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Journal of Basic and Clinical Research

Chief Patron

Sri Kamineni Suryanarayana

Patron

Dr. Kamineni Shashidhar

Chairman

Dr. Shruti Mohanty

Advisory Board

Dr. N.N. Samanta

Dr. M. Dasaradha Rami Reddy

Editorial Board

Editor-in-chief

Dr. K. Nagaraj

Associate Editors

Dr. Suresh R. J. Thomas Dr. M. Arun Kumar Dr. N. Madhavi

Assistant Editors

Dr. T. Venkatramanaiah Dr. K. Sateesh Malkappa

Dr. P. Karuna Sree Dr. N. Rajya Lakshmi Dr. P. Sai Krishna

Assistant Managing Editors

Dr. V.G Prasad Dr. J. Kishore Yadav Dr. Varun Malhotra

Editorial Committee

Dr. Md. Sikinder Hayath Dr. M Dattatrey Dr. K Venu

Dr. S. Mohd. Ali Dr. M. Subrahmanyam Dr. P. V Sai Satyanarayana

Dr. V. Satyanarayana Dr. M. Anantha Reddy Dr. Y. Venkata Rao

Dr. K. Saileela Dr. G.V.S.N Prasad Dr. Chapay Soren

Dr. A.D Archana

iJournal of Basic and Clinical Research 2014; 1(1) i

Correspondence : Address for correspondence regarding submission of articles

Dr. K. Nagaraj Editor-in-chief


Kamineni Institute of Medical Sciences

Sreepuram, Narketpally, Nalgonda (Dist.), Telangana State.

Email ID: [email protected]

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ii Journal of Basic and Clinical Research 2014; 1(1)


Journal of Basic and Clinical Research 2014; 1(1) 1


EditoRial 03

oRiginal aRtiClEs

Comparative study of obstructive sleep apnea among obese and non-obese adults: A hospital based study 05 Venu Kandala, Srikar Darisetty, Raghudeep Palla, Divyesh Kishen Waghray

Evaluation of Mass Drug Administration against ilariasis in Nalgonda district, Telangana State 10 Varun Malhotra, Prasad VG, Suguna D, Kishore Yadav J, Nagaraj K, S Bhayya.

Effect of facilitated self directed learning on poor performers among medical students 17 Shruti Mohanty, Sunitha N, Pragna Rao

REviEw aRtiClEs

Applications of Nanobiotechnology 21 RR Rao

Role of systematic reviews and meta-analysis in evidence based health care 25 Sreekumaran Nair N, Ravishankar, Melissa Glenda Lewis

CasE REpoRts

Pain Management in Chest Trauma: Intrapleural Analgesia 31 Vishwa Reddy Gankidi, Sai Satyanarayana Pelluri, Anjani Priya Vemula

A case of palpable purpura due to leukocytoclastic vasculitis 34 Nayeem Sadath Haneef, Ramachandra S, Arun Kumar M, Grace Swarupa Charles B

Adult Respiratory Distress Syndrome in dengue fever 37 Kanni YS, Rathod BH, Satya Srinivas A, Nithin Kumar

Recurrent massive hemorrhagic pleural effusion with pseudopancreatic cyst due to pancreatico-pleural istula : A case report 39 Venu Kandala, Venkat Kishan Tatikonda, Mateenuddin Saleem, Srikar Darisetty,

Raghudeep Palla, Syed Abdul Aleem

Quiz

Paediatric photo quiz 43 Dasaradha Rami Reddy M, Suresh R J Thomas, Sailaja K

Radiology quiz 44 Venkat Kishan Tatikonda, Kusuma Kumar K, RS Moorthy, Chethan BS, Yugandhara M Shaw

instRuCtions to authoRs 50

Volume: 1 / Issue: 1 July - December 2014Contents


Kamineni Education society

Kamineni institute of Medical sciences

Kamineni institute of dental sciences

Kamineni institute of paramedical

sciences


College of nursing


school of nursing

sree vidya peeth

KIDS

KIPS

KIMS-CON

KIMS-SON


Editorial

Currently Life style model of non-communicable

diseases is mainly concentrating on adulthood

risk factors like unhealthy diet, physical inactivity

and smoking. But adult risk factors are not able

to explain the social and geographical variation

of these diseases (MONICA study).1 The large

MONICA study (WHO MONICA project 1994) with

standardized data from 26 countries reveals weak

association between prevalence of conventional

adult risk factors and mortality from Coronary

Heart Disease (CHD). The study also shows that

only 25% of geographical variation in the disease

can be explained by smoking, blood pressure, and

total cholesterol.1 This has led to importance of life

cycle approach in prevention of non- communicable

diseases.

Today there is more literature on tracking of

conventional risk factors from childhood to

adulthood. The “fetal origins hypothesis” proposes

that non-communicable diseases including coronary

heart disease, Type II Diabetes and Hypertension

result from responses of fetus to undernutrition that

permanently change the structure and function of

the body.2 Early life model assumes that adult

diseases are programmed in fetal and adult life.

The term programming means adaptive responses

of the organisms to speciic conditions or insults such as undernutrition,chemical metabolites, drugs

etc. This programming may only occur during

narrow period of individual’s life. It is proposed

that programmed behavior is never forgotten.3

There are two distinct categories of programming

Biological (eg., maternal and fetal genotype, growth

hormones, glucocorticoids) and Environmental

(fetal and maternal nutrition, maternal psycho-social

and life style factors).3 Fetal nutrition is assumed

to be the most important. Fetal nutrition depends

on two factors, maternal nutrition and supply line

which carries nutrients from mother to fetus.3

Fetal undernutrition may fail to fuel the growth

process. Early nutrient environment may

Life cycle approach in prevention of non-communicable diseases

permanently alter gene expression, alter the clonal

selection of certain types of cells leading to alteration

of organ structure and may have permanent effect

on cell number which may affect the metabolism.

All these mechanisms may explain nutritional

programming.

A study conducted by Stein CE et al in South India

reveals that In India as in UK , coronary heart disease

is associated with small size at birth, suggesting

that its pathogenesis is inluenced by undernutrition in utero.4 The consistency of association between

fetal undernutrition and different adult outcomes

have been conirmed in different countries.The drawback of fetal origin hypothesis is that it did not

take into account confounding socio-economic

factors.Unlike early life model, life course approach

does not rely on assumptions regarding whether or

not critical period occurs early or later in life. Life

style model emerged as an attempt to integrate

both early life and adult life style risk factors in a

wider framework. Early life events are taken as irst stage along a pathway that determines risk later in

life. Social class at birth is related to childhood and

adult risk factors of non-communicable dieases.

Epidemiological basis of life style approach needs to

look at relative importance of inluences in different stages of life, which may vary according to type of

disease investigated. Pathways of risk have to be

studied to see the relationship between biological

and social factors that occur during life and their

association with health risks of non-communicable

diseases. Identifying pathways of risk involves use

of new epidemiological and statistical modeling

approaches.

Case study from Kerala reveals that there is a strong

reason to follow life course approach in India. Kerala

has highest prevalence of non-communicable

diseases and their risk factors in India. Survival

of Low Birth Weight (LBW) babies is substanially

high in Kerala than rest of India and these babies

: 3-4


are exposed to obesogenic environment. The ratio

of incidence of acute coronary syndrome in men

and women has decreased from 23:1 in 1967

to 4:1 in 2007 in Kerala.5 This may be explained

by restricted outdoor activity by girls and women

which decreases endogenous vitamin D synthesis

and imparts low skeletal mass and high body fat

composition.5 This study indicates the need for

life course approach targeting adolescents and

women.

The major biological risk factors of non-

communicable diseases emerge and act in early

life and continue throughout the life course and

they can affect the health of next generation.The

underlying socio-economic and environmental

factors have to be taken into consideration to

develop appropriate strategies.6 There is a need to

strategize through life course approach by focusing

on adult risk factors, societal change and targeted

approach (adolescents and women).

References:

1. WHO MONICA Project. MONICA Quality assessment

reports. Monia web publications 2-18. 12 June 2014.

Available from URL :http://www.kti.i/publications/monica/index.html (Accessed 12 June 2014).

2. Barker DJP. Fetal origins of coronary heart disease. BMJ

1995;311:171-4.

3. Harding JE. The nutritional basis of the fetal origins of

adult disease. Int J Epidemiol. 2001;30:15-23.

4. Stein CE, Fall CHD, Kunaran K, Osmond C, Cox V,

Barker DJP, Fetal growth and coronary disease in South

India. Lancet 1996;348:1269-73.

5. Sivasankaran S, Thankappa KR. Prevention of

non-communicable diseases requires a life course

approach: A case study from Kerala. Indian J Med Res.

2013;137:874-7.

6. Aboderin I, Kalache, Ben Shlomo Y, Lynch JW, Yajnik CS,

Kuh D, Yach D. Life course perspectives on Coronary

Heart disease, Stroke and Diabetes: Key issues and

implications for Policy and Research. Geneva: World

Health Organization 2002 (Document WHO/NMH/

NPH/02.1).

Dr. K. NagarajEditor-in-Chief

Professor & Head

Department of Community Medicine

Kamineni Institute of Medical Sciences,

Narketpally, Nalgonda District,

Telangana State - 508 254

phone : 08682 272018 Ext-314

E-mail : [email protected]

: 3-4


AbStRACt

Objective: This study was designed to know the relationship between Obstructive Sleep Apnea (OSA) and

Body Mass Index (BMI) and to identify the contributory factors of OSA in non-obese subjects.

Materials and Methods: A Cross-Sectional study was conducted in 30 subjects with history of snoring

and Epworth Sleepiness Scale (ESS) >10 by polysomnography. Out of 30 subjects 23 were diagnosed

as obstructive sleep apnea (OSA) [Apnoea Hypopnoea Index (AHI)>5]. These 23 subjects classiied into non-obese and obese groups based on BMI, <30 and ≥30 respectively. ESS, Anthropometric measurements [BMI,Neck Circumference (NC), Waist Circumference (WC), Hip Circumference (HC), Thyromental distance

(TMD) and Modiied Mallampati Score (MMS)] and polysomnographic recordings were scored and compared between the obese and non-obese subjects of OSA along with their life style habits. Student 't' test and

chi-square test was used to compare and assess statistical signiicance of difference in study variables between obese and non-obese subjects.

Results: Total number of cases with OSA were 23 (13 obese and 10 non-obese). No difference with reference to

mean age and sex distribution was observed between obese and non-obese subjects. Difference in mean BMI,

anthropometric measurements (NC, WC, HC, TMD), ESS, Arousal index, Oxygen desaturation parameters

[(Oxygen Desaturation Index (ODI), T % < SaO2] between obese and non-obese subjects was found to be

statistically signiicant. Mean value of lowest oxygen saturation was signiicantly lower in obese subjects as compared to non-obese subjects. Total sleep time, sleep eficiency, N3 stage and Rapid Eye Movement (REM) stage was signiicantly decreased in obese than non-obese patients.

Conclusion: OSA severity increased with obesity. Non-obese patients with OSA had structural abnormalities

(decreased TMD and MMS class 3) and life style factors which include smoking and alcohol consumption may

contribute to OSA.

Key words: Body Mass index, Epworth sleepiness scale, Modiied Mallampati score, Obstructive sleep apnea.

Comparative study of obstructive sleep apnea among obese and

non-obese adults: A hospital based study

Introduction:

Obstructive sleep apnea is age old disease and

is not a new one, is characterized by repetitive

episodes of upper airway collapse with air low limitation resulting in disruptive sleep, snoring and

*Corresponding Author :

Dr. Venu K, Department of Pulmonary Medicine,

Kamineni Institute of Medical Sciences, Narketpally,

Nalgonda District, Telangana State - 508 254,

[email protected]

Venu Kandala1, Yugaveer Kalagani2, Laxman babu V2, Srikar Darisetty3, Raghudeep Palla3,

Divyesh Kishen Waghray3

1Professor & Head, 2Assistant Professor, 3Post Graduate, Department of Pulmonary Medicine, Kamineni Institute of Medical Sciences,

Narketpally.

original article

oxygen desaturation. This disease is suspected

by snoring, excessive daytime sleepiness and

conirmed by polysomnography. Obstructive sleep apnea syndrome is deined as obstructive sleep apnea associated with excessive daytime

sleepiness. The OSA syndrome, characterized

by both an Apnoea Hypopnoea Index (AHI) ≥5 along with excessive daytime sleepiness was

present in 2% of women and 4% of men.1 Obesity

is a well recognized risk factor for a variety of

medical conditions such as obstructive sleep

: 5-9


apnea, type 2 diabetes mellitus, cardiovascular

diseases, hyperlipidemia, metabolic syndrome,

and nonalcoholic fatty liver disease.2 Nearly 60-

90% of patients with OSA were obese.3,4 Non-

obese people also get OSA and the occurrence of

OSA in non-obese patients may exhibit different

craniofacial abnormalities than obese patients.5,6

Materials and Methods:

Institutional Ethics committee approval and

informed consent from the study subjects was

obtained. This cross-sectional study was conducted

in 30 subjects, who attended the department of

pulmonary medicine, Kamineni Institute of Medical

Sciences (KIMS), Narketpally during October

2011 to September 2012. Age, sex, co-morbidity,

objective measurement for sleepiness (Epworth

Sleepiness Scale - ESS) and anthropometric

measurements [BMI, neck circumference, Waist

Circumference (WC), Hip Circumference (HC),

thyromental distance, Mallampati’s score] were

recorded. Neck circumference was measured

with a tape measure at the level of cricothyroid

membrane. Waist Circumference was measured at

a level midway between the lowest rib and the iliac

crest. Hip circumference was measured at a plane

which passes over the maximum circumference of

the buttocks. Thyromental distance was measured

from the thyroid prominence to a perpendicular

dropped from the soft tissue mentum. Mallampati’s

score was measured with mouth wide open,

tongue maximally protruded without phonation,

and classiied into Grades I-IV. Epworth Sleepiness Scale(ESS) is a scale which measures the day time

sleepiness by using a questionnaire which is based

on measurements of the sleep inducing potential of

certain routine diurnal activities. Snoring index(SI)

was deined as number of snores per hour of sleep. These patients were selected based on the

following criteria:

Inclusion criteria: Both genders, age > 15 years,

Body Mass Index (BMI) ≥ 18.5, patients who were having history of snoring, Epworth Sleepiness

Scale (ESS): ≥10, Apnea Hypopnea Index (AHI): ≥ 5)

Exclusion criteria: Pulmonary tuberculosis,

Chronic Obstructive Pulmonary Disease (COPD),

bronchial asthma, interstitial lung disease,

neuromuscular disorders, drug abuse, chronic

renal failure, congestive heart failure, pregnancy

and patients who were on treatment with sedatives

and hypnotics.

