. Perinatal or neonatal hemorrhage hasbeen observed occasionally in infants of womenInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 135

Sanjay Kumar et alANTIEPILEPTICS AND PREGNANCY: A REVIEWwho took phenobarbital late in pregnancy. Thishas been attributed to drug-induced suppression ofthe synthesis of vitamin K-dependent clottingfactors.Carbamazepine (CBZ) - The use ofcarbamazepine during pregnancy has beenassociated with an increased risk for spina bifidaof up to 1% (1/100), as compared to the generalpopulation risk of 1/1000. It is also associatedwith a unique facial appearance and theunderdevelopment of the fingers, toes, and nails.Similarly, malformations have been reported in6/248 (2.4%) of patients receiving oxcarbazepinein pregnancy (39) and 2/44 (4.5%) of patientsreceiving gabapentin (40) . Vigabatrin is associatedwith acquired visual field defects and its safety isnot established in pregnancy (41) . The cause of thisteratogenecity could be due to direct drug toxicity,drug-induced folate deficiency or geneticallydetermined lack of epoxide hydrolase or freeradicals(42) . The role of the hepatic mixedfunction oxidase system may be especiallyimportant in conferring teratogenic risk. However,systems such as epoxide hydrolase, glutathionereductase, hyperoxide dismutase and other toxinscavenging systems may be important modifiersthat lower the risk. Knowledge is alsoaccumulating on the interactions of AEDs withmolecular targets such as histone deacetylase andperoxisomes proliferator activator receptors thatmay play important roles in teratogenesis (43) .LamotrigineIt remains uncertain whether lamotrigine isassociated with an increased risk of facial clefting(44, 45, and 46) . However, The North AmericanPregnancy Register has reported that exposure tolamotrigine in the first trimester may cause anincreased risk of oral clefts (a rate of 8.9 per 1000,as compared to 0.37 per 1000 in the referencepopulation)(47) . Significant dose relatedteratogenesis with lamotrigine exceeding 200mg/day has been reported(48) . Lamotrigineclearance increases steadily through to 32 weeksof pregnancy. Plasma concentrations oflamotrigine fall early in pregnancy, so doseincrease may be necessary to control seizures. Atrough plasma lamotrigine concentration beforepregnancy, at the onset of the second trimester ofpregnancy and every two months duringpregnancy may help to guide any necessaryincrease in lamotrigine dose. Postpartum, thelamotrigine concentration rises within a few daysand prompt dose reduction may be required toprevent toxicity (49) .LevetiracetamThere have been small case series suggesting anincrease in low birth weight among infants ofWWE receiving Levetiracetam (50) . There appearsto be a substantial increase in clearance duringpregnancy and an associated fall of bloodconcentrations (51) . Although Levetiracetam issecreted into breast milk, recent data suggest thatthe neonatal concentrations are low.Neurocognitive defectsIn addition to structural malformations associatedwith AEDs, there has been increasing concernregarding the potential adverse effect of AEDs onfetal cognitive development. While structuralmalformation risk is essentially confined to thefirst trimester, cognitive effects of AEDs have thepotential to impact throughout gestation. Animalstudies suggest that these cognitive effects may bemediated by AED-induced neuronal apoptosis (52) .Several investigators have reported an increase in(53,educational requirements54) , poorerneuropsychological performance and reducedverbal IQ among children exposed prenatally toVPA (55) .AEDS and neural tube defectValproate and carbamazepine have beenindependently associated with the development ofneural tube defects (NTDs). NTDs are anomaliesof central nervous system and its membranesresulting from abnormal development of neuraltube. They are classified as either open defectslacking a covering of overlying skin, or closeddefects that are covered with skin. Robert andGuibaud (56) were the first to make the associationInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 136

Sanjay Kumar et alANTIEPILEPTICS AND PREGNANCY: A REVIEWbetween VPA and CBZ and the development ofNTDs. More recent studies have revealed anassociation between CBZ exposure in utero andNTDs (57, 58, and 59) . Other investigators haveidentified spinabifida aperta as the specific NTDassociated with VPA & CBZ exposure (60) .Pathophysiology of NTDsNTDs are uncommon malformations occurring in6/10,000 pregnancies. Spina bifida andanencephaly are the most commonly reportedNTD and affect nearly 2500 to 3000 births in theUnited States each year (61, 62) . The types of NTDassociated with AED exposure are primarilymyelomeningocele and anencephaly, which arethe result of abnormal neural tube closure betweenthe third and fourth week of gestational age. Inprevious thinking about NTDs, the fusion of theneural tube was visualized as a process in whichthe lateral edge met in the middle and fused bothrostrally and caudally. Recent studies havesuggested that there are multiple sites for neural(63, 64)tube closure and that different etiologiesmay result in different types of abnormality.There are four different sites along the neural tubewhere neurulation develops. The first ismidcervical. The second is at the cranial junctionof the prosencephalon and mesencephalon. Thethird is at the site of the stomodeum. This regionfuses in caudal direction only. VPA appears tohave species differential effects, being associatedwith spina bifida in humans and exencephaly inmice (65) .Management of anticonvulsant therapy inpregnancyWomen with epilepsy who are consideringpregnancy should be treated with the leastteratogenic but most efficacious antiepileptic drugfor their particular type of epilepsy at the lowesteffective dose. If a pregnant woman is maintainedon the same dose of an anticonvulsant throughoutpregnancy, total blood levels of the anticonvulsantwill tend to go down during the pregnancy due toa pregnancy related increase in hepatic and renalclearance of the drug and a pregnancy relatedincrease in the volume of distribution of the drug(this effect is least for carbamazepine) (66) . Thisdrop in total blood levels is partially counteractedby the fact that free (and, therefore, active) druglevels may increase due to a normal decrease inthe concentration of serum protein that occurs inpregnancy. Some of this reduction is related to thereduction in serum protein in pregnancy, meaningthat the total drug concentration is lower, but theunbound (active) concentration is stable. This isparticularly relevant for highly protein bounddrugs, such as VPA and phenytoin (67, 68) . As notedabove, a clinically significant reduction in plasmaconcentrations of both lamotrigine andoxcarbazepine occurs in pregnancy (69, 70) as wellas Levetiracetam (66, 67, and 68) . There is a paucity ofdata on the pharmacokinetics of the newer AEDs,such as gabapentin, topiramate and zonisamide(67) . Therefore, for any given total drug level thereis likely to be freer drug available duringpregnancy than there would be in a nonpregnantindividual. Because of the difficulty ininterpreting serum drug levels of anticonvulsantsduring pregnancy, it is advisable to check totalserum drug levels if available monthly in pregnantwomen and adjust their dose accordingly. It isbest to use the least number of drugs at the lowestdose possible to prevent seizures.In WWE, the goal of therapy is to maintainseizure control using the lowest effective AEDdose. The International League against Epilepsyposition paper recommends that drugconcentrations be determined during pregnancy(68) . It is recommended that – prior to pregnancy –an individual „therapeutic level‟ during a period ofoptimal seizure control should be determined,which can then serve as a „target level‟ forpregnancy (66, 68) . Among patients with goodcontrol, serum concentration should be performedeach trimester, but more frequent (for example,monthly) levels may be required in patients withcomplicated epilepsy, breakthrough seizures,significant side effects and those WWE requiringlamotrigine and oxcarbazepine where highlyInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 137

