IJCRR Vol 5 Issue 03 Healthcare

ISSN: 2231-2196 (Print) ISSN: 0975-5241 (Online) Internationally Indexed, Peer Reviewed, Multidisciplinary Scientific Journal ICV: 4.
18
International Journal of Current Research and Review

(IJCRR) Section: Healthcare
Vol 05 / Issue 03 / Feb 2013 Frequency: Fortnightly Language: English Published by: Radiance Research Academy, Nagpur, MH, India
Aug 2012
I J C R R
Vol 5 / Issue 03 / Feb 2013
Editorial Board 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 Ubon Ratchathani University, Thailand Dr. Chellappan Dinesh International Medical University, Malaysia Dr. R. O. Ganjiwale Nagpur University, MH, India Dr. Shailesh Wader 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 Dr. Parichat Phumkhachorn Ubon Ratchathani University, Thailand Dr. Manoj Charde Amravati University, MH, India Dr. Shah Murad Mastoi Lahore Medical and Dental College, Lahore, Pakistan Dr. Hitesh Wadhwa MD University, HY, India
International Journal of Current Research and Review Vol. 5 / Issue 03 / Feb 2013
I J C R R
About International Journal of Current Research and Review (IJCRR) International Journal of Current Research and Review (IJCRR) is one of the popular fortnightly international multidisciplinary science journals. IJCRR is a peer reviewed indexed journal which is available online and in print format as well. Indexed and Abstracted in: ScopeMed, Google Scholar, Index Copernicus, Science Central, Revistas Mdicas Portuguesas, EBSCO, DOAJ, BOAI, SOROS, NEWJOUR, ResearchGATE, Ulrich's Periodicals Directory, DocStoc, PdfCast, getCITED, SkyDrive, Citebase, e-Print, WorldCat (World's largest network of library content and services), Electronic Journals Library by University Library of Regensburg, SciPeople. Aims and Scope: IJCRR is a fortnightly indexed international journal publishing the finest peer-reviewed research and review articles in all fields of Science. IJCRR follows stringent guidelines to select the manuscripts on the basis of its originality, importance, 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. About the editors: IJCRR management team is very particular in selecting its editorial board members. Editorial board members are selected on the basis of expertise, experience and their contribution in the field of Science. Editors are selected from different countries and every year editorial team is updated. All editorial decisions are made by a team of full-time journal management professionals. IJCRR Award for Best Article: IJCRR editorial team monthly selects one Best Article for award among published articles. Disclaimer: Opinions expressed in the articles are those of authors and do not reflect the ideas or the opinions of the IJCRR. IJCRR does not take legal responsibility for the accuracy of the content or liability for any errors or omissions. IJCRR makes no warranty, express or implied, in the material contained in this journal. Ownership: IJCRR is owned and published by Radiance Research Academy, Nagpur, M.S., India. Subscription: As per COPE and OASPA policy, papers published in IJCRR are freely available to view and download on internet. Hard copy of IJCRR can be subscribed by contacting IJCRR editorial office. Hard copies of journal are provided to subscribers only. Permission: IJCRR journal design and style is property of Radiance Research Academy and protected under legal provisions of Copyright Act. No part of IJCRR may be reproduced in any form without prior written permission from IJCRR editorial office. For information on how to request permissions to reproduce articles or information from this journal, please contacteditor@ijcrr.com
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Healthcare
Index
STUDY OF OBESITY AND ITS RISK FACTORS AMONG WOMEN OF REPRODUCTIVE AGE GROUP Shashidhar Basagoudar, Chandrashekhar R. Page No. 23-28 RELATIONSHIP OF ULTRASONOGRAPHIC ENDOMETRIAL THICKNESS AND MORPHOLOGY TO BODY MASS INDEX IN POSTMENOPAUSAL WOMEN Shalaan R.M., Deghidi A.N., Hegazy A.I. Page No. 29-36 STUDY OF SUDDEN NATURAL DEATHS IN MEDICO-LEGAL AUTOPSIES WITH SPECIAL REFERENCE TO CARDIAC CAUSES Sandesh H. Chaudhari, Anand Mugadlimath, Mandar Sane, K.U. Zine, D. I. Ingale, Rekha Hiremath Page No. 37-42 COMPARISON OF SEROPOSITIVITY OF HIV, HBV, HCV AND SYPHILIS AND MALARIA IN REPLACEMENT AND VOLUNTARY BLOOD DONORS IN WESTERN INDIA Chetna Jain, N.C. Mogra, Jhaman Mehta, Rishi Diwan, Gaurav Dalela Page No. 43-46 NURSING STUDENTS APPROACHES TO LEARNING AND STUDYING: A CROSS-SECTIONAL STUDY IN AN INDIAN SETTING Juliana Linnette DSa Page No. 47-53 ENERGY BALANCE, PSYCHOSOCIAL PROBLEMS BIOCHEMICAL PROFILE OF OBESE CHILDREN AND
Kalpana C.A., Lakshmi U.K. Page No. 54-61 A COMPARATIVE SHEAR BOND STRENGTH EVALUATION OF THREE TOOTH COLORED RESTORATIVE MATERIALS USED IN PRIMARY TEETH AN IN VITRO STUDY K. Vimala Geetha, Eapen Thomas, Phani Babu Page No. 62-68 HEALTH INFRASTRUCTURE FACILITIES IN KARWAR DISTRICT OF KARNATAKA Rama B. Gouda, Guruprasad Ganeshkar Page No. 69-75
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Healthcare Index
HISTOPATHOLOGICAL STUDY OF MENINGIOMA IN CIVIL HOSPITAL, AHMEDABAD Smita Shah, R. N. Gonsai, Rinku Makwana Page No. 76-82 HISTOPATHOLOGICAL SPECTRUM OF SINONASAL MASSES A STUDY OF 162 CASES. Seema K. Modh, K. N. Delwadia, R. N. Gonsai Page No. 83-91 INCIDENCE OF CANDIDIASIS AND TRICHOMONIASIS IN LEUCORRHOEA PATIENTS Supriya Panda, P. Nagamanasa, Sandhya Sri Panda, T.V. Ramani Page No. 92-96 EVALUATION OF SIZE AND VOLUME OF MAXILLARY SINUS TO DETERMINE GENDER BY 3D COMPUTERIZED TOMOGRAPHY SCAN METHOD USING DRY SKULLS OF SOUTH INDIAN ORIGIN Vidya C.S., N.M. Shamasundar, Manjunatha B., Keshav Raichurkar Page No. 97-100 MEIER-GORLIN SYNDROME - A VERY RARE CONGENITAL MALFORMATION Vidyadevi Kendre, Shital Bhattad Page No. 101-103 PYOGENIC LIVER ABSCESS - CLINICAL, RADIOLOGICAL AND BACTERIOLOGICAL CHARECTERISTIC AND MANAGEMENT STRATEGIES C.P. Ganesh Babu, R. Kalaivani Page No. 104-107
Shashidhar et al
STUDY OF OBESITY AND ITS RISK FACTORS AMONG WOMEN OF REPRODUCTIVE AGE GROUP
IJCRR
Vol 05 issue 03
Shashidhar Basagoudar, Chandrashekhar R.

Department of Community Medicine, Raichur Institute of medical sciences, Raichur, India E-mail of Corresponding Author: drshashidharsb@gmail.com
Section: Healthcare
Category: Research Received on: 15/12/12 Revised on: 04/01/13 Accepted on: 19/01/13
ABSTRACT Objectives: 1. To find out the proportion of overweight or obesity among women of reproductive age group. 2. To find the association between various socio-demographic factors and overweight or obesity. Material and Methods: A cross-sectional study conducted among ever married women of reproductive age group who have attended the Urban health training centre during the study period of six month. Data was collected by direct interview through prestructured questionnaire and anthropometric measurement. Results: Among the 244 women studied 11.9% were having overweight, 9.9% were obese, 20.1% were underweight and only 58.2% of the women were having normal BMI. Overweight or obesity was significantly more among those women who were eating junk foods regularly, watch television while eating and those with mild to moderate physical activity. There was significant association between family history and overweight. There was no significant association between religion, type of family and type of diet with overweight. Overweight was more common in literates compared to illiterates and proportion of being overweight increases with higher socioeconomic status. Conclusion: Overweight or obesity is one of the major problems even in those areas with high prevalence of undernourishment. Physical inactivity and the dietary factors are the major risk factors for such high proportion of overweight or obesity. Keywords: obesity, overweight, reproductive age, BMI INTRODUCTION Obesity may be defined as an abnormal growth of the adipose tissue due to an enlargement of fat cell size or an increase in fat cell number. Obesity is expressed in term of body mass index (BMI).1 The latest WHO projections indicate that at least one in three of the world's adult population is overweight and almost one in ten is obese.2 According to National Family Health Survey-3 in India 14.8% (28.9% for urban and 8.6% for rural) of married women in the age group of 15-49 years were overweight or obese.3 Overweight or obesity can have a serious impact on health. Carrying extra fat leads to serious health effects such as cardiovascular diseases4,5, type 2 diabetes mellitus6, musculoskeletal disorders like osteoarthritis, gall bladder disease and some cancers (endometrial, breast and colon). These conditions cause premature death and substantial disability.4 Because of difference in the proportion of fat content, in Asians, the health risks caused due to overweight or obesity occur at lower levels of BMI compared to other regions of the world. 7, 8 The earlier BMI cut off values were developed by western researchers based on studies in Caucasian populations, Therefore new classification with lower cut off values of BMI was developed to classify overweight and obesity among Asian people.9 India being one among the Asian countries the new classification is applicable to Indians and it is also obvious that Indians are more
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at risk of complications due to overweight or obesity. Raichur is one of the underdeveloped districts of Karnataka. Most of the studies previously done in this area have shown about the under nutrition but as it is the phase of transition everywhere, it was essential to have data regarding overweight and obesity in this area also. Hence a study was conducted with the objective of assessing the proportion of women having overweight or obesity among women of reproductive age group and also to know the factors influencing the occurrence of overweight or obesity. MATERIAL AND METHODS A cross sectional study was carried out at the Urban Health Training Centre (UHTC), Amtalab, Raichur, which is part of the department of Community medicine, Raichur Institute of medical sciences. Study was conducted among the ever married women in the reproductive age group (1545 years) who have attended the UHTC during the study period of 6 months (January 2012 to June 2012). Women who were pregnant during study and those women who did not give consent for the study were excluded from the study. Oral consent for participation in the study was obtained from all the participants after informing about the study and its purpose. Data was collected about sociodemographic profile and some risk factors for obesity through prestructured questionnaire by interview method. Anthropometric measurement like weight and height are also recorded. BMI classification for Asians was utilized for assessing the overweight or obesity. Data was analyzed using SPSS 16 software. Data is expressed as proportion or percentage, association between various factors and obesity was assessed using chisquare test and p value of <0.05 was considered as significant. RESULTS A total of 244 women were studied during the period. Among them 65.6% were belonging to
Hindu religion, 33.2% were Muslims and rest 1.2% were belonging to other religion. Majority of the women (62.7%) were of the age-group 26-35 years, where as 33.2% were of the age group 1525 years and 4.1% were belonging to the age group of 36-45 year. Mean age of the study group was 27.85 years. (Refer table 1) Among the studied women 66.8% were illiterates, 5.3% were studied up to primary school, 12.3% middle school, 11.9% high school and only 3.7% were studied PUC or above. Majorities (65.6%) of the women were belonging to the nuclear family and 34.4% were belonging to the joint family. 66.4% of the women were house wives and 33.6% were working women. Among the working women 18% of the women were involved in the work which require moderate level of physical activity (tailor, cook, house maid, shop keeper etc) and 15.6% of the women were involved in the work which require heavy work (manual labourer). Majority (75.8%) of the women were belonging to the upper lower class (IV) of socioeconomic status according to modified Kuppuswamy classification (modified for the year 2012).10 20.9% were belonging to lower middle class (III), 2.9% belonging to the upper middle class, 0.4% to lower (V) class and none of them were belonging to upper class(I). (Refer table 1) Among the women studied 11.9% were having overweight at risk, 9.9% were obese, 20.1% were underweight and only 58.2% of the women were having normal BMI. (Refer table 2). Women in the age group of 36-45 years were more overweight or obese (30%) compared to other groups but the difference was statistically not significant. There was no statistically significant difference in occurrence of overweight or obesity with type of family and religion. Overweight or obesity was more common in literates (27.2%) compared to illiterates (19%) but the difference was not significant. There was inverse relation between family size and overweight or obesity although statistically not significant.
Shashidhar et al
There was increasing trend of overweight or obesity with increase of socio economical class although the difference was statistically not significant. Highest proportion of overweight or obesity was found in upper middle class i.e. 28.6%, where as 25.5% in lower middle class, 20.5% in upper lower class and none among the lower class. (Refer table 3) Non-vegetarian were having more overweight or obesity compared to vegetarians and those eating nonveg more frequently were having higher overweight or obesity compared to those eating less frequently. Only 5.3% of the heavy workers were overweight or obese compared to mild or moderate worker in whom it was 24.8% and difference was highly significant. (House wives were considered as moderate workers). Only 2 (0.81%) women were doing any energy consuming physical activity (ex- jogging, walking etc) apart from their routine domestic or occupational work. There was statistically significant higher occurrence of overweight or obesity among women who have the habit of eating junk foods or snacks in between the meals regularly (more than thrice a week) compared to the women who never eats or eats occasionally. There was statistically significant higher occurrence of overweight or obesity among women who eat food while watching television compared those do not have the habit of eating while watching. There was significantly more occurrence of overweight or obesity among the women with the family history compared to those not having the family history. (Refer table 4) DISCUSSION Present study included the women attending the UHTC; it covers population predominantly belonging to urban slum area. In our study 21.8% of the women were overweight or obese; this value was lower compared to the study conducted by Anuradha R et al11 in Chennai in which it was 27.7%. In our study proportion of underweight
was little higher compared to the Chennai study. In our study there was increasing trend of obesity with increasing age group but it was not statistically significant whereas in a study conducted by Misra et al12 there was significant increasing trend of obesity with increasing age. Our study showed there was no significant association between type of family and religion it was similar to the study conducted by Anuradha R et al.11 In our study obesity was more among the literates compared to the illiterates it was similar to the study conducted by Anuradha R et al11 but in the latter study the findings were statistically significant. In the present study there was no significant association between socioeconomic status and overweight but the propotion increased with increasing socioeconomic class where as in study conducted by Anuradha R et al there was highly significant association between SES and obesity. In the present study there was inverse relation between family size and overweight. It may be because the larger the family more the physical activity. In our study no significant association between type of diet and overweight but there was more proportion of overweight among those consuming mixed diet compared to the vegetarians, it was similar to the study conducted by Anuradha R et al.11 In the present study there was significant association between overweight and consuming junk foods or snacks between the meals. As consuming junk foods adds to extra calories consumption which leads to accumulation in the form of fat leading to overweight or obesity. Present study showed there was significant association between family history and overweight. It reconfirms that genetic factors are also major risk factors for overweight or obesity. In our study there was highly significant association between overweight and eating food while watching television. In a study conducted by Agarawal P et al13 it was shown that women who watch television regularly have higher chances of
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being overweight or obese. Those watch television while eating tend to overeat and also addicted to television are having lesser physical activity so increasing the chances of overweight or obesity. CONCLUSION Overweight or obesity is one of the major health problems even in those areas with high prevalence of undernourishment. We conclude that women of reproductive age group are having dual problem of overweight and underweight. Lesser physical activity, dietary factors like consuming junk foods regularly, consuming food while watching television and family history are the major risk factors for high proportion of overweight or obesity. Socioeconomic status, age group and literacy status plays a minor role for overweight or obesity. RECOMMENDATION Women of reproductive age group need to be educated periodically about the importance of regular physical activity, not to consume junk foods and not to eat while watching television. ACKNOWLEDGEMENT Authors would like to thank all the staff of UHTC & Department of Community Medicine, RIMS, Raichur. Authors would like to thank all the women who have participated in this study. 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. Park K. Textbook of preventive and social medicine. 21st ed. Jabalpur: Banarsidas Bhanot; 2011. P. 366-70. 2. World Health Organization. Fact sheet on obesity available on
http://www.who.int/features/qa/49/en/index.h tml cited on 29/11/2012 3. National Family Health Survey-3, India, 2005-2006 available on http://www.rchiips.org/NFHS/pdf/India.pdf cited on 29/11/2012 4. World Health Organization. ObesityPreventing and managing the global epidemic. WHO technical report series 894. Geneva: WHO;1999:456. 5. Gupta R, Gupta VP. Obesity is a major determinant of coronary risk factors in India: Jaipur heart watch studies. Indian Heart J 2008;60:26-33. 6. Colditz GA, Willett WC, Stampfer MJ, et al. Weight as a risk factor for clinical diabetes in women. Am J Epidemiol 1990;132:501-13. 7. Jafar TH, Chaturvedi N, Pappas G. Prevalence of overweight and obesity and their association with hypertension and diabetes mellitus in an Indo- Asian population. CMAJ 2006;175:1071-7. 8. Prasad DS, Kabir Z, Dash AK, Das BC. Abdominal obesity, an independent cardiovascular risk factor in Indian subcontinent: A clinic epidemiological evidence summary. J Cardiovasc Dis Res 2011; 2:199-205. 9. World Health Organization (WHO), International Association for the Study of Obesity (IASO), and International Obesity Task Force (IOTF). The Asia-Pacific Perspective: Redefining Obesity and Its Treatment. Geneva: World Health Organization. 2000:378-420. 10. Kumar N, Gupta N, Kishore J. Kuppuswamys socioeconomical scale: updating income ranges for the year 2012. Indian journal of public health 2012 Jan; 56(1):103-104. 11. Anuradha R, Ravivarman G, Jain T. The Prevalence of Overweight and Obesity among Women in an Urban Slum of Chennai.
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Journal of Clinical and Diagnostic Research. 2011 Oct; 5(5): 957-960. 12. Misra A, Pandey RM, Devi JR, Sharma R, Vikram NK, Khanna N. A high Prevalence of diabetes, obesity and dyslipidaemia in an
urban slum population in northern India. Int J Obes Relat Metab Disord 2001;25:1722-29. 13. Agrawal P, Mishra V. Covariates of overweight and obesity among women in north India. Population and health series. Jan 2004;990-6.
Table 1: Table showing the Socio-demographic profile of the study Women

Socio demographic characters of women Hindu Religion Muslim Others 15-25 Age group 26-35 36-45 Illiterate Primary school Education Middle school High school PUC and above Nuclear Type of family Joint House wife Working women with moderate Occupation physical work Working women with heavy physical work Socioeconomic status Upper middle(II) (Modified Kuppuswamy Lower middle (III) 2012) Upper lower (IV) Lower (V) Frequency 160 81 3 81 153 10 163 13 30 29 9 160 84 162 44 38 7 51 185 1 Percentage 65.6 33.2 1.2 33.2 62.7 4.1 66.8 5.3 12.3 11.9 3.7 65.6 34.4 66.4 18.0 15.6 2.9 20.9 75.8 0.4
Table 2: Table showing the classification of women based on the Body mass index
BMI Underweight (<18.5) Normal (18.5-22.99) Over weight (>23) At risk (23-24.99) Obese I (25-29.99) Obese II (>30) Total Frequency 49 142 29 17 7 244 Percentage 20.1 58.2 11.9 7.0 2.9 100.0
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Table 3: Table showing the association between socio-demographic factors and overweight
Socio demographic factors Age group 15-25 26-35 36-45 Nuclear Type of family Joint Hindu Religion Muslim Literacy Illiterate Literate Family size 1-4 5-8 >8 Socioeconomic Upper-middle (II) status Lower middle (III) Upper lower (IV) Lower (V) BMI <23 63(77.8%) 121(79.1%) 7(70.0%) 124(77.5%) 67(79.8%) 128(80.0%) 60(74.1%) 132(81.0%) 59(72.8%) 55(75.3%) 120(78.4%) 16(88.9%) 5(71.4%) 38(74.5%) 147(79.5%) 1(100%) Overweight (BMI>23) 18(22.2%) 32(20.9%) 3 (30.0%) 36(22.5%) 17(20.2%) 32(20.0%) 21(25.9%) 31(19.0%) 22(27.2%) 18(24.7%) 33(21.6%) 2(11.1%) 2(28.6%) 13(25.5%) 38(20.5%) 0(0%) P value 0.789 0.746 0.29 0.146 0.457 NS
NS- not significant
Table 4: Table showing the association between other factors and obesity
Other factors Type of diet Type of work Consuming Junk foods /snacks in between meals Watching tv while eating Family history Vegetarian Mixed diet Moderate worker Heavy worker No/ occasionally Yes regularly No/ occasionally Yes regularly Yes No BMI <23 15(83.3%) 176(77.9%) 155(75.2%) 36(94.7%) 162(82.2%) 29(61.7%) 166(83.8%) 25(56.8%) 24(63.2%) 167(81.1%) Overweight(BMI>23) 3(16.7%) 50(22.1%) 51(24.8%) 2(5.3%) 35(17.8%) 18(38.3%) 32(16.2%) 19(43.2%) 14(36.8%) 39(18.9%) 0.000(HS) 0.014(S) P value 0.77* 0.007(HS) 0.002(HS)
* Fisher exact test
S- significant
HS Highly significant
Shalaan R. M. et al
RELATIONSHIP OF ULTRASONOGRAPHIC ENDOMETRIAL THICKNESS AND MORPHOLOGY TO BODY MASS INDEX IN POSTMENOPAUSAL WOMEN
IJCRR
Vol 05 issue 03
Section: Healthcare
Shalaan R.M.1, Deghidi A.N.2, Hegazy A.I.3
Category: Research Received on: 25/12/12 Revised on: 16/01/13 Accepted on: 04/02/13
1 2
Department of Obstetrics and Gynecology, Zifta Hospital Egypt Department of Physical Therapy, College of Applied Medical Sciences, Majmaah University, Kingdom of Saudi Arabia 3 Department of Obstetrics and Gynecology, Benha University, Egypt E-mail of Corresponding Author: a.deghidi@mu.edu.sa
ABSTRACT Background: Menopause is that point in time where permanent cessation of menstruation occurs following the loss of ovarian activities. Ultrasonography is simple, non-invasive technique, highly acceptable to the patient. It offered detailed delineations of the uterus and its myometrium, endometrium and vessels. So, several uterine disorders can be evaluated by ultrasound.. BMI is an inexpensive and simple method of classifynging for weight categories that may lead to heath troubles Objective: To investigate the relationship between ultrasonographic endometrial thickness and morphology to body mass index in postmenopausal women. Materials and Methods: Three hundred postmenopausal women (mean age, 59.95+3.73 years; range 55-65) were studied. Age, years since menopause and BMI characteristics were recorded. The relationship between ultrasonographic endometrial thickness and and morphology to baseline characteristics was evaluated in each woman. Results: BMI was positively correlated with endometrial thickness (r= 0.841), but age and years since menopause were negatively correlated (r= -0.224) (r= -2.84). Conclusion: There is positive relationship between BMI and endometrial thickness in asymptomatic postmenopausal females. Keywords: Body mass index; endometrial thickness; transvaginal ultrasonographic. INTRODUCTION Menopause is a date for those women who still have a uterus, it is defined as the day after a womans last period ever finishes. This span of time is also referred to as change of life or climacteric. The average age of menopause is 51 years, and the normal age range for last period ever is somewhere between 45 to 55. 1 A woman who still has uterus can be declared to be in post menopause once she has gone 12 full months with no flow at all, not even any spotting. The reason for this delay in declaring a woman post menopausal is because periods become very erratic at this time of life, and therefore a reasonably long stretch of time is necessary to be sure that the cycling has actually ceased. At menopause, the ovaries produce less of the hormone estrogen. Less progesterone is produced as well. Although periods tend to be less regular around menopause, irregular bleeding can be a sign of problems.2 Transvaginal ultrasound is routinely performed as part of a pelvic examination in postmenopausal woman .3 The normal value of endometrial thickness in asymptomatic postmenopausal women is 5mm. Five millimeters has been cut off point for excluding endometrial pathology after menopause and more than 5mm need endometrial pathology
Shalaan R. M. et al
to exclude disease. 4 Body mass index BMI is a number calculated from a persons weight and height. BMI is an inexpensive and easy to perform method of screening for weight categories that may lead to heath problems.5 Formula = weight (kg) / (height (m))2 .6 BMI of 18.5- 24.9kg / m2 is normal weight . BMI under 18. 5 kg / m2 indicate under weight. BMI of 25-29.9 kg / m2 indicate overweight. BMI over 30 kg / m2 indicate obesity . BMI over 40 kg / m2 indicate morbid obesity Obesity increases endogenous free estrogen level including peripheral conversion of adrenal steroids by fat cells and decreased levels of sex hormones binding globulin.7 It has been shown that women who are 20 50 pounds overweight have threefold and women more than 50 pounds have tenfold increased risk of endometrial cancer.8 Several studies (Andolf et al., 1993)7 and (Douchi, et al., 1998)8 have reported relationship between obesity and endometrial thickness, also as risk factor in development of endometrial cancer that stimulate us to do this study. The aim of the work is to find if there is any relationship between ultrasonographic endometrial thickness and morphology to body mass index in postmenopausal women. METHODS Three hundred Postmenopausal women were included in this study. They attended outpatient clinics of Internal medicine at Zifta General Hospital and Benha University Hospital. Patients were at least one year post menopause. Participations in the study were voluntary and based on the women who want to fill and sign informed consent.They informed that all collected data and information will be strictly confidential and will not be accessed by any other party without prior permission from the participant. The participants had the right to withdraw from the study at any given time without giving any explanation. All cases were subjected to the following: Complete History Taking, General
examination including weight, height BMI is calculated as follows: BMI = weight (kg) / height (m2). Vaginal sonography was done to all patients by Ultrasonography apparatus(TOSHIBA (Japan) with transvaginal probe 7.53 MHZ). The transducer tip was covered with ultrasound coupling gel and introduced into a protective sheet; a small amount of gel was applied the uterus was also systematically scanned for other incidental pathology .The endometrial thickness is measured from the proximal and distal interfaces between highly reflective and surrounding poorly reflective layers and measured in longitudinal axis of the uterus. Endometrial texture is examined to notice the presence of asymmetry. Irregularity or local thickening of the endometrium denoting the presence of a symmetrical endometrial hyperplasia or endometrial carcinoma Endocervical canal was examined to exclude cervical pathological lesions .The ovaries were then examined to diagnose the presence or absence of associated ovarian lesions. Atrophic endometrium appeared as a thin echogenic line. The endometrium normally measures 5mm or less in anteroposterior diameter in postmenopausal women. Cases with endometrial thickness more than 5mm were subjected to curettage by Novak curette.9-11 Curette are introduced and sampling was done. The endometrial specimen was immediately preserved in 10% formalin and sent for histopathalogical examination. Statistical Analysis: The data were collected in file for each patient and then coded and fed to the computer on statistical package for social sciences (SPSS) version 11.0 for statistical analysis. Mean, Standard deviation and prevalence were calculated. Chi square test was done to compare between categorical variables. Paired students ttest was done to compare between nonparametric variables.
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RESULTS This study has been conducted on 300 asymptomatic menopausal women. The age of onset of menopause ranging from 55-65 years with a mean of 59.95 years and S.D +3.73 years and the years of age since menopause ranging
from 5 -15 years with a mean of 9.95 years and S.D of 3.73.The thickness of the endometrium ranges from 3-8 with a mean of 5.85 mm and S.D + 0.640 .The body mass index ranges from 21.2 46.7Kg/m2 with a mean of 28.74 Kg/m2 and S.D + 6 .
Table 1: Clinical data of study group

