AABS 3.3 (2016) by PaGe

eISSN: 2349-6991 pISSN: 2455-0396

Annals of Applied BioSciences An International, Open access, Indexed, Peer-reviewed Journal

Vol. 3, Issue 3, July-September 2016

DOI : 10.21276/aabs

Pacific Group of eJournals

Editor-in-Chief Dr Shelly Sehgal Dr Dipti Agrawal

Annals of Applied Bio-Sciences Co-Editor in Chief

Professor & Dean, School of Environment and Sustainable Development, Central University Gujarat, India Dr Igor Iuco Castro-Silva Professor, Clinica Odontologica, Faculdade de Ciencias do Tocantins, Brazil Kapil Agarwal Engineer, Nagoya City, Aichi, Japan Dr Devesh Palharya Consultant Pathologist, Bhopal, Madhya Pradesh, India Dr D A Bhiwgade Dept. of Biotechnology & Bioinformatics, Padmashree Dr. D. Y. Patil University, Navi Mumbai, India Dr Arpana Haritwal Consultant, Obs. & Gynaecology, Saket City Hospital, New Delhi, India Dr Radhika P Kamdar Emory University School of Medicine, Georgia, United States Dr Saba Hasan Asst. Prof. Amity University, Lucknow, Uttar Pradesh, India Dr Manav Kapoor Assistant Professor Neuroscience, Icahn School of Medicine, Mount Sinai, New York, NY, 10029, United States

Dr Shelly Sehgal Specialist Pathologist, Department of Pathology, SDN Hospital, Delhi, India Dr Dipti Agrawal Department of Gynecology and Obstetrics, SDN Hospital, Delhi, India

Co-Editor in Chief

Dr Sompal Singh Specialist Pathologist, Dept. of Pathology, N D M C Medical College & Hindu Rao Hospital, Delhi, India Dr Bhupendra Pushkar Asst. Professor, Dept. of Biotechnology, University of Mumbai, India

Associate Editors

Dr Vijayabhaskar Varadarajalu Chennai, Tamil Nadu, India Dr B K Guha Associate Professor (Anatomy), NSCB Medical College, Jabalpur, Madhya Pradesh, India Dr Hariom Gupta Associate Professor, SSMC and SGMH, Rewa, Madhya Pradesh, India Dr Shashikant Agarwal Associate Prof. JMC, Jhalawar, Rajastjhan, India

Managing Editor

Dr Prashant Goyal Director-Laboratory, Accuprobe Healthcare and Diagnostics, Delhi, India

Editorial Board

Dr Francesco Merolla Advanced Biomedical Sciences, University of Naples, Federico II, Italy Dr Chandrassegar Saravanan Novartis Institutes for Biomedical Research, Technology Square, Cambridge, MA, United States Dr Nandhakumar Balakrishnan College of Veterinary Medicine, North Carolina State University, Raleigh, United States Prof. M H Fulekar

Published by: Pacific Group of e-Journals (PaGe) Kotla Market, Mayur Vihar, New Delhi (India) Website: www.pacificejournals.com www.pacificejournals.com/aabs E-mail: contactus.aabs@pacificejournals.com

Annals of Applied Bio-Sciences Annals of Applied Bio-Sciences (AABS) is an international, fast double-blind peer-reviewed, indexed, open access, online and print multidisciplinary journal with high impact factor (2.9254) and IC value (56.90), published by ‘Pacific group of e-Journals’ (PaGe), an ISO 9001:2008 Certified academic publishing house, with a quick post-acceptance online publication.

Disclaimer 1.

AABS is a multidisciplinary journal in the all fields of sciences including Medicine(Anatomy, Anesthesia, Cardiology, Community Medicine, Dermatology, Internal Medicine, Neonatology, Oncology, Orthopedics, Pediatrics, Physiology, Plastic Surgery, Psychiatry, Radiology, Surgery, ENT, Nutrition, Anatomy, Forensic , Genetics, Obstetrics And Gynecology, Ophthalmology, Pediatric Surgery, Nephrology, Urology, Neurology etc.) and Dentistry, Nursing and Health Professions, Biological sciences, Biotechnology, Molecular biology, Cell biology, Genetic engineering, Biochemistry, Pharmacology, Pharmaceutical Science, Toxicology, Immunology, Microbiology, Virology, Veterinary Medicine, Veterinary Science, Agricultural, Environmental science, Ecology and Ecotoxicology, Biophysics, Biomedical sciences, Computational biology, Biological anthropology and Biological education etc.

Publication Frequency

Quarterly with continuous publication. Articles are published online in the current volume of the Journal as soon as they are accepted. However, the issue is published in printed form only at the end of the relevant quarter.

•

Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work’s authorship and initial publication in this journal.

Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal’s published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.

Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.

3. 4.

Thoughts, Language and examples in published research papers are entirely of Authors of Research Papers. It is not necessary that both Editor and Editorial Board are satisfied by the research paper. The responsibility of the matter of the research paper/ article is entirely of author. Scientific knowledge is ever changing. As new research and experiences broaden our knowledge, old concepts may be required to be looked into afresh. The Authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error by the authors, editors, or publisher, nor any other who has been involved in the preparation of the work warrants that the information contained herein in every aspect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are advised to confirm the information contained herein with other sources. In any condition and due to any reason, if any Educational/Research Institution (College or University) denies accepting the research paper published in AABS, it will not be the responsibility of the Editor, Publisher or the Management. Only the First author is entitled to receive the print copies of all co-authors.

All the legal disputes related to PaGe are subject to Delhi Jurisdiction only

Table of Contents Review Articles The Antifibrotic Role of Relaxin

R17-R22

Geeta Tripathi, Swati Gupta

Original Article Impact of Pediatric Emergency Team (PET) on PICU Transfers from Wards and

Case Reports

Overall Mortality Sunit Pathak, Gaurav Khandelwal, Rhythm Khera, Meenakshi Pathak Determination of Decayed, Missing and Filled Teeth (DMFT) index in the 12 years old Children of Hadishahr Province from Iran Farrokh Farhadi, Hossein Falsafi Miab, Ali Zarandi Evaluation of the Environmental Situation at Public Areas of Tirana by using Stray Dogs as Biomonitor Violeta Zanaj, DhimitĂŤr Rrapti Histomorphological Spectrum of Skin Adnexal Tumours : A Retrospective Study in a Tertiary Care Centre G Jeyanthi, Meenakumari Gopalakrishnan, N. Sharmila Thilagavathy, S. Shifa, K Kamaleshwari Study of Haematological Profile of Dengue Fever and its Clinical Implication Vibha Vipulbhai Gajera, Shilpi Sahu, Reeta Dhar To Study the Impact of Cigarette Smoking on Semen Quality of Adult Males. Prahlad Chandra Agrawal, Shiv Kumar Chandraker, Prarabdha Agrawal A study of Bone Marrow Aspiration Smears and Trephine biopsy in Pancytopenia Cases. Siva Chaithanya Bangi, Kotta Devender Reddy, V V Sreedhar Seroprevalence and Trends in Transfusion Transmitted Infections Among Blood Donors Rupal Shah, Aditi Dholakia Labour Analgesia and Its Outcome in Rural Population Rajani Rawat, Ruchika Garg, Shikha Seth, Arun Nagrath, Ramakant Rawat Uterine Arteriovenous Malformation Accidently Detected: a Case Report Shikha Joshi, Dipti Agrawal, Sunita Fotedar Amlodipine Induced Chylous Ascites in a Patient Undergoing Peritoneal Dialysis: A Case Report Sakul Gupta, Mega Lahori, Sanjay Bhat Post-coital Acute Rectovaginal fistula: a Rare Case Report Puja Jain, Rashmi Saini Unruptured 14 Weeks Tubal Ampullary Pregnancy : A Rare Case Report Puja Jain, Dipti Agrawal, Sunita Fotedar

Published by: Pacific Group of e-Journals (PaGe) Kotla Market, Mayur Vihar, New Delhi (India)

Website: www.pacificejournals.com www.pacificejournals.com/aabs

E-mail: contactus.aabs@pacificejournals.com

III

A218-A222 A223-A226 A227-A232 A233-A240 A241-A246 A247-A250 A251-A255 A256-A262 A263-A266 C47-C49 C50-C52 C53-C55 C56-C59

Review Article The Antifibrotic Role of Relaxin Geeta Tripathi*, Swati Gupta Command Hospital, King Georgeâ&#x20AC;&#x2122;s Medical University, Lucknow, Uttar Pradesh, India

Keywords: Relaxin, Relaxin Family Peptide Receptor 1 (RXFP1), liver, fibrosis.

ABSTRACT Relaxin, a polypeptide hormone of the insulin superfamily, is involved in the promotion of extracellular matrix remodeling. Emerging evidence supports a potential therapeutic role of relaxin in fibrotic diseases including liver. Relaxin has been shown to limit collagen production and promote collagen degradation. It not only prevents fibrogenesis, but also reduces established scarring. Together, these findings suggest that the liver is a target organ of relaxin. Therefore, the purpose of this review is to provide an overview of relaxin, its receptor, and their signaling with a focus on areas of potential translational research on fibrosis with emphasis on liver.

*Corresponding author: Dr. Geeta Tripathi, Command Hospital, King Georgeâ&#x20AC;&#x2122;s Medical University, Lucknow, Uttar Pradesh, India E-mail: Biotechgeet@gmail.com

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

Review Article

R-18

Introduction

Relaxin was initially found to induce relaxation of pubic ligaments in guinea pigs (Hisaw 1926). In pregnancy it was found to reduce spontaneous uterine contraction by softening of the cervix and elongation of the interpubic ligament and was thought to be a reproductive hormone, being produced in the reproductive tract of many pregnant mammals including the corpus luteum, placenta and uterus. Relaxin was later found to be a promising therapeutic agent to treat scleroderma because application of the hormone increased skin elasticity [1]. Later expression of relaxin and its receptor mRNA demonstrated the intriguing fact that relaxin has a role in numerous physiological processes far beyond reproduction. It promotes tissue remodeling via increased collagen turnover, and shows promise as an antifibrotic agent [2-4]. These discoveries of the diverse action of relaxin as well as the presence of relaxin receptors in tissues such as brain, kidney, heart, lung, and liver suggests a broader role of relaxin [5, 6]. The insulin-relaxin family is a group of evolutionary related proteins which possess a variety of hormonal activities. It is postulated that their respective genes had divergent evolution with time. The relaxin-like family of peptides present in humans includes relaxin 1, relaxin 2 (referred as relaxin), relaxin 3, and the insulin like peptides- InsL3, InsL4, InsL5 and InsL6 [1, 7]. These family members are synthesized as prepro-hormones compromised of a B-C-A domain configuration. The C domain peptide is removed to process the pro-hormone to the mature active peptide that consists of two interchain and one intra chain disulphide bonds between highly conserved cysteine residues on the A and B chains. The seven peptides have high structural but low sequence similarity but despite their structural similarity, relaxin and insulin have no common cellular effects (Bennett 2009). Relaxin family peptide receptors (RXFPs) Relaxin family peptide receptors were shown to be leucine-rich G-protein-coupled receptors (GPCRs) in 2002 after remaining elusive for many years. The discovery of identifying these cognate receptor was a major breakthrough in relaxin research [8]. The leucinerich GPCR receptor (LGR) family includes FSH, LH, TSH and relaxin receptors. These receptors were named LGR7 (now relaxin family peptide receptor; RXFP1) [8, 9] and LGR8 (now RXFP2) [10] respectively. These were called LGRs because receptors for relaxin and INSL3 contain leucine rich repeats in the extracellular domain and share 60% homology. Relaxin, relaxin 3 and InsL3 bind with different affinity to activate leucine rich receptors, RXFP1 and RXFP2.

Relaxin activates both RXFP1 and RXFP2 but InsL3 activates only RXFP3. Relaxin3 activates RXFP1, 3 and 4 but InsL5 activates only RXFP4. Relaxin 3 and InsL5 interact with GPCRs that are unrelated to LGRs. Relaxin 3 and InsL5 activate GPCR135 (now RXFP3) and GPCR142 (now RXFP4) [11, 12]. This review will focus on the recetors and their signaling in context to liver fibrosis. Distribution and structure of relaxin receptors In humans, RXFP1 mRNA is expressed in female reproductive organs such as the cervix [13], ovary, uterus, and placenta [8] as suggested by molecular techniques such as northern blotting and RT-PCR. It is expressed in male reproductive organs such as testis and prostate [8] as well as expressed in the nipple and breast of females [13, 14]. RXFP1 mRNA was also identified in adrenal, brain, bone marrow, heart, kidney, liver, lung, muscle, peripheral blood vessels, salivary glands, skin, and thyroid [8]. The RXFP2 mRNA in humans is expressed in brain, bone marrow, kidney, muscle, pituitary, peripheral blood cells, thyroid, testis, and uterus myometrium [8, 15, 16]. In addition to these, rats and mice also express RXFP1 in the oviduct and intestine [17] and express RXFP2 in the ovary and gubernaculum [10, 18]. In normal rat liver, RXFP1 but not RXFP2, is expressed at low levels, but in cirrhotic liver, expression of both receptors increases significantly. Quiescent hepatic stellate cells (HSC) that would normally store lipid droplet but once activated are responsible for liver fibrosis, express low levels of RXFP1 but not RXFP2 in normal state [19] but once activated HSC express both receptors. Thus, with initiation of fibrosis, there is an enhanced expression of both receptors in hepatic stellate cells. RXFP1 and RXFP2 receptors consists of a relatively large ectodomains that makes up over half of the receptor size and facilitates relaxin binding, this connects with a seven transmembrane spanning region, and an intracellular C-terminal tail making these receptors multidomain protein [20]. Both RXFP1 and RXFP2 contain unique N-terminal low density lipoprotein receptor type A (LDLa) modules. The LDLa module at the N-terminus is connected to ten leucine rich repeats (LRRs) by a short linker. The LRRs are â&#x20AC;&#x153;cappedâ&#x20AC;? at each end by cysteine-rich regions that are important to maintain the protein structure of LRRs [21, 22]. The LRRs are connected by another linker to connect to the seven transmembrane helices. The amino acid sequence of the receptors reveals the post translational glycosylation modification to be important for receptor functional maturation and trafficking to cell surface, receptor activation and receptor signaling [18]; these glycosylation occurs at N-terminally and phosphorylation at ten leucine

http://www.pacificejournals.com/aabs

R-19 rich repeats and at several sites in 7 transmembrane and C terminal tail respectively. Relaxin family peptide receptor signaling cascade The discovery of relaxin receptors has helped to study its different signaling pathways and its functional role in more depth. The recent discovery of the relaxin cognate receptors, RXFP1 and RXFP2, showed that in spite of relaxin’s structural similarity with insulin, it’s signaling through RXFPs is unlike insulin signaling through a tyrosine kinase receptor [20]. Relaxin could induce cyclic adenosine monophosphate (cAMP) was demonstrated in the mouse symphysis [23]. Sanborn et al further established this relationship between relaxin and increase in cAMP and was later confirmed in rat myometrial cells [24]. More advances in the signaling research lead to a general consent that relaxin binding to RXFP1 and RXFP2 elicits bioactivity by stimulating adenylate cyclase to increase cAMP, this stimulates downstream effector molecules such as PKA [18, 25-27]. In some cell types such as human macrophages (THP-1) and human breast adenocarcinoma cells (MCF-7), recent studies provide evidence that relaxin stimulates a biphasic cAMP response through RXFP1 with an initial phase of cAMP rise by activated by Gαs that lasts 10-15 minutes before inhibition by GαoB [28, 29]. The delayed phase of cAMP increase is through Gαi activation, that releases Gβ subunits, and these subunits then activate phosphatidylinositol 3 kinase (PI3K) to activate and translocate PKCζ to the cell membrane and activate adenylate cyclase for second, delayed round of cAMP production [28-30]. RXFP2 signaling seems not to be biphasic and is contrary to the complex-biphasic signaling of RXFP1. INSL3 or relaxin 2 stimulates RXFP2 to activate Gαs resulting in cAMP accumulation whereas, GαοВ and Gβg mediates the inhibition of RXFP2 mediated cAMP accumulation [29].

AABS; 3(3): 2016 tyrosine kinase activation [35, 36]. In THP1 cells and human pulmonary artery smooth muscle primary culture, ERK1/2 is quickly activated, within 5 minutes of RXFP1 activation [37] whereas in HeLa cells the response is noted after 45 to 90 minutes [38]. Thus, relaxin achieves its pleiotropic effects through activation of multiple pathways in different cell types.

In addition to the cAMP pathway, there is evidence that relaxin signals through multiple pathways [5, 25]. The diverse signaling of relaxin on different tissues results in various cellular and physiological processes including tissue remodeling, wound healing, cardiac protection, allergic responses and fibrosis [1, 6]. Bani and co-workers showed Relaxin to work through increased nitric oxide generation in guinea pig hearts, human breast cancer cells, mouse uterus and many other organs [31-33]. This nitric oxide production might use either a PI3K activated Akt pathway or IkB inactivation to increase in nitric oxide synthase 2 gene transcription via nuclear factor kB (NFkB) [34]. Relaxin is shown to signal through MAPK in human endometrial stromal cells and epithelial (HeLa cells) [5]. RXFP1 activation of ERK1/2 depends on the cell type. In human uterine cells and THP-1, RXFP1 also initiates

Hepatic Fibrosis Fibrosis of the liver is excessive accumulation of scar tissue that results from ongoing inflammation and liver cell death that occurs in most types of chronic liver diseases. Nodules, abnormal spherical areas of cells, form as dying liver cells are replaced by regenerating cells. This regeneration of cells causes the liver to become hard [39]. Fibrosis occurs when excessive scar tissue builds up faster than it can be broken down and removed from the liver. Chronic infection with hepatitis, heavy alcohol consumption, toxins, trauma or other factors can all lead to liver fibrosis. As the liver injury progresses, the scarring becomes more extensive, leading to cirrhosis and hence liver failure [39]. Chronic liver disease and cirrhosis was one among the leading causes of mortality in 2010. Mortality due to chronic liver disease and cirrhosis was over 1 % of total in 2010. Later research has also shown that genetic determinants and environmental factors influence the rate of fibrosis progression. Fibrotic scarring changes the normal architecture and function of the liver. Unrestricted scarring progresses to cirrhosis and loss of the hepatic parenchyma due to increases in collagen deposition. This diseased liver includes altered vasculature resulting in portal hypertension, ascites, encephalopathy and finally disruption of metabolic functions of the liver as a whole. In the early stages of liver fibrosis, few people experience symptoms because the liver functions relatively well. Fibrosis is the initial stage of the formation of scar tissue in the liver. An individual may have no symptoms and live a normal, sometimes very active life, for decades, and remain unaware that he or she has liver disease. As scar tissue builds up, due to inflammation and the continuance of liver injury, it connects with existing scar tissue, which can eventually disrupt the metabolic functions of the liver. If the disease progresses, it can lead to cirrhosis, a condition in which the liver is severely scarred, its blood flow is restricted, and its ability to function is impaired. If poked, a healthy liver is very soft. A liver that has developed fibrosis is firmer, and if the condition progresses to cirrhosis, the liver can be almost rock-hard. HSCs are the major contributor to injury-induced collagen production and removal of the causative agent or liver transplantation are currently the only treatments available.

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Review Article

R-20

Hepatic Stellate Cells Hepatic stellate cells, also known as perisinusoidal cells (earlier lipocytes or fat-storing cells), are pericytes found in the perisinusoidal space of liver [40]. The stellate cell is the major cell type involved in liver fibrosis, which is the formation of scar tissue in response to liver damage. Substantial evidence now exists to recognize HSCs as the main matrix-producing cells in the process of liver fibrosis. Liver injury of any etiology will ultimately lead to activation of HSCs, which undergo transdifferentiation to fibrogenic myofibroblast-like cells. HSCs are major mediators of the fibrotic process in liver during the wound healing process. In normal uninjured liver, HSC are quiescent cells that store vitamin A. As a result of injury, HSCs activate or transdifferentiate to a myofibroblast-like cell that is characterized by having a different phenotype and properties, including loss of normal retinoid-storing capacity, changes in cellular morphology and cytoskeletal organization, enhanced cell migration, adhesion, contractibility and proliferation, expression of α-SMA and acquisition of fibrogenic properties [41-43]. The expression of matrix-degrading enzymes such as matrix metalloproteinases (MMP)-1 and MMP 13 that degrade fibrillar collagen and MMP2 and MMP9 that degrade basement membrane collagen is reduced. Simultaneously, expression of tissue inhibitors of metalloproteinases (TIMPs) is increased [44]. Hence chronic liver injury leads to overall changes in expression of enzymes involved in matrix degradation resulting to a state towards accumulation of collagen and hepatic fibrosis. PPAR agonists and relaxin have been shown to prevent the activation of activated HSC, reversing them back to quiescent stage and thus preventing progressive hepatic fibrosis [9, 45, 46]. Recent studies has also demonstrated that integrin-linked kinase, an intracytoplasmic integrin-associated signaling molecule, has an important role in fibrogenesis. These findings reinforce the hypothesis that activation of HSCs may be triggered not only by circulating and locally released mediators, but also by alterations in the ECM itself, due to direct interaction between these cells and adjacent matrix fiber molecules. On a molecular level, the different morphologic features of fibrosis associated with various etiologies are probably related to the distribution of the primary sites of HSC activation[39]. The stellate cells are also involved in the regulation of portal venous blood flow and have a role in the development of portal hypertension and its complications. There is now strong evidence to support that portal hypertension may be in part caused by modulation of the contractile activity of stellate cells in the perisinusoidal space, which function as liver-specific pericytes and overall have implications in fibrosis [39].

Relaxin and fibrosis The role of relaxin in fibrosis of the liver has been less studied than that in other organs. The major collagen-producing cell in hepatic fibrosis is the HSCs, a perisinusoidal lipidstoring cell that transdifferentiates into a myofibroblastic cell with liver injury, with increased smooth muscle actin expression, collagen expression and secretion, contractility, and TIMP expression, and decreased MMP expression [47]. Relaxin is responsible for widespread extracellular remodeling of vagina, cervix and in some species, the pubic symphysis during pregnancy [1]. These findings were later confirmed using the relaxin-null mouse model [48]. The relaxin-null mouse developed multiple fibroses with aging, as evidenced by increased accumulation of interstitial collagen. In many cases, this excess collagen accumulation could be reversed by restoring relaxin levels in these animals [49]. Role of relaxin in preventing fibrosis have been examined in many major organs including skin, lung, and heart. Relaxin was reported to decrease the synthesis of TIMP-1 in dermal fibroblasts and enhance the expression of collagenase in culture of dermal fibroblasts [5]. Relaxin was shown to reduce fibrotic lesions and skin thickness, characteristics of scleroderma, by decreasing collagen secretion and increasing collagen degradation [4, 50, 51]. The RXFP1-null and relaxin-null mouse models demonstrate age-associated pulmonary fibrosis [52]. Relaxin treatment of the relaxin null mice that have knocked out relaxin gene and experimental models of lung fibrosis in the mouse model was enough to reverse pulmonary fibrosis [47, 52]. Relaxin inhibits the transition of cardiac fibroblasts to active myofibroblasts, decreases collagen I and III, and increases MMP secretion [53]. Relaxin has also been found to be a potent regulator of collagen in the ECM of heart [53]. Its antifibrotic role have resulted in unprecedented interest in relaxin. Relaxin has antifibrotic effects in experimental models of renal fibrosis. The relaxin-null mouse is itself a model of progressive renal fibrosis [4]. In hepatic fibrosis, HSCs are the major collagen secreting cells. In activated HSC, relaxin treatment decreased the expression of smooth muscle actin, type I collagen and total collagen and decreased the synthesis of new collagen. Furthermore, relaxin decreased TIMP-1 and TIMP-2 and increased interstitial collagenase levels [46]. The quiescent hepatic cells express RXFP1 at low levels, but not RXFP2. During progression to the activated phenotype, expression of RXFP1 and RXFP2 increases significantly. These changes are also seen in the cirrhotic liver, where expression of the receptors is increased, suggesting the role of these receptors and their ligands during fibrosis [19]. The in vivo effect of relaxin treatment on rat CCl4 model resulted in significant

http://www.pacificejournals.com/aabs

R-21 decrease in liver weight, hepatic hydroxyproline levels and reduction in collagen deposition [54]. Relaxin’s effects on fibrotic markers have been found similar to agonists of PPARg. Recently, relaxin have been shown to activate PPARg in HEK293T, THP1 and hepatic stellate cell line (LX2) [9, 26, 27, 55]. The progression of liver fibrosis with increased HSC activation is accompanied with decreased PPAR expression that makes PPAR ligands less useful in advanced liver fibrosis [56]. But in the early stages of HSC activation, combined effect of relaxin and PPARg agonists could be of therapeutic significance in reducing liver fibrosis [9, 26, 27, 55]. More studies are needed to determine if relaxin can improve less severe hepatic fibrosis, or fibrosis induced by less toxic means.

Conclusion

Fibrosis is a leading cause of organ failure and causes loss of organ function when normal tissue is replaced with excess of scarring connective tissue. Several organs are prone to this process regardless of the cause. Relaxin is emerging as an important, naturally occurring inhibitor of collagen turnover in several organs within the body. Relaxin studies have established it as well proven antifibrotic agent that does not appear to influence the extracellular matrix under normal conditions. Relaxin treatment has improved fibrosis in a variety of animal models, suggesting that this may be a valuable area for translational research in fibrosis. Investigating the mechanism of relaxin effects on extracellular matrix and its role in combination with other drugs could advance the field by providing better fibrotic treatments.