Sanjay Kumar et alANTIEPILEPTICS AND PREGNANCY: A REVIEWvariable and more clinically significantfluctuations in drug concentration have beenobserved (66, 68) .Can a woman breastfeed her baby if she istaking AEDs?All anticonvulsants are excreted in breast milk butlevels are exceedingly low and not a cause forconcern. Women are encouraged to feed in asecure position. Possible effects of anti-epilepticdrugs in breast milk include drowsiness andfeeding difficulties with the baby. These are morecommon with barbiturate anti-epileptic drugs.Other side-effects are rare.How a WWE be looked after in pregnancy?The risk of malformation in the baby caused byanti-epileptic drugs is highest during earlypregnancy, so counseling before pregnancy isessential. If anti-epileptic drugs are needed,normally the most effective single drug should begiven at the lowest possible dose that controls theseizures. To further minimize this risk, high dose(5 mg) folic acid is generally recommended for atleast 1 month preconceptually and throughout thefirst trimester (71) . Enzyme inducing AEDs andvalproate are known to interfere with folic acidmetabolism (72) and Kjaer et al. reported fewercongenital malformations in women taking AEDswith folic acid, compared to those not givenadditional supplementation (73) . Dansky et al (74)found significantly lower blood folateconcentration in WWE with abnormal pregnancyoutcomes. Treatment of mice with folic acid, withor without vitamins and amino acids, reducedmalformation rates and increased fetal weight andlength in mouse pups exposed to phenytoin inutero (75) . In the general population the utility offolate supplementation in reducing the risk forNTDs is clearly established. Whether risk will bereduced for WWE taking AEDs is unclear. Therecommended daily allowances of folate havebeen increased to 0.4mg/day for non-pregnantwomen, 0.6 mg/day for pregnant women and 0.5mg/day for lactating women. The increased folatecatabolism during pregnancy, coupled withvariation of requirements by individual womenhas led some to call for higher folatesupplementation on the order of 0.5-0.6 mg/day(76) . Women with epilepsy, like all women of childbearing age should take folate supplementationthe dosage recommended by Center for DiseaseControl and Prevention (CDC) but 0.4 mg/daymay not be high enough for many women who donot metabolize folate effectively (77) . Stoppinganti-epileptic treatment may be appropriate if theepilepsy produces a single type of seizure and thewoman has been free from seizures for theprevious 2 years and EEG and neurologicalexamination are normal. This must always bediscussed with the doctors who look after herepilepsy. Stopping anti-epileptic medications inpregnancy without medical advice can be veryharmful to the woman and her baby in the wombif severe seizures occur. All pregnant women withepilepsy should be offered detailed ultrasoundscanning for fetal abnormality. The use of enzymeinducing AEDs may induce fetal hepatic enzymeactivity culminating in vitamin K deficiency andincreased risk of neonatal bleeding and thatvitamin K should be administered to such womenin late pregnancy to minimize this risk (25) . Duringthe last month of pregnancy vitamin K 10 mg/dayby mouth is recommended for pregnant woman oncertain anti-epileptic therapies and in suchcircumstances it is usually recommended that thebaby should be given 1 mg vitamin Kintramuscularly or intravenously. Maternal oralvitamin K 1 , for example 10 mg/day for one monthprepartum, has been recommended when enzymeinducingantiepileptic drugs are prescribedbecause the drugs may potentially predispose thebaby to haemorrhagic disease of the newborn (78) .CONCLUSIONLabour and delivery is a relatively high risk timefor seizure recurrence. The reasons for this aremultifactorial including poor bioavailability andcompliance with AEDs, sleep deprivation, anxietyand hyperventilation in labour. All centersInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 138

