Hepatic Artery IJCRR P-143
Hepatic Artery IJCRR P-143
Hepatic Artery IJCRR P-143
Published by:
Radiance Research Academy,
Nagpur, MH, India
Aug 2012
I
J Editorial Board
C
Dr. Prof. Dato’ Proom Promwichit
Masterskill University, Malaysia
Dr. Nahla Salah Eldin Barakat
University of Alexandria, Alexandria, Egypt
Dr. Ann Magoufis
Ariston College, Shannon, Ireland
Dr. Pongsak Rattanachaikunsopon
R
Ubon Ratchathani University, Thailand
Dr. Chellappan Dinesh
International Medical University, Malaysia
Dr. R. O. Ganjiwale
Nagpur University, MH, India
Dr. Shailesh Wader
R
Nagpur University, MH, India
Dr. Alabi Olufemi Mobolaji
Bowen University, Iwo, Osun-State, Nigeria
Dr. Joshua Danso Owusu-Sekyere
University of Cape Coast, Cape Coast, Ghana
Dr. Okorie Ndidiamaka Hannah
University of Nigeria Nsukka, Enugu State
ISSN 0975-5241 Dr. Parichat Phumkhachorn
Ubon Ratchathani University, Thailand
IC Value of Journal: 4.18 Dr. Manoj Charde
Amravati University, MH, India
“Let the science be your passion” Dr. Shah Murad Mastoi
Lahore Medical and Dental College, Lahore,
Pakistan
Dr. Hitesh Wadhwa
Vol 4 / Issue 20 / Oct 2012
MD University, HY, India
International Journal of Current Research and Review (ijcrr) is one of the popular
fortnightly international multidisciplinary science journals. ijcrr is a peer reviewed
C
indexed journal which is available online and in print format as well. References
have shown that within short span of time, citations for ijcrr are increasing with
noticeable pace.
R
University Library of Regensburg, Science Central, SciPeople.
R
timeliness, accessibility, grace and astonishing conclusions. ijcrr is also popular for
rapid publication of accepted manuscripts.
Mission Statement:
To set a landmark by encouraging and awarding publication of quality research and
review in all streams of Science.
J
N. No.
01 Study of Socio-Demographic Profile of Anand Mugadlimath,
Poisoning Cases at Shri B M Patil M A Bagali and S R 80
Medical College Hospital and Research Hibare , D.I. Ingale,
Centre, Bijapur Neeraj Gupta,
Chandrashekar
Bhuyyar
C
02 Actinomycosis of Breast-A Case Report B. Arora, Sumit Giri,
D.R. Arora 85
03 Cell Adhesion Molecule Expression S. Indumathi,
Profiling of Human Umbilical Cord Rashmi Mishra, R. 89
Matrix and Adipose Stem Cells Harikrishnan, J.S.
Rajkumar
Neha Kantawala, M.
R
Dhanasekaran
04 Clinical Outcomes of AO Philos Plating Annamalai
for Proximal Humerus Fractures Regupathy 94
05 Prevalence of Overweight and Obesity Prasanna Kamath
among Adolescent School going B.T, Girish M 99
Children (12-15years) in Urban Area, Bengalorkar, Deepthi
South India. R, Muninarayan C,
Ravishankar S
R
06 Intra Rater and Inter Rater Reliability of Janakiraman
Sway Graph in Elderly Subjects Balamurugan, 106
Paulraj Anantha
Raja, Nagaraj.S
Ramachadran
Arunachalam
J
N. No.
11 Rate Pressure Product – A Diagnostic Sangeeta Nagpal,
Tool in Determining the Cardiovascular Kalpana Gupta, 134
Risk in Postmenopausal Women Jitendra Ahuja
12 Comparative Analysis of Communicable C.Kumaraswamy
And Non Communicable Diseases In Naidu, Y. Suneetha, 139
Rural And Urban Localities of Tirupati B. V. Sai Prasad
in India
C
13 Anomalous Origin of Hepatic Artery and Sunita Sethy, G.R.
its Relevance in Hepatobiliary Surgeries Nayak, D. Agrawal, 143
B. Mohanty,
R. Biswal
14 A Cross-Sectional Study of Awareness Ujwala U. Ukey,
About Hepatitis B among Nursing Satyanarayan Dash, 149
Students of Mims College at K. Rama Sankaram,
Vizianagaram, Andhra Pradesh N.R. Appajirao
R
Naidu, R.Sri Vidya
15 Body Sensor Network Security Using Umasankar K.,
Cryptography Approach Vetrivendan.R 156
R
17 Variant Heads of Biceps Brachii Muscle Sharadkumar Pralhad
Sawant , Shaguphta 170
T. Shaikh, Rakhi
Milind More
ABSTRACT
A retrospective analysis of all poisoning cases admitted to Shri B M Patil Medical College Hospital &
Research Centre Bijapur, Karnataka from Jan 2010 to Dec 2010 was done to study the pattern of
poisoning reported. Acute poisoning is a common medical emergency and one of the important causes of
morbidity and mortality in developing countries due to easy availability of poisonous substances and its
low cost. So it was important to know the pattern of poisoning at to Shri B M Patil Medical College
Hospital & Research Centre Bijapur. Objective of the study was to evaluate the pattern of poisoning at a
tertiary care hospital in North-Karnataka (Bijapur), and to study the socio-demographic profile of the
same. Data collected using a pretested proforma and the values were analyzed and presented.
Key Words: Poisoning, organophosphrous compounds, kerosene.
availability and the knowledge and local females who admitted for poisoning 65% patients
population regarding the properties of poisons 2. were married and 35% were unmarried (Table 5).
So this study has been aimed to determine the The hospital stay of the admitted patients with
various parameters of poisoning such as type of poisoning ranged from 01 to 82 days and the mean
poisoning involved, the most vulnerable age group hospital stay was 6.9 days. During the study period
and their marital status with religions. 21 (5.55%) of the patients had mortality due to
poisoning (Table 6). 353 cases (93.3 %) with
METHODOLOGY poisoning admitted to the hospital were Hindus
The present retrospective study was conducted by followed by Muslims in 25 cases [6.61%] (Table
department of Forensic Medicine& Toxicology . 7).
Shri B M Patil Medical college, Bijapur, North Most common (51.6%) poison used for poisoning
Karnataka from Jan 2010 to Dec 2010. Data was were organophosphrous compounds 197 cases
collected from all the poisoning cases admitted (51.63%), in 118(31.21%) cases the type of poison
that were admitted & treated at BLDEAs B M was not known and were treated symptomatically
Patil Medical College Hospital & Research Centre (Table 4).
Bijapur. Information was collected into a proforma In our study 86.5% (327) of cases were from rural
on the type of poison consumed, incidence on age domicile and only 13.5 % (51) from urban
and sex, marital status, religions, hospitalization population (Table 8).In season wise distribution,
days were noted from records for each case and highest cases were recorded in the month of March
analyzed. & April (16.9% & 9.2%) (Table 9).
RESULTS DISCUSSION
In our study there were total of 378 patients Poisoning is a major public health problem in
brought to BLDEAs B M Patil Medical College Bijapur district, with thousands of poisonings and
Hospital & Research Centre Bijapur, of whom the hundreds of deaths every year cases coming to
data were collected during the 12 months study tertiary centre represent just tip of the iceberg.
period from Jan 2010 to Dec 2010 due to Keeping this background in mind, retrospective
suspected poisoning. Total number of 32904 IPD analysis of all poisoning cases admitted to Shri B
cases were registered during the study period and M Patil Medical College Hospital & Research
2197 MLC cases done, in which 378 cases Centre Bijapur, Karnataka from Jan 2010 to Dec
(6.67%) were due to poisoning (Table 1). 2010 was done to study the pattern of poisoning
Total number of male patients admitted to hospital reported. Suicide is one of the oldest and
due to poisoning was 199 (52.64%) and female considered the best trends of sacrificing their life
were 179 (47.35%) with the male: female ratio by consuming different poisonous substances
being 1.2:1 (Table 2). Majority (45.76%) of which are easily accessible to them compared
victims with suspected consumption of poison was other methods. The morbidity, mortality in any
in between 21 to 30 age group followed by the age case of acute poisoning depends upon number of
group between 11 to 20 (26.45% )( Table3). factors such as nature of poison dose consumed,
Insecticides were the most common poison used level of available medical facilities and time
for suicidal purpose by the entire victim aged interval between intake of poison and provision of
between 15-65 years irrespective of age (Table 4). medical help.
We also found that out 199 (52.64%) males came The sex incidence affected with poisoning was
with poisoning, 55 % patients were married and more with male which out numbered the female
45% patients were unmarried. Out of the 179 the ration being 1.7:1 and tallies with the other
4. Shreemanta Kumar Dash, Manoj Kumar in adults (10 years experiences). J Assoc
Mohanty, Kiran Kumar Patnaik, Sachidananda Physic India. 1984; 32: 561- 563.
Mohanty. Sociodemographic profile of 15. Lall S B, Al-Wahaibi S S, Al-Riyami M M
poisoning cases. JIAFM, 2005; 27 (3): 133- and Al-Kharusi K. Profile of acute poisoning
138. cases presenting to health centres and
5. Jayaratnam J. Acute pesticide poisoning. A hospitals in Oman. Eastern Mediterranean
major global health problem. World Health Health Journal. 2003; 9 (5/6): 944-954.
Statist Quart. 1990; 43:139- 144. 16. Gupta S K, Peshin S S, Srivastava A, Kalukal
6. Eddleston M. Patterns and problems of T, Pandian T V. Epidemiology of acute
deliberate selfpoisoning in the developing poisoning. Natl Med J India 2002 May- June;
world. Q J Med 2000; 93: 715- 731. 15 (3): 177.
7. Karki P, Hansdak S G, Bhandari S, Shukla A, 17. Agarwal R, Barthwal S P. Nigam D K et al:
Koirala S. A clinico-epidemiology study of Changing pattern of acute poisoning in eastern
organophosphrous poisoning at a rural based UP hospital based study. J. Assoc Physic India
teaching hospital of Easter Nepal. 1995; 43: 907.
8. Srinivas Rao C H, Venkateswarlu V, Surender 18. Senanayake N and Peris H. Mortality due to
T, Eddleston M and Nick A Buckley. poisoning in developing agricultural country:
Pesticide Poisoning in South India- trends over 20 years. Hum Exp Toxicol. 1992;
Opportunities for prevention and improved 12: 435-438.
medical management. Trop Med Int Health. 19. Singh S, Wig N, Chaudhary D, Sood N K and
June 2005; 10(6):581- 588. Sharma B K. Changing pattern of acute
9. Thomas M, Anandan S, Kuruvilla P J, Singh P poisoning in adults: Experience of a large
R, David S. Profile of hospital admissions North-West Indian Hospital (1970- 1989). J
following acute poisoningexperiences from a Assoc Physic India. 1997; 45: 194-197.
major teaching hospital in south India. Adv 20. Chan Y C, Fung H T, Lee C K, Tsui S H,
Drug React Toxicol Rev. 2000; 19: 313-317. Ngan H K, Sy M Y, Tse M L, et al., A
10. Batra A K, Keoliya A N, Jadhav G U. prospective epidemiological study of acute
Poisoning: An unnatural cause of morbidity poisoning in Hong Kong. Hong Kong J.
and mortality in rural India. JAPI, Oct 2003; Emerg. Med. 2005; 12: 156-161.
51: 955-959. 21. Gulati R S. Spectrum of acute poisoning in a
11. Pillay V.V: MKR Krishna’s Hand book of service Hospital. J Assoc Phy India 1995; 43:
Forensic Medicine and Toxicology. 12th Ed. 908-909.
Paras Publication. Hyderabad: 276-299, 2001. 22. Nimal S, Laxman K. Pattern of acute
12. Taruni N G, Bijoy T H, Momonchand A: A poisoning in a Medical unit in central Sri
profile of poisoning cases admitted to RIMS Lanka. For Sci Int 1988; 36:101- 104.
Hospital Imphal. Journ Forensic Med Toxicol 23. Dhattarwal S K and Dalal S S. Profile of death
2001; 18: 31-33. due to poisoning in Rohtak, Haryana in the
13. Sharma B K, Harish D, Sharma V and Vij K. year 1995. J For Med Toxicol. 1995; 15: 51.
The epidemiology of poisoning: An Indian 24. Gupta B D, Vaghela P. Profile of Fatal Poisoning
view point. Journ Forensic Med Toxicol 2002; in and around Jamnagar.JIAFM, 2005; 27 (3): 145-
19: 5-11. 148.
14. Singh S, Sharma B K, Wahi P L, Anand B S 25. Zine K U, Mohanty A C. Pattern of acute
poisoning at Indira Gandhi Medical College and
and Chugh K S. Spectrum of acute poisoning
Hospital, Nagpur. J Ind Aca For Med. 1998; 20:
37-39
ABSTRACT
Primary actinomycosis of the breast is a very rare disease and most commonly caused by Actinomyces
israelii which normally inhabits mouth, colon, and vagina. Primary forms directly affect the breast but the
etiology is unknown. Possible causes include infection of the lactiferous ducts due to trauma during breast
feeding or kissing. In secondary actinomycosis, the infection at the primary sight ultimately reaches the
breast. The purpose of the study is to present, in detail, a case of a 50 year old woman, with the complaint
of swelling in the right breast of 6 months duration which was variable in size and associated with
discharging sinuses.
Keywords: Actinomycosis, breast, Actinomyces israelii.
INTRODUCTION
Actinomycosis is a chronic granulomatous or actinomycosis is primary when inoculation occurs
suppurative disease, usually caused by through the nipple. Secondary actinomycosis of
an anaerobic bacterium called Actinomyces the breast refers to the extension of a pulmonary
israelii, which is a common organism found in the infection through the thoracic cage in a process
nose and throat, flora of oral cavity, particularly in that can affect the ribs, muscles and finally the
the periphery of decayed teeth, and in the grooves breast [5]. Breast actinomycosis may present as
of tonsils, as well as female genital tract [1, 2]. It sinus tract or with mass-like features mimicking
is a Gram-positive, non-motile, non-sporing, non- malignancy. The clinical presentation makes it
acid- fast organism[3]. Disease is characterized by difficult to distinguish primary actinomycosis
development of abscesses, draining by multiple from mastitis and inflammatory carcinoma [6].
sinus tracts containing bloody suppurative We report a case of primary actinomycosis of the
discharges and “sulphur granules” which are breast caused by Actinomyces israelii that was
composed of branched filaments. The disease is diagnosed by fine needle aspiration cytology
classified clinically to the varieties of (FNAC) and was further confirmed on
cervicofacial, thoracic, abdominal and pelvic. histopathologic study of a specimen obtained by
Clinical signs of disease are different, depending excisional biopsy, Gram stain and culture.
on the site of infection. The infection is not
contagious. Actinomycosis is seen in all age CASE REPORT
groups and regions globally, but occurs frequently A 50-year-old woman, otherwise healthy,
between 15 to 35 years, and its reported frequency presented in surgery outpatient department of our
in men is two times that in women [4]. hospital with the complaint of swelling in the right
Primary actinomycosis of the breast was first breast of 6 months duration which often increased
described by Ammentrop in 1893. Breast and decreased in size and was associated with
episodes of on and off burst to discharge pus. No bottom. Half of these were removed with a Pasteur
history of lung disease, breast trauma, gingivitis, pipette and were crushed between two slides and
or tooth problems was found and it was diagnosed stained with Gram stain. Microscopy revealed
as chronic breast abscess and she was referred to Gram-positive filaments with Gram-negative
pathology department for FNAC. periphery (Fig.3). Remaining were crushed in a
Physical examination revealed a firm fluctuating drop of saline with a glass rod and inoculated on
swelling in upper outer quadrant of right breast brain heart infusion agar, blood agar and
measuring 6x4 cm in size, with marked thioglycollate broth and incubated both
induration in the surrounding area. The overlying anaerobically and aerobically with 5−10% carbon
skin was adherent to the swelling but the dioxide at 350−370 C for upto 14 days. The
underlying structures were free. On pressing the colonies of Actinomyces israelii were 0.5−2 mm in
swelling, pus-like discharge came out. No palpable diameter, white to grey-white, smooth, lobulated
adenopathy was found. Examination of oral cavity, resembling molar teeth.
face and neck for detecting any skin lesion or mass
was unremarkable. All other test results including DISCUSSION
blood biochemistry, hemoglobin electrophoresis, Breast actinomycosis is rare throughout the world
urine analysis and stool examination were within and only a few cases have been published so far
normal limits except for mild leukocytosis in the [5,7−11]. It has been called „the most
blood count. misdiagnosed disease‟, and it has been stated that
FNAC smears were prepared from pus-like „no disease is so often missed by experienced
discharge which oozed out on pressing the clinicians‟ [12]. Primary actinomycosis of the
swelling and stained with May Grunwald Giemsa breast is an unusual condition where the most
stain. Microscopy revelaed grains which commonly isolated pathogen has been A. israelii
comprised of hyphal fragments surrounded by a [13]. Possible causes of this condition include
peripheral zone of swollen radiating club-shaped trauma, lactation and kissing [14]. Most of the
structures presenting as sun-ray appearance in a reported cases of primary actinomycosis of the
background dense inflammatory infiltrate (Fig.1). breast were caused by A. israelii. In recent years,
Histopathology confirmed the diagnosis. Gross other strains have been found as well. For instance
examination revealed multiple grey white to grey Brunner et al. [11] reported a catalase-negative
yellow tissue pieces. The largest piece was skin strain of Actinomyces neuii as the possible
covered measuring 6x3x3cms. Cut surface was causative agent of an infected mammary
grey brown in some areas and dark tan in others. A prosthesis. Mohammed in 1993 described a case of
grain of dark colour was also seen in the dark tan actinomycosis of the accessory breast [9].
area. Haematoxylin & eosin stained sections
revealed lobules of breast tissue along with CONCLUSION
“sulphur granules” which were deeply stained with The physician should keep actinomycosis in mind
haematoxylin except in the periphery which was as a possible diagnosis and perform the
stained by eosin, which showed short, radiate, appropriate investigation, if the pathogenic
club-like structures. It was surrounded by areas of findings of a mass are in favour of granulomatous
granulation tissue comprising of predominantly inflammatory process or microabscess formation,
polymorphonuclear leukocytes, lymphocytes, and if work up for tuberculosis, and or fungal
plasma cells and fibroblasts (Fig.2). infections are negative. Actinomycosis should be
Pus was shaken with sterile water in a tube and vigorously sought and promptly treated in patients
“sulphur granules” were allowed to settle at the with chronic granulomatous disease presenting
with uncommon and prolonged clinical signs of Diagnosis by fine-needle aspiration cytology
infection. under ultrasound guidance. Breast J 2005;
11:57–59.
ACKNOWLEDGEMENT 7. Gogas J, Sechas M, Diamantis S, Sbokos C.
Authors acknowledge the immense help received Actinomycosis of the breast. Int Surg 1972; 57
from the scholars whose articles are cited and (8):664-65.
included in references of this manuscript. The 8. Schouten A. A case of primary actinomycosis
authors are also grateful to authors / editors / of the breast. Arch Chir Neerl 1973; 25(3):
publishers of all those articles, journals and books 319-23.
from where the literature for this article has been 9. Mohammed KN. Actinomycosis of the
reviewed and discussed. accessory breast treated with cotrimoxazole.
Med J Malaysia 1993; 48(2): 229-31.
REFERENCES 10. Jain BK, Sehgal VN, Jagdish S, Ratnakar C,
1. Baron EJ, Finegold SM. 80'ed. Mosby, St. Smile SR. Primary actinomycosis of the
Louis, Baltimore 1990; P: 521-23. breast: a clinical review and a case report.
2. Brook I. Actinomycosis. In: Goldman L, Dermatol 1994; 21(7): 497-500.
Ausiello D, eds.Cecil Medicine. 24th ed. 11. Brunner S, GrafS Riegel P, Altwegg M.
Philadelphia, Pa: Saunders Elsevier; 2011:P Catalase negative Actinomyces neuii subsp.
337. Neuii isolated from an infected mammary
3. Arora DR, Arora B. Actinomycetes in prosthesis. Int J Med Microbiol 2000; 290(3):
Textbook of Microbiology, CBS Publishers 285-87.
and Distributors, New Delhi. Bangalore 3rd 12. Mandell GL, Bennett JE, Dolin R: Principles
edition 2008, pp 481-86. and Practice of Infectious Diseases, ed 6.
4. Zaini F, Mchbod ASA, Emami M. Saunders, 2005, pp 2924–31.
Comprehensive medical mycology. Tehran 13. Attar KH, Waghorn D, Lyons M, Cunnick G:
University Publication. Tehran Iran 1999; P: Rare species of actinomyces as causative
39-40. pathogen in breast abscess. Breast J
5. de Barros N, Issa FK, Barros AC, D‟Avila 2007;13:501–05.