Acknowledgements

[It should include persons who provided technical help, writing assistance and departmental head that only provided general support. Financial and material support and conflict of interests must be written in this section.] None

Funding None

Competing interests None declared

AABS; 3(3): 2016 3. Mookerjee, I., et al., Endogenous relaxin regulates collagen deposition in an animal model of allergic airway disease. Endocrinology, 2006. 147(2): p. 754-61. 4. Bennett, R.G., et al., Relaxin decreases the severity of established hepatic fibrosis in mice. Liver International, 2014. 34(3): p. 416-426. 5. Sherwood, O.D., Relaxin’s Physiological Roles and Other Diverse Actions. Endocr Rev, 2004. 25(2): p. 205-234. 6. Dschietzig, T., et al., Relaxin-a pleiotropic hormone and its emerging role for experimental and clinical therapeutics. Pharmacol Ther, 2006. 112(1): p. 38-56. 7. Bathgate, R.A., et al., International Union of Pharmacology LVII: recommendations for the nomenclature of receptors for relaxin family peptides. Pharmacol Rev, 2006. 58(1): p. 7-31. 8. Hsu, S.Y., et al., Activation of orphan receptors by the hormone relaxin. Science, 2002. 295(5555): p. 671-4. 9. Singh, S. and R.G. Bennett, Relaxin signaling activates peroxisome proliferator-activated receptor gamma. Mol Cell Endocrinol, 2010. 315(1-2): p. 239-45. 10. Kumagai, J., et al., INSL3/Leydig insulin-like peptide activates the LGR8 receptor important in testis descent. J Biol Chem, 2002. 277(35): p. 31283-6. 11. Liu, C., et al., Identification of relaxin-3/INSL7 as an endogenous ligand for the orphan G-protein-coupled receptor GPCR135. J Biol Chem, 2003. 278(50): p. 50754-64. 12. Liu, C., et al., Identification of relaxin-3/INSL7 as a ligand for GPCR142. J Biol Chem, 2003. 278(50): p. 50765-70. 13. Kohsaka, T., et al., Identification of specific relaxinbinding cells in the human female. Biol Reprod, 1998. 59(4): p. 991-9. 14. Ivell, R., et al., Immunoexpression of the relaxin receptor LGR7 in breast and uterine tissues of humans and primates. Reprod Biol Endocrinol, 2003. 1: p. 114. 15. Hombach-Klonisch, S., et al., INSL-3 is expressed in human hyperplastic and neoplastic thyrocytes. Int J Oncol, 2003. 22(5): p. 993-1001.

1. Sherwood, O.D., Relaxin’s physiological roles and other diverse actions. Endocr Rev, 2004. 25(2): p. 205-34.

16. Mazella, J., M. Tang, and L. Tseng, Disparate effects of relaxin and TGFbeta1: relaxin increases, but TGFbeta1 inhibits, the relaxin receptor and the production of IGFBP-1 in human endometrial stromal/ decidual cells. Hum Reprod, 2004. 19(7): p. 1513-8.

2. Samuel, C.S., et al., Relaxin-1-deficient mice develop an age-related progression of renal fibrosis. Kidney Int, 2004. 65(6): p. 2054-64.

17. Kong, R.C., et al., Membrane receptors: structure and function of the relaxin family peptide receptors. Mol Cell Endocrinol. 320(1-2): p. 1-15.

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

e-ISSN: 2349-6991; p-ISSN: 2455-0396

REFERENCE:

Review Article

R-22

18. Halls, M.L., et al., Relaxin family peptide receptors-former orphans reunite with their parent ligands to activate multiple signalling pathways. Br J Pharmacol, 2007. 150(6): p. 677-91. 19. Bennett, R.G., et al., Relaxin receptors in hepatic stellate cells and cirrhotic liver. Biochem Pharmacol, 2007. 73(7): p. 1033-40. 20. Hsu, S.Y., et al., The three subfamilies of leucine-rich repeat-containing G protein-coupled receptors (LGR): identification of LGR6 and LGR7 and the signaling mechanism for LGR7. Mol Endocrinol, 2000. 14(8): p. 1257-71. 21. Kobe, B. and J. Deisenhofer, Crystal structure of porcine ribonuclease inhibitor, a protein with leucinerich repeats. Nature, 1993. 366(6457): p. 751-6. 22. Kobe, B. and A.V. Kajava, The leucine-rich repeat as a protein recognition motif. Curr Opin Struct Biol, 2001. 11(6): p. 725-32. 23. Braddon, S.A., Relaxin-dependent adenosine 6’,5’-monophosphate concentration changes in the mouse pubic symphysis. Endocrinology, 1978. 102(4): p. 1292-9. 24. Hsu, C.J., S.M. McCormack, and B.M. Sanborn, The effect of relaxin on cyclic adenosine 3’,5’-monophosphate concentrations in rat myometrial cells in culture. Endocrinology, 1985. 116(5): p. 2029-35. 25. Halls, M.L., R.A.D. Bathgate, and R.J. Summers, Relaxin Family Peptide Receptors RXFP1 and RXFP2 Modulate cAMP Signaling by Distinct Mechanisms. Mol Pharmacol, 2006. 70(1): p. 214-226. 26. Singh, S., R.L. Simpson, and R.G. Bennett, Relaxin activates peroxisome proliferator-activated receptor gamma (PPARgamma) through a pathway involving PPARgamma coactivator 1alpha (PGC1alpha). J Biol Chem, 2015. 290(2): p. 950-9. 27. Singh, S. and R.G. Bennett, Relaxin family peptide receptor 1 activation stimulates peroxisome proliferator-activated receptor gamma. Ann N Y Acad Sci, 2009. 1160: p. 112-6. 28. Nguyen, B.T., et al., Phosphoinositide 3-kinase activity is required for biphasic stimulation of cyclic adenosine 3’,5’-monophosphate by relaxin. Mol Endocrinol, 2003. 17(6): p. 1075-84. 29. Halls, M.L., R.A. Bathgate, and R.J. Summers, Relaxin family peptide receptors RXFP1 and RXFP2 modulate cAMP signaling by distinct mechanisms. Mol Pharmacol, 2006. 70(1): p. 214-26. 30. Nguyen, B.T. and C.W. Dessauer, Relaxin stimulates protein kinase C zeta translocation: requirement for

cyclic adenosine 3’,5’-monophosphate production. Mol Endocrinol, 2005. 19(4): p. 1012-23. 31. Bani, D., et al., Relaxin activates the L-arginine-nitric oxide pathway in vascular smooth muscle cells in culture. Hypertension, 1998. 31(6): p. 1240-7. 32. Failli, P., et al., Relaxin up-regulates inducible nitric oxide synthase expression and nitric oxide generation in rat coronary endothelial cells. Faseb J, 2002. 16(2): p. 252-4. 33. Bani, D., et al., Relaxin up-regulates the nitric oxide biosynthetic pathway in the mouse uterus: involvement in the inhibition of myometrial contractility. Endocrinology, 1999. 140(10): p. 4434-41. 34. Nistri, S. and D. Bani, Relaxin receptors and nitric oxide synthases: search for the missing link. Reprod Biol Endocrinol, 2003. 1: p. 5. 35. Bartsch, O., B. Bartlick, and R. Ivell, Relaxin signalling links tyrosine phosphorylation to phosphodiesterase and adenylyl cyclase activity. Mol Hum Reprod, 2001. 7(9): p. 799-809. 36. Bathgate, R.A., et al., Receptors for Relaxin Family Peptides. Ann NY Acad Sci, 2005. 1041(1): p. 61-76. 37. Zhang, Q., et al., Relaxin activates the MAP kinase pathway in human endometrial stromal cells. J Cell Biochem, 2002. 85(3): p. 536-44. 38. Dschietzig, T., et al., Relaxin, a pregnancy hormone, is a functional endothelin-1 antagonist: attenuation of endothelin-1-mediated vasoconstriction by stimulation of endothelin type-B receptor expression via ERK-1/2 and nuclear factor-kappaB. Circ Res, 2003. 92(1): p. 32-40. 39. Wallace, K., A.D. Burt, and M.C. Wright, Liver fibrosis. Biochem J, 2008. 411(1): p. 1-18. 40. Friedman, S.L., Liver fibrosis -- from bench to bedside. J Hepatol, 2003. 38 Suppl 1: p. S38-53. 41. Marra, F., Hepatic stellate cells and the regulation of liver inflammation. J Hepatol, 1999. 31(6): p. 1120-30. 42. Milani, S., et al., Procollagen expression by nonparenchymal rat liver cells in experimental biliary fibrosis. Gastroenterology, 1990. 98(1): p. 175-84. 43. Bataller, R. and D.A. Brenner, Liver fibrosis. J Clin Invest, 2005. 115(2): p. 209-18. 44. Arthur, M.J., Fibrogenesis II. Metalloproteinases and their inhibitors in liver fibrosis. Am J Physiol Gastrointest Liver Physiol, 2000. 279(2): p. G245-9. 45. Wang, Z., et al., Peroxisome proliferator-activated receptor gamma inhibits hepatic fibrosis in rats. Hepatobiliary Pancreat Dis Int. 10(1): p. 64-71.

http://www.pacificejournals.com/aabs

R-23 46. Bennett, R.G., K.K. Kharbanda, and D.J. Tuma, Inhibition of markers of hepatic stellate cell activation by the hormone relaxin. Biochem Pharmacol, 2003. 66(5): p. 867-74. 47. Samuel, C.S., E.D. Lekgabe, and I. Mookerjee, The effects of relaxin on extracellular matrix remodeling in health and fibrotic disease. Adv Exp Med Biol, 2007. 612: p. 88-103. 48. Zhao, L., et al., Collagen studies in late pregnant relaxin null mice. Biol Reprod, 2000. 63(3): p. 697-703. 49. Samuel, C.S., et al., The relaxin gene knockout mouse: a model of progressive scleroderma. J Invest Dermatol, 2005. 125(4): p. 692-9. 50. Unemori, E.N. and E.P. Amento, Relaxin modulates synthesis and secretion of procollagenase and collagen by human dermal fibroblasts. J Biol Chem, 1990. 265(18): p. 10681-5. 51. Unemori, E.N., E.A. Bauer, and E.P. Amento, Relaxin alone and in conjunction with interferon-gamma decreases collagen synthesis by cultured human

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

AABS; 3(3): 2016 scleroderma fibroblasts. J Invest Dermatol, 1992. 99(3): p. 337-42. 52. Samuel, C.S., et al., Relaxin deficiency in mice is associated with an age-related progression of pulmonary fibrosis. Faseb J, 2003. 17(1): p. 121-3. 53. Samuel, C.S., et al., Relaxin modulates cardiac fibroblast proliferation, differentiation, and collagen production and reverses cardiac fibrosis in vivo. Endocrinology, 2004. 145(9): p. 4125-33. 54. Williams, E.J., et al., Relaxin inhibits effective collagen deposition by cultured hepatic stellate cells and decreases rat liver fibrosis in vivo. Gut, 2001. 49(4): p. 577-83. 55. Singh, S. and R.G. Bennett, Relaxin activation of PPAR [gamma] is ligand independent. The FASEB Journal, 2009. 23(1 Supplement): p. 706.3-706.3. 56. Singh, S. and R.G. Bennett, Dominant-negative and knockdown approaches to studying PPAR activity. Methods Mol Biol, 2013. 952: p. 87-98.

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article Impact of Pediatric Emergency Team (Pet) on Picu Transfers from Wards and Overall Mortality Sunit Pathak*1, Gaurav Khandelwal2, Rhythmm3, Meenakshi4 1

Dept of Pediatrics, S.N. Medical College, Agra, India 2 F H Medical college, Tundla, Firozabad, India 3 S.N. Medical college, Agra, India 4 Dhawan diagnostic Pathology, Agra, India

Keywords: Pediatrics, Rapid Response Team, Pediatric Emergency Team, Medical Emergency Response Team

ABSTRACT A high index of suspicion is needed in pediatric patients with neurological symptoms being the sole presenting manifestation, to diagnose infection with the Human Immunodeficiency Virus (HIV). This is a write up of two such cases who were admitted to the pediatric intensive care unit with neurological manifestations. A 6 year old previously healthy child, who initially presented with intermittent drowsiness and fluctuation in blood pressure, later during hospital stay, developed progressive motor, cognitive, visual and language difficulties. Investigations revealed the child to be HIV positive and magnetic resonance imaging (MRI) findings were consistent with progressive multifocal leucoencephalopathy. A 12 yr old child had stroke initially (for which extensive work up had been done) and later, after 8 months presented with the same complaints along with severe pneumonia. He succumbed to severe opportunistic infections. That he was HIV positive, had not been detected during the first admission as left sided weakness was the only presenting manifestation.

*Corresponding author: Dr Sunit Pathak, Dept of Pediatrics, S.N. Medical College, Agra, India Phone: +91 8979834496 E-mail: drsunitpathak@gmail.com

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

A-219

Introduction

Cardiac arrest is the cessation of cardiac mechanical activity resulting in the absence of circulating blood flow. Cardiac arrest stops blood from flowing to vital organs, depriving them of oxygen, and, if left untreated, results in death. Despite the use of CPR, mortality rates for cardiac arrest are 80 to 97% for infants and children[1]. Cardiopulmonary arrest is often preceded by a critical period of physiologic instability, during which life saving interventions can decrease the mortality and improve outcomes in sick children[2-4]. Sick children have warning signs and symptoms prior to cardiopulmonary arrest and if these symptoms and signs are recognised on time,many lives can be saved . The introduction of Rapid Response Teams(RRT) and Medical Emergency Teams (MET) in western countries has been advocated .They are meant to be called before a patient has a cardiopulmonary arrest, so that life saving intervention can be carried out in hopes of improving outcomes. Studies in Western countries have shown reduction in cardiopulmonary arrests and hospital mortality after introduction of medical emergency teams (in adults) [5].There are very few studies on the implementation of such Rapid Response Teams in children and there are no standard criteria available to recognize sick children, as different age groups have different physiologic variables. In our study ,we are reporting successfull implementation of a Pediatric emergency team (PET) concept and its effectiveness in reducing overall mortality.

Methods

This study was conducted at Department of Pediatrics,Sarojini Naidu Medical college, Agra which is a 100 bedded tertiary care unit with approximately 400 Pediatric admissions per month. Pediatric patients are admitted across pediatric ward , from the 1st to 2nd floor. The hospital has a 6 bedded Pediatric Intensive Care Unit with close to 500 admissions annually. Along with general Pediatric services, we have surgical subspecialties (general pediatric surgery ,pediatric neurosurgery, orthopaedics and urology) services available in our hospital. We conducted a retrospective study, all children admitted to Pediatric wards were considered participants.Obsevations were made before and after implementation of the Pediatric Emergency Team (PET) concept in Pediatric wards. It was hypothesized that implementation of the PET concept would prevent subsequent cardio pulmonary arrests in the wards, reduce the number of admissions to the PICU from the wards and the overall mortality.The pre-intervention period was between november 2013 and october 2014 (phase-1) and post-implementation period was between november 2014 and October 2015 (phase-2). Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

AABS; 3(3): 2016 There are no standard Pediatric Emergency Team (PET) criteria available to recognize deterioration in children admitted to the wards. A Pediatric Emergency Team Chart highlighting the warning signs and symptoms of various illnesses was prepared. (Annexure 1). PLACARDS indicating these warning signs and symptoms were made and displayed in every ward , doctor and nurses duty room. A pocket sized Pediatric Ready Reckoner card was also prepared for nurses, highlighting the normal values of vital parameters and what needs to be done in an emergency. All nursing staff across the hospital were trained on recognition of early warning signs and symptoms in children. The Doctor and Nurses were also made to undergo PALS training. We Selected 4 of our senior nurses, with PICU experience of more than 2 years as PET (Pediatric Emergency Team) Nurses. They worked in two shifts- from 8am to 8pm and from 8 pm to 8 am. At any given point of time, there are around 40-50 Pediatric patients admitted to the wards . Out of these admissions, the “AT RISK” patients (around 10-15 on any given day),were identified by the pediatrician .Criteria to include patients in the “AT RISK” Group were:1) All Patients shifted out of the PICU after recovery.2) Patients admitted directly from the Emergency Room, who need frequent monitoring, but not sick enough to be admitted to the PICU. 3) All patients admitted through the ER after midnight.4) Any child in the ward about whom the primary admitting Pediatrician/ staff is concerned about.5) Neurosurgical and post surgical patients in the wards.A key aspect of the system was that, any staff member, irrespective of rank, may call the PET team.A List of these “AT RISK” patients was generated in the morning by the PET nurse. These would include some new patients and some patients carried forward from the previous day’s list. Patients who had improved considerably were removed from the list, after being seen by the PICU consultant. Detailed rounds were done three times a day- in the morning, evening and at night, initially by the PET nurse and later by a PICU Consultant. The potentially sick children were seen more often, as required. At any point, if the doctor or nurse felt that the child needed to be shifted to the PICU, the same was done, after keeping the primary treating Pediatrician informed. The PET chart (annexure 1) had to be filled in for every patient on the list. This was done by the nurses in the wards and when warning signs/symptoms were noticed, they would alert the Pediatric Emergency team on the PET mobile number. This ensured monitoring of the child more closely than other patients. The following variables were compared before and after implementation of the PET concept- the number of patients having cardiopulmonary arrest in the e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-220

ward, the number of patients transferred to the PICU from the wards, the number needing intubation on Day1 of transfer and the overall mortality of patients transferred in.

Results

130 patients needed to be shifted to the PICU because of worsening clinical status, out of a total of 5,560(2.33%) admissions during phase1(before introduction of PET), as against 96 out of 4,425(2.16%) admissions during phase 2(after introduction of PET). The mean age of patients transferred to PICU before and after introduction of PET was 3.2years and 5.5 years respectively. Total admissions in ward varied between two phases of observation. There was not a significant difference in the numberof patients transferred to the PICU between the two Phases.There were 2 cardiac arrest before introducing PET and there was no death in ward after introducing PET. 29 patients required intubation and mechanical ventilation within 8 hours after their transfer to PICU during Phase-1 (22.3%) and 7 during Phase-2 (8.1%),p value 0.021.Other interventions like use of boluses were not significantly different between the two groups. Out of all the patients transferred in to the PICU after starting PET, 2 (2.08%) died , whereas 14(10.7%)patients died before starting PET (p value 0.012) in PICU.

Discussion

The concept of applying pediatric emergency team(PET) in our hospital came to our mind when we saw two cardiac arrest cases in our ward and number of patients being transfered to PICU in a critically ill condition ,our pediatric team was thinking about the mistakes in managing the patients and atlast we reached a conclusion that our nurses and junior residents failed to recognise the ealy detoriating vital signs and syptoms.ICU-based Medical Emergency Team (MET) system was first described by Lee and colleagues in 1995[6].The formation of rapid response teams (RRTs)/medical emergency teams(MET)/`patientat-risk team’ (PART), as these have been variously called was based on the concept of “failure to rescue.”[7]. We hypothesised that,early recognition of the warning signs and symptoms of patients admitted to the wards and appropriate intervention reduces their rate of transfer to the PICU and their overall mortality. This is the second study from India on the impact of the Pediatric Rapid response Team (here Pediatric EmergencyTeam) on pediatric inpatients transfer to the PICU and their mortality.Our source of inspiration for advocating PET team in our hospital is from Original Research Article “Critical Care without Walls”- Impact of a “Pediatric Emergency Team” on Picu

Admissions from the Wards and Overall Mortality. We studied the impact of the Pediatric Emergency Team (PET) on the incidence of cardiopulmonary arrests in the wards, number of patients transferred to the PICU from the wards, the number of mechanical ventilation within 24 hours and the overall mortality of the patients transferred in. We used the criteria of cardiac arrest in ward , intubation and mechanical ventillation within 24 hours of their transfer to the PICU and the mortality in those patients to evaluate the effectiveness of PET. After applying PET we found no cardiac arrest cases in ward, a significant reduction in the number of patients needing intubation and mechanical ventillation within 24 hours after their transfer to PICU from 22.3% to 8.1% ( p value 0.021) (Table2).This is similiar to the first pediatric report published by Tibballis et al, who found reduction in code rate from 0.19 to 0.11 per 1000 admissions after starting MET[8]. In the study by Richard J. Brilli et al the code rate per 1,000 admissions decreased from 1.54(baseline) to 0.62 (post-MET) (risk ratio, 0.41; 95% confidence interval, 0–0.86; p value 0.02) [9]. In study conducted by Agarwal et al number of patients needing intubation and mechanical ventillation within 24 hours after their transfer to PICU, after starting PET reduced from17.9% to 5.8% (p value 0.012864,OR 0.2831,95% CI 0.1120 to 0.7156) [10].In our study mortality in patients needing intubation and mechanical ventillation within 24 hours after their admission to the PICU in our study decreased from 10.7% to 2.08% (p value 0.012)(Table2). This was similar to the study by Tibbalis et al (0.12 to 0.06 per 1000 admissions)after the implementation of MET at Royal Children’s Hospital in Melbourne[8]. In the study by Richard J. Brilli et al the pre-MET mortality rate was 0.12 per 1,000 days compared with the post-MET rate of 0.06 per 1000 days (risk ratio, 0.48; 95% confidence interval, 0–1.4, p _ .13). All the patients needing intubation within 24 hours of shifting to the PICU 5/7 survived (mortality-28.7%) after the implementation of PET, whereas 14/29(48.2%) needing intubation died, before starting PET[9]. In study conducted by Agarwal et al study mortality in patients needing intubation and mechanical ventillation within 24 hours after their admission to the PICU decreased from 6.2 % to 0% (p value 0.0366), after the implementationof PET[10]. The number of patients needing interventions fluid boluses and inotropes was more before starting PET, but the difference was not significant. There were 130 patients who needed to be shifted to PICU because of worsening clinical status for a total of 5,560(2.33%) admissions,before introduction of PET against 96 for for 4,425(2.16%),after introduction of PET. Goldhill, D.R. et al reported decrease in the number of unnecessary transfers to a higher level of care by a mean of 30%[11]. In study

http://www.pacificejournals.com/aabs

A-221

AABS; 3(3): 2016

Table 1: Characteristics and Overall Outcome of Patients in Wards before and after Starting PET Before PET

After PET

Total Admissions

Variables

5,560

4,425

Transfer to PICU

130

Cardiac arrest in ward

No of death in ward

Table 2: Characteristics of Patients Transfered to PICU before and after Starting PET Variables

Before PET

After PET

(n = 130)

(n=96)

p value

Interventions, % CPR

2 (1.53%)

Intubation within 24 hr

29(22.3%)

7(8.1%)

0.021

Fluid bolus

52(40%)

35(36%)

0.582

Inotrope

40(30%)

22(22.9%)

0.681

Outcome % Died in PICU

14(10.7%)

2(2.08%)

0.012

Survival to discharge

116(89%)

94(97.9%)

0.731

conducted by agarwal et al, 145 patients who needed to be shifted toPICU because of worsening clinical status for a total of 10088(1.43%) admissions,before introduction of PET against 103 for 7737(1.33%) admissions, after introduction of PET. In our study total number pf patient monitored by PET was 764,out of total 4,425 admission(17.26%).87.43% of the patients kept under PET were managed in the wards and did not need tranfer to the PICU ,because warning signs and symptoms were recognized early and they were appropriately managed in the wards-fluid boluses, administration of oxygen and nebulisations, administration of the first dose of antibiotic, seizure control etc.It may be said that implementation of a Pediatric Emergency Team concept (Pediatric RRT) will reduce the incidence of respiratory and cardiopulmonary arrests or sudden deteriorations outside of the critical care areas, thereby reducing overall mortality. The Institute for Healthcare Improvement’s Saving 100,000 Lives Campaign has advocated the deployment of in hospital medical emergency teams (METs)as a means to rescue patients and reduce hospital mortality rates, and has already been adopted with good results in many hospitals worldwide (for adult patients) [12-13]. We hence recommend implementation of the Pediatric Emergency Team (RRT) concept in all tertiary care hospitals, in an attempt to reduce in-hospital cardiopulmonary arrests and overall mortality in Pediatric patients.We hope that soon the importance of PET team will be realised by every pediatric hospital and it will be implemented to benefit the patients. Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

Acknowledgements

special thanks to Dr Meenakshi for providing technical assistance and helping in writing the article

Funding None

Competing interests None declared

References

1. Robert E O’Connor .Cardiopulmonary Resuscitation in Infants and Children 2. Buist MD, Jarmolowski E, Burton PR, et al. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. Med J Aust 1999; 171: 22-25. 3. Franklin C, Mathew J. Developing strategies to prevent inhospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med 1994; 22:244-247. 4. Shein RMH, Hazday N, Pena M, et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990; 98: 1388-1392. 5. James Tibballs, Sharon Kinney. Reduction of hospital mortality and of preventable cardiac arrest and death on introduction of a pediatric medical emergency team. Pediatr Crit Care Med 2009; 10:306 –312). e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-222

6. Lee A, Bishop G, Hillman KM, Daffurn K: The Medical Emergency Team. Anaesth Intensive Care 1995, 23:183-186 7. D. R. Goldhill et al. Identifying and managing seriously ill ward patients. Anaesthesia, 1999, 54, pages 853±860 8. Tibballs J, Kinney S, Duke T, et al: Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: Preliminary results. Arch Dis Child 2005; 90: 1148–1152 9. Brilli RJ Gibson R Luria JW et al. Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit. Pediatr Crit Care Med 2007;8 (3) 236- 247

10. Agarwal N, Ram G et al “Critical Care without Walls”Impact of a “Pediatric Emergency Team” on Picu Admissions from the Wards and Overall Mortality. Journal of Pediatric Critical Care 2015;2:11-16 11. Goldhill, D.R. et al. The patient-at-risk team: identifying and managing seriously ill ward patients. Anesthesia 1999;54:853- 860 12. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA 2006; 295: 324-327. 13. Institute of Health Care Improvement (IHI) 2006. How to guide pediatric supplement Rapid Response Team; http://www.ihi.org. Accessed on 10 February 2009

http://www.pacificejournals.com/aabs

Original Article Determination of Decayed, Missing and Filled Teeth (DMFT) Index in the 12 Years Old Children of Hadishahr Province from Iran Farrokh Farhadi1, HosseinFalsafi Miab2, Ali Zarandi3* Department of oral and maxillofacial surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran 2 Doctor of dentist, Faculty of Dentistry, Tabriz University of Medical Sciences, Iran 3 Department of Prosthodontics, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz , Iran

Keywords: Decayed, Missing and Filled Teeth, brushing, dental caries

ABSTRACT Background: decayed, missing and filled teeth (DMFT) index is introduced for determination of oral health and dental caries by World Health Organization (WHO). The purpose of this study was to determine the DMFT index among 12 years old school children in Hadishahr province of Iran. Methods: This research was performed as descriptive and cross-sectional study in 2013-2014 on 266 students. The DMFT index was found by standard method suggested by WHO. The data were analyzed using SPSS software (version 18.0) and showed as mean ± standard deviation (SD). Results: The mean± SD of DMFT value for students was 1.23 ± 0.09. 13.2% of children did not brush 53.8 % brush once and 33.1% brushed twice a day. Analysis showed that there was a significant correlation between DMFT index and brushing times. Also, there was not a significant association between DMFT index and educational level of parents. Conclusion: The mean DMFT values in 12 years old students were in low level of the global standards proposed by WHO.