Sanjay Kumar et alANTIEPILEPTICS AND PREGNANCY: A REVIEWdelivering obstetric care should therefore bemindful of the increased risk of seizure in labour,and manage WWE accordingly (25, 79, and 80) .Most AEDs are compatible with breast feeding.The optimal method of estimating drug exposureis to measure the milk drug concentration andmultiply it by the estimated daily intake.Typically, a value 10% of the weight-basedtherapeutic drug dose is considered safe. Theestimated levels for carbamazepine, phenytoinand VPA are 3–5% of therapeutic dose and areconsidered safe. Estimates for lamotrigine andLevetiracetam are approximately 10% andGabapentin approximately 12% (81, 82) . Duringtheir postnatal stay, WWE and all their maternitycare providers should be aware of the risk ofpostpartum seizures, particularly in the setting ofsleep deprivation. Ensuring such women getadequate sleep and attention to medicationcompliance is of the utmost importance. Althoughthe risk to the infant from maternal seizures isgenerally low, women with juvenile myoclonicepilepsy are a particular concern, since myoclonicjerks tend to be more frequent in the earlymorning, often around the time of infant waking(83) . To minimise the risk of harm if a seizureoccurs, changing or feeding the baby on the flooris recommended, the use of baby slings should beavoided, stair climbing should be minimisedwhere possible and bathing the baby should beavoided when alone(25,83) . The chances ofperinatal problems such as difficult labour,prematurity and low birth weight are a littlehigher in the case of pregnancies of women withepilepsy than in normal pregnancies. The risk ofjaundice during the neonatal period could also behigher in these children. Congenitalmalformations in newborns are sometimesassociated with pregnant women who have beentreated for epilepsy with anti epileptic drugs suchas phenobarbitol, valproic acid, phenytoin andcarbamazepine.ACKNOWLEDGEMENTAuthors acknowledge the immense help receivedfrom the scholars whose articles are cited andincluded in references of this manuscript. Theauthors are also grateful to authors / editors /publishers of all those articles, journals and booksfrom where the literature for this article has beenreviewed and discussed.REFERENCES1. Annegers JF, Hauser WA, Shirts SB, KurlandLT. factors prognostic of unprovoked seizuresafter febrile convulsions. N Eng J Med1987;316:493-82. Salazar A M, JabbariB, Vance SC, et al.epilepsy after penetrating head injury. I.Clinical correlates. A report of the VietnamHead Injury Study. Neurology 1985;35:1406-143. Annegers JF, Grabow JD, Groovers RV, et al.seizures after head trauma: a populationstudy. Neurology 1980;30: 683-94. Crawford PM, West CR, Chadwik DW, ShawMD. Arteriovenous malformation of thebrain; natural history in unoperated patients. JNeurol Neurosurg Psychiatry 1986;49: 1-105. Casazza M, Broggi G, Franzini A, et al.Cavernous angiomas and epileptic seizures:preoperative course and post operativeoutcome. Neurosurgery 1996;39: 26-326. Hauser WA, Annegers JF, Kurland LT.incidence of epilepsy and unprovokedseizures in Rochester, Minnesota: 1935-1984.Epilepsia 1993; 34:453-68.7. Annegers JF, Hauser WA, Beghi E, et al. therisk of unprovoked seizures after encephalitisand meningitis. Neurology 1988;27:729-338. Kinnunen E, Wikstrom J, prevalence andprognosis of epilepsy in patients with multiplesclerosis. Epilepsia 1986;27:729-339. Nelson KB, Ellenberg JH. Antecedents ofseizure disorders in early childhood. Am J DisChild 1986;140:1053-61Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 139

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Sanjay Kumar et alANTIEPILEPTICS AND PREGNANCY: A REVIEWand congenital malformations: correlationwith maternal plasma anticonvulsant levelsduring pregnancy. In : Janz D, Dam M,Richens A, Bossi L, Helge H, Schimdt D, eds.Epilepsy; pregnancy and the child. New York;Raven Press, 1982: 251-875. Zhu MX, Zhou SS. Reduction of teratogeniceffects of phenytoin by folic acid and amixture of folic acid, vitamins and aminoacids: a primary trial. Epilepsia 1989; 30:246-5176. Oakley GP, Folic acid preventable spinabifida and anencephaly. Bull World HealthOrgan 1998; 76 (suppl 2): 116-777. Centres for Disease Control and Prevention.Recommendations for the use of folic acid toreduce the number of cases of spina bifida andother neural tube defects. MMWR MorbMortal Wkly Rep 1992; 41 (RR-14): 1-778. Choulika S, Grabowski E, Holmes LB. Isantenatal vitamin K prophylaxis needed forpregnant women taking anticonvulsants? AmJ Obstet Gynecol 2004; 190:882-3.79. The Epilepsies: The Diagnosis andManagement of the Epilepsies in Adults andChildren in Primary and Secondary Care.Clinical guideline 20. October 2004.80. Robinson JN, Clearly-Goldman J.Management of epilepsy and pregnancy: anobstetrical perspective. Int Rev Neurobiol2008; 83:273– 82.81. Pennell PB, Gidal BE, Sabers A, Gordon J,Perucca E, for the international AEDpharmacology work group for the healthoutcomes in pregnancy and epilepsy forum.Pharmacology of antiepileptic drugs duringpregnancy and lactation. Epilepsy Behav2007; 11: 263–9.82. Ohman I, Vitols S, Tomson T.Pharmacokinetics of Gabapentin duringdelivery, in the neonatal period, and lactation:does a fetal accumulation occur duringpregnancy? Epilepsia 2005; 46:1621–4.83. Fox C, Betts T. How much risk does a womanwith active epilepsy pose to her newbornchild in the puerperium? A pilot study.Seizure 1999; 8:367–9.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 143