Item Age (years) Body Mass Index ( Kg/m2) Post menopausal Duration (Years) Endometrial Thickness (mm) Parity Mean+SD 59.95+3.73 28.74 +6 9.95 +3.73 5.85+0.640 3.9+ 2 Range 55 - 65 years 21.2 46.7 Kg/m2 5-15 years 3 - 8 mm 1-8 offsprings
Table 2: Means and standard deviation of endometrial thickness and BMI

Endometrial thickness BMI I<25 n=13 IIIIIIV25 30 30- 35 >35 n=44 n=143 n=100 Mean + SD t P
t1= 1.03 t2=3.69 t3=10.1
>0.05 <0.05 <0.001
t1= group I versus group II. t2= group I versus group III. t3= group I versus group IV
Table 3: Correlation coefficient , r, between Endometrial thickness and BMI
Endometrial thickness BMI R 0.841 p <0.001
To find a significance ,we used Chi square test. Chi square = 0.841, p < 0.001. There was highly significant positive correlation between Endometrial thickness and Body Mass Index. Table 4: Mean+SD of endometrial thickness according to age :
Endometrial thickness Age Mean + SD t P
55-60 (n=174) 60-65 (n=126)
4.94 + 0.9 4.55 + 1.01
-0.224 -0.224
<0.01 <0.01
Table 5: Correlation coefficient, r, between Endometrial thickness and Age
Endometrial thickness Age
R -0.224
P <0.05
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Chi square = -0.224 . p < 0.05. There was a significantly negative correlation was found between Endometrial thickness and Age. Table 6: Mean+SD of endometrial thickness according to years since menopause
Endometrial thickness Years since menopause 5-10 (n=174) 10-15 (n=126) Mean + SD t P
4.96 + 1.02 4.56 + 1
-2.84 -2.84
<0.01 <0.01
Table 7: Correlation coefficient , r, between Endometrial thickness and Years since menopause
Endometrial thickness Years since menopause r -2.84 P <0.01
Chi square = -2.84. p < 0.01. There was highly significant negative correlation was found between Endometrial thickness and Years since menopause.
Table 8: Distribution of endometrial thickness and histopathalogical findings
Endometrial thickness Histopathalogical findings Atrophic Chronic endometritis Endometrial Polyp Out of 12 Cases % Mean +SD
10 1 1
83.3 8.33 8.33
5.85+0.75 6.8 7.3
12 cases in this study had endometrial thickness more than 5mm to whom endometrial sampling was performed with the following results, 10 cases had atrophic Endometrium, one case showed Endometrial Polyp(Endometrial thickness =7.3, BMI =45) and only one case revealed a picture of Chronic endometritis (Endometrial thickness =6.8, BMI =39.7).
Histopathological examination for 12 cases with endometrial thickness more than 5 mm revealed that 10 cases (83.3%) showed atrophic endometrium , one case (8.3%) showed chronic endometritis and one case (8.3%) showed endometrial polyp .
Shalaan R. M. et al
Fig 1: Scatter plot showing the relationship between BMI & endometrial thickness
Fig. (2.a): U/S picture of post menopausal female aged 60 years old,BMI=45 showing thick endometrium about 7.3 mm.
Fig. (2.b): Histopathology of same case showing endometrial Polyp with endometrial glands surrounded by fibrotic stroma containing prominent hyalinized arterioles.
Shalaan R. M. et al
Fig. (3.a): U/S picture of post menopausal female aged 57 years old ,BMI =32.7 showing endometrial thickness = 6.8 mm.
Fig. (3.b): Histopathology of same case showing chronic endometritis show endometrial glands lined by columnar cells and surrounded by stromal cell, many lymphocytes and plasma cells. DISCUSSION The endometrial thickness was measured by the use of vaginal ultrasound, endometrial thickness below 5 mm endometrial thickness was used as a cut off value which is the chosen cut off value for our standard upper limit of normal endometrium (Neele et al.,2002). Significant disagreement persists with regard to the relationship between BMI and sonographic endometrial thickness in postmenopausal women.12 In the present study, it was found that BMI was significantly correlated with endometrial thickness in asymptomatic postmenopausal women. On stepwise multiple regression analysis, BMI was still correlated with endometrial thickness, irrespective of age and years since menopause. This study agrees in part with the report by Andolf et al.,7who demonstrated that endometrial thickness correlated with BMI. However, they omitted both age and years since menopause from their analysis. The observation disagrees with the report by Van den Bosch et al. 13 which indicated that no significant association could be found between endometrial thickness and weight or BMI, after adjusting for age. They concluded that age is a significant confounder regression analysis. The findings also disagree with those of Tsuda et al., 12 who reported that BMI showed no correlation with endometrial thickness in Japanese women with normal endometrium, while years since menopause was related to endometrial thickness. However,Van den Bosch et al.,13 excluded years since menopause, and Tsuda et al.,12 excluded age from the analysis. Although age and years since menopause are related variables, it remains unclear whether these two variables have similar effects on endometrial thickness. We consider it is necessary to include
Shalaan R. M. et al
both of these variables in the analysis. We found negative correlation of age or years since menopause with endometrial thickness.Tsuda et al.12 seported that years since menopause was a significant variable associated with endometrial thickness. They documented that for women less than 5 years since menopause, mean endometrial thickness was significantly greater than that for those more than 5 years from menopause. However, in their study, endometrial thickness did not differ with years since menopause in women more than 5 years on from menopause. There is a report that some but not all postmenopausal ovaries secrete estrogens and androgens.14 The major source of estrogens in postmenopausal women is peripheral aromatization in adipose tissue. The endometrium is a target organ for estrogens. It appears that sonographic endometrial thickness mainly reflects serum E2 levels.14The findings of this study agrees with Dandolu et al., 15 who reported that body weight and body mass index were higher in women with a thick endometrium independent on age and parity. For every 1-point increase in BMI, there was a 7.56 g increase in uterine weight. Berker al.,16 demonstrated that there was no statistically significant difference in respect of BMI. When endometrial histopathology was assessed according to endometrial thickness by ultrasonography, in nine of the 75 cases endometrium were greater than 5mm.No statistically significant association was found between BMI and endometrial thickness Increased prevalence of high BMI is another risk factor for endometrial cancer due to differing hormone levels.17 Significant association was found between BMI and endometrial thickness in the present study. CONCLUSION There is a positive relationship between ultrasonographic endometrial thickness and morphology to body mass index in postmenopausal women.
REFERENCES 1. Freeman EW.; Sammel MD. ; Lin. Symptoms associated with menopausal transition and reproductive hormones in midlife. Am .J. Obstet. Gynecol .2007 ; pp.30 40 2. Timmermans A.;Opmeer BC. ; Ersema, SV. And et al. Patient`s references in the evaluation of postmenopausal bleeding. An. Intern. J.Obestet. Gynecol .2007; 114 (9):1146 1149. 3. Warming l. ; Ravn,P.;Skouby,S. and et al. Measument precision and normal range of endometrial thickness in a postmenopausal by transvaginal ultrasound .Ultrasound in Obestet. Gynecol .2002 ;20(5): 492 49 4. Neele,SJM. ; Marchien Van baal,W.; Van Der Mooren, P. and et al. Ultrasound assessment of endometrium in healthy , asymptomatic early postmenopausal women . Ultrasound in obestet. Gynecol.2002;16 (3) :254- 259 . 5. Gallagher, D. How useful is body mass index for comparison of body fatness across age , sex and ethnic groups . Am. J. Epidemiology 1996; 143 239. 6. Mei Z.; Grummer-Strwan,lM. ; Pietrobelli A. and et al. Validity of body mass index compression screening indices for assessment of body fatness . Am . J . Clin . Nutr.2002; 7 : 597 -985. 7. Andolf E. ; Dahlander ,K. and Aspenberg, P.Ultrasonic thickness of the endometrium correlated to body weight in asymptomatic postmenopausal women.Obstet. Gynecol.1993; 82(6):936-40. 8. Douchi, T.;Yoshinaga M. ; Katanozka,M. and et al. Relationship between body mass index and transvaginal ultrasonographic endometrial thickness in postmenopausal women . Acta obstet. Gynecol. Scand.1998 ; 77 :905-908 . 9. Katanozaka M, Yoshinaga M, Douchi T, Nagata Y.Ultrasonographic endometrial
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thickness for detecting endometrial cancer in postmenopausal women. Med J Kagoshima Univ 1988;50:2933. 10. Karlsson B, Granberg S, Wikland M, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleedingA Nordic multicenter study. Am J Obstet Gynecol 1995;172:148894. 11. Granberg S, Wikland M, Karlsson B, Norstrm A, Fridberg LG. Endometrial thickness as measured by endovaginal ultrasonography for identifying endometrial abnormalities.Am J Obstet Gynecol 1991;164:4752. 12. Tsuda H. ;Kawabata,M. ;Kawabata,K. and et al. Improvement of diagnostic accuracy of transvaginal ultrasound for identification of endometrial malignancies by using cut off level of endometrial thickness based on length of time since menopause. Gynecol. Oncol. 1997;64(1):35-7.
13. Van den Bosch T. ;Vandendael,A. ;Van Schoubroeck,D. and et al. Age, weight, body mass index and endometrial thickness in postmenopausal women. Acta Obstet. Gynecol. Scand.1996; 75(2):181-2 14. Longcope C.; Hunter,R. and Franz C. Steroid secretion by the postmenopausal ovary. Am. J.Obstet. Gynecol. 1998; 138(5):564-8. 15. Dandolu V.; Singh, R.; Lidicker,J. and et al. BMI and uterine size: is there any relationship ? Int. J. Gynecol. Pathol., 2010; 27(6): 568-71. 16. Berker B.; Erkmen, M. and Sevim,D. Relationship between body mass index and endometrial thickness in postmenopausal women. Clin. Obstet. Gynecol2005.;11 (3): 34-44. 17. Parazzini F.; La Vecchia,C. ;Bocciolone,L. and et al.The epidemiology of endometrial cancer. Gynecol. Oncol1992. ;41(1):1-16.
Anand Mugadlimath et al
STUDY OF SUDDEN NATURAL DEATHS IN MEDICO-LEGAL AUTOPSIES WITH SPECIAL REFERENCE TO CARDIAC CAUSES
IJCRR
Vol 05 issue 03
Section: Healthcare Category: Research Received on: 13/12/12 Revised on: 04/01/13 Accepted on: 02/02/13
Sandesh H. Chaudhari1, Anand Mugadlimath2, Mandar Sane3, K.U. Zine4, D.I. Ingale2, Rekha Hiremath5
1
2 3 4 5
Department of Forensic Medicine, MIMER Medical College and Hospital, TalegaonDabhade, Maval, Pune, India Department of Forensic Medicine, Shri B M Patil Medical College, Bijapur, India Department of Forensic Medicine, KIMS, Bangalore, Karnataka, India Department of Forensic Medicine, Govt. Medical College, Aurangabad, MH, India Department of Anatomy, Shri B M Patil Medical College, Bijapur, KA, India
E-mail of Corresponding Author: dranandmdfm@gmail.com
ABSTRACT This prospective cross-sectional study was carried out at Government Medical College, Aurangabad (M.S.) during a period of one year. Most of the sudden deaths were in 41-50 years of age group. Males predominate the females among all sudden deaths with male to female ratio 4.3:1. Cardiovascular causes were the principle cause followed by the respiratory causes among all sudden deaths. Deaths due to coronary artery disease and myocardial infarction amount to almost half of the cases of sudden natural deaths (40.25%). Confirmation of cause of death by histopathological examination was emphasized. Keywords: sudden death, natural death, autopsy. INTRODUCTION The term sudden death refers to the sudden and unexpected deaths; the external examination fails to elicit cause of death. The majority of these are natural deaths. But very often, natural deaths form the basis of medico-legal investigations, if they have occurred suddenly and unexpectedly in apparently healthy persons and under the suspicious conditions. In such cases, it is usually not possible to certify the cause of death only on external examination of body. In all such cases, an autopsy is imperative to obviate the possibility of unnatural death. After the completion of autopsy the outcome may quite often reveal some natural disease, the presence of which may pose issues like association of the disease with trauma, work, crime, emotion, excitement, etc may suggest suspicion of foul play and its relative contribution towards death. The study of sudden death helps in establishing the precise causes of death and enable in assisting the legal authorities in detection of crime, improve the mortality statistical data and pacify the bereaved and aggrieved relatives where the medical negligence was the sufficient ground for legal proceedings. MATERIAL AND METHODS The material for the present study consists of the cases who died suddenly and/or unexpectedly and had been subjected to medico legal autopsy .The criteria for selection of cases was as per definition- Sudden death is a death which is not known to have been caused by any trauma, poisoning or violent asphyxia and where death occurs all of a sudden or within 24 hours of the onset of the terminal symptoms.
History about the cases was obtained retrospectively from the police record and meticulous autopsy was carried out in every case and the whole organ or pieces of organ showing gross pathologic changes were retained for histopathological examination and also for chemical analysis (CA). On the basis of histopathological report, final opinion as to cause of death was dispensed. RESULTS AND OBSERVATIONS Age wise distribution showed maximum number of cases belonged to 41-50 years age group with male predominance. Amongst these 159 cases, 129 cases (81%) were male and 30 (19%) were female. The male to female ratio was 4.3:1. [Table no.1] Among the causes of sudden death, 71 cases (44.6%) were due to cardiovascular causes (CVS), remaining were due to respiratory causes (25.7%), gastrointestinal causes (11.3%), 6.2% were due to central nervous system (CNS) causes, 5 cases each (3.1%) due to genitourinary (GUT) and miscellaneous causes and 9 (5.6%) showed multiple system involvement. [Table no. 2] Maximum cases of sudden death due to cardiac causes (44.6%) were seen in 41-50 years of age group; coronary artery disease (CAD) (71.83%) was the leading cause with male dominance .On histopathological examination, out of 13 cases of myocardial infarction, 4 cases (30.8%) showed microscopic changes suggestive of recent myocardial infarction and in 9 cases (69.2%), old healed scar of myocardial infarction was seen. It was observed that out of 71 cases of heart disease, biventricular hypertrophy was present in 15 cases (21%), solitary left ventricular hypertrophy in 32 cases (45%) and solitary right ventricular hypertrophy in 3 cases (4%). It was observed that in cardiovascular system, the minimum survival time was least (15 minutes), the mean survival time was also least 4.58 hours.
Out of 41deaths(25.7%) due to respiratory diseases, pulmonary Kochs [18 deaths (43.90%)] account for major cause of sudden death followed by pneumonia [12 cases (29.26%)], COPD [3 cases (7.31%)], pulmonary embolism [2 cases (4.87%)], solitary lung abscess [1 case (2.43%)] and deaths due to combined TB, Pneumonia, Pyothorax and lung abscess include rest of the diseases [5 cases (12.19%)]. In GIT, out of 18 cases, maximum number of cases of sudden death was due to liver pathology [7 cases (38.88%)]. In CNS, maximum numbers of sudden deaths were due to intracranial haemorrhage (60%) with male predominance.In GUT, out of 5 cases, 2 males (40%) died of pyonephrosis and each case of eclampsia, placental separation and pyonephrosis were responsible for female death. Miscellaneous causes of sudden death include septicemia, anemia, cerebral malaria and diabetic nephropathy, total 5 cases (3.14%) [Table no 3]. DISCUSSION The definition of a sudden death varies according to authority and convention. In this medico legal study of sudden death, the duration of death process ranged from 1 to 20 hours, but it was difficult to determine how long the fatal symptoms had been present, as death often occurs before the victim reaches hospital, the situation in which no data on the symptoms are available for want of eye witnesses. In the present study, incidence of sudden death was 9% amongst the medico legal autopsies conducted during the study period. The finding of incidence of sudden death in the present study is somewhat consistent with the study of Sarkoija T. et al (5%) 1 and Siboni A. et al (4.06%) 2. The present study do not match with that of Nordrum I. et al (27.8%) 3, Meina Singh et al (2.66%) 4, Azmak A.D. (28.98%) 5, and Ambade V.N. (15.48%) 6. Age distribution for the present study showed most of the cases (30.81%) belonged to 41 to 50
years age group with male predominance (Table no.1). This finding matches with the studies of Meina Sing A. et al (34.5%) 4 and Ambade V N. (20%) 6. In the present study, out of 159 total sudden deaths, 129 (81%) were male and 30 cases (19%) were female with male to female ratio 4.3:1(Table no1). This finding is consistent with the study of Azmak A D (males 83.4%, females 16.6%)5 Sarkoija T. et al (males 82%, females 18%)1,Nordrum I. et al (males 79.67%, females 20.32%)3, Thomas A.C. et al (males 73.9%, females 26%)7 and Ambade V. N. (males 79.27%, females 20.73%)6. Although there are numerous causes of sudden death, cardiovascular causes [71 cases (44.6%)] were the principle cause among sudden death in the present study. (Table no 3). Dr Narayan Reddy10 and Apurva Nandy11 stated that, most of the sudden deaths were due to cardiovascular causes, about 45 -50%. Similar findings were seen in the study of Kuller L. et al (49.5%)12, Siboni A. et al (46.2%)2, Di Maio V.J.M. et al (60.9%)13, Sarkojia T. et al (61%)1, Luke J.L. et al (38%)14, Nordrum I. et al (69.15%)3, Azmak A D (55%)5. Coronary artery disease was not only the principle cause among cardiovascular causes, [54 cases (76.05%)] but also important cause among all sudden deaths amounting to 33.96%, with male preponderance, which is consistent with previous studies1, 2,3,4,6,7,12,13,14. This is because underlying heart disease is nearly always found in victims of sudden cardiac death. Typically in adults it takes the form of atherosclerosis or scarring from a prior heart attack. Therefore, risk factors for sudden cardiac death include similar risk factors for atherosclerosis, such as smoking, high blood pressure (B.P.), indiscriminate use of alcohol, sedentary life style, and stress and strain in life and lack of regular medical check up. In young victims, a thickened heart muscle from any cause, typically high B.P., or valvular heart disease is important predisposing factor for
sudden cardiac death. Adrenaline released during intense physical or athletic activity often acts as a trigger for sudden cardiac death when less often, inborn blood vessel abnormalities of coronary arteries and aorta, may be present in young sudden death victims In the present study, out of 159 cases of sudden death, 41 cases (25.78%) were due to respiratory causes. The important were pulmonary tuberculosis 18 (43.90%) and pneumonia 12 cases (29.26%) (Table no. 3). The findings of deaths due to respiratory diseases are comparatively higher as compared to all above studies2, 3, 4, 7,9,12,13.. Most important causes of gastrointestinal diseases in our studies were gastroenteritis, cirrhosis of liver and peritonitis. The incidence of deaths due to liver pathology, 5 cases (27.7%) in our study nearly matches with the study of Kuller L. et al13 (27.7%) It is observed that in cardiovascular system, the minimum survival time was least (15 minutes); the mean survival time was also least 4.58 hours. This means that, when the lesion is in cardiovascular system the death sets in rapidly as compared to other systems. Study demonstrates the importance of histopathology in autopsy diagnosis of sudden deaths. Samples were taken for histopathological examination from the site showing gross pathological changes of heart, lung tissue, inflamed peritoneum, meninges, and brain tissue. Microscopic changes confirmed the gross diagnosis. CONCLUSIONS Incidence of sudden death among the total medico legal autopsies performed is 9%. Most of the sudden deaths are in the age group of 41-50 years (30.81%) with marked preponderance of males. Cardiovascular disease accounts for the maximum number of sudden deaths, in which Coronary artery disease is not only the main cause of cardiovascular deaths, but also among all sudden deaths.
Almost half of the sudden deaths show a strong correlation with chronic habits like smoking, tobacco chewing and alcoholism. The death sets in very rapidly in cardiovascular disease, as mean survival time is 4.58 hours. The most common causes of sudden deaths are coronary artery disease, tuberculosis, pneumonia and intracranial hemorrhage. Histopathological study helps in confirmation of the cause of death in sudden deaths. 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 and publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. REFERENCES 1 Sarkioja T, Hirvonen J. Causes of sudden unexpected deaths in young and middle aged persons. Forensic Sci Int 1984; 24:247-61. 2 Siboni A, Simonsen J. Sudden unexpected natural death in young persons. Forensic Sci Int 1986; 31:159-66. 3 Nordrum I, Eide TJ, Jorgensen L. Unexplained and explained natural deaths among persons above one year of age in a series of medico-legal autopsies. . Forensic Sci Int 1998; 93:89-98. 4 Meina Singh A, Subadani Devi S, Nabachandra H, Fimate L. Sudden death in Manipur A preliminary study. J Forensic Med Toxicol 2002; 19(2): 26-28.
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Azmak A.D. Sudden natural deaths in Edirne, Turkey from 1984 to 2005. Med Sci Law 2007; 47(2): 147-55. PMID: 17520960. Ambade V. N. Study of natural deaths in Nagpur Region. J Medicolegal Association of Maharashtra. 2002; 14(2): 11-14. Thomas A.C, Knapman PA, Krikler DM, Davis MJ. Community study of the causes of Natural sudden death. Br Med J 1988; 297(3): 1453-56. 999 Clark JC. Sudden death in chronic alcoholic. Forensic Sci Int 1988; 36; 105-111 De la Grandmaison, Durigon M. Sudden adult death: A Medicolegal series of 77 cases between 1995 and 2000. Med Sci Law 2003; 43(1): 89. Reddy Narayan KS. The Essentials of Forensic Medicine and Toxicology. Medical Book Co. Hyderabad 27th edi.2008:133-134. Nandy Apurba. Principles of Forensic Medicine,2nd edi.New Central Book Agency (P) Ltd., Calcutta 2007 :136-37. Kuller L, Lilienfeld A, Fisher R. Sudden and unexpected deaths in young adults. JAMA 1966;198(3): 248-52. Di Maio Vincent JM, Di Maio Dominick JM. Natural death as viewed by the medical examiner. A Review of 1000 consecutive autopsies of individuals dying of natural disease. J Forensic Sci 1991; 36(1): 17-24. Luke JL, Helpern M. Sudden unexpected death from natural causes in young adults. Arch Pathol 1968;85:10-16.
Table No. 1 Age and Sex Distribution of Cases Age (Yrs.) Male death Female death Total death Upto 1 1 1 2(1.25%) 2-10 0 1 1(0.62%) 11-20 1 1 2(1.25%) 21-30 11 11 22(13.83%) 31-40 26 5 31(19.49%) 41-50 46 3 49(30.81%) 51-60 24 2 26(16.35%) 61-70 14 5 19(11.94%) > 70 6 1 7(4.40%) Total (%) 129 (81%) 30 (19%) 159 (100%) Table No 2 System-wise affection System affected Male death Female death Cardiovascular system 68 03 Respiratory system 30 11 GIT 15 03 CNS 07 03 Genitourinary 02 03 Miscellaneous 02 03 Multiple system involvement 05 04 Total (%) 129 30
Total death 71 41 18 10 05 05 09 159
Percentage 44.6 25.7 11.3 06.2 03.1 03.1 05.6 100.0
Table no 3 Showing diseases and sex-wise distribution of cases System & diseases Male Death Female Death A] CVS Coronary artery disease (CAD) Myocardial infarction (MI) CAD + MI Aortic stenosis Pericarditis Cardiac tamponade Cardiomyopathy B] RS. : Pulmonary tuberculosis Pneumonia Pulmonary TB + pneumonia COPD Pulmonary TB + pyothorax Lung abscess Pulmonary TB + lung abscess Pulmonary embolism C] GIT: Gastroenteritis Cirrhosis of liver Fatty liver Peritonitis Hepatitis Hemorrhagic gastritis Intestinal obstruction Intestinal perforation Intestinal TB D] CNS: Meningitis Intracerebral hemorrhage Subarachnoid hemorrhage Cerebral abscess + meningitis E] GUT: Toxemia of pregnancy Placental separation Pyonephrosis F] Miscellaneous: Septicemia Anaemia Cerebral malaria Diabetic nephropathy G] Multiple system involvement: Cerebropulmonary oedema Meningitis + pneumonia Adrenal hemorrhage + pleural effusion Pulmonary embolism + liver abscess Bronchitis + pyonephrosis 50 09 03 03 01 02 -15 07 02 02 01 -02 01 02 03 02 03 01 01 01 01 01 01 02 03 01 --02 01 -01 -03 01 -01 -129 01 01 ----01 03 05 -01 -01 -01 02 ---01 ----01 -01 01 01 01 01 01 01 -01 02 -01 -01 30
Total Death 51 10 03 03 01 02 01 18 12 02 03 01 01 02 02 04 03 02 03 02 01 01 01 01 02 02 04 02 01 01 03 02 01 01 01 05 01 01 01 01 159
Total
Chetna Jain et al
COMPARISON OF SEROPOSITIVITY OF HIV, HBV, HCV AND SYPHILIS AND MALARIA IN REPLACEMENT AND VOLUNTARY BLOOD DONORS IN WESTERN INDIA
IJCRR
Vol 05 issue 03 Section: Healthcare Category: Research Received on: 17/12/12 Revised on: 03/01/13 Accepted on: 21/01/13
COMPARISON OF SEROPOSITIVITY OF HIV, HBV, HCV AND SYPHILIS AND MALARIA IN REPLACEMENT AND VOLUNTARY BLOOD DONORS IN WESTERN INDIA Chetna Jain1, N.C. Mogra1, Jhaman Mehta1, Rishi Diwan1, Gaurav Dalela2
1
Department of Pathology, Jhalawar Medical College and S.R.G. Hospital, Jhalawar, Rajasthan, India 2 Department of Microbiology, Jhalawar Medical College and S.R.G. Hospital, Jhalawar, Rajasthan, India E-mail of Corresponding Author: cjain9230@gamil.com
ABSTRACT Objective: This study was conducted to evaluate the seroprevalence of HIV, HBV, HCV, and Syphilis and Malaria among blood donors. The data generated will help the clinicians for judicious use of blood as well as awareness regarding the Transfusion transmitted infections. Research Design Methods: A total of 46,224 blood donors were screened during a period from April 2008 to October 2012, at blood bank, S.R.G. Hospital and Medical College Jhalawar - District, Rajasthan State. Results: Among these 22905 (49.55%) were voluntary donors and 25219 (54.58%) were replacement donors .Seropositivity for Human Immunodeficiency Virus (HIV) was 0.034%, Hepatitis B Virus (HBV) was 1.57%, Hepatitis C Virus (HCV) was 0.04%, Rapid plasma Reagin method (RPR) for syphilis was 0.019% and Malaria was 0.017% respectively. Conclusions: Infections are slightly more common among replacement donors compared to voluntary donors. There was a gradual decrease of Transfusion Transmitted Infections (TTIs) in blood donors over the years by reason of following of stringent blood donor selection criteria. Keywords: Transfusion Transmitted Infections (TTI), Seroprevalence, Human Immunodeficiency Virus (HIV), Hepatitis C Virus (HCV), Hepatitis B Virus (HBV). INTRODUCTION Blood transfusion is the biggest treatment modality to save lives of thalassemic children, DIC and Post Partum Hemorrhage women, surgeries, accidents etc. There is a 1% chance of Transfusion Transmitted Infections (TTIs) with each unit of transfusion. TTIs can exist as asymptomatic diseases in the host1.So all donors must be screened for high risk behavior related diseases2. Unsafe blood transfusion pays high cost to society. Morbidity and mortality resulting from transfusion of infected blood have far reaching consequences, not only for recipients themselves, but also for their families, communities and society3. The diseases transmitted by blood are HIV, Hepatitis B and C, Syphilis, Malaria and infrequently Cytomegalovirus, Epstein Bar Virus, Parvo virus B19, Brucellosis etc. Prevention of TTIs presents one of the greatest challenges of transfusion medicine4. As per guidelines of the ministry of health and family welfare (Government of India) under the Drug and cosmetic Act 1945, all blood donors are be to screened against five major infections HIV 1 and 2, HBsAg, HCV, syphilis and Malaria. Even with strict donor screening and testing practices, safe blood free from TTIs remain an intricate goal. Although technological developments have led to improve the more sensitive methods to detect markers of TTIs, the
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problems of false negative results because of window period, asymptomatic carriers, high genetic variability in viral strains and technical mistakes stay behind 6. Hepatitis B is one of the most common diseases transmitted by blood and infected two million people worldwide including an estimated 400 million chronically infected cases. Individuals with chronic infection have a high risk of developing liver cirrhosis and hepatocellular carcinoma7. The present study was undertaken to assess prevalence and trends of TTIs among voluntary and replacement blood donors in this part of the country as prevalence varies in different geographic areas of the country. MATERIAL AND METHOD Present study was carried out in blood bank of S.R.G. Hospital and Jhalawar medical college, Jhalawar, Rajasthan. 46224 donors were analyzed for prevalence of TTIs from April 2008 to October 2012. These were 22905(49.55%) voluntary donors and 25219(54.58%) were replacement donors. This study included replacement donors and replacement donors. The replacement donors defined as who donated for their patients and were close relatives, family members or friends of the recipient. We arranged Different outdoor camps to obtain the voluntary donations. At voluntary places care was taken to remove professional and paid donors by taking Proper history and clinical examination. A detailed pre donation questionnaire was included in donor registration foresee. Information regarding history of surgery, hospitalization, blood transfusion, occupation, high risk behavior and tattoo marks etc. were collected. All samples were screened for HIV (Elisa and Rapid test) 8, Hepatitis B surface antigen (Elisa, Hepalisa J. Mitra and co. and Rapid test) 9, Hepatitis C virus (Elisa Microlisa J. Mitra and co. and Rapid Test) 10, RPR-Rapid plasma Reagin method11 and Malaria- by Thick
smear examination. Tests were performed according to the manufacturers instructions of commercially available kit in blood bank in department of Pathology, Jhalawar Medical College and S.R.G. Hospital. The donated blood was discarded whenever the pilot donor sample was found positive for any TTIs. RESULTS 46224 blood donors were screened in last four years. The numbers of donations have increased from 8209 in 2008 to 12396 in 2011 (Table-1). Table no. 2 is showing the result of seropositive samples for HIV, HBV, HCV, VDRL and Malaria. Seropositivity was observed more in replacement donors than in voluntary donors. The year wise comparative study and present study also have shown in table 1 and 2 of seropositivity by replacement and voluntary donors. DISCUSSION TTIs continue to be a threat to safe transfusion practices. With every one unit of blood, there is a 1% possibility of transfusion associated risk including TTIs12. Professional donors and donors with high risk behavior such as drug addict, homosexuals and prostitutes constitute the major risk segment. In our study, voluntary donations were about 49.55% of the total. In Northern India, the voluntary donor rate vary from 9.1% to 52.33%.13 and the National AIDS Control Organization (NACO) suggests that in 2007, voluntary donations in India were about 55%. We encountered a steady rise in voluntary donors from 6.53% in 2008 to about 72.29% in 2011, a trend noted in other studies too14. Although there are many studies on the prevalence of TTIs in blood donors, data regarding comparison between seropositivity of Voluntary and Replacement blood donation is sparse. The HIV Seroprevalence in Indian scenario has been reported between 0.2% to 1%15.The
Chetna Jain et al
seropositivity of HIV has increased from 0.012% to 0.08% in last four years and more in replacement donors. Majority of donors were truck drivers (high risk behavior group), one was schoolteacher and a donor was student. More people migrating from rural to urban area may be a cause of increase numbers in HIV Seropositivity. Studies done by Chandra et al16 (2001-2006) at Lucknow, U.P. shows HIV positivity of 0.01% which is similar to our studies. It is also clear from national data that higher incidence of HIV was found in Maharashtra, Chennai and south India. The prevalence of HIV in our study has not increased possibly because of increase in the percentage of voluntary donations which has increased from 6.53% to 72.29% in recent past. Different studies from India have shown Hepatitis B seropositivity rate from 2% to 8% in different geographical areas. HBV is a major source of transfusion transmitted hepatitis and is associated with career rate, chronic liver diseases and hepatocellular carcinoma even. In present study there is a dramatic difference in seropositivity among voluntary and replacement donors. In replacement donors HBV is around 3.0%; while in voluntary donors it is less of around 0.68%. The prevalence was similar to study done by Chaudhary et al17 Lucknow. Jhalawar district is dived into 6 blocks. Among these families of Khanpur block show high Prevalence of HBV cases ; the reason may be the reuse of needles by quacks and compounders malpractices, social practices of tattoos, as this district is socioeconomically deprived and literacy rate is also low here. Prevalence of HCV is comparatively less (0.01% to 0.06%) in our study compared to other studies though it was comparatively higher among replacement donors (0.26%). In one case in 2011 we found a donor co-infected by HBV and HCV. Transfusion transmitted syphilis is not a main peril of modern blood transfusion therapy, transfusion transmitted syphilis rarely have been recognized. The screening of syphilis commonly done by the rapid plasma regain test; it is not the syphilis transmission that is worrisome being a sexually
transmitted disease it is presents point towards donors Indulgence in high risk behavior and higher risk of exposure to infections like HIV and hepatitis (Ness, 1991). The risk of TTI of HBV, HCV and HIV could be curtailed by foreword of few more sensitive and specific tests for screening of donors sample. Preface of nucleic acid amplification testing (NAT) for HCV, HIV, anti hepatitis B core antigen (HBcAg) and IgM for hepatitis B infection is recommended to identify the infections during window period.
CONCLUSION To conclude, with the implementation of firm selection norm of donor as per the guide lines laid down for the blood banks in the gazette notification by the Government of India and use of sensitive and specific laboratory screening tests, it is achievable to decrease the occurrence of seropositivity of transfusion transmitted infections and improve the blood product safety. REFERENCES 1. Widman FK (ed) (1985) Technical manual American Association of blood Banks, Arlington, PP 325-344. 2. Jasmin Jasani, Vaidehi Patel, Kaushik Bhuva, Anand Vachhavi. Seroprevalence of transfusion transmissible infections among blood donors in a tertiary care hospital. International Journal of Biological and Medical Research. 2012; 3(1) : 1423-1425, www.biomedscidirect.com. 3. World Health Organization (WHO). Blood safety strategy for African region. Brazzaville, World Health Organization, Regional office for Africa, Brazzaville 2007 : 1-25. 4. Srikrishna A, Sitalaxmi S, Prema Damodar S (1999) How safe are our donors? Indian J. Pathol Microbiol 42: 411-416. 5. Government of India. Drugs and Cosmetics rules, 1945 (Amended in 2009) awailable http://www.cdsco.nic.in/html/drugandcosmetics Act.pdf 6. Gagandeep Kaur, Sabita Basu, Ravneet Kaur; Patterns of infections among blood donors in a tertiary care centre : A retrospective study. The
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National Medical Journal of India Vol 23, No. 3, 2010. Karkis, Ghimire P, Tiwari BR, 2008. Trends in hepatitis B and hepatitis C seroprevalence among Nepalese blood donors. Indian Journal of Infectious Diseases, 61 : 324-326 Dawson G.J., er al. The Journal of the Infectious Diseases, (1988) 157 (1); 149 Reliable Detection of Individuals Seropositive for the Human Immunodeficiency Virus (HIV) by competitive Immunoassays using Escherichia coli-Expressed HIV structural Protenis. A.Boniolo M. Dovis, R. Matteja The use of an enzyme linked immunosorbent for screening hybridoma antibodies against Hepatitis B Surface antigen. J. Immunol Meth, 49:1 (1982) Sarin, S.K. and Hess. G. (1998). Transfusion associated Hepatitis, CBS Publishers, New Delhi. Caumes E., Janier M. Syphilis, editions techniques. Encyclo. Med Chir (Paris France) Maladies infectiouses. 8-039-A-10(1994) Garg S, Mathur D.R., Garg D.K., Comparison of seropositivity of HIV, HBV, HCV and
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syphilis in replacement and voluntary blood donors in Western India. Indian J Pathol microbial 2001, 44-409-12. National AIDS Control Organization (NACO) website 2012 http://www.nacoonline.org/upload/Final%20pu blications/Blood%20safety/voluntary%20blood %20donation.pdf Nanda A, Tyagi S, Basu S, Marwah N. Prevalence of transfusion transmitted infections among voluntary and replacement donors. Indian J hemat Blood Transf 2001; 19: 104-5. Sharma RR, Cheema R, Vajapayee M, Raou, Kumar S, Marwaha N, et al. prevalence of markers of transfusion transmissible diseases in voluntary and replacement blood donors. Nat Med J India 2004 ; 17 : 19-21. Chandra T, Kumar A, Gupta A. Prevalence of transfusion transmitted infections in blood donors: An Indian experience. Transfusion 2009; 49(10):2214-20. Chaudhary N, Phadke S (2001) Transfusion transmitted disease. India J Paediatr 68; 951958.
Table:-1 Trends in voluntary and Replacement Blood Donation