MS, Nisida AC, Chammas MC, Pinoti JA, 14. Lloyd-Davies JA: Primary actinomycosis of
Cerri GG: Imaging of primary actinomycosis the breast. Br J Surg 1951;38:378–81.
of the breast. AJR Am J Roentgenol 2000;
174:1784–86.
6. Capobianco G, Dessole S, Becchere MP,
Profili S, Cosmi E, Cherchi PL, Meloni GB: A
rare case of primary actinomycosis of the
breast caused by Actinomyces viscosus:
Fig. 1. Photomicrograph of FNAC smear showing grain of actinomycosis revealing sun-ray appearance in a
background of inflammatory infiltrate (May Grunwald-Giemsa 40X).
Fig. 2 Photo micrograph of histopathology slide showing sulphur granules (on left) stained with haematoxylin
in the centre and eosin at the periphery surrounded by areas of granulation tissue along with lobules of
mammary tissue (on right), (Haematoxylin &Eosin 40X).
Fig. 3 Gram-positive filaments in the centre with Gram-negative periphery (Gram 400X).
ABSTRACT
Introduction: The advancements and applications of redundant tissue sources such as human
subcutaneous adipose tissue (SF) and human umbilical cord matrix (HUCM) tissue are gaining
importance in recent years. Despite these advancements, certain stumbling blocks accounts for lack of
functional improvement of the diseased. One major bottleneck for the prevailing failures relies on
understanding the migratory and homing potential of stem cells. Cell adhesion molecules have been
identified to play a vital role in vascular adhesion, migration, extravasations and ultimately homing.
However, significance of cell adhesion molecules in therapeutic implications has not much concentrated
upon in recent years unlike mesenchymal stem cells. Objective: The present study showcases the
significance of cell adhesion molecules and addresses the major issue on identity of an ideal stem cell
source with maximum benefits. Research methodology: To this end, the cells obtained from the human
SF and HUCM were cultured until P3 and cultured cells were characterized for comparative expression
profile analysis of certain cell adhesion molecules. Outcome of the study: Cultured MSCs derived from
both these aforesaid sources exhibited a significant percentage of cell adhesion molecules, thereby
substantiating its efficacy on tissue homing and migration. Thus, both the sources were found superior
with regards to the expression of CAM and can be clinically exploited. However, umbilical cord matrix
serves a better therapeutic option for allogenic transplantation, which is evident from the sparse
expression of CD 34 at primary culture itself, thereby opening a gateway to circumvent the surgical
complications in clinical transplantations.
Keywords: human umbilical cord matrix, human subcutaneous adipose tissue, stem cells, cell adhesion
molecules, flowcytometry.
Adipose cell culture: Solid fat tissues were derived stem cells were isolated and expanded till
minced and collagenase digested using 0.075% passage 3 in α-MEM (Alpha- Minimal Essential
collagenase type-1, upon washing with 1x Media) based on their adherence. The in vitro
Phosphate Buffered Saline (PBS). Debris and experiments indicated that MSCs (Mesenchymal
lipocyte content from digested sample were Stem Cells) derived from both HUCM (Human
removed by centrifugation to obtain the Stromal Umbilical Cord Matrix) and SF (Subcutaneous
Vascular Fraction (SVF). Erythrocytes in cell Fat) was easily isolated due to plastic adherence.
fractions were lysed using 0.7% NH4Cl solution. The morphological appearance of the
The cells were resuspended and pelleted in PBS. mesenchymal stem cells of these two sources were
Viability and enumeration was done using Trypan initially round epithelial in nature with a transition
Blue method. 3x105 cells were seeded onto 25cm2 of long spindle shaped fibroblastic morphology at
culture flasks (Nunc) and incubated in growth P1 (Passage 1) onwards (Fig.1).
medium (DMEM-LG supplemented with 15% Phenotypic expression We examined the
fetal bovine serum (FBS) and 1% antibiotic expression of ALCAM (Activated Leukocyte Cell
solution) at 37OC, 5% CO2 and 95% humidity for Adhesion Molecule) (CD166), Integrin β1 (CD29)
2-4 days. The primary cultures were subcultured and H-CAM (Hyluronate Cell Adhesion
until passage 3 with media change twice every Molecule) (CD44), CD90 (Cluster of
week. Differentiation 90), CD13, CD34 at passage 0, 1
Phenotypic characterization using and 3 by flowcytometry. The dot plot output of the
flowcytometry About 1x105 cells of each sample flowcytometric analysis of the markers was
were phenotypically characterized for the illustrated (Fig.2). The comparison of surface
expression of following cell surface markers; antigenic expression profiles of cell adhesion
ALCAM, H-CAM, Integrin-β1, CD 13, CD 34 and molecules of these sources were comprehended in
Thy1. The cells were incubated with the antigenic the form of Mean ± SEM (Standard Error Mean)
cocktails (Table 1) at room temperature in dark for and estimated p value symbolized evidence of
20 minutes, washed with BD FACS wash buffer significant variations among the expressions of
and pelleted by centrifugation. The pellets were HUCM and SF samples (Table 2). The MSCs
resuspended in BD FACS flow and analyzed on derived from HUCM and SF shared a consistent
the flowcytometer (BD FACS Aria) using BD positivity of Cell adhesion molecules, ALCAM
FACS-Diva software. (CD166), Integrin β1 (CD29) and H-CAM
Statistical Analysis: The expression profile of (CD44). The expression of the defined MSC as
cell adhesion molecules obtained from well as cell adhesion molecule marker CD90 was
subcutaneous fat tissue and umbilical cord matrix found to possess a remarkable expression of
tissue samples (n=3) were represented as Mean ± greater than 90%. Similarly, both the sources
Standard Error Mean (SEM). The data were showed a constant positive expression for surface
analysed using two-tailed student t-test and the p- enzyme CD13 from passage 0 to passage 3. On the
values were calculated to determine the contrary, a marked variation was obtained in the
statistically significant variations. Results were expression profile of CD 34 positivity in MSCs
considered statistically significant when p<0.05, derived from either of the sources. Interestingly,
p<0.01, p<0.001, p<0.0001. CD34 was found to be negligible in HUCM right
from passage 0 opposite to the expression
RESULTS identified in SF (Fig.3), indicating imperativeness
Cell Culture: The human umbilical cord matrix of HUCM in allogenic transplantation.
(n=3) and subcutaneous adipose tissue (n=3)
ABSTRACT
This was a retrospective analysis study done to identify the results of Philos plating for the proximal
humeral fractures. The analysis was done on 11 patients with fracture to proximal humerus. The clinical
and functional outcome based on X ray, Constant score, DASH score were analyzed and complications
were studied in detail and discussed with literature following which the conclusions were made in this
study.
were males. The mean age in the study group was Constant score was 81.16 with minimum of 55 to
54.4 years and ranged from 17 years to 81 years. maximum of 100 (Figure 1). The results based on
In the above selected patients the nature of injury, Constant score was classified as excellent of 50%
the fracture pattern, neurovascular deficit and any cases, 16.6% of good result, 16.6% of moderate
previous significant history of hospitalization were and 16.6% of poor results. The mean DASH score
recorded in a proper performa. Patients underwent was 13.03 with minimum of 0.83 to maximum of
surgery either under regional, general or combined 41.9.
anaesthesia. Fracture was approached through the
deltopectoral approach. Long 5 holed plate or DISCUSSION
short 3 holed Philos plate was used. Standard post The results of the present study were compared
operative physiotherapy protocol was followed in with various literatures. The sex incidence, age
the study. Patients were followed up till the incidence were compared with Peter et al. 1 series,
fracture union. X rays were taken to evaluate the Baker et al.2 study, Bjorkenheim et al.3, Reto et
radiological union and Constant score, DASH al.4 study. The total revision surgery (Figure 2)
score were followed to assess the functional rate in the present study was 27.27%. Reto et al.4
outcome. reported 25.94 % of complications (Figure 3)
which included loss of reduction, screw
RESULTS perforation, loosening, implant breakage and
There were total of 11 patients in which 9 were avascular necrosis. There revision surgery rate was
females and 2 were males. The age group in the 19.6%. The complications rate reported by Sudan
study was from 18 years to 81 years with mean of et al.5 was 19.34% and included implant breakage,
54.45 years. The maximum age incidence was avascular necrosis and non union. Wright et al.6
between 41 years to 60 years. There were 8 reported 30% of fracture collapse and 10% of
patients with 2 part fractures and 3 patients with 3 revision surgery. Peter et al.1 reported 25% of
part fractures. Ten patients had fracture on right complication rate in their study and 18.75% of
side and one patient had fracture on left side. The revision surgery rate. . The mean constant score in
commonest mechanism of injury was following the study was 81.16 which ranged from 55 to 100.
trivial trauma like fall with out stretched hand in There were 50% excellent result, 16.6% good
old population and in younger group the mode of result, 16.6 % moderate result and 16.6% poor
injury was following high velocity injury. All the result. The mean Constant score in Bjorkenheim et
patients were taken for surgery and fracture was al.3 series was 73 which ranged from 30 to 93. The
approached through deltopectoral approach. For mean Constant score in Reto et al.4 series was 73
seven patients 3 holed Philos plate was used to fix and ranged from 13 to 100. In the study reported
the fracture and for four patients 5 holed Philos by Koukakis et al7. the mean Constant score was
plate was used. Patients were regularly followed 76.1 and ranged from 30 to 100 (Figure 4). The
up till fracture union. Physiotherapy was started mean DASH score in the study was 13.03 with the
from second post operative day. There were minimum of 0.83 and maximum of 41.9. The
complications seen in three patients. They mean DASH score in Baker et al. (2004) study
included impingement of screws, loss of was 33.9 and ranged from 4 to 92.
abduction, continuous pain, collapse of head and
implant back out (X-ray 1 and 2). All these CONCLUSION
patients underwent implant removal. The From the present retrospective study following
functional outcome was measured based on conclusions may be drawn
Constant score and DASH score. The mean
1) Proximal humeral fractures are difficult implant. J shoulder and elbow surgery, 2007.
fractures to treat and that even though with the March-April:16(2) 202-7.
fixed angle screw system on the plate has been 2. Baker P N, Candal Couto J, Ranan A and
designed to avoid cut out in osteoporotic bone, the Bennison K. Clinical outcomes
failure rate is high (about 30%). followingPhilosplatefixationproximalhumerus,f
2) Due to the spherical shape of the humeral head ractures,www.bess.org.uk/meetings/archive.asp
with 2-D screening there is risk of penetration of ?aspyear=2005&abstract=218
screws into the glenohumeral joint. 3. Bjorkenheim JM, Pajarinen J and Savolaine V.
3) It is a technically demanding surgery thus a Internal fixation of proximal humerus fractures
longer learning curve. with locking compression plate, Acta Orthop
4) The results are similar to the published Scand December 2004; 75(6): 741-745.
literature in terms of complication rates. 4. Reto H Babst, Christoph Sommer, Christian
Limitations in the study: The present study is Bahrs, Rainer Heuwinkel, Christain Hafner,
from a small group with less follow up sample. Parvo Rillman, George Kohut and Mathias
Further recommendation: A further multi centric Muller, Open reduction and internal fixation of
study with large group with more representation in proximal humerus fractures with an angular
all age group and a comparative study with other stable form plate,
procedures may be necessary for better www.hwbf.org/ota/am/ota06/otapa/OTA06126
conclusion. 5.htm
5. Marc Saudan, Richard E Stern, Anne Lubbeke,
ACKNOWLEDGEMENT Robin E Peter and Pierre Hoffmeyer. Fixation
Authors acknowledge the immense help received of fractures of the proximal humerus:
from the scholars whose articles are cited and Experience with a new locking plate,
included in references of this manuscript. The www.hwbf.org/ota/ota3/otapa/OTA03634.htm
authors are also grateful to authors / editors / 6. D M Wright, A Acharya, R H Austin and J C
publishers of all those articles, journals and books Kaye. Complications and suggestions
from where the literature for this article has been encountered with the philos plating system, J
reviewed and discussed. I extend my sincere Bone Joint surgery 2004; 87-B:165e.
thanks to Dr L Cochrane, Mr. David Nicoll, Mr. C 7. Koukakis Athanasios, Apostolou Constantinos,
A Wigderowitz and Prof J Abboud, Department Taneja Tarun. Fixation of proximal humeral
of Orthopaedics, Ninewells hospital, University of fractures using the philos plate, early
Dundee, UK for their esteemed guidance and experience, Clinical orthopaedics and related
untiring help during the study. research 2006; 115-120.
REFERENCES
1. Peter S Rose, Christopher R Adam and Michael
E Torchin. Locking plate fixation for proximal
humerus fractures, initial result with new
30.00%
25.00%
20.00% Present study
15.00%
10.00% Wright et al (2004)
5.00%
0.00% Peter et al (2006)
Revision
surgery Reto et al (2006)
100%
Present study
80%
60% Bjorkenheim et
40% al
Reto et al 13%
20%
0% Koukakis et al
Minim um
X- Ray 1 showing fracture collapse, implant migration and screw back out
ABSTRACT
Background: Prevalence of overweight and obesity has increased for the past few decades. World Health
Organization refers obesity as a global epidemic. There is a need to assess the prevalence and to find the
factors responsible, so as to implement timely interventions.
Aims: To assess the prevalence of overweight and obesity among school going children and the factors
responsible for the same. Method: The study was conducted in children studying at a private school in
Bangalore aged 12-15years. Obesity was assessed using International Obesity Task Force criteria based
on the body mass index. Pretested and semi structured questionnaire was used to collect the data on
physical activity, eating habits and leisure time activity.
Results: The overall prevalence of overweight was 10% and obesity was 5% among 761 adolescents
studied. The prevalence of overweight and obesity was 11% and 4% among boys and 9% and 5% among
girls respectively. Factors like junk food, chocolate eating, physical inactivity and time spent in watching
television and computer gaming were directly related to overweight and obesity.
Conclusion: Overweight and obesity are multifactorial and needs a multi pronged interventions at the
earliest for control and prevention.
What this study adds:
1. Obesity and overweight among school going children are the common nutritional problems in
developing countries including India.
2. Prevalence of overweight and obesity is more in school children in urban areas, there is no gender
difference and lack of physical activity is one of the main culprits.
3. During annual health assessment of children, equal importance has to be given for undernutrition as
well as overnutrition; policy has to be made to inculcate adequate physical activity and healthy dietary
habits compulsorily in addition to academic excellence.
Keywords: Overweight, Obesity, leisure time activity, Commutation, Body mass index, adolescence
chance of obesity, premature death and disability leave the children little or no time to play or
in adulthood. In addition to increased future risks, exercise. Studies on urban Indian school children
obese children experience breathing difficulties, from selected regions report a high prevalence of
increased risk of fractures, hypertension, and early obese and overweight children.9 Hence this study
markers of cardiovascular disease, insulin was undertaken to assess the prevalence of
resistance and psychological effects.4 Once overweight and obesity among high school
considered a problem of affluent developed children (12-15years) and to determine the factors
countries, obesity is fast growing to enormous responsible for it.
proportions in many developing countries also.
Rapid economic growth has overcame the METHOD
nutritional, socio-economic and health status of Design: A cross-sectional study was conducted in
many countries.5 Obesity has increased markedly a private school in an urban fast growing city,
with this nutritional evolution in most Asian Bangalore. All the children belonging to 8th, 9th
Countries. A similar nutritional transition is and 10th standard (12-15years) were included for
underway in India as well. In addition to the the study. A prior informed consent for the study
nutritional and socio-economic transitions, the was taken from the school administration. Those
behavioural transition of children is also possibly children who were absent on those days of study
contributing significantly to the rapidly rising were called on a separate day and a sincere effort
prevalence of obesity. Unhealthy eating habits and was made to cover all children. Data regarding
physical inactivity are the major culprits physical activity, leisure time activity, mode of
There is significant increase in the consumption of commuting to school, food preferences, eating
fats, sugars and energy rich foods. Rising income chocolates, fast food and junk foods, time spent
and urbanization leads to substitution of servants for television viewing, computer gaming were
or appliances for physical household work and collected using a pre-tested, semi-structured
motor vehicles for short distance travelling, questionnaire. The anthropometric data, height and
instead of walking or cycling.6 Junk food and fast weight were also recorded for all the children
food has replaced healthy homemade meals due to using the standard equipments.
paucity of time. This attitude has altered the lives Weight was recorded using a calibrated and
of school children in terms of bad eating habits, standardized mechanical bathroom weighing scale
lack of exercise, habits like computer gaming and to nearest 100grams. Height was recorded using
television viewing replacing the outdoor games. the standard wall mounted anthropometric height
The causes of childhood obesity are multifactorial. board to the nearest 0.1 cm. Two readings of
Overweight and obesity in children and adolescent height and weight were taken and the mean was
is generally caused by a lack of physical activity, considered as final.
unhealthy eating patterns resulting in excess BMI was calculated using the standard formula-
energy intakes, or a combination of both.7 Changes weight (kilograms)/height (meter2) and BMI
in dietary and physical activity patterns are often percentile was calculated according to Barlow SE
the result of environmental and societal changes and Expert Committee recommendations.10
associated with development and lack of Assessment of overweight and obesity:
supportive policies in sectors such as health, International Obesity Task Force (IOTF)
agriculture, transport, urban planning, classification was referred for the classification of
environment, food processing, distribution, the adolescent children as overweight or obese.11
marketing and education.8 Added to this, academic Overweight was defined as children BMI value
competitiveness, overzealous parents and teachers between 85th-95thpercentile for a specific age and
gender. Similarly obesity was defined as with BMI difference in overweight and obesity among them
value above 95th percentile for that specific age was found to be not significant statistically.
and gender. Data regarding the leisure time activity during
On completion of the study, we provided health games period at school, after school at home and
education and created awareness regarding on holidays, revealed that 70% of the children
overweight and obesity, their implication on their involved in playing outdoor games while among
health and how they can inculcate healthy lifestyle the remaining 5% were involved in household
practices. activities and the rest spent time either reading,
Statistical analysis gaming on the computer or sleeping.
Sample size was calculated as 788 considering the Regarding the mode of transportation from home
prevalence of overweight as 17.8% and e=2.67 as to school and back 45% used school bus, 20%
in the study.12 The data collected was collated were dropped by their parents in their own
using Excel spreadsheets with double checking of vehicles and the remaining walked or came by
errors. The results were assembled in tabular and cycling.
graphical formats. All data was expressed as About 55% of children brought home made food
percentage. Comparison of nutritional status for lunch, while 30% brought bakery products and
between boys and girls was done by using chi the remaining ate at the fast food centres near their
square test. P <0.05 was considered statistical school.
significant.
DISCUSSION
RESULTS The overall prevalence of overweight among
A total of 761 children in the age group of 12- children was 10% and obesity was 5%. The
15years were included in the study. Among them prevalence of overweight was 11% among boys
421children (55.32%) were boys and 340 and 9% among girls; 4% and 5% were obese
(44.68%) were girls. respectively. In a study by Kotian MS et. al, it was
The Table 1 depicts the summary of the assessed reported that prevalence of overweight was 9.9%
children’s BMI for age and their classification into and obesity was 4.8%.13 They also reported that
those who are overweight and obese as per overweight and obesity among boys was 9.3% and
International Obesity Task Force (IOTF).11 On the 5.2% and among girls was 10.5% and 4.3%. Our
whole there were 10% (76) of the children who study reflects similar findings. A similar study in
were overweight i.e. BMI value equal to or more Hyderabad showed that the prevalence of
than 85th percentile but less than 95th percentile for overweight was 7.2% among 12-17year group.14 In
that age and sex. There were 5% (38) children who this study, it was observed that there was not much
were obese i.e. BMI value equal to or more than difference in the prevalence of overweight and
95th percentile for that age and sex. Another obesity between genders. It was 11% and 4% for
incidental point of note worth is the presence of boys and 9% and 5% for girls, respectively.