Shilpa Khandare et alCOMPARISON OF POST 24 HOURS EFFECT OF COOLING AND SUSTAINED PASSIVESTRETCHING AS TREATMENT TECHNIQUES FOR REDUCTION OF SPASTICITY INHEMIPLEGICS USING H-REFLEXIJCRRVol 04 issue 21Section: HealthcareCategory: ResearchReceived on: 06/09/12Revised on: 15/09/12Accepted on: 26/09/12COMPARISON OF POST 24 HOURS EFFECT OF COOLING ANDSUSTAINED PASSIVE STRETCHING AS TREATMENTTECHNIQUES FOR REDUCTION OF SPASTICITY INHEMIPLEGICS USING H-REFLEXShilpa Khandare, Tushar J. PalekarPadmashree Dr. D.Y. Patil College of Physiotherapy, Pimpri, Pune, M.S., IndiaE-mail of Corresponding Author: shil287@yahoo.co.inABSTRACTBackground: Studies have shown that alpha motor neurons ( MN) serving skeletal muscles arehyperexcitable in presence of spasticity and can be activated by inputs that would normally evoke aresponse. There is activation of gamma motor neurons (gMN) for the degree of MN activation thus toanalyze its effect on spasticity, H reflex is used. Various modalities are used to reduce spasticity,cooling and sustained passive stretching is two of them. Studies have been conducted to find outefficacy of each but a comparative study to find out post 24 hours effect of them has not beenperformed. Objectives: To find out Post 24 hours effects of application of cooling and sustainedpassive stretch on reduction of spasticity using H reflex and comparing the two techniques to find outwhich is more effective. Method: Thirty patients (male=21, female=09) were selected between the agegroup 40-70 years with spastic hemiplegia due to cerebrovascular accident. The average time since theonset of hemiplegia was 9.23 8.36 months and the patients were selected for the study from the OPDof physiotherapy department, they were divided into two groups with 15 patients in each group Theaffected side of the patient was considered as Study group A Cooling was given and Study group BSustained Passive Stretching was given along with routine rehabilitation. H reflex was used as outcomemeasure to test spasticity in all the patients at pre and post 24hrs. Results: Our study did not find anystatistically significant difference between cooling and sustained passive Stretching for reducing thehypertonicity in triceps surae muscles (p

Shilpa Khandare et alCOMPARISON OF POST 24 HOURS EFFECT OF COOLING AND SUSTAINED PASSIVESTRETCHING AS TREATMENT TECHNIQUES FOR REDUCTION OF SPASTICITY INHEMIPLEGICS USING H-REFLEXof maximum amplitude of H to maximumamplitude of M wave (Hmax/Mmax ratio) as ameasure of excitability of the motor neuron pool.The purpose of the study was to find whichtreatment technique helps in longer reduction ofSpasticity, Cooling or Sustained passivestretching. Various modalities are used to reducespasticity, Cooling and sustained passivestretching are two of them. Studies have beenconducted to find out efficacy of each but acomparative study has not been performed on post24 hour’s effect of them. Thus at our Institute we,undertook this study to compare the effects ofcooling and Sustained passive stretching.Aim and objective: To find out the Post 24 HoursEffect of Cooling and Effects of Sustained passiveStretching as Treatment Techniques for reductionof Spasticity in HemiplegicsMETHODOLGYMaterialsElectro diagnostic EMG machine (RMS EMGEPMK ) was used to Study the M wave and Hreflex. Surface electrodes were used as pick up,Stimulating and earth electrodes. Ice cubeswrapped in a thin cloth were used to cool thesurface of the calf. Goniometer was used tomeasure the range of motion. Dynamic anklesplint was used to stretch the Tendo Achilles.Inclusion criteria:Sample: 30 Hemiplegics patients (21 malesand 9 Females)Age group: 40 - 70 yearsOnset of hemiplegia: more than 6 monthsAll had either internal capsule or MCAterritory Infarct.All had moderate to severe spasticity (1+ to 2on modified ashworth scale)Patients with unilateral hemiplegia wereincluded.Triceps surae was chosen as muscle for study.Affected side was considered as study group.Exclusion criteria:Unconscious patients.Acute flaccid paralysis.Any Orthopaedic abnormalitiesStudy Design: Comparative StudyMETHODSThirty patients (21 males and 9 females) wereselected between the age group 40-70 years withspastic hemiplegia due to cerebrovascularaccident. They were divided into two groups with15 patients in each group. One group receivedcooling where as other group received sustainedpassive stretching along with routinerehabilitation. The affected side of the patient wasconsidered as study group. H-reflex was measuredat Pre and Post 24 hours of treatment in both thegroups.The patients were selected for the study from theOPD of physiotherapy department. The patientswere those with spasticity in lower extremity.Thirty patients showed grade 1+ spasticity and 17patients showed grade 2 spasticity on ModifiedAshworth Scale.The skin resistance overlying the soleus muscleand tendo Achilles was made as minimalas possible by shaving the area and cleaning itwith alcohol. The procedure to elicit the H-reflexusually involves applying a percutaneous electricstimulus to a mixed nerve, which was applied tothe posterior tibial nerve in the popliteal fossa.Continuing to increase the stimulus intensitybeyond that required for an H-reflex result indirect stimulation of the motor axons and thepresence of an M-wave, Hmax and Mmax werealso considered.STATISTICAL ANALYSISFor finding the efficacy of each technique, paired t-test was applied. To compare these twotechniques unpaired t test was used. A level ofsignificance was set at p

Shilpa Khandare et alCOMPARISON OF POST 24 HOURS EFFECT OF COOLING AND SUSTAINED PASSIVESTRETCHING AS TREATMENT TECHNIQUES FOR REDUCTION OF SPASTICITY INHEMIPLEGICS USING H-REFLEXRESULTSIn present study both the group showed significantreduction of spasticity in triceps surae muscle asmeasured by H reflex. Our study found out highlysignificant reduction in pre and post 24 hourscooling given in study group. H amplitude wast=11.98, p