*Corresponding author: Dr Ali Zarandi, Assistant Professor, Department of Prosthodontics, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz , Iran E-mail: dr.alizarandi@gmail.com

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

Original Article

A-224

Introduction

The socioeconomic condition could affect the dental health. One of the main indicators for oral health indexes is decayed, missing and filled teeth (DMFT), which is introduced as oral health evaluation criteria in the most researches. The DMFT index could compare the rate of dental caries in epidemiological research of various populations (1, 2). By 2011, the global mean of DMFT index for school children ( 12 years of age) was 1.67 and almost in 78% of countries , DMFT index was more than 3.0(3).Several parameters such as oral hygiene, diet, and culture of people, social, economic status, habits of racial in target people and low level of fluoride in water used can affect DMFT index (4). According to WHO proposal, the ranking level for DMFT index including:very low (less than 1.2),low (1.2 to 2.6), average (2.7 to 4.4) and high (more than4.4). Various studies in some region of Iran have been investigated DMFT index school children(5-8). Basir et al. showed poor relation between the fluoride concentration in the drinking water and DMFT index. Shidfar et al. (9) informed that by increasing the fluoride concentration in the drinking water (up to 1 mg/L) tooth decay was reducedin the industrial city of Ilam. Dindarloo et al(10) confirmed existing direct relationship between Fluoride concentrationand DMFT which it is mean that by increasing of fluoride DMFT index be increased. On the other hands, DMFT has significant relation with variables parameters such as living location, parents’ works, interval of dental visit and brushing of teeth(11, 12).According to the determination DMFT indexas a main factor for evaluating the oral health in various region of Iran, the purpose of this study was to determine the DMFT index among 12 years old school children in Hadishahr province of Iran.

Materials and Methods

This descriptive and cross-sectional study was performed during 2013-2014 on 266 students who had 12 years old which were selected in Hadishar province, Iran. Inclusion criteria were: having 12 years old and sign a consent form byparents.Exclusion criteria were: having genetic disease such as Ectodermal dysplasia, amelogenesis imperfecta, as well as having periodontal disease, having systemic disease like as haemophilia or kidney disease. An oral health examination of 20 participants was conducted by two dentists who had sufficient clinical experience for this purpose.Because of more than 70% agreement between the two observers, experiment was done by one of the dentists. The design of the oral health analysis form is determined from the diagnostic procedures and standards according to the oralhealth examination assessment released by the WHO (13). Moreover, the questionnaires were finished by the students with the guidance of school teachers. The content of questionnaires included: demographic

dataofstudent (sex,age),the education levelof their parents, job of their parents, the oral hygiene habits (frequency of brushing, length of brushing,) and DMFT. Data Analysis: The data obtained from the study was analyzed using descriptive statistics (frequency, percentage and mean ± SD) by statistical software SPSS19.

Results

The demographic data of the students are shown in Table1 and 2.The DMFT index for all of the students was calculated 1.23 ± 0.9. Table 1: Sex, frequency of brushing, education level and job of parents Variables

No. (Frequency)

sex Frequency of brushing Education level of parents

Jobs of the parents

boys

119 (44.7%)

girls

147(55.3%)

Zero

35(13.2%)

Once

143(53.8%)

twice

88(33.1%)

Pre-high school

78(29.3%)

High school

97(36.5%)

Bachelor

71(26.7%)

sciences

19(7.1%)

doctor

1(0.4%)

Employee

81(30.5%)

self-employment 64(61.7%) Teacher

21(7.9%)

Total

266(100%)

Table 2: Relation between DMFT and sex, frequency of brushing, education level and job of parents Variables Zero

Frequency Once a day of brushing Twice a day Education level of parents

3.74± 0.07

0.000α

1.34±0.1 0.057±0.02 1.25±0.16

High school

1.1±0.14

Bachelor

1.41±0.18

sciences

1.1±0.36

doctor

Teacher

http://www.pacificejournals.com/aabs

P value

Pre-high school

Jobs of the Employee parents self-employment Total

No. (Frequency)

1.2±0.11 1.2±0.16 1.57±0.36

0.698b

0.545b

A-225 α:p value obtained by One Sample T test . b:One-Way ANOVA ( p < 0.05 : significant level).

Discussion

According to outcomes of this study, the mean DMFT values in students were 1.23±0.09. Moreover, statistically significant differences were found between the frequencies of brushing among the 12 years old students and DMFT index while significant relationship between DMFT and level of education and parent’s job was not found. Amirabadi et al. (2015) observed that the mean ±SD of DMFT value for 8-12 years old children in Zahedan City was 1.02 ± 1.36which it was lower than our study. Besides this, boys had higher mean DMFT value (1.01 ± 1.41) in comparison to girls (1.00 ± 1.41).In contrast to our study, analysis of variance analysis indicated that there is not a significant relationship between DMFT index and brushing times(14).The DMFT index of different region of Iran was reported by various investigations. This index between children was 1.48 ± 0.13 in Behshahr city, 2.98 ± 1.95 in Babol city, in Mianeh city 0.347±0.09 to 6.98±0.44 (for 6 years old) and 1.41±0.161 to 8.02±0.32 (for 9 years old),1.8 ± 1.73 in Dayer city(15-17). Differences between MDFT indexes between children are influenced by to many factors such as fluoride concentration of drinking water in various regions, nutrition habits, racial differences, socio-economic status. The DMFT of 12‑year‑old girls of Behshahr city was more than boys (1.21 ± 0.16), while the average of fluoride concentration in drinking water was equal 0.25 mg/land the fluoride content in Arsanjan was from 0.1(17, 18). Several public health agencies suggest that low level of the fluoride(1.5 mg/L according to the guideline of WHO) could be mixed to drinking waters to help the improvement of dental health and decrease MDFT index(19). Moreover, children with low level of oral hygiene habits have unfavorable oral health because the analyses of brushing habits and oral health status of children showed significant differences.

Conclusion

In this research the mean DMFT values in 12 years old students were in low level of the global standards proposed by WHO and no prelateship was found between level of education and jobs of parents with DMFT level. It is suggested that fluoride concentration of drinking water in Hadishar will be evaluated to found correlation between DMFT level and its concentration.

Funding None

COMPETING INTERESTS None declared

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

AABS; 3(3): 2016

References

1. Cypriano S, de Sousa Mda L, Wada RS. [Evaluation of simplified DMFT indices in epidemiological surveys of dental caries]. Revista de saude publica. 2005 Apr;39(2):285-92. PubMed PMID: 15895150. Epub 2005/05/17. Avaliacao de indices CPOD simplificados em levantamentos epidemiologicos de carie dentaria. por. 2. Akrad ZT, Beitollahi J, Khajetorab A. DMFT (Decayed, Missing, Filled, Teeth) Oral health index in sweets and cable industry workers. 2006. 3. Cheng Y-C, Huang H-K, Wu C-H, Chen C-C, Yeh J-I. Correlation between dental caries and diet, oral hygiene habits, and other indicators among elementary school students in Xiulin Township, Hualien County, Taiwan. Tzu Chi Medical Journal. 2014;26(4):175-81. 4. Pehrsson P, Perry C, Cutrufelli R, Patterson K, Wilger J, Haytowitz D, et al. Sampling and initial findings for a study of fluoride in drinking water in the United States. Journal of Food Composition and Analysis. 2006;19:S45-S52. 5. Nazemi S, Raei M. Fluoride concentration in drinking water in Shahroud (Northern Iran) and determination of DMF index in 7 year old children. J Occup Health Epidemiol. 2012;1(1):50-5. 6. Aghdasi H, Borujeni FG, Behzadpoor M, Hoseini F, Habibzadeh T. A survey of relationship between drinking water fluoride concentration and dmft index in guidance school students: a case study piranshahr and poldasht, west azarbayjan. Urmia Medical Journal. 2014;25(3):199-207. 7. Basir L, Khanehmasjedi M, hosein Haghighi M. Evaluation and comparison of floozies and DMFT and their relation with the amount of fluoride in three flowing source of drinking water (Karoon, Maroon, Karkheh) in 12-15 years old students in Khozestan 2002. journal of Dental School. 2008;24(1). 8. Mohammadi AA, Mahvi AH, Khafajeh AA. Evaluation of fluorine concentration in ground waters supplies in cities and villages Khaf county in Razavi Khorasan province (Iran). 9. Shidfar F, Aghilinejad M, Ameri A, Motavalian S, Radfar A, Hoseini S. Determination of DMF index among workers of industrial city of Ilam-Iran and it’s relation with Fluoride content of potable water. Iran Occupational Health. 2007;4(3):64-8. 10. Dindarloo K, Jamali HA, Lakbala P, Valizade H, Azad M, Mahmodi H. Determination of fluoride concentration in drinking water and its relation with DMFT: A case study in Hormozgan, Iran. Journal of Basic Research in Medical Sciences. 2016;3(3):28-36. e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-226

11. del Socorro Herrera M, Medina-Solis CE, MinayaSánchez M, Pontigo-Loyola AP, Villalobos-Rodelo JJ, Islas-Granillo H, et al. Dental plaque, preventive care, and tooth brushing associated with dental caries in primary teeth in schoolchildren ages 6–9 years of Leon, Nicaragua. Medical Science Monitor : International Medical Journal of Experimental and Clinical Research. 2013;19:1019-26. PubMed PMID: 24247119. 12. Azami-Aghdash S, Ghojazadeh M, Pournaghi Azar F, Naghavi-Behzad M, Mahmoudi M, Jamali Z. Fluoride Concentration of Drinking Waters and Prevalence of Fluorosis in Iran: A Systematic Review. Journal of Dental Research, Dental Clinics, Dental Prospects. 2013 Winter;7(1):1-7. PubMed PMID: 23486733. 13. Organization WH. Oral health surveys: basic methods: World Health Organization; 2013. 14. Bazrafshan E, Kamani H, Kord Mostafapour F, Mahvi AH. Determination of the Decayed, Missing, Filled Teeth Index in Iranian Students: A Case Study of Zahedan City. Health Scope. 2012;1(2):84-8. Epub 2012-07-31.

15. Davil M, Mazloomi S, Heibati B, Miranzadeh M, Heidari M. Drinking water fluoride concentration and its relationship with decayed, missing, and filled teeth index in Mianeh, Iran2013 January 1, 2013. 15- p. 16. Ramezani GH, Valaei N, Eikani H. Prevalence of DMFT and fluorosis in the students of Dayer city (Iran). Journal of the Indian Society of Pedodontics and Preventive Dentistry. 2004 Jun;22(2):49-53. PubMed PMID: 15491085. Epub 2004/10/20. eng. 17. Mahvi A, Zazoli M, Younecian M, Nicpour B, Babapour A. Survey of fluoride concentration in drinking water sources and prevalence of DMFT in the 12 years old students in Behshar City. J Med Sci. 2006;6(4):658-61. 18. Rahmani A, Rahmani K, Dobaradaran S, Mahvi AH, Mohamadjani R, Rahmani H. Child dental caries in relation to fluoride and some inorganic constituents in drinking water in Arsanjan, Iran. Fluoride. 2010;43(4):179-86. 19. Crittenden JC, Trussell RR, Hand DW, Howe KJ, Tchobanoglous G. MWH’s water treatment: principles and design: John Wiley & Sons; 2012.

http://www.pacificejournals.com/aabs

Original Article Evaluation of the Environmental Situation at Public Areas of Tirana by using Stray Dogs as Biomonitor Violeta Zanaj1, Dhimitër Rrapti2 Universiteti “Aleksandër Moisiu”, Durrës, Albania 2 Universiteti Bujqësor i Tiranës, Albania

Keywords: Biological Pollution, Contamination, Parasitic Fauna, Prevalence, Stray Dogs

ABSTRACT Fecalization of green space of towns in Albania is the extreme displaying of the dog’s pollution, who with faeces in these environments eliminate the causes of parasitic zoonoses they are given the status of contaminated environments. The aim of this study is to evaluate the environmental situation in the public areas of Tirana city by using stray dogs as biomonitor. The prevalene of infestation of stray dogs from intestinal fauna is reflected in the level of contamination of public areas that they frequent. For calculation of the prevalence of the infestation are gathered and analyzed with coproscopi 240 samples of faeces by stray dogs in 3 public areas of Tirana. The average prevalence of stray dog’s infestation from parasitic fauna was 77.5%. So are found: E.granulosus, D. caninum, T. hydatigena, M. lineatus, Ancylostomum spp, Uncinaria spp, T. canis, T. leonina, Trichuris spp, Giardia spp and Coccidia spp. Public areas of the capital city are more polluted by parasitic fauna of dogs because 77.5% of stray dogs that frequent resulted infested by these parasites. The territories that have many trees are more contaminated because the conditions under the shadows of trees are ideal for the longevity of exogenous stages of parasites. Contamination of public places from invasive stages of the dogs intestinal parasites is higher in the spring and autumn (p-value = 0.0001665).

*Corresponding author: Violeta Zanaj, Universiteti “Aleksandër Moisiu”, Durrës, Albania. E-mail: vzanaj@gmail.com

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

Original Article

A-228

Introduction:

“The world exists only by the dog’s intelligence.” These words are written in Vendidad, the oldest and most authentic first texts of humanity (8). The dog is the only animal that has followed the man across all over the Earth since the ancient times. In modern times the relations with this faithful and noble friend are resized, especially in terms of its use in the treatment of stress, neurosis,the eliminaton of loneliness, etc. Resizing of its usages has shortened the distance between him and the man in the family environment, in many cases it considered and treated as a family member. But we should not forget that the dog being the best friend of man, is even more dangerous for our health, if we do not take care for his health (1,6,7,14,21,22). Likely the man also the dog, is infected by many viral, microbic and parasitic diseases. Due to the numerous morphological and physiological similarities (likely the man and dog are omnivor mammals and live in the same environment) some diseases can be transmitted to the man by many different ways. The main factor for infection the man and pets due to the dogs parasitic zoonoses is the presence of stray dogs in the same environment, who due to ignorance of the danger posed by them (7, 14, 17, 20) and the speed of multiplication are adding more in the streets and other areas of our towns.There is estimated that in Tirana are about 15’000 stray dogs who mostly move or relax in the green areas of the city. Being numerous stray dogs are the main contributors the fecalization and denatyre of public areas. A ground covered by faeces is a good bed for the development of molds and mushrooms known as the primary cause of allergies in humans (13), but in such environment are created ideal conditions for the development of eggs of parasites zoonotic carried by dewormings dogs. In a study conducted in Tirana by a group of authors (18) is shown that 88.3% of dogs were infected by various representatives of intestinal helminthofauna. Public areas contaminated by dogs, are transformed from entertainment and recreational facilities in areas where

people and animals take different infections, which in some cases may seriously endanger their health and lifes.The aim of this study is to assess the environmental situation in public spaces in Tirana by using stray dogs that frequent these environments as biomonitor, aiming to raise the awareness of the community and local government on the importance of monitoring constantly the environmental sanitation, the planning and implementation measures that will minimize the risks to public health from environment with biological contamination.

Materials and Methods

The evaluation of environmental purity in Tirana, we have conducted by monitoring over a period of two years the level of stray dog’s infestation by intestinal fauna that frequented the public areas at three urban zones: Kavaja Street, river Lana and Park Lake. As biomonitor we have used stray dogs because they are really accumulators of intestinal parasitic fauna and as such are the main contaminants of public spaces with these parasites exogenous stages. The level of infestation of stray dogs will be appreciated by two indicators: prevalence of infestation and diversity of invasive species. Through prevalences we will find the quantitative evalutation of infestation, and through the diversity of invasive species we have the opportunity to evaluate the dangerousness of infestation. To calculate the parameters of these indicators there are gathered and analyzed with coproscopi (3, 5, 15, 19) 240 samples of stray dogs faeces that frequented the three urban public areas monitored. In each zone there were set 5 monitoring points, at the distance 200 -300 m from each other (a total of 15). In each monitoring point were collected two samples of faeces from stray dogs once in every season during two years (2013 and 2014). The analyses were conducted at the Institute of Food Safety and Veterinary of Tirana. Types of intestinal fauna were identified by taxonomic keys of eggs, proglotids and oocysts that were discovered during the application of qualitative and quantitative coproscopic techniques (3, 15).

Result

Table 1: The data of parasites species identified in faeces of stray dogs during 2013 and the infestation prevalence in relation with the seasons

Saeson

No. of dogs

E. granulosus

Cestodë të tjerë

Ancylostomum sp & Uncinaria sp

Toxocara canis

Toxascaris leonina

Trichuris sp

Giardia sp

Coccidia sp

Seasonal prevalence of dogs infestation of all parasites

The infestation prevalence in %

Spring Summer Autumn Winter Total

30 30 30 30 120

4(13.3%) 4(13.3%) 3(10%) 2(6.6%) 13(10,8%)

12(40%) 6(20%) 9930%) 8(26.6%) 35(29,16%)

5(16.6%) 4(13.3%) 4(13.3%) 4(13.3%) 17(14,16%)

7(23.3%) 3(10%) 5(16.6%) 3(10%) 18(15%)

5(16.6%) 3(10%) 5(16.6%) 3(10%) 16(13,33%)

6(20%) 3(10%) 5(16.6%) 6 (20%) 20(16,66%)

8(26.6%) 4(13.3%) 8(26.6%) 4(13.3%) 24(20%)

13(43.3%) 9(30%) 10(33.3%) 9(30%) 41(34,16%)

27(90%) 21(70%) 23(76.6%) 20(66.6%) 91(75.8%)

http://www.pacificejournals.com/aabs

A-229

AABS; 3(3): 2016

Table 2: The data of parasites species identified in faeces of stray dogs during 2014 and the infestation prevalence in relation with the seasons

Saeson

No. of dogs

E. granulosus

Cestodë të tjerë

Ancylostomum sp & Uncinaria sp

Toxocara canis

Toxascaris leonina

Trichuris sp

Giardia sp

Coccidia sp

Seasonal prevalence of dogs infestation of all parasites

The infestation prevalence in %

Spring

4(13.3%)

12(40%)

6(20%)

9(30%)

5(16.6%)

10(33.3%

8(26.6%)

16(53.3%

26(86.7%)

Summer 30

8(26.6%)

5(16.6%)

6(20%)

1(3.3%)

4(13.3%)

7(23.3%)

10(33.3%

24(80%)

Autumn

3(10%)

5(16.6%)

6(20%)

3(10%)

8(26.6%)

7(23.3%)

23(76.7%)

Winter

1(3.3%)

4(13.3%)

8(26.6%)

3(10%)

4(13.3%)

5(16.6%)

10(33.3%

22(73.3%)

Total

120

8 (6,66%)

36(30%)

20(16,66%)

29(24,16%) 12(10%)

26(21,66%)

27(22,5%)

47(39,16%) 95(79.2%)

Table 3: Data of parasites species identified in faeces of stray dogs during the two years together and the infestation prevalence in relation with the seasons

No. of dogs

E. granulosus

Cestodë të tjerë

Ancylostomum sp & uncinaria sp

Toxocara canis

Toxascaris leonina

Trichuris sp

Giardia sp

Spring

8(13.3%)

24(40%)

11(18.3%)

16(26.6%)

11(18.3%)

17(28.3%)

16(26.6%)

29(48.3%)

53(88.3%)

Summer

4(6.6%)

14(23.3%)

9(15%)

4(6.6%)

7(11.6)

11(18.3%)

19(31.6%)

45(75%)

Autumn

6(10%)

18(30%)

9(15%)

11(18.3%)

8(13.3%)

13(21.6%)

15(25%)

21(35%)

46(76.6%)

Winter

3(5%)

15(25%)

8(13.3%)

11(18.3%)

6(10%)

10(16.6%)

9(15%)

19(31.6%)

42(70%)

Total

240

21(8,75%)

71(29,6%)

37(15,4%)

47(19,5%)

29(12%)

47(19,6%)

51(21,2%)

88(36,6%)

186(77.5%)

Coccidia sp

Saeson

Seasonal prevalence of dogs infestation of all parasites

The infestation prevalence in %

Fig. 1: The infestation prevalence of stray dogs from intestinal fauna by year in %

Fig. 2: The prevalence of stray dogs infestation from intestinal parasitic fauna in relation to the season when it is important the monitoring of environmental situation

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-230

Fig. 3: The prevalence of stray dogs infestation from intestinal parasitic fauna in relation to urban areas where the environmental condition is monitored Table 4: Intestinal parasitic fauna species identified in faeces of stray dogs in the three urban areas where the environmental condition is monitored Public areas

The types of intestinal parasites that have been identified in faeces of dogs

Kavaja Street

E.granulosus

Others cestods

Ancylostoma spp & Uncinaria spp

T.canis

T. leonina

Trichuris spp

Giardia spp

Coccidia spp

Lana River

E.granulosus

Other cestod

Ancylostoma spp & Uncinaria spp

T.canis

T. leonina

Trichuris spp

Giardia spp

Coccidia spp

Park

E.granulosus

Other cestod

Ancylostoma spp & Uncinaria spp

T.canis

T. leonina

Trichuris spp

Giardia spp

Coccidia spp

P.s. Other cestods = Taenia hydatigena, Dipylidium caninum and Mesocestoides lineatus

Discussion

Numerous buildings and disregard of urbanization plans in most of our towns has reduced to extreme the green areas and generally what are called public space. Consequently those few public facilities are most frequented from citizens, accompanying animals and stray dogs. These are the only territories when they can live. Being out any care the stray dogs have a high load of intestinal fauna, exogenous stages of which derive in the external environment with faeces during defecation. For this reason they have become main contaminants of public spaces with faeces and parasitic pathogens, which through the legs of animals and of people, of arthropods and worms, wind, water, and via extensions of molds are distributed and contaminate the entire territory of the public areas. Table 1 shows the data on the parasites species that are found in faeces of stray dogs in 2013 and the prevalence of infection in relation to the seasons. By cestodes we have identified: Echinococcus granulosus, Dipylidium caninum, Taenia hydatigena, and Mesocestoides lineatus. The last three types for reasons of space are not presented

separately in the table but are named “others cestods”. By nematodes have identified: Acylostomatides (Ancylostoma spp and Uncinaria spp), Toxocara canis, Toxascaris leonina and Trichuris spp. By zoonotic protozooa have identified Giardia spp and Coccidia spp. Our results do not differ with those of the literature (2, 6, 11, 12, 13, 15). Prevalenvca average of infestation of stray dogs by representatives of the intestinal fauna that we identified through coproscopic analysis during the first year of a monitoring (2013) was 75.8%. The position of each individual parasite prevalence level of infestation would be: E.granulosus (10.83%) <T.leonina (13.3%) <Ancylostomatides (14:16%) <T.canis (15%) <Trichuris spp (16.6% ) <Giardia spp (20%) < Other Cestod (29.16% <coccidia spp (34.16%). So, it results that ccocidia spp and group “cestod others” are parasites more frequently in stray dogs. E .granulosus is parasite with a lower frequency (10.83%), but we should not forget that it is the cause of cystic echinococcus, one of the most dangerous zoonoses for humans and animals (1, 16, 22). During 2014, the average prevalence of dog’s infestation (Table 2) was 79.2% or 3.4% higher than in 2013. The order of each individual parasite infestation prevalence was: E.granulosus (6.6%) <T.leonina (10%) <Ancylostomatidet (16.66%) <Trichuris spp (21.6%) <Giardia spp (22.5%)

http://www.pacificejournals.com/aabs

A-231 T.canis (24.16%) < Other Cestod (36.6%) <Coccidia spp (39.16%). Even during this year, the most frequent parasites were the Ccocidia spp and the group “Other cestods”. Table 3 reflectes all the results of coproscopic analysis for the entire period of the experiment (two years). The average prevalence of dog’s infestation from intestinal parasites was 77.5%. The ccocidia spp stay in the highest position and lowest position is E.granulosusin in terms of individual infestation prevalence belongs for two years together. The differences between the average prevalence of infestation for the years 2013 and 2014 are random and are not confirmed by statistical analysis. Our results are similar to those reported in the literature. In a study conducted several years ago in the peri-urban area of Tirana resulted infested by intestinal fauna 88.3% of dogs (18), while in a study of this type orientied to family dogs perform in Germany (2) it reported that the prevalence of infestation was 32.2%. Approximate results reported by other researchers (10, 11). Prevalence of stray dogs infestation from zoonotic parasites that live and move in Tirana’s public areas is very high (77.5%). It is the direct result of the lack of care and the way they provide food. They are feed mainly in containers where the waste is collected and when they are hungry predated small rodents, arthropod and different soil worms. It is known that these groups of creatures are the paratenic hosts of dog’s intestinal parasites (5, 15, 19). The high prevalence of stray dog’s infestation from intestinal parasitic fauna is reflected in the level of contamination of the public areas. The higher is the degree of environmental contamination, the higher will be the pressure of the polluted environment on the health of the community who frequent it. Fig.2 reflectes the general trend of the level of stray dog infestation prevalence in relation to seasonal (winter 70% <summer 75% <autumn 76.6% <spring 88.3%.). Statistical analyzes have confirmed the seasonal impact on the prevalence of stray dogs infestation from zoonotic intestinal parasites (p-value = 0.0001665). Spring weather conditions favor the development and lifetime of exogenous stages of dogs intestinal fauna in the external environment, so during the spring and fall the infestation level is higher than during in winter and summer (5, 15, 19). The results of coproscopic analysis in relation to public areas where environmental health monitoring are reflected in the Fig.3. It is presented clearly the histogram of infestation prevalence of stray dogs that changes from Kavaja Street with 72.5% going up to 73.5% to River Lana and ends at Park with 86.25%. Stray dogs that attend territorial of park resulted in the highest level of Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

AABS; 3(3): 2016 infestation because due to numerous trees found in Park, exogenous parasites intestinal stages are protected from solar radiation that is lethal for them and at the same time provided normal humidity to develop throughout the year. In addition the park has more than anywhere else rodents, birds, arthropods and annelid worms that serve as a reservoir of dog’s intestinal fauna. From this result we come to the conclusion that the environments where there are more trees are more contaminated by exogenous stages of dogs zoonotic intestinal parasites compared to public areas where trees are absent. Another indicator with which is estimated infestation of stray dogs is the diversity of parasitic fauna, referring to the number of parasites species identified in stool of stray dogs in the three territories and the intervals of time when monitoring is performed. By identifying parasites’ types and knowing the pathogenicity of any we evaluate dangerousness of infestation. Regardless of season, year and environment where faeces are collected through coproscpic analysis are identified always the same representatives of the intestinal fauna of dogs. These results are presented in Table 4. So this phenomenon finds explanation to what we mentioned above that, stray dogs live in groups and are always on the move throughout the territory of the towns in search of food (despite the return to rest in preferred territories). In this way they come in contact with contaminated environments by their homologous realizing crossed infestation and the homogenisation of pollution in all urban spaces. Finally are identified all the representatives of intestinal parasitic fauna of dogs that were described at the beginning of the discussion. So, in public areas of our towns can be infected from all species of zoonotic intestinal parasites of dogs, no matter the season and the fact that the frequented areas are at center or peripheral part of the town.