Year 2008 2009 2010 2011 2012 (Jan to Oct.) Total Total accepted donors n 8209 9108 9300 12396 7211 46224 Voluntary donors N (%) 583 2865 5702 8962 4893 22905 6.53 31.45 61.31 72.29 67.85 49.55 Replacement donors n (%) 7626 6243 3598 3434 2318 25219 92.89 68.54 38.68 27.72 32.15 54.58
Table:-2 Comparison of seropositivity between voluntary and replacement donors

HIV Replacement Voluntary% % 2008 0.012 0.02 Year 2009 2010 2011 2012 0.02 0.02 0.01 0.02 0.06 0.07 0.08 0.03 HBV HCV RPR Malaria Voluntary Replacement Voluntar Replace Voluntar Replace Replacement Voluntary % % % y% ment % y% ment % % 0.6 3.6 0.03 0.06 0.4 0.5 0.01 0.02 0.8 0.28 0.29 0.72 1.9 1.69 2.56 3.3 0.01 0.02 0.02 0.01 0.01 0.01 0.26 0.02 0.13 0.01 0.1 0.01 0.08 0.02 0.72 0.02 0.01 0.01 0.02 0.01 0.01 0.03 0.03 0.02
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NURSING STUDENTS APPROACHES TO LEARNING AND STUDYING: STUDY IN AN INDIAN SETTING
A CROSS -SECTIONAL
NURSING STUDENTS APPROACHES TO LEARNING AND STUDYING: A CROSS-SECTIONAL STUDY IN AN INDIAN SETTING IJCRR
Juliana Linnette DSa

Yenepoya Research Centre, Yenepoya University, Deralakatte, Mangalore, Karnataka, India E-mail of Corresponding Author: dsa.julie@gmail.com
ABSTRACT Nursing students approach to learning is an important determinant of the education al attainment. Therefore it is important for the nursing educators and also for all those involved in curriculum planning to be knowledgeable about the students approaches to study and learning. Objectives: To determine the learning approaches of nursing students and to correlate the approaches to their preferences for courses and teaching. Methods: A cross- sectional design was used. The sample consisted of two cohorts of third year B.Sc. Nursing students (N=99) who were selected from two Colleges of Nursing in the south-west part of India. The colleges were selected using non-probability convenience sampling. After taking informed consent, the Approaches to Study Skill Inventory for Students was administered to them. The students completed the inventory taking an average time of 35 minutes. Results: The predominant learning approach was the strategic approach; the mean percentage computed was maximum in this approach (80.59), followed by deep approach (76.74) and surface apathetic approach (64.02). The mean of the subscales was highest in monitoring effectiveness (17.48) followed by alertness (16.87) and achieving (16.11).There was a significant positive correlation between surface apathetic approach and transmitting information. The deep approach and strategic approach had a significant positive correlation with both types of preferences, i.e. supporting understanding and transmitting information. Conclusion: The strategic approach to learning was predominantly used by students. The knowledge of the learning approaches of students and their preferences to different types of teaching and courses will be useful for teachers who can create learning environments which can encourage students to achieve their learning outcomes. Keywords: Learning Approaches, Nursing Students, Learning Preferences, Cross-sectional Study INTRODUCTION In nursing education, considerable attention is given to curriculum development, organization of the teaching- learning activities, assessment of the students performance and certification of students. The manner in which the students approach their learning is an important determinant of educational attainment that needs attention to improve curriculum design and delivery. Research into students learning began in the 1970s. Martin and Saljo (1) did the initial work on learning approaches using qualitative interview-based studies. They described the qualitative differences in learning by the way students conceptualized learning. Based on the students intention as they approached the task of learning, two approaches were identified, i.e. the deep approach and the surface apathetic approach. In deep approach, the students
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developed a high level of understanding; they intended to understand the material and interacted critically and had the skill to transfer such learning. By this approach they could integrate and apply the knowledge acquired that lead to higher learning outcomes. On the other hand, those students who adopted the surface approach had a low level of understanding. Their main focus was on rote-learning which resulted in poor quality learning outcomes. A third approach to learning was identified in a later study as the strategic approach (2). Those who adopt a strategic approach are focused on achieving high grades. Depending on the nature of the task at hand, the strategic approach is a combination of both the surface approach and the deep approach. Since, under this approach, the students focus on doing well in exams, they carefully plan their studies in such a way so as to score high marks as, for example practicing to answer previous examination questions. Again, depending on the examination pattern, they also modify their approach to learning. By this, they perform better in their assessment outcomes in comparison to those who follow deep surface approach. Learning styles and learning approaches have been extensively researched in many countries. However, in India, there is limited published research literature on this subject. It is important that nursing and midwifery educators and curriculum planners should be knowledgeable about students approach to learning and studying to bring about improvement in their teaching methods. This is the main reason that prompted the researcher to conduct this study. The aim of the study was to investigate the learning approaches followed by nursing students and to correlate the learning approaches with their preferences to courses and teaching. The purpose was to identify the learning approaches that will help in implementing the curriculum effectively and lead to quality learning outcomes.
MATERIALS AND METHODS A cross-sectional descriptive quantitative study was carried out in two nursing colleges in Mangalore, in the south-west part of India. A cohort of 46 third year students of B.Sc. Nursing programme from one college and another cohort of 53 students from another college constituted the sample; the total study sample was 99. The nursing colleges were selected using nonprobability convenient sampling. Data Collection The Approaches and Study Skill Inventory for Students (ASSIST) developed by Tait & Entwistle(3-4) was used for the study. This inventory, a self-report questionnaire had 52 items which were scored on a five-point Likerttype scale. The scale ranged from 1 (disagree) to 5 (agree).The ASSIST had three sections: Section A had six items regarding conceptions of learning. This section, according to the authors of the tool, was in the early stages of its development and so it was omitted. Section B identified three approaches to studying, i.e.deep approach, strategic approach and surface apathetic approach. The deep approach had 16 items on learning, while surface apathetic approach had 16 items and strategic approach had 20 items. Section C was on preferences for different types of courses and teaching which were categorized as supporting understanding (related to deep approach) and transmitting information (related to surface approach), which had four items each. The reliability of the scale was estimated using Cronbachs alpha as a measure of internal consistency on 46 students. The reliability of the whole inventory was 0.819. The sub-scales deep approach had an alpha of 0.694, surface apathetic approach 0.841 and strategic approach 0.789. Ethical Consideration: Approval to conduct the study was taken from the heads of the institutions where the study was conducted. Informed consent was taken from the students who were willing to
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participate in the study. The purpose of the study was explained to them and they were assured of anonymity and confidentiality of their responses to the inventory. The ASSIST was administered to the students at the start of the academic session. The students took an average time of 35 minutes to complete the inventory. Data collected were analyzed using Statistical Package for Social Science (17.0). Scoring was done as per the scoring guidelines provided with the ASSIST. Statistical Methods: Mean, Mean Percentage and Standard Deviation were computed for the data on the scales and subscales of the inventory. The data on the subscales of approaches were also ranked. Pearson correlation coefficient was computed for determining the correlation between learning approaches and preference for different types of courses and teaching, setting the level of significance for the study as p>0.05.
RESULTS Mean Percentage of Learning Approaches and Preferences The mean score analyzed in each of the learning approaches were converted to mean percentage scores in order to make a comparison between each of the approaches. This was done as the maximum possible score in the strategic approach ranged from 20- 100, whereas in the deep and surface apathetic approach it ranged from 16- 80. The mean percentage score in each of the scales is shown in Fig.1. The highest mean percentage scores was in strategic approach (80.59) , below that was deep approach (76.54) and the least was in the surface apathetic approach (64.02), while for the preferences for different types of courses and teaching the mean percentage score was almost same in both supporting understanding (80.60) and transmitting information( 80.30).
Fig. 1 Mean percentage scores of the learning approaches and preference of the students Comparison of the means in each of the subscales of the learning approaches: The data in Table 1 shows that the mean scores on the sub-scales monitoring effectiveness, alertness to assessment demands and achieving was highest among all sub-scales which were 17.48, 16.87 and 16.11 and ranked 1,2 and 3 respectively. The sub-scale fear of failure had the highest mean (14.53) in the surface apathetic approach, while use of
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evidence had the highest mean (16.10) in the deep approach. Strategic approach was found to
be the predominant learning approach among undergraduate nursing students.
Table1. Mean, Standard Deviation and Rank of the Learning Approaches of the Students (N=99)
Learning Approaches Scales and Sub-scales Deep Approach: Seeking meaning Relating Ideas Use of Evidence Interest in ideas Surface Apathetic Approach: Lack of purpose Unrelated memorizing Syllabus boundedness Fear of failure Strategic Approach: Organized studying Time management Alertness to assessment demand Achieving Monitoring effectiveness Mean (1- 5) 15.69 14.99 16.10 14.62 11.40 12.86 12.57 14.53 14.99 15.13 16.87 16.11 17.48 Standard Deviation () 2.83 3.05 3.09 2.84 4.08 3.16 3.61 3.05 3.18 3.24 2.29 2.79 2.16 Rank
5 7 4 9 13 11 12 10 7 6 2 3 1
Correlation between approaches to learning and preferences for different types of courses and teaching The section of ASSIST on Preferences for different types of courses and teaching had eight items. Four items reflected supporting understanding that is related to deep approach while the other four items reflected transmitting
information that is related to surface apathetic approach. The data in Table 2 shows that supporting understanding was positively and significantly correlated with deep and strategic approach, while it was not significantly correlated with surface apathetic approach.
Table 2. Correlation between preferences for different types of course and teaching approaches to learning
Preferences Supporting Understanding (related to deep approach) Transmitting Information (related to surface apathetic approach) Deep Approach .461** .305** Strategic Approach Surface Apathetic Approach .231* .311** .155 .216*
*significant at 0.05; **significant at 0.01 The findings suggest that students who used the deep approach and those who used strategic approach had a preference for courses and teaching that supported understanding and which
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were based on transmitting information. The students who used the surface apathetic approach did not prefer courses that support understanding, but preferred the courses that transmitted information. This is evident by the significant positive correlation found between surface apathetic approach and transmitting information. DISCUSSION It has been found that some students fail not because of lack of sufficient study, but due to the approaches that they adopt to study (5) Nursing students utilize various approaches or styles of learning, which have been extensively investigated in many countries using mainly Kolbs learning styles inventory. Many studies have also been conducted to identify the approaches to studying and the learning style of medical students. But in India there is a dearth of published studies that have explored the learning approaches of nursing students. The findings of this study indicate that the strategic approach to learning is the one predominantly followed by the students. This finding is in agreement with the findings reported by Fleming et al (6), and Cowman (7). In an Irish study Fleming et al (6), found that the dominant learning style of the nursing students in the first year of their programme was strategic approach (78%). They reported that 12% of the students exhibited the surface approach and only 9% had exhibited the deep approach to learning. The findings of the analysis of the same cohort in their final year showed that the dominant learning style continued to be the strategic approach, with a slightly higher percentage (80%), as compared with the first year students exhibiting this approach. In another Irish study, Cowman(7), found that the degree level nursing students had the highest mean score in strategic approach in contrast with the certificate-level nurses who had the highest mean score for either deep or surface apathetic approaches to learning. In India, one unpublished doctoral study was conducted by
DSa (2006). It aimed at determining the effectiveness of a problem-based learning (PBL) package on clinical reasoning, clinical skills and attitude of nursing students towards care of antenatal clients in selected institutions of Karnataka state (8). Using the ASSIST, the researcher studied the learning approaches adopted by B.Sc. nursing students who had either studied under the traditional method (n=72) or by following the problem-based learning approach (n=90). In both the groups, the predominant approach to studying was the strategic approach. PBL did not bring about a significant change in their learning style. Mc Kee et al (9) in a longitudinal study of medical and Nursing students approaches to study, reported, contrary to the findings of the current study, that the highest mean score for both nursing students and medical students was the deep approach. Mansouri et al (10) also found in their study that the nursing students predominantly used the deep approach to learning. Strategic approach is one in which the intention is to achieve the highest possible grades. The strategic approach summarizes the five subscales: organized studying, time management, alertness to assessment demands, achieving and monitoring effectiveness. In the present study, the researcher found that the mean score on monitoring effectiveness was highest and ranked first among the subscales while alertness to assessment demand ranked second and achievement motivation ranked third among the subscales. Entwistle and Ramsden (11) were of the view that this approach is related to using organized study methods and good time management. It also involves monitoring ones study effectiveness (12) and alertness to the assessment process aspects which are akin to metacognitive alertness and self-regulation (13-14). The students who use strategic approach prepare themselves according to the assessment methods. The findings of the study by Mansouri et al (10),
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suggested that students who had adopted a strategic approach in the first place or a deep approach in the second place had better academic outcome as indicated by higher grade point average (GPA). The present study however did not aim at determining the relationship between the approach to studying and the academic performance. The present study has also found a significant positive correlation between the surface apathetic approach scores and preference for courses and teaching strategies that promote transmission of information, similar to the findings of McKee et al (9). The present study findings show that the strategic approach was the predominant learning style among nursing students. This kind of approach is committed to achievement. Activities that can lead to deep approach of learning need to be incorporated into the teaching learning programme of the students. It is encouraging to note that surface apathetic approach which leads to poor quality of learning outcome is not the favoured approach among the students although they have a fear of failure as evidenced by the higher mean scores. Strategic approach is therefore the preferred approach. But it is disappointing to note that the deep approach is not favoured. The nursing profession demands that the nurses need to be good critical thinkers and decision makers. For this, it is essential to have a deep approach to learning. The constructive approach to the teaching learning process needs to be adopted. Students need to know explicitly what are the objectives they need to achieve. The teaching learning methodology and the assessment techniques need to be aligned. Currently large group lecture sessions are taken for undergraduate students. This teacher-centered classroom encounters focus mainly on transmitting information rather than understanding. Research has shown that the conducive environment fosters learning (15). Small group discussions problem based learning
methods need to be utilized for teaching. Through good teaching practices, educators can engage students in ways that foster deep approaches to learning (16). CONCLUSION The results of this study showed that nursing students predominantly used strategic approach to learning and studying. While interpreting the findings it is important to be aware of the limitations of the study. The ASSIST measured the broad approaches of a group of students. To explore the individual approach, qualitative studies combined with the qualitative approach on a larger sample would increase the generalizability of the findings. Educators in Nursing should determine the learning approaches of the students when they are enrolled in the program, so that they can be assisted to develop their approaches in ways that will enhance their learning. The knowledge of the learning style and the preferences to teaching and courses will also be useful for teachers who can create learning environments which can encourage students to achieve their learning outcomes. ACKNOWLEDGEMENT The author is thankful to all the students who participated in the study and to the scholars whose articles are cited in the references of this manuscript. The author is grateful to Mr Walter DSa, for editing this manuscript, and to the IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript. REFERENCES 1. Marton F, Saljo, R. On qualitative differences in learning: I - outcome and process. Brit J Educ Psychol 1976; 46: 4-11. 2. Ramsden P. Student learning and perceptions of the academic environment. High Educ 1979; 8: 411-27.
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Tait H, Entwistle, NJ, McCune V. Approaches to Study Skill Inventory for Students (ASSIST) (1997) Edinburgh: Centre for Research on Learning and Instruction. Tait H, Entwistle N, McCune V. ASSIST: A reconceptualisation of the approaches to studying inventory. In Rust C editor. Improving student learning: Improving students as learners. Oxford, United Kingdom: The Oxford Centre for Staff and Learning Development: 1998. p. 262- 71. Newble DI, Jaeger K. The effects of assessment and examination on the learning of medical students. Med Educ 1983; 17: 165-71. Fleming S, McKee G, Huntley-Moore S , Patterson A. Nursing students approaches to learning and studying: A longitudinal study. Proceedings of the 9th Annual Interdisciplinary Research Conference Transforming Healthcare through Research, Education & Technology; 2008 Nov 5-7; Dublin, Ireland. http://www.nursingmidwifery.tcd.ie/assets/eventsconference/doc-2008/2008-conferenceproceedings.pdf Cowman S. The approaches to learning of student nurses in the Republic of Ireland and Northern Ireland. J Adv Nurs 1998; 28 (4): 899-910. DSa JL. Effectiveness of a problem-based learning package on skills and attitude of nursing students towards care of antenatal clients in selected institutions of Karnataka state. Unpublished PhD dissertation, Manipal University. Karnataka, India. 2006.
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McKee G, Patterson A, Fleming S, HuntleyMoore S. Nursing and medical students approaches to learning and studying: a longitudinal study. http://ocs.aishe.org/index.php/international/2 009/paper/viewDownloadInterstitial/129/47 Mansouri P, Soltani F, Rahemi S, Nasab MM, Ayatollahi AR, Nekooeian AA, Nursing and midwifery students approaches to study and learning. J Adv Nurs 2006; 54(3): 351-8. Entwistle NJ, Ramsden P. Understanding student learning. London: Croom Helm; 1983. Entwistle N J, McCune V, Walker P. Conceptions, styles and approaches within higher education: analytic abstractions and everyday experience. In Sternberg RJ & Zhang L-F editors. Perspectives on cognitive, learning, and thinking styles. 2000. Mahwah, N J: Lawrence Erlbaum.2000. Vermunt J. The regulation of constructive learning processes. Brit J Educ Psychol 1998; 68(2):149-71. Pintrich PR, Garcia T. Self-regulated learning in college students: knowledge, strategies and motivation. In Pintrich PR, Brown DR, Weinstein C-E editors. Student motivation cognition and learning. Hillsdale, N.J: Lawrence Erlbaum.1994, p. 113-34. Trigwell K, Prosser M. Development and use of the approaches to teaching inventory. Educ Psychol Rev 2004:16(2): 409-24. Ramsden P. Learning to teach in higher education 2nd ed. London: Routledge Falmer; 2003.
Kalpana C.A. et al
ENERGY BALANCE, PSYCHOSOCIAL PROBLEMS AND BIOCHEMICAL PROFILE OF OBESE CHILDREN
ENERGY BALANCE, PSYCHOSOCIAL PROBLEMS BIOCHEMICAL PROFILE OF OBESE CHILDREN IJCRR

AND
Kalpana C.A., Lakshmi U.K.