Shilpa Khandare et alCOMPARISON OF POST 24 HOURS EFFECT OF COOLING AND SUSTAINED PASSIVESTRETCHING AS TREATMENT TECHNIQUES FOR REDUCTION OF SPASTICITY INHEMIPLEGICS USING H-REFLEXobserved within a few second of the application ofcold to the skin, these change are thought to berelated to decrease in the activity of the gammamotor neurons as a reflex reaction to stimulationof the cutaneous cold receptors 5,6 . Price R et al 7(1993) concluded that cold facilitates alphamotoneuronsand inhibits gamma-motoneurons.Consequently, for these effects to result inspasticity reduction, the net effect of gammainhibition must exceed that of alpha facilitation. Ifthese mechanisms operate simultaneously,spasticity tests, which incorporate muscle spindleactivation, would be sensitive to gamma inhibitionand would reveal cold-induced spasticityreduction, H-reflex tests of the monosynapticreflex arc that bypass the spindles would detect thealpha facilitation, resulting in elevated H-reflexes 4,8,9 . Krause BA et al (2000) their studyshowed that cold application reduces spasticity.Patients with UMN lesion were taken, as sampleshowed reduction in clonus and spasticity with icewater immersion at 15 c after 10 minutes ofcooling and his study found there was facilitationof motor neurone pool 6 . The effect of Sustainedpassive stretching could be on the Ib afferent fiberand the Golgi tendon organ would be fired whilethe calf muscle is stretched. Then the impulsewould be transmitted by the type Ib afferent fiberthrough the interneuron thus, inhibiting the MN.Another possibility is the type II afferent fiber: inthis case, the muscle spindle of the calf musclewould be fired while the muscle is stretched. Theimpulse would be transmitted by the type IIafferent fiber through the spinal cord, thus,inhibiting the neuron excitability of MN. Anobvious decrease of spasticity was observed after asingle session of passive stretching treatment.Similarly, H/M ratio was measured in our studyshowed increased in it prior to Cooling andSustained passive Stretching given in both studygroups and there was highly significant reductionin H/M ratio after treatment. Comparing the H/Mratio of the triceps surae in study group significantcorrelation was found in the present study inmuscle tone. We believe that the H/M ratio is aneurophysiological expression, but the others(passive range of motion) may be influenced bythe elasticity of the muscle. (Nishikawa T, 2002) 10triceps surae can improve the range of motion ofthe ankle joint and the motor neuron excitabilities.Jun Kimura (1983) reported that direct evaluationof tone is subjective and erroneous, thus anindirect method using H reflex can be used. Theyconsidered the amplitude of H to maximumamplitude of M wave Hmax/Mmax ratio as ameasure of excitability of the motor neuron pool.He found that the ratio increased with spasticity,thus H reflex was used to measure the spasticityindirectly. Similar results were shown by our studyHmax/Mmax ratio increased with spasticity andshowed significant reduction after use of both thetreatment techniques 2 . This is a safe andeconomical method for treating stroke patients.However, this treatment standing for a long timemay not be suitable for all patients.CONCLUSIONIt is concluded that Cooling and Sustained passivestretching are equally effective in reducingspasticity in hemiplegics.ACKNOWLEDGEMENTAuthor would like to thank Dr. D. Y. PatilVidyapeeth, Pune, for funding this research.Authors also acknowledge the immense helpreceived from the scholars whose articles are citedand included in references of this manuscript.REFERENCES1. The World health reports 2004: Deaths bycause, sex and mortality stratum in WHOregions, estimates for 2002. Geneva: WorldHealth Organization.2. Senelick Richard C., Rossi, Peter W.,Dougherty, Karla (1994). Living withInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 147

Shilpa Khandare et alCOMPARISON OF POST 24 HOURS EFFECT OF COOLING AND SUSTAINED PASSIVESTRETCHING AS TREATMENT TECHNIQUES FOR REDUCTION OF SPASTICITY INHEMIPLEGICS USING H-REFLEXStroke: A Guide For Families.Contemporary Books, Chicago.3. Nathaniel H. Mayer. ClinicophysiologicConcepts of Spasticity and MotorDysfunction in Adults with an UpperMotoneuron Lesion. Muscle and Nerve1997. DOI: 10.1002/(SICI)1097-4598.4. Jun Kimura: Electrodiagnosis of Diseases ofNerve and Muscle. Principles and Practice.1 st ed, 1983, F. A. Davis5. Krause BA, Hopkins JT, Ingersoll CD,Cordova ML, Edwards JE. The relationshipof ankle cooling and rewarming to thehuman soleus H reflex. J Sport Rehabil2000;9:1–10.6. Price R, Lehmann JF, Boswell Bassette S etal. Influence of cryotherapy on spasticity atthe human ankle. Arch Phys Med Rehabil1993;74(3):300-4.7. Pierrot-Deseilligny E, Mazevet D. Themonosynaptic reflex: a tool to investigatemotor control in humans: interest and limits.Neurophysiol Clin 2000; 30:67–80.8. Capaday C. Neurophysiological methods forstudies of the motor system in freely movinghuman subjects. J Neurosci Methods1997;74: 201–218.9. R. D. Adams, M Victor: Principles ofNeurology. 5 th ed, 1991, McGraw-Hill BookCo.10. Nishikawa T, Takuma Ozaki, KosakuMizuno, Grabiner MD. Increased reflexactivation of the peroneus longus followingapplication of an ankle brace declines overtime. Journal of Orthopaedic Research 2002;20 (6):1323-6.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 148