Conclusion

1. Public areas of the capital city are polluted by exogenous stages of dog’s parasitic zoonotic fauna, because 77.5% of stray dogs that frequented resulted infested by these zoonotic parasites. 2. Biological pollution of public areas by dog’s zoonotic intestinal fauna from the risk posed to public health is uniform throughout the territory of Tirana because the stray dogs that are carriers and spreaders of its move in search of food from one territory to another . 3. Contamination of public places from invasive stages of the dogs intestinal parasites with zoonotic highlighted character is higher in the spring and autumn (p-value = 0.0001665). e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-232

4. Public environments where there are many trees are more contaminated because the territories under the shadow of trees create ecological ideal nursery for the development and lifetime of exogenous stages of dogs intestinal parasites 5. To minimize pollution public spaces in the towns for stray dogs we recommend: a) capture, sterilization and their periodic deworming; b) as the many part of stray dogs originate from rural areas, to be stop by the law the omission of dogs in the urban area.

Funding

10. 11.

12. 13.

None

Competing Interests

14.

None declared

Reference

1. Alain Villeneuve Les zoonoses parasitaires. 2003 2. Barutzkia D, Schaper R.Endoparasites in Dogs and Cats in Germany 1999–2002.Info_waavp 2003 3. Bauer Ch.: Praktikum der Veterinar Medizinchen Parasitologie. Verlage der Ferberlschen Universitat buchhandlung, 1995. 4. Biopollution and invasive species. International center for technology assessment.www.icta.org/globalwarming-and-the.../biopollution-invasive-species/‎ 5. Casarosa L. : Parassitologia degli Animali Domestici. Seconda Edizione. C. G.Edizioni Medico Scientifiche. Torino.1980. 6. Cosme Alvarado-Esquivel 2013.Toxocariasis in waste Pickers: A Case Control Seroprevalence Study January 22, 2013DOI: 10.1371/journal.pone.0054897 7. Christopher M Watson, F Edward Hebert .2012. Pediatric Hookworm Infection . 8. Dominique Guillo. Les chiens et les humains. 2009 9. Elliott, M. Biological pollutants and biological

15.

16. 17. 18.

19.

pollution - an increasing cause for concern. Marine Pollution Bulletin, 2003,46, 275-280. Gastrointestinal parasites in small animals. Merck Veterinary Manual, 2014-2015 le Nobel W.E, Robben S.R, Döpfer D, Hendrikx .M, &.2004 Infections ëith endoparasites in dogs in Dutch animal shelters.Tijdschr Diergeneeskd. 2004 Jan 15;129(2):40-4. Overgaauw PA.Prevalence of intestinal nematodes of dogs and cats in The Netherlands.. Vet. Q., 19 (1997) Parasitic Roundworms Diseases. NIAID Fact Sheet. National Institute of Allergies and Infectious Diseases. 2007. 99 Paul A.M. OvergaauwFrans van Knapen. Veterinary and public health aspects of Toxocara sppVet. ParasitologyVolume 193, Issue 4, 15 April 2013, Pages 398–403 Soulsby E.J.L.Helminths, Arthropods and Protozoa Of Domesticated Animals. Seventh Edition.Lea Febiger. Philadelphia, 1982 Tobiasen J. Zoonotic Disease. Crosby. Vet. Med. 2011 Veterinary Medical Information for Dog and cats. http://Vetinfo.com. Dog ëorms 2011 Xhaxhiu D& Kusi I & Rapti Dh & Kondi K& Postoli R & Rinaldi L&. Principal intestinal parasites of dogs in Tirana, Albania. Parasitol Res (2011) 108:341–353 Zanaj S. Parazitologjia e përgjithshme dhe helmintologjia veterinare. 1998.Univ.Bujq. i Tiranës.

20. Zanaj S, Koli P, Hysenbegaj V. (2006).Helmintët parazitarë të qenve të rrugës një rrezik i përhershëm për shëndetin publik. Rev Mjekësore 3:105–11. 21. Zoonotic Diseases & Dogs Toxocariasis. Oregon Veterinary Medica Association 2011 22. Zoonotic Diseases. Dogs & Pets Parasites . Oregon Veterinary Medica Association 2011

http://www.pacificejournals.com/aabs

Original Article Histomorphological Spectrum of Skin Adnexal Tumours : A Retrospective Study in a Tertiary Care Centre G Jeyanthi.1, Meenakumari Gopalakrishnan2, N. Sharmila Thilagavathy.3, S. Shifa4, K. Kamaleshwari.5 Department Of Pathology, Madurai Medical College, Madurai, Tamilnadu, India Keywords: Genetic inherited syndrome, Hair follicle, Eccrine, Apocrine differentiation.

ABSTRACT Background: Skin Adnexal Tumours (SATs ) are large and divergent group of tumours which are classified based on their appendageal differentiation into eccrine,follicular,sebaceous and apocrine.They pose daunting diagnostic challenges to both clinicians and pathologists alike.This study aims to evaluate the histopathological charecterestics of skin adnexal neoplasms and correlate with their clinical profile. Methods: This is a retrospective study of skin adnexal tumours (28 cases) diagnosed on histopathological examination over a period of two years .( January 2014 to December 2015 ). Results: Skin adnexal tumours are uncommon lesions with an incidence of 0.27%.These tumours were common in the 51 to 60 age group and showed a female preponderance. Head and neck region particularly the scalp was commonly involved. Benign tumours were more common (78.6% ) than the malignant ones (21.4%). .Sweat gland tumours constituted the largest group (61%) followed by hair follicle tumours (21%)and sebaceous tumours (14%).Apocrine gland tumours were less common. Nodular hidradenoma was the most common benign tumour and sebaceous carcinoma was the most common malignant tumour encountered in the present study. Conclusion: SATs are relatively uncommon lesions and have distinct histopathological features. Clinical diagnosis is difficult as most of these lesions are nondescript and histopathological examination is essential for its diagnosis.

*Corresponding author: Dr. G. Meenakumari, 23, Suryanagar First Street, K. Pudur, Madurai, Tamilnadu, India, 625007 Phone: +91 9994901811 E-mail: meenakumariilango1971@gmail.com

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

Original Article

A-234

Introduction

presentation, associated syndromes if any ,were tabulated and correlated with the histopathologic diagnosis.

Skin adnexal tumours (SATs) poses a diagnostic challenge to both the treating clinician as well as the dermatopathologist since a similar looking nodule or papule show a wide histopathological spectrum. The spectrum ranges from a benign adnexal tumour that is cured with excision to a malignant counterpart that is locally aggressive and has a potential for distal metastasis. These adnexal tumours arise from the pluripotent stem cells that differentiate along one or more primary adnexal structures including eccrine ,follicular, apocrine and sebaceous glands or may differentiate along multiple cell lines .[1]Although the site and distribution of the lesions provide some clue to the diagnosis, histopathology is indispensable in the diagnosis of SATs.[2] Few clinicopathological studies on skin adnexal tumours are available in the literature. This study aims at histopathological analysis and clinicopathological correlation of the skin adnexal tumours in our tertiary care hospital.

Result

Out of total 10,303 specimens received in our department during this period ,28 cases were skin adnexal tumours ,incidence being 0.27%. In the present study ,SATs were observed in all age groups ranging from 10 to 96 years. The highest incidence was observed in the 51 to 60 age group. (9/28 cases , 32.1 % ) followed by 61 to 70 age group (6/28 21.4 %).out of the 28 cases 16 were females with a male :female ratio of 0.75:1 (Table 1 ) Histologically 22 were benign (78.6%) and 6 malignant tumours.(21.4 %). (Figure 1). Sweat gland tumours constituted the largest group (17/28 cases, 61 %) followed by hair follicle tumours (6/28, 21 %) and sebaceous tumours .(4/28,14%).(Figure 2). Clinically most cases presented as nodules and cysts. Head and Neck region , particularly the scalp was commonly involved. Table 2 depicts the various types of skin adnexal tumours encountered in the present study and their clinical presentation and diagnosis.

Materials and Methods

This is a retrospective study spanning over a period of two years from January 2014 to December 2015 in our tertiary care teaching hospital. The clinical records of the cases diagnosed as Skin adnexal tumours in our department of Pathology, Madurai Medical College were retreived . All the slides from these cases were reviewed by a panel of pathologists. Special stains like PAS stain was done wherever necessary. The age, gender, site, clinical

Nodular hidradenoma was the most common benign tumour in the present study (6/28 cases ). Out of the 6 malignant tumours reported in the present study ,3 were sebaceous carcinoma and 3 were malignant sweat gland tumours. All the 6 malignant tumours encountered in the present study were seen above 50 years of age.

Table 1: Age and Sex Wise Distribution ADNEXAL TUMOURS

MALE

FEMALE

0-10 YRS

1. Nodular hidradenoma

2. Cylindroma

3. Chondroid syringoma

11 -20 YRS

21 3141 51-60 61 71 -30 40 -50 YRS -70 -80 YRS YRS YRS YRS YRS

SWEAT GLAND TUMOURS BENIGN

4. Spiradenoma 5. Eccrine poroma

1 1

2 1

1 1

MALIGNANT 6. Porocarcinoma

7. Ductal eccrine adenocarcinoma

8. Adenoid cystic carcinoma

1 1 1

HAIR FOLLICLE TUMOURS

http://www.pacificejournals.com/aabs

81-90 91 AND YRS ABOVE

A-235 ADNEXAL TUMOURS

AABS; 3(3): 2016 MALE

FEMALE

9. Trichoepithelioma

10. Pilomatricoma

0-10 YRS

11 -20 YRS

21 3141 51-60 61 71 -30 40 -50 YRS -70 -80 YRS YRS YRS YRS YRS

81-90 91 AND YRS ABOVE

BENIGN

11. Trichilemmoma

APOCRINE GLAND TUMOURS BENIGN 12. Syringocystadenoma papilliferum

SEBACEOUS GLAND TUMOURS BENIGN 13. Sebaceoma

MALIGNANT 14. Sebaceous carcinoma

TOTAL

Fig. 1:

Fig. 2:

Table 2: Clinical Presentation and Diagnosis ADNEXAL TUMOURS

NO. OF CASES

SITE

CLINICAL PRESENTATION/CLINICAL DIAGNOSIS

1. Nodular hidradenoma

Scalp(3) Face (1) Luteal region (1) Abdomen(1)

Dermato fibroma,(3),sebaceoma(1) sebaceous cyst (2)

2. Cylindroma

Face (3) Scalp (1)

Nodule (2) Cyst (1) Associated with Brooke Spiegters syndrome.(1)

3. Chondroid syringoma

Upper lip (1) Ear (1)

Cyst (2)

SWEAT GLAND TUMOURS BENIGN

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-236

ADNEXAL TUMOURS

NO. OF CASES

SITE

CLINICAL PRESENTATION/CLINICAL DIAGNOSIS

4. Spiradenoma

Arm (1)

Nodule (1)

5. Eccrine poroma

Scalp(1)

Nodule(1)

Thigh (1)

Squamous cell carcinoma(1)

7. Ductal eccrine adenocarcinoma 1

Chest(1)

Skin nodule(1)

8. Adenoid cystic carcinoma

Scalp (1)

Cyst (1)

9. Trichoepithelioma

Scalp (1) Nape of neck(1) Thigh(1)

Cyst(1) Nodule (2)

10. Pilomatricoma

Scalp (2)

Dermoid cyst(1) Sebaceous cyst(1)

11. Trichilemmoma

Scalp(1)

Squamous cell carcinoma(1)

Umbilicus(1)

Nodule(1)

Scalp (1)

Squamous cell carcinoma(1)

Eyelid (1) Scalp (2)

Squamous cell carcinoma (3)

MALIGNANT 6. Porocarcinoma

HAIR FOLLICLE TUMOURS BENIGN

APOCRINE GLAND TUMOURS BENIGN 12. Syringocystadenoma â&#x20AC;&#x2030;papilliferum SEBACEOUS GLAND TUMOURS BENIGN 13. Sebaceoma MALIGNANT 14. Sebaceous carcinoma

Discussion

Skin appendageal tumors are large and divergent group of tumours which are classified into 4 main groups based on their differentiation into adnexal structures present in normal skin: hairfollicle, sebaceous, apocrine and eccrine glands.[3]Some exhibit multilineage differentiation as the tumour originate from multipotential undifferentiated cells present within the epidermis or appendageal structures.[1] SATs are relatively uncommon tumours.In our study the incidence was 0.27% which is in concordance with the study by Chayanika Pantola et.al.[4] Wide range of age distribution was observed in the present study with the commonest age group being 51 to 60 years. Similar observations were made in the study by Ankit et.al.[5]There was a female preponderance in the present study with a male:female ratio of 0.75:1 which correlated with other studies.[6,7] Clinical diagnosis of SATs is often rendered difficult as most of them present as nodules ,cysts and papules. In the

present study correlation between clinical and histological diagnosis was observed in only few cases similar to studies by Radhika et.al.[7] Skin adnexal neoplasms are clues to hereditary tumour syndrome such as Brooke- Spiegter (Cylindroma), Cowdens syndrome (Trichilemmoma) and Muir Torre syndrome (sebaceous tumours). [8]In our study we received a case of cylindroma associated with Brooke â&#x20AC;&#x201C; Spiegter syndrome. SHTs were common in the head and neck region as in the studies by Ankit et.al and Radhika et.al.[5,7] Most SATs are benign tumours and incidence of malignant tumours is low .In our study too benign tumours were more common (78.6 %) which was in par with studies by Ankit et.al and Vani et.al .[5,6] In the present study tumours with eccrine differentiation were the commonest ( 61%) followed by hair follicle ( 21%),sebaceous ( 14%) and apocrine differentiation . ( 4%) Similar observations were reported in studies by Vani et.al and Radhika et.al. [6,7] Nodular hidradenoma was the most frequent tumour

http://www.pacificejournals.com/aabs

A-237 encountered in the present study as in studies by Chayanika Pantola et.al,Vani et.al and Radhika et.al . [4,6,7] Tumours with eccrine differentiation : In the present study, 6 cases of nodular hidradenoma were reported. They were common in females (4/6 cases ) and occurred in the head and neck region commonly involving the scalp. Similar observations were reported by Chayanika Pantola et.al and Gayathri et.al. [4,9] In the present study, clinically 3 cases were diagnosed as dermatofibroma,one as sebaceoma and two as sebaceous cyst. Histologically these tumours are composed of nodules and nests of monomorphous polyhedral cells with small ductular lumens. Clear cell change may be seen. 4 cases of cylindroma were encountered in the present study. They were also common in females involving head and neck region. In the present study, one case was associated with Brooke-Speigter syndrome. It is an inherited syndrome associated with cutaneous adnexal lesions such as spiradenoma, cylindroma, trichoepithelioma and basal cell adenoma of salivary gland.[10] Histologically cylindromas are charecterized by many well defined variably sized islands of central large cells and peripheral small basaloid cells surrounded by thick PAS positive basement membrane like material imparting “jijsaw puzzle “pattern.(Figure 3 )

AABS; 3(3): 2016 One case of spiradenoma and one case of eccrine poroma were seen in the present study.Spiradenoma orginate from the straight intradermal eccrine duct and present as a solitary painful nodular lesion in young adults commonly involving upper extremities and trunk. However in our study it was seen in an elderly female presenting as a nodule involving the arm. They occur as a well circumscibed nodule in the dermis composed of large cells with vesicular nuclei ,pale abundant cytoplasm and small cells with hyperchromatic nuclei and scant cytoplasm. Perivascular space which is an important histological clue first described byVan Den Oord and Chris De Wolf Peters in 1998 [11] was observed in our case. Poromas orginate from the outer cells of intraepidermal excretory ducts of sweat gland commonly involving palms and soles.They are composed of nodules of basaloid cells. (Figure 4). In our study, poroma presented as a nodule involving the scalp in an adult male.

Fig. 4: Eccrine poroma -Tumor cells grow in the form of cords and nest arising from the epidermis. (10 x. H & E)

Fig. 3: Cylindroma- Shows irregular nests of basaloid cells arranged in a “jigsaw” manner surrounded by a thick eosinophilic basement membrane.(10 x ,H & E )

Chondroid syringomas also called as mixed tumour of the skin were the next common tumor with eccrine differentiation reported in the present study.They commonly affect nose,cheek and upper lip.In the present study,out of the two cases reported one involved upper lip and other occurred in the neck region. Similar observations were made in the study by Gayathri et.al.[9] Histologically ,these tumours are similar to benign mixed tumour of salivary glands . Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

One case of Porocarcinoma was reported in the present study. It occurred as a growth involving the thigh and clinically it was diagnosed as squamous cell carcinoma. Porocarcinoma usually arise in a pre-existing benign poroid tumour and are found in the extremities as in our case. Histologically these tumours have infiltrative borders and tumour cells exhibit varying degrees of nuclear atypia and brisk mitotic activity. One case of ductal adeno carcinoma presenting as a nodule in the chest was reported in the present study. It is a malignant sweat gland tumour with the tumour cells exhibiting cytonuclear atypia, mitotic activity, lymphovascular invasion, perineural invasion and infiltrative growth pattern. e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-238

One case of adenoid cystic carcinoma encountered in the present study presented as a cyst involving the scalp in an elderly male. It is a very rare malignant tumour affecting older adults .It can occur in any anatomical site but more common in the scalp [12]which correlated with the present study. Histological appearance is similar to its salivary gland counterpart. Before diagnosing primary cutaneous adenoid cytic carcinoma, Salivary gland adenoid cystic carcinoma and adenoid Basal cell carcinoma should be excluded.

One case of Trichilemmoma involving scalp was reported in the present study. These are benign tumours arising from the outer root sheath of hair follicles. Clinically they present as a small papule or veruccous lesion involving the face of older adults. The tumour is composed of lobules of uniform cells with clear cytoplasm with basophilic cells arranged in a palisaded manner at the periphery ,surrounded by PAS positive diastase resistant Basement membrane material.(Figure 6 )

Tumours with follicular differentiation: In the present study 6 cases of SATs with hair follicle differentiation were reported. Of these, 3 cases were Trichoepitheliomas. One case presented as a cyst in the scalp and other two presented as nodule involving scalp and thigh. Trichoepitheliomas can be found in any area of hair bearing skin commonly involving head and neck region in adults. These tumours are composed of nests of basaloid cells with peripheral palisading surrounded by dense stroma. Keratin filled horn cysts are usually seen within the nests. Artefactual retraction is uncommon. 2 cases of Pilomatricoma both presenting clinically as a cyst involving scalp were encountered in the present study. Pilomatricoma commonly affects children and adolescents .They have predilection for head and neck and upper extremities. Early lesions are cystic. Histologically they are composed of uniform basaloid cells transformed into pale eosinophilic anucleated shadow cells admixed with keratin. (Figure 5 )Familial occurrence and multiple lesions are associated with Turners syndrome,Gardner syndrome and Rubinstein Taybi syndrome. They were not encountered in the present study.

Fig. 5: Pilomatrixoma (Calcifing epithelioma of Malherbe ).Showing two basic cell types: basaloid cells and â&#x20AC;&#x153;shadowâ&#x20AC;? or ghost cells.( 10 x, H & E)

Fig. 6: Trichilemmoma. Shows plate like growth of glycogen rich clear cells.( 10 x ,H & E)

Tumours with apocrine differentiation :One case of syringocystadenoma papilliferum presenting as a nodule in the umbilical region of a 96 year old male was reported in this study. These are benign tumours usually affecting young adults common in face and scalp. Histologically it is charecterized by papillary structures with a dermal fibrovascular core lined by two layers of epithelial cells. (Figure 7 )Marked plasmacytic infiltrate is present in the fibrovascular core.

Fig. 7: Syringocystadenoma papilliferum â&#x20AC;&#x201C; Shows papillae lined by two layers of epithelial cells. ( 10 x ,H & E)

http://www.pacificejournals.com/aabs

A-239 Tumours with sebaceous differentiation: One case of sebaceoma was reported in the present study. Sebaceoma formerly called as sebaceous epithelioma is a benign tumour composed of basaloid epithelial cells admixed with single or clusters of mature sebaceous cells. Sebaceous carcinoma was the most common malignant tumour encountered in the present study. Similar observations were made in the study by Hesari K et.al. [13] Sebaceous carcinoma predominantly arise from Meibomian glands or glands of Zeis in the eyelids. In our study one case had eyelid involvement and other two had involvement of scalp .All the three cases were clinically diagnosed as squamous cell carcinoma. Unlike sebaceous adenoma and sebaceoma, sebaceous carcinoma is charecterized by infiltrative growth pattern and composed of pleomorphic basaloid cells exhibiting increased mitotic activity. Sometimes it is difficult to differentiate it from clear cell squamous cell carcinoma and clear cell basal cell carcinoma. Cytoplasmic glycogen is less abundant in sebaceous carcinoma when compared to clear cell basal cell carcinoma and clear cell squamous cell carcinoma which can be demonstrated by PAS.[14] Immunohistochemically ,sebaceous carcinoma shows strong positivity for EMA (Epithelial Membrane Antigen )whereas squamous cell carcinoma stains weakly and Basal cell carcinoma is negative for this marker.

Conclusion

Skin adnexal tumours are infrequent lesions most commonly occurring in the fifth to sixth decade of life. They commonly involve the head and neck region. Benign tumours are more common than malignant ones. The clinical presentation is often nondescript with most of these lesions presenting as nodule and papule. Histologically it poses diagnostic difficulties to pathologists alike due to their wide spectrum and frequency of differentiation along different cell lines in the same lesion. Since histopathology serves as the gold standard for diagnosing skin adnexal tumours ,familiarity with the various presentation of these lesions is essential for the surgical pathologist.

Acknowledgements None

Funding None

Competing Interests None Declared

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

AABS; 3(3): 2016

Reference

1. Ahmed TS S, Priore JD and Seykora J T.Tumors of epidermal appendages. .Levers Histopathology of the Skin,D.E.Elder, R.Elenitsas, B.L.Johnson and G.F.Murphys,Eds, 9th edition,Lippincott Williams & Wilkins,Philadelphia,PA,USA,2005:867-868. 2. Stantaylor R,Perone J.B,Kaddu S and Kerlh. Appendage tumors and hamartomas of the skin , in Fitzpatricks Dermatology in General Medicine,K. Wolff,L.Goldsmith,S.Katz ,B.A.Gilchrest,A.S.Paller and D.J.Leffell,Eds.,7 th edition,McGraw Hill,New York,NY,USA,2008:1068-1087. 3. Elder D, Murphy G, Rubin A. Lever`s Histopathology of skin. In : Tumors of the epidermal appendages. Campbell L ,Stewart ,Robert A , Novoa,John T .Seykora.In: editors. 11th ed. Philadelphia: Wolters Kluwer; 2015. 4. Chayanika Pantola,Sanjay Kala,Asha Agarwal,Sonal Amit ,Saurabh Pantola.Cutaneous Adnexal Tumours: A Clinicopathological Descriptive study of 70 cases. World Journal of Pathology 2013;2:13 5. Sharma A,Paricharak D G, Nigam J S ,Rewri S,Soni P B,Omhare A et al, Histopathological study of Skin Adnexal Tumours – Institutional Study in South India,Journal of Skin Cancer 2014 .(2014) 6. Vani D,Ashwini N.S,Sandhya M,Dayananda T.R, Bharathi M. A 5 year histopathological study of skin adnexal tumours at a tertiary care hospital. IOSR Journal of Dental and Medical Sciences.2015;4:1-5. 7. .Radhika K, Phaneendra BV, .Rukmangadha N, Reddy MK.A study of biopsy confirmed skin adnexal tumours:experience at a tertiary teaching hospital. J Clin Sci Res 2013:2:132 -8. 8. Giovanni Ponti ,Giovanni Pellacani,Stefania Seidenari et al .Cancer -associated genodermatosis:Skin neoplasms as clues to heriditary tumour syndrome. Crit Rev Oncol Hematol. 2013;85(3): P.239-56. 9. Sri Gayathri S, Ezhilvizhi Alavandar,Ashok Kumar. An Analysis of skin appendageal Tumors in South India.Journal of Evolution of Medical and Dental Sciences.2013;1(6):907 -912. 10. Kanitakis. Adnexal tumours of skin as markers of cancer -prone syndromes. J Eur Acad Dermatol Venereol. 2010;24(4): P. 379-87. 11. Joost J.van den Oord,Chris De Wolf – Peters:Perivascular spaces in eccrine spiradenoma – A clue to its histological diagnosis.Am J Dermatopath.17(3):266-270,1995. e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-240

12. N A Obaidat, K O Alsaad, D Ghazarian .Skin adnexal neoplasms part-2;An approach to tumors of cutaneous sweat glands. J Clin Pathol. 2007;60: P. 145 - 159. 13. Hesari K, Balighi K, Afshar et al N. Cilinicopathological

study of 1016 consecutive Adnexal Skin Tumors. Acta Medica Iranica. 2013;15(12): P. 879-85. 14. A Neil Crowson , Cynthia M , Margo , Martin C.Malignant adnexal neoplasms.Modern Pathology, 2006 ;19:P. S 93 â&#x20AC;&#x201C; S 126.

http://www.pacificejournals.com/aabs

Original Article Study of Haematological Profile of Dengue Fever and its Clinical Implication Vibha V. Gajera1, Shilpi Sahu2, Reeta Dhar3 Dept. of Pathology, Mahatma Gandhi Mission Institute of Health sciences, Navi Mumbai, India Keywords: Dengue, thrombocytopenia, DHF, DSS

ABSTRACT Background: Dengue virus, a mosquito-borne human viral pathogen, has recently become a major national health problem.The disease is transmitted in rainy season. There are four dengue virus serotypes, called DEN-1, DEN-2, DEN-3, and DEN-4. The clinical manifestation of dengue infection varies from asymptomatic to severe life threatening illness in the form of DHF/DSS. Dengue haemorrhagic fever or DSS may be fatal in 40% to 50% of untreated patients. Laboratory diagnosis of dengue virus infection depends upon demonstration of specific antibodies in serum samples. Early diagnosis and monitoring is largely dependent on haematological parameters. As no specific antiviral therapy is available, supportive therapy is of most importance. Methods: NS1, Ig M & Ig G detection by Dengue Day 1 Test kit, haematological parameters by automated analyzer & peripheral smear, coagulation profile analysis by ACL-7000 coagulation meter, LFT by BACKMAN COULTER AU480. Result: Out of 100 cases, 95 (95%) of the patients had fever, 39 (39%) cases had leukocyte count <4,000/ mm3, thrombocytopenia (<1,00,000/mm3) was observed in 81, 48 cases had derranged LFT with thrombocytopenia,17 cases had prolonged APTT which correlated with thrombocytopenia, 14 cases had raised APTT & deranged LFT which also showed thrombocytopenia. Conclusion: Thrombocytopenia was most predominant haematological discrepancy. Most cases (70%) were of classical DF & (28%) were cases of DHF who had fever, showed thrombocytopenia & deranged haematological parameters which signifies disease severity. 2% cases presented with hypotension & altered consciousness with severe thrombocytopenia & prolonged APTT (DHF/DSS) which indicates very poor prognosis & had fatal outcome. Initial leukopenia & leukocyte count returning to normal by ninth to tenth day after therapy in most of the cases indicates that leukocyte count an important benchmark for clinical improvement. Dengue fever does not have specific medical therapy hence clinical recovery monitoring is largely dependent on haematological parameters.