Department of Food Science and Nutrition, Avinashilingam Institute for Home Science and Higher Education for Women, Coimbatore, Tamilnadu, India E-mail of Corresponding Author: cakalpana272@gmail.com
ABSTRACT Childhood obesity is reaching epidemic proportions in both developed and developing countries. Reduced physical activity and increased energy intake both have major contribution to the establishment of childhood obesity. Psychological and social problems, increased plasma insulin, elevated blood lipid, lipoproteins and blood pressure are the various factors known to be associated with childhood obesity. Hence, the study was conducted to determine the energy balance, psychosocial problems and biochemical profile of selected obese children. Time utilization pattern of obese boys and girls (n=64) was studied to assess their physical activity and energy expenditure levels. The energy balance was calculated by finding the difference in the energy intake and energy expenditure of the children. Psychosocial and behavioural adjustment problems faced by obese children at school and home were studied for both the boys and girls. Biochemical parameters namely blood glucose, haemoglobin and lipid profile which included total cholesterol, serum triglycerides, HDL, LDL and VLDL cholesterol were determined using standard procedures. Both boys and girls exhibited a positive energy balance which was higher in obese boys than in obese girls. The mean total cholesterol level of obese boys (158.3 mg/dl) was within the normal range but in the case of obese girls the level (178.7 mg/dl) was found to be slightly higher than the normal. Overweight and obese children are likely to develop lifestyle diseases like diabetes mellitus and cardiovascular diseases at a younger age which are largely preventable. Strategies aimed at reducing caloric intake and increasing caloric expenditure through regular exercise are necessary to meet the challenges. Keywords: Childhood obesity, energy balance, psychosocial problems, biochemical profile INTRODUCTION Obesity is reaching epidemic proportions in both developed and developing countries and is affecting not only adults but also children and adolescents [1].Once considered a problem of affluence, obesity is fast growing in many developing countries also. As a result of rapid socioeconomic advancements in recent decades, the population is undergoing significant changes in lifestyle, dietary and meal patterns, such as increased consumption of fats and oils, decreased intake of complex carbohydrates, eating out and skipping meals. Both physical activity and energy intake have a major contribution to the establishment of childhood obesity [2]. Sleep duration may be related to a childs exposure to obesity related factors in the environment [3]. Physical health risk of obesity may not manifest themselves for years but the psychological and social problems are experienced every day. Obese children often suffer from teasing by their peers. Some are harassed or discriminated by their own family. [4]. Obesity is a key factor for many chronic and non communicable diseases. Increased plasma insulin levels, elevated blood lipid and lipoprotein levels,
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and elevated blood pressure are the various factors known to be associated with childhood obesity leading to adult morbidity and mortality. [5]. Childhood obesity prevention involves maintaining energy balance at a healthy weight, while protecting overall health, growth and development and nutritional status. Interventions that combine a dietary component, physical exercise and/or behavioural therapy are effective in treating childhood obesity. Hence, the study was conducted to determine the energy balance, psychosocial problems and biochemical profile of selected obese children. MATERIALS AND METHODS Childhood obesity is associated with a number of problems and co-morbidities; hence the following parameters were studied on 32 obese boys and 32 obese girls. 1. Assessment of Physical Activity Pattern Time utilization pattern of both obese boys and girls (n=64) was studied to assess their physical activity and energy expenditure levels. An equal number of normal boys and girls (n=64) were also assessed for their time utilization pattern for comparison with the obese children. For studying the time utilization pattern, each child was asked to prepare an activity time log for a week stating the time spent on each activity from the time one gets up in the morning to the time one goes to bed. The activities were then classified into sedentary, moderate and heavy based on the type of activity. The time spent for each type of activity was calculated for the whole day along with the time spent for sleep for determining the difference in activity pattern and sleep hours of obese children. 2. Determination of Energy Balance Energy balance is the state in which an individuals energy expenditure equals his or her metabolizable energy intake. Negative energy balance occurs when expenditure is greater than intake and positive energy balance occurs when
intake is greater than expenditure. Hence, an in depth study on energy balance was carried out on the 64 obese children. Basal Metabolic Rate (BMR) and physical activity are the two major factors which determine the energy expenditure of an individual. The energy expenditure of the obese children was assessed using the time utilization pattern. The average workload per day was computed with the number of hours spent for each activity in school and at home along with hours spent for sleep. Energy expenditure for sedentary, moderate, heavy activities and sleep was determined using the formula [6] Sedentary activity - 0.02 Kcal body weight minutes Moderate activity - 0.04 Kcal body weight minutes Heavy activity - 0.08 Kcal body weight minutes Sleep - 0.01 Kcal body weight minutes The basal energy requirement is regularly estimated as the energy need per kg of body weight which is assumed as one calorie for every hour per kilogram of body weight. Thus the basal energy expenditure for 24 hours for children is calculated as 1 X 24 X body weight. Energy that is saved during sleep is calculated as 0.1 X body weight X hours of sleep. This is reduced from the total basal energy expenditure for 24 hours to get the basal energy expenditure of the individual. Total Energy Expenditure (TEE) was calculated from the Basal Metabolic Rate (BMR) and the type of physical activities of the children. The actual food intake was determined from 24 hour recall method. From the average daily food intake, the energy intake was computed using the nutritive value of Indian foods and compared with the recommended dietary allowances [7]. The energy balance was thus calculated by finding the difference in the energy intake and energy expenditure of the children.
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3. Psychosocial and Behavioural Adjustment Problems Obesity is a stigmatized condition. Obese children are exposed to the consequences of public disapproval for their fatness. This stigma is seen in schools, homes and in the society. Hence, the psychosocial and behavioural adjustment problems faced by obese children at school and home were studied for both the boys and girls. Based on the scale developed by Parikh and Das [8], a Psychosocial and Behavioural Adjustment Scale (PSBA Scale) was constructed by the investigator after identifying 60 relevant statements through review of literature and in consultation with psychology experts and categorizing into six groups with equal number of positive and negative statements. Self perception of physical attributes, behaviour in the family, emotional and behavioural problems, social and academic problems and problems with values and adjustment were the aspects included in the development of this scale. The children were asked to respond to each statement in terms of their own agreement and disagreement on a five point continuum. The scores given for positive statements were as follows: Strongly agree 5 Agree 4 Doubtful 3 Disagree 2 Strongly disagree 1 The order was reversed for the negative statements. The total score was the summation of numerical weight assigned to each response. This 5 point scale was given scores of 1,2,3,4 and 5 with 5 being the maximum score indicating least problems and 1 being the lowest score indicating most problems. 4. Biochemical profile Biochemical parameters namely blood glucose, haemoglobin and lipid profile which included total cholesterol, serum triglycerides, HDL, LDL and VLDL cholesterol were determined in the
laboratory for the selected children (n=64) using the following standardized methods. a. Blood Haemoglobin An accurate volume of blood (0.02ml) was drawn from a finger prick using a haemoglobin pipette and delivered on to a (1x1 cm) strip of Whatman No.1 filter paper. The filter paper with the blood sample was dropped into Drabkins solution in a test tube and allowed to stand for 30 minutes. The solution was then centrifuged and the supernatant was read in a photo electric colorimeter. The mean haemoglobin levels were then compared with reference values. b. Blood Glucose A finger prick was done for the selected overweight and obese children to collect their blood sample and blood glucose was estimated using a Glucometer. c. Blood lipid profile With the help of a laboratory technician, 5ml of blood was drawn from the vein of obese children and blood lipid profile comprising of Total cholesterol, Triglycerides, Low density Lipoprotein, High density Lipoprotein and Very Low Density Lipoprotein was estimated using standard procedures. d. Blood Pressure Obesity and overweight may predispose children to increased blood pressure. Elevated blood pressure in children is an early risk factor for cardiovascular disease and is positively associated with BMI [10]. Hence, blood pressure was measured for the selected obese children (n=64) with the help of an experienced medical officer. RESULTS AND DISCUSSION 1. Mean hours spent on physical activities by Obese and Normal children The mean hours spent in various physical activities during the day by obese boys and girls in comparison with normal children are presented in Table I.
Kalpana C.A. et al
Table I: Mean hours spent on physical activities per day by obese and normal boys and girls
Duration of Activity (hours) Sleep Sedentary Moderate Heavy Mean SD Obese Normal Boys Boys (n=32) (n=32) 8.1 0.3 7.1 0.40 13.30.31 2.20.25 0.40.07 8.30.16 5.30.12 2.3 0.17 t value 1.29NS 3.70** 4.97** 2.11* Mean SD Obese Normal Girls Girls (n=32) (n=32) 7. 40.16 7.10.06 11.40.13 4.70.30 0.40.10 8.6 0.06 4.4 0.16 2.2 0.14 t value 1.16NS 3.11** 1.02NS 6.11**
**Significant at 1% level; * Significant at 5% level; NSNot significant The duration of sleep hours per day for obese boys was 8.1 and for normal boys were 7.1 with no significant difference. The hours spent per day on sedentary activities among obese boys was found to be higher by 13.3 hours compared to only 8.3 hours spent by normal boys which was found to be statistically significant (p<0.01). The time spent per day in moderate activity by the obese boys was only 2.2 hours than the normal boys who spent 5.3 hours and the findings were found to be significant (p<0.01). A lesser and negligible time of 0.4 hours was spent by the obese boys per day on heavy activities when compared with normal boys who spent 2.3 hours and the difference was statistically significant (p<0.05). Sleep hours of both obese (7.4) and normal girls (7.1) showed no statistically significant difference. Obese girls spent significantly more time of 11.4 hours on sedentary activities when compared to the normal girls who spent only 8.6 hours and found to be significant (p<0.01). The time spent on moderate activities by obese girls was 4.7 hours and by normal girls was 4.4 hours
2500 2000 2291 1848
daily and the difference was not significant. The duration of time spent on heavy activities by obese girls was comparatively very less (0.4 hours) than the normal girls who spent 2.2 hours with a significant difference (p<0.01). Obese children spent less time on house hold work and active transport and also performed less moderate/vigorous activities, but they spent longer times on low intensity activities, including leisure time reading, computer use, video games, study and inactive transport [11]. 2. Energy Balance Based on Energy Intake and Energy Expenditure of Selected Obese Boys and Girls. Details on the energy balance based on energy intake and energy expenditure of selected obese boys and girls are presented in Figure 1.
Obese boys
Energy (kcal)
1500 1000 443 500 0
Energy Intake
Energy Expenditure
Energy Balance
Kalpana C.A. et al
2500 2000
2119
2055
Obese girls
Energy (kcal)
1500 1000 500 0
64 Energy Intake Energy Expenditure Energy Balance
Energy intake of obese boys was found to be more than those of obese girls and the difference was significant (p<0.05). The energy expenditure was found to be more among obese girls when compared to obese boys which was also significant (p<0.05). Both boys and girls exhibited a positive energy balance which was higher in obese boys than in obese girls and the difference between them was found to be not significant. This can be attributed to increased energy intake and decreased energy expenditure
among boys. Weight maintenance is largely a balance between the calories consumed through diet and those expended to support physical activity, for thermo genesis and to support basal physiologic function [12]. 3. Mean Scores of Psychosocial and Behavioural Adjustment Problems Table II presents the mean scores obtained for Psychosocial and Behavioural Adjustment Problems by the selected obese children.
Table II: Mean scores obtained for psychosocial and behavioural adjustment problems by the selected obese children Maximum Scores= 60
Scores obtained Psychosocial and Behavioural aspects Boys n=32 33.33.35 34.04.02 34.04.20 32.74.77 32.55.84 31.45.59 Girls n=32 36.65.39 37.06.23 37.86.57 35.54.42 36.76.60 39.65.05
t value
Perception of Physical Attributes Attitude and Behaviour in Family Emotional Characteristics and Behaviour Social Behaviour Academic Behaviour Values and Adjustment
0.925NS 0.518 NS 0.257 NS 1.449 NS 0.471 NS 0.216 NS
NS Not significant The findings revealed that none of the children scored lowest indicating that every obese child faced adjustment problems but not to a maximum extent. The difference in scores were found to be statistically not significant between obese boys and obese girls in all aspects .This observation may be because the selected children were in the school going age and not in the adolescent period
Kalpana C.A. et al
where greater extent of adjustment problems are very common. 4. Biochemical profile of selected obese boys and girls
The biochemical profile of selected obese boys and girls is given in Table III.
Table III:Biochemical profile of selected obese boys and girls

Blood indices Haemoglobin (g/dl)* Blood Glucose (mg/dl)# Total Cholesterol (mg/dl) Triglyceride (mg/dl)
$ $ $
Standard value 11.5 80-120 <170 <150 35-70 <110

$ $
Mean SD Boys (n=32) 14.1 1.5 89.0 6.3 158.3 16.7 137.7 52.2 32.8 3.2 98.7 10.3 27.6 10.5 Girls (N=32) 12.8 1.5 91.6 5.0 178.7 56.7 96.8 38.7 43.2 6.3 117.2 44.6 19.6 7.8
HDL-Cholesterol (mg/dl) LDL Cholesterol (mg/dl)
VLDL - Cholesterol (mg/dl)
20-60
* NIN [13]
# WHO [14] $ NCEP [15] The mean values of triglycerides were lesser than the normal values among both boys and girls with 137.7 mg/dl and 96.8 mg/dl respectively. HDL cholesterol level was found to be lower than the standard value for obese boys (32.8 mg/dl) whereas it was within the normal range for obese girls (43.2 mg/dl). LDL cholesterol values of obese boys (98.7 mg/dl) were within the normal value but it was higher than the standard value for girls (117.2 mg/dl). Mean VLDL cholesterol values for both obese boys and girls with 27.6 mg/dl and 19.6 mg/dl respectively were well within the normal values. It is evident from the table that total cholesterol and LDL cholesterol values of obese girls were slightly higher than the normal values compared to obese boys. In general, biochemical profile does not warrant any alarming diseases among the selected obese children. 5. Mean blood pressure of selected obese boys and girls The mean blood pressure values of selected obese boys and girls are presented in Table IV.
a. Haemoglobin levels The mean haemoglobin values of both obese boys with 14.1g/dl and obese girls with 12.8 g/dl were above the normal value indicating that none of the selected children suffered from iron deficiency anaemia. A similar finding was observed in a study conducted at Pakistan on a total of 103 children (6-11 years) of which 74 per cent were obese and all the obese children had normal or above normal haemoglobin levels [16]. b. Blood glucose levels It is observed from the table that the mean blood glucose level of both the obese boys (89mg/dl) and obese girls (91.6mg/dl) were within the normal range (80-120 mg/dl) indicating the absence of diabetes mellitus and impaired glucose tolerance among the selected obese children. c. Lipid profile The mean total cholesterol level of obese boys (158.3 mg/dl) was within the normal range but in the case of obese girls the level (178.7 mg/dl) was found to be slightly higher than the normal.
Kalpana C.A. et al
Table IV: Mean blood pressure of selected obese boys and girls
Standard value* Blood pressure (mm Hg) Systolic pressure Diastolic pressure 110-120 70-80 Boys (n=32) 104.00 5.16 69.40 6.93 Girls (N=32) 103.00 4.83 70.00 6.67 Mean SD
* Source : www.health.harvard.edu A study conducted on school children in India revealed that systolic or diastolic incident hypertension was found in 17.34 per cent of overweight children versus 10.1 per cent of remaining normal students (p<0.01) [17].Another study conducted at Ireland reported that obese boys (51%) and obese girls (49%) had initial blood pressure measurements in the hypertensive range. There was a correlation between the degree of obesity and systolic blood pressure, particularly in boys [18]. But in the present study, the systolic and diastolic pressures of both the obese boys and girls were found to be within the normal range and similar among both groups and the findings do not support some of the earlier studies. CONCLUSION Childhood obesity is one of the most serious public health challenges of the 21st century. The fundamental causes behind the increasing trend of childhood obesity include changing lifestyles of families, an increased intake of energy-dense foods and a trend towards decreased levels of physical activity. Overweight and obese children are likely to develop lifestyle diseases like diabetes mellitus and cardiovascular diseases at a younger age which is preventable. Prevention of childhood obesity therefore needs high priority. Lifestyles and behaviours are established at a young age. It is important for parents and children to focus on making longterm healthy lifestyle choices such as changing eating habits, increasing physical activity, engaging in a support group activity and setting realistic weight management goals. ACKNOWLEDGEMENT The authors extend their sincere thanks to the University Grants Commission, New Delhi for providing financial assistance to conduct this research. 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. Flynn, D; Colecchia, A; Sacco, T; Bondi, M; Roda, E. and Marchesini, G. (2006), Hepatic steatosis in obese patients clinical aspects and prognostic significance, Obesity Review, Vol. 5, Pp. 27-42. 2. Stubbs, C.O. and Lee, A.J. (2004), The Obesity Epidemic: Both Energy Intake and Physical Activity Contribute, MJA, Vol.181, No.9, Pp. 489 - 491. 3. Speiser, P.W. Rudolf, M.C. and Anhalt, H. (2005), Childhood Obesity. J.Clin. Endocrinol Metab, 90: Pp.1871-1877. 4. Cornette, R. (2008). The Emotional Impact of Obesity on Children. Worldviews Evid Based Nurs 5 (3): 13641. 5. Lau, D.C.W., Douketis, J.D., Morrison, K.M., Hramiak, I.M. and Sharma, A.M. (2007), Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children (Summary), CMAJ, Vol.176, No.8, Pp. S1 - S13.
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6.
Swaminathan, M. Principles of Nutrition and Dietetics. Second Edition, Bapco Publishing, Bangalore, 2005. p.528. 7. Indian Council of Medical Research (ICMR). (2006), Dietary Guidelines for Indians, Indian Council of Medical Research, Hyderabad, Pp. 72 - 74. 8. Parik and Das, (1988), Secondary Handbook of Psychological and Social Instruments. Personality, Concept Publishing CO, New Delhi, Pp.70-75 9. Brion, M.A., Ness, A.R., Smith,G.D. and Leary, S.D. (2007), Association Between Body Composition and Blood Pressure in a Contemporary Cohort of 9 Year Old Children, J.Hum.Hyperten, Vol.21, Pp. 283 - 290. 10. Li, Y., Zhai,F., Yang, X., Schouten,E.G., Hu,X., He,Y., Luan,D. and Ma,G. (2007), Determinants of Childhood Overweight and Obesity in China, Brit.J.Nutr, Vol.97, Pp. 210 - 215. 11. Jennifer, L.B. and James, M. (2008) Neighborhoods and Obesity, Nutrition, Vol.66 (1), Pp.2-20. 12. National Institute of Nutrition (1990), Techniques of Iron Status Measurement Manual of Collection, Processing and Estimation of Samples for Iron and Iodine Status Measurements. National Institute of Nutrition, Hyderabad, India.
13. World Health Organisation (2003), Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases. WHO Technical Report Series 916, Geneva, Switzerland. 14. National Cholesterol Education Programme (NCEP), 2005, Expert Panel on Blood Cholesterol in Children and Adolescents, Amer. Heart. Ass., 112, 3184-3209. 15. Ramzan, M., Ali, I. and Salam, A. (2009), Iron Deficiency Anemia in School Children of Dera Ismail Khan, Pakistan, Pakistan Journal of Nutrition, Volume: 8 Issue: 3, Page No.: 259-263 16. Manuraj, K. Sundaram, R. Paul, A. Deepa, S. Krishna Kumar R. (2007) Obesity in Indian children: Time trends and relationshipwith hypertension, The National Medical Journal of India vol. 20, No. 6. 17. Finucane, F. M., Pittock, S., Fallon, M., Hatunic, M., Ong, K. Burns, N. Costigan, C., Murphy. N. and Nolan J. J. (2008,) Elevated blood pressure in overweight and obese Irish children, Irish Journal of Medical Science, Volume 177, Number 4 , Pp.379-381
K. Vimala Geetha et al
A COMPARATIVE SHEAR BOND STRENGTH EVALUATION OF THREE TOOTH COLORED RESTORATIVE MATERIALS USED IN PRIMARY TEETH AN IN VITRO STUDY
IJCRR
A COMPARATIVE SHEAR BOND STRENGTH EVALUATION OF THREE TOOTH COLORED RESTORATIVE MATERIALS USED IN PRIMARY TEETH AN IN VITRO STUDY K. Vimala Geetha, Eapen Thomas, Phani Babu
Department of Pedodontics and Preventive dentistry, Meenakshi Ammal Dental College, Alapakkam Main Road, Maduravoyal,Chennai, India E-mail of Corresponding Author: drphanibabu@gmail.com
ABSTRACT The goal of research and development is to develop an ideal restorative material. The ideal restorative material would be identical to natural tooth structure, in strength adherence and appearance. Hence the aim of the study was to evaluate the shear bond strength (SBS) of three recently evolved tooth colored restorative materials used in primary teeth dentine and verify, after SBS testing, the failure mode of the adhesive interface. Sixty extracted deciduous human molars with one of the proximal and occlusal surfaces free of caries were selected and randomly assigned into three groups according to the restorative material used. Teeth were sectioned parallel to occlusal surface to expose the mid coronal dentin of the non carious surface and the restorative materials were packed into a plastic straw (3 mm x 2 mm) covering the centre of flattened occlusal surface. SBS tests were performed and the obtained values were statistically analyzed using ANOVA and Turkey tests (p<0.05). The failure mode analysis was performed with an Instron machine. Proportions were estimated and compared by using Pearsons chi-square test or Fishers exact test (2-tailed) appropriately. From the results of the study, it may be concluded that the intra-group comparison showed, Group III (Admira) giving higher mean shear bond strength followed by group I (N 100). The lower bond strength is reported in-group II (Vitremer). The adhesive and cohesive modes of bond failures that are obtained in all three materials (N100, Vitremer, Admira) were not statistically significant. Keywords: Deciduous teeth, shear bond strength, Vitremer, Ketac N 100, Ormocer. INTRODUCTION Dental amalgam has been the restorative material of choice for many decades.1However, the increasing awareness about the safety of dental amalgam have helped the dental profession to focus on the need to develop alternative restorative materials like glass ionomer cements and resin composites. 2 Resin modified glass ionomers were developed as hybrids of conventional glass ionomer cements and visible light activated composite resins to overcome the disadvantages. They are more esthetic and less water sensitive than conventional glass ionomers, but are also harder to use and less esthetic than composite resins. Several studies indicated that resin modified glass ionomers have higher dentin bond strengths than conventional glass ionomer restorative materials. 3,4,5 One of the resin modified glass ionomer cements that is most commonly used as posterior restorative material is Vitremer. KetacTMN100 is the first paste/paste, lightCured resin modified glass ionomer material developed with nanotechnology. Because it adds benefits not usually associated with glass ionomers, it has resulted in a whole new category of glass ionomer restorative: the nano-ionomer.
The technology of Ketac N100 restorative represents a blend of fluoroaluminosilicate (FAS) technology and nanotechnology. In an attempt to overcome some of the limitations and concerns associated with the traditional composites, a new packable restorative material was introduced called ormocer, which is an acronym for organically modified ceramic technology. Ormocer material contains inorganicorganic copolymers in addition to the inorganicsilanated filler particles. Ormocer was formulated in an attempt to overcome the problems created by the polymerization shrinkage of conventional composites because the coefficient of thermal expansion is very similar to natural tooth structure.6 One of the simplest means to evaluate restorative materials is by testing the bond strength to dentin and/or enamel. This is done either by applying a tensile or shear stress to a bonded specimen and measuring the load per unit area at the time of rupture of the bond.7 There has been much work published examining the shear bond strengths of various restorative materials, but little work has been done on the materials vitremer, N100 - the nanoionomer and Admira as they are newly developed restorative materials. Till date very little literature is available regarding the shear bond strength performance of these materials in deciduous teeth. Keeping this in mind, the present study was conducted to compare the shear bond strength of tooth colored restorative materials in deciduous teeth. RESEARCH METHODOLOGY The present study was planned and conducted in the Department of Pedodontics and Preventive Dentistry, Sri Ramachandra Dental College and Hospital, Chennai. Sample selection Sixty extracted deciduous human molars with one of the proximal and occlusal surfaces free of
caries were selected and stored in physiologic saline at room temperature until use. The teeth were randomly divided into three groups of twenty teeth each and mounted in a self cure resin, leaving only the crown exposed. Different colours were added to self cure acrylic to differentiate between the groups. Specimen preparation Teeth were sectioned parallel to the occlusal surface to expose mid-coronal dentin of the noncarious surface using a low speed diamond disk with water coolant. Plastic straws measuring (3mm X 2mm) were cut and placed on the dentin surface to be used for bonding and restoration subsequently. The restorative materials were packed into a plastic straw covering the centre of flattenedocclusal enamel and dentin surfaces. Restorative procedure All the restorative procedures were done according to the manufacturers instructions. Group I - Ketac N100Nano-Ionomer self etch Primer is applied for 20 seconds within the plastic straw with the help of an applicator tip, air dried and light cured for 20 seconds. Then, the Ketac N100 Nano-Ionomer restorative material is packed in to the plastic straw in increments and light cured for 40 seconds. Group II - Vitremer (3M ESPE)-Vitremer self etch primer was applied for 20 seconds within the plastic straw with the help of a applicator tip, air dried and light cured for 20 seconds. Then, the Vitremer (3M ESPE) restorative material is packed inside the plastic straw in increments and light cured for 40 seconds. Finally, the gloss is applied to the restorative material inside the plastic straw and light cured for 20 seconds. Group III - Ormocer (Admira - Vocco)- Total Etch, etching gel from Ivoclar, Vivadent was applied for 15 seconds within the plastic straw, rinsed with water and air-dried. Ormocer based bonding agent was applied for 20 seconds in the etched area, air dried and cured or 20 seconds. Then the Admira restorative material is packed
inside the plastic cylinder and light cured for 40 seconds. Shear bond strength test Each restorative combination was subjected to shear bond strength analysis using INSTRON universal testing machine, Lloyd Instrumentsmodel type: LR100K in CIPET (Central Institute of Plastic Engineering Technology) Guindy, Chennai. The shear bond strength was assessed by applying force through the chisel with the test speed of 2mm/minute between the restorative material and tooth material junction. The stress failure was calculated and recorded as the shear bond strength in kg f/cm2 using Dapmat& Control software. The values for bond strength were calculated as Mega Pascal (Mpa) and the results were evaluated statistically using Student's independent t-test. One way ANOVA was used to calculate the p-value. Multiple Range test by Turkey-HSD procedure was employed to identify the significant groups at 5% level. Evaluation of the failure mode after SBS test The mode of fracture in each specimen was observed under Stereomicroscope (zoom Stereomicroscope - SMZ-U model) in Government Veterinary College, Madhavaram, and Chennai using the following criteria: 1. Adhesive fracture - Fracture between tooth and restorative material. 2. Cohesive fracture Fracture within the restorative material. RESULTS Mean and standard deviation (SD) values of SBS test of all three restorative materials are presented in table 1. Table 2 shows the intra-group comparative evaluation of mode of bond failures in all three restorative materials. Statistical analysis Mean and standard deviation were estimated from the sample for each study group. Mean
values were compared between different study groups by using students independent t-test or one-way ANOVA followed by Turkey-HSD procedure. Proportions were estimated and compared by using Pearsons chi-square test or Fishers Exact test (2-tailed) appropriately. In the present study, p<0.05 was considered as the level of significance. DISCUSSION In the present study primers were used both with N100 as well as Vitremer. N100 showed higher bond strength almost equal to Admira (Ormocer), on the other hand Vitremer showed statistically significant lower bond strength than N100 and Admira. This difference in the bond strength of Vitremer to N100 may be attributed to the absence of Nanofillers and Nanoclusters in Vitremer. While the difference in bond strength of Vitremer and Admira may be due to the application of a specially designed ormocer (Admira) bonding agent used with Admira. Garberoglio&Brannstrom found that tubule diameter varied from 0.8 to 1.6m in primary posterior teeth, which appears to be greater than the tubular diameter in permanent teeth.8 However the nanoclusters and nanofillers present in N100 have a diameter size that is smaller than the primary dentin tubular diameter. Therefore, the increased bond strength of N100 may be due to the impregnation of nanoclusters within the dentinal tubules increasing the resin tag formation to primary teeth.8 In shear bond strength tests, a wide variety of configurations have been used including loops, points, and knife edges to apply the shearing force. Clearly, different methods of load application lead to differing stress distributions. The single plane shear test used in this study avoids applying torque to the specimens during loading as is common with other shear tests.9 In some in-vitro SBS test studies, the bond strength is standardized by using 5mm of surface
area.10 However, in primary teeth, this standardization cannot be applied because the occlusal dentin will be closer to the pulp which has lower calcium content and higher water content which could affect the bonding. Hence, in this study the measurement of 3mm in width and 2mm in height is tested. The values for shear bond strengths in the present study were higher possibly reflecting the differing surface area of the specimen tested. Emily in her study stated that several factors influence the bond strength, one of which is the type of dental substrate. Dentin has a heterogeneous surface consisting of approximately 30% organic matter by volume, and consequently has low surface energy.11 Admira Bond dentin/enamel bonding agent contains special adhesive Ormocers with calcium complexing functionality, which enhances the bond strength to tooth structure. Due to its chemical affinity, Admira Bond bonds firmly to both the tooth and filling material. This might explain the superior performance of Admira in deciduous teeth specimens. The Ketac N100 nano-ionomer restorative further contains a unique combination of two types of surface treated nanofillers (approximately 5-25nm) and nanoclusters (approximately 1.0 to 1.6 microns). Nanofillers are discrete nonagglomerated and non-aggregated fillers of 5-25 nm in size. The nanofiller and nanocluster fillers are loosely bound agglomerates of nano-sized zirconia/silica that appear as a single unit enabling higher filler loading, radioapacity and strength. The factors mentioned above may explain the comparable performance of bond strength of N100 to Admira. Under stereomicroscopic examination of the bond failure sites it was found that Admira showed the least cohesive fracture rate of 40% (8 specimens) and an adhesive fracture rate of 60% (12 teeth specimens). The performance of N100 was comparable to admira showing cohesive fracture
rate of 45% (9 specimens) and adhesive fracture rate of 55% (11 specimens). In vitremer, the maximum bond failure site was observed as cohesive showing 75% (15specimens) and adhesive fracture rate of 25% (5 specimens). Yumiko stated that the cohesive resin fracture is indicative of higher bond strength of restorative materials.9 Whereas, Borba& Garcia Godoy stated that the bond strength values was not related to the failure mode recorded visually or with the SEM.10 McCarthy et al in their study stated that the bond failure of the glass ionomers are primarily cohesive, light cured GIC more than chemically cured.3 From the results obtained in the present study, the glass ionomers i.e. N100 and vitremer got the higher cohesive failure rates of 45% and 75% respectively and hence are in accordance with Borba& Garcia Godoy and Mc Carthyeta al. The result of this in-vitro study brings forth the present need for more clinical and scientific research with regard to understanding the performance of restorative materials available. CONCLUSION Overall shear bond strength mean of three tooth colored restorative materials to primary teeth was statistically higher in Admira followed by N100 and least being the Vitremer. The stereomicroscipic analysis revealed a predominant cohesive failure mode in Vitremer followed by N100 and least being the Admira. The stereomicroscopic analysis revealed a predominant adhesive failure mode in Admira followed by N100 and least being the Vitremer. ACKNOWLEDGEMENT Authors acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. The authors are also greatful to authors/ editors/ publishers of all those articles, journals and books from where the literature for this article has been
reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped in bringing quality to this manuscript. REFERENCES 1. Hubel S, Mejare I. Conventional versus Resin Modified Glass Ionomer cement for class II restorations in primary molars. A 3 year clinical study. Int J Paediatr Dent 2003;13(1):2-8. 2. K.M.Y. Hse, S. K. Leung, S.H.Y. Wei. Resin Ionomer materials for children: A review. Australian Dental Journal 1999;44 (1):1-11. 3. Mc Carthy MF, Hondrum SO, Mechanical and bond strength properties of light-cured and chemically cured glass ionomer cements. Am J OrthodDentofacialOrthop 1994 Feb;105(2):135-141. 4. Almuammar MF, Schulman A, Salama FS. Shear bond strength of six restorative materials. J ClinPediatr Dent. 2001; 25 (3):221-225. 5. SfondriniMF, Cacciafesta, Pistorio A, Sfondrini G. Effects of conventional and high- intensity light curing on enamel shear bond strength of composite resin and resin modified glass ionomer. Am J OrthodDentofacialOrthop 2001;119(1):30-35.
6. Ajlouni R, Bishara SE, Soliman MM et al. The use of Ormocer as an alternative material for bonding orthodontic brackets. Angle Orthod. 2005 Jan;75(1):106-8. 7. Camile S. Farah, Vergil G Orton, Stephen M. Collard. Shear bond strength of chemical and light cured glass ionomercements bonded to resin composities. Australian Dental Journal 1998; 43(2):81-86. 8. Sumikawa DA, Marshall GW, Gee L, Marshall SJ. Microstructure of primary tooth dentin. Pediatric Dentistry 1999; 21(7):439444. 9. Hosoya Y, Kawashita Y, Yoshida M, Suefuji C, Marshall GW Jr. Fluoridated light activated bonding resin adhesion to enamel and dentin: primary vs. permanent. Pediatric Dentistry 2000;22(2): 101-106. 10. Hosoya Y, Nishiguchi M, Kashiwabara Y, Horiuchi A, Goto G. Comparison of two adhesives to primary vs. permanent bovine dentin. J ClinPediatr Dent 1997;22(1):69-76. 11. Emily Placido et al. Evaluation of shear bond strength of two resin-modified glass ionomer cements. Virginia Commonwealth University;2003.
Table I: Mean SBS values of the restorative materials