Supriya Panda et alLOWER RESPIRATORY TRACT INFECTION- BACTERIOLOGICAL PROFILE ANDANTIBIOGRAM PATTERNLOWER RESPIRATORY TRACT INFECTION- BACTERIOLOGICALPROFILE AND ANTIBIOGRAM PATTERNIJCRRVol 04 issue 21Section: HealthcareCategory: ResearchReceived on: 01/09/12Revised on: 14/09/12Accepted on: 23/09/12Supriya Panda, B. Prema Nandini, T.V.RamaniDept. of Microbiology, Maharajah’s Institute of Medical Sciences, Nellimarla,Vizianagaram, Andhra Pradesh, IndiaE-mail of Corresponding Author: drsupriyapanda@gmail.comABSTRACTObjective: A study was conducted to know bacteriological profile and antibiogram pattern of lowerrespiratory tract infection (LRTI) in a rural setup. Methods: Sputum samples from 95 patients withsymptoms of LRTI and endotracheal aspirates from 5 patients admitted to intensive care unit (ICU)were processed for culture and antibiotic sensitivity test was done to commonly used antibiotics.Results: Aetiological diagnosis was possible in 83 patients. Sixty five patients were culture positive forsingle pathogen and 18 patients were culture positive for two pathogens. Males (n=63) were foundmore at risk to LRTI than females (n=37).LRTI was found more prevalent in 51-60 year age group(n=24). K.pneumoniae (31.3%) was the commonest single pathogen isolated followed by Coagulasepositive Staphylococci (26.5%), Streptococcus pneumoniae (15.6%) and Pseudomonas aeruginosa(3.6%). Str. pneuminiae strains were sensitive to ciprofloxacin (95%) and erythromycin (89%), butresistant to ampicillin (31.5%). K.pneumoniae and Pseu.aeruginosa strains were sensitive to ofloxacin(95-100%) ; and cefotaxime and ceftriaxone(67-100%). Conclusion: The present study reveals thatK.pneumoniae is the emerging pathogen of LRTI in rural setup with a low prevalence of antibioticresistance among the pathogens.Key words: Lower respiratory tract infection, sputum culture.INTRODUCTIONInfections of the Lower respiratory tract areresponsible for 4.4% of all hospital admissions and6% of all general practitioner consultations(1).They account for 3 to 5% of deaths in adults(2).The problem is much greater in developingcountries where pneumonia is the most commoncause of hospital attendance in adults(3).Since the etiological agents of Lower respiratorytract infections(LRTI) can not be determinedclinically , microbiological investigation isrequired for both treatment and management ofindividual case and epidemiological purposes(4).But routine laboratories in the rural set up are notable to perform sputum culture for variousreasons. Therefore, antimicrobial therapy isfrequently empirical and presumptive, which iscomplicated by the increasing prevalence ofresistance among bacteria causing LRTI (5).AIM OF THE STUDYThe objective of the present study is to find out thebacteriological spectrum and antibioticsusceptibility pattern of Lower Respiratory TractInfection among the patients attending MIMSGeneral Hospital, Nellimarla, a village situated 8kilometer away from Vizianagaram town.MATERIALS AND METHODSSTUDY GROUP: After taking the approval frominstitutional review committee, 100 consecutivepatients between the age group of 21-90 yearswith productive cough and fever for more than twoweeks presented to outpatients department ofInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 149

Supriya Panda et alLOWER RESPIRATORY TRACT INFECTION- BACTERIOLOGICAL PROFILE ANDANTIBIOGRAM PATTERNMedicine and TB chest; and admitted to Medicineward and intensive care unit(ICU) were includedin the present study.STUDY PERIOD: For a period of 8 months fromJanuary 2011-August 2011.EXCLUSION CRITERIAPatients with pulmonary tuberculosis, congestiveheart failure, pulmonary infarction, AIDS andthose receiving Immune suppressive therapywere excluded from the study.LABORATORY INVESTIGATIONTwo sets of sputum samples from each patientand endotracheal aspirates from patients onventilator were collected after taking informedconsent from them and from close relatives forthe unconscious patients and processed within2 hours. The samples were subjected to thefollowing investigations :-1. Gram stained smears were examined to see thecharacter of exudates, number and type oforganisms. Specimens containing more than25 polymorphonuclear leucocytes and lessthan 10 epithelial cells per low power fieldwere included in the study (6).2. Culture of sputum was done on Blood agarwith a streak of Staphylococcus aureus,chocolate agar and Mac Conkey agar. Bloodagar and chocolate agar were incubated incandle jar at 37 degree centigrade.** Any bacteria showing heavy growth on cultureor a moderate or light growth along with Gramstain report compatible with the culture resultswere considered to be the causative agents(4).3. Identification of bacterial isolates were doneby the relevant biochemical tests.4. Antibiotic sensitivity test was done bymodified Kirby Bauer’s method for Grampositive organisms to Ampicillin+Sulbactam-10mcg,Amoxyclav-10mcg,Vancomycin-30mcg,Ceftazidime-30mcg, Ampicillin-10mcg, Netilmicin-30mcg, Ciprofloxacin-5mcg and Cefazolin-30mcg ; and for Gramnegative organisms to Ampicillin +Sulbactam- 10mcg, Amoxyclav- 10mcg,Cefotaxime-30mcg, Tetracycline-30mcg,Amikacin-30mcg, Gentamycin-10mcg,Ofloxacin-5mcg, Ceftriaxone-30 mcg andChloramphenicol-30mcg.Colonies of Staph.aureus on milk agaragarTube coagulase testInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 150

Supriya Panda et alLOWER RESPIRATORY TRACT INFECTION- BACTERIOLOGICAL PROFILE ANDANTIBIOGRAM PATTERNAlpha haemolytic colonies of Str.pneumoniae onblood agarBile solubility test for Streptococcus pneumoniaeTube methodPlate methodOptochin sensitivity of Str. pneumoniaeInt J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 151