19% of undernourished children. The prevalence Prevalence of overweight and obesity was more in
of overweight 11% among boys and 9% among the males as compared to females in the studies
girls and 4% and 5% were obese respectively, conducted at Delhi, India14 and Punjab.9
according to IOTF.11 Prevalence of overweight was 14.3% among boys
As observed in table1, the difference in the and 9.3% among girls and obesity was 2.9% in
nutritional status among boys and girls was boys as compared to girls which was 1.5% as
statistically significant. (p=0.002). But the reported by Ramesh Goyal et al.8 The presence of
overweight and obesity on almost same level in
our study may be attributed to the equal amount of urban areas has been replaced by high calorie
encouragement and participation of both girls and snacks and junk foods and also that unsafe roads,
boys in the physical activities. This is to be lack of free space for playing and increased
appreciated on the part of the school television viewing and computer use has made life
administration in inculcating this attitude. sedentary comparable this study.23
One of the major reasons for childhood obesity Some of the children who were obese were found
was watching television, using computers for long to be academically low achievers, rarely mingled
durations instead of outdoor games. Physical with others and spent most of their free time
activity during leisure period either at school or at sleeping, eating junk food or reading non-
home was found to be related inversely to academic books. This may be either their low
overweight and obesity. Children with outdoor achieving nature clubbed with eating habits made
game activity in association with good eating them obese or it may be that the combination of
habits were found to be healthy and protected from obese, loneliness made them low achievers- point
obesity and overweight. Similar reports were which needs further study. The best measure
given by a study by Kotian MS et al 13, Laxmaiah available to prevent and protect the child from
A et al at Hyderabad 14 and Eisenman JC et al in overweight and obesity is to start at their young
US 16 Supreet et al in a study at Punjab.9 Moazeri age itself, for the dietary habits and practices
H et. al reported that the analysis of association instilled at their young age will last their entire
between BMI and physical activity in children lifetime.
revealed that as the amount of physical activity Limitations of this study- In our study waist-hip
increased the prevalence of overweight and ratio and skin fold thickness were not used for
obesity decreased in Tehran17 and similar findings assessing the nutritional status of overweight and
were reported by Foldmark CE et al18 Kelishadi R obesity, the application of international standards
et al.19 In our study as in table 2, 70% of the of BMI in an Indian setting may have limitations.
children have mentioned that one of the chief Quantification of physical activity and calorie
passtime is television viewing. Similarly Bar-or O intake could have been done before correlating
et al have reported that the sedentary lifestyle of with overweight and obesity. Information
children and adolescents has been attributed to regarding the parents’ and familial history of
television viewing, computer games, internet, overweight and obesity could have been
overemphasis on academic excellence and ever considered.
increasing automated transport.20
The habit of eating chocolates and junk food was CONCLUSION
more in those who were overweight and obese To conclude, among the 761 children in the study,
than other children. This is similar to the one the overall prevalence of overweight was 10% and
reported by Ramesh K Goyal et al.8 In their study obesity was 5%. Overweight and obesity were
they have stated that junk food and chocolate 11% and 4% among boys and 9% and 5% among
eating habit have positive relation with prevalence girls respectively. The prevalence was high among
of obesity and overweight. These correlate well children who were physically inactive, using
with previous reports which suggest that junk motor vehicles for commuting, eating junk foods,
food(bakery items, pizza, burger, cheese, butter, chocolates and those who were spending more
oily items) and chocolate intake tends to be more time indoor either watching television or computer
common among overweight and obese adolescents gaming. This problem of obesity and overweight is
than among normal weight adolescents.21,22 A truly a multifactorial one.
study by Bhave S et al have reported that food in
The obese adolescents reach adulthood and add to reviewed and discussed. No financial funding was
the spiralling problem of diabetes, heart disease taken for preparation of this manuscript.
and hypertension. The impact of this on the health ETHICS COMMITTEE APPROVAL
scenario of our country will be devastating and Name of committee- Institutional Ethics
alarming. Obesity does not have any mentioning in Committee of Sri Devaraj Urs Medical College,
the nutritional health status of school children, Kolar, Karnataka, India. Approval reference
may be, due to the large number of number-No:DMC/KLR/MEU/IEC/CER/229/2011-
undernourished children in our country even to 12. DATED 16-05-2012.
this day of commendable growth and development
in other fields. REFERENCES
Unless effective interventions and preventive 1. World Health Organization. Preventing chronic
strategies are initiated at the local and national diseases. A Vital investment. World Global
level, the present increasing trend of obesity Report.Geneva: World Health Organization;
suggests that the trend of increasing cardiovascular 2005. (Accessed January 4, 2010, at
diseases in adults observed in the recent decades http://www.who.int/chp/chronic_disease_report
will increase even further. This calls for concerted /full_report.pdf)
effort targeted at improving lifestyles of children 2. De Onis, M.; Lobstein, T. Defining obesity risk
and adolescents. status in the general childhood population:
It is appropriate time that both under-nutrition and Which cut-offs should we use? Int J Pediatr
over-nutrition are given equal importance during Obes 2010; 5: 458-60.
health assessment of children annually. Measures 3. Reilly, J.J.; Kelly, J. Long-term impact of
have to be taken to improve the dietary habits overweight and obesity in childhood and
which last, life time if imparted and implemented adolescence on morbidity and premature
at young age itself. The physical growth and mortality in adulthood: Systematic review. Int J
development has to be made a part of the overall Obes 2011; 35: 891-98.
personality development on par with academic 4. Raj M, Sundaram KR, Paul M, Deepa AS,
excellence. Kumar RK. Obesity in Indian children: Time
If done at the earliest with right earnest, our trends and relationship with hypertension. Natl
children can grow up into healthy young adults Med J India 2007; 20:288-93
with better health indices and parameters for a 5. WHO Technical Report Series 916. Diet,
better India. nutrition and prevention of chronic diseases.
Geneva: WHO; 2003. (Accessed January 4,
ACKNOWLEDGEMENTS 2010, at http://whqlibdoc.who.int/
We would like to thank the head of the institution, trs/who_trs_916.pdf)
the teachers and more so the students for having 6. Waker H. Simple obesity in children. A study
been very co-operative in the collection of the on the role of nutritional factors. Med Wieku
data. We thank our entire department faculty for Rozwoj 2006; 10:3-191.
being encouraging and supportive throughout this 7. US Department of Health and Human Services.
study. Authors acknowledge the immense help Childhood Obesity. (Accessed January 4, 2010,
received from the scholars whose articles are cited at
and included in references of this manuscript. The http://aspe.hhs.gov/health/reports/child_obesity
authors are also grateful to authors / editors / /htm)
publishers of all those articles, journals and books 8. Goyal RK, Shah VN, Saboo BD, Phatak SR,
from where the literature for this article has been ShahNN, Gohel MC, et al. Prevalence of
ABSTRACT
Background: Accurate quantification of clinically significant changes of balance impairment is a key
factor in understanding the effects of various disorders and treatment techniques on balance, the sway
graph instrument is designed to measure the shift in COG in standing posture.
Objective: To test the reliability of sway graph and to develop it as an accurate outcome measure of
balance impairments.
Subjects: One hundred and eighty nine community dwelling older adults (Mean age: 66 years)
participated.
Study design: Prospective study design
Methods: Subjects were tested twice with sway graph by the same examiner on consecutive days to
evaluate intra rater reliability and Subjects were tested by two examiners with sway graph to evaluate
inter rater reliability. The reliability was calculated using intra class correlation coefficients (ICC).
Results: The ICC result for inter rater reliability and Intra rater reliability of sway deviation variables
were r-0.98, r-0.96 for A-P swing and r- 0.96, r-0.97 Lateral swing. The SDD of the variable were
19.391& 19.828 for A-P swing and 13.837&14.281 for Lateral swing. Cronbach’s alpha index score were
very proximal to 1(0.983, 0.981) proving excellent internal consistency.
Conclusion: The study showed good reliability results for sway graph and notably minimal systematic
error in measuring sway with in elderly subjects.
Key words: Centre of gravity (COG), Balance, Reliability, Sway
its force generating capacity and a thorough this study is to test the reliability of sway graph
evaluation of the independent contribution of in elderly population. If proven to be reliable
balance requires evaluating these other
this tool could very easily become a major
relationship to accurately determine the true
magnitude of effect1 innovative step towards development of new
Several tools have been reported in literatures to tool to measure balance in various postures.
measure balance which includes centre of
pressure (COP), Brunel balance assessment, METHODS
Berg balance scale, Trunk impairment scale, arm Subjects
A total of 189 subjects were selected from a
raise and forward reach tests, step/tap and step- population of 562 community dwelling old
up tests reached and Time up and Go (TUG) aged subjects with a mean (S.D) age of 66 years
tests.6 A recent review of literatures shows (4.0), the mean height was 159 (5.5) cm, the
mean weight was 59 (10.3) kg.
dissatisfaction with parameters of static postural
The scholars involved in the study were all
recordings has led researchers to develop faculties of our medical college and none of the
dynamic testing protocols using moveable plat- subjects reported any neurological condition,
postural hypotension, musculo- skeletal
forms, visual images and weighted pulleys, all
impairments and psychological disorders. The
designed to test subjects reaction to external study was approved by the institutional ethical
forces.3, 4, Hausdortt JM states that there seems committee and all the subjects provided written
informed consent.
to be a need to perform reliability
assessments of postural control in groups Raters
with identified fallers and non-fallers. No The study involved four raters (I, II, III, and IV)
reliability studies have been reported that to record sway graph. The rater I and III were
post graduate students of the institution and they
specifically included fallers. However, since possess an under graduate degree with at least 1
one-third of community-dwelling people years of clinical experience and rater II &IV
over 65 years of age experience one or more were consultant physiotherapist of the institution
with vast experience.
falls each year, it seems important to include
Procedure
elderly subjects in reliability studies on As an initial step in the beginning session, all
balance measuring tools.15Clinical studies need raters tested all subjects. The order in which the
raters tested the subjects was randomly assigned
an objective and valid measure of balance to
from a series of order obtained from a numbers
compare groups of patient, effectiveness of encoded Latin square design. The test was
treatments, prognosis and progression. We have demonstrated to subjects prior to
commencement and standardized instructions
attempted to develop a safe, less expensive and
were given. The subjects were made to wear the
accurate outcome measuring tool (sway graph) sway graph device, which consist of a lumbar
which can quantitatively measure swaying in belt, a back pointer with pen holder (matching
standing postures and the primary objective of S2 spinous process) and graph sheet to record
the sway readings with two degree of freedom
which measures Anterior-Posterior swing and similarity between the data of the raters and the
Lateral swing. Now, the subjects were made to smaller value of SE is indicating very minimal
stand on a static platform e.g. floor for 45 systematic error. Cronbach’s alpha reliability
seconds with their back facing the table with estimates were 0.981
graph, so that the pen is in contact with the Intra rater reliability
graph sheet, a standard foot position (4 inches There was no significant difference between
apart) and angle (150 toe out) was used and the Test 1 and Test 2 of rater I in both variables. The
table height is adjustable in par with the subjects ICC value (0.96, 0.97) and small SE value (0.5,
height. After the first reading the subjects were 0.5) of table 01 clearly indicates existence of
turn over to the next rater and the procedures minimal random and systematic error. The
were repeated. Each rater was unaware of the standard deviation value of both variable were
scores of other raters and the marks on subjects A-P swing 19.828 and Lateral swing 14.281.The
are removed following each rater, the subjects data of both Test 1 and Test2 of the rater showed
were not shown their graph pattern after the test. excellent similarity as suggested by r value.
To obtain intra rater data’s the test was Cronbach’s alpha reliability estimates were
conducted again after a week period by rater I. 0.983
STATISTICAL ANALYSIS:
All data were analyzed statistically using SPSS DISCUSSION
20 for windows software. The Intra class Though impairment in balance is acknowledged
correlation coefficient was used as parameter of as a major predictor of falls, there have always
reliability and ICC model 3 was used to been limitations in recommending specific
determine intra rater reliability, inter rater clinical assessment scales of balance.8, 9, 10, 11 Our
reliability was computed using ICC model 2. study suggests that Antero-Posterior swing and
The 95% confidence interval was used to Lateral swing measurement by sway graph
determine statistical significance. Cronbach’s device can be reliably performed by the same
alpha reliability estimates were used as an index therapist and also by different therapist with
to determine internal consistency or average accuracy. The amount of measurement error
correlation and higher the score, the more being reasonably low is indicative of an
reliable the generated scale is. Nunnaly (1978) evidence to support the use of sway graph as an
has indicated 0.7 to be an acceptable reliability objective measurement tool among other scales
coefficient but lower thresholds are sometimes in practice.
used in the literature.18 The clinical assessment of balance is used as a
means for measuring the integrity of the postural
RESULTS stability system, which involves the integration
Inter rater reliability of information from somatosensory,
The mean value of Anterior –Posterior swing musculoskeletal, visual, and vestibular systems
deviation and Lateral swing deviation for both and cognition.12 According to Horak and
the raters were shown in Table 01.Inter rater Shumway-Cook evaluating balance by
reliability was excellent with a high ICC value observing subjects response under given
of 0.98 for Anterior –Posterior swing deviation conditions of varying sensory input provides
and ICC of 0.96 for Lateral swing deviation. information on the mechanism of postural
The standard deviation for both variables A-P control and this approach provides a systematic
swing and LAT swing were 19.391 & 13.837 evaluation. According to David Levine Chattecx
respectively. There was a statistically significant balance system (CBS) has a least reliability in
antero-posterior direction because the base of The authors are also thankful to the engineers of
support is relatively short in this position, but Anna University for helping us in constructing
the postural sway occurs about the ankle joint, the device.
which is physically separated by a large distance
from the centre of gravity of the body.17 The REFERENCES
reliability found in our study may be due to the 1. Horak FB. Postural orientation and
fact that the displacement of COG is recorded equilibrium: what do we need to know about
from close proximity to S2 unlike pressure neural control of balance to prevent falls.
distribution recorder which is used to measure Age Ageing. 2006; 35 (suppl 2):ii7–ii11.
balance, error can be introduced from foot 2. Berg K.Balance and its measure in the
movements without COG displacement. The elderly: a review Physiother can 1989;
most important characteristic feature of the 41:240-246.
device has been though, there is a difference in 3. Nashner .Adapting reflexes controlling the
the skill levels and experience of the therapists human posture. Exp Brain Res 1976;26:59-
(raters) there exist no short fall in the 72
repeatability of balance measurements by Sway 4. Nashner LM.Fixed patterns of rapid postural
graph. The sway graph device constructed by responses among leg muscles during
our team measure with only two degree of stance.Exp Brain res 1977; 30:13-24.
freedom and it allows only static balance 5. Nashner LM, Black FO, Wall C.Adaptation
measure in standing posture, which makes it to altered support surfaces and visual
rather odd to be used in certain population of conditions in patients with vestibular deficits
patient with severe impairments. But, with the neurosci 1982; 2:536-544.
given potential uses and reproducibility of this 6. SF Tyson LA Connell, How to measure
tool to all health care professionals, further balance in clinical practice Clinical
development and testing are in order. rehabilitation September 2009; 23: 824-840.
7. Shumway-Cook A, Horak F.B Assessing the
CONCLUSION influence of sensory interaction on balance.
This study clearly demonstrates the potential of Suggestion from the field. Phys Ther 1986;
the device as a clinical tool with good 66:1548-1550.
reproducibility; sway graph device will 8. Scott V, Votova K, Scanlan A, Close J.
definitely add more cost effective objectivity to Multifactorial and functional mobility
static balance measurements in standing posture. assessment tools for fall risk among older
More over these results may form a basis for adults in community, home-support, long-
further research examinations of this tool with term and acute care settings. Age Ageing.
more added features and to investigate validity 2007; 36: 130–139.
issues. 9. Perell KL, Nelson A, Goldman RL, et al.
ACKNOWLEDGEMENT Fall risk assessment measures: an analytic
Authors acknowledge the immense help review. J Gerontol A Biol Sci Med Sci.2001;
received from the scholars whose articles are 56:M761–M766.
cited and included in references of this 10. American Geriatrics Society; British
manuscript. The authors are also grateful to Geriatrics Society, and American Academy
authors / editors / publishers of all those articles, of Orthopaedic Surgeons Panel on Falls
journals and books from where the literature for Prevention. Guideline for the prevention of
this article has been reviewed and discussed.
falls in older persons. J Am Geriatr 15. Hausdortt JM, Edelberg HK, Mitchell Sl,
Soc.2001; 43:664–672. Goldberger AL Increased gait unsteadiness
11. National Institute of Clinical Excellence. in community dwelling elderly fallers. Arch
Clinical Guideline 21: The Assessment and Phys Med Rehabil1997, 78:278-283.
Prevention of Falls in Older People, 2004. 16. Byl NN. Spatial orientation to gravity and
www.nice.org.uk. Accessed June 21, 2005. implications for balance training.
12. Susan W. Muir, Katherine Berg, Bert Orthopedic Physical Therapy Clinics of
Chesworth, et al. Balance Impairment as a North America, October 1992:207-40.
Risk Factor for Falls in Community- 17. David Levine, Michael W.Whittle, MD,
Dwelling Older Adults Who Are High Jeannette A. Beach et al Test-retest
Functioning: A Prospective StudyJ Apta reliability of the Chattecx Balance System in
Phys ther. 2010; 90: 338-347. the patient with hemiplegia Journal of
13. Berg KO, Maki BE, Williams JI, et al. Rehabilitation Research and development,
Clinical and laboratory measures of postural Vol.33, February 1996, 36-44.
balance in an elderly population. Arch Phys 18. J.Reyanldo A.Santos Cronbach’s Alpha: A
Med Rehabil. 1992; 73:1073–1080. tool for assessing reliability scale.Vol.37,
14. Berg KO, Wood-Dauphine´e SL, Williams April 1999.22-25.
JI, Maki B. Measuring balance in the
elderly: validation of an instrument. Can J
Public Health. 1992; 83(suppl 2):S7–S11.
Table: 01 Intra Correlation coefficient and description of intra and inter rater reliability in Anterior –
Posterior swing scores
Table: 02 Intra Correlation coefficient and description of intra and inter rater reliability in Lateral swing
scores
MEASUREMENTS INTER RATER INTRA RATER
(Lateral-Swing) RELIABILITY(N=189) RELIABILITY(N=189)
FIGURE 01
SWAY GRAPH DEVICE
HOLDER
PEN
BELT
FIGURE 02
FIGURE 03
SWAY GRAPH
RECORDING
AND CALCULATIONS
ABSTRACT
Introduction: In the identification of sex in human skeletal remains, sacrum is an important bone of the
human skeletal system. Being a component of axial skeleton and because of its contribution to the pelvic
girdle and in turn to the functional differences in the region between the sexes, it has an applied
importance in determining the sex and related disorders with the help of measurements carried upon it.
Therefore a study for sex determination was carried on 50 sacra, in the department of Anatomy Kasturba
medical college, Manipal. India
Materials and methods: The parameters used for the study were the different dimensions of the sacrum.
Using the same the sacral index, auricular index were calculated. The morphology of the sacral hiatus and
the extensions of the auricular surface were also studied. All the measurements were carried out using the
digital vernier calliper. The readings were recorded and their mean and standard deviations were
calculated.
Results and conclusion: All the parameters chosen for the study were found to be reliable in sexing the
sacra and identifying the related disorders.
Keywords: Sacrum, sacral index, auricular index, sacral hiatus, auricular surface, sex determination
help of measurements carried upon it (MM Patel et are from Agra, Varanasi and Burdwan and regions
al, 2003). respectively. Therefore, the present study was
Sacrum is a large, triangular bone formed by undertaken with a view to study the sex-
fusion of five vertebrae and forms postero-superior differences in the South Indian population.
wall of pelvic cavity, wedged between the two
innominate bones. Its blunted caudal apex MATERIALS AND METHODS
articulates with the coccyx and its superior wide The present study was performed on 50 adult sacra
base with the fifth lumber vertebra at the (25 male and 25 female) obtained from the
lumbosacral angle. Since it is a component of axial Department of Anatomy, Kasturba Medical
skeleton and because of its contribution to the College, Manipal, India. All the sacra were normal
pelvic girdle and in turn to functional differences and fully ossified.
in the region between the sexes, it has an applied The following parameters of sacrum were
importance in determining the sex with the various measured using digital Vernier calliper. (Figure I)
measurements carried upon it (Standrig et al, 1. Maximum width of the sacrum: was
1988). measured on the anterior surface with the
The sacral hiatus is an opening present at the sliding calliper by taking two points at the
caudal end of the sacral canal. It is formed due to upper part of auricular surface anteriorly (or
the failure of fusion of laminae of 5th sacral lateral most part of alae of sacrum).
vertebra. Sacral hiatus has been utilized for 2. Maximum height / length of sacrum:
administration of epidural anaesthesia in obstetrics measured along the midline from the antero-
as well as in orthopaedic practice for treatment and superior margin of the promontory to the
diagnosis. The area of auricular surface defines the middle of antero-inferior margin of last sacral
magnitude of weight transmission to the hip bones vertebra.