*Corresponding author: Dr.Vibha V. Gajera, SARJU, 402/8/B, Alkapuri society, Near Shree Gattu Vidyalaya, GIDC, Ankleshwar, 393002, District-Bharuch, Gujarat, INDIA Phone: +91 9925238099 E-mail: drvibhagajera@gmail.com

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

Original Article

A-242

Introduction

coagulation or haemorrhagic lesions. Damage to circulatory vessels appears to occur when antigen antibody complexes activate the complement system with the release of cytokines7.All these inflammatory response produces vasculopathy and also increases shock8.

Humans are the main amplifying host of the virus. Rainy season or post rain season favours the collection of water in various sites like old tyres, coolers, old earthenware pots, coconut shells etc. This acts as a good site for mosquito breeding2. Navi Mumbai is an endemic area for dengue. Dengue virus infections results in wide spectrum of clinical manifestations ranging from asymptomatic to symptomatic disease as classical dengue fever, dengue haemorrhagic fever with and without shock syndrome, and unusual manifestations including encephalitis, liver failure and severe bleeding without shock.

Laboratory diagnosis of dengue virus infection depends upon demonstration of specific antibodies in serum samples by haemagglutination inhibition, complement fixation, neutralization test or ELISA. Reverse transcriptase PCR and hybridization probes for nucleic acid are other newer tests for diagnosis. Hence this study was undertaken to predict prognosis of dengue infection with help of haematological parameters.

Dengue fever is a viral infection transmitted by Aedes aegypti mosquitoes. Dengue is now endemic in over 100 countries with dramatic increase in geographical range recorded in recent years1.

Clinical presentations depend on age; virus strain and immune status of the host3.Dengue virus cause 2 forms of clinical syndromes. (1) Classical dengue fever (DF) - The onset is sudden with chills and high fever, intense headache, muscle pain, joint or bony pain (Break bone fever), retro orbital pain and photophobia. Other common symptoms include weakness, abdominal pain, sore throat and general depression. Some patients with dengue fever have evidence of mucosal or cutaneous bleeding without other evidence of DHF/DSS like haemoconcentration or fluid leak; such patients are classified as dengue fever with unusual bleeding4 .It may be associated with leukopenia and thrombocytopenia5. (2) Dengue haemorrhagic fever/Dengue shock syndrome (DHF/DSS) - After an incubation period of four to six days the patient develops clinical features like of dengue fever. There may be varying degree of tender hepatomegaly or less commonly splenomegaly. All patients have some degree of haemorrhagic phenomenon like positive tourniquet test, petechial spots, bruising at venepuncture site, bleeding from gums, epistaxis, hemetemesis or melena, muscle hematoma, hematuria and rarely intracranial haemorrhage may occur. DHF/DSS shows thrombocytopenia (platelet count <1,00,000/cu.mm) and >20% of rise in average haematocrit6. The most significant pathophysiologic changes among dengue virus infections are seen in DHF/DSS, due to plasma leakage from intravascular to extravascular compartments. The leakage of plasma leads to hemoconcentration, hypotension, hypoproteinemia and collection of fluid in serous cavities. The plasma leakage occurs as a result of acute increase in vascular permeability which is attributed to transient functional disturbance due to action of short acting chemical mediators. Immune reactions contribute to the formation of complexes that initiate intravascular

As there is no specific antiviral treatment, management is essentially supportive and symptomatic. Early and effective replacement of losses with plasma, plasma expander and/ or fluid and electrolyte solution results in a favourable outcome in most cases.

Materials and Methods

The study includes clinically suspected 100 cases of dengue with serological confirmation of either dengue specific NS1 antigen assay and/or IgM and/or IgG antibodies detection were selected. Evaluation of hematological and coagulative parameters and peripheral smear study were carried out. Serologically positive cases of dengue which were also positive for other coexistent infections E.g. Malaria, typhoid, are excluded from the study. Paediatric age group was excluded. Serology derived from a venous blood sample was collected from the patients presenting with symptoms suggestive of dengue. A commercially available Dengue Day1 test kit was used to detect NS1 antigen and IgM and IgG antibodies. The test results were expressed as positives/negatives for antigen and both antibodies. Evaluation of hematological parameter was done by collecting 2 ml of samples on EDTA prefilled bottles which were examined for Haemoglobin count, Haematocrit, Platelet count, Total leucocyte count, Differential leucocyte count. The analysis is done by the automated analyzer SYSMEX XT 1800i(3-part differential) /ADVIA 2120i (5-part differential). APTT/PT was done by collecting 2ml blood on sodium citrate prefilled bottles. The analysis was done by ACL-7000 coagulation meter. Evaluation of LFT was done by BACKMAN COULTER AU480.

Result:

One hundred patients, diagnosed as dengue based on NS1, Ig M & Ig G positivity & haematological parameters with LFT & coagulation profile were done. In our study out of 100 patients, 70 (70%)cases were males and 30 (30%)cases were females. The male : female ratio

http://www.pacificejournals.com/aabs

A-243

AABS; 3(3): 2016

was 2:1. Out of 100 patients, 49 (49%) were in age group of 15 to 25 years followed by 33 (33%)cases in the age group of 26 to 35 years, 10 (10%)cases in the age group of 36 to 45 years and 5 (5%)cases with age more than 55 years,3 (3%) cases were recorded in the age group of 46 to 55 years. In this study, 95 (95%) of the patients had fever as presenting symptom. Other symptoms like myalgia in 70 (70%)cases, arthralgia in 60(60%)cases, headache in 50 (50%)cases.

Table 7: Correlation Between Haematological Finding & APTT (out of 63 cases) Platelet Normal

Platelet Decreased

APTT Increased

No cases

APTT Normal

No cases

Table 8: Correlation Between LFT & APTT

Table 1: Rise In Haematocrit

LFT Increased

LFT Normal

HCT (%)

No. of Patients

Percentage

APTT Increased

>40%

28%

APTT Normal

<40%

72%

Table 2: Distribution of Patients According to Leukocyte Count (/mm3) Leucocyte Count (/mm3)

No. of patients

Percentage

<4,000

39%

4,000-11,000

49%

>11,000

12%

Table 3: Distribution of Patients According to Platelet Count (/mm3) Platelet count (/mm3)

No. of patients

Percentage

<20,000

10%

20,000-50,000

37%

50,000-1 lakh

34%

>1 lakhs

19%

Table 4: Distribution Of Patients According To APTT (/sec) (Out of 63 cases) APTT (/sec)

No. of patients

Percentage

Normal

73%

Raised

27%

Table 5: Distribution Of Patients According To Liver Function test(LFT) (Out of 76 cases) LFT(AST &ALT)

No. of patients

Percentage

Normal

43%

Increased

57%

Table 6: Correlation Between Haematological Finding & LFT (Out of 76 cases) Platelet Normal

Platelet Decreased

LFT Increased

No cases

LFT Normal

1 case

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

Discussion

Haematological profile of 100 cases were done which were confirmed by serologically. Study include ,81 cases were NS1 positive, 16 cases were Ig M positive & 5 cases showed positivity for both.15 cases were IgG positive. Primary dengue virus infection is characterized by elevations in specific NS1 antigen levels 0 to 9 days after the onset of symptoms; this generally persists upto 15 days. Ig M positivity indicates recent primary infection & IgG positivity indicates recent secondary infection. Out of 100 patients, majority 82(82%)cases were in age group of 15 to 35 years,13 (13%) patients were in age group 35 to 55 years and 5(5%) were more than 55 years of age. Most of these patients were adults, this may be due to the fact that most of them are working population, construction site labourers & travellers. Habitats for Aedes aegypti are domestic containers, stagnant water, ornamental containers and roof gutters.These findings were comparable with a study conducted by Fu Xi Qiu et al9 in which 81% of the patients were among more than 20 years. 70 (70%) patients were male and 30 (30%) were females with a male to female ratio of 2:1.This is due to the fact that males predominantly form the working population & more prone to infection by mosquito bite in a day time. These findings were comparable with a study conducted by Agarwal et al10 in which male to female ratio was 1.9:1. In our study, haematocrit was raised ( > 40%) in 28 (28%) cases. Study done by Nazish Butt et al11 showed raised haematocrit (>40%) were found in 52(50%) of patients.It is higher than our finding of 28%. This is probably due to the fact that they had more cases of DHF/DSS. In DHF and DSS, there is an acute increase in vascular permeability that leads to leakage of plasma into the extravascular compartments, resulting in haemoconcentration and hypotension.12 e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-244

In our study, thrombocytopenia (<1,00,000/mm3) was observed in 81% of the patients.Among them 10 (10%) patients had severe thrombocytopenia (<20,000/mm3), 37(37%) patients had moderate thrombocytopenia (20,000 to 50,000/mm3), while 34(34%) patients had mild thrombocytopenia (50,000 to 1,00,000/mm3).)Only 19(19%) patients had platelet count >1,00,000/mm3. A study done by Narayanan et al 13 in 59 patients, 14 patients had a platelet count less than 50,000cells/cu.mm ;29 patients had platelet count between 50,000-1,00,000 and only 16 patients had platelet count more than one lakh . Cause of thrombocytopenia is controversial, but the possibilities include impaired megakaryocyte production earlier in the disease, platelet injury by virus itself, platelet specific antibodies, immune complexes or DIC. Out of 100 cases, 28 (28%) patients had bleeding manifestations who had platelet count less than 30,000/ cu.mm & these cases were clinically diagnosed as DHF.70(70%) cases were classical DF & 2 cases had evidence of circulatory failure. DHF is due to antibody mediated immune enhancement which causes platelet destruction. Shock in DSS occur due to sudden extravasation of plasma to extravascular sites like the pleural and abdominal cavity. This occurs because of increased vascular permeability due to immune activation. In our study, 17(17%) cases had evidence of pleural effusion & 3(3%) cases had ascites. Both categories were associated with thrombocytopenia . In our study out of 63 patients, 46(73%) had normal APTT , 17(27%) patients had raised APTT & 7 patients had raised PT. Raised APTT correlates with finding of severe thrombocytopenia. Out of these 2 patients had clinical evidence of DSS. However ,most patients(73%) had normal APTT . So, prolonged APTT was not a significant finding in our study. As opposed to a study conducted in Taiwan in 2003 which showed that 77 patients out 79 (97.5%) patients with DHF had prolonged APTT and 33 out of 48 (68.8%) had prolonged APTT in classical dengue fever patients14. In this study cases of DHF were more so prolonged APTT was significant. But in our study 70% cases showed classical dengue fever which were not associate with prolonged APTT. So this finding was not significant . Prolongation of APTT is due to excess activation of fibrinolysis during infection causes increased tendency of bleeding15.This phenomenon occurs in cases of DSS. Leukopenia was more common in DF and DHF Grade I and II. DSS did not show leukopenia. Neutropenia may be due to marked degeneration of mature neutrophils and “shift to left”

during febrile phases of illness.13However this parameter can be used as a benchmark for clinical improvement15. In our study, out of 100 patients 39 (39%) cases had leukocyte count <4,000/ cu.mm,49(49%)cases had leukocyte cases count 4,000 – 11,000/cu. mm and 12(12%) cases had leukocyte count >11,000 cu.mm. Leukopenia was more common in DF and DHF Grade I and II.DSS did not show leukopenia. Similar findings were found in study done by Krishnamurthy K. et al16 in 1964, observed that out of 89 cases, 28 (31.46%) had leukopenia (<5,000/ mm3), remaining 61 (68.54%) cases had normal leukocyte count and there was no leukocytosis in any of the cases. In our study, out of 100 cases 50(50%) cases had lymphocyosis which show presence of plasmacytoid lymphocytes.It has been suggested that the atypical lymphocytes in secondary dengue infection can be representative of augmented immune response in an attempt to control the spread of dengue virus-infected cells.17 Plasmacytoid lymphocytes have been reported by John Gawoski and Winnie Ooi which mainly represents that serum immunoglobulin production is enhanced during dengue viral infection which correlated with our study.18 In our study, out of 76 cases, 43(57%) cases had deranged LFT. These 43 cases correlated with haematological discrepancy.Our findings were compared with Fu-Xi Qi et al9 study observed overall abnormal LFT in 68 (44.2%). This is due to virus is particularly found in the

hepatocytes, kupffer cells and the endothelium, along with immune complex formation. It has been suggested that it may be due to excess release of AST from damaged myocytes during dengue infections. In our study majority that is 95 (95%) of the patients had fever as presenting symptom. Other symptoms like myalgia in 70 (70%), arthralgia in 60(60%), headache in 50(50%), backache in 40(40%), abdominal pain 30(30%) ,petechia 40(40%),pleural effusion 17(17%),ascites 5(5%) and subconjuctival haemorrhage 3(3%). Altered sensorium due to intracranial bleed or hypoxia of brain due to hypotension was present in 2 (2%) case. All cases(95%) of fever correlated with thrombocytopenia. 5(5%) cases presented with weakness & bodyache which showed a normal platelet count. DSS(2%) patients presented with altered sensorium & hypotension had fatal outcome. A study conducted by Sharma et al19 showed that most commonest presenting symptom among the dengue cases

http://www.pacificejournals.com/aabs

A-245 was fever (100%). The symptoms reported included bodyache (98%), vomiting (28%) loose motion (12.7%), abdominal pain (10.5%), skin rash (43.1%) and altered sensorium (0.5%). In our study ,we received post therapy samples of 51 cases. Out of these 2 cases were fatal & did not show any recovery & had bad prognosis.49 cases showed improvement in platelet count within 5 to 6 days after therapy. In these patient platelet counts were improved from 40,000 /cu.mm to 2 lakh after therapy & had good prognosis.

Conclusion

In our study 100 serologically confirmed cases of dengue viral infection were studied to analyze the haematological parameters which will help in predicting prognosis of disease. Most cases (70%) were of classical DF & (28%) were cases of DHF who had fever, showed thrombocytopenia & deranged haematological parameters which signifies disease severity. 2% cases presented with hypotension & altered consciousness with severe thrombocytopenia & prolonged APTT (DHF/DSS) which indicates very poor prognosis& had fatal outcome.. Thrombocytopenia was most predominant haematological discrepancy. Raised haematocrit was not significant significant (72% had normal haematocrit) in our study & correlated with uncomplicated DF cases. Cases with raised LFT (57%) correlated with thrombocytopenia. APTT prolongation was significant in cases of DHF & DSS but not significant in cases of dengue fever. Pleural effusion was found in 17% of cases who had severe thrombocytopenia.

AABS; 3(3): 2016

Acknowledgements

We acknowledge the technical staff of the central lab.

Funding None

Competing Interests None declared

Reference

1. Bulletin of the WHO; 1980; 58(1):1-21. 2. Schwartz E. Study of dengue fever among Israeli travellers to Thailand.WHO, Dengue Bull 2002; 26: 162-7. 3. Raghunath D, Rao Durga C (Ed); Prida Malaist ; Immunopathogenesis of DHF ;Arthropod Borne Viral infections- Current status and Research ; Vol 8, Tata Mc- Graw Hill, New Delhi;2008: 137 4. Kabra SK, Jain Y, Singhal T, Ratageri VH. Dengue hemorrhagic fever. Clinical manifestations and management. Ind J Ped 1999; 66: 93-101. 5. DENGUE .Guidelines for diagnosis, treatment, prevention and control, 2nd Edition, World Health Organization, Geneva 2009: 1-144. 6. Victor TJ,Malathi M, Asokan R, Padmanaban

P.Laboratory- based dengue fever surveillance in Tamil Nadu. Indian J Med Res. 2007;126:1125.

Dengue fever does not have specific medical therapy hence clinical recovery monitoring is largely dependent on haematological parameters.This study concludes that parameter like platelet count, haematocrit, leukocyte count & coagulation studies aid greatly in clinical monitoring of patients.

7. Ronald M. A (Ed); Pathogenesis of infectious diseases, 1stedition,Mosby international, USA; 1999:517. 8. Wang S, He R, Patarapotikul J, Innis BL, Anderson R.Antibody enhanced binding of dengue- virus to human platelets. J ViroS 1995.20; 213;1: 254-7. 9. Qui FX, Gubler DJ, Liu JC, Chen QQ. Dengue in China. A clinical review. Bull World Health Organ 1993; 71(3/4): 349-59. 10. Agarwal R, Kapoor S, Nagar R, Misra A, Tandon R, Mathur A, et al. A clinical study of the patients with dengue hemorrhagic fever during the epidemic of 1996 at Lucknow, India. Southeast Asian J Trop Med Public Health. 1999; 30(4): 735-40. 11. Butt N, Abbassi A, Munir S.M, Ahmad S.M, Sheikh Q.H; Haematological and Biochemical indicators for early diagnosis of Dengue viral infections; Journal of the college of physicians and Surgeons Pakistan; 2008; Vol 18:282-285. 12. Bethell B .D, Gamble J; Non-invasive measurement of micro vascular leakage in patients with Dengue hemorrhagic fever; Journal of clinical infectious diseases; 2001; Vol 32:243-253.

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Leukopenia was present in 39% of cases. Initial leukopenia &leukocyte count returning to normal by ninth to tenth day after therapy in most of the cases indicates that leukocyte count an important benchmark for clinical improvement. Cases with lymphocytosis (50%) with atypical lymphocytes were representative of augmented immune response in an attempt to control the spread of dengue virus-infected cells.

Conclusion

Original Article

A-246

13. Narayanan M, Aravind M A; Dengue FeverClinical and laboratory parameters associated with complications; Dengue bulletin; 2003; Vol 27:108115. 14. JW Liu, B S Khor ,C H Lee, Dengue haemorrhagic fever in Taiwan. Dengue bulletin;2003;Vol 27:19. 15. Halstead SB. Dengue Hematological Aspects. Seminars in hematology.1982; 19(2): 116-28. 16. Krishnamurthy K, Kasturi TE, Chittipantulu G. Clinical and pathological studies of an outbreak of Dengue like illness in Visakhapatanam. Ind J Med Res 1965; 53(8): 800-12.

17. Carlos CC, Oishi K, Cinco MT, Mapua CA, Inoue S, Cruz DJ, et al. Comparison of clinical features and hematologic abnormalities between dengue fever and dengue hemorrhagic fever among children in the philippines. Am J Trop Med Hyg 2005;73(2):435- 440. 18. John M. Gawoski, Winnie W Ooi. Dengue Fever Mimicking Plasma Cell Leukemia. Archives of Pathology and Laboratory Medicine 2003;127(8)1026â&#x20AC;&#x201C; 7. 19. Sharma S, Sharma SK, Mohan A. Clinical profile of Dengue hemorrhagic fever in Adults during - 1996 outbreaks in Delhi, India. Dengue Bull 1998; 22: 1-7.

http://www.pacificejournals.com/aabs

Original Article To Study The Impact of Cigarette Smoking on Semen Quality of Adult Males Prahlad Chandra Agrawal1*, Shiv Kumar Chandraker1 and Prarabdha Agrawal2 Department of Pathology, Chandulal Chandrakar Memorial Medical College, Durg, C.G. India 2 Pt, J. N. M. Medical College, Raipur, C.G., India

Keywords: Cigarette Smoking, Sperm count, Sperm motility, Semen Analysis

ABSTRACT Background: To asses the effect of cigarette smoking on semen parameter viz sperm volume,count,motility & morphology among adult males. Methods: Present work is carried out in 228 males of C.C.M. medical college Durg C.G. randomly between April 2016 to July 2016 & were divided into two groups. Group 1 (nonsmokers n=140) & Group 2 ( smokers n=88) represents 36.6%. Semen obtained by masturbation after 3-5 days period of abstinence, examined for its volume,sperm count per ml, sperm count per ejaculate,percentage of motile sperm, & percentage of normal morphology spermatozoas in above two groups. Result: Total 228 adult male were taken in study, belongs to 21-40 years of age.The nonsmokers (no=140) were with mean age of 34.40±5.88(mean±SD). The smokers (n=88) have mean age 33.27±4.74(mean±SD).There were significant effect of cigarette smoking on sperm count,motility & morphology. Group of smokers found lower sperm count,motility,with increased abnormal morphology spermatozoas. Conclusion: Cigarette smoking has adverse effect on various parameter of seminal fluid & may have future effect on fertility potential of person.

*Corresponding author: Prahlad Chandra Agrawal, Department of Pathology, Chandulal Chandrakar Memorial Medical College, Durg, C.G. India Phone: +91 9425212528 E-mail: drpcagrawal206@gmail.com

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

Original Article

A-248

Introduction

In the last 50 years there is significant reduction in semen parameter quality due to change in life style of persons, environmental factors like diet,obesity,smoking,alcohol intake & EMWs from cell phone users which affects testicular tissue structure & function either due to thermal or nonthermal effect.[1] Besides this cigarette smoking has deleterious effect on many system of body including respiratory & cardiovascular system. These environmental factors are important because it is preventable & one can improve the fertility potential in early reproductive life,by quiting the smoking. Male infertily contributes 40% worldwide. Various study reveals cigarette smoking has impact on male as well as on female infertility.[2] Cigarette smoking is increasingly reaching to 1/3 of world population above 15 years of age, despite knowing its injurious effect.[3] Government has taken adequate measures to aware & alert the peoples for its hazardous effect but has no fruitfull outcome. Quantity & prevalence of cigarette smoking is higest up to 50% in Zordon as compare to developed nations.[4] Cigarette smoking contains large numbers of carcinogens like radioactive polonium, cadmium, benzopyrene, dimethylbenzathracene, dimethyl nitrosamine naphthalene, methnaphthelene. The exact effect on function of spermatozoa is not assessed yet, though the effect is noticed a long time ago. The mechanism of effect on sperm is not also understood till date.[5] So the impact of cigarette smoking & semen characteristics is still unresolved.[6] Cigarette smoking may be associated with impaired fertility in male & may lead to decrease in sperm count, motility & reduced percentage of morphologically normal sperms.[7] Regarding effect of smoking on semen quality many studies done worldwide[8] showed smoking results in impaired sperm count, motility & normal morphology sperms.[9] Some shown that smoking has detrimental effect on sperm quality.[10] where as in another study the results are inconsistent & inconclusive.[8] The present study is conducted to asses effect of cigarette smoking on semen volume,count,motility & its morphology.

Materials and Methods

The present study is conducted in the department of pathology C.C.M. medical college Durg C.G. where semen analysis of persons done randomly, belongs to age group between 21-40 years. Study were done from April

2016 to July 2016. Exclusion critaria used here are males with varicocoele, undescended testis ,azoospermia, H/O trauma, scrotal surgery or chronic illnesses like diabetes, hypertenstion, tuberculosis or malignancy. In our study 228 males were included. Out of which 140 were nonsmokers & 88 were smokers.Quantity of smoking is varies from 2 to 20 cigarettes per day & from period 5 years to 10 years. Semen collected in sterile wide mouth plastic container after 3-5 days of abstinence, near the laboratory. Semen is allow to liquify before analysis. Routine analysis done at R.T.as per the guide line of WHO. [11] Volume of semen is measured by aspirating semen in pipette, sperm count per ml done by neubauer chamber after diluting 1:20 with D.W.,determination of sperm count in whole ejaculate done by multiplying the sperm count per ml by total volume of sample, motility is done by placing one drop of semen in glass slide, cover it with cover slip & morphology is studied by pap staining. Datas are analysed checked & expressed as mean ± SD . A P value of < 0.05 considered significant.

Result

Out of total 228 adult males range between 21-40 years, 140 nonsmokers with a mean age of 29.96 ± 5.80, while smokers are 88 with mean age of 29.01±5.72. Table 1 shows different parameter of semen sample such as volume, count, motility, morphology & other cells. In both the group there were no significant difference between volume of semen & age, whereas as per figure 1 the sperm count per ml & percentage of motile sperms is lower in group 2 smokers(85.94 millions &68.75%) as compare to group 1 nonsmokers(92.19 millions&73.75%). Grade of motility is different in both the group. Group 1 nonsmokers have many actively motle sperms. Sluggishly motile spermatozoas seen equivocally in both group. Immotile sperms seen in smokers. As per figure 2 normal morphology sperm was significantly lowered in smokers(64.46%) as compare to nonsmokers (69.14) Table 1: Showing the mean values and standard deviation, along with P-values for Unpaired T test in group 1 and group 2. (* p < 0.05)

Group 1

Group 2

Mean ± S.D.

Age

29.96 ± 5.80

29.01 ± 5.72

0.48

Volume

3.30 ± 0.48

3.21 ± 0.52

0.18

Sperm

92.19 ± 8.88

85.94 ± 5.82

0.00

Motile

73.75 ± 7.10

68.75 ± 4.66

0.00

Morphology

69.14 ± 6.66

64.46 ± 4.36

0.00

http://www.pacificejournals.com/aabs

P Value

A-249

AABS; 3(3): 2016

Fig. 1: A mean sperm count millions/ml, B mean Volume Semen, C mean sperm Count, D mean percentage of motility sperm in group 1 & 2.

Fig. 2: Mean percentage of normal morphology sperm in Group 1 & 2.

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-250

Discussion

Several studies explored the adverse effect of smoking on sperm production, motility,its morphology(2). Smokers contributes 38.59%(n=88) in this study. Figure 1 showing results of study indicating that cigarette smoking affects sperm motility & leads to decreased active motility(68.75% vs 73.75%) .The number of immotile sperms increased in this group. This findings is tallied with the finding of earlier studies related to relationship between cigarette smoking & sperm motility.[12] However our results are not matching with result of Ozgur et al.[13] who stated that there were no change in semen parameter among smokers & nonsmokers. Our reports are also not consistent witn finding of collodol et al.[14] showed no significant difference in sperm motility between smokers & nonsmokers. As per figure 1 our finding of sperm morphology negatively affected by smoking (64.46% normal morphology sperms in smokers as compare to 69.14% in nonsmokers) is same as reported by Kuzle et al & Collodol et al.[10][14]Volume of semen is comparable with both the groups, similar to a study done by Trummer et al.[15] who found no difference in semen parameter between smokers & nonsmokers.

Conclusion

Cigarette smoking has injurious effect on semen quality like sperm count,its motility, morphology with its subsequent impact on male fertility. It is a preventable environmental factor, so one can quit the smoking & improve the male fertility.