Gro u p N1 0 0 VI T REM E R ADM I R A M ea n S.D . 8 .6 9 2 .2 0 7 .1 5 1 .9 2 8 .7 8 2 4 0 p- v a l ue 0 .0 3 (N S) Sig nif ica nt g ro u p s a t 5 % l ev el NI L
P ri mar y
One-way ANOVA was used to calculate the p-value. ** Multiple Range Test by Turkey-HSD procedure was employed to identify the significant groups at 5% level.
Table 2: Comparison of mode of bond failure after SBS testing

M a teria l N1 0 0 (G RO UP I ) Vit re mer (G RO UP I I ) Ad mir a (G R OUP I I I ) Ty pe o f f ra ct ur e Ad he si ve Co he s i ve Ad he si ve Co he s i ve Ad he si ve Co he s i ve No 11 9 5 15 12 8 % 55% 45% 25% 75% 60% 40% p- v a l ue
P =0 .7 5 (N S) P =0 .4 9 (N S) P =0 .7 4 (N S)
** Pearsons Chi-square test was used to calculate the p-value.
Figure 1: Specimen mounted in Acrylic Block
Figure 3: Specimen placed in INSTRON universal testing machine
Figure 2: Restorative material placed in DE junction (occlusal view)
Figure 4: Stereomicroscope
Figure 7: Debonded adhesive failure
specimen
showing
Figure 5: INSTRON universal testing machine
Figure 6: Debonded cohesive failure
specimen
showing
Rama B. Gouda et al
HEALTH INFRASTRUCTURE FACILITIES IN KARWAR DISTRICT OF KARNATAKA
HEALTH INFRASTRUCTURE DISTRICT OF KARNATAKA

IJCRR
Vol 05 issue 03 Section: Healthcare Category: Research Received on: 25/12/12 Revised on: 18/.01/13 Accepted on: 12/02/13
FACILITIES
IN
KARWAR
Rama B. Gouda, Guruprasad Ganeshkar

Department of Economics, Karnatak University, Dharwad, Karnataka State, India E-mail of Corresponding Author: rama.eco@gmail.com
ABSTRACT Health infrastructure is one of the basic infrastructural facilities which are helpful in the easy execution of economic activities, these are to be called as the heart of basic amenities. The objective of the present is to know the Government health services provided and developed in different talukas of Karwar District in Karnataka State. And it has been put forth and explained how the health facilities are developed and distributed among the people of this district which comprises eleven talukas. The present study is based on secondary data collected from published and unpublished sources of Government and non-government institutions. From the study analysis it is found that there is wide disparities in the provision of health infrastructure in different talukas of Karwar district. Hence with this attempt and study findings some remedial measures or suggestions are discussed. Keywords: Health, Infrastructure, PHCs, Development, Service INTRODUCTION Health infrastructure is nothing but the availability of necessary health amenities, like, hospital buildings, beds, transport facilities, etc., and health equipments like, medicines, x-ray, laboratory services etc. in the health sector in a economy. Basic amenities are the infrastructural facilities, the provisions of which are very vital for economic development. The scarcity of these reduces the economic development. The comfortable and proper living of people is made possible through the provision of these facilities. Without provision of these no society or nation would develop. The economic development of different sectors will be depending upon the availability and accessibility of these infrastructural facilities. Hence health infrastructure is an essential factor for the Human Resource or Manpower Development of a country. Review of Literature Dutt P. R. (1965), Karne Manisha (2007), revealed the importance of Health Centres and there infrastructure facilities as the institution for the promotion of the health and welfare of the people. This seeks to achieve its purpose of welfare and relief as may be related to the general public health work .Impressive health outcomes and a thought to be attributable to the priority assigned by the government to health care, as evidenced by clinics, immunization campaigns, vector control and a commitment to minimzing inequality in access to health care. Lavees Bhandari and Siddartha Dutta (2007), Manisha Tiwari ( 2004 ) examined that the last couple of decades have witnessed tremendous level of development in the field of medical sciences. And mentioned that health care system covers all those services which protect and promote health of the community. Thus there are many studies which concluded with revealing the importance and need for health
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infrastructures in the economics development of the country. The main objective of the study is to reveal how the health services have been provided and developed in different Talukas of Karwar District in Karnataka State. It further attempts to understand and explain how the health and health facilities like hospitals, beds and drugs stores are developed and distributed among the people of Karwar District which comprises eleven Talukas. DATA SOURCES AND METHODOLOGY The study is based on secondary data collected from official documents and other published and unpublished materials like Government reports, District at a Glance, Research articles and books etc. The information contained in sources has been analyzed and used for the same. As for the development of a state or region, three types of infrastructural facilities and all-round development are complimenting with each other keeping this purpose in view, review of secondary literature has been done in relation to health infrastructure like establishment of Government Hospitals, Primary Health Centres, Beds and Drug stores etc in Karwar district. RESULTS AND DISCUSSION The following discussion shows the structure and composition of health infrastructure in different talukas of Karwar district. Different aspects of health infrastructure like number of Government hospitals, availability of Beds, PHCs, Drugs Shop etc. in the study area are discussed with the help of datas presented in the table. Problems in the provision of health infrastructure are discussed in the last part of this discussion. 1. Government Hospitals The Government Hospitals play vital important role in protecting the health of the people in Uttar Kannada (Karwar) district. An analysis has been made to know the extent of health infrastructure facilities particulars offered in each taluka during different years.
The study found that there are only 13 Government hospitals in different talukas of Karwar district and this has been not increased since 1998-99 to 2009-10, where in only 7.69 percent (1) Government hospital is there in Ankola, Bhatkal, Honnavar, Karwar, Kumata, Mundagod, Siddapur, Sirsi, and Yallapur respectively. But in Haliyal and Supa(Joida) there are 15.38 percent (2) Government hospitals since 1998-99 to 2009-10.There is not significant change in study area. (Uttar Kannada, District Statistical Glance, 1998-99 to 2009-10). 2. Beds in Government Hospitals in Karwar District The provision of beds to the patients in the hospitals is very important in treating the same in the hospitals. The provision of bed is very prominent in the hospital service. Table - 1 indicates about the provision of beds to the number patients in the hospitals of each taluka from the year 1998-99 to 2009-10. Thus comprising all the eleven taluka hospitals the total number of beds provided was 618 in the year 1998-99, out of which, Ankola had 1.30 percent (80), Bhatkal 7.28 percent (45), Haliyal 11.33 percent (70), Honnavar 3.40 percent (21), Karwar 48.54 percent (300), Kumata 5.02 percent (31), Mundagod 0.97 percent (6), Siddapur 4.85 percent (30), Sirsi 9.22 percent (57) and Supa 3.24 (20) and Yallapur 4.85 percent (30) beds had been provided. Karwar Taluka had provided the highest number of beds and Mundagod had provided the least number of beds in the hospitals. During the year 2009-10, all the eleven Talukas of the district increased the number of beds 920 to 970. Ankola, Honnavar, Kumata and Supa talukas provided 5.15 percent (50) beds and Bhatkal, and Sirsi talukas was provided 10.31 percent (100) beds, Haliyal taluka had provided 8.25 percent (80) beds, Karwar had provided the highest number of beds i.e., 41.24 percent (400) and remaining talukas i.e., Mundagod, Siddapur
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and Yallapur had provided least number of beds i.e., 3.09 percent (30) only. It implies that the provision of beds in the hospitals of all the talukas was not the same. The number of beds did increase in the subsequent years except in Siddapur and Yallapur Taluka. 3. Primary Health Centres (PHCs) As the mothers health is important in caring the health of child in the rural areas, the primary health centres are looking after the health of ruralties. The primary health centres are providing better health infrastructure facilities in the rural areas. As is shown in the Table - 2 that in the rural areas of Uttara Kannada (Karwar) district there were 36 Primary Heath Centres during the year 1990-91, in the year 1995-96 there were 55 PHCs and which increased to 58 in the year 2000-01. During the year 2005-06 the total numbers of PHCs were 59 and in 2009-10 this number of PHCs has been increased to 83. In the same way, during the year 2009-10 Ankola and Bhatkal, had few number of PHCs i.e., 6.02 percent (5) separately. Haliyal and Supa had 8.43 percent (7) separately. Honnavar and Yallapur talukas had provided 10.84 percent (9) of PHCs. Karwar had provided the highest number of PHCs i.e., 15.66 percent (13), Kumata, Mundagod and Siddapur talukas had provided 8.23 percent (6) Sirsi taluka had provided 12.05 percent (10) Primary Health Centres. The above study reveals that the number of PHCs had been increased slowly in Uttara Kannada district and rural areas. But still there is need of increasing such Health Centres to some extent. This analysis shows that there is a significant disparity in the provision of PHCs and other Government hospital facilities in Rural and Urban areas. Where in these facilities are better in urban talukas compared to rural talukas. 4. Beds in Primary Health Centres (PHCs) Even the provision of beds has been made in the primary health centres of Karwar district. Most of the primary health centres are providing the bed
facilities for proper treatment of pregnant and other patients. As per study the Table 3 reviews the provision of total number of beds in Primary Health Centres of Uttara Kannada district was 230 during the year 1990-91, whereas during the year 2000-01 and 2009-10 the provision of beds could increase to 390 and 366, respectively. Taluka-wise distribution of beds in Primary Health Centres during the year 1990-91 shows that Ankola, Karwar, Mundagod and Siddapur had 7.83 percent (18) separately. Haliyal and Supa taluka accounts 5.22 percent (12), Honnavar had 13.04 percent (30) beds PHCs, Kumata taluka PHCs possessed the highest number of beds that is 14.78 percent (34) and Sirsi and Yallapur PHCs had 10.43 percent (24) beds each. In the same way, during the year 2009-10 Ankola and Bhatkal PHCs possessed 6.56 percent (24) beds each. Haliyal and Sirsi talukas had 11.47 percent (42), Honnavar PHCs possessed the highest number of beds i.e., 13.11 percent (48), Karwar had 9.83 percent (36) beds, Kumata, Mundagod, Siddapur, Supa and Yallapur PHCs had 8.20 percent (30) beds each talukas PHCs. In the above Table of information we come to know that in each subsequent year that is from 1990-91 to 2009-10 the number of beds in PHCs could increase constantly. During the year 1990-91 Haliyal and Supa talukas had least beds in PHCs and Kumta taluka had highest numbers of beds in PHCs. In the same way during the year 2009-10 Ankola and Bhatkal had very least number of beds in PHCs and Honnavar taluka had highest number of beds in PHCs. 5. Drug Shops Drug shops are the stores where medicine and chemicals are preserved and sold, all types of medicines and surgical instruments are supplied and provided to the hospitals and patients. Thus, the drug shops are as important as hospitals in preserving the health of public.
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The Table -4 reveals that the total district had 101 drug shops during the year 1993-94, out of which 5.94 percent (6) were found in Ankola. Further the number of drug shops were found in Honnavar, Karwar, Kumata, Yallapur, Mundagod and Siddapur constitute 10.89 percent (11), 11.88 percent (12), 6.93 percent (7), 3.9 percent (4), 21.79 percent (22) and 0.99 percent (1). Thus, Sirsi had the highest number of drug shops and Supa had the least number of drug shops. In this way, from the years1993-94 to 2009-10, the number of drug stores could increase from 101 to 338. Out of which Ankola taluka had 5.62 percent (19), Bhatkal taluka had 7.10 percent (24), Haliyal and Honnavar talukas had 12.13 percent (41), Karwar had 13.91 percent (47), Kumata had 11.24 percent (38), Mundagod and Siddapur had 4.73 percent (16), Sirsi taluka had the highest number of drug shops i.e., 24.26 percent (82) and Supa had very least number of drug shops i.e., 0.89 percent (3) and Yallapur had 3.25 percent (11) respectively Thus, from the above information in the table we can observe that the number of drug shops increased from the year to year. The Sirsi had more number of drug shops and Supa belonged to the least number of drug shops in Karwar District. Problems in the Provision of Health Infrastructure Facilities In the study area there are so many reasons for the poor growth of health infrastructure facilities in the Karwar district of Karnataka State. Those are., 1) Lack of financial resources. Means the public expenditure on health in Karnataka was less than 1 percent of GDP indicating inadequacies in the public provision of critical health services; 2) Shortage of building facilities for health centres; 3) Lack of physical infrastructure like., supplies, diagnostic facilities, laboratory equipments, etc. and these are extremely helpless condition which a very sad reflection on the functioning of health centers and a general deterioration of physical infrastructure
facilities; 4) Lack of human resource (manpower); 5) Scarcity of road and transport facilities; 6) Inbalanced growth of plane and hilly zones as well as Urban and Rural areas; 7) Lack of health education to the people; 8) Doctors and other staff are not showing interest to serve in rural area like., SCs and PHCs; 9) Not proper establishment of health policies and programmes. Suggestion to improve to health infrastructure facilities On the basis of the findings of the present study there are so many solutions to resolve problems in connection to provision of health infrastructures and some suggestions to the improvement of health infrastructure facilities in the study area like: 1) Proper allocation of the financial resources and increase the public expenditure on health care. 2) Equal distribution and creating the new health infrastructure amenities. 3) Government should take the support of NGOs and Private Institution for the development of health infrastructure. 4) Construction of buildings in the Ideal Location to help these beneficiaries and staff. 5) Full fill the shortage staff in a health centers among all type of health care. 6) Maintain the balanced growth of plane and hilly zones as well as Urban and Rural areas. 7) Make the strict rules to continuously absent and rude behaved staff. 8) Make the new policy and establishment to helpful to all people in a state. etc. CONCLUSION It is concluded that, in the present study area different types of health infrastructure facilities are available like, health hospitals, primary health centres and beds, drug shops etc. During the past years the vast spread and development of health infrastructure facilities and several health policies and programmes are implemented at both
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National and State level. But the facilities were not distributed equally among all talukas in study area. There is disparity in the provisions of health facilities in different talukas of Karwar district. And even in case of rural and urban composition in relation to health infrastructure there is differentiation, where as health infrastructure are well developed in Urban taluka places compared to rural areas of Karwar district. Hence, Government should give priority to bring about equality in distribution of health infrastructure facilities in different talukas of karwar district and also it must concentrate to increase health infrastructure facilities in rural areas of it to view the good health status of population. ACKNOWLEDGEMENT We are thankful to all the authors who have made significant contributions to the Health studies of which we have made references in the present study. And we are also grateful to IJCRR editorial board members, team of reviewers who have helped us to bring quality to this paper. REFERENCES 1. Dutt P. R., Rural Health Services in India: Primary Health Centres, Centra Health Education Bureau, New Delhi, 1965.
2. Madan G.R., Indian Rural Problems, Radha Publications, New Delhi, 2002. 3. Kasturi Sen., Restructuring Health Services: Changing Contexts and Comparative Perspectives, Zed Books, London, 2003. 4. Krishnareddy M.M., Health and Family Welfare, Public Policy and Peoples Participation in India, Kanishka Publishers and Distributers, New Delhi, (2000). 5. Om Prakash Sharma., Rural Health and Medical Care in India: A Sociological Study, Manak Publication Pvt. Ltd., 2000. 6. Dinesha P. T. Jayasheela and V.Basil Hans., Health Infrastructure in India Present Challenges and Future Prospects. ed., by- Dr. Talwar Sabanna., Serials Publications, New Delhi (India), 2010. 7. Government of Indias report on Eleventh Five Year Plan- 2007-2012 publications Planning commission of India, Oxford University Press, 2007. 8. Lavees Bhandari and Siddartha Dutta., Health Infrastructure in Rural India, India Infrastructure Report - 2007 9. Karne Manisha, Public Health care in India Issues and Problems, Health Action December. pp. 8-11. 2007.
Table- 1 : Beds in government hospitals in karwar district

Taluka Ankola Bhatkal Haliyal Honnavar Karwar Kumata Mundagod Siddapur 1998-99 8 (1.30) 45 (7.28) 70 (11.33) 21 (3.40) 300 (48.54) 31 (5.02) 6 (0.97) 30 (4.85) 2000-01 50 (5.43) 50 (5.43) 80 (8.70) 50 (5.43) 400 (43.49) 50 (5.43) 30 (3.26) 30 (3.26) 2005-06 50 (5.43) 50 (5.43) 80 (8.70) 50 (5.43) 400 (43.49) 50 (5.43) 30 (3.26) 30 (3.26) 2009-10 50 (5.15) 100 (10.31) 80 (8.25) 50 (5.15) 400 (40.24) 50 (5.15) 30 (3.09) 30 (3.09)
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57 (9.22) 20 Supa (Joida) (3.24) 30 Yallapur (4.85) 618 District (100.00) Source: District Statistical Glance. Sirsi
100 100 100 (10.88) (10.88) (10.31) 50 50 50 (5.43) (5.43) (5.15) 30 30 30 (3.26) (3.26) (3.09) 920 920 970 (100.00) (100.00) (100.00) Note : Figures in bracket denote percentage.
Table- 2: Primary Health Centres (PHCs) in Karwar District

1990-91 3 Ankola (8.33) 3 Bhatkal (8.33) 2 Haliyal (5.56) 5 Honnavar (13.90) 3 Karwar (8.33) 4 Kumata (11.11) 3 Mundagod (8.33) 3 Siddapur (8.33) 4 Sirsi (11.11) 2 Supa (Joida) (5.55) 4 Yallapur (11.11) 36 District (100.00) Source: District Statistical Glance. Taluka 1995-96 4 (7.27) 4 (7.27) 6 (10.91) 8 (14.55) 5 (9.09) 5 (9.09) 4 (7.27) 4 (7.27) 7 (12.73) 3 (5.46) 5 (9.09) 55 (100.00) 2000-01 2005-06 2009-10 4 4 5 (6.90) (6.78) (6.02) 4 4 5 (6.90) (6.78) (6.02) 7 7 7 (12.07) (11.87) (8.43) 8 8 9 (13.79) (13.56) (10.84) 6 6 13 (10.34) (10.17) (15.66) 5 5 6 (8.62) (8.47) (7.23) 4 4 6 (6.90) (6.78) (7.23) 5 5 6 (8.62) (8.47) (7.23) 7 7 10 (12.07) (11.87) (12.05) 3 4 7 (5.17) (6.78) (8.43) 5 5 9 (8.62) (8.47) (10.84) 58 59 83 (100.00) (100.00) (100.00) Note : Figures in bracket denote percentage.
Table- 3 : Beds in Primary Health Centres (PHCs) in Karwar District

Taluka Ankola Bhatkal Haliyal Honnavar Karwar Kumata Mundagod 1990-91 18 (7.83) 22 (9.56) 12 (5.22) 30 (13.04) 18 (7.83) 34 (14.78) 18 (7.83) 1995-96 24 (6.90) 28 (8.05) 36 (10.34) 48 (13.79) 30 (8.62) 40 (11.49) 24 (6.90) 2000-01 24 (6.15) 24 (6.15) 42 (10.77) 48 (12.31) 36 (9.24) 30 (7.69) 48 (12.31) 2005-06 24 (6.74) 24 (6.74) 42 (11.80) 48 (13.48) 36 (10.11) 30 (8.43) 24 (6.74) 2009-10 24 (6.56) 24 (6.56) 42 (11.47) 48 (13.11) 36 (9.83) 30 (8.20) 30 (8.20)
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18 (7.83) 24 Sirsi (10.43) 12 Supa(Joida) (5.22) 24 Yallapur (10.43) 230 District (100.00) Source: District Statistical Glance. Siddapur
24 24 30 (6.90) (6.15) (8.43) 46 42 44 (13.21) (10.77) (12.36) 18 42 24 (5.17) (10.77) (6.74) 30 30 30 (8.62) (7.69) (8.43) 348 390 356 (100.00) (100.00) (100.00) Note : Figures in bracket denote percentage.
30 (8.20) 42 (11.47) 30 (8.20) 30 (8.20) 366 (100.00)
Table- 4 : Drug shops in Karwar District

1993-94 Drug Shops 6 Ankola (5.94) 15 Bhatkal (14.85) 15 Haliyal (14.85) 11 Honnavar (10.89) 12 Karwar (11.88) 7 Kumata (6.93) 4 Mundagod (3.96) 4 Siddapur (3.96) 22 Sirsi (21.79) 1 Supa (Joida) (0.99) 4 Yallapur (3.96) District 101 (100.00) Source: District Statistical Glance. Taluka 1999-00 2005-06 2009-10 Drug Shops Drug Shops Drug Shops 13 16 19 (5.14) (5.16) (5.62) 27 22 24 (10.67) (8.39) (7.10) 22 38 41 (8.70) (12.26) (12.13) 33 41 41 (13.04) (13.23) (12.13) 40 45 47 (15.81) (14.52) (13.91) 33 35 38 (13.04) (11.29) (11.24) 8 10 16 (3.16) (3.23) (4.73) 10 16 16 (3.96) (5.16) (4.73) 58 74 82 (22.92) (23.87) (24.26) 3 2 3 (1.19) (0.65) (0.89) 6 11 11 (2.37) (3.55) (3.25) 253 (100.00) 310 (100.00) 338 (100.00) Note : Figures in bracket denote percentage.
Smita Shah et al
HISTOPATHOLOGICAL STUDY OF MENINGIOMA IN CIVIL HOSPITAL, AHMEDABAD