(Standrig et al, 1988). 3. Width of base / transverse diameter of the
Though sacrum is often considered to be an body of 1st sacral vertebra: measured by
important bone, while dealing with sex differences taking one point on each side of the lateral
in skeletal material, there is paucity of metrical most part on the superior surface of the body of
data available for this bone. Metrical study of 1st sacral vertebra.
sacrum has been done by various authors (Wilder 4. Transverse diameter of the wing (ala):
H. in 1920, Faweet E. in 1938, Davivongs V. measured on both the sides by taking one point
in1963). Jit I et al, (1968) and Singh S et al (1968) on the lateral most part of superior surface of
advocated the demarking point, which identify the the body of 1st sacral vertebra and another
sex with 100% accuracy. Singh S et al (1968) have point on the lateral most part of the alae.
reported that even within the same general 5. Auricular surface length: It is the vertical
population, mean value may be significantly auricular length, measured on the lateral aspect
different in bones from different zones. Singh and of sacrum by taking one point on the upper
Singh have shown that demarking point should be most part of auricular surface and another point
calculated separately for different regions of on the lower most part of the auricular surface.
population because the mean of a parameter 6. Extensions of auricular surface in relation to
differs in values in different regions. The available the sacral segments and morphology of the
literature clearly shows that the Indian sacra have sacral hiatus were also observed.
not been studied widely except by Mishra et al Using the above parameters sacral index, auricular
(2003), Singh et al (1988)and Raju et al (in 1981), index on either side were calculated.
Jana et al (1988). The materials studied by them 7. Sacral index: Width × 100 / Height.
8. Auricular index: Length of auricular surface × regions. Comas & Charles (1961) reported a wide
100 / Width variation between the male and female in the
The readings were recorded, tabulated and Chinese, Negroes and Bushmen. Davivongs
subjected for statistical analysis. (1963) in his study of Australian aboriginal sacra
has re-ported mean length of sacrum to be
RESULTS 96.52mm and 88.12mm in the male and female
The mean and standard deviations of various respectively, which is very much in agreement
parameters are given in Table1. with the measurements in the present study.
The mean values of width and height of the The mean width (Table 1) of the male sacra in the
sacrum, transverse diameter of the wing and the present study is 100.1mm which is close to similar
auricular surface length was more in males as observations made by Mishra et.al (2003).in the
compared to females. However the width of the Agra region (105.34mm) and Raju et al. (1981) in
base was higher in females than in males. the Varanasi region (105.33mm) respectively.
The mean values of sacral index (Table 2) and However, in the females the present study showed
auricular index (Table 3) is higher in females than a lesser value (99.6mm) than that of Agra and
in males. Varanasi regions. In the Australian aboriginal
The extension of the auricular surface females, the maximum width of sacrum was
corresponding to the sacral segments was also 101.24mm, which is higher than that of males
noted. (Table 4) (99.92mm) of the same race (Davivongs V, 1963).
Morphology of the sacral hiatus was also studied Thus there exists a regional and racial difference
(Figure II, III, IV) and tabulated in Table 5. Also in the length and width of the sacrum. The female
complete agenesis of dorsal bony wall of sacral ranges of transverse diameters of body of S1
canal (Figure V) was observed in one of the sacra. (Table 1) are narrower than that of males and fall
within the corresponding male ranges. The result
DISCUSSION is that the separation of any female sacrum from
The sacrum has always attracted the attention of the males by the above measurements alone is
the medico-legal experts for establishing the sex, impossible. The differences in the length of
because of its contribution to pelvic girdle and auricular surface (Table 1) between the males and
associated functional sex differences. females is significantly higher in male than in
While teaching sex differences in bones much female supporting the normal description in the
stress is laid on the importance of sacrum. text books of Anatomy that the auricular surface
Actually, very little data is available to test the for articulation with ilium is shorter in females
validity of the number of parameters described to than that of males.
identify the sex of sacra (Devivongs V, 1963). Based on the sacral index, anthropologists have
The demarking points of various parameters will classified the sacra into specific groups. The mean
help to identify the sex with certainty, which is of sacral index (Table 2) of the male and female
paramount importance in medico-legal cases. sacra in the present series are 115.92mm and
The mean length (Table1) of the male sacra in the 125.2mm respectively falls under the platyheiric
present study is 87.2mm, which is lower when group (sacral index>106). Similar observation was
compared to that of Agra region (107.53mm) reported by Martin (1960) (males: 112.4mm and
studied by Mishra et al. and the Varanasi region females: 114.8mm), Raju et al (1981) and
(104.96mm) studied by Raju et al (1981). The Davivongs (1963). However Mishra et al., in his
mean length of the female sacra (81.65mm) is also study has classified the male sacra (sacral index:
shorter when compared to Agra and Varanasi 98.22mm) under dolichoheiric group (narrow
Table 1: Showing the mean and standard deviation of various parameters included in this study
Parameters Sex Mean (mm) S.D
Width of sacrum M 100.1 1.47
F 99.6 1.0
Length M 87.2 1.17
F 81.65 1.26
Transverse diameter of alae M 31.2 0.5
F 30.0 0.3
Auricular surface length M 56.4 0.7
F 54.2 0.5
Width of base M 49.8 0.5
F 50.0 0.6
Table 2: Showing the mean and standard deviation of the sacral index calculated in males and females. (Mm-
millimeter)
Male(mm) Female(mm)
Table 3: Depicting the mean and standard deviation of the auricular index calculated in males and females on
both sides. (Mm- millimeter)
Male(mm) Female(mm)
Left Right Left Right
Mean 62.52 62.69 69.38 70.26
S.D 10.02 9.67 11.58 10.27
Table 5: Morphology of the sacral hiatus. (Higher incidence in males and females are boldfaced.)
Morphology Male Female
% %
Inverted V 54.5 24.1
Inverted U 18.2 37.9
Elongated V 9.1 10.3
Elongated U 9.1 10.3
Irregular 9.1 17.2
Fig I: Showing pattern of taking various Figure II: Showing irregular sacral hiatus
measurements using Vernier calliper
Figure III: Showing inverted V shaped sacral Figure V: Showing complete agenesis of dorsal
hiatus bony wall of sacral canal
ABSTRACT
Objective: we estimate the prevalence of ischemic heart disease in younger age group (< 40 years)
patients with metabolic syndrome. Research Design and Methods: 100 patients who satisfied the
selection criteria were thoroughly examined and undertook relevant routine investigation to assess the
diabetic status, hypertension, and lipid profile. Anthropometry i.e. height, weight, Body Mass Index,
waist circumference and diabetic complication, were selected for Tread Meal Test. Those who are Tread
Meal Test positive were taken for study. Results: The mean value of metabolic syndromes of Waist
Circumference, Triglyceride, High Density Lipoproteins, Systolic Blood Pressure , Diastolic Blood
Pressure and Fasting Blood Sugar in ischemic heart disease patients was (95.67+8.22), (193.10+36.92),
(36.63+3.2), (148.04+12.63), (89.43+4.94) and (130.60+25.83) respectively. All criteria of metabolic
syndrome were significantly different in between Ischemic Heart Disease and non Ischemic Heart Disease
group. Conclusions: The finding of the present study clearly reveals that high prevalence of Ischemic
Heart Disease in younger metabolic syndrome patients.
Keywords: acute ischemic stroke, C- reactive protein, Serum lipid profile
The occurrence of Ischemic Heart Disease(IHD) 100 patients who satisfied the selection criteria
has increased noticeably for the period of last were thoroughly examined and underwent relevant
decade, not only in urban areas but in rural areas routine investigation to assess the diabetic status,
also, but it is not that abrupt because life style hypertension, lipid profile. Anthropometry i.e.
variation have affected populace in urban areas height, weight, BMI, waist circumference and
more than in rural areas.(4) diabetic complication were selected for TMT.
This syndrome is often related with obesity, Those who are TMT positive were taken for study.
diabetes mellitus, dyslipidemia, and hypertension.
All of these abnormalities promote a RESULTS
cardiovascular disease risk, and collectively they Age of the patients varied between 29 - 40 years.
are categorizing as the insulin resistance syndrome Mean age of patients was 36.05 years. Out of 100
or the metabolic syndrome. (5) patients, 62 were males and 38 were females.
Although the all entities of the metabolic Mean age of male patients was 36.30 and mean
syndrome are evidently connected with increased age of female patients was 35.57 years. There was
risk for coronary heart disease (CHD), we wanted no case found below 29 years. All age group had
to quantify the increased prevalence of CHD male predominance except 29-31 years of age
among people with metabolic syndrome. group where all the patients were females. This
The current study was designed to evaluate the can be due to less number of patients studied.
cross sectional relationship between the metabolic Maximum numbers of patients were in age group
syndrome (defined by the ATP III criteria) and the 38-40 years.
prevalence of ischemia heart disease in Indian Out of 100 patients 46 were Tread Meal Test
subjects. positive (having Ischemic Heart Disease). Out of
these 46 patients, 24 (52.17%) were male and 22
MATERIAL AND METHOD (47.83%) were female. In non-IHD group out of
This study was conducted in the Department of 54 patients, 38 (70.37%) were male and 16
Medicine and Cardiology, JLN Medical College (29.62%) were female. The prevalence of IHD
and Hospital, Ajmer. The study included the among males was found to be 38.70% (24/62) and
patients who attended the medical OPD and get that in females was 57.89% (28/38).P value is
admitted in the wards during June 2008 to May 0.0674 denote that ischemic heart disease is
2009. equally distributed in male and female and there is
Selection Criteria: no sex correlation. As in our study 52.17% male
1. Asymptomatic patient having no history of and 47.83% female had ischemic heart diseases
chest pain suggestive of coronary artery disease. those were fulfilling the criteria for metabolic
2. Obese personalities. syndrome.
3. Age less than 40 years. Out of 100 patients with metabolic syndrome, 31
4. Patient irrespective of blood sugar / blood (31.00%) had both IHD and blood sugar level
pressure level but fit for TMT. >110 mg/dl. Out of 46 patients with IHD, 31
(67.39%) had blood sugar level >110 mg/dl. In
Exclusion Criteria males with IHD, out of 41 patients, 15 (36.58%)
1. Follow up patient of myocardial infarction / had blood sugar >110 mg/dl. In females with
CVA / angina. IHD, out of 38 patients, 16 (42.10%) had blood
2. Patient of valvular heart disease. sugar >110 mg/dl. Female patients having high
3. Patient of conduction defect. blood sugar level and IHD was more in
4. Patient of COPD / bronchial asthma. comparison to male.
Out of 100 patients with metabolic syndrome, 44 >150 mg/dl.In males out of 62, 23 (37.09%) had
(44.00%) had both IHD and high blood pressure TG >150 mg/dl and in females out of 38, 19
(BP >130/85 mmHg).Out of 46 patients with IHD, (50.00%) had TG >150mg/dl. Percentage of
44 (95.65%) had blood pressure >130/85 mmHg. females with increased TG (50.00%) was more
In male patients 24/62 (38.70%) had IHD and than males (37.09%).
hypertension. In female patients 20/38 (52.63%) Out of 100 patients with metabolic syndrome, 26
had IHD and hypertension. Percentage of females (26.00%) had both IHD and increased waist
having high blood pressure and IHD was more circumference. Out of 46 patients with IHD, 26
than males. (26/46 - 56.52%) had both IHD and waist
Out of 100 patients with metabolic syndrome, 45 circumference more than cut off value. In male
(45.00%) had both low High Density Lipoprotein patients, out of 62, 10 (10/62 - 16.12%) had both
(HDL) level and IHD. Out of 46 patients with IHD and increased waist circumference above cut
IHD, 45 (97.83%) had low HDL level (below cut off value. In female patients out of 38, 16 (16/38 -
off value).In male patients, 23/62 (37.1%) had 42.10%) had both IHD and increased waist
both IHD and low HDL level (<40 mg/dl). In circumference above cut off value. Percentage of
female patients, 22/38 (57.89%) had both IHD and females with increased waist circumference and
low HDL level (<50 mg/dl).Percentage of female having IHD (42.10%) was more than the
patients having low HDL level was more in percentage of males (16.12%).
comparison to male patients.
Mean+SD
Metabolic
IHD non IHD P value Signification
syndromes criteria
(n=46) (n=54)
The mean value of metabolic syndromes of Waist Pressure (SBP), Diastolic Blood Pressure (DBP)
Circumference (WC), Triglyceride (TG), High and Fasting Blood Sugar (FBS) in ischemic heart
Density Lipoprotein (HDL), Systemic Blood disease patients was (95.67+8.22),
(193.10+36.92), (36.63+3.2), (148.04+12.63), was 36.05 years. The mean age among male was
(89.43+4.94) and (130.60+25.83) respectively. It 36.30 years and mean age of female patients was
was observed that mean values of 4 criteria of 35.57 years.
metabolic syndrome except HDL were higher in Out of 100 patients with metabolic syndrome 46
IHD patients group as compared to non IHD (46%) were found to have IHD. Among these 46
patient group. Mean value of HDL was lower in IHD patients 24 (52.17%) were male and 22
IHD patients as compared to non IHD patients. All (47.83%) were female. The prevalence of IHD
criteria of metabolic syndrome were significantly among male was found to be 38.70% (24/62) and
different in between 2 groups (IHD/non IHD that in female was 57.89% (22/38). There is no
group). significant correlation between sex and IHD
(P=0.0674). In contrast to our observation a
DISCUSSION study carried out by NCHS (8) showed prevalence
The study was carried out in the Department of of IHD is 38%. In our study it was 46% because in
Medicine and Cardiology, JLN Medical College & our study all criteria of metabolic syndrome were
Associated Group of Hospitals, Ajmer on the present.
patients who were referred for TMT. All patients A study carried out by R. Gupta (2002) (4) showed
who fulfill the NCEP ATP III criteria were the prevalence rate of IHD in urban males was
included in this study. 60.98 per thousand and rural males was 67.01 per
This study was conducted on 100 patients, thousand while in urban females prevalence rate
attending Medicine outdoors and wards found to was 30.82 per thousand and rural females was
have metabolic syndrome. In our study we 27.33 per thousand. But in our study the
categorized metabolic syndrome group patients prevalence of IHD among male and female was
into two groups TMT positive patients and TMT comparable. This was due to less number of
negative patients. patients studied.
Metabolic syndrome is very common with 44% of Among 46 IHD patients maximum numbers of
the western countries population over 50 years of patients were present between age group 38 - 40
age meeting the NCEP ATP III diagnostic years. In our study, criteria of age is restricted to
criteria.(5)It is estimated that it affect 65% male only younger patients (<40 years age).
and 47.8% female in India (6).Recent study Mukherjee (1968) (9), Bhargava (1966) (10) and
showed that the metabolic syndrome is associated Naik CH (1968) (11) have reported premature
with an increased prevalence of IHD. One possible ischemic heart disease as 26.5%, 15.2% and 20%
reason for the high prevalence of IHD associated respectively.
with metabolic syndrome is the direct effect of Comparing blood sugar and IHD in metabolic
insulin resistance on the heart and arteries (7). syndrome we found that, out of 100 patients with
A study was conducted by the National Centre for metabolic syndrome, 31 (31.00%) had both IHD
Health Statistics (NCHS) 3 Centre for Disease and blood sugar level >110 mg/dl and out of 46
Control and Prevention in two phases - Phase I patients with IHD, 31 (67.39%) had blood sugar
(1988-1995) and Phase II (1991-1994) showed >110. In male with IHD out of 41 patients, 15
that excess prevalence of IHD was attributed to (36.58%) had blood sugar >110 mg/dl and in
metabolic syndrome and/or diabetes was 37.4% in female with IHD, out of 38 patients, (42.10%) had
the group with metabolic syndrome. blood sugar >110 mg/dl.
In our study, there were 100 patients with Out of 100 patients with metabolic syndrome 44
metabolic syndrome, out of which 38 were female (44.00%) had both IHD and high blood pressure.
and 62 were male. Mean age among total patients Out of 46 patients with IHD, 44 (95.65%) had
blood pressure >130/85 mmHg. In males patients In comparing IHD and WC, out of 100 patients
24/62 (38.70%) had IHD and hypertension. In with metabolic syndrome, 26 (26.00%) had both
females 20/38 (52.63%) had IHD and IHD and increased WC. Out of 46 patients with
hypertension. Percentage of females having high IHD, 26 (26/46 - 56.52%) had both IHD and WC.
blood pressure and IHD was more than males. In males, out of 62, 10 (16.12%) had both IHD
Elevated blood pressure is a risk factor of prime and increased WC (>102 cm) and in females out
importance and established association with of 38, 16 (42.10%) had both IHD and increased
coronary atherosclerosis. Naik (1968) (11) WC (>88 cm). Percentage of females with
reported that 36% cases of IHD were increased WC and having IHD (42.10%) was more
hypertension, But in our study high blood pressure than the percentage of males (16.12%).
was present in 44 (95.65%) with IHD because in Philip WJT (2005) (14) studied prevalence of IHD
our study all metabolic syndrome criteria were in patients with increased WC (female >88 cm,
present which increases coronary atherosclerosis. male >102 cm) and showed that prevalence was
Out of 100 patients with metabolic syndrome 45 16%. But in our study prevalence of IHD was
(45.00%) had both low HDL and IHD. Out of 46 26%; this was because of presence of all criteria of
patients with IHD, 45 (97.83%) had low HDL metabolic syndrome.
(below cut off value). In males, 23/62 (37.1%) had In comparison of mean of various criteria for
both IHD and low HDL level (<40 mg/dl). In metabolic syndrome patients among IHD and
females 22/38 (57.89%) had both IHD and low Non-IHD patients (Table 1). We found that the
HDL level [<50 mg/dl (F>M)]. mean values of metabolic syndrome criteria for
In the Framingham Heart Study (1986) (12), IHD waist, TG, HDL, SBP, DBP and BS in IHD
was present in 44% patients with low HDL level patients was (95.67+8.22), (193.10+36.96),
(<40 mg/dl). But in our study low HDL level was (36.63+3.2), (148.04+12.63), (89.43+4.94),
found in 97.83% patients, high prevalence in our (130.60+25.83) respectively.
study was due to presence of all criteria of It was observed that mean value of metabolic
metabolic syndrome. syndrome criteria (except HDL) were higher
This study revealed that 42 patients out of 100 among IHD patients as compared to Non-IHD
with metabolic syndrome i.e. 42% had both IHD patients. Whereas the mean value of HDL was low
and TG >150 mg/dl and out of 46 patients with in IHD compared to Non-IHD patients.
IHD, 42 (91.30%) had TG >150 mg/dl. Further in
males out of 62, 23 (37.09%) had TG >150 mg/dl CONCLUSION
and in females, out of 38, 19 (50.00%) had TG From this study it is concluded that TMT positive
>150 mg/dl. Percentage of females with increased ischemic heart disease in metabolic syndrome
TG (50.00%) was more than males (37.09%). patients have more waist circumference, high
A prospective cohort study was carried out by fasting plasma glucose, high blood pressure and
Nordegestgard BG et al (2007) (13) in 7857 high TG level but low HDL level. So there is a
women and 6394 men with high TG levels (>150 high prevalence of IHD in younger metabolic
mg/dl) and were followed up from 1976 to 2004. syndrome patients.
They found that 1567 women (19.94%) and 1912
men (29.90%) developed IHD. But in our study REFERENCES
prevalence of IHD was 37.09% in males and 50% 1. Sharma M, Ganguly N K. Premature
in females with high TG levels. High prevalence Coronary Artery Disease in Indians and its
in males and females in our study was due to Associated Risk Factors. Vasc Health Risk
presence of all metabolic syndrome criteria. Manag. 2005 September; 1(3): 217–225.
2. Bulatao RA, Stephens PW. Global estimates 9. Mukherjee AB: Precious ischemic heart
and projections of mortality by cause, 1970- disease. IMA 1968; 512: 207.
2015. Preworking paper 1007. Washington: 10. 10.Bhargava RK, Husain SA, Dave AS,
Population Health and Nutrition Department, Narang NK, Banerjee A, Gupta U. Incidence
World Bank; 1992. of heart diseases in Rajasthan. J Assoc
3. Aggarwal A, Aggarwal S, Goel A, Sharma V, Physicians. India. 1966; 14 (1):15-23
Dwivedi S.A retrospective case-control study 11. Naik CH. Incidence and epidemiology of
of modifiable risk factors and cutaneous coronary artery disease in Gujarat. Indian
markers in Indian patients with young Heart J. 1968 Jan; 20(1):3-10.
coronary artery disease. J R Soc Med Cardio 12. Castelli WP, Garrison RJ, Willson PW,
2012; 1: 8 Abbot RD, Kannel WB : Incidence of
4. Gupta R, Gupta VP, Sama M et al: coronary heart disease and lipoprotein
Prevalence of coronary heart disease and cholesterol levels; the Framinghan Study.
coronary risk factor in urban Indian JAMA 1986; 256: 2835-2838.
population: Jaipur Heart Watch-2. India Heart 13. Nordestgaard BG, Benn M, Schnohr P,
2002; 54: 59-66. Tybjaerg-Hansen A. Nonfasting triglycerides
5. Adult Treatment Panel III, Executive and risk of myocardial infarction, ischemic
summary of third report of the National heart disease, and death in men and women.