Supriya Panda et alLOWER RESPIRATORY TRACT INFECTION- BACTERIOLOGICAL PROFILE ANDANTIBIOGRAM PATTERNBeta haemolytic Streptococcus and its Bacitracin sensitivityRESULTSOut of 100 patients presented clinically as LRTI,aetiological diagnosis could be possible in 83cases(65 for single pathogen and 18 for mixedinfections)in the present study(table no.2).Maximum number of cases were males (n=63) andfrom 51-60 years (n=24)of age group(table no1&3).A total of 101 isolates of pathogenic bacteriawere isolated from these 83 culture positivecases.Commonest organism isolated wasK.pneumoniae both as single pathogen and inmixed infection.(table no 4 &5). Out of 40 isolatesof K.pneumoniae, 29 isolates were from inpatientsand 19 isolates were from 51-70 year of agegroup(table no 4&6).Fourteen isolates ofK.pneumoniae(n=40)and 3 isolates ofPseu.aeruginosa(n=3) were resistant to ampicillin+sulbactam combination,30 isolates of coagulasepositive Staphylococcus(n=34) and 6 isolates ofStr.pnuminiae(n=19) were resistant toampicillin.(table7-10)Table 1: Total No. of patientsNo. of cases male femaleInpatientsOutpatients554540231522Total 100 63 37Table 2 : culture for pathogens (n=100)Culture positiveculturenegativemale female totalfor single pathogenfor mixed infection421123076518total 53 30 83 17Table 3: distribution of cases age wiseAge in years No. of cases21-30 1231-40 2241-50 1951-60 2461-70 1971-80 281-90 2total 100Table 4 : Number of organisms isolatedOrganismtotal no.mal femIP OPisolatede aleK.pneumoniaeCoag.+ve Staph.Str.pneumoniaePseu.aeruginosaGroup A beta Strept.Prot.mirabilis403419030302291806030102111613002027211103010113130800201Total 101 59 42 64 37Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 152

Supriya Panda et alLOWER RESPIRATORY TRACT INFECTION- BACTERIOLOGICAL PROFILE ANDANTIBIOGRAM PATTERNTable 5 : culture positive for mixed infectionsMixture of organisms Male Female TotalCoag.+ve6 2 8Staph+K.pneumoniaeCoag.+ve staph. +Str. 1 3 4pneumoniaeStr.pneumoniae+2 0 2K.pneumoniaeK.pneumoniae +beta haem 1 1 2strept.K.pneumoniae + Prot. 1 1 2mirabilistotal 11 7 18Table 6: Age distribution of K.pneumoniae isolatesAge No. of isolates21-30 yrs 531-40 yrs 941-50 yrs 551-60 yrs 9 47.5%61-70 yrs 1071-80 yrs 181-90 yrs 1total 40Table 7: Antibiotic sensitivity pattern.K.pneumoniae Coag.+ve staph. Str.pneumoniae Ps.aeruginosa Pr.mirabils(n=40) (n=34) (n=19) (n=03) (n=02)S R S R S R S R S RAmpicillin NA 04 30 13 06 NA NAAmpicillin+sulbactam 26 14 28 06 18 01 0 03 02 0Amoxyclav 06 34 28 06 15 04 01 02 02 0Amikacin 40 0 NA NA 03 0 02 0Cefazolin NA 26 08 17 02 NA NACefotaxime 34 06 NA NA 02 01 02 0Ceftazidime NA 31 03 18 01 NA NACeftriaxone 36 04 NA NA 02 01 02 0Ciprofloxacin NA 27 07 18 01 NA NAChloramphenicol 30 10 NA NA 01 02 02 0Erythromycin NA 31 03 17 02 NA NAGentamycin 37 03 NA NA 03 0 02 0Netilmycin NA 34 0 19 0 NA NAOfloxacin 37 03 NA NA 03 0 02 0Tetracycline 26 14 NA NA 02 01 0 02Vancomycin NA 34 0 19 0 NA NADISCUSSIONIn the present study, LRTI is more common inmales than a female which is consistent with otherstudies from India (7). This is due to moreprevalent associated risk factors (eg. Smoking,chronic alcoholism, COPD) of pneumonia inIndian males than females (8). Maximum numberof patients(24%) were from older age group (51-60years).This is in accordance with a study fromFinland, the rate of pneumonia increased for eachyear of age over 50 years.(9).Microbiologicaldiagnosis was possible in 83% of cases. Studiesfrom different areas reported an aetiologicaldiagnosis between 45% to more than 80%.( 8)The major single pathogen causing LRTI areKlebsiella pneumonia (31.3%), Coagulase positivestaphylococci (26.5%), Streptococcus pneumonia(15.6%) and Pseudomonas aeruginosa (3.6%) inthis study.This is comparable with a report fromNigeria(10) where commonest organism isolatedwas K.pneumoniae accounting for 38% of theisolates. A higher prevalence of Klebsiellapneumonia has also been reported from India inlast two decades. (11,12,13)Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 153