IJCRR
Smita Shah, R. N. Gonsai, Rinku Makwana

Department of Pathology, B. J. Medical College, Ahmedabad, India E-mail of Corresponding Author: rinku.makwana.30@gmail.com
ABSTRACT Objective: This study was done to determine the clinical and histological pattern of intracranial meningioma, to determine the sociodemographic characteristic and clinical presentation and correlate this to the clinical patterns of intracranial meningioma, to find out the anatomical location of meningioma and to document the WHO histological grade of meningioma. Materials and Methods: We have studied 51 cases of meningioma. Meningioma was diagnosed primarily by contrast enhanced CT Scan and Magnetic Resonence Imaging (MRI) of brain. This was confirmed by histopathological examination. Histopatholgical results were examined according to age and sex distribution, anatomical location of tumor, histological type and WHO grading of tumor. Correlation of clinical features and radiological findings were made with histpathological results. Results and conclusion: Most of the sufferer was female 34 (67%). The commonest age group was 40-59 years. The commonest site of tumor was convexity of brain 26 (60%). The commonest histopathological type was meningotheliomatous meningioma 20 (39%). The 92% of the meningioma was WHO GRADE I tumor. Keywords: meningioma, WHO grading of meningioma, prognosis of meningioma, INTRODUCTION The tumor originating from the meninges was termed as meningioma by Cushing in 19221. Meningiomas originate from the arachanoidal cap cell, a meningothelial cell in the arachnoidal membrane. They generally arise were arachnoidal villi are many2. The arachnoid cap cells are most prevalent near collections of arachnoid villi at the dural venous sinuses and their large tributaries. Meningiomas may arise anywhere the cap cells are located2. Meningiomas are account for 15% of all intracranial tumors. They commonly occur in the fourth to sixth decades of life, with a mean age of 45 years at diagnosis. Females have meningiomas more often than males; ratio is 2:1 for intracranial and 4:1 for spinal meningiomas3. The etiology of meningioma is unknown. Cases exist in which the tumor has arisen under a fracture, from an area of scared dura, or around a retained foreign body. Low and high dose radiation has been implicated in meningioma formation especially during childhood. Neurofibromatosis 1 and 2 genetic diseases inherited in autosomal dominant fashion may be associated with meningioma4. 90% of meningiomas are located intracranialy and of these 90% are supratentorial. According to site meningiomas are located at parasaggital, convexity, sphenoid ridge, suprasellar, posterior fossa, olfactory groove, middle fossa, tentorial, peritorcular, lateral ventricle, foramen magnum , spinal, orbit or optic nerve sheath, few located at ectopic site5. At spinal level meningioma clearly favors the thoracic region. Cervical being uncommon and lumber is rare. Also recognized are epidural, calvarial and intrapetrous as well as
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variant located entirely outside the craniospinal confines6. Although most meningiomas are benign, they have a surprisingly broad spectrum of clinical characteristics, and histologically distinct subsets are associated with high risk of recurrence, even after seemingly complete resection. In rare instances, meningiomas are malignant. The WHO classication aims to better predict the divergent clinical characteristics of meningiomas with a histological grading system based on statistically signicant clinicopathological correlations. Meningiomas are classified as benign, atypical, or malignant. Benign meningiomas are not encapsulated; they grow invaginating, but demarcated, from the brain. They grow with finger-like projections, and penetrate surrounding mesenchymal tissue, including bone. They may produce both an osteoblastic and a lytic reaction2. Meningiomas show positive immunostain with vimentin, desmoplakin, and epithelial membrane antigen. They have a grade 1 biological behaviour. Meningiomas grow in 3 primary histologic patterns: (1) meningothelial, (2) fibroblastic, or (3) transitional, a combination of meningothelial and fibrous. Meningothelial meningiomas consist of lobules of cells with oval pale nuclei, with chromatin marginated around the nucleus. The cell has an ill-defined cellular membrane, and nuclear and cytoplasmic invaginations often produce pseudoinclusions2. Fibroblastic meningiomas have parallel interlacing bundles of spindle-shaped cells with abundant collagen and reticulin between cells. Transitional meningiomas have a mixed pattern of both meningothelial and fibroblastic features. They more often contain whorls or psammoma bodies. Benign meningiomas of WHO grade I can invade the dura, dural sinuses, skull, and even extracranial compartments, such as orbit, soft tissue, and skin. Although these types of invasion make it more dicult to resect the tumour, they are not considered as atypical or malignant. By
contrast, brain invasion is associated with recurrence and mortality rates similar to atypical meningiomas in general, even if the tumour seems completely benign otherwise8. WHO grade II meningiomas include atypical, chordoid, and clear cell meningiomas9. Both grade II and III WHO classifications of meningiomas require brain invasion as a criterion10. WHO grade II meningiomas make up 5% to 7% of all meningiomas11. Some pathologists feel that a meningioma should be called malignant only when there is frank brain invasion, although brain invasion has been documented in benign, atypical, and anaplastic meningiomas and felt to be an additional criteria for malignant classification8. Atypical meningiomas are diagnosed based on increased mitotic index of equal to or greater than 4 mitoses per 10 highpower fields or 3 or more of the following features: increased cellularity, small cells with high nuclear to cytoplasmic ratio, prominent nucleoli, uninterrupted patternless or sheet-like growth, and foci of "spontaneous" or "geographic necrosis"10. Clear-cell and chordoid variants of meningioma are associated with higher recurrence rates even without the above criteria12,13. Thus, these meningiomas are graded as WHO grade II by denition. Clear-cell meningiomas make up only 0.2% of all meningiomas. This type usually behaves aggressively and can metastasize to the CSF. Clear-cell meningiomas often occur in patients of younger age and occur more often in the spinal and cerebellar pontine region. Recurrence rate of clear-cell meningiomas is 46% to 80%14 . Clear-cell meningioma is composed of sheets of polygonal cells with clear, glycogen-rich cytoplasm positive for periodic acid Schi, and dense perivascular and interstitial collagenisation. Chordoid meningiomas are histologically similar to chordoma, with cords of small epithelioid tumour cells that contain eosinophilic or vacuolated (i.e., resembling physaliferous cells) cytoplasm embedded in a basophilic, mucin-rich
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matrix. Clear-cell meningiomas are most common in the spinal cord and posterior fossa, whereas chordoid meningiomas are typically supratentorial. WHO grade III meningiomas make up 1.0% to 2.8% of all meningiomas. These include anaplastic, rhabdoid, and papillary types9. Malignant meningiomas have further increase in mitoses and cellularity with conspicuous necrosis15. Anaplastic or malignant meningiomas by definition must have equal to or greater than 20 mitoses per 10 high-power field10. Atypical and malignant meningiomas have a much higher recurrence rate after resection than do benign meningiomas. Recurrence rates were 6.9% for benign meningiomas, 34.6% for atypical meningiomas, and 72.7% for malignant meningiomas8. Papillary and rhabdoid meningiomas are rare variants and have an aggressive clinical course and higher rates of recurrence, metastases, and mortality10. Papillary meningiomas generally occur in the pediatric population.9 Their cell processes terminate in papilla on blood vessels, with tapering of their processes to form pseudorosettes. Rhabdoid meningioma is a new pathologic variant of malignant meningioma with peritumoral edema, bone involvement, and significant cystic components on Magnetic Resonence Imaging (MRI) study of brain16. The prognosis for meningiomas following gross total resection depends on the histology. In a single series of 1799 meningioma specimens from 1582 patients followed for an estimated average of 13 years, 93.1% of benign meningiomas, 65.4% of atypical meningiomas, and 27.3% of malignant meningiomas were cured by surgery8. Recent research has investigated possible prognostic factors in atypical and malignant meningiomas specifically. In an analysis of 76 atypical meningiomas and 10 malignant meningiomas, high mitotic count, brain invasion, and parasagittal-falcine location were
significantly associated with decreased 17 recurrence-free survival . Also, Ki-67 index greater than 4% was also associated with decreased time to recurrence. These appear to be important pathologic indicators of aggressiveness of these tumor types. A recent study found that anatomic location of tumor also to have prognostic significance18. They reviewed 378 patients with meningioma, looking for causes for high-grade pathology. They found that nonskull-base meningiomas, prior surgery, and male sex all increased risk of grade II or III pathology, which extrapolates to poorer prognosis and increased likelihood of recurrence. MATERIAL AND METHOD This was descriptive study. This study was carried out at the histopathology laboratory, Department of Pathology, B. J. medical college Ahmedabad, from January 2010 to August 2011. We have studied 51 cases. Histological subtype and WHO grading for all meningiomas were carried out. The parameters like patients age, gender, location of tumor, microscopic appearance of tumor were studied. RESULTS The present study was conducted at pathology department of B. J. Medical College and Civil Hospital Ahmedabad, Gujarat, India. A total of 51 cases diagnosed as meningioma by histopathological examination were studied. Detailed clinical history and radiological findings were assessed in all 51 cases. In our study meningiomas were most common in the age group of 40-59 years (59%), followed by in the age group of 20-39 years (21%). Meningiomas were least common in the age group of <20 years (06%). Out of 51 cases 34 (67%) were female and 17 (33%) were male. In our study most common clinical feature was headache, seen in 38 (75%)
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of cases followed by vomiting, seen in 9 (17%) of cases. In our study most common location of tumor was convexity of brain in 26 (51%) of cases. 46 (90.2%) cases were in intracranial location. In our study most common histological subtype was meningotheliomatous meningioma 19 case (37%). And most of the tumor was WHO GRADE I (47 case 92%). Whereas WHO GRADE II and WHO GRADE III tumor comprise respectively 8% and 0% of total cases. DISCUSSION: The present study was conducted in the department of Pathology, B. J. Medical College and Civil Hospital Ahmedabad, Gujarat, India. In present study meningiomas were most common in the age group of 40-59 years 59%. Haradhan et al 200919 studied 25 cases of meningiomas, with most tumor were in the age group of 40-59 years 60%. Among the 51 patients, in our study 34 (67%) were female and 17 (33%) were male, with male to female ratio being 1:2. Akyildiz EU et al 201020 were studied 245 cases of meningioma, 74 (30.2%) were male and 171(69.8%) were female, with male to female ratio being 1:2.3. Joseph wanjeri et al 201121 a study of 78 cases of meningioma, females 69.2% were more affected than males 30.2% with male to female ratio being 1:2.3. In all of these studies meningiomas were most common in female, with male to female ratio nearly 1:2. Among the 51 patients, in our study most common location of tumor was intracranial 46(90.2%) cases, with tumor located most commonly at convexity of brain 26 (51%) of cases. Akyildiz EU et al 2010 study20, intracranial location of tumor was found in 96% of cases. In our study most common clinical feature was headache (75%) followed by vomiting (17%). Haradhan deb nath et al 200919 study of 25 cases of meningioma, most common clinical feature was headache (72%) of cases followed by vomiting (60%) of cases.
In our study most common histological type of tumor was meningothelial meningioma 37% , psammomatous meningioma 19% and fibroblastic meningioma 16%cases. Joseph wanjeri et al 201121, The commonest cellular subtype were fibroblastic 25.4%, transitional (mixed) 25.4% and meningothelial (syncitial) 22.5%. Haradhan deb nath et al 200919 study, most common histological subtype was meningothelial meningioma 32% transitional meningioma 20% and fibroblastic meningioma 20% cases. In all three studies meningothelial meningioma and fibroblastic meningioma were common histological subtype. In our study, WHO GRADE I tumour were 92%, WHO GRADE II tumour were 08% and WHO GRADE III tumour were 0%. Joseph wanjeri et al 201121 study found that, According to WHO classification, the benign form (grade I) was the commonest at 94.7%. Grade II (atypical) and grade III (malignant) represented 4% and 1.3% respectively. Akyildiz EU et al 2010 study20, WHO GRADE I tumour were 82%, WHO GRADE II tumour were 6%. Our result is consistent with above studies, in all these studies most common WHO GRADE were GRADE I. In our study we found two cases of clear cell meningioma. Both are in age group <20years and one is located in spinal region and other at CP angle, which are common locations for clear cell meningioma. In our study we found 4 cases of WHO GRADE II tumour. Two of them were clear cell meningioma, as clear cell meningioma entity itself put tumour into GRADE II. And out of other two, one was meningothelial meningioma and one was fibroblastic meningioma as both of them show increased mitotic activity, 4 mitoses per high power field. CONCLUSION Meningiomas occurred more frequently in females than in males with a female to male ratio
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of 2:1. Adults were more affected than their elderly counterparts. The mean age was 42.6. Majority of Patients presented with complain of headache of longer duration and vomiting. Most meningiomas were at intracranial location. Most intracranial meningiomas occur in the supratentorial compartment. Majority of meningioma are histologically benign with WHO GRADE I and hence curable by surgical resection. ACKNOWLEDGEMENT The 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. Cushing H. The meningiomas (dural endotheliomas): their source, and favoured seats of origin. Brain 1922;45:282-316. 2. Kleihues P, Burger PC, Scheithauer BW. Histological typing of tumours of the central nervous system. 2nd ed. World Health Organization. Berlin: Springer-Verlag, 1993:30. 3. Das A. Tang WY. Smith Dr. meningiomas in Singapore, demographic and biological characteristics. J Neurooncol 2000.47, 15360. 4. Al-Mefty O, Kersh JE, Routh A, Smith RR. The long term side effects of radiation for benign brain tumors in adult. J Neurosurg 1990; 73; 502-512. 5. Christensen HC, Kosteljanetz M, Johanses C. Incidence of gliomas and meningiomas in Denmark. 1943 to 1997. Neurosurgery 2003, 52: 1327-34. 6. Lang FF, Macdonald OK, Fuller GN, DeMonte F. Primary extradural meningiomas. A report on nine cases and
review of the literature from the era of computerized tomography scanning. J Neurosurg 2000,93:940-950. 7. Kleihues P, Cavenee WK, International Agency for research on cancer, Pathology and genetics of tumors of nervous systems, Lyons: IARC Press 2000 8. Perry A, Scheithauer BW, Sta ord SL, Lohse CM, Wollan PC. Malignancy in meningiomas: a clinicopathologic study of 116 patients, with grading implications. Cancer 1999; 85: 204656. 9. Bollag RJ, Vender JR, Sharma S. Anaplastic meningioma: Progression from atypical and chordoid morphotype with morphologic spectral variation at recurrence. Neuropathology 2010;30(3):279-87. 10. Campbell BA, Jhamb A, Maguire JA, Toyota B, Ma R. Meningiomas in 2009: controversies and future challenges. Am J Clin Oncol 2009;32(1):73-5. 11. McGovern SL, Aldape KD, Munsell MF, Mahajan A, Demonte F, Woo SY. A comparison of World Health Organization tumor grades at recurrence in patients with non-skull base and skull base meningiomas. J Neurosurg 2010;112(5):925-33. 12. Zorludemir S, Scheithauer BW, Hirose T, Van Houten C, Miller G, Meyer FB. Clear cell meningioma. A clinicopathologic study of a potentially aggressive variant of meningioma. Am J Surg Pathol 1995; 19: 493505. 13. Couce ME, Aker FV, Scheithauer BW. Chordoid meningioma: a clinicopathologic study of 42 cases. Am J Surg Pathol 2000; 24: 899905. 14. Tong-tong W, Li Juan B, Zhi L, Yang L, BoNing L, Quan H. Clear cell meningioma with anaplastic features: case report and review of literature. Pathol Res Pract 2010;206(5):34954. 15. Maier H, Ofner D, Hittmair A, Kitz K, Budka H. Classic, atypical, and anaplastic
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meningioma: three histopathological subtypes of clinical relevance. J Neurosurg 1992;77:616-23. 16. Kim EY, Weon YC, Kim ST, et al. Rhabdoid meningioma: clinical features and MR imaging findings in 15 patients. AJNR 2007;28(8):1462-5. 17. Vranic A, Popovic M, Cor A, Prestor B, Pizem J. Mitotic count, brain invasion, and location are independent predictors of recurrence-free survival in primary atypical and malignant meningiomas: a study of 86 patients. Neurosurgery 2010;67(4):1124-32. 18. Kane AJ, Sughrue ME, Rutkowski MJ, et al. Anatomic location is a risk factor for atypical and malignant meningiomas. Cancer 2011;117(6):1272-8.
19. Haradhan Deb Nath, MD mainuddin, MD

kmal Uddin, Ehsam mahmood et al, surgical outcome of supratentorial meningioma. A study of 25 cases. JCMCTA 2009;41-44. 20. Alkyildiz EU, Oz B, Comunoglu N, Aki H et al. The relationship between histomorphological characteristics and ki67 proliferation index in meningioma Bratisl Lek listy 2010;111(9) 505-509. 21. Joseph. Wanjeri et al. Histology and clinical pattern of meningiomas at the Kenyatta National Hospital Nairobi, Kenya. A thesis submitted for the award of the degree of master of medicine in neurosurgery, University of Nairobi, 2011.
Table 1: WHO criteria for meningioma grading7

WHO grade I Histological subtype histological features Meningothelial, fibroblastic, 1) Lacks criteria of atypical and anaplastic meningioma transitional, angiomatous, microcystic, secretory, lymphoplasmacytic, metaplastic, psammomatous II (atypical) any of Choroid, clear cells 1) Mitotic index 4mitoses/ten HPF three criteria 2)Atleat three of five parameters: -Increased cellularity -High nuclear/cytoplasmic ratio (small cells) -Prominent nucleoli -uninterrupted pattern less or sheet like growth -foci of spontaneous necrosis 3)Brain invasion III (anaplastic) either Papillary, rhabdoid 1) Mitotic index 20 mitoses/10 HPF of one criteria 2) Anaplasia (sarcoma, carcinoma or melanoma like histology)
Table 2: Distribution of the patient by age:

Age Years <20 20-39 40-59 >60 Total Number 03 11 30 07 51 Percentage 06% 21% 59% 14% 100%
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Table 3: Distribution of patient by site of tumor

Site Convexity of brain CP angle Sphenoidal sinus Ventricles Sellar region Cerebellum Spinal Other Number 26 08 04 03 01 01 04 01 Percentage 51% 16% 07% 06% 02% 02% 08% 02%
Table 4: Distribution of patient by Histological subtype and grade of tumor

Histological subtype Meningothelial Fibroblastic Transitional Microcystic Psammomatous Secretory Clear cell Total Number 19 08 06 04 10 01 02 51 Percentage 37% 16% 10% 08% 19% 02% 04% 100%
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HISTOPATHOLOGICAL SPECTRUM OF SINONASAL MASSES A STUDY OF 162 CASES
HISTOPATHOLOGICAL SPECTRUM OF SINONASAL MASSES A STUDY OF 162 CASES. IJCRR