Cholesterol Education Program (NCEP) JAMA. 2007; 298(3):299-308.
Expert Panel on Detection, Evaluation and 14. James WPT. The SCOUT study: risk-benefit
treatment of high blood cholesterol in adult. profile of sibutramine in overweight high-risk
JAMA, 2001; 285: 2486-2497. cardiovascular patients. Eur Heart J
6. Coronary Heart Disease in India.Park a 2005;7(Suppl. L):L44–L48.
Textbook of Preventive and Social Medicine,
17th ed, 2001: 274.
7. Stout RW: Insulin and atheroma, 20 year
prospective study. Diabetes Care, 1990;
13:631-54.
8. Alexander EM, Landsman PB, Teutehsm, and
Hattner SM: NCEP defined metabolic
syndrome diabetes and prevalence of
coronary heart disease among NHANES III
participants aged 50 years and older. Diabetes
2003; 52: 1210-1214
ABSTRACT
Superficial palmar arch (SPA) is an arterial arcade and a dominant vascular structure of the palm. In hand
surgeries like vascular graft applications arterial repairs, free and pedicled flaps, clinicians should be
aware of these variations, because in most of the traumatic events and the surgical procedures of the hand
the SPA plays an important role. In the present case, the superficial palmar arch is incomplete and there is
no communication between the superficial branches of radial and ulnar arteries. The ulnar artery is giving
a proper digital and two common palmar digital branches and the superficial branch of radial artery is
giving a common palmar digital branch to supply the half of radial side of middle finger and ulnar side of
index finger and radialis indicis supplying the radial side of index finger.
Keywords: anastomosis, arteria princeps pollicis, flexor retinaculum, radialis indicis, superficial palmar
arch
ACKNOWLEDGEMENT
Authors acknowledge the immense help received
from the scholars whose articles are cited and
included in references of this manuscript. The
authors are also grateful to authors / editors /
publishers of all those articles, journals and books
from where the literature for this article has been
reviewed and discussed.
REFERENCES
1. Coleman SS, Anson BJ. Arterial patterns in the
Fig.1-Showing incomplete superficial palmar arch hand based upon a study of 650 specimens.
Surg Gynecol Obstet. 1961; 113: 409–424.
DISCUSSION 2. Gellman H, Botte MJ, Shankwiler J,
The superficial arteries of the hand formed several Gelberman RH. Arterial patterns of the deep
diversified patterns that permitted into well- and superficial palmar arches. Clin Orthop
defined categories. According to Coleman’1 Relat Res. 2001; 383: 41–46.
(1961) classification, in type A: Both superficial 3. Al-Turk M, Metcalf WK. A study of the
palmar branches of UA and RA take part in superficial palmar arteries using the Doppler
supplying the palm and fingers, but in doing so fail Ultrasonic Flowmeter. J Anat. 1984; 138: 27–
to anastomose and seen in 3.6% of cases. In the 32.
present case also there is a similar observation. 4. Ruengsakulrach P, Brooks M, Hare DL,
Ikeda et al. conducted stereoscopic arteriography Gordon I, Buxton BF. Preoperative assessment
of 220 cadaver hands and reported complete SPA of hand circulation by means of Doppler
in 96.4% of cases and 3.6% as incomplete arch. ultrasonography and the modified Allen test. J
Gellman et al2.2001 reported 84.4% of cases as Thorac Cardiovasc Surg. 2001; 121: 526–531.
complete SPA and 15.5% of cases as incomplete 5. Pola P, Serricchio M, Flore R, Manasse E,
SPA. Al Turk and Metcalf 3 (1984) showed Favuzzi A, Possati GF. Safe removal of the
complete SPA in 84% of cases and incomplete in radial artery for myocardial revascularization: a
16% using Doppler flow meter. Harvesting RA for Doppler study to prevent ischemic
use as arterial by-pass conduits needs to look complications to the hand. J Thorac Cardiovasc
specifically for variation in collateral circulation Surg. 1996; 112: 737–744.
like presence of incomplete SPA (Ruengsakulrach
P4 2001).
ABSTRACT
Objectives: The objectives of this study are to determine the age by study of skull sutures and comparing
the age with standard data mentioned in different textbooks and previous studies.
Material and Method: Present study based on closure of skull sutures among 220 cases between age
group of 15 - 70 years with age interval of 5 years and 20 cases from each age group were studied, who
were exposed to digital X-ray of skull for closure of suture ecto-cranially for age estimation. The closure
of sagittal, coronal, lambdoid, parieto-mastoid, parieto-temporal (squamous) and baso-occiput with baso-
sphenoid sutures were studied and compared with standard data mentioned in different textbooks and
previous studies. Age of each individual studied was confirmed from birth certificate, service record,
driving license, passport, ration card or voter’s card.
Result: Each suture was found to close at particular age group. Suture closure occurred for sagittal,
lambdoid, coronal, parieto-mastoid, parieto-temporal and baso-occiput with baso-sphenoid at age group
of 50-60 years, 45-55 years, 50-60 years, 55-70 years, 60-70 years and 18-25 years respectively.
Conclusion: Age of closure of sagittal, coronal, lambdoid, parieto-mastoid, parieto-temporal and baso-
occiput with baso-sphenoid suture was matching with standard data given in most of the textbooks and
other studies. Sutures closure occurred from their endo-cranial to ecto-cranial aspects. Closure of skull
sutures occurred earlier in male than in females. The most successful estimate was done from sagittal
suture, next lambdoid suture and then coronal suture.
Keywords: Skull sutures, Age estimation, Sagittal suture, Coronal suture, Lambdoid suture.
the most reliable evidence for estimating the age given in Table – 7. [1, 2, 3, 4, 7, 14, 15]
of person. [2] Comparison of time of closure of baso-occiput
with baso-spheoid suture was given in Table – 8.
MATERIAL AND METHODS [2, 3, 4, 5, 6, 7, 8, 17, 18]
In this study, 220 cases (male and female both),
between age group of 15 - 70 years with age DISCUSSION
interval of 5 years and 20 cases from each age Identification means determination of individuality
group were studied who were exposed to digital of a person. Study of closure of skull sutures is a
X-ray of skull both antero-posterior and lateral very important tool for age estimation in adult.
view for closure of suture ecto-cranially. Age of The most commonly studied aspect of cranial
each individual studied was confirmed from birth sutures is the degree of their obliterations as an
certificate, service record, driving license, indicator of age. Suture closure scoring system as
passport, ration card or voter’s card and compared per Buikstra and Ubelaker [19] was given in Table
with radiological findings for accuracy. In this – 9. Meindl and Lovejoy scoring system (1985)
study, we considered only complete union of the [20] was given in Table – 10. Acsadi and
sagittal, coronal, lambdoid, parieto-mastoid, Nemeskeri scoring system (1970) [21] and
parieto-temporal (squamous) and baso-occiput Perizonius (1984) [22] scoring system was given
with baso-sphenoid sutures instead of taking into in Table – 11. In our study, we considered only
account other scoring system of suture closure and complete union of sutures instead of taking into
compared with standard data mentioned in account other scoring system of suture closure.
different text books and previous studies. Observations of cranial suture closure were first
observed as far back as the 1st century in the work
OBSERVATION of Hippocrates, but were not utilized as an
In our study, age of earliest union for sagittal, ‘identification tool’ with relation to age until a
lambdoid, coronal, parieto-mastoid, parieto- much later date. [11, 12, 13] Vesalius and his pupil
temporal and baso-occiput with baso-sphenoid Fallopius were credited for the first noting the
suture was 46 years, 38 years, 46 years, 43 years, apparent progression of suture obliteration with
54 years and 17 years respectively and age group age in 1542. [11, 12, 23, 24, 25, 26] Despite some
for sagittal, lambdoid, coronal, parieto-mastoid, early descriptions of the variability of cranial
parieto-temporal and baso-occiput with baso- suture closure, scientific studies addressing its
sphenoid suture was 50-60 years, 45-55 years, 50- relationship with age have been published in great
60 years, 55-70 years, 60-70 years and 18-25 years number from the 19th century to present [10]. This
respectively as per Table – 1. Different sutures continued popularity has survived not due to its
closure in different age groups were given in Table validity but rather the idea that, if it has been
– 2. Comparison of time of closure of sagittal studied for so long, surely there has to be
suture was given in Table – 3. [2, 3, 4, 5, 6, 7, 8, 9, something to it, and thus it becomes a traditional
10, 11, 12, 13] Comparison of time of closure of research obsession. [26]
lambdoid suture was given in Table – 4. [1, 2, 3, 4,
5, 6, 8, 14, 15] Comparison of time of closure of CONCLUSION
coronal suture was given in Table – 5. [1, 2, 3, 4, Age of closure of sagittal, coronal, lambdoid,
5, 6, 7, 8, 14, 15, 16] Comparison of time of parieto-mastoid, parieto-temporal and baso-
closure of parieto-mastoid suture was given in occiput with baso-sphenoid suture was matching
Table – 6. [1, 2, 6, 14, 15] Comparison of time of with standard data given in most of the textbooks
closure of parieto-temporal (squamous) suture was and other studies. Sutures closure occurred from
their endo-cranial to ecto-cranial aspects. Closure 9. Dwight T., The closure of the sutures as a sign
of skull sutures occurred earlier in male than in of age, Boston Medical surgery Journal, 1890,
females. The most successful estimate was done 122: 389-392.
from sagittal suture, next lambdoid suture and then 10. Parsons FG and Box CR, The relation of
coronal suture. Studies of the ecto-cranial suture cranial sutures to age, Journal of the Royal
closure have the potential to underestimate age Anthropology Institute, 1905, 35: 308.
and to overcome this, study of both endo-cranial 11. Todd TW and Lyon DW, Endo-cranial suture
and ecto-cranial suture closure should be done. closure, its progress and age relationship, Part
I, American Journal of Physical Anthropology,
ACKNOWLEDGEMENT 1924, 7: 325-384.
Authors acknowledge the immense help received 12. Todd TW and Lyon DW, Cranial suture
from the scholars whose articles are cited and closure, its progress and age relationship, Part
included in references of this manuscript. The II, American Journal of Physical
authors are also grateful to authors / editors Anthropology, 1925, 8: 23-25.
/publishers of all those articles, journals and books 13. Mc Kern TW and Steward TD, Skeletal age
from where the literature for this article has been changes in young American males, analysed
reviewed and discussed. from the stand point of identification,
Headquarter QM. Res and Dev Command,
REFERENCES Natick, MA, 1957.
1. Pradeep et al, Age estimation in old 14. Krogman, The Human skeletal in Forensic
individuals by CT scan of skull, Journal of Medicine, 1st edition, Charles C. Thomas,
Indian Academy of Forensic Medicine, 2004, 1962, Page 18-71, 76-89, 92-111.
26(1): 10-13. 15. Parikh C.K., Textbook of Medical
th
2. Reddy K.S.N., The essentials of Forensic Jurisprudence and Toxicology, 5 edition,
Medicine and Toxicology, 26th edition, CBS Publishers, 1990, Page 39-50.
Medical Book Company, 2007, Page 62-70. 16. Ramachandran C, Skeletal anatomy: Medico-
3. Dikshit P.C., Textbook of Forensic Medicine legal radiological age determination, 1st
and Toxicology, 1st edition, Peepee publishers, edition, Paras Medical Publishers, 2003, Page
2007, Page 55-60. 15-31, 79-87, 92-96.
4. Nandy A., Principles of Forensic Medicine, 17. David Dolinak, Evan W Matshes, Emma O
2nd edition, New Central Book Agency, 2001, Lew, Forensic Pathology: Principles and
Page 78-80. Practice, Elsevier, 2005, Page 585 – 586.
5. Mukherjee J.B., Forensic Medicine and 18. Pekka Saukko, Bernard Knight, Knight’s
Toxicology, 4th edition, Academic publishers, Forensic Pathology, 3rd edition, Arnold, 2004,
2011, Page 141-142. Page 120-121.
6. Karmakar R.N., Forensic Medicine and 19. Buikstra J, Ubelaker DH, Standards for Data
Toxicology: Oral, Practical and M.C.Q., 3rd Collection from Human Skeletal Remains,
edition, Academic Publishers, 2010, Page 13. Fayetteville, AR: Arkansas Archaeological
7. Pillay VV, Textbook of Forensic Medicine Survey, 1994.
and Toxicology, 15th edition, Paras Medical 20. Meindl, Richard S. And C. Own Lovejoy,
Publisher, 2008, Page 77. Ecto-cranial suture closure: a revised method
8. Vij K., Textbook of Forensic Medicine and for the determination of skeletal age at death
Toxicology, 5th edition, Elsevier, 2011, Page based on the lateral-anterior sutures, American
42-43.
Journal of Physical Anthropology, 1985, 24. Singer R., Estimation of age from cranial
68(1): 57-66. suture closure: Report on its unreliability,
21. Acsadi G.Y. and J. Nemeskeri, History of Journal of Forensic Medicine, 1953, 1: 52-59.
human lifespan and mortality, Budapest, 25. Masset C., Age estimation on the basis of
Akademiai Kiado, 1970. cranial sutures in age markers in human
22. Perizonius W.R.K., Closing and non closing skeleton, 1st edition, Springfield III, Charles C.
sutures in 256 crania of known age and sex Thomas, 1989, Page 71-103.
from Amsterdam (A.D. 1883-1909), Journal 26. Hershkovitz et al., Why do we fail in ageing
of Human Evolution, 1984, 13: 201-216. the skull from the sagittal suture? American
23. Ashley-Montagu M.F., Ageing of the skull, Journal of Physical Anthropology, 1997, 103:
American Journal of Physical Anthropology, 393-399.
1938, 23(3): 355-375.
Table – 11: Acsadi and Nemeskeri (1970) and Perizonius (1984) scoring system
Score Description
0 Open suture. There is little space left between the edges of adjoining bones.
1 Incipient closure. Suture is closed, but clearly visible as a continuous, often zigzagging line.
2 Closure in process. Suture line becomes thinner, has fewer zigzags and may be interrupted by
complete closure.
3 Advanced closure. Only pits indicate where the suture is located.
4 Closed suture. Suture completely obliterated, even its location can’t be recognized.
ABSTRACT
Objective: Rate pressure product (RPP) is an indirect measure of Myocardial oxygen
consumption (MVO2).It increases progressively with exercise and the RPP at peak of exercise is
Peak rate pressure product (PRPP). The low value of PRPP suggests significant compromise of
coronary perfusion. In the present study effect of exercise on RPP of Pre menopausal women and
Post menopausal women were compared.
Research Design and Methods: The study was conducted on a total of 50 healthy volunteer
women. They were subjected to treadmill exercise test and baseline and maximum RPP was
calculated.
Results: The RPP in premenopausal women increased significantly from 10.83 ± 2.11 to 28.98 ±
2.93 mm of Hg beats / min x 10-3 during exercise and in postmenopausal from 12.52 ± 2.69 to
28.03 ± 4.14. The percentage increase in RPP was significantly more in Premenopausal women
(63%) as compared to postmenopausal women (55%).
Conclusions: It can be concluded that Rate pressure product reaches the critical value before the
symptoms appear and the percentage increase in Rate pressure product was less in
postmenopausal women. The results also suggest that the measurement of Peak rate pressure
product in response to exercise can detect Coronary Artery Disease (CAD) even before the
appearance of clinical signs and symptoms in postmenopausal women and thus can be used as a
diagnostic tool.
Table II shows changes in hemodynamic parameters (SBP, HR and RPP) in both the groups
Characteristics Baseline Maximum Percentage change
Heart rate
Group A 84.32±11.18 168.96 ± 11.40# 59
Group B 88.92±18.06 157.6 ±21.14* # 43*
SBP
Group A 128 ± 14.71 172.08 ± 18.96# 25
Group B 141.12 ± 12.01* 178.08± 13.74 #* 21
RPP
Group A 10.83± 2.11 28.98 ± 2.93# 63
Group B 12.52 ± 2.69* 28.03± 4.14# 55*
All values are mean ±SD
* P < 0.05 as compared to group A
# P < 0.05 as compared to baseline value
All the baseline hemodynamic parameters were significant increase in RPP from 12.52 ± 2.69 to
significantly more in healthy postmenopausal 28.03 ± 4.14. The percentage increase in RPP was
women as compared to healthy Premeopausal significantly more in Premeopausal women (63%)
women. There was significant increase in SBP, as compared to postmenopausal women (55%).
HR and RPP during exercise in both the groups. Maximum HR was significantly less in group B as
The RPP in Group A increased significantly from compared to group A. The percentage increase in
10.83 ± 2.11 to 28.98 ± 2.93 mm of Hg beats / HR was significantly more in Premeopausal
min x 10-3 during exercise. Group B also showed a
women (59%) as compared to Premeopausal present study the PRPP was 28.98 and 28.03 mm
women (43%). Hg x Beats / min x 10-3 in pre menopausal women
There was no statistically significant difference in and post menopausal women respectively. The
percentage change in SBP between the groups. percentage increase in RPP was 63% in
premenopausal women and 55% in
DISCUSSION postmenopausal women. The peak RPP is an
Abnormal hemodynamic response to exercise may accurate reflection of the myocardial oxygen
indicate an increased risk of CAD, even if signs demand and myocardial work load. The higher
and symptoms of ischemia are absent. Both HR the RPP, the higher will be the MVO2. The ability
and SBP are important variables determining to reach high RPP is associated with more
changes in myocardial oxygen consumption adequate coronary perfusion. Reaching the high
between rest and exercise (9).During exercise HR, RPP without symptoms or evidence of severe
SBP and RPP increases with increase work load ischemia suggests adequate left ventricular
on the heart to provide adequate blood supply to functions and the low value of PRPP suggests
the active myocardium. significant limitation of coronary perfusion and
All the hemodynamic parameters increase decreased LV function leads to angina. .
significantly with exercise in both the groups. This Maximum RPP is reported to range from 10th
is due to increase in sympathetic discharge during percentile value of 25,000 to a 90th percentile of
exercise(11,12) .RPP increases progressively with 40,000(15). RPP exceeding 22 is commonly
exercise and attained the peak value of 28.98 ± associated with myocardial ischemia and angina
2.93 mm Hg x beats per minute x 10-3 in (8).
premenopausal women and 28.03± 4.14 in Both HR and SBP are also useful in the diagnosis
postmenopausal women. The percentage increase of ischemic heart disease in postmenopausal
in RPP was significantly less in postmenopausal women. In our study there was a significant
women (55%) as compared to premenopausal increase in HR and SBP in both the groups during
women (63%). The less percentage increase in exercise. The percentage increase in SBP was
postmenopausal women is due to age related comparable in both the groups. On the other hand
depletion of functional myocytes, cardiac the percentage increase in HR was significantly
receptors and increased myocardial stiffness that less in postmenopausal women as compared to
decreases the ventricular pumping and premenopausal women. The less increase in HR is
cardiovascular response of the heart to exercise. due to age related depletion of cardiac myocytes
(13) which has been proposed as a mechanism for
Angina results from imbalance between oxygen decreased contractile performance and decrease
supply and demand and is precipitated due to hemodynamic responses (3).
increase in work of myocardium to a critical level The baseline HR, SBP and RPP were more in
which is fixed in each patient. The work of the postmenopausal women than premenopausal
myocardium is measured by RPP. Most normal women. It may be attributed due to marked
individuals develop a RPP of 20 to 35 mm Hg x sympathetic activation and decrease
beats / min x 10-3. In many patients with parasympathetic activity due to low estrogen. The
significant Ischemic Heart Disease, RPP value increased sympathetic activation in
exceeding 25 mm Hg x beats / min x 10-3 are postmenopausal women is due to endothelial
unusual (14). Studies reported the rate pressure dysfunction Also with menopause, there is
product exceeding 22,000 is commonly associated increased level of vasoconstriction and oxidative
with myocardial ischemia and angina (9). In the stress. All these factors contribute to hyperkinetic
circulation characterized by elevated HR and SBP. 5. John Ross, Jr. Cardiovascular system. In: Best
Menopause also increases aortic stiffness. and Taylor’s physiological basis of medical
practice. West JB(Ed).12th edition. New Delhi:
CONCLUSION B.I .Waverly Pvt. Ltd; 1990 p. 265.
Results from this study indicate that HR x SBP, 6. Sarnoff SJ, Braunwald E. Hemodynamic
easily measurable hemodynamic parameters are valid determinants of oxygen consumption of heart
predictors of MVO2 during exercise in a population with special reference to the tension-time index
of postmenopausal women. It can be concluded that .Am J Physiol 1958; 192: 148-156.