Overnight polysomnography was performed in

our sleep lab center and the polysomnographic

data including sleep stages, ODI, total sleep time

spent with oxygen saturation <90%, lowest oxygen

saturation and sleep eficiency were calculated. Oxygen Desaturation Index (ODI) is deined as number of instances per hour of sleep during which

blood oxygen saturation drops by 3% or more

from the baseline value. Oxygen saturation time

<90% (T%) is the duration of sleep during which

the oxygen saturation falls below 90% (expressed

as percentage of the total sleep time). Sleep

Eficiency is the ratio between total sleep time and total recording time. Severity of OSA diagnosed

by apnea hypopnea index(AHI) and classiied as mild OSA with AHI of 5 to 15, moderate OSA with

AHI of 16 to 30,and severe OSA with AHI > 30.7

NREM sleep has 3 stages . N1 stage of NREM

(Non rapid eye movement) sleep characterized by

transition of wakefulness and sleep, with a EEG

waveform transition from alpha rhythm to theta

rhythm. N2 stage of NREM sleep is characterized

by presence of abrupt electrical activity in the brain

which manifests itself on the EEG in the form of K

complexes and sleep spindles, with a background

theta rhythm. N3 stage of NREM consists of delta

rhythm, also referred to as slow wave sleep.

Rapid Eye Movement (REM) stage percentage

is the duration of REM sleep which is expressed

as a percentage of the total sleep time. After

polysomnography, 23 subjects were diagnosed

as OSA i.e. AHI ≥5, these subjects were classiied non-obese and obese based on BMI classiication. (BMI <30 non-obese and ≥30 were obese)8

and comparison was done between non-obese

and obese patients of obstructive sleep apnea.

Venu et al: Obstructive sleep Apnea among obese and non-obese adults

: 5-9


table 1 : Comparison of age, sex, anthropometric parameters, ESS, ArI, SI between

obese and non-obese

table 2 : Distribution of OSA severity according to bMI

Comparison parameter

BMI

Age (Years)

Neck Circumference (cms)

Waist Circumference (cms)

Hip Circumference (cms)

Thyromental distance (cms)

ESS

Snoring Index

Arousal Index

26.9±2.28

41.7±9.64

38.9±3.32

96.5±9.75

100±5.35

5.67±0.47

14.6± 2.67

83.4±35.36

10.0± 4.7

33.3±3.33

48.31±11.74

41.54±2.82

106.38±7.51

107.46±6.84

6.692±0.343

16.85 ±1.91

142.77 ±48.99

29.38± 7.11

<0.001

0.16

<0.05

0.01

0.01

0.001

0.02

0.004

<0.001

Non-obesen=10

(mean±SD)

Obese n=13

(mean±SD)P Value

bMI bMI bMI bMI

<30 30-34.99 35-39.99 >40

Mild (5-15/h) 4 - - -

Moderate (16-30/h) 6 1 1 0

Severe (>30/h) 0 3 6 2

OSA severity (AHI)

Results:

Our study was carried out in 30 subjects who

had history of snoring and Epworth sleepiness

scale score more than 10. Among the 23 subjects

diagnosed as obstructive sleep apnea (AHI>5), 13

were obese and 10 were non-obese. There was no

statistically signiicant difference with reference to mean age between obese and non-obese patients.

Males constitute 80% and 84% of the obese and

non-obese patients respectively. The difference in

sex distrebution between obese and non-obese

was not statistically signiicant. Obese subjects had higher neck circumference (41.54 vs 38.9), waist

circumference (106.38 vs 96.5), hip circumference

(107.46 vs 100.0), thyromental distance (66.92 vs

56.7), than non-obese subjects and the difference

was found to be statistically signiicant (Table1). It was also observed that obese patients had higher

ESS score (16.86 vs 14.6), Snoring index (SI)

(142.77 vs 83.4), Arousal index (ArI) (29.38 vs

10.0), Oxygen desaturation index (69.46 vs 26.7),

than non-obese subjects and the difference was

found to be statistically signiicant (Table 1,2). Total time percentage spent with oxygen saturation

<90% (18.69 vs 11.1) was higher in obese subjects

than non-obese and this difference was found to

be statistically signiicant (Table 1,3).


: 5-9


Table 3 : Comparison of oxygen saturation parameters, sleep eficiency, sleep stages and habits between non-obese and obese

Discussion:

The present study has shown that severity of

obstructive sleep apnea was more in obese than in

non-obese. The severity of OSA increased with the

obesity. Obese patients had signiicantly increased apnea hypopnea index, respiratory arousal index,

total sleep time spent with oxygen saturation < 90%,

and oxygen desaturation index and anthropometric

parameters (NC, HC, WC, TMD) than non-obese

patients. Our study results were comparable to

other previous studies which have shown that

severity of obstructive sleep apnea increases with

the severity of obesity.6,9 The pathophysiology

of OSA is due to the accumulation of fat on the

tongue, soft tissue surroundings of the pharynx

in obese individuals. The accumulation of fat is

also proportional to body mass index and obesity.

This causes narrowing of the airways at the lower

level of pharynx which results in increased airway

resistance and increased collapsibility during

sleep; which ultimately leads to OSA.11

In the study of Sakakibara et al, comparison of

Cephalometric measurements revealed that obese

patients with OSA had enlarged upper airway soft

tissue, where as non-obese patients had bony

structure abnormalities like lower thyromental

distance than obese5 and Rajiv Garg et al and

Chierakul et al observed Mallampati score

abnormality contributory for OSA in nonobese.6,9

In our study OSA was observed in non-obese

individuals which may be due to abnormalities in

anthropometric parameters (lower thyromental

distance, Mallampati class 3 abnormality),

and life style of individuals like smoking habit

and alcohol consumption may be contributory

causes for OSA. Rajiv Garg et al9 and Chierakul

et al6 showed no signiicant mean age and sex

ODI 26.7±11.11 69.46±30.24 <0.001

T% < 90% SaO2 % 11.10±2.69 18.69±5.02 0.001

Lowest SaO2 % 82.6±5.76 65.69±6.45 0.001

Sleep Eficiency % 85.4±6.5 79.08±5.75 0.02

N1 stage % 11.5±5.82 14.92±4.01 0.11

N2 stage % 58.8±4.96 59.46±7.2 0.96

N3 stage % 15.8±4.85 11.54±3.15 0.02

REM stage % 17.9±4.25 12.46±3.38 0.003

Comparison parameter P valueNon-obese

n=10(mean±SD)

Obese n=13

(mean±SD)

Obese patients had statistically signiicant decrease in sleep eficiency (79.08 vs 85.4), N3 stage (11.54

vs 15.8) and REM stage (12.46 vs 17.9) than

non-obese patients (Table 3). Obstructive sleep

apnea severity increases with the obesity (Table

2). Higher proportion of non-obese subjects and

MMS Class 3 and 4 (50%) as compare to obese

subjects (38.4%). However this difference was

not stastically signiicant (P=0.72). Sixty percent and ifty percent of non-obese OSA patients (10) had smoking habit and history of alcohol intake

respectively, compared to 61.5% and 46% of the

study subjects in the obese group This difference

was not statistically signiicant (P=0.72, P=0.81).


: 5-9


difference in non-obese and obese patients of

OSA and also observed that AHI, ODI and T% with

SaO2<90% were signiicantly increased in obese

than non-obese and lowest oxygen saturation

was signiicantly decreased in obese than non-obese. Our study also had similar indings. YK Gupta et al10 showed decreased sleep eficiency in obese than non-obese which was not statistically

signiicant (80.15 vs 85.51± 11.48, p=0.42). J. Antczak et al12 observed N1 stage was signiicantly increased in obese than in non-obese, and also

observed signiicantly decreased N3 stage and REM stage in obese than non-obese. In our study

N1 stage was increased in obese than non-obese

but not signiicant and also observed signiicantly decreased N3 and REM stage in obese than non-

obese.

There are multiple imaging techniques available

to evaluate the upper airway in patients with OSA

such as Cephalometric radiography, CT, MRI,

luoroscopy and somnoluoroscopy but these methods are cumbersome and expensive.10 In this

study we used thyromental distance and Mallampati

score to evaluate the structural abnormalities.

Conclusion:

OSA is more common in obese than in non-obese

and the severity of OSA increased with the obesity.

Decreased thyromental distance, Mallampati score

abnormalities, smoking and alcohol habits are

contributory factors for obstructive sleep apnea

in non-obese. Proper evaluation of contributory

factors helps in appropriate treatment plan.

References:

1. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr

S. The occurrence of sleep-disordered breathing among

middle-aged adults. N Engl J Med 1993; 328: 1230-5.

2. Haslam DW, James WP. Obesity Lancet 2005; 366:1197–

209.

3. Strohl KP, Redline S. Recognition of obstructive sleep

apnea. Am J Respir Crit Care Med 1996;154:279– 86.

4. Guilleminault C, Tikian A, Dement W. The sleep apnea

syndromes. Annu Rev Med 1976;27:465–84.

5. Sakakibara H, Tong M, Matsushita K, Hirata M, Konishi

Y, Suetsugu S. Cephalometric abnormalities in non-

obese and obese patients with obstructive sleep apnea.

Eur Respir J 1999;13:403-10.

6. Chierakul N, Chaipattarapol C, Ruttanaumpawan P,

Nana A, Naruman C, Tangchityongsiva S. Comparision

of clinical and polysomnographic characteristics of non

obese and obese patients with obstructive sleep apnea.

J Med Assoc Thai 2007; 90:48-53.

7. Roche F, Gaspoz JM, Court-Fortune I, et al: Screening

of obstructive sleep apnea syndrome by heart rate

variability analysis. Circulation 1999; 100:1411-5.

8. Obesity: preventing and managing the global epidemic:

report of a WHO Consultation on obesity, Geneva, June

3–5, 1997. Geneva: World Health Organization; 1998.

9. Garg R, Singh A, Prasad R, Saheer S, Jabeed P,

Verma R.A comparative study on the clinical and

polysomnographic pattern of obstructive sleep apnea

among obese and non-obese subjects. Ann Thorac Med.

2012; 7:26-30.

10. Gupta YK, Jaiswal A, Gupta R, Jain AK, Kumar D,

Behera D. Pattern of Sleep disordered breathing

in obese Indians. Indian J Sleep Med 2009; 4(1):

19-31.

11. Rollheim J, Osnes T, Miljeteig H. The relationship

between obstructive sleep apnoea and body mass index.

Clin Otolaryngol Allied Sci 1997; 22:419-22.

12. Antczak J, Horn B, Richter A, Jernajczyk W, Bodenschatz

R, W Schmidt EW. The inluence of obesity on sleep quality in male sleep apnea patients before and during

therapy. J Physiol Pharmacol. 2008;59(S6):123-34.


: 5-9


AbStRACt

background : Lymphatic ilariasis is an important public health problem in India, and Nalgonda district of Telangana State is one of the endemic districts where mass drug administration programme is undertaken

every year to achieve the goal of elimination of the disease. The present study was undertaken to evaluate

the percentage coverage and compliance rates of the programme during 2014, and study reasons for non-

compliance.

Materials and Methods : The guidelines of National Vector Borne Disease Control Programme (NVBDCP)

were used to select a total of 130 households from four clusters (three rural and one urban). Each household

was visited by a team and data was recorded on pre-structured questionnaire available in operational guidelines

manual of NVBDCP.

Results : The study population consisted of 561 individuals from 130 households, out of which 537 were

eligible for mass drug administration. The study revealed that only 428 (79.70%) of the eligible individuals were

covered by the drug distributors. The overall compliance rates for diethylcarbamazine and albendazole were

67.78% and 64.43% respectively. ‘Fear of side effects’, ‘forgot to take medicines’ and dificulty in giving tablets to children were main reasons for non-compliance. Side effects were reported by only 1.35% of cases.

Conclusions : The study reveals that coverage rates are as important as compliance rates to achieve

elimination of lymphatic ilariasis, and efforts should be made to improve coverage rates by involving more human resources, supervision and incentive linked to work-output, and compliance rates by information,

education and communication activities.