Seema K. Modh, K. N. Delwadia, R. N. Gonsai

Department of Pathology, B.J. Medical college, Ahmedabad, India E-mail of Corresponding Author: drseemamodh@gmail.com
ABSTRACT Introduction: Lesions of the sinonasal region are commonly encountered in clinical practice and important from clinical and pathological perspectives as they have a varieties of histological patterns. Aims and Objectives: 1) To study the incidence of benign and malignant lesions of sinonasal region. (2) To study distribution of various lesions for sex differences and symptomatology. (3) To compare the findings of the study with other studies. Methods: Present study included 162 polypoidal lesions of the nasal cavity. The study period constituted from December 2011 to October 2012. All the tissues were fixed in 10% buffered formalin, processed, stained with H & E and studied for various histopathological patterns. Periodic acid Schiffs and reticulin stains were used wherever necessary. Results: Among 162 cases, 110 cases (67.11%) were nonneoplastic and 52 cases (32.09%) were neoplastic. Among the non-inflammatory lesion, nasal polyp (83.64%) was the commonest lesion followed by fungal infection. Benign tumours (69.23%) were more frequent than malignant tumours (30.77%). Among benign neoplastic lesions, angiofibroma (41.67%) was commonest and hemangioma (19.4%) was the next common lesion. All lesions were common in second and third decades, with male predominance. Malignant lesions were comparatively less to that of benign lesions. Squamous cell carcinoma was most common malignant lesion. Conclusion: Categorizing the sinonasal lesions according to histopathological features into various types, helps us to know the clinical presentation, treatment, clinical outcome and prognosis of the disease, so all polypoidal lesions need histological examination. Keywords: Nonneoplastic, Neoplastic, Benign, Malignant. INTRODUCTION Sinonasal lesions are common lesion encountered in clinical practice and important from clinical and pathological perspectives as they give rise to a varieties of histological patterns and grades of malignancies. The presence of mass in the nose is a seemingly simple problem; however, it raises numerous questions about differential diagnosis. Although neoplasms of the nose and paranasal sinuses are not common, they are of interest because of their various types. It has been found, the nose and paranasal sinuses account for less than 1% of all malignant tumors in general, not more than 3% of the head and neck region malignancies. It may be due to the most often occurring simple nasal polyps or polypoidal lesions due to various other pathological entities ranging from infective granulomatous disease to polypoid neoplasm including the malignant ones. The nose and nasal sinuses are exposed to various infections, chemically irritating, antigenically stimulating, mechanically, traumatic and undoubtedly many other influences. Consequences of these
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multifaceted deleterious exposures include the formation of tumor like and truely neoplastic conditions [1]. Clinically sometimes, it becomes quite impossible to distinguish between inflammatory conditions presenting as simple polyps, polypoidal lesions due to specific disease and polypoid neoplasm (benign and malignant). Therefore it becomes important that all polyps and polypoidal lesions should be submitted for histopathological examination. Nasal polyps are defined as prolapsed lining of the nasal sinuses. They are essentially rounded projections of edematous membrane [2]. They are often bilateral and multiple which lead to visible broadening of nose [3]. The commonest site of origin is in the ethmoidal labyrinths, particularly from the mucosa of middle turbinate [4]. Nasal polyps most often occur in middle aged males. M:F ratio is 3:1 [3]. The symptoms of tumors of nose and paranasal sinuses often masquerade as chronic inflammatory condition. Even though these malignant neoplasms have extremely low incidence, they have a long clinical history with frequent local recurrence and they cause relatively great amount of morbidity. In nasal cavity, tumors of various type have a tendency to become polypoid. Thus an epithelial papilloma of the nasal cavity often resembles a nasal polyp. Some lesions are specific to certain location, for e.g., epithelial papilloma of turbinate, juvenile angiofibroma of nasopharynx. Thus the study was undertaken to study the histopathology and classify the lesions of nasal cavity and to study the relative distribution of various lesions for age and sex. MATERIAL AND METHODS This study comprised of 162 consecutive cases, the specimen of which were received in the histopathology section of the Dept. of Pathology of our institution with the clinical diagnoses of Nasal polyp from January 2012 to October 2012. The age and sex of the patients were recorded. The consent of all the patients included
in the study was taken. The tissues were routinely processed for histopathological sections and were stained by H&E stain. Special stains by Reticulin and PAS methods were undertaken wherever applicable. The cases were classified into Nonneoplastic and Neoplastic lesions. The Neoplastic lesions were further classified according to WHO classification on histopathological examination. (Shanmugaratnam 1978)[5]. RESULTS AND OBSERVATIONS Histopathological examination revealed that out of 162 cases clinically diagnosed as nasal polyp, there were 110 cases (67.11%) with different types of nonneoplastic lesions and 52 cases (32.09%) of neoplastic ones. Among the 52 neoplastic lesions, there were 36 cases (69.23%) of benign tumors and remaining 16 cases (30.77%) were malignant in nature. Inflammatory polyp was the commonest lesion observed in this region. It constituted 83.64% (92 cases) of all nonneoplastic cases. The other nonneoplastic lesions in the decreasing order of frequency were fungal infection (7 cases, 6.36%), mucormycosis (4 cases, 3.64%), rhinosporodiosis (2 cases, 1.82%), rhinoscleroma (2 cases, 1.82%), non-specific inflammation (2 cases,1.82%) and one case (0.91%) of wegners granulomatosis was seen. Inflammatory polyp was the most common lesion involving this region. The age range of patients was 10 to 80 years, but peak was seen in 2nd to 4th decade of life. These polyps were typically bilateral in 62% cases. The patients presented with symptoms of nasal stuffiness and obstruction and mass protruding from the nostril. Other symptoms were total and partial loss of smell, headache due to sinusitis, sneezing, and mucoid or watery discharge. On examination, the mass was glistening grape-like, insensitive to probing and did not bleed on touch. Microscopically, the polyps were composed of loose mucoid stroma and mucus glands, covered
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by respiratory epithelium. The stroma was infiltrated by lymphocytes, plasma cells, neutrophils and eosinophils. Allergic nasal polyps show abundant eosinophis in the stroma as well as the other inflammatory cells. Fungal infections were more common in 3rd and 4th decade. They presented with foul smelling nasal discharge, which on microscopy, showed inflammation ranging from negligible to large number of neutrophils and histiocytes within granulation tissue. Most common fungal infection was Aspergillosis. Mucormycosis was more common in 5th decade with male preponderance. Microscopically, there was formation of non-invasive mycetomas/ fungus balls. Rhinosporodiosis was present in 5th and 6th decade. The diagnosis was made by the identification of many globular cysts reaching up to 200 nm in diameter. Each of these cysts represented a thick-walled sporangium containing numerous spores. Rhinoscleroma was present in 5th decade with male predominance. Microscopically, the predominant cells were foamy macrophages (Mikulicz cells) and plasma cells. Other nonneoplastic lesions include non-specific inflammation which were observed in 65 years old male and 45 years old male patients & wegners granulomatosis which was present in 17 years old male which on examination, showed a leukocytoclastic vasculitis with geographic necrosis surrounded by palisaded histiocytes, lymphocyte-poor granulomatous reaction, and epithelial ulceration. Neoplastic lesions Among the 52 cases of neoplastic lesions, there were 36 benign cases (69.23%) and 16 malignant ones (30.77%). Angiofibroma and hemangioma were the most common lesions observed in the benign group. There were 15 cases (41.67%) of angiofibroma .It was more common in the 2nd decade and there
was marked male preponderance in this type of neoplasm. Microscopically, it was composed of an intricate mixture of blood vessels and fibrous stroma. Next common benign neoplasm was hemangioma with 7 cases (19.4%).It was more common in 3rd to 5th decade with male to female ratio of 1:1.33. There were 4 cases (11.1%) each of squamous papilloma and inverted papilloma, which commonly presented with mass, nasal obstruction, or epistaxis. Microscopically, papillomas were composed of proliferating columnar and/or squamous epithelial cells, with an admixture of mucin-containing cells and numerous microcysts, but inverted papilloma has invaginations of the surface epithelium into the underlying stroma. Other neoplastic lesions include 3 cases (8.33%) of fibrous dysplasia, one case (2.78%) each of cement-ossifying fibroma, neurilemmoma and plasmacytoma. The distribution of cases has been shown in table no -1. The distribution of the malignant neoplastic lesions has been depicted in table no -2. Squamous cell carcinoma was the commonest malignant lesion observed, which was most common in 6th and 7th decade. There was histological evidence of squamous differentiation, in the form of extracellular keratin or intracellular keratin and/or intercellular bridges. The tumour cells were arranged in nests, masses, or as small groups of cells or individual cells. One case of transitional cell carcinoma was present in 40 years old male and one case of adenocarcinoma was present in 50 years old male. Microscopically in adenocarcinoma, a well differentiated seromucinous composition and tubulopapillary architecture was seen. Next common was the hemangiopericytoma with 2 cases (12.5%) both in males. Microscopically, the lesions appeared vascular and highly cellular, oval tumor cells arranged themselves around blood vessels but they had little atypia, necrosis, or mitotic activity.
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Other malignant neoplastic lesions include acinic cell carcinoma with 2 cases (12.5%) both in females and one case (6.25%) each of chondrosarcoma, rhabdomyosarcoma and teratocarcinosarcoma which were present in 42 years old male, 28 years old male and 30 years old female respectively. DISCUSSION Polypoidal masses in the nasal cavity form a complex group of lesions with a wide spectrum of histopathological features. While there are many nonneoplastic lesions including mainly the allergic and inflammatory one, there are also good number of neoplastic tumefaction in the nose and nasal sinuses. These lesions are often quite impossible to distinguish clinically and are labelled as nasal polyp[6]. Histopathological examination of such polypoidal masses show a spectrum of lesions ranging from nonneoplastic ones to neoplastic tumors including benign and malignant neoplasms. The true nasal polyps are the tumor like nonneoplastic polypoidal masses arising from nasal cavity and sinuses. Two types are encountered- one is associated with nasal allergy and another with numerous inflammatory or granulomatous polyp. In our study, we have observed 110 cases (82.06%) of nasal polyps. The incidence of nasal polyps was slightly higher in this study (82.06%) compared to the observations by Tondon et al (64%) and Anjali et al (62.85%) [7]. The age range of the patients was from 10 to 80 years. Most commonly patients are in 2nd to 3rd decade which is comparable with Ghosh and Bhattacharya (1966) [8] and Zafar et al (2008[9]). There is male preponderance with male to female ratio of 1.53:1 which was same as that observed by Zafar et al and Dasgupta et al [6,7]. Although adolescence or early childhood is stated to be the commonest age of occurrence, there are reports of this disease occurring in all age groups (Maloney and Collins 1977, Fechner 1990)[10,11]. Nasal
polyps were bilateral in 60% cases in our study, while according to Batsakis bilateralism was the rule [12]. In our study, 7 cases (6.36%) of fungal infection were found in the age group of 20-60 years with male predominance which is comparable with Ghosh and Bhattacharya [8]. In our study, 4 cases (3.64%) of mucormycosis were found with peak in the 5th decade with male predominance. This findings were similarly observed by Dafale et al [13]. The incidence of Rhinoscleroma in our study (1.82%) was same as that observed by Zafar et al [9], but lower than that observed by Tondon et al (9% of all inflammatory lesions). In the study by Tondon et al [7], younger peak age of presentation was noted (20-29 years) compared to our observation where the peak age was in 5th decade, however, the sex ratio was almost the same (1:25). Rhinosporodiosis consisted of 1.82% of all the neoplastic lesions which was similar to that observed by Bjerregaard et al (1992) [14] in which incidence was 3.3%. This chronic granulomatous disease caused by rhinosporodiosis seeberi, often present as polypoidal mass that develop on nasal mucosa. This lesion is common in the endemic zones of India including West Bengal (Sammaddar and Sen 1990)[15]. Wegener's granulomatosis (WG) is a multisystemic disease characterized by a necrotizing granulomatous vasculitis affecting predominantly the lower and upper respiratory tract, lung and kidneys [16]. The prevalence of the disease is about 3 persons per 100,000 people, equally in both sexes. We found one such case in 17 years old male. In our study, out of 110 nonneoplastic lesions, 2 cases were of nonspecific inflammation. This was probably because of wrong site or inadequate biopsy. Angiofibroma were the most common benign tumor in our study. Juvenile angiofibroma are the
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characteristic lesions with blood filled spaces separated by excessive fibrous tissue occurring chiefly in the adolescent males [16]. Angiofibroma in our study constituted 41.67% of cases and occurred mainly in the young people, mainly the cases of juvenile angiofibroma, occurring in the pubertal age group and predominantely in males. Hemangioma were second most common benign neoplasm observed in the present study and constituted 19.4% of cases as observed by Bjerregaard et al(1992)[14] and more common in 3rd to 5th decade as documented by Sayed and Al-Serhani et al[17]. These neoplasms presented as bleeding nasal polyp. This was observed in the young as well as elderly people. Willis (1962) has regarded this neoplasm as hamartoma or malformation rather than true neoplasm, but occurrence of such lesions in elderly people with a history of less than 6 months duration is against the theory of hamartomatous origin. Papillomas in the nose and nasal sinuses are stated to be commonly occurring benign epithelial neoplasm. This group includes squamous papilloma and inverted papillomas. Such lesions were more common in adult males (Oberman 1964) [18]. We have also observed 8 such cases (22.22%) and they were three folds more common in the males. Similar observations were made Tondon et al (1971) [7]. Maximum number of cases occurred in 4th and 5th decade comparable to study by Panchal et al (2005)[19]. According to Tsai et al[20], fibrous dysplasia in nasal cavity is rare. However, we found 3 cases (8.33%).Microscopic features were similar to fibrous dysplasia at other sites and consistent with Ruggieri et al and Tsai et al showing narrow, curved misshaped discontinuous woven bone trabeculae having a characteristic fishhook configuration, interspersed with fibrous tissue of variable cellularity. The woven bone trabeculae were not surrounded by osteoclasts. According to Jayachandran and Meenakshi [21], cement-ossifying fibroma is a rare benign, non-
odontogenic tumor like lesions, a subdivision of fibro-osseous lesions. The age of occurrence is between 20 to 40 years with male to female ratio of 1:2. In our study, one case (2.78%) was seen in maxilla of a 35 year old female. The most striking feature if this lesion on microscopy was the presence of large, sharply defined, irregularly shaped, calcified spherules set in a densely fibrotic stroma. Neurilemmoma arising in the nasal cavity are rare. We encountered one case (2.78%) of neurilemmoma, in a female aged 13 years. A different study found neurilemmoma in less than 4% of cases [22]. Histology revealed uniform spindle cells arranged in loose stroma (Antoni B.) Nuclei were arranged in a palisaded pattern (Verocay body). Similar observations were made by another study. Extramedullary plasmacytomas are uncommon tumors, with a worldwide annual incidence of 3 per 100,000 population. They account for 1% of all tumors of the head and neck and 4% of all nonepithelial tumors of the nasal tract [16]. We encountered one such case in 30 years old female. The malignant polypoid tumors of nose and nasal sinuses constitute an important and varied group. Often to, these lesions simulate the simple nasal polyps or chronic inflammatory disease and thus delay in the diagnosis. Malignant tumors in this location are not common in our country (Jussawalla et al 1984, Chaturvedi et al 1986)[23],however carcinomas are, by far, the commonest malignant lesion. In our series, we have observed 38 carcinomas (92.75%) out of 41 malignant lesions The commonest carcinoma of the nose and sinuses is the squamous cell carcinoma. Squamous cell carcinoma constituted 43.75% of cases in our study. Comparable findings were observed by Panchal et al(2005) [19]and Bjerregaard et al(1992[14]).SCC was more common in 6th to 7th decade with male to female ratio of 1.67:1 as documented by Ghosh and Bhattacharya[8].
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Transitional cell carcinoma and adenocarcinomas also occur but are less frequent (Frazel and Lewis 1963). Adenocarcinoma constituted 6.2% of all cases and was present in 50 years old male.Similar findings were observed in study by Panchal et al(2005)[14]. Transitional cell carcinoma constituted 6.2% of cases with presentation in 40 years old male. Tumors of minor salivary gland origin occur in nose as well as nasal sinuses, large majority of such tumors are malignant. Acinic cell carcinoma however was rare and found only in 2 cases. Only 3 cases were belonged to the sarcoma group in our study, consisting of one case each of chondrosarcoma, rhabdomyosarcoma and teratocarcinosarcoma. Such malignancy of connective tissue origin are rare but can present as primary neoplasm of nose and paranasal sinuses.( Birt 1930, Manon and Soule 1965)[24]. Rhabdomyosarcoma involves the head and neck region in 40 to 45% of cases. The sinonasal tract is involved in about 10% of cases affecting the head and neck. We encountered a case of rhabdomyosarcoma in 28 years old male. Teratocarcinosarcomas in the nose, sinuses, or nasopharynx have various elements resembling immature neuroepithelial tissue, including (a) well-formed glands lined with atypical epithelium, (b) nonspecific myxoid tissue, (c) rhabdomyosarcomatous differentiation, (d) benign and malignant cartilage, and (e) cellular areas [16]. We encountered one such case in 30 years old female. Hemangiopericytoma is a rare angiogenic tumor accounting for only 5% of total cases. We observed two such cases one in 52 years old male and 29 years old male. CONCLUSION To conclude, classifying the sinonasal lesions according to histopathological features into various types, helps us to know the clinical presentation, treatment, clinical outcome and prognosis of the disease.
Although most of nasal polyps sent for histopathology are inflammatory, secondary to infection or allergy, various benign and malignant lesions of nose may present as polypoidal masses, so all polyps need histopathological examination. ACKNOWLEDGEMENT We would like to express our gratitude to Department of Pathology and Department of ENT surgery, B.J. Medical College, Ahmedabad. We also acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. We 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. We are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript. REFFERENCES 1. Kumar v, Abbas AK, fausto N. chapter 16, In: Robbins and Cotran Pathologic Basis of Disease. 7th ed ; Philadelphia, : Elsevier inc ; 2004.pp.783. 2. Kale U, Mohite U, Rowlands D and Drake Lee AB. Clinical and histopathological correlation of nasal polyps: Are there any surprises? J Otolaryngol 2001; 26: 321-323. 3. Friedmann I, Bennett MH, Piris J. Inflammatory conditions of nose. In I Friedmanns systemic pathology, Vol.1 Nose, Throat and Ears. Edinburg London, Churchill Livingstone, 3rd edition; 1986:1945. 4. Ballantyne, John and Groves. Nasal Polyposis. In Scott Browns diseases of the ear, nose and throat. 3rd edition, Butterworths and Co. Ltd., 1971: 225-230. 5. Shanmugaratnam, K. (1978): Histopathological typing of upper respiratory tumors, Geneva, W.H.O. P-15
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14.
Dasgupta A,Ghosh RN,Mukherje C. Nasal polyps- Histopathologic spectrum.Indian J Otolaryngol and Head and Neck Surg 1997;49:32-36. Tondon PI, Gulati PL, Mehta H. Histological study of polypoial lesions in the nasal cavity. Ind J Otolaryngol 1971;23(1):3 Ghosh A, Bhattacharya K. Nasal and nasopharyngeal growth- A 10 year survey. J Ind Med Ass 1966; 47:13. Zafar U, Khan N, Afroz N, Hasan SA. Clinopathological study of non-neoplastic lesions of nasal cavity and paranasal sinuses. Indian Journal of Pathology and Microbiology 2008;5(1):26-29. Maloney,J.R. and Collins,J. (1997): Nasal polyps and bronchial agthura. British Journal of Diseases of Chest. 71:1. Frankel SK, Cosgrove GP, Fischer A, Meehan RT, Brown KK. Update in the Diagnosis and Management of Pulmonary Vasculitis. Chest. 2006; 129:452-465. Batsakis JG. The pathology of head and neck tumors: Nasal cavity and paranasal sinuses. Head Neck Surg 980;2 :410-9. S.R. Dafale, V.V. Yenni, H.B. Bannur. Histopathological study of polypoidal lesions of nasal cavity- a cross sectional study. Al, Ameen J Med Sci 2012; 5(4) : 403-406. Bjerregaard B, Okoth- Olende,et al. Tumors of nose and maxillary sinus-10 years survey. J Layngol Otol 1992; 106:337.
15. Samaddar, R.R. nd Sen,M.K.(1990): Rhinosporodiosis in Bankura. Indian Journal of Pathology and Microbiology, 33:129. 16. Rosai and Ackermans Surgical pathology, Elsevier 9th edition, 2004 17. Sayed YE, Al-Serhani A. Lobular capillary hemangioma (pyogenic granuloma) of nose. J Laryngol Otol 1997;117 : 941. 18. Oberman, H.A. (1964): Papilloma of nose and paranasal sinuses. American Journal of Clinical Pathology, 42:245. 19. Panchal L, Vaideeswar p,et al. Sinonasal epithelial tumors: A pathological study of 69 cases. J Postgrad Med 2005;1(1):30-34. 20. TsaI TL, ho CY, Guo YC, et al. Fibrous ysplasia of the ethmoid sinus. J Chin Med Assoc 2003; 66:192. 21. Jayachandran S, Meenakshi R. Cementoossifying fibroma. Indian J Dent Res 2004;;15 :35-9. 22. Hasegawa SL, Mentzel T, Fletcher CDM. Schwannomas of the sinonasal tract and nasopharynx. Mod Pathol. 1997; 10: 777784. 23. Jussawalla, D.J., Sath, P.V., Yeole, B.D. and Natekar.M.V. (1984) : Cancer incidence in Aurangabad City. Indian Journal of Cancer.21-25. 24. Birt, B.D. (1930): Reticulum cell sarcoma of the nose and paranasal sinuses. Journal of Laryngology and otology 84: 615.
Table 1-Non-neoplastic lesions

Diagnosis Inflammatory polyp Fungal infection Mucormycosis Rhinosporodiosis Rhinoscleroma Non-specific inflammation Wegners granulomatosis No. 92 7 4 2 2 2 1 % 83.64 6.36 3.64 1.82 1.82 1.82 0.91 Male 60 4 4 1 2 1 1 Female 42 3 1 1 Age range in years (Average) 10-80 26-60 42-68 41-70 45-46 63-74
Seema K. Modh et al
Table 2-Neoplastic lesions

Diagnosis Benign Angiofibroma Hemangioma Squamous papilloma Inverted papilloma Fibrous dysplasia Cement-ossifying fibroma Neurilemmoma Plasmacytoma Malignant Squamous cell carcinoma Transitional cell carcinoma Adenocarcinoma Acinic cell carcinoma Chondrosarcoma Rhabdomyosarcoma Teratocarcinosarcoma Hemangiopericytoma No. 36 15 7 4 4 3 1 1 1 16 7 1 1 2 1 1 1 2 % 69.23 41.67 19.4 11.1 11.1 8.33 2.78 2.78 2.78 30.77 43.75 6.25 6.25 12.5 6.25 6.25 6.25 12.5 Male 15 3 3 3 1 4 1 1 1 1 2 Female 4 1 1 3 1 1 3 2 1 Age range in years (Average) 10-39 21-60 28-38 42-73 16-28 35 13 30 41-76 40 50 38-58 42 28 30 29-52
Angiofibroma Inflammatory polyp : Proliferation of tubular glands lined by ciliated, respiratory-type epithelium and goblet cells, without nuclear atypia. The stroma is edematous with inflammatory cells and eosinophils
Seema K. Modh et al
Mucormycosis. Hyphae are broad, often distorted and frequently appear twisted. Branching is rightangled (arrow) and septae are absent (PAS stain).
Non-keratinizing Squamous cell carcinomashowing many broad, interconnecting bands of neoplastic epithelium without keratinization characterizes this lesion and pleomorphic cells with loss of polarity and marked mitotic activity are present (H&E section)
Supriya Panda et al
INCIDENCE OF CANDIDIASIS AND TRICHOMONIASIS IN LEUCORRHOEA PATIENTS

IJCRR
Vol 05 issue 03
1
Supriya Panda1, P.Nagamanasa1, Sandhya Sri Panda2, T.V. Ramani1

Department of Microbiology, Maharajahs Institute of Medical Sciences Nellimarla, Vizianagaram, Andhra Pradesh, India 2 Department of OBG, Maharajahs Institute of Medical Sciences, Nellimarla, Vizianagaram, Andhra Pradesh, India E-mail of Corresponding Author: drsupriyapanda@gmail.com
Section: Healthcare Category: Research Received on: 05/12/12 Revised on: 23/12/12 Accepted on: 14/01/13
ABSTRACT Objective: Aim of the present study was to know the incidence of candidiasis and trichomoniasis in women of childbearing age complaining leucorrhoea. Methods: Vaginal swabs collected from each patient were processed immediately for hanging drop, wet mount and 10% KOH mount preparations; and gram stain. Culture was done on Sabourauds Dextrose Agar. Candida isolates were identified by germ tube test, chlamydospore formation, sugars fermentation and assimilation tests. Results: Out of 50 cases included in this study, 17 cases (34%) were negative for both Candida and T. vaginalis. T.vaginalis was present in 3 cases (6%) and Candida in 26 cases (52%). Mixed infection by both was present in 4 cases (8%). C.albicans was the commonest candida species (83%) causing leucorrhoea. Leucorrhoea was more common in 31-35 years old and who came from rural areas. Low back pain and pain in the lower abdomen was the most common associated clinical feature. Conclusion: Present study reveals that candidiasis and trichomniasis are the most common cause of leucorrhoea. Key words: leucorrhoea, Candida, T. vaginalis INTRODUCTION Leucorrhoea is the most common complaint among sexually active women of childbearing age in primary health care (1). Physiological leucorrhoea does not need medical intervention. However leucorrhoea with profuse quantity, foul smell, with changes in its colour or with blood seek immediate medical assistance. It is a symptom associated with many illnesses and having varied aetiology. It is difficult to treat because the signs and symptoms are not specific for any single underlying cause (2). Infection of vaginal mucosa by Trichomonas vaginalis and Candida is the most common cause of leucorrhoea .These are treatable as well as preventable causes as both these infections are transmitted sexually. Although 25 % of both the infections are asymptomatic (3, 4), chronic inflammation would be an anticipated progression to dysplasia if it remains unresolved (5, 6). There is an association between T.vaginalis and the risk of cervical neoplasia (7). Chronic trichomoniasis can cause complications like pelvic inflammatory disease and infertility. AIM The present study was undertaken to know the incidence of candidiasis and trichomoniasis in married, non-pregnant, nondiabetic women of childbearing age presenting with leucorrhoea in north coastal Andhra Pradesh. MATERIAL AND METHODS A prospective study of 62 consecutive married, non-pregnant women attending Out Patient Department (OPD) of Gynaecology in MIMS general hospital from June to August 2010 with complaint of leucorrhoea was done. Written consent was taken from them. All of them gave the history of their sexual partner as their spouse. Exclusion Criteria: age less than 16 years and more than 45 years, diabetes mellitus, sole
Supriya Panda et al
cervical erosion, cervical growth, endometrial and myometrial growth, unmarried and pregnant women. Specimen Collection: Cuscos speculum was introduced without lubricant. Vaginal discharge was collected in the posterior blade and was taken by 3 cotton swabs. These were transported and processed immediately. Processing: One swab collected in normal saline was used to prepare Hanging drop preparation immediately in the Gynaecology OPD. With the second swab direct wet mount, 10 % KOH mount and Gram stained smear were prepared. Sabourauds Dextrose Agar medium with gentamycin was inoculated with the third swab and incubated at 37 degree centigrade for 48 hrs. T.vaginalis was identified by its motility in hanging drop and wet mount preparations; in gram stained smear as gram negative, variable shape, with eccentric lenticular nucleus and foamy cytoplasm, slightly larger than a leucocyte(8). Candida isolates were subjected for species identification as Candida albicans by germ tube test, chlamydospore formation in cornmeal agar medium and growth at 42 degree C. Other Candida species were identified by sugars fermentation and sugars assimilation tests (9). RESULTS Out of 62 cases presented with leucorrhoea, 12 cases were excluded (sole cervical erosion=6, Cervical polyp=1, fibroid uterus=5) and 50 cases were included in the study. Clinical profiles included Age- 19 45 years, Weight- 40 57 Kgs , Rural background- 48 cases ( 96%), Urban background- 2 cases ( 4 %), Low back pain with low abdominal pain- 37 cases ( 74 % ), Pruritus vulvae- 30 cases (60 %), Foul smell discharge- 19 cases (38%), Burning micturation-14 cases ( 28%), Pallor- 7 cases (14%), Per speculum examination- curdy discharge with white flakes- 28 cases, strawberry mucosa- 3 cases Out of 50 patients, 17 cases (34 %) were negative for both Candida and T.vaginalis. Only T.vaginalis was present in 3 cases (6%) and only Candida in 26 cases (52%). Mixed infection by both was seen in 4 cases ( 8% ).Out of 30 cases of candidiasis, 23 cases (77%)were detected by gram stain, 28 cases(93%) by wet mount
preparation and 30 cases by culture(100%).All seven cases of trichomoniasis were detected by both wet mount preparation and gram stain. Candida albicans was the commonest species isolated accounting for 83 % of the isolates (25 out of 30). Follow up: Out of 50 patients, 24 patients were treated for candidiasis, 3 patients were treated for trichomoniasis and 4 patients for both. Partners were treated by the same regimen directly or indirectly through the clients. All of them were asked for a follow up after 7 days. Repeat test was done in 26 patients after 7-15 days. All of them were negative for both Candida and T.vaginalis. DISCUSSION In the present study highest incidence of leucorrhoea was seen in the age group of 31-35 years (34%) followed by 21-25years old (26%). N.Jindal et al from Amritsar has reported a consistent increase in the incidence of leucorrhoea from second to fourth decade of life. This could be because of sexual activity, which is at its peak during this age (10). Most of the women with leucorrhoea presented to Gynaecology OPD with low back pain and pain in the lower abdomen (74%) in our study. Pruritus vulvae was the second common clinical presentation (60%) followed by foul smelling discharge (38%) and burning micturation (28%) in the present study. In a study from Mumbai by Dr.Sampda Rajurkar,Seth G.S.Med. College & KEM hospital, most common symptom associated with leucorrhoea was Low back pain (71.4%) followed by foul smelling discharge (40.3%) and itching (35.3%) (11).Where as a study from Southern Iran had reported commonest clinical manifestation in leucorrhoea patients to be itching (57%) followed by local irritation (30%) and dysparaunea (24%) (12).Out of 50 samples tested, 17(34%) cases were negative for both Candida and T.vaginalis. Twenty six samples (52%) were positive for Candidiasis and 3 cases (6%) were positive for Trichomoniasis. Mixed infection by Candida and T.vaginalis was seen in 4 cases (8%) in our study. In a study from India by Poria VC et al., Candida accounted for 29.33% (by culture) and T.vaginalis accounted for 20%(by wet mount preparation) of leucorrhoea(13).Studies from
Supriya Panda et al
abroad also revealed similar incidence of Candidiasis in leucorrhoea patient. Abauleth R.et al from France had reported incidence of Candidiasis and trichomoniasis as 29.4% & 6.9% respectively (14). In a study of leucorrhoea in Tibetan community by Dai Q et al, the incidence of candidiasis and trichomoniasis was found to be 6.5% & 2.5% respectively (15). Low rate of incidence in their study is due to their decision to include both symptomatic and asymptomatic women. All the seven cases of Trichomoniasis were reported from women with rural background in our study, but Tanuja Chakraborty et al from Surat has reported higher incidence of Trichomoniasis in urban women than rural women (16).We could not detect any case of Trichomoniasis in urban women. This may be due to inclusion of few numbers of (only 6 number) cases from urban background in our study. T.vaginalis is the cause of acute vaginitis in 5-50% of cases, depending on the population studied (17). Out of 50 women with leucorrhoea, 49 of them gave the history of first occurrence where as only one had recurrent infection in the present study. This is in accordance with the finding that recurrent vulvovaginitis is rare & occurs only in less than 5% of the population (18). In our study, C.albicans was the commonest species isolated (83%), followed by C.tropicalis(7%)and C.guielliermondi(3.3%),C.krusei(3.3%),C.parap silosis(3.3%).Poria VC et al reported an isolation rate of C.albicans to be 56.8%. In their study, C.tropicalis is the most common non-albicans species accounting for 20.4% of the isolates (13).Whereas N.Jindal et.al reported C.glabarata as the most common non-albicans species (11%) in their study and C.albicans accounted for (74.4%) of the isolates (10). According to Linda French et al C.albicans accounts for 80-90% of patients with vulvovaginal candidiasis; and
Age in years 16-20 20-25 26-30 31-35 36-40 41-45 Total
among the non-albicans species, C.glabrata is the most common species reported (18). In the present study, mixed infection by both Candida and T.vaginalis was seen in 4 cases. Mixed infection is possible as both share a common route of transmission (sexually transmitted) and several pathogens may coexist (2). Although wet mount preparation is having a sensitivity ranging from 40-75%(18), in our study wet mount preparation was having a sensitivity of 93% and Gram stain was having a sensitivity of 77% for detection of Candida infection. CONCLUSION Leucorrhoea was commonly seen in women who came from rural areas. Prevalence of candidiasis (60%) was found to be much higher than trichomoniasis (14%). C.albicans contributed for 83% of candidiasis. Leucorrhoea was commonly seen in 31-35 years old. Low back pain and pain in the lower abdomen was the most common associated clinical features. ACKNOWLEDGEMENT We 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. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Table No. 1: Age distribution of patients with leucorrhoea.