RPP reaches the critical value before the symptoms 7. Navalta JW, Sedlock DA, Park K-S.
appear and the percentage increase in RPP was less Physiological responses to downhill walking in
in postmenopausal women. The results also suggest older and younger individuals. Journal of
that the measurement of PRPP in response to exercise physiology 2004;7(6):45-51
exercise can detect CAD even before the appearance 8. Zargar JA, Naqash IA, Gurcoo SA, Mehraj-Ud-
of clinical signs and symptoms in postmenopausal Din. Comparative evaluation of the effect of
women and thus can be used as a diagnostic tool. metoprolol and esmolol on rate pressure product
and ECG changes during laryngoscope and
ACKNOWLEDGEMENT endotracheal intubation in controlled
We acknowledge the immense help received from hypertensive patients. Indian J Anaesth 2002;
the scholars whose articles are cited and included in 46: 365-368.
references of this manuscript. We are also grateful to 9. Robinson B F. Relation of heart rate and
authors / editors / publishers of all those articles, systolic blood pressure at the onset of pain in
journals and books from where the literature for this angina pectoris. Circulation 1967; 35:1073-
article has been reviewed and discussed. 1083
10. Siegelova J, Fier B, Duek J, Placheta Z,
REFERENCES Cornelissen G, Halberg F.Circadian variability
1. Sekarbabu Hariram, Sowmya S, Hamsalatha P, of rate pressure product in essential
Gayathri G, Priyadarsini C, Thiripurasundari M, hypertension with enalpril therapy. Scripta
Saranya, Vivekanand P .Screening the Clinical Medica (Brno) 2000; 72:67-75.
Parameters in Menopause Women. Research 11. Ellestad MH. Stress testing.4th edition. New
Journal of Pharmaceutical, Biological and Delhi: Jaypee Bothers; 1996 p. 17.
Chemical Sciences. July – September 2011; 12. Ellestad MH. Stress testing.4th edition. New
2:1065. Delhi: Jaypee Bothers; 1996 p. 379.
2. Ariyo AA, Villablanca AC. Can HRT, 13. Sussman MS, Anversa P.Myocardial aging and
designerestrogens and phytoestrogens reduce senescence. Ann Rev Physiol 2004; 66:29-47
cardiovascular risk markers after menopause? 14. Chaitman BR .Exercise stress testing. In: Heart
Postgraduate Medicine: Estrogens and disease: A Textbook of Cardiovascular
Lipids2002; 111: 23–30. Medicine. Braunwald E, Zipes DP, Libby P
3. Kamellian R.Dimitrova, Kerry DeGroot, Adam (eds).6th ed.Philadelphia: WB Saunders; 1997
K. Myers, Young D. Kim Estrogen and p.153-157.
homocysteine. Cardiovascular research 2002; 15. Fletcher GF, Cantwell JD, Watt EW. Oxygen
53: 577-588 consumption and hemodynamic response pf
4. Torella D, Rota M, Nurzynska D et al. Cardiac exercises used in training of patients with recent
stem cell and myocyte aging, heart failure, and myocardial infarction. Circulation 1979;
insulin-like growth factor-1 overexpression 60:140-144.
CircRes 2004; 94: 514–524.
ABSTRACT
Communicable diseases (CD) are the main cause of death around the world for years followed by non-
communicable diseases (NCD) causing major problems in industrialized countries. Among all NCDs and
CDs, Cancers (NCD) and Tuberculosis (CD) constitute the major cause of morbidity and mortality in
developing countries, including India. The specific aim of this study is to quantify the prevalence of
communicable (Tuberculosis) and non communicable diseases (Cancers) in urban and rural areas of
Tirupati and to analyze the relative epidemic using a comparable framework. The data was analyzed
statistically using Chi-Square test and Odds ratio with 95% confidence interval. All analyses were
performed with SPSS version 13 software. Compared to rural areas, people from Urban areas of Tirupati
(52.1% Vs 47.9%) has increased risk of NCDs: patients with Breast Cancer (33% ), Cervical Cancer
(35%), Oral Cancer (8.9%), Prostrate Cancer (6.3%), Skin Cancer (4%) and Other Cancers (12.9%) like
Bladder, Colon, Lung, Rectal, Stomach, Uterine. There was a significant urban-rural difference in having
Tuberculosis in the years 2010 to 2011 (71.4% vs 28.6%, respectively; P < 0.001) and there was a
significant urban-rural difference in Communicable and non communicable diseases in the years 2010-
2011(54.1% vs 45.9%, respectively; P = 0.03). These finding suggests that there is an increasing
prevalence of Communicable and non communicable diseases in Tirupati as a result of lifestyle changes
and urbanization. These are the challenges that are to be tackled in new millennium.
Keywords: Communicable diseases, Non-communicable diseases, Rural, Urban
Table 1: Non communicable diseases in urban and rural areas of Tirupati (2010-2011)
*Abbreviations: df – degrees of freedom, χ2 used to test categorical variables for statistical significance, P
refers to the probability
Bar Chart
70 LOCALITY
RURAL
URBAN
60
50
Count
40
30
20
10
0
BREAST CERVICAL ORAL OTHER PROSTRATE SKIN
CANCER TYPE
Chart 1: Prevalence of the non communicable diseases in urban and rural areas
Table 3: Communicable and Non Communicable diseases in Urban- rural communities of Tirupati
(2010-2011)
Disease Type Patients, n (%) df χ2 P
Rural Urban
Communicable 10 (4.59) 25 (13.5) 1 4.699 0.03
Non Communicable 145(66.5) 158 (85.4)
ABSTRACT
Background: Introduction of laparoscopic cholecystectomy, hepatobiliary surgeries and liver
transplantations has stimulated a renewed interest in hepatic arterial anatomy. The variant arterial
anatomy recognized during routine cadaveric dissection offers great learning potential. This imparts the
concept of patient individuality and subsequent individualization of medical and surgical therapies and
helps the surgeons for safe surgery and low morbidity. Objective of the study: To report on hepatic
artery variations observed in the dissecting room and to find out the different pattern of hepatic arteries by
cadaveric dissection. Materials and Methods: Twenty five human cadavers of SCB Medical College
were dissected to study the source and pattern of hepatic arterial supply to liver. Results: Twenty four
cadavers exhibited typical common hepatic arterial supply from the celiac trunk. Only one female body
out of twenty five cadavers had an anomalous origin of common hepatic artery. Common hepatic artery
originated from the superior mesenteric artery. Conclusion: Aberrant hepatic vascularisation should be
assessed preoperatively to avoid fatal complications in hepatobiliary surgeries.
Keywords: Hepatic artery, Superior mesenteric artery, Hepatobiliary surgeries.
excision of the tumour feasible. Knowledge of condition. The dissection of arteries were done and
these variations is also important in planning the then coloured and photographed. The
whole and split liver transplantation. (Grays measurement of length and external diameter of
Anatomy-40th edition, Liver, 1169-70). arteries were done by sliding Vernier Callipers.
The hepatic arteries may arise from the abdominal
aorta, the left gastric or the superior mesenteric RESULT
arteries (2). The hepatic arterial anatomy is After a careful dissection of twenty five cadavers,
aberrant in almost 33-41% individuals (1, 2, 3, 4). we analyzed the variation pattern of celiac axis,
The most common anomalies include, the right superior mesenteric artery and the source and
hepatic artery arising from superior mesenteric distribution of hepatic arteries.
artery (25%) and left hepatic artery arising from Celiac trunk: Except one, all the cadavers
the left gastric artery (25%) (4) . Anomalies of the exhibited classical (Hepatoleinogastric) pattern of
common hepatic artery, usually a branch of the celiac trunk's origin and distribution. In a study of
celiac trunk, are relatively uncommon (5). twenty five celiac trunks, the length of celiac trunk
However, Kadir et al., (1991) demonstrated varied from 6 to 25mm and the width from 9 to 20
angiographically a 5% incidence of the replaced mm. The celiac trunk was constricted at its site of
common hepatic artery (6) whereas Woods and origin from the abdominal aorta. The distance on
Traverso (1993) found the replaced common the aorta between the sites of origin of celiac and
hepatic artery, branching off the superior superior mesenteric arteries varied from 10 to
mesenteric artery in 2.5% of the cases (7). 15mm. In twenty three cases, splenic artery was
An aberrant hepatic artery may cause a potential the largest branch of celiac trunk, whereas in two
error in the angiographic diagnosis of traumatic cases common hepatic was the largest branch.
liver hematoma (8). Moreover the existence of However left gastric was found as the first and
aberrant hepatic arteries emphasizes the mode of smallest branch of celiac trunk in all cases.
development of liver during perinatal period (9). Anomalous celiac trunk had only 2 branches [Fig-
Liver transplantation and peripancreatic surgery 1],[Fig-2]
needs extensive, adequate and clear knowledge of (1)Left gastric artery
varied blood supply of liver. (2)Splenic artery
the common bile duct and anterior to the portal It was routing to posterior of the head of pancreas
vein. [Fig-1, Fig-2]. The CHA then gave a branch- and first part of the duodenum. Later it had normal
Gastroduodenal artery and continued as the Proper course. Another classification method is the one
Hepatic artery. The proper hepatic artery was adopted by Michel et.al in 1955
further divided into 2 branches-right and left
hepatic artery. The right hepatic artery further I. standard anatomy : 55 - 61 %
gave cystic artery. II. replaced LHA : 3 - 10 %
Cystic artery: In twenty cases the cystic artery III. replaced RHA : 8 - 11 %
was single and arising from the right hepatic IV. replaced RHA and LHA : 0.5 - 1 %
artery. The left hepatic artery was found in one V. accessory LHA from LGA : 8 - 11 %
case and proper hepatic artery in four cases. VI. accessory RHA from SMA : 1.5 - 7 %
Superior mesenteric artery: Except one, all 24 VII. accessory RHA and LHA : 1 %
cadavers exhibited normal branching pattern. In VIII. accessory RHA and LHA and replaced
one case the Common Hepatic Artery was the 1st LHA or RHA : 2 - 3 %
branch and middle colic artery arose from the right
IX. CHA replaced to SMA : 2 - 4.5 %
X. CHA replaced to LGA : ~ 0.5 %
colic artery [Fig-1, 2 & 3].
XI. Others
DISCUSSION o CHA separate origin from aorta : ~ 2 %
Aberrant hepatic arterial anatomy occurs in 33- o double hepatic artery§ : 3.7 %
41% of reported literature (3), (6), (10). The o PHA replaced to SMA; GDA origin from
common hepatic artery is usually a branch of the aorta : 0.3 %
celiac trunk (2). This classical "Michels type -I"
pattern with right and left hepatic arteries Anomalous CHA seen in our study was similar to
originating from the common hepatic artery (of Michels, IX type. Moreover the existence of such
celiac origin) occurs in about 55% of the an arterial variant in patients having liver
population (7). Although the normal pattern of metastasis carries the risk of misperfusion of intra-
arterial supply of hepatic parenchyma and biliary arterial chemotherapeutic agents (14). The intra-
tract is well described (11), there is a considerable arterial chemotherapy technique for isolated, non-
variation in the relative contribution of normal and resectable liver metastasis achieves complete
abnormal arteries to parenchyma and biliary tree perfusion of whole liver only in patients with
in the presence of anomalies (12),(13). classical arterial anatomy. Patients having variant
The replaced hepatic arteries (replaced right arterial anatomy need vascular reconstruction prior
hepatic and replaced common hepatic arteries) to intra-arterial chemotherapy or the use of double
usually do not occupy the same position in the port catheter pumps, for ideal, uniform perfusion
hepatoduodenal ligament as the normally (15).
occurring hepatic artery. Those typically lie lateral The knowledge of hepatic arterial variations can
to the portal vein behind the head of the pancreas be useful in the selection of donors for partial
and enter the lesser omentum posterolateral to the hepatic grafts in living related liver transplantation
common bile duct (6), (7). In Michels 200 liver (LRLT) (16). Such anomalies should be ruled out
dissections, he found half of the replaced common preoperatively (17) by angiography, Axial CT
hepatic arteries (RCHA) actually passed through and/or DCEMRI (18). Hepatic arterial anatomy
the pancreatic substance while the other half must be defined precisely to ensure optimal donor
passed posterior to it. In our case the common hepatectomy and graft arterialization (19).
hepatic artery never entered the pancreatic tissue. Moreover the preoperative knowledge of
anomalous vessels is also helpful for modification authors/editors/publishers of all those articles,
of surgical approach (20). Arterial anomalies journals and books from where the literature for
preserved and managed appropriately do not this article has been reviewed and discussed.
necessarily compromise graft outcome.
To our knowledge a unique case of aberrant REFERENCES
common hepatic artery (of superior mesenteric 1. Michels NA. Variations in blood supply of
origin) with a anomalous celiac trunk, having only liver, gallbladder, stomach, duodenum and
two branches-left gastric and splenic artery was pancreas. Year book of the Am Philosophical
found in this study. The persistence of lower half soc, 1943: 150.
of ventral longitudinal anastomosis between the 2. Last RJ. Vessels and nerves of the gut. In:
10th to 13th splanchnic (vitelline) arterial roots that Sinnatamby CS, editor. Last's Anatomy:
normally disappear may be the possible Regional and Applied. 10 th Ed. Edinburgh:
embryological explanation for this variability. Churchill Livingstone, 1999: 236-238, 254-
Such variations may be attributed to the rotation of 6.
gut, caudal displacement of abdominal viscera and 3. Kemeny MM, Hogan JM, Goldberg DA et al.
hemodynamic changes taking place during Continuous hepatic artery infusion with an
organogenesis and differentiation (21), (22). implantable pump: problems with hepatic
artery anomalies. Surgery. 1986
CONCLUSION Apr;99(4):501–504.
In our study we found a variant of celiac trunk, 4. Rosse C, Gaddum-Rosse P. The gut and its
replaced common hepatic artery taking origin from derivatives. In: Hollinshead's textbook of
superior mesenteric artery in (4%) of our Anatomy. 5` h Ed. Philadelphia: Lippincott-
dissections which is not very uncommon. Raven, 1997: 568-80.
Vascular injuries are the most lethal technical 5. Michels NA. Newer anatomy of the liver and
injuries encountered in laparoscopic its variants blood supply and collateral
cholecystectomy (24). Injury to hepatic blood circulation. Am J Surg 1966; 112: 337-47.
supply is more common in the presence of 6. Kadir S, Lundell C, Saeed M. Celiac, Superior
aberrant arterial anatomy. Preoperative knowledge and inferior mesenteric arteries. In: Kadir S,
of normal and variant arterial anatomy can prompt editor. Atlas of normal and variant
to take measures to preserve the vessels and avoid angiographic anatomy. Philadelphia: WB
fatal injury (25). The aberrant vessels can be Saunders, 1991: 297-308.
identified on visceral angiography, dynamic 7. Woods MS and Traverso LW. Sparing a
contrast enhanced magnetic resonance imaging replaced common hepatic artery during
(DCEMRI) and/or spiral CT [18]. pancreaticoduodenectomy. Am Surg 1993; 59:
719-21.
ACKNOWLEDGEMENTS 8. Konstam MA, Novelline RA, Athanasoulis
The authors thank all the students of SCB Medical CA. Aberrant hepatic artery: a potential cause
College, Cuttack, Odisha who were assigned to for error in the angiographic diagnosis of
dissection of cadavers for their efforts in data traumatic liver hematoma. Gastrointest Radiol
collection and those authors and scholars 1979; 4: 43-5.
mentioned in the reference for their enlightening 9. Severn CB. A morphological study of the
and informative articles, journals and books that development of the human liver (II),
helped to draw inferences of the study. The establishment of liver parenchyma,
authors are also grateful to
extrahepatic ducts and associated venous endoscopic US, CT and MR imaging. Radiol
channels. Am J Anat 1972; 133: 85. Soc N Am 1994; 190: 745-51.
10. Lygidakis NJ, Makuuchi M. Pitfalls and 19. Takayama T, Makuuchi M, Kawarasaki H, et
complications in the diagnosis and al. Hepatic transplantation using living donors
management of hepatobiliary and pancreatic with aberrant hepatic artery. J Am Coll Surg
disease. Thieme Med Inc, 1993: 113, 231. 1997; 184: 525-8.
11. Padbury R, Anatomy AD. In: Toouli J, editor. 20. Volpe CM, Peterson S, Hoover EL, Doerr RJ.
Surgery of the biliary tract. Edinburgh: Justification for visceral angiography prior to
Chuchill Livingstone, 1993: 3-19. pancreaticoduodenectomy. Am Surg 1988; 64:
12. Makisalo H, Chaib E, Krokos N, Calne R. 758-61
Hepatic arterial variations and liver related 21. Reuter ST, Redman HC. Vascular anatomy.
diseases of 100 consecutive donors. Transpl In: Gastrointestinal angiography, 2nd Ed.
Int 1993; 6: 325-9. Philadelphia, London, Toronto: W B
13. Shaw BWJ, Wood RP, Stratta RJ et al. Saunders, 1977: 31-65.
Management of arterial anomalies 22. Arey LB. Developmental Anatomy: A
encountered in split liver transplantation. textbook and laboratory manual of
Transplant Proc 1990; 22: 420-2. embryology. 7 th Ed. Philadelphia: W B
14. Civelek AC, Sitzmann JV, Chin BB et al. Saunders, 1974.
Misperfusion of the Liver during hepatic 23. Gray’s Anatomy: The Anatomical Basis of
artery infusion chemotherapy. Am J Clinical Practice by S Standring, Elsevier
Roentgenol 1993; 160: 865-70. Health Sciences, 40th edition, 1169-70.
15. Eid A, Reissman P, Zamir G, Pikarsky AJ. 24. Deziel DJ, Millikan KW, Economou SG,
Reconstruction of replaced right hepatic Doolas A, Ko ST, Airan MC. Complications
artery, to implant a single-catheter port for of laparoscopic cholecystectomy: A national
intra-arterial hepatic chemotherapy. Am Surg survey of 4292 hospitals and an analysis of
1998; 64: 261-2. 77604 cases. Am J Surg 1993; 165: 9-14.
16. Daly JM, Kemeny N, Oderman P, Botet J. 25. Biehl TR, Traverso LW, Hauptmann E, Ryan
Long term hepatic arterial infusion JA Jr. Preoperative visceral angiography alters
chemotherapy. Arch Surg 1984; 119: 936- intraoperative strategy during the whipple
41. procedure. Am J Surg 1993; 165: 607-
17. Dooly WC, Cameron JL, Pitt HA et al. Is 12.
preoperative angiography useful in patients
with periampullary tumors? Ann Surg 1990;
211: 649-55.
18. Muller MF, Meyenberger C, Bertschinger P et
al. Pancreatic tumors: Evaluation with
Fig. 1 : Showing Anomalous Origin of Common Hepatic Artery from Superior Mesentric Artery
(upon dissection of abdomen) (Author-Dr Sunita Sethy)
Fig.2- Showing Anomalous Origin of Common Hepatic Artery from Superior Mesentric Artery
(after removal of Stomach)- (Author-Dr Sunita Sethy)
Fig.3- Showing branching pattern of Superior Mesentric Vessels (Author-Dr Sunita Sethy)
ABSTRACT
Context: Hepatitis B is an inflammatory disease of the liver caused by Hepatitis B virus and is a global
public health problem. In India the carrier rate of hepatitis B is higher among health care personnel.
Nurses are probably the most commonly exposed health care staff exposed to needle prick,
injuries and contact with infectious fluids. They are exposed to this risk right from there student career.
Objectives: To determine the awareness about HBV, Hepatitis B, its transmission and prevention.
Methods: A descriptive cross sectional study was conducted among 119 nursing students with the help of
prestructured questionnaire having questions about HBV, Hepatitis B, its transmission and Hepatitis B
vaccine. The statistical tools like Z test of difference between two proportions, mean and standard
deviation (SD) values were employed.
Results: Overall 77% of all the students knew that Hepatitis B is a member of Hepadnavirus family. On
an average 81.27% of the students were correct regarding knowledge on Hepatitis B infection. After
considering all the statements, answer to transmission of Hepatitis B was observed to be correct in
71.01% of students. Prevention of Hepatitis B by vaccine administration was correctly known to 104
(87.39% of 119) respondents.
Conclusions: Majority of the nursing students were aware about Hepatitis B. The knowledge regarding
most of the parameters was significantly higher among BSc nursing students as compared to GNM
students. It was also observed that there is a lack of knowledge about the hazards of Hepatitis B, its
transmission and efficacy of vaccine.