Key words : Evaluation, Lymphatic Filariasis, Mass Drug Administration, Nalgonda District.

Evaluation of Coverage and Compliance of Mass Drug

Administration programme for elimination of lymphatic ilariasis in Nalgonda District of telangana State

Introduction:

Lymphatic ilariasis (LF), commonly known as elephantiasis, is a neglected tropical disease.

Infection is usually acquired in childhood causing

hidden damage to the lymphatic system.

The painful and profoundly disiguring visible manifestations of the disease, lymphoedema,

elephantiasis and scrotal swelling occur later in life

and lead to permanent disability. These patients

are not only physically disabled, but suffer mental,

social and inancial losses contributing to stigma and poverty. Currently, more than 1.4 billion people

in 73 countries are living in areas where lymphatic

ilariasis is transmitted and are at risk of being infected. Globally, an estimated 25 million men suffer

with genital disease and over 15 million people are

aflicted with lymphoedema. Eliminating lymphatic ilariasis can prevent unnecessary suffering and contribute to the reduction of poverty1.

*Corresponding author:

Dr. Varun Malhotra,

Dept of Community Medicine, Kamineni Institute of Medical

Sciences, Narketpally, Nalgonda District,

Telangana State - 508 254, [email protected]

Varun Malhotra1*, Prasad VG2, Suguna D1, Kishore Yadav J1,Nagaraj K3, S bhayya4

1Assistant Professor, 2Associate Professor, 3Professor & Head, 4Professor, Dept of Community Medicine, Kamineni Institute of Medical Sciences,

Narketpally.

original article

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In 1997, the 50th World Health Assembly vide its

agenda item 20 urged Member States to take

advantage of recent advances in LF and develop

national plans that would lead to elimination of LF2.

In 2000, World Health Organization (WHO) initiated

the Global Programme to Eliminate Lymphatic

Filariasis (GPELF) with the goal to eliminate LF

as a public health problem by the year 2020 3.

Elimination means that LF ceases to be a public

health problem and will be measured by microilaria carrier state of less than 1%, and children born after

elimination to be free from circulating antigenaemia.

The National Health Policy of India (2002) has set

the goal of elimination of LF in India by 20154.

To achieve this goal the National Task Force has

recommended the strategy with two major thrust

areas i.e. (a) Transmission control by administration

of annual single dose of anti-ilarial drugs i.e. diethylcarbamazine (DEC) and albendazole called

Mass Drug Administration (MDA), and (b) Disability

prevention and management of individuals who

already suffer from the disease5.

The concept of MDA is to approach every

individual in the target community and administer

single dose of anti-ilarial drugs. As the longevity of adult worms is approximately 5 years, repetition

of annual dose for at least 5 years with minimum

85% actual dose compliance will achieve the

objective. Hence, the quality of MDA programme

in the community as measured by coverage and

compliance rates is important for success of the

elimination programme5.

The present study was undertaken to study the

overall coverage and compliance rates during the

annual MDA conducted during 2014 in Nalgonda,

an endemic district of Telangana State.

Material and Methods:

Annual MDA was undertaken in Nalgonda district

on 28th, 29th and 30th January 2014. As per the

directions, house to house visits were made by drug

distributors (DDs), and DEC and albendazole was

administered to the eligible population. Children

under 2 years, pregnant women and severely ill

persons were excluded from the MDA programme.

The DDs were instructed to persuade the eligible

population to consume tablets on the spot and

avoid taking tablet on empty stomach. The DDs

were provided with a note book to keep record of

name of head of the family, number of tablets given

and reason for not accepting the tablets.

The present study for evaluation of MDA was

carried out by the study team within a month after

the MDA activity. The evaluation was conducted

as per NVBDCP guidelines i.e. by selecting four

clusters; three from the rural and one from urban

area (each cluster having at least 30 households).

The clusters were selected by two stage random

sampling. In irst stage Primary Health Centres/ Urban Health Centre were selected, while second

stage was undertaken to select the village in

rural areas, and ward in urban area within the

jurisdiction of selected PHC/UHC. In each cluster,

the households were selected by systematic

sampling.

Data was collected by four teams, each team

consisting of a faculty of Department of Community

Medicine, one post graduate, and two interns.

Information was obtained from one individual,

preferably head of the family and recorded

on structured questionnaire as per NVBDCP

operational manual5. Data was compiled,

and analyzed using SPSS statistical package

version 19.

Results:

Total and Eligible Population : The study sample

consisted of 561 (425 rural and 136 urban)

individuals in 130 households (100 in rural and 30

in urban) in four clusters. The age distribution of the

population revealed that only 2.48% of population

was below 2 years of age, while maximum

population (70.41%) belonged to age group more

than 14 years. Distribution of population as per sex

revealed that 51.87% of study population was male

while 48.13% were females. As per the guidelines,

children below 2 years of the age, pregnant women

and seriously ill patients are not eligible to receive

MDA. Thus the individuals eligible to ingest the

drugs in four study clusters were 537 (95.72%) out

of 561(Table 1).

Malhotra et al: Mass Drug Administration programme for elimination of lymphatic ilariasis

: 10-16


Eligible Population

population covered by DDs

Kalavalapalli 131 116 88.55

Paddadevulapally 147 105 71.43

Kasarabad 131 114 87.02

Bhongir 128 93 72.66

Total 537 428 79.70

Village % coverage

table 2: Number of Households covered by Drug Distributor

Coverage: The number of families that were

visited by DDs in each cluster is as shown in

Table 2. As seen from the table 2, only 80% of the

households were visited by the DDs, and 26 out

of 130 (20.00%) houses were not covered, while

Table 3 shows that 79.70% of eligible population

was covered by the DDs.

table 3: Population Coverage by DDs in Each Cluster

table 1: Eligible population in Each Cluster

Number of

Village Households

in cluster

Kalavalapalli 34 137 131 95.62

Paddadevulapally 36 153 147 96.08

Kasarabad 30 135 131 97.04

Bhongir 30 136 128 94.12

Total 130 561 537 95.72

total Eligible % eligible

population population populati

No of households No of

Name of Village included in the households

survey covered by DD

Kalavalapalli 34 29 (85.29) 5(14.71)

Paddadevulapally 36 28(77.78) 8(22.22)

Kasarabad 30 26(86.67) 4(13.33)

Bhongir 30 21(70.0) 9(30.0)

Total 130 104(80.00) 26(20.00)

total Not

covered


: 10-16


table 4: Compliance rate DEC in each Cluster

Compliance Rates: The compliance rate by the

population who were eligible and also covered by

DDs for DEC is shown in Table 4. It is seen that

85.05% of those who received DEC took the drug

in full dosage while 2.80% ingested partial dosage

and 12.15% did not comply.

Similarly, the compliance rate for albendazole

among those who were eligible to receive MDA,

and were also provided with the drug by DDs is

shown in Table 5. It is seen that 86.07% of those

who received albendazole took the drug, while

13.93% did not comply.

table 5: Compliance Rate for Albendazole

table 6: Coverage and Compliance of DEC

Drug Drug Drug Village Coverage compliance compliance Non compliance DEC Full dose DEC partial DEC

Kalavalapalli 116 108 Nil 08

Paddadevulapally 105 69 6 30

Kasarabad 114 98 6 10

Bhongir 93 89 Nil 4

Total 428 364 (85.05%) 12 (2.80%) 52 (12.15%)

Drug compliance

Village Full dose

Albendazole

Kalavalapalli 116 108 08

Paddadevulapally 93 75 18

Kasarabad 114 90 24

Bhongir 79 73 06

Total 402 346 (86.07%) 56 (13.93%)

Non Compliance

Albendazole

Drug Coverage

Albendazole

Percentage Village complied out of eligible



Kasarabad 131 114 98 74.81

Bhongir 128 93 89 69.53

Total 537 428 364 67.78

Eligible Population Population

population covered complied


: 10-16


table 7: Coverage and Compliance of Albendazole

Effective Compliance Rate : The effective

compliance rates for DEC and albendazole

calculated based on actual consumption of full

dosage of each drugs out of eligible population

decreased to 67.78% for DEC (Table 6) and

64.43% for albendazole (Table 7). These

decreases, obviously relect a combined effect of non-coverage and non-compliance, and are better

indicators of outcome measure.

Reasons for Non-compliance: The reasons for

non-compliance as revealed by the respondents

are tabulated in Table 8. As seen, fear of side effects

table 8: Reason for Non Compliance among those who received the drugs

Reason Number Percentage

Fear of side effects 14 25.0%

Forgot to take tablets after food 9 16.07%

On some other medication 12 21.43%

Not at home 9 16.07%

Dificult to give tablets to young children 12 21.43%

Total 56 100.00%

(25.0%), receiving other medications (21.43%) and

dificult to give tablets to small children (21.43%) were main reasons for non-compliance. The other

reasons were ‘forgot to take tablets’ (16.07%) and

the absence of individuals at home (16.07%).

Side Effects: The respondents were asked

about side effects after ingestion of medication.

As depicted in Table 9, the side effects were rare

and only 5 (1.35%) individuals had side effects

(Vomiting-3, dizziness-2). The side effects were

mild in nature, and none of the individual required

referral to a health facility for management of side

effects.

Percentage Village complied out of eligible



Kasarabad 131 114 90 68.70

Bhongir 128 79 73 57.03

Total 537 402 346 64.43

Eligible Population Population

population covered complied


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Discussion:

Coverage of MDA: As mentioned earlier, a

compliance rate of 85% or more in the target

population in endemic districts is considered

essential for eliminating LF. Obviously, this

means that a much higher coverage rate should

be achieved so that those who do not comply due

to any reason are discounted, and the overall

compliance rate remains above 85%. The present

study revealed that the coverage rate was 79.70%

which in itself is below the expected compliance

rate of 85%. MDA coverage in state of Andhra

Pradesh as reported by Directorate General of

Health Services since 2007 has been between

89.13-93.30%6. In a study conducted in Nalgonda

district after MDA activities in 2010 reported a

coverage rate of 46.2%7 while, Nirgude A S et al

reported a coverage rate of 79.70% in the same

district after MDA programme during 20118.

Compliance Rate: Although the coverage is

direct relection of programme management, the compliance rates are more intimately related to

IEC activities and community involvement. The

present study showed that the compliance rates

for both DEC and albendazole among those who

were covered was above 85%, but fell to 67.76%

for DEC, and 64.43% for albendazole due to poor

coverage. In comparison, the study by Nirgude

et al8 detected a much lower compliance rate of

43.04% after MDA activities during 2011 in the

same district. This relects an improving trend in compliance rates and a positive sign towards

programme success. In a study conducted in

Thiruvanthapuram district of Kerala by Nujum

ZT9 during 2007 reported a low compliance rate

of 39.5%, while a study10 conducted to evaluate

the MDA programme conducted during 2012 in

Bankura district of W Bengal detected an effective

compliance rate of 93.7%.

Reasons for Non-Compliance: In any mass

drug administration programme, perceived side

effects are important for programme success. In

the present study fear of side effects (25%) was

the commonest cause of non-compliance. Other

reasons were ‘being on other medications’ (21%)

and ‘forgot to take medicines’ (21%). All these

reasons can be tackled by improving the Information

Education Communication (IEC) activities prior to

MDA programme so that the target population is

well aware of beneit and safety of the programme. Tablet albendazole is a 400 mg tablet, and many

children are unable to swallow the tablet. It may

be worthwhile to introduce a liquid preparation

for children below 5 years of age. Various studies

conducted earlier in India have also reported ‘fear

of side effects’ as an important reason for non-

compliance7, 8, 9, 10, 11.

Side Effects: In comparison to perceived

side effects, the actual side effects were

minimal and mild and did not require any

treatment. Other studies in India10,12 have also

reported a low incidence of side effects. This

relects the safety of the drugs, and deserves to be highlighted during IEC activates prior to MDA

every year to augment compliance rate.

table 9: Side Effects due to MDA

Village Compliance No of cases with side effect

Kalavalapalli 108 2

Paddadevulapally 75 Nil

Kasarabad 98 3

Bhongir 89 Nil

Total 370 5 (1.35%)


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Conclusions:

Mass drug administration is the backbone of

elimination of lymphatic ilariasis, a disease that causes disigurement, disability and discrimination. The world today has knowledge as well as

resources to eliminate the disease. The study

reveals that coverage rates are as important

as compliance rates to achieve elimination of

lymphatic ilariasis, and efforts should be made to improve coverage rates by involving more

human resources, supervision and incentive

linked to work-output. Similarly efforts should be

made to improve compliance by the community

by information, education and communication

activities and community involvement in planning

and implementation of MDA programme.

Conlict of interest: None declared

References:

1. Lymphatic Filariasis. Fact Sheet No 102. World Health

Organization, Media Centre. Available from www.who.

int/mediacentre/factsheets/fs102/ en/.

2. Elimination of lymphatic ilariasis as a public health problem. Resolution of the executive board of the

WHO. Available from www.who.int/lymphatic_ilariasis/resources/WHA_50%2029.pdf.

3. Lymphatic Filariasis. WHO. Progress report 2000-2009

and strategies 2010-2020. Available from Whqlibdoc.

who.int/publications/2010/ 97892415007 22_eng.

pdf?ua=1.