No. of patients 2 13 6 17 6 6 50
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1. 2. 3. 4. 5. 6. 7. 8.
Table No. 2: Clinical features associated with leucorrhoea (n=50) Signs & symptoms No. of patients positive 37 Low back pain with pain in the lower abdomen 30 Itching (pruritus vulva) 19 Foul smelling vaginal discharge Burning and increased micturition 14 Leg or calf pain 9 Loss of weight 7 Pallor 7 Breathlessness 7
Table No. 3: Distribution of aetiological agents (n=50) Type of infection Candidiasis Trichomoniasis Both (candiiasis and Trichomoniasis) Total No. of Sample tested 50 50 50 No. of sample positive 26 3 4 % 52 6 8
Table No. 4: Distribution of pathogenic organisms according to area. S.NO 1 2 3 AREA URBAN RURAL TOTAL No. of patients 6 44 50 Only Candida 5 21 26 Only T.vaginalis 0 3 3 Both 0 4 4
S.No 1 2 3 4 5
Candida species C.albicans C.tropicalis
Table No. 5: Types of Candida Species No. isolated Percentage (%)

25 7 6 6 6 83 7 3.3 3.3 3.3
C.guilliermondii C.krusei C.parapsilosis
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Table No. 6: Percentage positive of Candida by different methods of detection. Gram stain Wet mount Culture No. of Cases Percentage 23 77% 28 93% 30 100%
REFERENCES 1. National Centre for Health Statistics. National Ambulatory Medicine Care Survey. Available at www.cdc.com/nchs/about/major/ahcd/ahcd1 .htm 2. Schaaf VM, Perez-Stable EJ, Borchardt K. The limited value of symptoms and signs in the diagnosis of vaginal infections. Arch Intern Med.1990;150:1929-1933 3. D.C.Dutta. Text Book of Gynaecology.5th Edition, 2009. NCBA Publication. 4. Howkins and Bourne Shaws Text Book of Gynaecology.15th Edition.2011.Elsevier Publication. 5. Balkwill F and Mantovani A. Inflammation and cancer: back to Virchow? Lancet 2001; 357: 539-546. 6. Lisa M Coussens and Zena Werb. Inflammation and cancer. Nature 2002; 420: 860-867. 7. Zuo- Feng Zhang and Colin B Begg. Is Trichomonas vaginalis a cause of cervical neoplasia? Results from a combined analysis of 24 studies. International Journal of Epidemiology 1994; 23(4):682-690. 8. G.Ewart Cree. Brit J Vener Dis.1968;44:226 9. Jagdish Chander. Text Book of Mycology.3r edition. January 2009, Mehta Publisher. 10. N.Jindal, P.Gill, A.Aggrawal. An epidemiological study of volvovaginal candidisis in women of childbearing age.Indian J Med Microbbiology.2007; 25: 75-176. 11. Dr.Sampda Rajurkar. Seth G S Medical College and KEM Hospital, Mumbai.2010. Available at www.authorstream.com/RSS/category/Educ ation
12. Ghotbi Sh, Beheshti M, Amirizade S. Causes of leucorrhoea in Fasa, Southern Iran. Shiraz E-Medical Journal. Vol 8, No.2. April 2007. 13. Poria VC, Joshi BK, Agrawal HH, Mohile NA. Study of Candida and Trichomonas vaginalis in Leucorrhoea. J Indian Med Assoc.1989 Aug; 87(8):184-185. 14. Abauleth R, Boni S, Kouassi-Mbengue A, Konan J, Deza S. Causation and treatment of infectious leucorrhoea at the Cocody University Hospital. Sante 2006 Jul-Sep; 16(3):191-195. 15. Dai Q, Hu L, Jiang Y et al. An epidemiological survey of bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis in the Tibetan area of Sichuan Province, China. Eur J Obstet Gynecol Reprod Biol. 2010 Jun; 150(2):207209. 16. Tanuja Chakraborty, SA Mulla, JK Kosambiya, Vikas K Desai. Prevalence of Trichomonas vaginalis infection in and around Surat. Indian J Pathology and Microbiology 2005; 48(4):542-545. 17. Linda O, Eckert MD. Acute vulvovaginitis. The New England J of Medicine.2006; 355: 1244-1252. 18. Linda French, Jennifer Horton, Michelle Matousek. Abnormal vaginal discharge: Using office diagnostic testing more effectively.The Journal of Family Practice. Oct 2004. Vol 53, No 10:805-814.
Vidya C.S. et al
EVALUATION OF SIZE AND VOLUME OF MAXILLARY SINUS TO DETERMINE GENDER BY 3D COMPUTERIZED TOMOGRAPHY SCAN METHOD USING DRY SKULLS OF SOUTH INDIAN ORIGIN
IJCRR
EVALUATION OF SIZE AND VOLUME OF MAXILLARY SINUS TO DETERMINE GENDER BY 3D COMPUTERIZED TOMOGRAPHY SCAN METHOD USING DRY SKULLS OF SOUTH INDIAN ORIGIN Vidya C.S.1, N.M. Shamasundar1, Manjunatha B.1, Keshav Raichurkar2
1
Department of Forensic Medicine, JSS Medical College, JSS University Mysore, KA, India 2 Chief Radiologist, Vikram Hospital Mysore, KA, India E-mail of Corresponding Author: vidyasatish78@rediffmail.com
ABSTRACT In the field of forensic medicine, normally the available materials after sufficiently long period of death will be utilized to determine various body characteristics such as age sex etc for identification of individual.Identification of corpses is a difficult forensic procedure and it is mandated by laws and social rules. Comparison of ante mortem and post mortem medical records, such as dental documents, plays an important role in the identification of corpses. Gender has long been determined from the skull, the pelvis and the long bones with an epiphysis and metaphysic in unknown skeletonsaccording to krogmann. The methods such as 3D CT scan have been utilized to determine the gender. Objective: The aim of the present study is to evaluate size and volume of maxillary sinus to determine gender by 3D CT Scan method. This work is of National importance in identifying the sex of a person in the forensic medicine and also for criminal investigations. Method: The skulls of known sex were obtained from recently buried bodies. Initially skulls were scanned by 3D Multiaxial CT scan and dimensions and volume of maxillary sinuses were observed by using dedicated software. Results: The preliminary analysis of data discriminative by CT method has been tabulated. The volume of the maxillary sinuses of both sides was significantly greater in males compared to female skulls. The p value of left width and right sided volume of maxillary sinuses 0.015 and 0.021 respectively were considered statistically significant. Computerized tomography measurements of maxillary sinuses may be useful to support gender determination in forensic medicine. INTRODUCTION Forensic pathologists may be asked to identify the ethnic group and gender of a cranium of unknown origin. [1] Forensic personal identification is a fundamental topic of forensic sciences and technologies to identify live subjects, recently deceased bodies and human remains often at a crime scene by using several appropriate techniques. It has been reported that computerized tomography is a suitable imaging method in the identification of unknown human remains and presents a lot of advantages as compared with conventional radiographs. [2] The volumes of maxillary sinuses are of interest to surgeons operating endoscopically as variation in maxillary sinus volume. Other surgical disciplines, such as dentistry, maxillafacial surgery may benefit from this information.[3] This research was extended to predict the gender from an unknown cranium which will be applicable in the fields of forensic anthropology. The aim of the present study is to
Vidya C.S. et al
evaluate size and volume of maxillary sinus to determine gender by 3D CT Scan method. MATERIAL AND METHOD The skulls of known sex were procured from the department of anatomy for the study. A sample size for the complete project was 80 skulls and at present 30 skulls were studied. Macerated skulls were taken, cleaned thoroughly and subjected for 3D axial multislider, Siemens sensation cardiac 16 slice CT scan at Vikram hospital Mysore. Images were obtained with slice collimation of 1mm thickness. Axial and coronal images with slice thickness of 4mm were obtained for measurements of height, AP length and width of maxillary sinuses of both sides by using dedicated software (images 1,2). Volume of maxillary air sinuses of both sides were automatically estimated using syngovolume Siemens, by area length method using freehand interactive drawing of area in each axial sections.( image 3). Statistical Analysis Statistical analysis was performed with Systat 13 package. Mean and SD to assess the level of the parameters in males and females were determined. Independent sample t test. Differences with a p value, p < 0.05 were considered significant. RESULTS The preliminary analysis of data discriminative by CT and plastination method have been tabulated.The discriminative analysis will be done when 80 skulls are studied. The dimensions and volume of maxillary air sinuses are shown in Table 1. The volume of the maxillary sinuses of both sides was significantly greater in males compared to female skulls. The p value of left width with and right sided volume of maxillary sinuses 0.015 and 0.021 respectively were considered statistically significant.
DISCUSSION In the present study, all the mesurements and volume of maxillary sinuses of both sides was significantly greater in male skulls compared to female skulls. By the above observations, analysis made by CT scan method, left width and right sided volume showed statistically significant values. Teke HY and others in 2006 studied width, length and the height of the maxillary sinus in 127 adult patients by CT. the discriminative analysis showed that the accuracy of maxillary sinus measurements- ie , the ability to identify gender was 69.4% in females and 69.2% in males.[4] Amusa YB et al in 2011 studied 24 dried skulls of Nigerians. The height, width , depth and volume of each of the sinuses were determined. In all the paranasal sinuses, the right side was found to be larger than the left except for the maxillary sinus whee the left side was found to be larger. The average volume on the right was 11.59 + 5.36 cc and 14.98+10.77cc on the left. [5] It has been reported that maxillary sinuses remain intact although the skull and other bones may be badly disfigured in victims who are incinerated and, therefore, that maxillary sinuses can be used for identification.[6] Uthman A.T in 2011 studied maxillary sinus dimensions in 88 patterns between age group of 20-49 yrs by CT scan. The width, length and height of the maxillary sinuses in addition to the total disrtance across both sinuses were measured. Data were subjected to discriminant analysis for gender using multiple regression analysis. Maxillary sinus height was the best parameter that could be used to study sexual dimorphism with an overall accuracy of 71.6% . using multivariate analysis 74.4% of male sinus and 73.3% of female sinus were sexed correctly.[7] Johnson PS and others studied dimensions of 120 maxillary and frontal sinuses from head CT
Vidya C.S. et al
images. The mean value of the maxillary sinus volume was 15.7+ 5.3 cm3 and significantly larger in males than in females. There was no statistically significant correlation between the volume of maxillary sinuses with age or side. [8] Kim HJ et al studied 33 hemisectioned Korean CT images. From the three-dimensional reconstructed images of the maxillary sinus, six categories of maxillary sinus were created, categorized according to their lateral aspects and shapes of the inferior walls. All measures antpost length, height, width and volume of the sinus were larger in males than in females. The maximum a-p length of sinus was 39.3+ 4.2 mm (male - 40.7 mm , female 37.4 mm) its maximum height was 37.1+ 5.6 mm and max width was 32.6+ 65 mm. the average volume of the sinuses was 15.1+ 6.2ml.[9] In the present study, the measurements and volume of maxillary sinus of males were slightly more compared with females. CONCLUSION Gender determination is an important step in identification in forensic medicine. Computerized tomography is a significant advance in radiology and it is becoming increasingly available and replacing gradually the conventional radiographs. It gives the opportunity of avoiding the superimposition of structures beyond the plane of interest and allowing the visualization of small differences of density. Craniometric points can be precisely located and measurements can be more accurately performed than on conventional radiographs. This research work is of national importance in identifying the sex of a person in forensic anthropology and also for criminal investigations. ACKNOWLEDGEMENTS I sincerely thank the support of my institution and ICMR funding for my research work. Ialso
thank all the IJCRR reviewers and editorial board members. REFERENCES 1. Fernandes CL. Forensic ethnic identification of crania : the role of the maxillary sinus a new approach . American journal of forensic medicine and pathology: Dec 2004; vol 25(4) : 302-313. 2. Tatlisumak E, Asirdizer M and Yavuz MS . Theory and applications of CT imaging and analysis. Usability of CT images of frontal sinus in forensic personal identification. In Tech. 2011; 257-267. 3. Fernandes CL. Volumetric analysis of maxillary sinuses of zulu and European crania by helical, multislice Computed tomography. J laryngol otol. 2004; 118(11) : 877-81. 4. Teke HY, Duran S, Canturk N and Canturk G. determination of gender by measuring the size of the maxillary sinuses of computerized tomography scans. Surg radiol anat. 2007; 29: 9-13. 5. Amusa YB and etal. Volumetric measurements and anatomical variants of paranasal sinuses of Africans (Nigerians) using dry crania. International journal of medicine and medical sciences. 2011; vol 3 (10): 299-303. 6. Lerno P. Identification par le sinus maxillaire. Odontol leg.1983; 216: 39-40. 7. Uthman AT, Al-Rawi NH, Al- Naaimi AS and Al- Timimi JF. Evaluation of maxillary sinus dimensions in gender determination using helical CT scanning. Journal of forensic sciences. 2011; vol 56(2) : 403-408. 8. Sahlstrand-Johnson et al . Computed tomography measurements of different dimensions of maxillary and frontal sinuses. BMC Medical Imaging. 2011; 11:1-8. 9. Kim HJ. Personal- computer-based three dimensional reconstructions and simulation
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of maxillary sinus. Surg Radiol Anat.2002; 24: 393-399. Table 1 Shows Female: Male Distribution of the mean Value, SD and P Value of Maxillary Sinus Parameters by CT Scan Method
FEMALES (N=12) PARAMETERS MEAN SD Left height 3.025 0.407 Left A-P 3.158 0.375 1.975 0.331 Left width Left volume 10.908 3.31 Right height 2.825 0.367 Right A-P 2.858 0.345 Right width 1.883 0.307 9.733 3.389 Right volume MALES (18) MEAN SD 3.106 0.560 3.278 0.444 2.372 0.510 13.5 6.513 3.022 0.545 3.100 0.499 2.194 0.556 13.606 5.247 P value 0.652 0.435 0.015 0.171 0.246 0.128 0.059 0.021
Image 1 : Shows measurements , width and anteroposterior length of maxillary sinus
Image 2 : Axial Section , Measuring Height of Maxillary Sinus
Image 3 : Estimation of volume by area length method of each slices
Vidyadevi Kendre et al
MEIER-GORLIN SYNDROME A VERY RARE CONGENITAL MALFORMATION
MEIER-GORLIN SYNDROMEMALFORMATION IJCRR

Vol 05 issue 03 Section: Healthcare Category: Case Report Received on: 27/12/12 Revised on: 18/01/13 Accepted on: 13/02/13
VERY
RARE
CONGENITAL
Vidyadevi Kendre, Shital Bhattad

Dept of Pediatrics, MIMSR Medical College, Latur, MH, India E-mail of Corresponding Author: vidyakendre@rediffmail.com
ABSTRACT The Meier-Gorlin syndrome or ear, patella, short stature syndrome (MIM 224690) is a rare autosomal recessive disorder. It is characterized by severe intrauterine and postnatal growth retardation, microcephaly, bilateral microtia, and aplasia or hypoplasia of the patella. Despite the presence of microcephaly, intellect is usually normal (1). This case study discusses a case on Meier-Gorlin Syndrom. INTRODUCTION The Meier-Gorlin syndrome is a rare autosomal recessive disorder.it was first described by Meier and Rothschild (2) and the second case reported by Gorlin et al.1975 (3) so named after the two. While almost all cases have primordial dwarfism with substantial prenatal and postnatal growth retardation, not all cases have microcephaly, and microtia and absent/hypoplastic patella.(4) CASE REPORT A newborn born by nonconsanguineous marriage to phenotypically normal parents, He was born normally at 37-week gestation and weighed 2.1 kg, small for his gestational age, antenatal history was not significant. On examination, He had microtia and microcephaly with his head circumference of 30 cm and length being 46 cm at birth, metopic sutural prominence and hyper extensibility of joints with typical nose, which is more prominent and narrow, with a convex in profile view. On day 4th of life he had systolic murmur but no signs of congestive cardiac failure. No cyanosis and spo2 was maintained and other systems were within normal limits. Routine blood investigations were normal. 2 D ECHO showed, small VSD.
DISCUSSION The Meier-Gorlin syndrome is a rare autosomal recessive disorder.it was first described by Meier and Rothschild and the second case reported by Gorlin et al.1975 so named after the two. Cohen et al. (1991) (5)used the designation ear, patella, short stature syndrome (EPS) for a condition they observed in 2 sisters who had bilateral microtia, absent patella short stature, poor weight gain, and characteristic facial features. Other skeletal anomalies included complete habitual dislocation of the elbow, slender ribs and long bones, abnormal modeling of the glenoid fossas with hooked clavicles, and clinodactyly. Bone age was significantly delayed and there was flattening of the epiphyses. Hurst et al. (1988) (6)found 2 males with similar characteristics. Few studies have documented variable results of endocrine work-up, including growth hormone assays. Loeys et al. [1999](7) reported two brothers with MGS, delayed bone age, one of whom was subjected to glucagon stimulation test with subnormal GH and borderline Somatomedin C.Bongers et al. (2001) (8) reported 6 female and 2 male patients from 7 families with Meier-Gorlin syndrome and reviewed the literature on this condition. Most of their patients had bilateral small ears, patellar aplasia/hypoplasia, and short stature, except for monozygotic twins who had normal patella on physical examination. Radiographic studies of the patellae were recommended in patients with this condition to understand the patellar abnormality better. Guernsey et al 2011(9) had done genetic work up of 45 idividuals with MGS and found mutations in five genes from the pre-replication complex (ORC1, ORC4, ORC6, CDT1, and CDC6), crucial in cell-cycle progression and growth. In our case, physical characteristics like microotia, typical nose, microcephaly and IUGR are present. Which is reported in many cases
(10). But we got VSD in addition to typical features. REFERENCES 1. Bicknell, L. S., Bongers, E. M. H. F., Leitch, A., Brown, S., Schoots, J., Harley, M. E., Aftimos, S., Al-Aama, J. Y., Bober, M., Brown, P. A. J., Van Bokhoven, H., Dean, J., and 15 others. Mutations in the pre-replication complex cause Meier-Gorlin syndrome. Nature Genet. 43: 356-359, 2011. 2. Meier, Z., Rothschild, M. Ein Fall von Arthrogryposis multiplex congenita kombiniert mit Dysostosis mandibulofacialis (Franceschetti-Syndrom). Helv. Paediat. Acta 14: 213-216, 1959. 3. Gorlin, R. J., Cervenka, J., Moller, K., Horrobin, M., Witkop, C. J., Jr. Malformation syndromes: a selected miscellany. Birth Defects Orig. Art. Ser. 11: 39-50, 1975. 4. Shalev, S. A., Hall, J. G. Another adult with Meier-Gorlin syndrome - insights into the natural history. Clin. Dysmorph. 12: 167169, 2003. Cohen, B., Temple, I. K., Symons, J. C., Hall, C. M., Shaw, D. G., Bhamra, M., Jackson, A. M., Pembrey, M. E. Microtia and short stature: a new syndrome. J. Med. Genet. 28: 786-790, 1991. Hurst, J. A., Winter, R. M., Baraitser, M. Distinctive syndrome of short stature, craniosynostosis, skeletal changes and malformed ears. Am. J. Med. Genet. 29: 107-115, 1988. Loeys, B. L., Lemmerling, M. M., Van Mol, C. E., Leroy, J. G. The Meier-Gorlin syndrome, or ear-patella-short stature syndrome, in sibs. Am. J. Med. Genet. 84: 61-67, 1999. Bongers, E. M. H. F., van Kampen, A., van Bokhoven, H., Knoers, N. V. A. M. Human syndromes with congenital patellar
5.
6.
7.
8.
9.
anomalies and the underlying gene defects. Clin. Genet. 68: 302-319, 2005. Guernsey, D. L., Matsuoka, M., Jiang, H., Evans, S., Macgillivray, C., Nightingale, M., Perry, S., Ferguson, M., LeBlanc, M., Paquette, J., Patry, L., Rideout, A. L., and 11 others. Mutations in origin recognition complex gene ORC4 cause Meier-Gorlin syndrome. Nature Genet. 43: 360-364, 2011.
10. Terhal PA, Ausems MG, Van Bever Y, Ten Kate LP, Dijkstra PF, Kuijpers GMC. 2000. Breast hypoplasia and disproportionate short stature in the Ear-Patella-Short Stature Syndrome: Expansion of the phenotype? J Med Genet 37:719721.
C.P. Ganesh Babu et al
PYOGENIC LIVER ABSCESS - CLINICAL, RADIOLOGICAL CHARECTERISTIC AND MANAGEMENT STRATEGIES
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IJCRR
PYOGENIC LIVER ABSCESS - CLINICAL, RADIOLOGICAL AND BACTERIOLOGICAL CHARECTERISTIC AND MANAGEMENT STRATEGIES
C.P. Ganesh Babu1, R. Kalaivani2
1
Dept. of General Surgery, Mahatma Gandhi Medical college And Research Institute, Pondicherry, India 2 Dept of Microbiology, Mahatma Gandhi Medical college And Research Institute, Pondicherry, India E-mail of Corresponding Author: ganeshvanicp@yahoo.co.in
ABSTRACT Pyogenic liver abscess is one of the most common clinical condition seen in private set up. 100 patients with pyogenic liver abscess were managed at department of general surgery, MAPIMS between may 2006 to October 2009. The investigations conducted were abdominal ultrasound, chest x ray, complete blood count, liver function tests and hem agglutination tests. Depending on the size of the abscess the patients were managed by parental antibiotics and percutaneous needle aspiration or surgery. Results : pyogenic liver abscess common in males and seen in right lobe. 20% were multiple. percutaneous needle aspiration with parental antibiotics is the most successful therapy. Keywords: pyogenic liver abscess, needle aspiration. INTRODUCTION Pyogenic liver abscess is a condition with significant morbidity and mortality. The most common presenting clinical symptoms are upper abdominal pain, tenderness, hepatomegaly, high grade fever, nausea, and vomiting. These features are variable depending on the size of the abscess, general health of the patients, associated diseases and complications. In majority of cases, underlying cause could not be identified. It may be because of bacterial or parasitic invasion of liver . Majority of abscess are solitary and sub- diaphragmatic and noted in the right lobe of liver. For the last two decade , the advances in the imaging field coupled with ultrasound guided percutaneous needle aspiration and drainage brought dramatic changes in the pattern of treatment of liver abscess.. The aim of our study was to determine the clinical, radiological and bacteriological characteristic of the condition. MATERIALS AND METHODS 100 patients with pyogenic liver abscess were managed in the department of surgery in MAPIMS from may 2006 to October 2009. All the patients were sent to radiology department for the confirmation of diagnosis on ultrasound, chest x ray was also performed. Ultrasound guided percutaneous needle aspiration and drainage was performed in the radiology department. Other investigations include complete blood count, liver function tests, heamagglutination tests.(Table 3). Abscess smaller than 5cm were managed by parental antibiotics therapy while larger than 5cm were planned to be
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managed by ultrasound guided percutaneous aspiration. RESULTS In our institution 85 out of 100 (85%) were males and 15 out of 100 (15%) were females, male: female ratio is 6:1. The patients age was ranging from 20 80 years. Mean age 50 years.5 Majority of patients (75%) with pyogenic liver abscess presented with upper abdominal pain , high grade fever was noted in 62%, hepatomegaly plus tenderness (20%) patients, jaundice in 12%, loss of appetite in 12%, nausea and vomiting was complaint in 5% of patients. (Table 2) 8. Eighty five patients were diagnosed accurately on ultrasound with characteristic of lesion which plays central role for quick diagnosis. Intravenous antibiotic therapy ( cephalosporin combination with metronidazole and aminoglycosides) started to all patients. 52 patients improved completely by this regime. These patients were having a single abscess less than 5cms size. 28 patients having single abscess larger than 5cm were managed with antibiotic regime and percutaneous needle aspiration.4 . 20 patients having very large abscesses (10cm) were planned to be managed by antibiotic with catheter drainage. 15 patients got improved by this mode of management. Two patients planned for open surgery. 3 patients died, one due to septicemia, 2 because of organ failure. Blood cultures of 100 patients confirmed the presence of Escherichia coli in 36% while microbiological report of abscess aspirates of 63 patients confirm Escherichia coli.(Table 4). Other laboratory tests confirmed as Hb <10 g/dl in 25 patients, WBC count > 11000 in 75 cases, bilirubin > 3mg in 15 cases, alkaline phosphatase > 150iu/L in 50 cases (Table 3).
DISCUSSION In our study the most significant clinical feature of pyogenic liver abscess was upper abdominal pain with high grade fever, hepatomegaly and jaundice as reported by others. Patients with pyogenic liver abscess need rapid diagnosis. Advances in the imaging modalities like ultrasound and CT scan made a quick and early diagnosis possible. Abdominal ultrasound is diagnostic and always play a central role in diagnosis. Because of ultrasound the mortality of liver abscess has reduced from 30% to 10 to 20%. These improvement are due to improved imaging and effective antimicrobial therapy. In our study the diagnostic rate of ultrasound is 85%. Percutaneous aspiration in combination with systemic antibiotics should be considered as first line treatment. 28 patients with >5cm size abscess were managed by aspiration and antibiotics. Twenty patients with >10cms were managed by catheter. Failure of catheter drainage in our study is 5%... open surgery was planned. These patients were inaccessible to radiological intervention as they were multiple and large. 2 patients planned for surgery and 3 died because of sepsis. Literatures suggest that diabetic patients have increased risk. In our study 12 patients were diabetic and they were not responding well to antibiotic and stay longer. Escherichia coli was the most common pathogen isolated from aspirates/ blood of our patients. However, klebsiella, streptococcus, and enterococcus are also blamed.10). The underlying causes cannot not be made out. Literatures suggest most are cryptogenic. Only 12% of cases in our study were noted with complaint of acute/ chronic features of cholangitis .9).
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CONCLUSION Patients with pyogenic liver abscess tend to be at high risk of morbidity especially elderly and diabetic. An early and accurate diagnosis coupled with aspiration/ drainage results in dramatic changes in prognosis. A high index of suspicion , rapid diagnosis and early administration of antibiotics with radiological interventions is an effective management strategy. REFERENCES 1. Oschner A, Debaker M, Murray S. pyogenic abscess of liver. An analysis of forty-seven cases with of literature . Am j; Surg 1938; 40; 292-319. 2. Mehnaz A, Mohsin S. liver abscess in children not an uncommon problem JPMA 1991; 273- 275. 3. Balci NC, Semelka RC, Noone TC, et al. pyogenic hepatic abscess MRI findings on T-1 and T2 weighted and serial gadolinium enhanced gradient echo images. J of MRI 1999; 9; 285- 90. 4. Chyus, HG Lor, Kan PS, Metroweli C. pyogenic liver abscess treatment with
needle aspiration clinical radiol 1997 ; 52; 912- 6 5. Smoger SH, Mitchel CK, AcClave SA. Pyogenic liver abscess; a comparison of older and younger patients. Age and aging 1998; 27: 443- 8. 6. Stalin SC, Yelin AK , Donovan AJ, et al, pyogenic liver abscess; modern treatment. Arch Surg 1991; 126: 991- 6. 7. Karatassas A, Williams JA. Review of the royal Adelaide hospital 1980 -1987. Aust NZ Jsurg 1990; 60: 893 -7. 8. Chiru CT, Lin DY, Wu CS, et al. A clinical study of pyogenic liver abscess. J formes. Med assoc 1990; 86: 571- 576. 9. Lee KT, sheen PC, Chen JS, et al. pyogenic liver abscess - multivariate analysis of risk factors. World J Surg 1991; 15: 372 -7. 10. Gazi B, zibari, pyogenic liver abscess. Surgical infection 2000; 1; 15 - 21.
Table 1: Age distribution of patients with pyogenic liver abscess

AGE 20 31 41 51 61 71 IN YEARS 30 40 50 60 70 80 NUMBER OF PATIENTS 8 10 12 22 26 22 PERCENTAGE 8% 10% 12% 22% 26% 22%
Table 2: Clinical features of pyogenic liver abscess

PRESENTING FEATURES Upper abdominal pain High grade fever hepatomegaly jaundice Loss of appetite Nausea & vomiting NUMBER OF PATIENTS 75 62 20 12 12 5 PERCENTAGE 75% 62% 20% 12% 12% 5%
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Table 3: LAB FINDINGS

Lab findings Hemoglobin < 10g/dl WBC > 11000/dl Bilirubin> 3mg Alkaline phosphatase >150iu/l ALT> 30IU/l Number of patients 25 75 15 50 30 percentage 25% 75% 15% 50% 30%
MICROORGANISMS ISOLATED (Table 4)

MICROORGANISMS E.coli
PERCENTAGE 63% 15% 08% 06% 05% 03%
K.pneumonia Pseudomonas sp. Stap.aureus/ S.epidermis Bacteriods Anearobic strepto

IJCRR Vol 5 Issue 03 Healthcare

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ISSN: 2231-2196 (Print) ISSN: 0975-5241 (Online) Internationally Indexed, Peer Reviewed, Multidisciplinary Scientific Journal ICV: 4.

International Journal of Current Research and Review

Shashidhar Basagoudar, Chandrashekhar R.

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Table 1: Table showing the Socio-demographic profile of the study Women

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NS- not significant

* Fisher exact test

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Table 1: Clinical data of study group

Table 2: Means and standard deviation of endometrial thickness and BMI

t1= 1.03 t2=3.69 t3=10.1

>0.05 <0.05 <0.001

55-60 (n=174) 60-65 (n=126)

4.94 + 0.9 4.55 + 1.01

Table 5: Correlation coefficient, r, between Endometrial thickness and Age

Endometrial thickness Age

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4.96 + 1.02 4.56 + 1

83.3 8.33 8.33

5.85+0.75 6.8 7.3

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E-mail of Corresponding Author: dranandmdfm@gmail.com

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Total death 71 41 18 10 05 05 09 159

Percentage 44.6 25.7 11.3 06.2 03.1 03.1 05.6 100.0

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Total Death 51 10 03 03 01 02 01 18 12 02 03 01 01 02 02 04 03 02 03 02 01 01 01 01 02 02 04 02 01 01 03 02 01 01 01 05 01 01 01 01 159

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Table:-1 Trends in voluntary and Replacement Blood Donation

Table:-2 Comparison of seropositivity between voluntary and replacement donors

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NURSING STUDENTS APPROACHES TO LEARNING AND STUDYING: STUDY IN AN INDIAN SETTING

Juliana Linnette DSa

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NURSING STUDENTS APPROACHES TO LEARNING AND STUDYING: STUDY IN AN INDIAN SETTING

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NURSING STUDENTS APPROACHES TO LEARNING AND STUDYING: STUDY IN AN INDIAN SETTING

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NURSING STUDENTS APPROACHES TO LEARNING AND STUDYING: STUDY IN AN INDIAN SETTING

be the predominant learning approach among undergraduate nursing students.

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NURSING STUDENTS APPROACHES TO LEARNING AND STUDYING: STUDY IN AN INDIAN SETTING

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NURSING STUDENTS APPROACHES TO LEARNING AND STUDYING: STUDY IN AN INDIAN SETTING

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NURSING STUDENTS APPROACHES TO LEARNING AND STUDYING: STUDY IN AN INDIAN SETTING

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