Keywords: Hepatitis B, Hepatitis B virus, Awareness, Nursing students,
India has the intermediate endemicity of year to fourth year present in the classrooms of the
Hepatitis B with Hepatitis B surface antigen college in the campus on the day of study were
(HBsAg) prevalence between 2% and 10% included. Ultimately there were a total of 119
among the population studied. The number of students i.e. 71 from Bachelor of Science (BSc)
carriers in India has been estimated to be over 40 nursing and 48 from General Nursing Midwifery
millions. 5, 6 In India the carrier rate is higher (GNM) streams. The participants were fully
among health care personnel (10.87%) as informed about the design and purpose of the
compared to the blood donors (6%) and general study. Anonymity of the participants was
public (5%). Among healthcare workers maintained throughout the study. The data
seroprevalence is two to four times higher than collection was done with the help of a pre-tested
that of the general population.8 structured questionnaire distributed among these
Hepatitis B infections may occur in the health students in the classroom and they were asked to
care settings due to lapse in the sterilization fill the questionnaire. The questionnaire consisted
technique of instruments or due to the improper of closed ended questions to assess the knowledge
hospital waste management because 10 to 20% and awareness about HBV and Hepatitis B, its
of health care waste is hazardous which may transmission and Hepatitis B vaccine. Data entry
create a variety of health risks.9 The majority of was done in Microsoft excel 2007 software.
the infections are subclinical, so approximately Statistical analysis was done with help of SPSS
80% of all HBV infections are undiagnosed.4 software. The statistical tools like Z test of
Among the health care personnel, HBV is difference between two proportions; mean and
transmitted by skin prick with infected, standard deviation (SD) values were employed.
contaminated needles and syringes or through Statistical significance was considered at p values
accidental inoculation of minute quantities of <0.05.
blood during surgical, gynecological and dental
procedures.6 Nurses are probably the most RESULTS
common health care staff exposed to needle A total of 119 nursing students were included in
prick injuries and contact with infectious fluids. the study. Bachelor of Science (BSc) nursing
They are exposed to this risk right from there students were 71 (i.e. 59.66%) and General
student career. Hence it is important that nurses as Nursing Midwifery (GNM) students were 48 (i.e.
well as nursing students should have a thorough 40.34%). The mean age of BSc nursing students
knowledge regarding Hepatitis B to minimize was 20.11 ± 2.23 years and that for the GNM
the health care settings acquired infections students was 21.06 ± 2.28 years. The details
among them and other health personnel. regarding the number and age of the study
With this background, the present study was participants according to the academic year is
conducted among the nursing students to shown in Table 1. The mean age of the GNM
determine the awareness about HBV, Hepatitis B, nursing students was significantly more than that
its transmission and prevention. of the BSc nursing students (p=0.0237).
Table 2 shows the observations regarding this
MATERIALS AND METHODS knowledge about Hepatitis B virus (HBV) in the
The study was conducted at the College of study participants. The different aspects like
Nursing of Maharajah’s Institute of Medical family of Hepatitis B virus (HBV), its structure
Sciences (MIMS), Nellimarla during July 2012. and size were included in it. The study participants
The type of study was descriptive cross sectional were grouped according to their study courses as
study. All the nursing students ranging from first BSc nursing and GNM nursing and comparison
between them on various parameters was made. increased risk for Hepatitis B. Only 15 (21.13% of
Overall 77% of all the students knew that Hepatitis 71) of Bsc nursing students and 16 (33.33% of 48)
B is a member of Hepadnavirus family. GNM students which accounts for total
Significantly higher proportion of BSc nursing 31(26.05% of 119) students were correct regarding
students had a knowledge about it (Z=2.32, knowledge that HBV infection was previously
p=0.0203). Overall 56% students had a knowledge known as serum hepatitis.
that diameter of HBV is 42 mm. It was also found The correct knowledge regarding transmission of
to be statistically highly significant in BSc nursing Hepatitis B considering all the statements was
students (Z=2.11, p=0.0348). The total students observed in an average of 71.01% students
having knowledge about 4 genotypes of HBV whereas 29.99% of the students had an incorrect
were 68%. Significantly higher number of GNM knowledge about Hepatitis B transmission as
nursing students had knowledge about this shown in Table 4. Overall 58% of the respondents
parameter (Z=2.14, p=0.0324). The number of had correct knowledge about sexual transmission
respondents who could answer correctly that HBV of Hepatitis B. Significantly higher number of BSc
is not a retrovirus was 61 (51.26% of 119) nursing students were correct about it (Z=2.59,
including 30 (42.25% of 71) Bsc and 31 (64.58 % p=0.0096).However Hepatitis B is not transmitted
of 48) GNM. Thus higher number of GNM by hand shaking was known correctly to higher
respondents knew about this parameter and this number of GNM students and is statistically
difference was found to be statistically significant highly significant (Z=3.25, p= 0.0012).
(Z= 2.391, p= 0.0168). The knowledge that HBV Transmission of HBV by needle prick injuries
is one amongst smallest enveloped viruses and it being more common than Human
can be detected in clinical specimens by Immunodeficiency Virus (HIV) was correctly
Polymerase chain reaction (PCR) was present in known to a total of 85(71.43% of 119) respondents
respectively 49% and 51% of the respondents. which included 55(77.46% of 71) BSc nursing and
There was no statistical difference between the 30(62.5% of 48) GNM students.
BSC and GNM nursing students regarding this Regarding the awareness about prevention of
parameter. Hepatitis B by vaccine, 104 (87.39% of 119)
The awareness of respondents about Hepatitis B respondents had correct knowledge and only 15
infection is shown in Table 3. On an average (12.61%) were incorrect. The dose schedule of the
81.27% of the students were correct and remaining vaccine was known correctly to 99 (83.19% of
18.73% were incorrect regarding knowledge on 119) respondents and remaining 20 (16.81%) had
Hepatitis B infection. Except for statements about incorrect knowledge of the doses. The correct
liver inflammation due to acute HBV infection and knowledge regarding vaccine gives 85-90%
increased risk of doctors and nurses for Hepatitis protection against HBV was observed in only 28
B, there was no statistically significant difference (39.44% of 71) and 25(52.08% of 48))
in the knowledge between Bsc and GNM students respectively of BSc nursing and GNM students
regarding other statements. After applying Z test thus amounting to a total of 53 (44.54% of 119)
for difference between two sample proportions, respondents.
significant difference was noted among Bsc and
GNM students regarding awareness that acute DISCUSSION
illness is due to HBV causing liver inflammation In the present study considering all the statements
(Z= 1.98, p=0.0468). Similarly significantly higher about HBV, correct knowledge about HBV was
proportion of BSc nursing students had a correct observed in about half of the respondents. Half of
knowledge that Doctors and nurses are at an the students being unaware about the details of
HBV structure and characters may be due to its Eighty-eight percent of the participants were
theoretical importance only and less practical aware regarding the prevention of Hepatitis B by
application. This observation is in coherence with vaccine. Whereas other studies reported that
another study among the dental students which awareness about Hepatitis B vaccine was present
revealed that on an average, 59.23% of the among only 66% 10 of first year nursing students,
students were correct regarding knowledge about sixty-five percent among medical students11 and
HBV.4 However this knowledge is less in thirty-five percent11 among non medical students.
comparison with another study among the medical Requirement of screening test for detection of
students in which 86.7 % of them had correct Hepatitis B surface Antigen (HBsAg) among
knowledge about HBV.6 patients undergoing surgery was not known to
About three-fourths of the study participants were one-fourth of the nursing students. Whether nurses
aware that HBV infection resulted in Hepatitis B. are at the risk of contracting Hepatitis B or not was
Another study among the first year nursing also not known to one-fourth of the students. This
students from North India revealed that only 42% lack of awareness about the above two aspects
of the students had correct knowledge regarding may increase the risk of Hepatitis B transmission.
etiology of hepatitis B.10 The higher knowledge in This has been proved by another study.12
the nursing students in the present study could be Studies conducted in the general public in India13
due to the reason that the study group included and abroad14, 15 have revealed that the awareness
students from all the academic years of the nursing about HBV and Hepatitis B is less. These studies13,
14
course and Hepatitis B is covered in classes also showed that awareness level is significantly
extensively as a part of study curriculum. more in those with higher education levels and
Transmission of Hepatitis B on exposure to blood source of knowledge about Hepatitis B is mainly
or other body fluids, needle prick injuries and public media like newspapers and Television. In
unprotected sexual exposure was correctly known the present study awareness among the nursing
to respectively four-fifth, three-fourth and half of students was observed to be better than that among
the participants. These findings are coherent with the general public. This could be easily explained
another study among the dental students wherein that the nursing students were a part of health team
majority of them knew about transmission of and Hepatitis B was covered in the study
Hepatitis B by blood borne, needle injuries or curriculum for them. However the importance of
sexual exposure.4 In the present study the number the subject is to be emphasized, so that
of correct answers about this statement is more transmission of Hepatitis B can be decreased
than that observed in another study among the first among the patients as well as among the health
year nursing students where 35.2% were aware personnel including nurses.
that unsafe blood transfusion could lead to
Hepatitis B. The awareness was further found to CONCLUSION
be less among them regarding unprotected sex and The present study concludes that overall majority
reusing of needle-syringes as a potential risk factor of the nursing students were aware about Hepatitis
for Hepatitis B.10 Correctness of the statement that B. The knowledge regarding most of the
Hepatitis b is not transmitted by hand shaking was parameters was significantly higher among BSc
observed among 68% of the respondents. This nursing students as compared to GNM students. It
observation is in contrast to the study4 by other was also observed that there was a lack of
investigators who obtained 95% correct answers knowledge about the hazards of Hepatitis B, its
among the respondents. transmission and efficacy of vaccine. It is also
alarming that screening of patients for HbsAg was
15. Wai CT, Mak B, Chua W, Tan MH, Ng S, Singapore. World J Gastroenterol
Cheok A, et al. Misperceptions among 2005;11:5002-5.
patients with chronic hepatitis B in
ABSTRACT
A body sensor network (BSN), is a network of sensors de-ployed on a person’s body, usually for health
care monitoring. Since the sensors collect personal medical data, security and privacy are important
components in a body sensor network. At the same time, the collected data has to readily available in the
event of an emergency. In this paper, we present IBE-Lite, a lightweight identity-based encryption
suitable for sensors, and developed protocols based on IBE-Lite for a BSN.
Keywords: Security, Body Sensor Networks, Identity-based cryptography
From the basic ECC primitives, we derive the from string str, the sensor does Encrypt(m, str) to
following BE-Lite primitives, setup, and keygen, determine the cipher text c. Alg. 3 shows the
encrypt and decrypt. For ease of explanation, we process.
assume in this subsection that all primitives are BSN Security Protocols
executed by the patient. The actual protocols We first describe the initialization phase where the
involving the patient, CA and doctor are explained patient configures the BSN, followed by the data
in the next subsection. The intuition behind is to collection phase which outlines how a sensor
let a sensor independently generate a public key encrypts the collected data. The data transfer phase
on-the-fly using an arbitrary string. For example, a describes how a BSN transfers data to storage site,
sensor collecting EKG readings on Monday 1 and finally, the query phase which occurs when a
Powell first create a string str = (monday|1 doctor needs to obtain data from the storage site.
pm|EKG). Using this string, the sensor can derive We assume that an agreed upon syntax is used to
a public key, ystr to en-crypt the data and send it describe the string needed to derive a public key,
to the storage site. There is no corresponding and this descriptions termed as STR. For example,
secret key created. In fact, the sensor cannot create the patient deciding to collect data on a hourly
the secret key needed to decrypt the message. basis will set the sensors in the BSN to affix
When the patient wishes to release this timestamp rounded to the nearest hour when
information to a doctor, the patient can derive the creating strain other words, two EKG readings
corresponding secret key,xstr, by using the same collected on Monday at1:05 pm and 1:20 pm will
string str = (monday|1pm|EKG). both be described using the same string star =
This secret key only allows the doctor to decrypt {monday|1 pm|EKG}.As mentioned earlier, we
messages encrypted by a sensor using the same assume an honest-but-curious storage site which
string. This simplifies the key management, since will try to learn the contents of the stored data, but
the patient can generate the secret key on-demand will otherwise not delete the stored data. We also
without keeping track of which keys were used to assume a separate security mechanism is in place
encrypt which data. The only requirement is that so that only the patient can store BSN data onto
the string used to describe the event is the same. the storage site. Initialization: The patient first
Setup: We select an elliptic curve E over GF(p), executes Setup to obtain the master secret key X =
where p is a big prime number. We also denote P (x1, · · · , xn), and public parameters hay, P, p, q,
as the base point of E and q as the order of P, h(.)i. The patient loads the parameter shy, P, p, q,
where q is also a big prime. Asset of n secret keys h (.)i into every sensor in the BSN. The patient
x1, · · · , xn ∈ GF(q) is chosen to generate the then registers the master secret key together with
master secret key = (x1, · · · , xn).The n public additional instructions with the CA. Data
keys are then generated to make up the master collection: Let the sensor collect data d at events.
public key = (y1, · · · , yn)where yi = xi · P, 1 ≤ i <
n. Finally, a collision resistant one-way hash SECURITY ANALYSIS
function h: {0, 1}_ → {0, 1}n is chosen. The We begin by examining the basic primitives,
parameter shy, P, p, q, h(.)i followed by an analysis of the protocols
are released as the system public parameters. themselves.
Eigen: To derive a secret key xstr corresponding to Analysis of Basic Primitives
public key generated by a string str, the patient Our Setup is similar to that of the basic ECC setup
executes Eigen (str) = xstr, xstr =nXi=1hi (str) · xi, scheme, except that instead of picking a single
where hi(str) is the i-th bit of h(str).Encrypt: To secret x, our Setup picks n secrets and n
encrypt a message m using a public key derived corresponding public keys. Knowing only one star
and h(str), the doctor cannot determine the protocols provide flexibility. The string strcan be
patient’s master secret X since there are n used to specify access to the data, without using
unknown xi. The doctor is only able to determine additional certificates. For instance, consider the
X when he has in this pos-session n different string str ={Date | ER | Doctor} used to encrypt
secret keys x1str, · · · , xnstr.The use of star and data. A doctor wanting to obtain the corresponding
yet as the private key and public key derived from secret key will have to convince the CA that he is
string str does not violate the discrete logarithm indeed an ER doctor on the given date. The
property of ECC where, given a y = x · P, it is process of specifying what str to construct can be
infeasible to determine x given y and P, since both programmed by the patient without additional
are simply the result of addition of points. Also, permissions from the CA.
both Encrypt and Decrypt are secure since both
rely on well established ECC encryption and RELATED WORK AND RESULT
decryption methods. The motivation behind a BSN is to place low cost
Analysis of Protocols sensors directly on the patient for health care
Our protocols protect the privacy of the patient’s monitoring. With this in mind, several research
data by encrypting all the information before prototypes have been developed [18, 28, 8, 19].
forwarding the data to the storage site. After a The use of identity-based cryptography (IBE) [25,
sensor collects the data, the sensor encrypts the 2, 5] for medical applications was also suggested
data using Encrypt, resulting in the tupleSince all by [22, 21], but our work presents practical
tulles are in cipher text; the storage site learns implementation actual sensors rather than a
nothing about the patient’s data. The protocols general architecture. Other applications of IBE
also prevent unauthorized access to the patient’s include [13, 1, 11].Sensor network security is a
data. Each piece of data collected by a sensor is widely researched area [24, 12], with solutions
encrypted with a yet, the public key derived from focusing on key deployment [7, 14, 17, 16, 4],
the strings. When the doctor receives permissions public key cryptography [15, 23, 9] and
to access data encrypted under star, the doctor management [6, 20, 3]. Unlike prior work, our
receives the secret key star, which cannot be used security protocols incorportateidentity-based
to decrypt any other cipher text not encrypted cryptography primitives.
using yet. A compromised sensor does not allow
the adversary to obtain any useful data about a CONCLUSION
patient from the storage site since the sensor only In this paper, we presented IBE-Lite, a lightweight
stores the publicly known parameters. identity based encryption method suitable for a
At most the adversary obtains the cipher text pair body sensor net-work. We provided protocols
(c1, c2).The adversary can try to launch a based on IBE-Lite to provide security and privacy
matching attack by first creating many public keys support for a BSN. We evaluated our protocols
using different strings str. The adversary then using a combination of security analysis,
encrypts all possible values using the different simulations, and practical implementation on
public keys to determine whether there is a match actual sensors.
forth tuple (c1, c2). This is possible since the
number of potential EKG readings for example is REFERENCES
bounded. However, both c1 and c2 contains a 1. N. Asokan, K. Kostiainen, P. Ginzboorg, J.
random number n generated by Otto, and C. Lou. Applicability of identity-
the sensor. Since the adversary cannot predict the based cryptography for disruption-tolerant
value of, the matching attack fails. Finally, our networking. In MobiOpp 2007.
2. D. Boneh and M. Franklin. Identity-based 12. C. Karlof, N. Sastry, and D. Wagner. Tinysec:
encryption from the Weil pairing. In CRYPTO a link layer security architecture for wireless
2001. sensor networks. In SenSys 2004.
3. S. Capkun, L. Butty´an, and J.-P. 13. A. Kate, G. Zaverucha, and U. Hengartner.
Hubaux.Self-organized public-key Anonymity and security in delay tolerant
management for mobile adhoc networks. IEEE networks. InSecureComm 2007.
TMC 2003. 14. L. Lazos and R. Poovendran. Serloc: Secure
4. H. Chan, A. Perrig, and D. Song. Random key range-independent localization for wireless
redistribution schemes for sensor networks. In sensor networks. ACM TOSN 2005.
IEEESP 2003. 15. A. Liu, P. Kampanakis, and P. Ning. Tinyecc:
5. C. Cocks. An identity based encryption Elliptic curve cryptography for sensor
scheme based on. quadratic residues. In LNCS networks (version 0.3).2007.
2260 (2001). 16. D. Liu and P. Ning. Establishing pair wise
6. W. Du, R. Wang, and P. Ning. An efficient keys in distributed sensor networks. In CCS
scheme for authenticating public keys in 2003.
sensor networks. InMobiHoc 2005. 17. D. Liu, P. Ning, S. Zhu, and S. Jajodia.
7. L. Eschenauer and V. D. Gligor. A key- Practical broadcast authentication in sensor
management scheme for distributed sensor networks. InMobiQuitous 2005.
networks. In CCS 2002. 18. B. Lo and G. Z. Yang. Key technical
8. R. Ganti, P. Jayachandran, and T. Abdelzaher. challenges and current implementations of
Satire:A software architecture for smart attire. body sensor networks. InBSN 2005.
In Mobisys2006. 19. D. Malan, T. Fulford-Jones, M. Welsh, ands.
9. J. Girao, D. Westhoff, E. Mykletun, and T. Moulton. Code blue: An ad hoc sensor
Araki.Tinypeds: Tiny persistent encrypted network infrastructure for emergency medical
data storage in asynchronous wireless sensor care. In BSN2004.
networks. Ad HocNetworks 2007. 20. D. J. Malan, M. Welsh, and M. D. Smith. A
10. V. Gupta, M. Wurm, Y. Zhu, M. Millard, S. public-key infrastructure for key distribution
Fung,N. Gura, H. Eberle, and S. C. Shantz. in tinyosbased on elliptic curve cryptography.
Sizzle: A standards-based end-to-end security In SECON 2004.
architecture forthe embedded internet. In
PerCom 2005.
11. U. Hengartner and P. Steenkiste. Exploiting
hierarchical identity-based encryption for
access control to pervasive computing
information. InSecureComm 2005.
ABSTRACT
Background: The regular use of contact lens for improving vision has seen an increasing trend
worldwide and this can be attributed to increase in awareness through better advertisement, easy
availability and handling, better products through advanced manufacturing strict guidelines. Our
Objectives was to assess knowledge and compliance regarding contact lens wear and care among female
college students in Saudi Arabia. Methods: A cross-sectional descriptive study was conducted from
March to May, 2010, among randomly selected 50 female students of King Saud University, Riyadh, who
were aged between 18 – 25 years. Data were collected through pre-designed, pre-tested self- explained
questionnaire with the help of optometrist. Results: It was found that significant number of the study
population (88%) was regularly cleaning the lens case. However, only 58 percent of them cleaned their
hands before putting the contact lens in the lens case while the remaining either did not clean at all (18%)
or cleaned irregularly (24%). There were findings related to the habit of immersing the lens, only half the
lens in the cleaning solution (34%). Regular visit to eye practitioners (38%) and use of contact lens
beyond the expiry date (10%). Conclusion: It appears that primarily it is poor hand hygiene, inadequate
care of the lens and the lens case, improper use of the cleaning solution and irregular follow up visits to
the eye practitioners for eye check among the young female population.
Keywords: Contact lens, Saudi Arabia, eye infections, lens care.