4. National Health Policy 2002 (India). Available from www.

childlineindia.org.in/CP-CR_Downloads/ National_

Health_Policy_2002.pdf.

5. Guidelines on ilariasis control in India and its elimination (2009). Available on www.nvbdcp. gov.in/ Doc/

Guidelines-Filariasis-Elimination_ India.pdf.

6. MDA coverage since 2007. National Vector Borne

Disease Control Programme. DGHS. Ministry of Health

and Family Welfare. Available from http:// nvbdcp.gov.in/

il_mda.html .

7. Saiprasad GS, Takalkar Anant A, Prasad VG, Nir-

gude AS, Naik PR, Palve S. Evaluation of Mass Drug

Administration in Elimination of Lymphatic Filariasis in

Nalgonda District. Indian J Public Health 2010;54(4):

194-99.

8. Nirgude AS, Naik PR, Nagaraj K, Reshmi SS, Takalkar

AA, Prasad VG. Evaluation of coverage and compliance

of Mass Drug Administration programme 2011 for

Elimination of Lymphatic Filariasis in Nalgonda District of

Andhra Pradesh, India. National Journal of Community

Medicine 2012;3:288-93.

9. Nujum ZT. Coverage and compliance to mass drug

administration for lymphatic ilariasis elimination in a district of Kerala, India. Int Health 2011;3:22-6.

10. Ghosh S, Samanta A, Kole S. Mass drug administration

for elimination of lymphatic ilariasis: Recent experiences from a district of West Bengal, India. Trop Parasitol

2013;3:67-71.

11. Patel PK. Mass drug administration coverage evaluation

survey for lymphatic Filariasis in Bagalkot and Gulbarga

districts. Indian J Community Med 2012;37:101-6.

12. Chattopadhyay D, Bisoi S, Basu M, Dutta S, Chatterjee

T, Roy S. Annual mass drug administration to eliminate

lymphatic ilariasis: A study in Purba district of West Bengal. International Journal of Basic and Applied

Medical Sciences 2012;2:43-51.


: 10-16


AbStRACt

background: First year MBBS students admitted to the medical college come from diverse background and

training. Some students are unable to cope with the pressure due to sudden change in the teaching methods

and examination pattern leading to poor performance in examinations. Since the MBBS course is of four and

half years duration, there was a need to design an intervention to enable and empower the students to adapt

to the change and encourage self learning.

Materials and Methods: Students who repeatedly scored less than 30% marks in written and viva voce

weekly assessment examinations were included in the study group. The study comprised of twenty two medical

students belonging to a batch of 100 students. A pre-study structured questionnaire, based on the feedback

of senior students, was administered to identify the dificult areas experienced by the students and post study questionnaire was given to assess any alteration in their dificulties. The outcome of the intervention was assessed by formative assessment. The intervention was in the form of facilitated active learning of 2 hours

each for two days in a week for six weeks period. During this period a faculty member was assigned to each

group, comprising of 11 students each, to facilitate learning.

Results: Commonest dificulty expressed was recalling the subject, though understanding the subject was not a major problem. In the post intervention internal assessment written test, each student in the study group

showed a marked improvement in his/her performance. Thirty two percent (32%) of the study group had an

improved score by at least 20%.

Conclusion: Early identiication of slow learners and introducing facilitated learning in early irst year will help them to overcome their learning dificulties.

Key words: Facilitated learning, self directed learning, slow learners.

Effect of facilitated self directed learning on poor

performers among medical students

Introduction:

Students with below average cognitive abilities

who are not disabled are called slow learners.

They struggle to cope with the traditional academic

demands of the regular classroom. Actually, they

are normal students but the problem with them

is that they are simply not interested in studying

under traditionally accepted system of education.1

While learning has many ends, teaching has only

one: to enable or cause learning.2 Educational

environment and training have a great impact

on students learning and performance outcome.

Although the study of learning has been given

considerable attention, the major shortcoming of

early theories was that the learner was viewed as

a passive receiver of information-an empty vessel

to be illed with good information by teachers. The history of learning theory has shown a shift from this

notion to one that accepts that the learner already

has considerable knowledge and understanding

about the world and takes an active part in creating

new knowledge. This shift, from an ‘instructivist’


Dr. Shruti Mohanty, Dept. of Biochemistry, Kamineni Institute of

Medical Sciences, Narketpally, Nalgonda District,

Telangana State - 508 254. [email protected]

Shruti Mohanty1*, Sunitha N2, Pragna Rao3

1Professor & Head of Biochemistry, 2Lecturer, Kamineni Institute of Medical Sciences, Narketpally, 3Professor & Head of Biochemistry, Kasturba

Medical College, Manipal.

original article

: 17-20


to a ‘constructivist’ approach, is the direction that

teaching has taken over the past several years.

This latter approach is an important concept in the

teaching of adolescents and adults.3

The present study was undertaken in a private

medical college in the rural district of Telangana

State that admits 60% students from state

common entrance test and 40% from management

quota. The students come from different medium

of instructions whereby it becomes dificult for some students to follow lectures, write answers

in English and answer viva-voce after admission

into the medical college. The syllabus being

vast and extensive the students have dificulty in differentiating the ‘must know’ and ‘desirable to

know’ areas resulting in insuficient preparation for examinations and improper time management.

Students must do more than just listen: They must

read, write, discuss, or engage in solving problems.

Most important, to be actively involved, students

must engage in such higher-order thinking tasks

as analysis, synthesis, and evaluation. Within this

context, it is proposed that strategies promoting

active learning be deined as instructional activities involving students in doing things and thinking

about what they are doing.4 Hence, the need to

introduce facilitated active learning that eventually

transforms them into independent self directed

lifelong learners.

Self Directed Learning (SDL) is deined as an approach where learners are motivated to assume

personal responsibility (Garrison, 1997.)

The present study was undertaken to assess

the effect of facilitated self directed learning

and eventually performance of slow learners in

Biochemistry.

Material and Methods

Institutional Ethics committee appproval and

informed consent from the study subjects was

obtained. The study was conducted among a group

of twenty two irst year medical students, which included 13 girls and 9 boys ( n =22) belonging

to a batch of 100 students who repeatedly scored

less than 30% marks in biochemistry written and

viva voce weekly assessment examination. The

students were randomly divided into two groups

of eleven students each, and a trained faculty

member was assigned to each group to act as a

facilitator and to assist in learning methodologies.

A pre study structured questionnaire, based on

the feedback of the previous batch students

was administered to identify the problem areas

in learning and performance in examinations in

Biochemistry.

Students attended two hours each of study

time twice a week for six weeks period during

the schedule tutorial timings. The facilitator

highlighted the importance of self planned learning

and instructed students about the self learning

techniques. Students selected speciic topics for preparation and were encouraged to use

question banks as a means to focus on learning

goals. The students were given assignments to

complete at home and submit to their facilitator.

The materials used were text books, class notes

and question banks. Brain storming sessions

in the form of clinical case solving exercises

followed by group discussions were undertaken

to inculcate higher order cognitive skills ability

and to emphasize the importance of application of

basic science in patient care. Seminar presentations

was introduced to help them overcome fear and

inhibition of public speaking. In order to evaluate

for recall and study completion, assessment was

done periodically by the facilitator by conducting

written tests, viva-voce, and quiz.

Post study questionnaire was administered to

determine the effect of the intervention on the

dificulties identiied before the study. The outcome of the study was evaluated by their performance in

the midterm examination along with others of their

batch. Their performance was compared with the

written test conducted before the study, based on

which the study group was selected. The difference

in marks in the two written tests was expressed in

percentage and analyzed for interpreting the extent

of improvement in performance.

Mohanty et al: Facilitators to promote self directed learning

: 17-20


Sl.

No.Questionnaire

Pre study

(n=22)

Agree Disagree Agree Disagree

n (%) n (%) n (%) n (%)

Biochemistry is easy to 14 8 20 2

understand (63.64%) (36.36%) (90.90%) (9.10%)

Topics are dificult to 17 5 5 17

recall (77.27%) (22.73%) (22.73%) (77.27%)

Require personal guidance 20 2 15 7

by a faculty member (90.90%) (9.10%) (68.18%) (31.82%)

Relevance of case 13 9 20 2

discussions in irst year (59.09%) (40.91%) (90.90%) (9.10%)

Repeated exam makes 16 6 20 2

me more conident (72.72%) (27.28%) (90.90%) (9.10%)

Feel inferior if isolated for 4 18 5 17

extra study hours (18.19%) 81.81%) (22.73%) (77.27%)

21 1 3 19

(95.45%) (4.55%) (13.63%) (86.37%)

1

2

3

4

5

6

7

Post study

(n=22)

Dificult to differentiate between

‘must know’ and

‘nice to know’ areas

table 1: Pre and Post study questionnaire administered to identify the problem areas before and to determine

the effect of the intervention after the study - expressed in percentage. (n = 22)

table 2: Students improvement in performance in formative examination after

the intervention compared to their previous score

Increase in marks Number of students showed

(%) improvement n (%)

1 0 - 10 5 (22.72)

2 11 - 20 10 (45.45)

3 21 - 30 5 (22.72)

4 31 - 40 1 (4.55)

5 41 - 50 1 (4.55)

Sl.No.


: 17-20


Result and Discussion

Analysis of the pretest and posttest questionnaire

(Table 1) revealed that only 63% of the students

found the subject content easy to understand

before the intervention which markedly increased

to 91% after the intervention.

However, the scores reversed regarding

recalling the subject learnt earlier, where

77% of students expressed their dificulty in recalling the content studied earlier

before the study and only 23 % agreed after the

intervention. Majority (91%) of students could

appreciate the relevance of clinical case discussion

during biochemistry learning after the study in

comparison to 59% of students before the study.

Most of the students (95.5%) also had dificulty in identifying the core subject content ‘must know’

from ‘nice to know’ topics before intervention which

decreased noticeably to 13.6% after the study

period.

After the said intervention of facilitated self

directed learning, a signiicant increase in recall of the subject was observed when compared to

before study period. The percentage of students

requiring personal guidance from faculty member

also declined signiicantly, suggesting that students were more conident about independent learning. Secondly, the percentage of students not

comfortable with extra classes for poor performance

also increased signiicantly, endorsing the fact that they were conidant of learning through self study. In addition all students showed improvement

during post intervention test results, with 32.8 %

showing an improvement of more than 20% (Table

2). The above observations can be attributed to

the focused and need based support provided

by the facilitators during the intervention. The

facilitator helps deine the course objectives and goals. Secondly, intensive practice in writing and

speaking along with group discussions of clinical

case studies in small groups make the students

more comfortable and capable of expressing the

subject content.

Conclusion:

With minimal intervention and effective need based

facilitation, self directed study method can enable

and empower the students to overcome their

learning dificulties and score well in examination. This study also highlights that some students

are slow to learn but they do not have a learning

deiciency. What is essential is to customize the methodology for effective learning.

Conlict of interest: The authors declare no

conlict of interest.

References:

1. Borah RR. Slow Learners: Role of Teachers and

Guardians in Honing their Hidden skills. International

Journal of Educational Planning & Administration 2013;

3: 139-43.

2. Cross KP. In Search of Zippers. AAHE Bulletin 1988;

40(10):3-7.

3. Smith, Peter J, Blake, Damian. Facilitating learning

through effective teaching : at a glance, Adelaide, South

Australia: NCVER, 2005.

4. Bonwell, CC. Active Learning: Creating Excitement in

the Classroom. Available at https://www.ydae.purdue.

edu/lct/HBCU/documents/Active_Learning_Creating_

Excitement_in_the_Classroom.pdf (Last accessed 01

June 2014).


: 17-20


R.R.Rao*

*Professor & Head, Department of Microbiology, Kamineni Academy of Medical Sciences & Research Center, Hyderabad.

Applications of Nanobiotechnology

Nanotechnology encompasses many ields of Natural sciences and Nanobiotechnology refers

to the intersection of nanotechnology and biology.

Broadly speaking anything with a dimension of less

than 100 nm can be named as ‘nanostructured’ and

these days it also seems that anything that its into this deinition will be termed ‘nanostructured’.1 The

Physicist Richard Feynman in 1959, in his famous

speech mentioned the possibility of manipulating

and controlling them on a molecular scale in order

to achieve electronic and mechanical systems with

atomic sized components.2 He further made a remark

that the development of technologies to combat

such small systems would be inter disciplinary

combining the ields of Physics, Chemistry and Biology and could offer a new world of possibilities

that could radically change the technology that

is existing currently. Moore in 1965 noted that

the number of transistors on a chip had roughly

doubled every year since 1959 and predicted that

each new generation of micro systems would help

to develop the next generation at lower cost with

smaller components. To date the semiconductor

industry proved Moore’s law. The continuous down

scaling of systems will have a profound impact on

society and on lives and continues to open up new

frontiers and possibilities.

Fundamentals of Nanotechnology

Nevertheless, no exponential growth can continue

forever and the semiconductor industry will

eventually reach the atomic limit for downsizing

the transistors.

Interestingly the current trends in the development

indicate that atomic limit might not be the limiting

factor for technical development in near future

although it may take time to achieve it. As the

systems become more diverse and become so

small, quantum effects dominate. In addition

microbiology and biochemistry are becoming

important for applications of all the developments.