Acknowledgements None

Funding

5. Osser S, Liedholm P, Ranstam J. Depressed semen quality: a study over two decades. Arch Androl1984;12(1):113-116. abstract 6. Arabi M, Moshtaghi H. Influence of cigarette smoking on spermatozoa via seminal plasma. Andrologia2005. Aug;37(4):119-124 7. Lewin A, Gonen O, Orvieto R, Schenker JG. Effect of smoking on concentration, motility and zona-free hamster test on human sperm. Arch Androl 1991. JulAug;27(1):51-54. ABSTRACT. 8. Chia SE, Lim ST, Tay SK, et al. Factors associated with male infertility: a case-control study of 218 infertile and 240 fertile men. Brit J Obstet Gynaecol (2000).107, 55-61 9. Zinaman MJ, Brown CC, Selevan SG, Clegg ED. Semen quality and human fertility: a prospective study with healthy couples. J Androl 2000. JanFeb;21(1):145-153 10. Künzle R, Mueller MD, Hänggi W, Birkhäuser MH, Drescher H, Bersinger NA. Semen quality of male smokers and nonsmokers in infertile couples. Fertil Steril 2003. Feb;79(2):287-291 11. World Health Organization (WHO). Laboratory manual for the examination of human semen and sperm-cervical mucus interaction. 3rd ed. Cambridge, England: Cambridge University Press, 1992. 12. Wang SL, Wang XR, Chia SE, Shen HM, Song L, Xing HX, et al. A study on occupational exposure to petrochemicals and smoking on seminal quality. J Androl 2001. Jan-Feb;22(1):73-78

None

Competing Interests None

Reference

4. Haddad LG, Malak MZ. Smoking habits and attitudes towards smoking among university students in Jordan. Int J Nurs Stud 2002. Nov;39(8):793-802

1. Brugo-Olmedo S, Chillik C, Kopelman S. Definition and causes of infertility. Reprod Biomed Online2001;2(1):41-53 10.1016/S14726483(10)62187-6 2. Augood C, Duckitt K, Templeton AA. Smoking and female infertility: a systematic review and metaanalysis. Hum Reprod 1998. Jun;13(6):1532-1539 3. Zenzes MT. Smoking and reproduction: gene damage to human gametes and embryos. Hum Reprod Update 2000. Mar-Apr;6(2):122-131

13. Ozgur K, Isikoglu M, Seleker M, Donmez L. Semen quality of smoking and non-smoking men in infertile couples in a Turkish population. Arch Gynecol Obstet 2005. Feb;271(2):109-112 14. G. COLLODEL et al. Semen Quality of Male Idiopathic Infertile Smokers and Nonsmokers: An Ultrastructural Study. J Andro l2010;31:108-113. 15. Trummer H, Habermann H, Haas J, Pummer K. The impact of cigarette smoking on human semen parameters and hormones. Hum Reprod 2002. Jun;17(6):1554-1559

http://www.pacificejournals.com/aabs

Original Article A Study of Bone Marrow Aspiration Smears and Trephine Biopsy in Pancytopenia Cases Siva Chaithanya Bangi*, Kotta Devender Reddy and V. V. Sreedhar Upgraded Department of Pathology, Osmania Medical College, Hyderabad, India Keywords: Pancytopenia, Megaloblastic Anemia, Aplastic Anemia, Bone Marrow Examination

ABSTRACT Background: Pancytopenia is the simultaneous presence of anemia, leucopenia and thrombocytopenia. Peripheral pancytopenia may be a manifestation of a wide variety of disorders which primarily or secondarily affects the bone marrow. Bone marrow failure syndromes and malignancies are serious and life threatening causes, but certain nonmalignant conditions such as infection, and nutritional anemia are equally important. The severity of pancytopenia and the underlying pathology determine the implementation of correct management and prognosis. Methods: A prospective study was conducted in the Upgraded Department of Pathology, Osmania government general hospital during July 2011 to September 2013that evaluated 110 patients fulfilling the criteria of pancytopenia. Detailed history, thorough clinical examination, complete hemogram, peripheral examination and reticulocyte count evaluation was performed in all the 110 patients. Bone marrow aspiration was performed in all 110 patients and in addition trephine biopsy was done in the same setting in patients where it is indicated. Result: The patients aged from 15 to 75 years,average age at presentation was 30.9yrs. The most common cause of pancytopenia was Megaloblastic anemia (53%) followed by Nutritional anemia (16%), aplastic anemia (9%) and Leukemiaâ&#x20AC;&#x2122;s (7.4%). Majority (79%) of the patients had hyper cellular bone marrow followed by hypocellular (13%) and norm cellular marrow (8%). Conclusion: A detailed primary hematological investigations coupled with bone marrow examination viewed in light of the history and physical findings are vital in establishing the diagnosis in pancytopenia patients. Bone marrow Aspiration and Trephine biopsy are complementary to each other in cases requiring both the procedures.

*Corresponding author: Dr. Siva Chaithanya Bangi, D 6/3 quarters BITS Pilani Hyderabad Campus, Jawaharnagar, Shameerpet, Telangana, India-500078. Phone: +91 9985567435 E-mail: chinnababub30@gmail.com

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

Original Article

A-252

Introduction

The bone marrow is the largest and most widely distributed organ in the body. It is the principle site for blood cell formation. In the normal adult, its daily production and export of blood cells amounts to about 2.5 billion red cells, 2.5 billion platelets and 1.0 billion granulocytes per kilogram of body weight1. “Pancytopenia” is defined as the decrease in all the three formed elements in the blood that is erythrocytes, leucocytes and platelets which results in anemia, neutropenia and thrombocytopenia.2 Pancytopenia therefore exists in the adult when hemoglobin level is less than 13.5 g/dl in males or 11.5 g/dl in females; leucocyte count is less than 4 x 109/L and platelet count is less than 150 x 109/L.3 The spectrum of disorders primarily or secondarily affecting the bone marrow may manifest with peripheral pancytopenia. Patients usually present with complaints pertaining to anemia, thrombocytopenia and rarely leucopenia which in later stages is responsible for downhill course. Various factors encompassing geographical distribution and genetic disturbances may cause variation in the incidence of disorders causing pancytopenia4,5,6. Underlying pathology determines the management and prognosis of the patients7. Pancytopenia is a serious hematological problem, the underlying cause of which is diagnosed by bone marrow aspiration and biopsy. Bone marrow examination is extremely helpful in the evaluation of pancytopenia.8

Materials and Methods

The present study was conducted in the Upgraded Department of pathology, Osmania Medical College, Hyderabad on patients with pancytopenia during the period of July 2011 to September 2013. Study Design: Prospective study. Study Period: The present study was conducted during July 2011 to September 2013. Source of Data: Patients diagnosed as pancytopenia after hemogram in the Upgraded Department of Pathology at Osmania Government General Hospital, Hyderabad. Sample Size: 110 Patients with pancytopenia. Sampling Procedure: Data collected from the records of Hematology section of Upgraded Department of Pathology, Osmania government general Hospital Hyderabad. Inclusion Criteria 1. Patients with age more than or equal to 15 years. 2. Patients with pancytopenia.

Hemoglobin: Less than 13.5 gm/dL in males; 11.5 gm/dL in females. Total leucocyte count less than 4000 /cmm. Platelet count less than 1, 50,000 /cmm. Exclusion Criteria 1. Patients with age less than 15 years. 2. Patients on cancer chemotherapy. Procedure: The study was approved by the Ethical and Research Committee of Osmania government general Hospital, Hyderabad. During the study period, all patients presenting with and fulfilling the inclusion criterion were included in this study after obtaining informed written consent. All patients underwent bone marrow examination. These patients were subjected to routine hematological investigations. The peripheral smear was studied after staining with Leishman’s stain. Satisfactory samples of bone marrow can usually be aspirated form the sternum, iliac crest or anterior or posterior iliac spines. bone marrow and stain them with Romanowsky dyes as peripheral blood films. A trephine biopsy and aspiration biopsy can be carried out through the same skin incision but with the bone being entered at two different points. Fix the specimen in 10% formalin solution buffered to pH 7. Sections of marrow should be stained as a routine by haematoxylin and eosin.

Result

Patient’s age ranged from 15 to 75 years. Maximum number of cases were in the age group of 15 to 24 years (42%) and three cases were in the age group of More than 65 years (3%). Out of 110 patients, 55 patients (50%) were males and 55 patients (50%) were females. Accounting a ratio of male to female was 1:1. The commonest symptom was shortness of breath (47%) followed by fever (20%), bleeding manifestations (14%), yellowish discoloration (11%), easy fatigability (3%). Pallor was universally present in all the patients followed by splenomegaly (37%), icterus (35%), hepatomegaly (19%) and lymphadenopathy (5%). Seventy five percent (75%) of patients had hemoglobin value less than or equal to 6 gm%. Majority 36% had total leucocyte between 2100 to 3000 cells/cmm followed by 34% had between 3100 to 4000 cells/cmm. Patients (58%) whose platelet count was less than or equal to 50000 cells/ cmm had more bleeding tendencies as compared to patients who had platelet count of more than 50000 cells/cmm.

http://www.pacificejournals.com/aabs

A-253

AABS; 3(3): 2016

Majority (62%) of the patients had dimorphic blood picture on peripheral smear followed by Microcytic hypochromic picture (20%). Majority (79%) of the patients had hyper cellular bone marrow fig.1followed by hypocelluar (14%) and norm cellular marrow (8%). The most common cause of pancytopenia was Megaloblastic anemia (53%) followed by Nutritional anemia (16%), aplastic anemia (9%) and Leukemiaâ&#x20AC;&#x2122;s (7.4%). In majority of patients of megaloblastic anemia bone marrow is hyper cellular (96.5%). Majority of patients in megaloblastic anemia had iron stores 1+ (50%) when graded after perls stain. Out of total 110 cases 10 cases were Aplastic anemia figure. 2 . Out of 10 cases 4 cases had clinically significant history. These are listed below

3. 58yrs, female, known case of myasthenia gravis. 4 .23 yrs. Female, known case of RVD on Zidovudine. Eight (7.40%) out of one hundred ten patients of pancytopenia were due to malignancy of hematolymphopoietic system involving the marrow. All the cases were acute leukemiaâ&#x20AC;&#x2122;s. 5(62%) out 8 were of myeloid series, 3(38%) out of 8 were of lymphoid series. Seven (6.30%) out of one hundred ten patients of pancytopenia were due to hypersplenism. The commonest age of presentations was between 25-34 yrs. 4 (3.60%) out of 110 cases with majority falling in age group of 45-54yr with peripheral blood picture showing Normocytic hypochromic (50%)/ Microcytic hypochromic (50%) had hypercellular (50%) to hypo cellular marrow (50%), had marrow plasmacytosis with marrow plasma cells more than 10%

2. 59yrs. Male, known case of ITP.

Three (2.70%) out of one hundred ten cases of pancytopenia were cases of metastatic deposits involving the bone marrow figure 3&4. The commonest indications for trephine biopsy were to investigate Hypo plastic marrow and dry tap in our institution table.2.

Fig.1: Picture Showing Hypercellular Marrow.

Fig. 2: Bone Marrow Biopsy of Aplastic Anemia

1. 28 yrs. Female, known case of Plummer Vinson syndrome.

Fig. 3: Bone Marrow Aspiration Deposition of Small Round Cells.

Smears

Showing

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

Fig. 4: bone marrow biopsy showing metastatic deposits of Adenocarcinoma(alcian blue stain).

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-254

Table 1: list of cases with metastatic deposits in bone marrow Age (yrs.)

sex

BM NO.

Biopsy No.

P.s

aspiration

Biopsy Impression

male

59/12

1625/12

Normocytic/Hypochromic

Dry tap

Metastatic deposit of spindle cells. Advised IHC

male

109/13

2949/13

Microcytic/Hypochromic

Dry tap

Metastatic deposits of Round cells ?NHL Advised IHC

male

110/13

3225/13

Normocytic/Hypochromic

Dry tap

Metastatic deposits of Adenocarcinoma

Table 2. Number of patients undergone Trephine Biopsy and their indications. Indication for trephine biopsy

Number of patients

Hypo plastic marrow

Dry tap

Rule out granuloma

Malignancy

Total

Discussion

In the present study out of 110 cases studied the most common cause was Megaloblastic anemia (53%) followed by Nutritional anemia (mixed) (16%),aplastic anemia. The commonest cause of pancytopenia, reported from various studies throughout the world has been aplastic anemia . This is in sharp contrast with the results of present study where the commonest cause of pancytopenia was megaloblastic anemia. This seems to reflect the higher prevalence of nutritional anemia in Indian subjects as well as in developing countries. The principal hematologic manifestations are varying degrees of anemia, leucopenia and thrombocytopenia, anisopoikilocytosis, macro ovalocytes and hypersegmented neutrophils. In the present study, In majority of patients (68%) red blood cell morphology was dimorphic with anisopoikilocytosis. In majority of patients the reticulocyte count fall in range of 0.1-2%. Erythroid hyperplasia with megaloblastic maturation was seen in all the patients. Hypersplenism (19 %) was the second most common cause of pancytopenia as studied by Osama Ishtiaq et al.9, (12 %) due to portal hypertension, (5 %) due to chronic malaria and (4 %) were undiagnosed. In present study Seven (6.30%) out of one hundred ten patients of pancytopenia were due to hypersplenism. The commonest age of presentations was between 25-34 yrs. (43%) with overall female predilection. Gagandeep Kaur et al.10 in their study studied 784 bone marrow aspirations performed during a 69 months period, 9(1.1%) patients showed metastatic bone marrow involvement . In present study Three (2.70%) out of one hundred ten cases of pancytopenia were cases of metastatic deposits involving the

bone marrow. One case was adenocarcinoma, others needed Immunohistochemistry evaluation.

Conclusion

The etiological spectrum of pancytopenia is diverse. The present study reveals megaloblastic anemia is the commonest cause in Indian scenario where the etiology is nutritional and wide spread use of certain traditional medicines unknown. Bone marrow examination is an important diagnostic tool in hematology which is instrumental in confirming the underlying diagnosis, or excluding a primary marrow involvement and suggesting alternative investigations for diseases like hypersplenism, PNH etc. Bone marrow aspiration is sufficient to make a diagnosis in cases of nutritional anemiaâ&#x20AC;&#x2122;s and initial diagnosis of leukemia. However, aspiration is often unsuccessful and may yield a dry tap in patients with aplastic anemia or myelofibrosis or metastatic deposits in marrow. Bone marrow trephine biopsy is essential for diagnosis in such conditions or when the aspiration is inconclusive. Thus both procedures are complimentary and help in providing a prompt and precise diagnosis in the Setting of pancytopenia.

Acknowledgements

I express my profound sense of gratitude to Dr.V.Vijay Sreedhar M.D. Professor and HOD and other Professors and faculty of the Department, Osmania Medical College, Hyderabad, for their valuable advice. I also thank Technicians and the technical staff of the department of Pathology for their kind cooperation. I thank Dr.G.R.Praveen jyothi for helping me in review of E-literature available.

http://www.pacificejournals.com/aabs

A-255

Funding

AABS; 3(3): 2016

1. Hoffman R, Benz EJ, Shattil SJ, Furie B, Cohen HJ, Siberstein LE. Hematology. Basic Principles and practice. 3rd ed. USA: Churchill Livingstone; 2005. 2. Ur-Rehman H, Fazil M, Mohammad F. Clinical presentation of pancytopenia in children under 15 years of age. J Postgrad Med Inst 2003; 17(1): 46-51. 3. Firkin F, Chesterman C, Penington D, Rush B. De Gruchy’s Clinical haematology in Medical Practice. 5th Ed. Oxford: Blackwell; 1989. 4. International agranulocytosis and aplastic anaemia study. Incidence of aplastic anaemia, the relevance of diagnostic criteria. Blood 1987; 70 (6):1718-21.

5. Wintrobe MM. Clinical Haematology. 8th Ed. Philadelphia: Lea and Febiger; 1981. 6. Keisu M, Ost A. Diagnosis in patients with severe pancytopenia suspected of having aplastic anaemia. Eur J Haematol 1990; 45: 11-4. 7. Varma N, Dash S. A reappraisal of underlying pathology in adult patients presenting with pancytopenia. Trop Geogr Med 1992; 44(4): 322-7. 8. Dodhy MA, Bokhari N, Hayat A. Aetiology of Pancytopenia, A five-year experience. Ann Pak Inst Med Sci 2005 Apr-Jun;1 (2):92-5. 9. Osama I, Baqai Hz, Anwar F, Hussain N. Patterns of pancytopenia in a general medical ward and a proposed diagnostic approach. JAMC 2002; 16(1):8-13. 10. Gagandeep Kaur, Sabita Basu, Paramjit Kaur and Tanvi Sood: “metastatic bone marrow tumors: study of nine cases and review of the literature”; J Blood Disorder and Transfusion 2011; Vol 2 , Issue 3:2-3.

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

e-ISSN: 2349-6991; p-ISSN: 2455-0396

None

Competing Interests None declared

Reference

Original Article Seroprevalence And Trends In Transfusion Transmitted Infections Among Blood Donors Rupal Shah1* and Aditi Dholakia2 Dept. of Pathology, GCSMCH , Ahmedabad, Gujarat, India Dept. of Pathology, GMERS Medical college, Vadodara, Gujarat, India 1

Keywords: TTI, Sero-Prevalence, Voluntary Donors, Replacement Donors, Blood Bank

ABSTRACT Introduction: Timely transfusion of blood saves millions of lives, but unsafe transfusion practices put millions of people at risk of transfusion transmitted infections (TTIs).There are several infectious as well as non-infectious risks associated with transfusion of blood. With every unit of blood transfused, there is 1%chance of transfusion associated problems including transfusion transmitted infections. In India blood is screened for five diseases which could be transmitted through blood and produce serious illness- HIV, Hepatitis B, Hepatitis C, Syphilis and Malaria. Aims and objectives : (1) To assess the trend of transfusion transmitted infections (TTIs)among blood donors from the records (2011-2013) at blood bank, GCSMCH, Ahmedabad, Gujarat. (2) To study the sero-prevalence of TTIs among blood donors from the records. Methods: A record based study was conducted from June 2011- December 2013. Data were collected from the records of blood bank. Data regarding sex, screening test results and type of donors were collected from the records. Results: Out of 2178 donors, voluntary donors were(4.17%) in comparison to replacement donors (95.83%). Amongst blood donors, prevalence of HBV (0.73%), HCV (0.09%), HIV (0.09%) and Syphilis (1.65%) were noted. Conclusion: TTIs were more prevalent in replacement donors than voluntary donors. The number of voluntary donors has risen from 2011 -2013, but there is male preponderance in both voluntary and replacement donors than females.

*Corresponding author: Dr. Rupal Shah, 401, Ananya Residency, Paliyadnagar, Near Jay Ambegruhudyog, Naranpura, Ahmedabad, Gujarat-380013. INDIA Phone: +91 9825586560 E-mail: rupu_desai@yahoo.co.in

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

A-257 Introduction Florence nightingale, more than 100 years ago said “no stronger condemnation of any hospital or ward could be pronounced than the single fact that zymotic (infectious) disease has originated in it, or that such a disease has attacked other patients than those brought in with them.” It should be obligatory on those who are involved in transfusion of blood to a patient for saving his life, that the blood transfusion does no harm to the patient. [1] Nothing could be worse than the fact that in an attempt to save life, blood & blood products having transmissible infectious agent have been given as morbidity and mortality resulting from it have far reaching consequences not only for the recipients themselves, but also for their families, communities & the wider society.[1] Blood transfusion is the process of receiving blood products into one’s circulation intravenously. There is a 1% chance of transfusion associated problems including transfusion transmitted diseases. Hence it is necessary to understand the organisms which could be transmitted through blood transfusion and means by which this could be prevented.[1, 2] Globally, more than 81 million units of blood are donated each year. [3] More than 18 million units of blood are not screened for transfusion transmissible infections. [4] Meticulous pre-transfusion testing & screening particularly for transfusion transmissible infection (TTI) is the need of the hour.[1] As per guidelines of the ministry of health and family welfare(government of India)under the Drug and Cosmetics Act, 1945 (amended from time to time),all the blood donations are to be screened against the five major infections namely HIV I and II,HBsAg,HCV, syphilis and malaria.[5, 6] The first and most important step in ensuring the blood and its products for transfusion do not have any pathogenic organisms, is by the proper selection of blood donors. It should be done carefully. The donor should be in good health in order to avoid any untoward effect to the donor or the recipient. Blood collected from voluntary donors and relatives/friends of patients without any coercion on them is safe.[1]

AABS; 3(3): 2016

Aims and objectives:

1. To assess the trend of transfusion transmitted infections (TTIs) among blood donors from the records (20112013) at blood bank, GCSMCH, Ahmedabad, Gujarat. 2. To study the sero-prevalence of TTIs among blood donors from the records.

Materials and Methods

The present study was carried out in Gujarat Cancer Society Medical College, Hospital and Research Center, Ahmedabad, Gujarat, India. A total of 2178 blood donors were analyzed for prevalence of transfusion transmitted infections over a period of two and half years from Jun-2011 to Dec-2013 to determine the prevalence of HIV I & II, HBV, HCV, syphilis and malaria in order to provide information for relevant policies. These included replacement donors who donated for ailing patients and were family members, close relatives or friends of the recipient. The voluntary unpaid blood donors were obtained from walk-in donors, students and employees of the institutions .Care was taken to eliminate professional and paid donors by taking history and clinical examination. Basic information regarding age, sex, occupation, number of previous donations was obtained. A five milliliter blood sample was collected from each healthy donor using plain blood collection tube, taken at the time of blood donation. The sample was kept at room temperature until fully clotted. Blood samples were spun at 2000 relative centrifugal force for 10 minutes at room temperature and serum was collected from them to perform infectious diseases screens. Serological tests using enzyme linked immunosorbent assay (ELISA) technique were performed to screen blood donors for anti-HIV I & II, anti-HCV, HBsAg. All samples were screened for HBsAg (MONOLISA-BIORAD), antiHIV I, II & anti-HCV (ELISA, MICROLISA, J.MITRA & CO). Anti-syphilis antibodies were detected by using indirect haemagglutination assay (TPHA-BIORAD).

The aim of the present study was to find out seroprevalence of TTI in voluntary and replacement donors in our hospital transfusion service set-up. This study also aids in evaluating the safety of the collected donations.[2]

For malaria detection, Romanowsky stained peripheral smear was examined by pathologist under oil immersion lens of microscope and reported as positive or negative for malaria. If positive, specified as P.Falciparum or P.Vivax species. Tests were performed according to manufacturer’s instructions. Samples giving equivocal (gray zone) or preliminary reactive readings were confirmed by repeating the sample in duplicate using the same kit and testing it using another methodology. Repeatedly reactive samples were considered seropositive. All the kits used in screening process for all tests have a sensitivity and specificity greater than 99.8% according to manufacturer claim. Moreover, all preliminary reactive units for any of above transfusion

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Amongst the undesirable complications arising out of transfusion of blood and blood products,TTIs like HIV, hepatitis B and C, syphilis are most significant for long term detrimental side effects.[1]

Original Article

A-258

transmitted pathogens were discarded immediately prior to getting the confirmatory results. Descriptive analysis was used for the prevalence rates. Only confirmed results were included in the study. The prevalencerate was calculated based on the numbers of donations tested and numbers of donations with positive results in confirmatory tests.

Results

sero-prevalence of above mentioned infections in replacement donors. Total sero-prevalence of HIV, HBV, HCV, Syphilis and Malaria was 0.09%, 0.73%, 0.09%, 1.65%, 0% among 2178 blood donors during the study period. (Table 4) Comparing our data, it seems it co-related with data from various studies carried out at various centers mentioned in table 5.