Supriya Panda et alLOWER RESPIRATORY TRACT INFECTION- BACTERIOLOGICAL PROFILE ANDANTIBIOGRAM PATTERNK.pneumoniae is the commonest organism causingLRTI in inpatients whereas among outpatients,S.aureus is the commonest organism causingLRTI in the present study. All the 3 isolates ofPseudomonas aeruginosa were from ICU patientswith ventilator and isolated as single pathogen.Nidhi Goel et al also reported this organism as thecommonest cause of ventilator associatedpneumonia (14). All 2 isolates of Proteus mirabiliswere also from ICU patients with ventilator, but asmixed infection along with Klebsiellapneumoniae.Isolation rate of K.pneumoniae both as singlepathogen & in mixed infection is 48.2% in ourstudy; and 72.5% of these isolates were frominpatients and 47.5% were from age group 51-70yrs. Patients in the older age group are moresusceptible to gram negative pneumonia becauseof waning immunity and pulmonary defensemechanisms, underlying chronic diseases andsilent aspiration. Institutional care also makes thepatients more susceptible to gram negativepneumonia (4)..In the present study, incidence ofmixed infections was 21.7% which is consistentwith the fact that incidence of mixed infectionsdoes not usually exceed 30% (15).Identification ofpolymicrobial infection is very important fortreatment strategies.We got 3 isolates of Beta hemolytic Group-AStreptococcus in the age group 61-70 years. It cancause pneumonia by the spread of infection fromthe pharyngeal mucosa(16).There are reportsregarding increasing prevalence of drug resistanceamong the strains of Streptococcus pneumoniaefrom India (17).Among our strains of Str.pneumoniae ,although 31.5% resistance was notedfor ampicilin, they have shown high degree ofsensitivity to ciprofloxacin(95%) anderythromycin(89%).There are also reports from India regardingincrease prevalence of drug resistance amonggram negative bacilli strains from LRTI (14,18).But in the present study,K.pneumoniae and Pseud.aeruginosa strains have shown 95 to 100 %sensitivity to ofloxacin and 67 to 100 % sensitivityto cefotaxime and ceftriaxone.All the strains of Gram positive cocci and Gramnegative bacilli were senisitive to netilmycin andamikacin respectively although Staph. aureusstrains have shown 88% resistance to ampicillin .Resistance to Beta lactamase resistant antibioticswere 100 % for Pseudomonas aeruginosa, 85 %for Klebsiella pneumoniae,21% forStreptococcus pneumoniae and18% forCoagulase positive Staphylococi.CONCLUSIONIn the present study commonest organism isolatedfrom patients with LRTI was Klebsiellapneumonia (48.2%) both as single pathogen & inmixed infection. Incidence of drug resistanceamong the strains was less. The most effectiveantibiotics for Gram negative bacilli causing LRTIwas Amikacin and for Gram positive cocci wasNetilmicin in the present study. Cephalosporinsmay be started before culture report can begenerated. However resistance to Beta lactamaseantibiotics requires further evaluation by morestandardized method.ACKNOELEDGEMENTWe acknowledge the immense help received fromthe scholars whose articles are cited and includedin references of this manuscript. The authors arealso grateful to authors/ editors/ publishers of allthose articles, journals and books from where theliterature for this article has been reviewed anddiscussed.REFERENCES1. Anderson.H,Esmail A,Hollowell J,LittlejohnsP, Strachen D.Epidemeologically based needsassessment,Lower respiratory diseases, DHAProject Research programme.1993; p 6-12.2. Editorial.Antibiotics and respiratoryillness.Br.Med.J.1994;3:13. Mac Farlance J.Community acquiredpneumonia.Br J Dis Chest 1987;81:p116-27.Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 154

Supriya Panda et alLOWER RESPIRATORY TRACT INFECTION- BACTERIOLOGICAL PROFILE ANDANTIBIOGRAM PATTERN4. Fang Gd , Fine M,orloff J, Arisumi Detal.New and Emerging etiologies forcommunity acquired pneumonia withimplication for therapy ,a prospective multicenter study of 359 cases.Medicine(Baltimoore) 1990;69:p307-165. Guthrie R. Community acquired lowerrespiratory tract infections: aetiology andtreatment.Chest.2001;20:p2021-346. Murray,P.R and Washington ,J(1975):Amicroscopic and bacteriological analysis ofexpectorated sputum.Mayo clin.proc,50,p339-44.7. Aroma Oberoi,ArunaAggrawal.Bacteriological profile,serology andantibiotic sensitivity pattern of microorganisnsfrom community acquired pneumonia.JKSCIENCE ,2006;8:p-79-82.8. S.Bansal,S.Kashyap,L.S.Lal andA.Goel.Clinical and bacteriological profile ofcommunity acquired pneumonia inShimla,Himachal Pradesh. Indian J Chest Dis& Allied Sci,2004;46:p17-229. Barlett JG,Dowell SF,MandellLA,etal.Practice guidelines for themanagement of community acquiredpneumonia in adults. Cli. InfectDis,2000;31:P347-8210. A.O.Okesola&OM Ige. Trends inbacteriological pathogens of lower respiratorytract infections.Indian J of Chest Dis & AlliedSci,2008;50:p269-72.11. Madhu SV,Gupta U, Guleria JS, Talwar V.Clinical and bacteriological profile ofhospitalized community acquiredpneumonia:A preliminary study.Indian J ChestDis Allied Sci,1990;32:p95-100.12. Kulpati Das, Kumar A.Flexible fibreopticbronchoscopy in lower respiratory infection.Indian J Chest Dis Allied Sci,1980;22: p39-46.13. Sharma TN,Jain NK,Nanavati V,MangalHN,SarkarSK,SinghV.Transbronchofiberoptic bronchial aspirationin lower respiratory tract infection.Indian JChest Dis Sci.1981;23:p73-80.14. Nidhi Goel, Uma Chaudhary,Riru Aggrawal,Kiran Bala.Antibiotic sensitivity pattern ofgram negative bacilli isolated from lowerrespiratory tract of ventilated patients ofintensive care unit. ResearchArticle.2002;13:p148-5115. deRoux A, Ewig S,Garcia E,MarcosMA,Mensa J,Lode H etal. Mixed communityacquired pneumonia in Hospitalisedpatients.Eur.Respir.J.2006:27:795-800.16. Harrison’s principle of internal medicine.15 thedition.2003,p90317. Kiran Chawla, Bimala Gurung, ChiranjayMukhopadhyay,Indira Bairy.Reportingemerging resistance of Streptococcuspneumoniae from India. J of Global InfectiousDisease,2010;2:p10-1418. P Gauchan, B Lekhak,J B Sherchand..Theprevalence of LRTIs in adults.J of Institute ofMedicine. Tribhuban University;vol.28(2):p10-14Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,Page 155