In early 1990's researchers got interest in

Feynman‘s observations probably because the

term ‘nanotechnology’ gained serious attention

just then following its use by K.Eric Drexier in

his book ‘Engines of creation: The coming Era of

nanotechnology’ which took Feynman’s concept of

billions of tiny factories and added the idea that

they can make more copies of themselves through

computer control instead of human operator.3 The

Japanese scientist Norio Tanaguchi of the Tokyo

University of Science was irst to use the term ‘nanotechnology’ in a conference in 1974. He deined “nanotechnology mainly consists of the processing

of separation, consolidation and deformation of

material by one atom or molecule”. In 1980s the

concept of nanotechnology was conceptually

explored in depth by K. Eric. Drexier and his 1991

PhD at MIT media lab was the irst doctoral degree on the topic of molecular nanotechnology for which

he received American publishers’ award for Best

Computer Science Book of 1992. Meanwhile

the advances in interface and colloid science

took place due to the scholarly work of Richard

Adolf Zsigmondy and Irvin Langmuir and both of

them received Nobel Prize for their contribution

to Chemistry. Harry Kroto, Richard Smalley and

Richard Curl discovered fullerenes in 1985 and

they shared Nobel Prize in Chemistry. Richard

*Corresponding author :

Dr. R.R.Rao, Department of Microbiology, Kamineni Academy

of Medical Sciences & Research Center, Hyderabad,

Telangana State. [email protected]

Review article

: 21-24


Smalley and Kroto collaborated and discovered

C60

and other fullerenes as a third allotropic form of

Carbon.4 Subsequently discoveries included

endohedral fullerenes and large form of fullerenes

in the following year. The discovery of carbon

nanotubes is largely attributed to Sumio lijima of

NEC in 1991. In the early 1990s Huffman and

Kraetschmer of the University of Arizona were

able to develop the technique of synthesizing and

purifying large quantities of fullerenes. A fullerene is

any molecule composed of entirely of carbon in the

form of a hallow sphere, ellipsoid or tube. Spherical

fullerenes are also called ‘buckyballs’ and the

cylindrical types are called carbon nanotubes or

‘buckytubes’. Fullerenes are similar to Graphite in

structure which is composed of staked grapheme

sheets of linked hexagonal rings. They can also

contain pentagonal or heptagonal rings). This

opened the doors for their characterization and

functionalization by hundreds of investigators.

Soon rubidium doped C60

was found to be a mid

temperature super conductor. Dr. T. Ebbsen at

a meeting of Material Research Society in 1992

described to a spell bound audience, his discovery

and characterization of carbon nanotubes. There

after hundreds of researchers further developed the

ield of nanotube-based nanotechnology. Today the visions of Richard Feynman are shared by many

others and nanotechnology is seen as general cross

disciplinary technology and it has the potential to

create an industrial revolution comparable or far

exceeding the impact of electricity and information

technology.5

Nanotechnology is not a new entity. It is old and

one can ind it in the sun screen that is used in summer and some paints as well as coatings can

also be called nanotech since they all contain

nanoparticles with unique optical properties.

Nanoparticles have been known in optics for

hundreds of years and they have been used to stain

and colour glasses for centuries.6 Catalysis which

is a major industrial process is highly dependent

on nanoscale catalytic particles. Nanoscale wires

and tubes have only recently really been given

attention with the advent of Carbon nanotubes and

Rao: Applications of Nanotechnology

semiconductor nanowires while nanoscale ilms are even present in anti-relecting coatings on the glasses and binoculars. Thin metal ilms have been used for sensitive detection with surface plasmons

for decades (Surface plasmons are excitations of

charges at surface).

Nano-components:7

The methods and components of nanotechnology

are constantly undergoing developments and each

generation is providing foundation for the next

one. The Scanning Tunnel Microscopy (STM) and

Atomic Force Microscopy (AFM) came into use

in1980s and opened up new ways to investigate

nanoscale materials. The transmission electron

microscopy (TEM) introduced in 1930s offered

the possibilities of images as well as created

nanodevices by electron beam lithography.

Several nanoscale structures were developed in

1990s such as Carbon 60 molecules and Carbon

nanotubes. In recent years more complex nano-

structures such as semiconductor nanowire

hetero-structures have proved to be useful as

building blocks or components in nanodevices.

Nano-components are useful in electronics optics /

photonics medical, biological as well as better and

smarter materials.

A main problem is reliable integration of the

nanoscale components into micro systems, since

production methods are often not compatible. Self-

assembly of devices in liquids is an expanding ield within nanotechnology but usually requires the

components to be covered with various surfactants

which usually also inluence the components’ properties. The current integration technique for

nanowire or tube systems seem to be Electron

beam lithography (EBL) of metal structures onto

substrates with randomly positioned nanowires

deposited from the liquid dispersion. By using low alignment or electrical ield the wire deposition from the liquids can be constructed to some extent.

The EBL method has allowed for systematic

investigation of ‘nanowires’ and ‘tubes’ for electrical

properties and creation of high performance

electronic components such as chemical sensors or

: 21-24


medical problems and reines their applications. Nanobiotechnology is also concerned in developing

new tools that are applicable to medical / biological

ields. The imaging of native biomolecules, biological membranes and tissues is also a major

area of Nanobiotechnology. Others include use of

Cantilevers array sensors (Cantilever is abeam

anchored only at one end) and applications of

nanophotonics for manipulating the molecular

processes in the living cells.

In simple language Nanobiotechnology is

miniatured biotechnology applied to biology or

medicine and Bionanotechnology is a speciic application of nanotechnology. A good example

of Bionanotechnology is DNA nanotechnology or

cellular engineering and conversely many new

medical technologies involving nanoparticles as

delivering systems or sensors fall under the term

Nanobiotechnology.9

Material properties and applications studied in

bionanoscience include mechanical (deformation,

adhesion and failure etc.), electrical / electronic

(electromechanical stimulation, capacitors and

storage batteries etc.), optical (absorption,

luminescence and photochemistry etc.), thermal

(thermo-mutability, thermal management etc.),

biological (the interaction of cells with nanoparticles,

nanodevices, molecular laws, defects and biosensing etc.), nanoscience of diseases (cancer,

organ or tissue failure etc.) and computing (e.g

DNA computin)

References:

1. Drexler KE. New era of nanotechnology. New York:

Anchor Press; 1986. Engines of creation: The coming

era of nanotechnology; 99–129.

2. Feynman RP. There's plenty of room at the bottom. Eng

Sci.1960;23:22–36.

3. Nano A. The A to Z of nanotechnology And nanomaterials.

The Institute of nanotechnology, Azom Co Ltd; 2003.

4. Freitas R., Jr Nanotechnology, nanomedicine and

nanosurgery. Int J Surg. 2005;3:243–6

5. Freitas RA., Jr Nanodentistry. J Am Dent Assoc.

2000;131:1559–66.

6. Reifman EM. Diamond teeth. In: Crandall BC, editor.


ield-effect transistors. Scanning probe microscopy has been used to create and study nanotube

junction properties.8

Materials reduced to nanoscale can show different

properties compared to what they exhibit on

macro scale enabling unique applications. For

example opaque substances become transparent,

stable material becomes combustible, insoluble

substances like gold becomes soluble. A material

such as gold which is chemically inert at normal

scales, can serve as potent chemical catalyst

at a nanoscale. Much of the fascination with

nanotechnology comes from these quantum

and surface phenomena that matter exhibits at

nanoscale. Material referred to as nanomaterials

generally fall into two categories: fullerenes

and inorganic nanoparticles. Nanoparticles or

nanocrystals made of metals, semiconductors or

oxides of particular interest for their mechanical,

electrical, magnetic, optical and chemical properties.

Nanoparticles have been used as quantum dots

and as chemical catalysts. Nanoparticles exhibit

a number of special properties relative to bulk

matter. Copper nanoparticles smaller than 50 nm

are considered super hard. Ferro electric materials

smaller than 10 nm can switch the magnetism

directly using room temperature thermal energy

thus making the material unsuitable for memory

storage. Suspensions of nanoparticles are possible

because of interaction of the particle surface with

the solvent is strong enough to overcome the

differences in density. Nanoparticles exhibit unique

optical properties because they are small enough to

conine their electrons to produce quantum effect. For example gold nanoparticles appear deep red

or black in solution.

Nanobiotechnology:

Nanobiotechnology indicates the merging

of biological research with various ields of nanotechnology. Biologically inspired

nanotechnology uses biological systems as the

inspiration for technologies not yet created. The

most important objective of Nanobiotechnology is

to involve applying nanotools to relevant biological/

: 21-24



Nanotechnology: Molecular speculations on global

abundance.Cambridge, Mass: MIT Press; 1996. 81–6.

7. Frietas RA., Jr Current status of nanomedicine and

medical nanorobotics. J Comut Ther Nanosci. 2005;

2:1-25.

8. Moghuni,SM,Hubter,AC, MurraymJC. Nanomedicine:

Current status and future prospects. FASEBJ

2005:19:311-30.

9. Fahy GM. Molecular nanotechnology and its possible

pharmaceutical implications. In: Bezold C, Halperin JA,

Eng JL, editors. 2020 visions: Health care information

standards and technologies. Rockville, MD: U.S

Pharmacopenial Convention; 1993. 152–9.

: 21-24


N.Sreekumaran Nair1*, Ravishankar2, Melissa Glenda Lewis2

1Professor of Biostatistics and Director, Public Health Evidence South Asia, Manipal University, Manipal, 2Research Scholar, Biostatistics,

Manipal University, Manipal.

Role of systematic reviews and meta-analysis in

evidence based health care

Introduction:

In broad sense, health care means prevention,

treatment and management of illness as well as

preservation of health of the people. This has been

achieved through various simple and complex

strategies and programmes jointly experimented

and implemented by multiple agencies and

professional organisations. In earlier days, the

health care system was dominated by eminence

based decision making in which expert opinion was

regarded as the ultimate evidence of effectiveness

of any programme. However, this approach

underwent major criticism during last two decades

mainly because of the chance of bias in the

approach and led to the emergence of evidence

based or evidence informed health care.

The evidence based health care relies on provision

for providing healthcare based on knowledge of a

combination of best available research indings, clinical experience & expertise, client needs and

preferences.1 This approach has been accepted

globally and at present almost all major healthcare

providing agencies have incorporated it in their

policy. The most dificult component in evidence informed health care is how to synthesise the

best available research indings? Looking at the magnitude of research articles getting published

every day, reading all these articles and targeting

the healthcare practice based on this knowledge

is almost an impossible task for any healthcare

provider. In this context it would be a great support,

irstly if there is a methodology which provides robust approach to pool all available evidence and

generate summary of evidence and secondly if

there can be a group/institution or an agency which

can conduct this synthesis and provide up to date

comprehensive research evidence for immediate

use to health care practitioners and policy makers.

Systematic review combined with meta-analysis

has been accepted as a potential robust method of

health care research evidence synthesis and there

are major international organisations exclusively

working for this purpose. The present article

sensitises the readers to the concept of systematic

reviews and meta-analysis, major organisations

involved in evidence synthesis and also the

historical development of meta-analysis.

Systematic Reviews

Reviews in health care are detailed reports related

to history, treatment strategies and outcomes

of intervention regarding a disease or a health

condition which are usually written by an expert

based on experience and available literature.

Even though these reviews are important, they are

proved not to be focussed on any speciic question and more prone to bias. To address this issue,

there emerged another concept called “Systematic

reviews”. These reviews are conducted to

answer a focussed research question based

on all available literature with a robust scientiic methodology. Systematic review methodology

involves scientiic processes to collect, combine, analyse and summarise all available evidences

*Corresponding author :

Dr. N Sreekumaran Nair,

Dept. of Biostatistics, Manipal University, Manipal,

Karnataka - 576 104, [email protected]

Review article

: 25-30


with minimum or no bias. Therefore systematic

reviews and meta-analysis occupy the top position

in the hierarchy of evidence.

Systematic reviews and meta-analysis are known

to produce highest form of evidence in medical

research.2 In a systematic review, a focussed

research question is formulated, all the procedures

of review are explicitly deined in advance, available research articles on the concerned question are

selected by a structured search strategy and

selected articles are assessed for quality with

standard quality evaluation tools. Results from

such selected articles are extracted with the help

of a predesigned data extraction tool and are

combined using a statistical method called meta-

analysis. Thus it helps to obtain a single concise

answer to every focussed research question,

enabling to arrive at a irm conclusion about the effectiveness of an intervention.

The steps involved in a systematic review process

are;3

1. Framing research question: the irst step in a systematic review process is to identify a

focused research question which is relevant and

answerable. The selection of an appropriate,

unique research question is the foundation of

the systematic review.

2. Protocol preparation: systematic review

requires an explicitly described protocol. The

protocol has a speciic structure and requires basic training for its preparation.

3. Literature search: systematic review involves

a structured and a rigorous literature search

so as to procure all the available and relevant

literature pertaining to the identiied research

question. The literature search strategy should

be extensive and must involve expert guidance

for its development. The aim of this process is

to gather all available literature pertaining to

the research question into one basket. This is

one of the crucial aspects that differentiate a

systematic review from a narrative review.

4. Data extraction: data (results) pertaining to

the pre-speciied outcomes are extracted in an objective manner from all collected studies by

means of a valid data extraction tool.

5. Quality assessment: The methodological

quality of the collected studies is assessed by

means of a pre-speciied scientiic technique.

6. Statistical analysis: the results of collected

individual studies are quantitatively combined

by robust statistical technique called “Meta-

analysis”.