A total of 2178 apparently healthy donors were screened over a period of two and half years from Jun-2011 to Dec-2013. Out of them, 91 (4.17%) were voluntary donors which included walk in donors at the blood bank of hospital. The remaining 2087 (95.83%) were replacement donors.(Fig: 1) As per table 1, out of 2178 blood donors, maximum number of donors i.e. 1225 (56.24%) were between 18-30 years of age. In remaining donors, 654 (30.02%) were between 31-40 years of age. 260 (11.93%) donors were between 41-50 years of age and 39 (1.79%) donors belong to 51-60 years of age. As per table 2, among 2178 blood donors, 91 (4.17%) were voluntary donors and 2087 (95.82%) were replacement donors. In voluntary blood donors, 86 (94.5%) were male and 5 (5.49%) were female donors. Same as in replacement blood donors, 2070 (99.18%) were male and 17 (0.81%) were female blood donors. This shows the pre-dominance of males compared to females in blood donation for the studied years. As per table 3, sero-prevalence of HIV, HBV, HCV, Syphilis and Malaria was found to be 0%, 1.09%, 0%, 1.09%, 0% respectively in voluntary blood donors against the figures of 0.09%, 0.71%, 0.09%, 1.67%, 0% being the

Fig. 1: Types of Donors

Table 1: Age Wise Brerak up of Blood Donors Year 2011 2012 2013 Total

Total Number of Donors 301 865 1012 2178

18-30 171 (56.81%) 496 (57.34%) 558 (55.13%) 1225 (56.24%)

Age Group (in Years) 31-40 41-50 80 (26.57%) 42 (13.95%) 272 (31.44%) 86 (9.94%) 302 (29.84%) 132 (13.04%) 654 (30.02%) 260 (11.93%)

51-60 8 (2.65%) 11 (1.27%) 20 (1.97%) 39 (1.79%)

Table 2: Year and Gender Wise Break-up of Blood Donors Year 2011 2012 2013 Total %

Male 17 32 37 86 94.50%

Voluntary Donors Female Total 3 20 1 33 1 38 5 91 5.49% 4.17%

% 6.64 3.82 3.75 –

Male 277 824 969 2070 99.18%

Replacement Donors Female Total 4 281 8 832 5 974 17 2087 0.81% 95.80%

http://www.pacificejournals.com/aabs

% 93.36 96.18 96.25 –

Total Blood Donors 301 865 1012 2178

A-259

AABS; 3(3): 2016

Table 3: Distribution of Seropositive Cases INFECTIONS HIV HBV HCV SYPHILIS MP* TOTAL * Malarial Parasite

VOLUNTARY DONORS (Total No.20) 0 0 0 1 (5%) 0 1 (5%)

INFECTIONS HIV HBV HCV SYPHILIS MP* TOTAL

(Total No. 33) 0 0 0 0 0 0 (0%)

YEAR : 2011 REPLACEMENT DONORS (Total No. 281) 0 1 (0.35%) 0 9 (3.2%) 0 10 (3.55%) YEAR : 2012

TOTAL (Total No. 301) 0 1 (0.33%) 0 10 (3.33%) 0 11 (3.66%)

(Total No. 832) 0 5 (0.60%) 2 (0.24%) 8 (0.96%) 0 15 (1.8%)

(Total No. 865) 0 5 (0.57%) 2 (0.23%) 8 (0.92%) 0 15 (1.73%)

* Malarial Parasite YEAR : 2013 REPLACEMENT DONORS (Total No. 974) 2 (0.20%) 9 (0.92%) 0 18 (1.84%) 0 29 (2.97%)

TOTAL (Total No. 1012) 2 (0.19%) 10 (0.98%) 0 18 (1.77%) 0 30 (2.96%)

YEARS 2011 – 2013 VOLUNTARY DONORS REPLACEMENT DONORS (Total No.91) (Total No. 2087) 0 2 (0.09%) 1 (1.09%) 15 (0.71%) 0 2 (0.09%) 1 (1.09%) 35 (1.67%) 0 0

TOTAL (Total No. 2178) 2 (0.09%) 16 (0.73%) 2 (0.09%) 36 (1.65%) 0

INFECTIONS HIV HBV HCV SYPHILIS MP* TOTAL

VOLUNTARY DONORS (Total No.38) 0 1 (2.63%) 0 0 0 1 (2.63%)

* Malarial Parasite INFECTIONS HIV HBV HCV SYPHILIS MP*

* Malarial Parasite Table 4: Year Wise Break-up of Seropositive Blood Donors Year

Total No. of Donors

HIV

HBV

HCV

Syphilis

Malaria

2011

301

2012

865

2013

1012

Total

2178

0.09%

0.73%

0.09%

1.65%

0.00%

Prevalence Rate

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-260

Table 5: Comparision of Ttis Prevalence Rate in Different Parts of India Place

HIV%

HBV%

HCV%

Syphilis%

Reference

Bangalore (Karnataka)

0.44

1.86

1.02

1.6

Srikrishna A et al(1999)

Ludhiana (Punjab)

0.084

0.66

1.09

0.85

Gupta N.et al(2004)

Delhi

0.56

2.23

0.66

–

Pahuja S et al(2007)

West Bengal

0.28

1.46

0.31

0.7

Bhattacharya P et al(2007)

Lucknow (UP)

0.23

1.96

0.85

0.01

Chandra T et al(2009)

Southern Haryana

0.3

1.7

0.9

Arora D et al(2010)

Ahmedabad (Gujarat)

0.16

0.98

0.11

0.23

Shan N and Shah J M et al(2013)

Ranchi (Jharkhand)

0.08

1.01

0.1

0.03

Sundaram S et al(2015)

Present Study

0.09

0.73

0.09

1.65

2016

Discussion

Globally mass of evidence supported that blood transfusion is an efficient route of TTIs transmission. [7] Therefore prescribing decisions should be based on national guidelines on the clinical usage of blood; taking the individual patients needs into consideration, with minimum cost and wastage, optimum safety and efficacy. [8] Despite of pre-donation counselling and medical fitness tests, the presence of TTI is inevitable in blood donations. With every unit of blood, there is 1% chance of transfusion associated problems including TTI. The risk of TTI has declined dramatically in high income nations over the past two decades, but the same may not hold good for the developing countries. The national policy for blood transfusion services in our country is of recent origin and the transfusion services are hospital based and fragmented. Voluntary donors are motivated blood donors who donate blood at regular intervals and replacement donors are usually one time blood donors who donate blood only when a relative or a friend is in need of blood. [9] Investigation of the prevalence TTIs is often conducted in blood donor population because of convenience and access to a large sample size. They are generally considered a healthier segment of the community and have been used as a surrogate marker for the prevalence of infection in the population at large. [7] Voluntary donors constituted 4.17% as compared to 95.83% of replacement donors. This findings are similar with results of the earlier studies. [10-15] Majority of the donors 56% were aged between 18- 30 years which is in keeping with the age of college students who are often called to donate at our institution. Other study has similar age distribution (68%). [2] Ninety – eight percent (98%) donations were from males, a finding similar to the other studies. [2,9,16] This could be explained on the basis that the Indian women have a very high incidence of anemia

especially in the child bearing ate and hence are likely to face disqualification while being screened for blood donation.[2] Overall prevalence of TTI was 2.57% with a higher prevalence in replacement donors and male donors. In present study prevalence of HIV, HBV, HCV and Syphilis were 0.09%, 0.73%, 0.09%, 1.65% respectively. Many of the Indian studies show prevalence rates for HIV 0.51 – 3.87%, HCV 0.12-4%, HBV(HBsAg) 1.2-3.5% and Syphilis 0.3-0.82%.[10,11,14] A very low prevalence rate in my study may be attributed to increased number of donors donating at the blood bank with strict screening criteria when compared to the number of donations from the camps as well as because of small sample size.[2] In present study, prevalence of HIV is correlated with all of the studies mentioned in Table 5. While HBV prevalence correlates with Ludhiana[17] and Ahmedabad (Gujarat)[22] center studies. (Table 5) Various studies in India have shown the sero-prevalence of HCV ranging from the lowest (0.14%) in the study by Sunderam S et al[23] in 2015 to the higher one of 1.09% (Gupta et al, 2004[17] ). A significantly lower prevalence of HCV (0.09%) has been noted in present study. (Table 5) Sexually transmitted infections are widespread in developing countries and constitute a major public health problem. The TPHA reactivity in my study was 1.65% which is compared to study done by Srikrishna A et al . [15] (Table 5). The reason for wide variations of HBV and HCV prevalence may be either a particular geographical distribution or declining rate of its positivity in healthy population. The wide variations of HBV and HCV seroprevalence in different studies in India might be due to the use of different generation ELISA kits, having different sensitivities and specificities. [9]

http://www.pacificejournals.com/aabs

A-261

AABS; 3(3): 2016

Conclusion

Despite stringent donor screening and testing practices, safe blood free from TTIs remains an elusive goal because the threat of TTIs agents entering the blood supply is not static. This finding showed growing evidence in the burden of TTIs in blood donors. Voluntary blood donors have significantly lower rates of prevalence for markers of TTIs as compared to replacement blood donors. Awareness of general population about voluntary regular blood donation should be created to minimize the chances of spreading transfusion transmitted infections. Replacement donors carry a relatively higher risk of transfusion transmitted infections due to chances of missing professional donors during donor screening procedures. Hence blood from replacement donors should be accepted only in cases of dire emergencies when transfusion of blood or blood products would be lifesaving. The major concern in transfusion services today is increased seropositivity among replacement donors for HCV, HIV, HBsAg and syphilis. With the advent of nucleic acid amplification techniques (NAT), western countries have decreased the risk of TTI to a major extent. But the cost – effectiveness of NAT is poor. The NAT has added benefits but its high financial cost is of concern, especially in underdeveloped countries like India. Apart from NAT for donor screening, other factors such as public awareness, vigilance of errors, educational and motivational programs are sure to help in decreasing the infections.

10.

11.

12.

13.

14.

References

1. Dr. R. K. saran – World Health Organisation – Transfusion Medicine Technical Manual (Second Edition). 2003; 2:7-21; 12:143-173. 2. Gupta PK, Kumar H, Basannar DR, Jaiprakash M. Transfusion transmitted infections in armed forces: prevalence and trends. MJAFI. 2006; 62:348-350.

15.

16.

3. WHO factsheet on Blood Safety and Donation, 2008 4. WHO guidelines of Blood Transfusion Safety Aappia, CH-1211 Geneva 27,Switzerland 5. Government of India. Drugs and Cosmetics Rules, 1945 (Amended till 30th Jun’05) available at http:// www.cdsco.nic.in/html-drugsandcosmeticsact.pdf 6. National Blood Policy produced and published by NACO (National AIDS Control Organization), Ministry of Health and Family Welfare, Govt of India, New Delhi.Jun’03 (Reprint2007) 7. Khan ZT, Asim S, Tariq Z, Ehsan MA, Malik RA, Ashfaq B, Hayat: Prevalence of transfusion transmitted infectious in healthy blood donors in Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

17.

18.

Rawalpindi District, Pakistan: a five year survey. Inter J of Pathology. 2007; 5(1): 21-25. WHO: The cinical use of blood in medicine, obstetrics, paediatrics, surgery and anaesthesia , transfusion and burns, Geneva, Switzerland ; 2001. Giri PA, Deshpande JD, Phalke DB, Karle LB: Seroprevalence of transfusion transmissible infections among voluntary blood donors at a tertiary care teaching hospital in rural area of India: J. Fam. Med. Primary Care .2012; 1: 48-51. Kakkar N, Kaur R, Dhanoa J. Voluntary donors – need for a second look. Indian J PatholMicrobiol. 2004; 47:381-383. Garg S, Mathur DR, Garg DK. Comparison of seropositivity of HIV, HBV, HCV and syphilis in replacement and voluntary blood donors in western India. Indial J PatholMicrobiol. 2001; 44:409-412. Sing B, Verma M, Verma K. Markers for transfusion associated hepatitis in north Indian blood donors: prevalence and trends. Jpn J Infect dis. 2004; 57:49-51. Asif N, Kokhar N, Ilahi F. Seroprevalence of HBC, HCV and HIV infection among voluntary nonremunerated and replacement donors in northern Pakistan. Pak J Med Sci. 2004; 1:24-28. Matee MIN, Magesa PM, Lyamuya EF. Seroprevalence of human immunodeficiency virus, hepatitis B and C viruses and syphilis infections among blood donors at the Muhimbili National Hospital in Dar Es Salaam, Tanzania. BMC Public Health. 2006; 6:21. Doi: 10.1186/1471-2458-6-21. Pattanshetty A, Kulkarni K, Baragundi M. Seroreactivity of Syphilis Among Blood Donors of A Blood Bank. Annals Of Pathology And Laboratory Medicine, 2016:3(1), A41-44. P.Pallavi, C.K. Ganesh and et al. Seroprevalence and Trends in Trends in Transfusion Transmitted Infections among Blood Donors in University Hospital Blood Bank: A 5 Year Study. Indian J Hematol Blood Transfus. 2011; 27(1):1-6. Pattanshetty A, Kulkarni K, Baragundi M. Seroprevalence of Co-Infections Among Blood Donors in A Blood Bank of A Tertiary Health Care Centre. Annals Of Pathology And Laboratory Medicine, 2016:3(1):A29-32. Pahuja S, Sharma M, Baitha B, Jain M. Prevalence and trends of markers of hepatitis C virus, hepatitis B virus and human immunodeficiency virus in Delhi blood donors. A hospital based study. Jpn J InfDis. 2007; 60:389–391. e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-262

19. Chandra T, Kumar A, Gupta A. Prevalence of transfusion transmitted infections in blood donors: an Indian experience. TropDoct. 2009; 39:152–154. doi: 10.1258/td.2008.080330 20. Arora D, Arora B, Khetarpal A. Seroprevalence of HIV, HBV, HCV and syphilis in blood donors in Southern Haryana. Indian J PatholMicrobiol. 2010; 53:308–309. 21. Bhattacharya P, Chakraborty S, Basu SK. Significant increase in HBV, HCV, HIV and syphilis infections among blood donors in West Bengal, Eastern India 2004–2005. Exploratory screening reveals

high frequency of occult HBV infection. World J Gastroenterol. 2007; 13:3730–3733. 22. Shah N, Shah JM, Jhaveri P, Patel K, Shah CK, Shah NR. Seroprevalence of HBV, HCV, HIV and syphilis among blood donors at a tertiary Care Teaching Hospital in Western India. Gujarat Medical Journal.2013; 68(2): 35-39. 23. Sundaram S, Karir S, Haider S, Singh S.B, Kiran A. sero-prevalence of transfusion transmitted infections among blood donors at blood bank of Rajendra Institute of Medical Sciences, Ranchi. Healthline journal.2015; 6(1);36-40.

http://www.pacificejournals.com/aabs

Original Article Labour Analgesia and Its Outcome: In Rural Population Rajani Rawat1, Ruchika Garg2*, Shikha Seth1, Arun Nagrath1 and Ramakant Rawat1 1

Dept. of Obs. & Gynecology, UP Rural Institute of Medical Science and Research, Saifai, India 2 Dept. of Obs. & Gynecology, S.N. Medical College Agra, India Keywords: Labour Analgesia, Pain Relief, Programmed Labour Protocol

ABSTRACT Introduction: The purpose of the study was to assess the effect of programmed labour protocol on labour analgesia, duration of labour , maternal and foetal outcome and mode of delivery. Methods: A prospective randomized study was done in UP Rural institute of Medical Science and Research, Saifai, Uttar Pradesh, India. One hundred and twenty primigravidae at 37 to 42 week gestation with vertex presentation and in the active phase of labour without any foetal or maternal complication were randomly allocated in two groups. 60 women received programmed labour protocol while other 60 women were managed expectantly with traditional method. Labour duration, pain relief, mode of delivery , maternal and foetal outcome noted in both groups were analyzed. Results: Duration of all stages of labour were reduced(p<0.001). Average blood loss was comparatively less in the study group. There was no foetal or maternal complications. 55% women in the study group had excellent pain relief. There was no impact on caesarean section rate. Conclusions: Programmed labour protocol decreases the labour duration and provide significant pain relief without any maternal and/or foetal complications.

*Corresponding author: Dr Ruchika Garg, Dept. of Obs. & Gynecology, S.N. Medical College, Agra, IndiaÂ

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

Original Article

A-264

Introduction

Labour is a physiological but painful event. The agony and stress a woman suffers during labour is beyond description, aggravated by anxiety , fear and ignorance. In a civilized society, freedom from pain is one of the basic rights of a person. Pain relief during labour reduces maternal stress, prevents maternal hyperventilation and undue muscular efforts and decrease exhaustion and thus improves maternal outcome. Labour analgesia, apart from reducing maternal distress , controls alterations of placental circulation and safeguards foetal hypoxia and depression at birth. Epidural analgesia has proved to be beneficial and has significantly contributed to pain relief with improved obstetric outcome1,2. However in developing countries like India , wherein majority of women are cared for in small hospitals with limited resources, facilities for providing epidural analgesia appears to be a distant dream . In such a scenario, programmed labour protocol appears to be a boon. Programmed labour protocol was developed by Dr Daftary in India3. It is based on four pillars1. 2. 3. 4.

Oxytocics to ensure adequate uterine contractions. Antispasmodics to facilitate cervical dilatation. Analgesics to provide optimum pain relief Partogram to assess the progress of labour

In our present study , we adopted this protocol with some modifications. Programmed labour protocol was compared with the traditional method in primigravida.

Methods

The present study was undertaken in the department of obstetrics and gynaecology in UP Rural Institute of Medical Science and Research, Saifai from January 2012 to January 2013. It was approved by the ethical committee of the institute. Nulliparous women between 37-42 weeks gestational age with vertex presentation and in active phase of labour with cervical dilatation of 3-4 cm and bishop’s score >6 and admission Non Stress Test (NST) satisfactory were included in the study. None had clinical evidence of cephalo-pelvic disproportion or history of medical disorders like hypertension ,cardiac disease ,bronchial asthma, diabetes and jaundice. They were randomly allocated to two groups—a) study group and b)control group. The study group consisted of 60 women who received programmed labour protocol while the control group of 60 pregnant women were managed with traditional method. In all women, general examination, systemic examination and obstetric examination including vaginal examination were performed. Informed consent for inclusion in the study was obtained.

In the study group, an amniotomy was performd to ensure presence of clear liquor and satisfactory heart rate pattern. A partogram was plotted alongside the “ standard nomogram” and all labour events were charted on the partogram to guide the obstetrician in the management of patient. An intravenous infusion of Ringer’s lactate was started. If the frequency of uterine contractions were not adequate, labour was augmented either with 25mcg tablet of misoprostol or 2 units of oxytocin in 500 ml of 5% glucose until atleast three contractions every 10 minutes lasting 35-45 seconds were established. Injection pentazocine 6 mg diluted in 10 ml of normal saline and injection diazepam 2 mg diluted in 10 ml of normal saline were injected slowly intravenously through separate syringes to initiate pain relief. The drugs were repeated every two hours if required. At the same time, injection tramadol 1mg/ kg body weight was injected intramuscularly and injection drotaverine hydrochloride (antispasmodic) 40 mg injected intravenously. Injection drotaverine was repeated every 2 hours if required for a maximum of 3 doses. Pain score of the patient wasnoted as perceived by the women at the beginning of protocol. Visual Analog Scale(VAS) was used for the pain assessment. After delivery, 125ug carboprost tromethamine was injected intramuscularly. In the control group, diazepam, pentazocine ,tramadol,drotaverine and carboprost tromethamine were not used. Partographic monitoring of labour was done. The assessment was done as followsa) Duration of first, second and third stage of labour b) Level of analgesia using following scale i. ii. iii. iv.

Score 0- no relief Score 1- mild relief Score2- moderate relief Score 3- excellent relief

c) Mode of delivery d) Amount of blood loss] e) Maternal and foetal/neonatal complications f) Side effects of the drugs used g) Apgar score at 1 minute and 5 minute Statistical analysis was done using z test. P value <0.05 was considered statistically significant.

Results

Both groups were comparable in age, gravidity and locality of residence. The mean age of women in the study group was 23.3 years while in the control group it was 22.6 years. Mean gestational age was 38.6 weeks in study group and 39 weeks in control group. The mean time of onset of analgesia was 18 minutes.

http://www.pacificejournals.com/aabs

A-265

AABS; 3(3): 2016

Partographic events in labour were analyzed. The mean duration of active phase of labour was 3.44±0.65 hours in the study group compared to 5.1 ±0.60hours in the control group. The mean duration of second and third stage of labour was 25.3 ±5.09minutes and 4.36 ±1.26minutes in the study group compared to 38.2 ±5.16minutes and 7.12±2.05 minutes respectively in the control group(Table I). All these differences were highly significant ( p< 0.0001). The average blood loss was much reduced, 100 ml in the study group compared to 150 ml in the control group. Majority of the patients delivered vaginally in both the groups( 95% in study group and 88.33% in control group) (Table II).There was no statistically significant difference in both groups as regards the mode of delivery. Only two patients in the study group had caesarean section, the indication being non reassuring foetal heart rate in both. Mean apgar score was above seven in all cases in the study group except one baby who had heart rate <100

with respiratory depression; this baby was delivered by caesarean section for foetal distress. This was comparable to control group where Apgar score was less than seven in two babies; one baby delivered by forceps for deep transverse arrest and another baby delivered by caesarean section for foetal distress. However larger studies are required to assess the effect of drugs used in programmed labour on neonates. There was no neonatal mortality. We observed in this study that 55% women had excellent pain relief in labour, 41.67% had moderate pain relief while 3.33% women had mild pain relief. Pain relief score in the study group were highly significant(p<0.0001)(table III) Frequency of drug related side effects were observed more in study group as compared to the control group(table IV.) Tachycardia was the most common side effect followed by nausea and vomiting in the study group. All these minor side effects subsided after 10-12 hours.

Table I. Duration of The Stages of Labour Cases(n=60) Controls(n=60) Z value p value

active phase of labour (hours) 3.44±0.65 5.1±0.60 14.353 P<0.0001

2nd stage (minutes) 25.3±5.09 38.2±5.16 13.786 P< 0.0001

3rd stage (minutes) 4.36±1.26 7.12±2.05 8.88 P< 0.0001

Table II. Comparison of Mode of Delivery Mode of delivery Normal delivery forceps ventouse Caesarean section

Study group(n=60) 57(95%) 1(1.66%) 0 2(3.33%)

Control group (n=60) 53(88.33%) 2(3.33%) 1(1.66%) 5(8.33%)

Z value 1.13

P value p>0.05

1.175

p>0.05

p>0.05 is considered statistically not significant

Table III. pain Relief Score Pain relief score 3 2 1 0

Study group (n=60) 33(55%) 25(41.67%) 2(3.33%) 0

Control group (n=60) 0 12(20%) 37(61.67%) 11(18.33%)

Z value 8.56 2.64 8.72 3.66

P value P<0.0001 P=0.0083 P<0.0001 P=0.0003

P value <0.05 is considered statistically significant

Table IV. Side Effects and Complications Maternal morbidity tachycardia Nausea vomitting diarrhoea drowsiness Cervical/ vaginal tears

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

Study group ( n=60) 6(10%) 4(6.67%) 4(6.67%) 3(5%) 2(3.33%) 2(3.33%)

Control group (n=60) 7(11.67%) 5(8.33%) 3(5%) 1(1.67%) 0 1(1.67%)

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Original Article

A-266

Discussion

The experience of the study revealed that patients treated with ‘Programmed labour protocol’ had progressive, shorter and more comfortable labours with less blood loss. In our study, mean duration of active phase of labour in primigravida was 3.44±0.65 hours(study group) and 5.1±0.60 hours(control). It was statistically significant(p< 0.0001). Mean duration of second stage of labour was 25.3±5.09 minutes(study) and 38.2 ±5.16minutes(controls) which was statistically significant. Daftary et al3 reported duration of active phase and second stage of labour in the study group as 3.5 hours and 26 minutes respectively. The mean duration of third stage of labour was 3.5 minutes. Chauhan et al4 found duration of first stage of labour to be 3.4 hours in the study group as compared to 4.5 hours in control group. Mean duration of third stage of labour was 4.36 ±1.26 minutes(study group) and 7.12 ±2.05minutes(control group). Excellent pain relief was observed in 55% cases and moderate pain relief in 41.67% cases in the study group. Prasertsawat et al5 observed excellent pain relief in labour in 24-50% and Suvonnakote et al6 in 40% cases. Veronica et al 7 reported total pain relief in 70% cases. Meena Jyoti et al8 noticed that 54% achieved good and 32% achieved moderate pain relief. Daftary et al3 reported excellent pain relief in 24% of cases. Chauhan et al4 observed satisfactory pain relief in 88% primigravidae and 92% multigravidae in study group. In our study , the mean time of onset of analgesia was 18 minutes while Husslein et al9 reported that analgesic effect was observed after 10 minutes. Li and Weng 10 observed analgesic effect in 26.10 minutes. Chauhan et al4 reported mean time of onset of analgesia around 16 minutes. The average blood loss in the study group was 100 ml as compared to 135 ml reported by Reddy and Carey.11 Daftary et al3 reported average blood loss of 60 ml in cases. Chauhanet al4 and Meena Jyoti et al8 also had similar findings. Programmed labour did not have any significant impact on caesarean section rates. Majority of the patients in both the groups delivered vaginally( 95% in cases and 88.33% in controls). This was in accordance with the finding of Daftary 3,Veronica7 and Jyoti et al. 8 There was no foetal or maternal mortality. Apgar score 1 minute and 5 minute was >7 in 98.33% cases and 96.66% controls. Daftary et al3, Chauhanet al4 and Jyoti M et al8 also had similar observations. Bajaj et al 12 reported an Apgar score of >8 at 1 minute in all neonates of the tramadol group. Minor side effects of the drugs were observed in our study. Suvonnakote et al6 and Prasertsawat et al³ reported minimal side effects in women receiving tramadol. Veronica

et al7 reported tachycardia (80%) as commonest side effect followed by nausea and vomiting(10%)

Conclusion

Programmed labour protocol’ is a simple, inexpensive, easy and effective method for painless and safe delivery. The overall duration of labour is significantly reduced with marked labour analgesia . However there is no impact on caesarean section rate. Side effects of the drugs are minimal and safe for the foetus as well. This protocol is a boon in rural setting so that the childbirth becomes an event of joy and satisfaction for the mother.

References

1. Agrawal D, Makhija B, Arora M, Haritwal A, Gurha P. The Effect of Epidural Analgesia on Labour, Mode of Delivery and Neonatal Outcome in Nullipara of India, 2011-2014. Journal of Clinical and Diagnostic Research : JCDR. 2014;8(10):OC03-OC06. doi:10.7860/JCDR/2014/9974.4930. 2. Agrawal D, Makhija B, Fotedar S. Impact of Epidural Analgesia on labour: A Review. Annals of Woman and Child Health. 2015;1:R1-9 3. Daftary SN, Desai SV, Nanavati MS . Programmed labour- An indigenously developed protocol of labour management.Int J Gynecol Obstet .2003;6:47-49. 4. Chauhan R, Gupta R. A clinical study of programmed labour and its outcome. J Obstet Gynaecol $ Family Welfare .2003;5:8-9 5. Prasertsawat PO, Herabutya Y,Chaturachinda R. Obstetric analgesia. Current Therapeutic research. 1986;40:1022-8. 6. Suvonnakote T, Thitadilok W, Atisook R. Pain relief during labour. J Med Assoc Thailand .1986;69:575-80. 7. Veronica Irene, Vaneet Kaur. Programmed labor for optimizing labor and delivery. JK Science .2008;10:62-4. 8. Jyoti M, Singhal P, Choudhary D. Programmed labour. J Obstet Gynaecol India. 2006;56:53-55. 9. Husslein P, Kubista E, Egarter C. Obstetrical analgesia with tramadol, results of a prospective randomized comparative study with pethidine. Zeitschrift Gebrtshilf umb perinatolfgie . 1987;191:234-7. 10. Li E, Weng L. Influence of dihydroetorphine hydrochloride and tramadol on labour pain and umbilical blood gas. Zhonghua Fu Chan Ke Za Zhi .1995;30:345-8. 11. Reddy W, Carey JC. Effect of umbilical vein oxytocin on puerperal blood loss and length of the third stage of labor. Am J Obstet Gynaecol .1989;160:260-8 12. Bajaj P, Meena R, Prasad R. Intravenous tramadol for labour analgesia.Indian Pract. 1997;50: 1051-4.

http://www.pacificejournals.com/aabs

Case Report Uterine Arteriovenous Malformation Accidently Detected: A Case Report Shikha Joshi*, Dipti Agrawal, Sunita Fotedar Dept. of Gynecology and Obstetrics, Swami Dayanand Hospital Dilshad Garden, Delhi, India

Keywords: Arteriovenous Malformation, Embolisation, Mri, Ultrasound, Uterine Artery

ABSTRACT Uterine arteriovenous malformation (AVM) is a rare condition and is potentially life-threatening condition. Uterine arteriovenous malformations result from formation of multiple arteriovenous fistulous communications within the uterus without an intervening capillary network. This case report describes a 30-year-old woman with previous LSCS presented in emergency with episode of heavy vaginal bleeding with hypovolemic shock. Two weeks earlier, she had taken MTP pills for missed abortion. Transabdominal ultrasound (US) of the pelvis showed increased vascularity with multidirectional flow of the uterus with retained products .Colour Doppler was done which shows mass of size 35 mm with multiple small anaechoeic spaces in the anterior wall of cervix at the level of previous LSCS scar with increased systolic and diastolic blood flow with colour aliasing. MRI findings of an AVM include a focal uterine mass that consists of a group of distinct, serpiginous flow voids on T2W imaging. Beta HCG was 30mIU/mL. Patient was referred to higher centre for embolization of AVM which was performed successfully.