INTRODUCTION contact lens has also been used for prosthetic and
Contact lens use for the correction of refractive cosmetic reasons for example to enhance eye
error is gaining momentum world-wide. This colour. There are lots of different designs available
could be attributed to the advancement in contact in terms of lens type and materials and at an
lens manufacturing technology; improved lens affordable cost. These have made contact lens
materials, production techniques as well as storage wear popular among the young people particularly
and care products. There have also been females in Saudi Arabia.
improvements on awareness and/or education on Contact lens can act as a vector for
the proper use of contact lenses and contact lens microorganisms to adhere to and transfer to the
care products. In Saudi Arabia, contact lens use ocular surface if not used and cared properly. In
has also been on the increase.[1] Apart from its the presence of reduced tissue resistance,
use for the correction of refractive error and microorganisms or transient pathogens can invade
management of problem of ocular adnexa such as and colonize the cornea or conjunctiva to produce
in exophthalmos to prevent exposure keratopathy inflammation or infection.[4] Noncompliance has
or cornea problems such as keratoconus,[2, 3] been implicated as one of the causes of
complications in contact lens wear; the inadequate related to contact lens use, cleaning and
adherence to the practitioner’s instructions on the maintenance.
use of contact lenses and care products.[5] These
complications which range from mild eye MATERIALS AND METHODS
irritations to keratitis have in most cases posed a A cross sectional descriptive study was conducted
threat to the oculo-visual function. Studies,[6, 7] using a structured questionnaire among the female
have identified several risk factors associated with students at King Saud University in Riyadh aged
lens wear complications in an attempt to 18-25. The study got clearance from the
encourage successful lens wear and to minimize University Ethics Committee and was
disease burden. Amongst the identified risk implemented among the female students. Any
factors, some are non-modifiable such as gender or female who has ever worn contact lens for any
age,[8] of which we cannot influence whereas period of time and for whatever reason was
others are modifiable such as poor hand cleaning enrolled in this study. To get a better
and lens case hygiene[9] hence can be targeted in understanding of some questions and to capture
minimizing vision loss and maximizing successful appropriate information, a pilot study (pre- test)
lens wear. was conducted on 10 students a week prior of
Ocular health education or knowledge in the starting research work and after review few
correct and careful practice regarding contact lens modifications were done in the questionnaire for
wear can prevent complications resulting from the the final research work. A total of 50 contact lens
wearer's inappropriate behavior. One of the ways wearers were identified and a structured
of investigating this is from the person's questionnaire was introduced to collect the
perception regarding his own knowledge of information from March to May 2010 after getting
contact lens wear.[10] There are three primary the informed consent for the participation in this
areas of concern namely: contact lens wear study. The questionnaire was in Arabic language
schedule, lens care, and contact lens replacement and had 35 questions. The tool was validated by
schedule. Consequently the study of knowledge of three Optometry experts working in the
compliance can contribute to the planning of Department of Optometry before using in this
educational and health campaigns aimed at present study. For analysis purpose the
reducing some of the ocular complications questionnaire was also back translated in English
associated with contact lens wear. to ensure the same meaning is conveyed.
Whilst many eye care practitioners are familiar The questionnaire was based on the knowledge
with the notion that many contact lens wearers are and practices of contact lens wear, care and its
non-compliant, there is very little up-to-date possible complications. All the questions were
objective data available to support this belief in prepared in Arabic language and the answers were
Saudi Arabia. In this report we present also given in Arabic language by the participants
independent research which describes the lens who participated in the study. The questionnaire
wear and care habits of female contact lens was designed in a very comprehensive manner
wearers in Riyadh, Saudi Arabia. Educational which consisted of 35 questions related to general
status of patients is one of the factors thought to demographic data, socio economic status, contact
influence compliance.[11] The current study was lens hygiene and hand cleaning, compliance to eye
conducted among the female college students with care provider's instructions and behavioral aspects.
a primary objective to assess the knowledge and The tool was objective type which was not time
compliance of contact lens care and their practice consuming as the participant has to tick her answer
on the appropriate box (answers being 'Yes',
'NO'&/ 'Sometimes'). The data that was collected problem while on changing the cleaning solution,
in the questionnaires was coded and it was 24% (12) were using the same brand and the
analyzed using Epi_info software version 3.5.1 remaining 2 (4%) uses water temporarily.
2008, (CDC Atlanta). Compliance associated with Contact lens wear:
Regarding history of lens related complications,
RESULTS 10% (5) reported having experienced a contact
Demographic characteristics: Fifty females lens related complication. Patients were also
participated in the study and their age distribution queried on their knowledge of complications
was as follows; 54% were under age group of 18- associated with contact lens wear. More than half
21 years and the remaining 46% were between 22- of the patient surveyed (65%) reported that they
25years (Table-1). 74% (37) students were single had not experienced a contact lens-related
while the rest 26% (13) were married (Graph -1). complication.
Out of the fifty contact lens users, 92% (46 Pearson Chi square test was used to find out the
females) were using soft lens and 8% (4 females) association between the age, level of education
were RGP lens users. Majority of the participants and compliance of contact lens care based on the
66% (33) were using contact lens for cosmetic subject’s responses. There was a statistically
purposes while the remaining 34% (17) were using significant association between age and Cleaning
for refractive purpose. It was observed that 52% the lens cases (p=0.002), washing hands before
(26) of them got their contact lenses from cosmetic inserting contact lenses (p=0.054), cleaning hands
center while 38% (19) got theirs from optical shop before keeping the lens in the lens cases
and only 10% (5) got their lenses prescribed from (p=0.000), Immersing lens in cleaning solution
hospital (Table 2) (0.000), whereas no statistically significant
Lens supply: It was also found that 82% (41) of association noted between age and follow up with
the lens users were cleaning the lens case the eye care practitioner among our subjects
regularly. Out of fifty participants, 46 (92%) of (p=0.109). The level of education showed
them clean their hands before using contact lens statistically significant association with cleaning
and 4 (8%) of them doesn’t clean their hands of lens case (p=0.005), cleaning hands before
before inserting contact lens in the eye. Only 58% keeping lens in the lens case (p=0.000), Immersing
(29) of them clean the hands before putting the lens in cleaning solution (p=0.002) and Follow up
contact lens in the lens case and remaining either visits with the eye care practitioner (p=0.004),
do not clean at all 6 (12%) or clean sometimes 15 whereas washing hands before inserting contact
(30%) (Table 3) lenses in the eye does not showed any significant
Lens care: Other significant finding of the study association with level of education (p=0.295).
is that 74% (37) immerse the lens in cleaning (Table 5)
solution completely while 26% (13) of them place
the lens half immersed in the cleaning solution. It DISCUSSION
was also established that only 62% (31) of them Contact lenses are a convenient alternative to
visit the eye practitioner regularly. There was also eyeglasses and it is considered as a better option
usage of expired contact lens by 10% (5) for certain eye conditions, such as keratoconus and
participants regularly, and 16% (8) of them use the irregular astigmatism. Contact lenses usually
expired contact lens sometimes (Table-4). provide better vision and freedom of movement
The distribution of subjects according to the usage for some users, but improper care and cleaning of
of cleaning solution was shown in Graph 2. It these products can cause discomfort, blurred
showed 72% (36) subjects don’t have any ocular vision and pain. Contact lenses are not only worn
to correct vision and it can be worn for cosmetic or replacing the lenses in the case. In the present
therapeutic purposes. In this study, 34% of study also, 74% of the participants immerse their
females were found to be wearing CLs to correct lenses completely in the solution while cleaning
refractive error and 66% were using CLs for the the lenses. In a similar study conducted by Mayers
cosmetic purposes. et al,[14] 71% of contact lens wearers put their
In this study patient’s compliance on the use and lenses directly into the lens case without rinsing
care of contact lenses were weighed against lens and rubbing the lenses to clean them; 11 percent
supply, lens care regimen and contact lens rinsed only, and only 7 percent performed rinse-
replacement schedule. The place of contact lens and-rub” cleaning technique. The lack of hands’
supply; cosmetic centers, Optical showrooms and cleaning before touching the lens could introduce
hospitals, has been found to be associated with dirt on the lens surface which can be transferred to
contact related complications,[9] as there are the eye, resulting in irritation and/or infection
limited instructions given to patients on the use of especially where the lenses are not properly
contact lenses. In this study, 52% of the cleaned. This study also found that 31% of contact
participants agreed to have purchased their contact lens wearers wait up to 12 months to replace their
lens from the cosmetic centers while only 10% had lens case and most the lens wearers reported to
obtained there lenses from an optometrist from visit the optometrist regularly. A study done by
hospitals. This is contrary to the recent study in Hickson-Curran et al,[15] among 787 contact lens
Australia by Wu and Stapleton,[12] where wearers revealed that 48 percent replaced their
majority (66%) of the participants was said to have case annually.
obtained their lenses from the optometrist. This Compliance with contact lens care and
disparity between these studies reflects the maintenance instructions is considered to be the
difference in years of contact lens practices and most important aspect of the safe and comfortable
laws on who can and cannot fit contact lenses as use of lenses. The use of contact lenses is known
well as level of education given to patients in the to increase the microbial load in the eye which can
two countries. In Saudi Arabia for instance, adversely affect corneal health (16), ranging from
contact lens practice is more recent compared to a mild ocular redness and irritation to a very
Australia. Another reason for the differences in the severe sight threatening situation like
two studies could have stemmed from the sample Acanthamoeba keratitis. Poor contact lens hygiene
size and the demography of this study as the study and microbial contamination of the lens storage
had considered only female contact wearers. case have been observed to be related to microbial
According to Claydon et al,[13] the major areas of keratitis (17,18,19) .A proper hand wash and
non-compliance in contact lens wear have been hygiene plays an important role in controlling the
highlighted as the lack of hand and lens-case risk of infection while handling contact lenses. In
hygiene, the over wearing of contact lenses, the this study, 30% of subjects’ clean their hands
poor attendance of patients at aftercare before inserting CLs in the eye and remaining 12%
appointments and the inadequate use of care and doesn’t wash their hands at all. This may cause
maintenance systems. In our study, majority of the risk of ocular infections secondary to CL wear.
participants cared for their lens cases regularly and Appropriate counseling regarding contact lens
92% of lens wearers reported cleaning their hands care, maintenance instructions and personal
before putting on the lenses in the eye, and this hygiene should be given to the subjects in the clear
was also seen in the study by Wu and manner by eye care practitioners. Proper lens care
Stapleton.[12] However, over half of the subjects is essential for safety and success, but so is
(58%) actually cleaned their hands before adherence to prescribed replacement schedules
and recommended wearing schedules, as well as Eye care practitioners should equally educate
regular return visits to the eye-care practitioner. patients on the replacement schedule of their
In our study, 92% of subjects were using soft CLs lenses. It is relatively easy to blame patients for
and 8% were using RGP CLs. Soft contact lenses poor compliance but experience has shown that
deteriorate over time as they become worn, dirty poor compliance can be avoided or at least
and accumulate protein deposits that cannot be reduced by proper training at the initial fitting of
removed even by elaborate cleaning. This can contact lenses and reinforcement at the follow up
affect visual acuity and increase discomfort. There visits. While some contact lens patients are
are chances of infection of the lens leading to noncompliant on purpose, most patients would be
corneal ulcer. Regular visit to the optometry clinic more compliant with their replacement schedule if
is believed to encourage prompt replacement of they had reminders or a way of remembering when
lenses as faults or abnormalities would be to replace their lenses. There should be a place on
identified on time and appropriate management an eye care practitioners written contact lens
initiated. Also, each patient encounter is an prescription for the recommended wearing time,
opportunity to review and reinforce proper replacement schedule.
wearing and replacement time and contact lens
care. Continually educating patients that contact CONCLUSION
lenses are medical devices and reviewing proper Contact lenses are the safest forms of vision
lens wearing and replacement schedules is the best correction when patients follow the proper care
way to avoid noncompliance. and wearing instructions. Contact lens wearers
could be damaging their eyes by not using proper
RECOMMENDATIONS hygiene in caring for their lenses. Poor hand
Many patients see contact lens solely as a cosmetic hygiene, inadequate lens care and not
item and not as a medical device. This attitude remembering when to come back for aftercare
leads to the purchase of contact lens and care visits are the common non-compliant behaviors in
products from the cosmetic shops and over the lens wearers. Higher educational status does not
internet. Therefore, there is need to enact laws that always mean higher compliance amongst contact
will regulate dispensing of contact lenses by lens wearers. Proper contact lens care and regular
unqualified persons as well as purchase or sale of follow-up visits to their eye care practitioner are
contact lenses and care products over the internet. essential for a patient’s safety and wearing
Education, improving communication, behavioral success. Appropriate counseling regarding contact
modifications are the main factors that helps to lens wear and care should be given to the subjects
improve the compliance level in any population. by contact lens dispensers or Optometrists or
When eye care practitioners dispense contact Ophthalmologists. Clean and safe handling of
lenses, there is need to educate patients on the contact lenses is one of the most important
proper wearing schedule; for example not to sleep measures where contact lens wearers should
in lenses that are not approved for overnight wear. follow to protect their ocular health and sight.
This gives patients the opportunity to ask to be However, due to the limitation of the study to only
fitted in a higher-Dk lens if overnight wear is an females, this may not be generalized to the general
option. Patients should also be given helpful tips population in Saudi Arabia. Therefore, there is
or written instruction on the steps to follow while need for more studies that will involve both, male
cleaning the lenses as well as while fitting and and females.
replacing the lens in the case.
Irregular 19 (38%)
ABSTRACT
Aim: To study the occurrence of the variant heads of biceps brachii muscle.
Materials and Methods: The 50 specimens of the 25 donated embalmed cadavers (20 males & 5
females) were dissected and observed for variations in the origin and insertion of biceps brachii muscle
bilaterally in the department of Anatomy at K.J.Somaiya Medical College, Sion, Mumbai, INDIA. The
dissection of arm and forearm was done meticulously in all the 50 specimens. The photographs of the
supernumerary head of biceps brachii muscle were taken for proper documentation and for ready
reference.
Results / Observations: Out of 50 specimens, the supernumerary head was found in six specimens. The
humeral head was taking origin from the anteromedial surface of the shaft of the humerus in three
specimens and from the anterolateral surface of the shaft of the humerus in three specimens. In all six
specimens, the supernumerary head joined with the other two heads and form a common tendon which
got inserted into the radial tuberosity of the radius and bicipital aponeurosis. In the present study the
incidence of supernumerary head of biceps brachii was 12%. In all the six specimens, the supernumerary
head was found unilaterally (5 males & 1female specimen). In three specimens (50%) the supernumerary
head was supplied by median nerve, the musculocutaneous nerve was absent in that specimen while in all
other specimens the muscles of front of arm were supplied as usual by musculocutaneous nerve. The
blood supply of the supernumerary head was from the brachial artery and vein. There were no variations
in the vascular pattern of arm and forearm in all the specimens.
Conclusion: Topographical anatomy and variations in the heads of the biceps brachii muscle is clinically
important for surgeons, orthopaedicians and radiologists.
Key words: Biceps Brachii Muscle, Supernumerary Head, Musculocutaneous Nerve, Median Nerve,
Surgeons, Orthopaedicians, Radiologists.
reported anomalies have been manifested as cadavers varied between 65-80 years. Te skin is
supernumerary fascicles that originate from the reflected by making a longitudinal incision on the
coracoid process, tendon of pectoralis major, anterior aspect of the arm extending from the level
articular capsule and head of the humerus or from of acromian process to a point 2.5 cm below the
humerus itself (6). Among those variations, the elbow joint & horizontal incisions on both
presence of a supernumerary fascicle arising from proximal and distal ends of the longitudinal
the shaft of the humerus, which is known as the incision. The arms were then dissected carefully to
humeral head of biceps brachii, is known to be the expose the full length of the biceps brachii muscle
most common anomaly (3, 7, 8). Multiple from its proximal to distal attachment. The
supernumerary heads of four to seven have also presence of supernumerary heads, their origins and
been reported to a lesser extent (1, 3, 4, 5). A large insertions were recorded. The photographs of the
body of evidence suggests a wide range of racial supernumerary head of biceps brachii muscle were
variations in the occurrence of humeral head of taken for proper documentation and for ready
biceps brachii muscle. It was shown to have an reference.
incidence of 7.1% in Indians, 8% in Chinese, 10%
in European whites, 10 % in Sri Lankans, 12% in RESULTS / OBSERVATIONS
African Blacks, 15% in Turkish, 18% in Japanese, Out of 50 upper limbs of 25 cadavers,
21.5% in South African Blacks and 8.3% in South supernumerary heads of the biceps brachii were
African Whites, and 37.5 % in Colombians (3, 8, present in 6 specimens. The supernumerary head
9, 10, 11,12, 13, 14, 15, 16). From a clinical was taking origin from the anteromedial surface of
standpoint of view, muscle anomalies are difficult the shaft of the humerus in three specimens and
to differentiate from soft tissue tumors (5). High from the anterolateral surface of the shaft of the
median nerve compression around the elbow joint humerus in three specimens. In all the six
has been described as resulting from a number of specimens, the supernumerary head joined with
clinical and anatomical entities. The existence of the other two heads and form a common tendon
an anomalous muscle in and around the elbow which got inserted into the radial tuberosity of the
region may cause high median nerve palsy and radius and bicipital aponeurosis. In the present
compression of the brachial artery (5). Further, study the incidence of supernumerary head of
knowledge of the incidence of humeral head of biceps brachii was 12%. In all the six specimens,
biceps brachii will facilitate preoperative diagnosis the supernumerary head was found unilaterally (3
as well as the surgical procedures of the upper male & 3 female specimens). In three specimens
limb (5,9). (50%) the supernumerary head was supplied by
median nerve, the musculocutaneous nerve was
MATERIALS AND METHODS absent in that specimen while in all other
This study was carried out on a total of 25 donated specimens the muscles of front of arm were
embalmed cadavers (20 males and 5 females) supplied as usual by musculocutaneous nerve. The
during routine gross anatomy dissections in the blood supply of the supernumerary head was from
Department of Anatomy at K.J.Somaiya Medical the brachial artery and vein. There were no
College, Sion, Mumbai, India. The cadavers were variations in the vascular pattern of arm and
preserved in 10% formalin. The age group of the forearm in all the specimens.
Fig. 1: The right supernumerary head was taking origin from the anteromedial surface of the shaft of the
humerus and was supplied by the musculocutaneous nerve.
Fig. 2: The left supernumerary head was taking origin from the anteromedial surface of the shaft of the
humerus and was supplied by the musculocutaneous nerve.
Fig. 3: The left supernumerary head was taking origin from the anteromedial surface of the shaft of
the humerus and was supplied by the musculocutaneous nerve.
Fig. 4: The right supernumerary head was taking origin from the anterolateral surface of the shaft of the
humerus and was supplied by the median nerve.
Fig. 5: The right supernumerary head was taking origin from the anterolateral surface of the shaft of the
humerus and was supplied by the median nerve.
Fig. 6: The right supernumerary head was taking origin from the anterolateral surface of the shaft of the
humerus and was supplied by the median nerve.
11. Torre, F. R. L.; Cegarra, J. N. & Berruezo, J. 17. Santo Neto, H.; Camilli, J. A.; Andrade, J. C.;
P. Biceps brachii muscle attached to the Meciano, F. J. & Marques, M. J. On the
extensor carpii radialis brevis muscle: an incidence of the biceps brachii third head in
unreported anatomical variation in humans. Brazilian white and blacks. Anat. Anz.,
Anat. Anz., 176:319-21, 1994. 180:69-71, 1998.
12. Kosugi, K.; Shibata, S. & Yamashita, H. 18. Warner, J. P.; Palleta, G. A. & Warren, R. F.
Supernumerary head of biceps brachii and Supernumerary Head of the Biceps brachii,
branching pattern of the musculocutaneous Case report demonstrating clinical relevance.
nerve in Japanese. Surg. Rad. Anat., 14:175- Clin. Ortho. Res., 280:179-81, 1992.
85, 1992. 19. Le Minor JM. A rare variant of the median
13. Kumar, H.; Das, S. & Rath, G. An anatomical and musculocutaneous nerves in man.
insight into the third head of biceps brachii Archieves Anatomy Histology Embryology
muscle. Bratisl. Lek. Listy., 109:76-8, 2008. 1992; 73: 33-42.
14. Tountas, C. P. & Bergman, R. A. Anatomic 20. Venierators D and Anangnastopoulou S
variations of the upper extremity. New York, classification of communication between the
Churchill Livingstone, 1993. musculocutaneous and median nerves.
15. Rincon, F.; Rodriquez, I. Z. & Sanchez A. Clincal Anatomy. 1998; 11: 327-331.
The anatomic characteristics of the third head 21. Roberts, W. H. Anomalous course of the
of biceps brachii muscle in Colombian median nerve medial to the trochlea and
population. Rev. Chil. Anat., 20:197-200, anterior to the medial epicondyle of the
2002. humans. Anat. Anz., 174:309-11, 1992.
16. Swieter, M. G. & Carmichael, S. W. Bilateral
three-headed biceps brachii muscles. Anat.
Anz., 148:346-9, 1980.