7. Preparation of the review document: the

systematic review is prepared according to the

pre-decided criteria in a manner as stated in

the protocol. The limitations, existing biases,

strength of the evidence and recommendations

for further research are clearly stated.

8. Publication of the review: the developed

review is published in a suitable journal.

9. The above described rigorous procedures make

the systematic review evidence much distinct

from that of a narrative review.

Systematic review protocol

Every systematic review begins with a well

structured protocol, which describes all the

underlying systematic review processes explicitly.

Nair et al: Systematic reviews and meta-analysis

: 25-30


box 1: Structure of a systematic review protocol4

lDEtAILS OF tHE AUtHORS

lbACKGROUND: Description of the condition, Description of the intervention, How the intervention

might work, why it is important to do this review

lObJECtIVES

lMEtHODS: Criteria for considering studies for this review, Types of studies , Types of participants,

Types of interventions, Types of outcome measures

lSEARCH MEtHODS

lDAtA COLLECtION AND ANALYSIS: Selection of studies, Data extraction and management,

Assessment of risk of bias in included studies, Measures of treatment effect, Unit of analysis

issues, Dealing with missing data, Assessment of heterogeneity, Assessment of reporting biases,

Data synthesis, Subgroup analysis and investigation of heterogeneity, Sensitivity analysis

lOther details

Meta-analysis

The word “Meta” denotes something that goes to

a higher level or is more comprehensive. “Meta-

analysis is the statistical analysis of the results

from separate but similar i.e., comparable studies,

leading to a quantitative summary of the pooled

results”.3

The procedure of meta-analysis involves two

stages;4

1. Computation of summary estimate: for each

study to be combined, a summary statistic or

an effect measure is computed. The summary

statistic may be a risk ratio, odds ratio, risk

difference if the data are dichotomous or a

difference between means if the data are

continuous.

2. Computation of overall estimate or pooled

estimate: the summary (pooled) intervention

effect estimate is calculated as a weighted

average of the intervention effects estimated

in the individual studies. Meta-analysis is an

optional part of a systematic review. Results of

the collected studies can also be synthesized

in a narrative manner if quantitative pooling is

not appropriate due to heterogeneity among

studies or non availability or scarcity of data.

There are two different models commonly

suggested for pooling of numerical results using

meta-analysis, namely ixed effects model and random effects model.

Fixed effects model is based on the assumption

that the variability across the “intervention effect

estimates” of different studies is due to chance

or sampling variation (Fig.1).5 This model, we

assumes that there is only one true effect and

consequently the estimates coming from different

studies are considered to be the representative of

the same effect. Therefore the ixed effects model accounts for only source of variability i.e., within-

study variability.

The ixed effects model is given by;

Yi = θ + ε

i

Where, Yi is the observed effect from ith study.

θ is the true intervention effect.

εi is the sampling error in the ith study.


: 25-30


Fig 1: Fixed effects model5

Fig 2: Random effects model5

One the other hand Random effects model assumes

that, each study estimates its own unknown true

effect which follows some distribution ie; true

treatment effects for the different studies could be

distributed around different central values (Fig.2).5

Thus random effects model accounts for two

sources of variation; between studies and within

studies.

Random effects model:

Yi = μ + z

i + e

i

Yi is the observed effect from ith study.

μ is the true intervention effect.z

i variability in the ith study.

ei is the sampling error in the ith study.

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2

m

Study 1

Study 2

Study 3

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2

q

Study 1

Study 2

Study 3


: 25-30


The decision regarding the type of model to be

adopted depends on the extent of heterogeneity

among studies. If studies are more homogenous,

it is suggested to go with a ixed effects model, whereas a random effects model is chosen in

presence of signiicant heterogeneity. There are various statistical tests available for testing

heterogeneity. The results of meta-analysis are

graphically presented as “forest plots” (Fig. 3).

These pictorial forms facilitate easy understanding

and interpretation. Graphical representation of

meta-analysis is referred to as “Forest plot”.

Relevance of systematic reviews and meta

analysis in evidence generation7

The systematic reviews can be considered as

highly effective means for evidence generation

because of the following reasons;

1. Increased precision: integration of several

studies reduces uncertainty and helps to

obtain a precise result with enhanced statistical

power.

2. transparent appraisal: all the procedures are

clearly described in advance and results are

statistically combined. Therefore the results are

more reliable and robust.

3. Generalizable result: systematic reviews clear

the confusions which might have been created

by conlicting results of different studies.

Fig 3: Forest plot of Antibiotic therapy for preventing infections in patients with acute stroke6

4. Resource sensitive: systematic reviews are

a cost effective and a quicker way of evidence

synthesis.

5. Powerful tool for documenting knowledge

gaps in literature: systematic reviews highlight

where there is a lack of evidence, which inturn

stimulates new research.

Conclusion:

The systematic reviews and meta-analysis play a

pivotal role in the process of evidence generation.

The methodology of systematic reviews and meta

analysis has been updated periodically adding more

transparency and objectivity to reviewing process.8

Several international organizations like Cochrane

collaboration (www.cochrane.org),1 Campbell

collaboration (www.campbellcolloboration.org),9

Evidence for Policy and Practice Information

and Co-ordinating (Eppi) Centre (www. eppi.

ioe.ac.uk),10 International initiative for impact

evaluation (www.3ieimpact.org), Centre for

Reviews and Dissemination (CRD) (www.

york.ac.uk),11 UK department for international

development (www.uid.org) and Public Health Evidence South Asia (PHESA) (www.phesa.

manipal.edu)12 have regularly been working

on producing high quality systematic reviews

of evidence for health care and developmental

interventions. Systematic reviews and meta

analysis are one of the prime sources of evidence


Study or Subgroup

Chamorro 2005

De Falco 1998

Harms 2008

Schwarz 2008

total (95% CI)

Total events

Heterogeneity: Tau² = 0.00; Chi² = 1.56, df = 3 (P = 0.67); I² = 0%Test for overall effect: Z = 3.52 (P = 0.0004)

Events

11

4

6

15

36

total

67

30

39

30

166

Events

13

8

13

27

61

total

69

30

40

30

169

Weight

16.9%

7.6%

12.2%

63.3%

100.0%

M-H, Random, 95% CI

0.87 [0.42, 1.81]

0.50 [0.17, 1.48]

0.47 [0.20, 1.12]

0.56 [0.38, 0.81]

0.58 [0.43, 0.79]

Experimental Control Risk Ratio Risk Ratio

M-H, Random, 95% CI

0.01 0.1 1 10 100Favours [experimental] Favours [control]

: 25-30


generation. The domain of meta-analysis is ever

expanding with incorporation of robust statistical

techniques and availability of user friendly software

packages.

References:

1. A brief description of the Cochrane Collaboration

[internet]. 2014 [cited 2014 Apr 8]. Available from

http://ph.cochrane.org.

2. CRD’s guidance for undertaking reviews in health

care. Third edition. New York: Centre for Reviews

and Dissemination, York Publishing Services Ltd,

2008.

3. Matthais E, George DS, Jonathan AC. Systematic

reviews and Meta-analysis. Oxford textbook of

Public Health. Fourth edition. Newyork: Oxford

University press, 2002.

4. Cochrane Handbook for Systematic Reviews

of Interventions. Version 5.0.1. England: Wiley

Blackwell Publications, 2008.

5. Borenstein M, Hedges LV, Higgins JPT, Rothstein

HR. Introduction to Meta-Analysis. UK: John Wiley

& Sons, Ltd, 2009.

6. Westendorp WF, Vermeij JD, Vermeij F, Den Hertog

HM, Dippel DW, van de Beek D et al. Antibiotic

therapy for preventing infections in patients with

acute stroke. Cochrane Database Syst Rev. 2012

Jan 18; 1:CD008530.

7. Wagenaar AC. Importance of Systematic Reviews

and Meta-analyses for Research and Practice. Am

J Prev Med. 1999; 16: 9-11.

8. Rosenberg W, Donald A. Evidence based medicine:

an approach to clinical problem-solving. BMJ. 1995;

310:1122-1126.

9. A brief description of the Campbell Collaboration

[internet] 2013 [cited 2014 Apr 7]. Available

from http://www.cochrane.org/about-us/

campbellcollaboration.

10. What is EPPI centre? [Internet]. 2014 [cited 2014

Apr 7]. Available from http://eppi.ioe.ac.uk/cms/

Default.aspx?tabid=63.

11. About CRD [internet]. 2014 [cited 2014 Apr 9].

Available from http://www.york.ac.uk/inst /crd/

about_us.htm.

12. About PHESA [internet]. 2014 [cited 2014 Apr 8].

Available from http://www.phesa.manipal.edu/

about.html.


: 25-30


Vishwa Reddy Gankidi1*, Sai Satyanarayana Pelluri2, Anjani Priya Vemula1

1Post Graduate,2Professsor & Head, *Department of Emergency Medicine, Kamineni Institute of Medical Sciences, Narketpally.

Key words: Intercostal nerve block, intrapleural analgesia, visual analogue scale.

Pain Management in Chest trauma: Intra Pleural Analgesia

Introduction:

The development of regional techniques of

analgesia has revolutionized the management of

blunt thoracic trauma.¹ The standard of care has

evolved from intubation and mechanical ventilation

for all patients to optimization of pain control.2 It

appears that in appropriately selected patients,

intra pleural analgesia is one of the simple

techniques for pain control in thoracic trauma.3

Use of intra-pleural analgesia for pain control

after severe blunt injury, signiicantly improves subjective pain perception and critical pulmonary

function tests compared to intravenous narcotics.4

It is associated with less respiratory depression,

somnolence and gastrointestinal symptoms than

intravenous narcotics.4 Intra pleural analgesia is

safe with permanent disability being extremely rare

and negligible mortality attributable to treatment.5

Case Report:

A 27 year old male patient, came to emergency

room with alleged history of assault, with chief

complaints of chest pain and shortness of breath.

On examination he was afebrile, Pulse: 126/min,

BP: 90/50 mmHg, respiratory rate: 28/min, pain:

70% of Visual Analogue Scale (VAS). On respiratory

system examination, chest expansion was absent

on right side, subcutaneous emphysema was

present on right side, chest compression test was

positive. On percussion, hyper resonant note heard.

On auscultation air entry was absent on right side.

On CVS examination S1 and S2 were normal and

no murmur heard. Patient was clinically diagnosed

to have right sided pneumothorax (Fig.1, 2).

Treatment was initiated with needle thoracocentesis

on right 2nd intercostal space in mid clavicular

line (Fig. 3). Posterior intercostal nerve block was

given for 4th, 5th and 6th ribs. Through the same port

epidural catheter was inserted (Fig. 4) and intra-

pleural analgesia was given with 1% Xylocaine,

and intercostal tube was inserted for treatment of

pneumothorax. Pain decreased from 70% to 10%

VAS with intercostal nerve block. Later long term

analgesia was obtained by intra pleural analgesia,

giving further top ups with 1% xylocaine.

Discussion:

Pain due to fractured ribs and incision result in

hypo ventilation and hypoxaemia.3 Parenteral and

epidural administration of narcotics, iniltration of incisional site with local anesthetics and intercostal

nerve blocks are some of the techniques used to

control pain.3 In the above case we have used

intercostal nerve block for immediate pain relief

and intra-pleural analgesia top ups for long term

pain relief (Fig.4). Advantages of giving intra-

pleural analgesia include:

1. Simplicity of technique.

2. Top ups can be given as and when required since

the catheter placed is left in pleural space.

3. Plasma concentration of local anaesthetic

solutions are 3 to 4 times lower.

4. Risk of intravascular injection of local anaesthetic

solution is minimal


Dr. Vishwa Reddy Gankidi,

Department of Emergency Medicine, Kamineni Institute of


Telangana state - 508 254, [email protected]

Case Report

: 31-33


5. The number of injections required will be

minimized as compared to intercostal block.4

Intra pleural analgesia is not only useful in chest

trauma but also in cancer pain, herpes pain and

pancreatic pain.5

The technique appears to have a few recognized

complications such as pneumothorax, accidental

intravascular injection of the drug, chest wall

haematomas and pleural effusion.5

Fig. 1 : Chest x-ray - tension pneumothorax

Fig. 3 : Needle thoracocentesis

Fig. 2 : Ct Scan - Subcutaneous emphysema

and tension pneumothorax

Fig. 4 : Intra pleural – Epidural Catheter

Gankidi et al: Pain management in chest trauma

: 31-33


References:

1. Murphy DF. Interpleural analgesia. Br J Anaesth 1993;

71(13):426-434.

2. Gomez MN, Symreng T, Johnson B, Rossi NP, Chiang CK.

Intrapleural bupivacaine for intraoperative analgesia-a

dangerous technique. Anaesth Analg 1988;67:S78.

3. Murrell G. A new complication of the intrapleural catheter

method for postoperative analgesia. Anaesthesia and

Intensive Care 1988;16:499-500.

4. Lefever EB, Rosenthal RM, Ramamurthy S.

Intrapulmonary placement of a pleural catheter. Reg

Anesth. 1992;17(2):107-9.

5. Brockmeier V, Moen H, Karlsson BR, Fjeld

NB, Reiestad F, Steen PA. Interpleural or thoracic

epidural analgesia pain after thoracotomy. A double

blind study. Acta Anaesthesiol Scand. 1994;38(4):

317-21.