*Corresponding author: Dr Shikha Joshi, 27/76 Gali No 8 Vishwas Nagar Shahdara Delhi 110032, India Phone : +91 09582647083 E-mail: drshikhajoshi@gmail.com

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

Case Report

C-48

Introduction

Uterine arteriovenous malformation (UAVM) is a lifethreatening rare condition. Bleeding is the major presenting symptom which may be postpartum, postabortal , menstrual (1,2). A UAVM consists of a proliferation of vascular channels with fistula formation. The size of these vessels can vary considerably. They are classified as congenital or acquired.(2,3) Acquired uterine AVMs are usually traumatic, resulting from prior dilation and curettage (D&C), therapeutic abortion, uterine surgery, or direct uterine trauma.(1,4,5). Traditionally, uterine AVMs have been treated by uterine artery ligation or hysterectomy. Transcatheter uterine artery embolization is an alternative conservative management in patients who wish to preserve their fertility or young women .(6,7)

Case Report

A 30-year-old woman with previous LSCS presented with episode of heavy vaginal bleeding with hypovolemic shock. Two weeks earlier, she had taken MTP pills for missed abortion. This was her second pregnancy previously she had a caesarean section for fetal distress two years back. She was diagnosed as 7 weeks missed abortion for which she had taken medical treatment from a local practioner On examination, she was afebrile and hemodynamically low with hemoglobin (Hb) level of 4.7 g% . Vaginal examination showed minimal bleeding with closed os . Human chorionic gonadotropin (hCG) level was less than 30mIU/mL.TAS and TVS showed empty uterus with an endometrial thickness of 4.3mm. There was increased vascularity of the uterus with prominent vessel seen on the left lateral wall of the uterus, which likely originated from the left uterine artery . A diagnosis of an AVM was

Fig. 1: Color Doppler Showing Increased Vascularity

considered and required confirmation. Color Doppler (figure1) shows mass of size 35 mm with multiple small anaechoeic spaces in the anterior wall of cervix at the level of previous LSCS scar with increased systolic and diastolic blood flow with color aliasing MRI findings of an AVM includes a focal uterine mass that consists of a group of distinct, serpiginous flow voids on T2W imaging with an ill-defined border that and is associated with prominent vascularity Patient was referred to higher centre for embolisation of the AVM.Pelvic angiogram (figure 2) shows bilaterally enlarged tortous uterine arteries .Embolisation of both uterine arteries were performed with 300–500 μm and 700–1000 μm polyvinyl alcohol (PVA). The postembolisation arteriogram showed complete embolisation of the AVM with slow flow of contrast in both uterine arteries No complications were encountered. The patient’s vaginal bleeding decreased post-embolisation and she was eventually discharged.During the follow up two weeks later, no repeat bout of bleeding with stable vitals.She reports having a regular menstrual cycle and has remained asymptomatic. The patient has also indicated here desire to conceive again in the future.

Discussion

Uterine vascular abnormalities are rare entities in gynaecology. However, it is a potentially life-threatening disorder in which patients present with vaginal bleeding that may be profuse and cause hemodynamic instability. To date, there are fewer than 100 cases reported in the literature (1,7,8). AVM consists of proliferation of arterial and venous channels with fistula formation and a mixture of capillary-like vessels. Uterine AVM may be congenital or acquired (2,3 )Congenital AVM is believed to arise from arrested vascular embryologic development resulting in

Fig. 2: Uterine Artery Angiogram

http://www.pacificejournals.com/aabs

C-49 anomalous differentiation in the capillaries and abnormal communication, between arteries and veins .Acquired AVM are more common and usually follows a history of previous uterine trauma, such as curettage procedures, caesarean section, or pelvic surgery.. Doppler , MRI, angiogram are the gold standard in diagnosing AVM . Gray scale ultrasound (US) can detect the presence of multiple tubular or “spongy” anechoic or hypoechoic areas within the myometrium of a normal endometrium (2,4,) However, other conditions may present a similar appearance, such as retained products of conception, hemangioma, gestational trophoblastic disease Thus, using colour and spectral Doppler US is important for obtaining more accurate informationIn addition, uterine AVM will exhibit intensely vascular and multidirectional flow not considered in the differential diagnosis.Our patient had taken MTP pills for missed abortion, presented with heavy bleeding ,low BP and anemia managed conservatively. Clinicians should raise high suspicion in their mind with such conditions where there is profuse bleeding with haemodynamically unstable. Curettage is non therapeutic and can often aggravate bleeding .Management of uterine AVM depends on the hemodynamic status, degree of bleeding, patient age, and desire for future fertility. Acute treatment involves stabilising the patient’s hemodynamic status, and stopping blood loss. Traditionally, a hysterectomy was the treatment of choice. However, the patient’s desire for future pregnancy is an important consideration, so UAE is treatment of choice

AABS; 3(3): 2016

Acknowledgements None

Funding None

Competing interests: None declared

References

Uterine arteriovenous malformation (AVM) is a rare dangerous,life threatening yet treatable condition and if detected in time can avoid hysterectomy and save life .

1. Fleming H, Ostor AG, Pickel H, Fortune DW. Arteriovenous malformations of the uterus. Obstet Gynecol 1989; 73:209–214 2. Polat Petal Colour Doppler Ultrasound in the Evaluation of Uterine Vascular Abnormalities. Radiographics. 2002;22:47–53 3. Grivell R, Reid K, Mellor A. Uterine Arteriovenous Malformations: A review of the Current Literature. Obstet Gynaecol Survey. 2005;60(11):761–767. 4. Diwan RV, Brennan JN, Selim MA, et al. Sonographic diagnosis of arteriovenous malformation of the uterus and pelvis. J Clin Ultrasound1983; 11:295–298. 5. Huang MW, Muradali D, Thurston WA, Burns PN, Wilson SR. Uterine arteriovenous malformations: gray scale and Doppler ultrasound features with MR imaging correlation. Radiology 1998; 206:115–123. 6. Garner EI, Meyerovitz M, Goldstein DP, Berkowitz RS. Successful term pregnancy after selective arterial embolization of symptomatic arteriovenous malformation in the setting of gestational trophoblastic tumor. Gynecol Oncol 2003; 88:69–72 7. Pope SL, Fleisher AC, Bream PR. Intramyometrial arteriovenous malformation. J. Womens Imaging 2003; 5:79–82. 8. Hoffman MK, Meilstrup JW, Shackelford P, Kaminski PF. Arteriovenous malformations of the uterus: an uncommon cause of vaginal bleeding.Obstet Gynecol Surv 1997; 52:736–740 9. Garner EI, Meyerovitz M, Goldstein DP, Berkowitz RS. Successful term pregnancy after selective arterial embolization of symptomatic arteriovenous malformation in the setting of gestational trophoblastic tumor. Gynecol Oncol 2003; 88:69–72 10. Y N Chia, C Yap, B S Tan. Pregnancy Following Embolisation of Uterine Arteriovenous Malformation – A Case Report. Annals, Academy of Medicine, Singapore 2003;32:658-60

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Since the first description of a successful embolisation treatment for uterine AVM in 1986, it has been commonly used in the emergency setting as well as less urgent circumstances. Various embolic materials have been used, including polyvinyl alcohol, glue , detachable balloons, and haemostatic gelatine. Some cases may require repeat embolisation (4). In addition, because uterine AVM is commonly diagnosed in women of childbearing age, angiographic embolisation has made hysterectomy no longer necessary. However, hysterectomy remains the treatment of choice in post-menopausal patients or as an emergency treatment in life-threatening situations With conservative therapy several pregnancies after embolization have been reported with successful outcomes. Spontaneous resolution of uterine vascular malformations and subsequent pregnancy has also been reported in at least 5 cases.(8,9,10)

Conclusion

Case Report Post Coital Acute Rectovaginal Fistula A Rare Case Puja Jain* and Rashmi Saini Department Of Obstetrics & Gynaecology, Swami Dayanand Hospital Shahadra, Delhi.

Keywords: Rectovaginal fistula, Postcoital

ABSTRACT Most case of Rectovaginal fistula are caused by obstetric injuries, surgical complications, infections and rarely may follow coital Acts. Postcoital non obstetric vaginal laceration due to consensual sexual Act are generally minute mucosal tears and generally heal by themselves, but in some cases, the vaginal mucosa is lacerated deeper and bleeding may require suturing of open vessels. The aim of this case report is to highlight a rare case of acute low rectovaginal fistula which a 25 yrs old women developed by penile penetration through the full thickness of rectovaginal wall after consensual intercourse and its management in emergency settings.

*Corresponding author: Dr Puja Jain, 5204, ATS Advantage, Ahinsa Khand I, Indirapuram, Ghaziabad, U.P.-201012. Phone : +91 9899807202 E-mail: dranujpuja@gmail.com

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

Case Report

C-54

Introduction

A Rectovaginal fistula (RVF) is an epithelial communication between rectum and vagina. Rectovaginal fistula may cause distressing symptoms, and their severity depends on the size and site of the fistulous tract[1]. There are several causes of rectovaginal fistula. RVF commonly occurs from obstetric injuries. Perineal lacerations during childbirth predispose to RVF. Perineal lacerations are more common in primigravidas and precipitous birth or following instrumental vaginal delivery. In developing countries RVF resulting from child birth injuries constitute 76-97 % of total and rest can be from surgeries, malignancies and infection.[2] Failure to recognize and correctly repair perineal lacerations, further increase the chances of RVF.

After 6 weeks follow up, we observed the complete healing of the rectovaginal laceration with no fistula formation and patient was continent to both faeces and flatus. Patient resumed her sexual activity after 1 month and reported no discomfort. After follow up this Patient for 1 year we observed that there was complete healing and there was no chronic fistula formation.

Although coitus is a physiological phenomenon, it may sometimes be risky especially in women with little or no fore play. Although trauma at sexual intercourse remains an everyday occurrence, most are minor and manifest as self limiting injuries with minimal vaginal bleeding requiring no medical attention [3,4,5]. However RVF from a consensual sexual intercourse is a rare event and few case reports showed that. Nulliparity, low level of education, non consensual and premarital sex with little or no foreplay were strongly correlated with the risk of coital trauma[6]. Risk factors for genital injury following sexual intercourse also include intercourse during pregnancy, pueperium and after gynecologic surgery, and at menopause [4].

Case Report

We report a rare case of isolated acute rectovaginal fistula sparing anal sphincters and perineum following consensual vaginal intercourse. This Patient P1L1 reported to our emergency with H/O of bleeding P/V and pain after having intercourse with her partner. On examination she was stable, her P/R = 90/m, BP= 120/76, there was slight pallor & chest & CVS examination was normal. On speculum examination there was a 3.5 cm laceration on the posterior vaginal wall forming a fistula between rectum and vagina, the fistula extended approximately 1.5cm above the hymeneal ring but did not extended to the post fornix or perineum. Slight bleeding was present from the edges. We started a IV line and initial M/N was given with antibiotics, analgesics and with consent Patient was shifted to OT for repair of acute RVF. Under full aseptic precautions, three layers suturing of rectal vaginal mucosa and rectovaginal septum was done with vicryl 2-0 in this case. In postoperative period pt was put in broad spectrum antibiotics, analgesics and was also given stool softener. Postoperatively the patient was continent to faeces and flatus and discharged on sixth postoperative day.

Fig. 1: rectovaginal fistula

Discussion

RVF is a devastating condition; mainly results from child birth injuries following obstructed labors in developing countries where access to comprehensive obstetric care is limited [6].The occurrence of rectovaginal fistula caused by coital trauma necessitates, however, specific anatomic predisposition and/or special circumstances. RVF from coital injury is reported in the case of sexual violence where excessive force is used to control the survivor, such as rape, sexual abuse and use of foreign objects[7]. The perversion that characterizes the sexual orientation of certain groups can cause genital mutilations that are sometimes important[7]. Genital malformations of agenesis type or vaginal diaphragms also offer favorable condition for the development of rectovaginal fistula. [8].Conversely there are v few case reports of consensual sexual intercourse[9] as was this case. Non obstetric vaginal lacerations differ significantly from lacerations sustained during childbirth

http://www.pacificejournals.com/aabs

C-55 and are generally classified into 2 types .The first one is relatively minor and is associated with normal sexual intercourse or with first experience of sexual debut. These lacerations usually resolve with minimal or no treatment. The second type is more extensive and often results in copious vaginal bleeding and can be life threatening and requires immediate intervention [10]. Various presentations of coital injuries requires careful evaluation ,correct diagnosis and management for successful outcome with minimal morbidity.[11].The transvaginal approach of the repairing rectovaginal fistulas was used in this case because the results were better.[11]. Rahman et al (2003) reported 39 patients undergoing transvaginal repair for low rectovaginal fistulas with 100% success rate using this approach[12].Therefore early diagnosis, repair and treatment is essential to avoid late complications. It should be strongly based on site and condition of RVF. It should be done as early as possible to hasten the psychological recovery of the patient.

Conclusion

Rectovaginal fistula is a rare complication of postcoital injury. An early diagnosis requires high index of suspicion followed by prompt and good physical examination including examination under anesthesia (EUA) to exclude the presence of RVF. Early repair of postcoital RVF occurring during consensual intercourse or during honeymoon has to be strongly considered based on the site and condition of RVF to hasten psychological recovery of couples. By this we see that by taking appropriate antiseptic precautions, and antibiotic coverage, simple suturing of rectal and vaginal mucosa are enough to treat acutely formed low rectovaginal fistulas resulting from coitus. Decision to form colostomy and diversion of faeces in the repair of such injuries should be taken cautiously.

Acknowledgements None

Funding None

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

AABS; 3(3): 2016

Competing Interests Not Declared

Reference

1. Meeks G , Ghafar M (2012) Rectovaginal fistula. Glob Libr. Womens med. 2. S Hembah-helekaan I pam(2010) coitally related vaginal injury in woman in north central nigeria .The Internet journal of sexual medicine. 3. Abdullahi. H.M. Yakasai I A (2014) coital laceration resulting in RVF. A case report Int J cure microbiol App. Sci 3:845-849. 4. Mitra P Mukherjee S Hassan H, soreng PS Adhikari s et al .(2012). Rectovaginal fistulas of different etiologies : Clinical case reports NJOG 7:43-46. 5. Sally ,EP., Matt, Mc Danald ,D claire, T. 2001. Unrecognized coital laceration ina series of non virginal adolescents girls. J Paediat. Adol. GYNECOL.,14(3):149. 6. Onsrud M Sjoveian S Luthiriri R ,Mukwege D(2008) Sexual violence-related fistulas in the DemocraticRepublic of Congo. Int J Gynaecol Obstet:256-259. 7. Mulleta M Williams G.Postcoital injuries treated at the Addis Ababa Fistula hospital,1991-97.Lancet 1999;354:2051. 8. Kriplani A ,AgarwalN,Garg P,Sharma M.Transvaginal repair of post coital rectovaginal fistula in patients of vaginal agenesis.J Obstet Gynaecol.2007;27;209. 9. Singh Nisha (2013) Case Series of three postcoital rectovaginal fistulas. J gynacol surg 29: 70. 10. Ahmed, E., Syrd, S. A., Praveen, N, 2006. Female consensual coital injuries.J. Coll. Physicians 11. Rahman, M S ., AL-Suleman , S.A.,EL- Yahia, A.R., Rahman, J. 2003. Surgical treatment of rectovaginal fistula of obstetric origin: a review of 15 years experience in a teaching hospital. J . Obstet. Gynaecol., 23:607 610. 12. Nisa ,S 2013. Case series of three postcoital rectovaginal fistule. J Gynaecol surg , 29(2): 7071,doi: 10 1089/gyn.2011.0097.

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Case Report Unruptured 14 Weeks Tubal Ampullary Pregnancy: A Rare Case Report Puja Jain*, Dipti Agrawal, Sunita Fotedar Department Of Obstetrics & Gynaecology, Swami Dayanand Hospital Shahadra, Delhi.

Keywords: Tubal pregnancy, Ampullary, unruptured

ABSTRACT Ectopic pregnancy is a life threatening condition and presents itself in diverse ways .Ninety five percent of ectopic pregnancies occur in fallopian tube .Ampulla is the most common site of ectopic tubal pregnancy. Diagnosis and exact location of ectopic pregnancy is usually easy during the first trimester of pregnancy by ultrasonography .However in developing countries, where resources are limited, most women do not undergo ultrasound examination during pregnancy, leading to late diagnosis. The reported average duration of diagnosis of unruptured tubal pregnancy is between 5 and 9 weeks of gestation. Rarely tubal pregnancy can remain asymptomatic and unruptured for longer duration than usual scenario. This case reports a rare case of viable, unruptured, tubal ampullary ectopic pregnancy of 14 weeks gestational age

*Corresponding author: Dr Puja Jain, 5204, ATS ADVANTAGE, Ahinsa Khand I, Indirapuram, Ghaziabad, U.P. 201012. India Phone: +91 9899807202 E-mail: dranujpuja@gmail.com

This work is licensed under the Creative commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

C-57

Introduction

Ectopic pregnancy is one of the most common life threatening condition in early pregnancy.[1] Incidence of ectopic pregnancies varies from 10-39.5/1000 deliveries. [2,3,4]The vast majority of ectopic pregnancy implant in the fallopian tube with most common site being ampullary portion (70.0%), fimbrial (11.1%), isthmic (12.0%) and interstitial (2.4%). [5] Many risk factors are associated with ectopic pregnancies. Subsequent presentations of ectopic pregnancy varies from being asymptomatic to hemodynamic instability as a result of disturbed pregnancy.[6]Tubal pregnancy has always being considered as a complication of the first trimester pregnancy. Most of the tubal ectopic pregnancies rupture between 5th to 9th weeks of gestation causing hemorrhage and shock.[7]It is very rare for an ectopic pregnancy to progress into second trimester and remain asymptomatic. This event is rare because it is unusual for the fallopian tube to dilate to a point of carrying second or third trimester fetus. We are reporting a rare case of ampullary tubal pregnancy which progressed unruptured until 14 weeks with live fetus in situ.

AABS; 3(3): 2016 had previous 3 full term vaginal deliveries. She had no risk factors for ectopic pregnancy. On examination pulse rate was 90beats per minute ,B P was 100/60 mmhg, with moderate pallor. On abdominal examination a 6 by 8 cm sized suprabubic mass firm in consistency with restricted side to side mobility was present. A closed cervical os with slight bleeding coming through os was visible on per speculum examination. Bimanual examination revealed enlarged uterus with cervical motion tenderness ,with a lump of about 8 by 8 cm palpable through right adenexal in continuation with abdominal mass. Transabdominal sonography revealed an 14 weeks live intrabdominal pregnancy with empty uterine cavity. Minimal fluid was present in the cul de sac. Patients hemoglobin was 8 gram %,blood group was B+ with normal liver and kidney function test. Exploratory laprotomy was done after obtaining informed consent which revealed a right sided tubal ampullary lump of 10 by 10 cms (fig 1 ).Right sided salpingectomy with left sided tubal ligation was done .On cut section of tubal ampullary lump a live fetus of about 14 weeks gestational age with placenta was revealed.(fig 2).

Discussion

A 40 year old patient gravida 4 Para 3, presented to the opd with history of 3 and Â˝ months amenorrhea .This was her first antenatal visit..She reported to the opd when she experienced on and off spotting since one month and pain in abdomen . She had regular cycles with normal flow .She

The incidence of ectopic pregnancies varies from1039.5/1000 deliveries.[2,3,4].Ectopic Pregnancy is the leading cause of first trimester pregnancy related morbidity and mortality(38 deaths/100,000events).[8] The ampullary portion of the fallopian tube is the most common location. Bouyer et al reported [5] the site of ectopic pregnancy from a 10 year population based study of 1800 cases. They found

Fig. 1: unruptured tubal pregnancy

Fig. 2: 14 weeks fetus with placenta

Case Report

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Case Report

C-58

that only 4.5% were extratubal( tuba ovarian & abdominal) and 73% were ampullary. Risk factors for ectopic pregnancy include a previous ectopic pregnancy, the presence of tubal damage from an infection or prior abdominal/pelvic surgery, history of infertility, treatment for invitro fertilization, increased maternal age and smoking.[9] Half of the women with ectopic pregnancies have no identifiable risk factors .The incidence is on the rise probably due to increase in sexually transmitted diseases and availability of assisted reproductive techniques in the country.[5] Ectopic pregnancies are easily diagnosed clinically in a ruptured state but the diagnosis in unruptured state is difficult because there may be neither symptoms nor signs which can be elicited.[10] Early pregnancy transvaginal sonographic examination helps to identify the site of pregnancy and to diagnose ectopic pregnancy early before the occurrence of tubal rupture which can be life threatening. More accurate detection of ectopic pregnancy has been made possible by the association of beta subunit of human chorionic gonadotropin (beta â&#x20AC;&#x201C; hcg) and transvaginal ultrasonography.[11] Transvaginal sonographic diagnosis is significantly reliable, accordingly undisturbed tubal pregnancy is commonly diagnosed at 6.9+/- 1.9 weeks .The presence of an adenexal gestational sac with a fetal pole and cardiac activity is seen as the most specific sign of ectopic pregnancy, but such a sign is seen in only 10%-17% of cases.[12] However, in many rural areas that lack health education and proper antenatal care early diagnosis is missed and the patient is first presented with tubal rupture..Cisse et ai in a study in Senegal, reported 242 out of 252(94.9%) being detected at the time of rupture.[13] Tubal pregnancies generally rupture between 5-9 weeks of gestation.[4]Lack of sub mucosal layer within the fallopian tube wall allows ovum implantation with in the muscular wall and the rapidly proliferating trophoblasts erode the muscularis layer, so pregnancy cannot continue and tubal rupture occurs at 7.2+/-2.2 weeks.[5]The silent presentation of advanced tubal pregnancies were reported with significant presentations. N Kwasong et al and Sachan et al [14] reported some cases of advanced ectopic pregnancies. Late diagnosis of ectopic pregnancy leads to major complications in almost all cases and needs surgical intervention. The treatment of advanced tubal pregnancy is always a total salpingectomy. It is difficult to perform conservative tubal surgery due to excessive deformation

of fallopian tube[4],thus in our case total right sided salpingectomy was done. In ectopic pregnancies future fertility is a serious concern. Early diagnosis of ectopic pregnancy in the unruptured state may facilitate conservative tubal surgeries like salpingostomy or medical treatment to achieve successful future pregnancy outcome.

Conclusion

There has been a rise in the incidence of ectopic pregnancies since 1970s. Ectopic pregnancy should always be considered in patients of child bearing age who present with early pregnancy problems of lower abdominal pain and irregular vaginal bleeding. Advanced tubal ectopic pregnancy is rare. Awareness of risk factors and improved technologies like serum beta hcg doubling time and transvaginal sonography allows for ectopic pregnancy to be diagnosed earlier .Moreover women should be encouraged to seek medical attention as soon as they miss their periods .Timely diagnosis and treatment will help to reduce maternal morbidity and mortality and restore fertility.

Acknowledgements None

Funding None

Competing Interests Not Declared

Reference

1. Murray H,Baakdah H,Bardell T,Tulandy T.Diagnosis and treatment of ectopic pregnancy,CMAJ,2005;173(8):P905-12. 2. Shao R 2010.Understanding the mechanisms of human tubal ectopic pregnancy:new evidence from knockout mouse models.Hum Reprod;259(3):584-587. 3. Kirk E Bourne T 2011.Ectopic pregnancy.Obstet Gynecol Reprod Med.21(7):207-211. 4. Nkwabong ETincho EF.2012.A case of a 26 â&#x20AC;&#x201C;weeks ampullary pregnancy mimicking iud .Anatol J Obstet Gynecol;1(2):1-3. 5. Bouyyer J ,Coste J,Fernandez H,Pouly JL, job spira N.sites of ectopic pregnancy ; a ten year population based study of 1800 cases .Hum Reprod 2002;17(12):p 3224-30. 6. Tay JI Moore J , Walker JJ. Ectopic pregnancy .BMJ, 2000; 320 (7239):P916-9. 7. Saxon D Falcone T ,Mascha EJ,Marino T Yaom M Tulandi T.A study of ruptured tubal ectopic pregnancy. Obstet Gynecol .1997:90(1):p46-9.

http://www.pacificejournals.com/aabs

C-59

AABS; 3(3): 2016

8. Grimes DA. The morbidity and mortality of pregnancy: still risky business.Am. J.Obstet Gynecol.1994;170(5pt20:p .1489 -94. 9. Radaelili T ,Bulfamente G ,Cetin I ,Marconi ,AM ,Pardi G .2003 . Advanced tubal pregnancy associated with severe fetal growth restriction ; acase report . The journal of Maternal and fetal and neonatal medicine ;13 ,422-425. 10. Kirk E ,Bourne T Dianosis of ectopic pregnancy with ultrasound. Best pract Res Clin Obstet Gynecol.2009:1-8. 11. Kadar N De Vore G Ramcro R Discriminatory hcg zones; its use in sonographic evaluation

fo ectopic pregnancy .obstet gyanecol ;1981;58920:156-61. 12. Condous G Okaro E ,Khalid A ,Lu C V an Huffel S ,Timmerman D ,etal. The accuracy of transvaginal ultrasonography fo the diagnosis of ectopic pregnancy prior to surgery .Hum .Reprod .2005 ;p1404-9. 13. Marion LL Meeks GR.2012.Ectopic pregnancy : History ,incidence ,epidemiology and risk factors .Clin Obstet Gyanecol:55(20:271-274. 14. Sachan R Gupta P Patel ML . 2012 . Second trimester unruptured ampullary ectopic pregnancy with variable presentation: Two unusual cases .IJCRI 3(8):1-4.

Annals of Applied Bio-Sciences, Vol. 3; Issue 3: 2016

e-ISSN: 2349-6991; p-ISSN: 2455-0396

Annals of Pathology and Laboratory Medicine Annals of Pathology and Laboratory Medicine (APALM) is an international, Double-blind peer-reviewed, indexed, open access, online and print journal with an Impact Factor (IFJ): 2.8952 and IC Value (ICV 2014): 67.16

Annals of Woman and Child Health

Pacific Group of eJournals ISO 9001:2008 Certified academic publishing house

www.pacificejournals.com

Printed at: Allied Traders, New Delhi

Annals of Woman and Child Health (AWCH) is an International, Fast Double-blind peer-reviewed, Indexed, Open access, online multidisciplinary journal, related to woman and child health