Gankidi et al: Pain management in chest trauma

: 31-33


Nayeem Sadath Haneef1*, Ramachandra S2, Arun Kumar M3, Grace Swarupa Charles b4

1Associate Professor, 2Professor & Head, 3Professor, 4Post Graduate, Dept. Of Dermatology and Venereology, Kamineni Institute of Medical Sciences, Narketpally.

Key words: Allergic vasculitis, Leukocytoclastic vasculitis, Palpable purpura.

A Case of palpable purpura due to leukocytoclastic vasculitis

Introduction:

Purpura is an important cutaneous inding seen in platelet disorders like thrombocytopenia,

coagulation disorders like haemophilia, connective

tissue disorders, inlammatory disorders like vasculitis, infections or due to external trauma

or ageing etc.1,2 However, commonest cause of

‘palpable purpura’ is leukocytoclastic vasculitis,

also known as allergic vasculitis or hypersensitivity

vasculitis.3,4 This is in contrast to the common

tendency to consider platelet disorders irst when encountered with a patient of purpura. A case of

palpable purpura due to leukocytoclastic vasculitis

is being reported to create awareness about this

important cutaneous sign.

Case report:

A 22 year old female patient presented with

asymptomatic, red coloured, elevated lesions over

limbs since 3 days and joint pains since 2 days.

Initially the lesions appeared over feet and later

on the legs, thighs, buttocks and upper limbs were

involved.

There was no history of fever, sore throat, abdominal

pain, bowel abnormality, hematuria, burning

micturition, bleeding gums or menorrhagia. There

was no history of drug intake or topical medication

prior to the onset of lesions.

Cutaneous examination revealed multiple,

palpable, purpuric lesions and few targetoid lesions

over extensor aspect of bilateral upper and lower

limbs, including buttocks (Fig. 1, 2). The lesions

were more predominant and conluent over acral areas. Face, trunk, palms, soles and mucosae

were spared. Hair and nails were normal. Systemic

examination was unremarkable.

Histopathology of a purpuric lesion showed

ibrinoid necrosis of supericial dermal capillaries, perivascular neutrophilic and lymphocytic

inlammation, karyorrhexis of neutrophils and extravasation of red blood cells (Fig.3,4). Direct

immunoluorescence was positive for IgG and IgM. These features were suggestive of leucocytoclastic

vasculitis. Routine hematological and biochemical

investigations were normal.

Based on the characteristic distribution of palpable

purpura over dependent (acral) areas along with

typical histopathology and immunoluorescence indings, a diagnosis of leucocytoclastic vasculitis was made. Patient responded well to oral

prednisolone (initially 1 mg/kg/day and gradually

tapered) and dapsone (100 mg/day) therapy within

a week.

Discussion:

Purpura is seen in platelet disorders like

thrombocytopenia, coagulation disorders like

haemophilia, connective tissue disorders,

inlammatory disorders like vasculitis, infections like gonococcemia or meningococcemia, external

trauma, solar damage, ageing etc.1,2 Among these,

inlammatory disorders and infections tend to cause palpable purpura. Leukocytoclastic vasculitis is the

commonest cause of ‘palpable purpura’.3,4


Dr. Nayeem Sadath Haneef,

Dept. of Dermatology &Venereology, Kamineni Institute of


Telangana state- 508 254, [email protected]

Case Report

: 34-36


positive C-ANCA or P-ANCA. Histopathology

shows characteristic swelling of endothelial cells,

ibrinoid necrosis of vessel wall, neutrophilic iniltration with leukocytoclasis and extravasation of RBCs.7 Direct immunoluorescence shows IgM or IgG with complement 3 (C3) deposits in

supericial dermal small vessels and perivascular area.7 Treatment is largely supportive in view of the

self-resolving nature of this disease. Avoidance of

triggering factors, compression stockings and limb

elevation for oedema, symptomatic treatment with

antihistaminics or NSAIDs when needed may be

suficient. Some patients may require systemic corticosteroid therapy, antineutrophilic drugs like

dapsone, colchicine, immunosuppressive drugs

like azathioprine, cyclosporine, cyclophosphamide,

methotrexate or newer biological drugs like

inliximab and rituximab. Establishment of exact etiology is an important aspect of management

of purpura. Leukocytoclastic vasculitis is the

commonest cause of palpable purpura. Thus

this case report of palpable purpura highlights

the importance of considering the other causes

apart from platelet disorders and leukocytoclastic

vasculitis as the common etiologic factor.

Fig. 1: Multiple, palpable, purpuric lesions and targetoid

lesions over upper limbs

Fig. 2: Multiple, palpable, purpuric lesions and targetoid

lesions over lower limbs

Haneef et al: Palpable purpura due to leucocytoclastic vasculitis

Leukocytoclastic vasculitis (also known as ‘allergic

vasculitis’ or ‘hypersensitivity vasculitis’) is a type

of small vessel vasculitis, especially affecting

post capillary venules.3 Drugs or infections are

the commonest causes besides others like

collagen vascular disorders and malignancies.5,6

The skin lesions typically arise as a crop of

palpable purpura over stasis prone areas like

feet and lower legs but sparing intertriginous

regions. Various other lesions such as papules,

nodules, plaques, vesicles, bullae, pustules, necrotic

ulceration, post-inlammatory hyper-pigmentation, oedema, livedo reticularis and urticaria may occur.

The lesions are mostly asymptomatic, though

pruritus, pain or burning may be present along

with constitutional symptoms like fever, arthralgia,

myalgia and anorexia. The lesions usually resolve

within few weeks or months.2,6

Diagnosis of this condition is mainly by exclusion,

and hence a thorough history, systemic examination

and investigations aimed at inding the aetiology or ruling out systemic involvement are essential.

It should be kept in mind that up to 50% of the

cases can be idiopathic. Some patients may show

: 34-36


Fig.3: Vasculitic changes in dermal capillaries(10X) Fig.4: Vasculitic changes in dermal capillaries(40X)

References:

1. Palit A, Inamadar AC. Vasculitis: Approach to diagnosis

and therapy. Indian J Dermatol Venereol Leprol

2006;72:334-45.

2. Cines DB, Blanchette VS. Immune thrombocytopenic

purpura. N Engl J Med 2002;346:995-1008.

3. Bagai A, Albert S, Shenoi SD. Evaluation and therapeutic

outcome of palpable purpura. Indian J Dermatol Venereol

Leprol 2001;67:320-3.

4. Khetan P, Sethuraman G, Khaitan BK et al. An aetiological

& clinicopathological study on cutaneous vasculitis.

Indian J Med Res 2012;135:107-13.

5. Ayturk S, Demir MV, Yaylaci S, Tamer A. Propylthiouracil

induced leukocytoclastic vasculitis: A rare manifestation.

Indian J Endocr Metab 2013;17:339-40.

6. Yadav B S, Sharma S C, Kapoor R K. Paraneoplastic

leukocytoclastic vasculitis in chronic lymphoid leukemia.

J Can Res Ther 2006;2:206-8.

7. Gupta S, Handa S, Kanwar AJ, Radotra BD, Minz RW.

Cutaneous vasculitides: Clinico-pathological correlation.

Indian J Dermatol Venereol Leprol 2009;75:356-62.

Haneef et al: Palpable purpura due to leucocytoclastic vasculitis

: 34-36


Kanni.Y.S1*, Rathod.b.H2, Satyasrinivas A3, Nithin Kumar4

1Professor & Head, 2Associate Professor, 3Asst. Professor, 4Post Graduate, Department of General Medicine, Kamineni Institute of Medical

Sciences, Narketpally.

Key words: ARDS, Dengue fever.

Adult Respiratory Distress Syndrome in Dengue Fever

Introduction:

Today, dengue is one of the most important

emerging tropical viral diseases of humans in the

world. The World Health Organization [WHO]1

estimates that there are 50 to 100 million infections

yearly, including 50,000 Dengue Hemorrhagic

Fever [DHF] cases and 22,000 deaths, mostly

among children. Pulmonary manifestations are

rarely seen in DHF. Pleural effusion and pneumonitis

have been described as rare complication of DHF.

There are few case reports of dengue fever with

adult respiratory distress syndrome (ARDS)2,3,4

cited in literature. In the present article, we report a

similar case of dengue fever with ARDS.

Case Report:

A 27 year old female presented with history of high

grade fever since 2 days, shortness of breath since

1 day. Fever was associated with chills, rigors,

headache, myalgia and retro-orbital pain. There

was no history of rash or joint pain. Shortness of

breath was sudden in onset and progressive.

On examination, patient was febrile with tachycardia

(Pulse-110/min) and normotensive (BP-100/60 mm

Hg). Patient was tachypneic and had crepitations

bilaterally. There were no signs of meningeal

irritation. On abdominal examination, patient had

diffuse tenderness.

Investigations revealed thrombocytopenia

[Hemoglobin-11.4 g%, Total Leucocyte Count-3000

cells/cu.mm; neutrophils-56%, lymphocytes-38%,

Eosinophils-4%, Monocytes-1%, Basophils-1%;

Platelet count-60,000 cells/cu.mm, haematocrit-44]

Hepatic enzymes were normal. Prothrombin time

and activated partial thromboplastin time was

normal. Ultrasonography of the abdomen was

normal. In view of low platelets and leucopenia,

dengue fever was suspected and patient was

tested for dengue serology and IgM and IgG was

positive [Bio Standard Diagnostics, KIMS].

The Chest X ray showed bilateral luffy opacities, Serial arterial blood gas analysis showed

PaO2/FiO

2 ratio of 200 suggestive of ARDS.

The patient was intubated and was shifted under

intensive care. She was put on positive pressure

support ventilation and supportive medications.

Antibiotics were given to prevent secondary

nosocomial infections. Single donor platelet

transfusion was given. The patient improved over

the next 3 days after which she was extubated. The

patient was monitored in the ward till the patient

became asymptomatic and was discharged after

seven days of hospitalization.

Discussion:

The etiology for ARDS is varied and dengue is

reported as a rare cause for this condition. Wang

et al2 reported an incidence of 1.8% ARDS in their

study involving 606 dengue patients in China. All

these patients had concomitant DHF. Sen et al3

reported a patient of dengue hemorrhagic fever who


Dr. Kanni. Y. S, Department of General Medicine,

Kamineni Institute of Medical Siences, Narketpally, Nalgonda

District, Telangana State - 508 254, [email protected]

Case Report

: 37-38


progressed into ARDS. The patient recovered after

mechanical ventilation and supportive treatment.

Devarajan et al4 reported two cases of ARDS in

dengue from Chennai, India.

The exact pathophysiology of ARDS in dengue

is still unknown despite large scale research.

Wang et al reported from their study that sepsis

and upper gastrointestinal bleeding are the main

causes for these patients to progress in ARDS.

On univariate analysis bad prognosis in dengue

patients with ARDS was attributed to old age,

increases liver function tests, presence of urinary

albumin, increase in blood urea nitrogen, decrease

in GFR, development of bleeding (external and

internal) and bacterial co-infection.

Management of ARDS in dengue is similar to

ARDS of any other etiology. Initial therapy is

focused on maintaining adequate oxygenation and

tissue perfusion through mechanical ventilation

and luid management. Minimizing nosocomial complications, preventing multi organ dysfunction

syndrome and attenuating the inlammatory response also play important roles in ARDS

management5. The supportive management

for dengue also inluences the outcome of the condition. It involves hydration, and platelet

transfusion if required.

In the present case, the patient was diagnosed

to have dengue hemorrhagic fever conirmed by positive dengue serology, thrombocytopenia,

elevated hematocrit and signs of plasma leakage.

The aetiology for ARDS was assumed to be dengue

when a detailed evaluation for the known causes

of ARDS were ruled out. The good prognosis of

the patient could be attributed to patient’s younger

age, minimal delay in administering necessary

treatment and antibiotic therapy to prevent

nosocomial infections.

In conclusion, clinicians in endemic and hyper-

endemic areas need to be aware of this rare and

unusual complication of ARDS and an appropriate

therapy (hydration, platelet transfusion, positive

pressure ventilatory support) without delay results

in better outcome.

References:

1. World Health Organization Dengue haemorrhagic fever:

diagnosis, treatment, prevention and control. 2nd edition.

Geneva, Switzerland: World Health Organization: 1997.

2. Wang CC, Liu SF, Liao SC, Lee IK, Liu JW, Lin AS, et

al. Acute respiratory failure in adult patients with dengue

virus infection. Am J Trop Med Hyg 2007;77:151-8.

3. Sen MK, Ojha UC, Chakrabarti S, Suri JC. Dengue

hemorrhagic fever (DHF) presenting with ARDS. Indian J

Chest Dis Allied Sci 1999;41:115-9.

4. Devarajan TV, Prashant PS, Mani AK, Victor SM,

Khan PS. Dengue with ARDS. J Ind Acad Clin Med

2008;9:146-9.

5. Taylor MM. ARDS diagnosis and management:

implications for the critical care nurse. Dimens Crit Care

Nurs 2005;24:197-207

Kanni et al: Acute Respiratory Distress Syndrome in dengue fever

: 37-38


Venu Kandala1*, Venkat Kishan tatikonda2, Mateenuddin Saleem3, Srikar Darisetty4, Raghudeep

Palla4, Syed Abdul Aleem4

1Professor & Head, 3Professor, 4Post Graduates, Department of Pulmonary Medicine, 2Assistant Professor, Department of Radiology,

Kamineni Institute of Medical Sciences, Narketpally.

Key words : ERCP, octreotide, pancreatico-pleural istula, pancreatico-jejunostomy, pleural luid amylase, pseudocyst.

Recurrent massive hemorrhagic pleural effusion with

pseudopancreatic cyst due to

pancreatico-pleural istula : A case report

Introduction:

Pleural effusions are commonly encountered in

clinical practice by physicians. Pleural diseases

are often secondary to pulmonary diseases.

In most of the cases, thorough history taking,

examination, analysis, pleural biopsy and speciic diagnostic procedures clinch the diagnosis. In a

small percentage of cases (15-20%),1 the cause is

not established inspite of all the procedures.

Pleural effusions secondary to abdominal

conditions remain clinically silent. They are often

under-diagnosed or undiagnosed, particularly with

acute pancreatitis because of the predominant

respiratory symptoms. Pleural effusions in acute

pancreatitis can be left sided, bilateral, massive

and recurrent. Pancreatic pleural effusions with

pseudopancreatic cyst and pancreatico-pleural

istulas are rare.2

Case report:

A 42 year old male, chronic smoker and alcoholic

came to seek medical assistance in Pulmonary

Medicine department for dry cough, chest pain and

breathlessness of 2 weeks duration.

Chest pain was intractable, sharp, stabbing,

without any radiation. He has developed

progressive breathlessness. The patient had loss

of appetite and weight. There were no symptoms

of hemoptysis, paroxysmal nocturnal dyspnoea

or abdominal pain. He had no history of trauma,

but had history of chronic alcoholism and acute

pancreatitis.

Physical examination showed asthenic built,

cachexia, pallor, increased temperature, no icterus,

no clubbing or lymphadenopathy, with signs of left

sided pleural effusion. Abdominal examination did

not reveal any visceromegaly and ascites. There

were no complaints of abdominal discomfort, and

the abdomen was non tender on palpation.

Routine laboratory investigations showed

normocytic, normochromic anaemia with a blood

hemoglobin of 9.5 gm%.

Total leukocyte count was 8,000 cells/cu.mm;

Differential count : neutrophils – 70%, lymphocytes

– 24%, eosinophils – 3%, monocytes – 3%,

basophils - 0%. Blood urea, serum creatinine

and liver function tests were within normal limits.

Chest X ray revealed a left sided moderate pleural

effusion (Fig 1).

Ultrasound chest was done and showed the same

indings with no ascites. Pleural luid was aspirated on ten occasions, and about ten litres of luid was


Dr Venu K, Department of Pulmonary Medicine,

Kamineni Institute of Medical Sciences, Narketpally,

Nalgonda District, Telangana State - 508 254,

[email protected]

Case Report

: 39-42


aspirated, which was hemorrhagic and rapidly

reilling. Pleural luid analysis revealed sugar : 44 mg%, protein : 3.4 gm%, Total count : 10,000 cells/

cu.mm(polymorphs – 80%, lymphocytes – 20%).

ADA : 62.1 U/ml. Bacterial and fungal elements,

including AFB was negative. Because of the high

Adenosine deaminase levels, empirical anti-

tubercular drug therapy was given without any

response. ECG was normal. Further evaluation of

the pleural luid revealed pleural luid amylase – 2132 U/L and serum amylase – 180 U/L. Serum

lipase was 80 U/L. Pleural biopsy was done, which

was negative for malignancy and non speciic pleuritis was reported.

Multidetector computerized tomography of the

chest and abdomen was performed, which revealed

pseudopancreatic cyst and pancreaticopleural

istula (Fig.2).

Patient was put on Octreotide 100 micrograms

subcutaneously for 3 weeks. Pleural luid accumulation stopped and the patient was referred

for surgical intervention, and thereafter lost for

follow up.

Discussion:

Pancreatico-pleural istula is a very rare condition. It is seen in about 0.4 – 4.5% of the cases with

chronic pancreatitis with pseudopancreatic cyst.2,1

Case reports of pancreatico-pleural istulas were published in journals as early as 1960.

The irst detailed description was given in 1973 by Tombroff,3 most of the patients-99% of them,

are chronic alcoholics.1 Recent review of 52

published cases by Ali et al4, showed that chest

pain, breathlessness and abdominal pain were

the predominant symptoms in chronic alcoholics.

Often, they are middle aged, between 40 – 50

years. In our case report too, the patient was a

chronic alcoholic and came with complaints of chest

pain and breathlessness. Pulmonary symptoms

are more common than abdominal in many of the

pancreatico-pleural istulas, and as in our case5 the

most common being breathlessness. The average

duration of the symptoms varies from 5-6 weeks.

In the present case, patient had symptoms for 2

weeks.

Pleural effusions are predominantly left sided in

these cases. However, right sided and bilateral

Fig 1 : Chest X-ray showing a left sided moderate

pleural effusion

Fig 2 : Multi-detector computerized tomography image

showing a pancreatic pseudocyst with a

communicating pancreatico pleural istula

Venu et al: Recurrent massive pleural effusion

: 39-42


effusions do occur in about 19% and 14% of cases

respectively.6 Most of the pleural effusions are

massive, recurrent, with or without hemorrhagic

effusion.7 They remain elusive diagnostically.

They often undergo detailed pulmonary evaluation

with less attention to abdominal symptoms.

Ultimately the pancreas would be the primary site

of pathology. These cases may be associated with

ascites (20%) and pericarditis (4%). The major

complication of these patients is superinfection

and ultimately sepsis, which is the cause of high

morbidity and mortality. Pseudopancreatic cyst

is more common with pancreatico-pleural istula than ascites. Recurrent, massive hemorrhagic

pleural effusions with minimal abdominal and

predominant respiratory symptoms puts the doctor

in a dilemma, and even increased serum amylase

and pleural luid amylase can also be found in gynecological cancers, lung cancer, metastatic

tumours, pneumonia, esophageal perforation,

lymphoma, leukemia and pulmonary tuberculosis.

In most of the cases, pleural luid amylase is very high; and serum amylase is moderately elevated.

In our case report, the pleural luid amylase was 2132 U/L but serum amylase was 180 U/L. All

other biochemical parameters were within normal

limits. This has given a high index of suspicion for

the presence of a pancreatico-pleural istula.

Further conirmation of the case was established by ultrasonography of the abdomen, which

demonstrated a pancreatic pseudocyst. CT scan

of the abdomen established the diagnosis of

chronic pancreatitis and pseudopancreatic cyst.

However some authors feel that endoscopic

retrograde cholangio pancreaticography should

be done along with magnetic resonance cholangio

pancreaticography, which would increase the

sensitivity for the detection of pancreatico-pleural

istula with pseudopancreatic cyst since it was effective for the diagnosis of istulas.3,4,8 The

abdominal ultrasound is not considered sensitive

for the diagnosis since the presence of stomach

and intestinal gas will interfere with the identiication of a pancreatico-pleural istula.9,2,4

A simple chest radiography is the irst line of investigation, which provides the evidence of

a massive pleural effusion.9,6 A computerized

tomography scan of the chest and abdomen

is valuable in the diagnosis. Currently, it

is the gold standard for the diagnosis of a

pleural effusion. Computerized tomography

scan may demonstrate the istula if obtained immediately after the endoscopic retrograde

cholangiopancreaticography. Magnetic resonance

cholangiopancreaticography is reported to be useful

in demonstrating the istula and pathology. This procedure helps in visualizing the duct anatomy,

small intra and extrapancreatic collections, and

pancreatico-pleural istulas where endoscopic retrograde cholangio pancreaticography fails10,5

since it may not be able to demonstrate the istula if there is a ductal rupture.9,6 Complete delineation

of the duct anatomy is necessary for surgical

management.

There are no speciic treatment guidelines for the management of pancreatico-pleural istulas based on earlier randomized controlled trials. Only a few

case reports are available.4

The treatment approach is classiied under

- Medical

- Surgical

- Non- invasive

- Invasive - Minimal invasive and complete

invasive

Medical treatment is conservative and includes

good nutrition, somatostatin analogues like

octreotide (50-150 ug) for 3 weeks to 6 months;

and chest tube drainage.2,4 The effectiveness of

conservative management varies from 30-60% in

some series, 0-33% in other series. In our case,

we have initially treated the patient conservatively

with nutritional support, octreotide (100 ug) via

subcutaneous route and repeated thoracentesis.

By this measure, only 50 – 60% of the cases

are beneited. Remaining cases may require endoscopic stenting after endoscopic retrograde

cholangio-pancreaticography, but where there is a


: 39-42


References:

1. Dixit R, Sharma S, Dave L. Massive haemothorax

in asymptomatic pseudocyst pancreas. Lung India

2008;25:126-8.

2. Ribeiro B, Gomes D, Rosa A, Amaro P, Tome L,

Leitao M, Freitas D. Derrame pleural recidivanteper

istula pancreatico-pleural. Journal Portugues de Gastroenterologia 2000;7:161-4.

3. Monteiro E, Terra JCA, Figueiredo LBP, Miranda LHS.

Pseudocisto de pancreas associado a derrame pleural

macico. J Pneumol 2002;28(3):159-62.

4. Ali T, Srinivasan N, Vu Le, Chimpiri R, Tiemey M.

Pancreatico-pleural istula. Pancreas 2009;38(1): 26-31.

5. Materne R, Vranckx P, Pauls C, Coche EE, Deprez P,

Van Beers B.E. Pancreatico-pleural istula : diagnosis with magnetic resonance pancreatography. Chest

2000;117(3):912-4.

6. Sut M, Gray R, Ramachandran M, Diamond T.

Pancreaticopleural istulas : a rare complication of ERCP induced pancreatitis. Ulster Medical Journal

2009;78(3):185-6.

7. Safadi BY, Marks JM. Pancreatico-pleural istula: the role of ERCP is diagnosis and treatment. Gastrointestinal

Endoscopy 2000;51:213-5.

8. Humphrey G, Stringer M. Pancreatico-pleural istula: A rare cause of massive pleural effusion. J Ped

gastroenterology and Nutrition 2003;36:134-7.\

9. Dhebri AR, Ferran N. Non surgical management of

pancreaticopleural istula. J. Pancreas 2005;6(2): 152-61.

10. Vyas S, Gogoi D, Sinha SK, Singh P, Yadav TD,

Khandewal N. Pancreaticopleural istula : an unusual complication of pancreatitis diagnosed with magnetic

resonance cholangiopancreatography. J. Pancreas

2009;10(6):671-3.

pseudopancreatic cyst and ductal rupture requires

repair of the duct and distal pancreatectomy,

internal drainage with pancreaticojejunostomy.2,4

In our case, the patient was managed conservatively

and was referred to department of surgery because

of pseudopancreatic cyst for further evaluation.

The case was then lost for follow up.

Conclusions:

1. Pleural effusion due to pancreaticopleural

istulas and pseudopancreatic cysts are very rare. (0.4 – 4.5%)

2. Pancreatic pleural effusion can be silent, and

present with massive, recurrent hemorrhagic

effusion and confuse with malignant effusion

and other causes of hemorrhagic effusion.

3. Serum amylase and pleural luid amylase should be done along with multidetector computerized

tomography for early detection.

4. 50 – 60 % of the cases respond to conservative

management.

5. Pseudocyst with disruption of the pancreatic

duct requires surgical intervention with stenting

and pancreaticojejunostomy.

Source of Support: Nil.

Conlict of Interest: None declared.


: 39-42


Dasaradha Rami Reddy M1*, Suresh R J thomas1, Sailaja K2

1Professor, 2Associate Professor, Department of Paediatrics, Kamineni Institute of Medical Sciences, Narketpally.

Paediatric Photo Quiz

What is the diagnosis in this 11 year old girl with typical facies, having dificulty in opening the mouth fully, since birth?

Please refer page number 46 for the answer.*Corresponding Author :

Dr.M.Dasaradha Rami Reddy,

Dept. of paediatrics,

Kamineni Institute of Medical Sciences, Narketpally, Nalgonda District,

Telangana State - 508254, [email protected].

Quiz

: 43


Venkat Kishan tatikonda1*, Kusuma Kumar K2, R S Moorthy3, Chethan b S1, Yugandhara M Shah1

1Assistant Professor, 2Consultant Radiologist, 3Professor & HOD, Department of Radiodiagnosis, Kamineni Institute of Medical Sciences,

Narketpally.

Radiology Quiz

A 45 year old female complaining of bilateral loin pain and backache since 3 months was referred to

Department of Radiology for an ultrasound abdomen to exclude renal calculi. Following are the ultrasound

images.

Fig. 1 : USG image of long axis of Right Kidney


Dr. Venkat Kishan Tatikonda, Department of Radiodiagnosis,

Kamineni Institute of Medical Sciences, Narketpally, Nalgonda

District, Telangana State - 508 254, [email protected]

Quiz

: 44-45


Fig. 2 : USG image of long axis of Left Kidney

What is the probable diagnosis?

Please refer page number 47 for the answer.

Tatikonda et al: Radiology Quiz

: 44-45


Answer: WHIStLING FACE SYNDROME

Whistling face syndrome is a disorder with

dysmorphic facies. It is also known as Freeman

Sheldon syndrome.1 It is characterized by small

mouth, and pursed lips (appears as if child is

whistling) and H shaped dimpling of chin. It is

due to contractures of facial muscles. It is one

of the multiple contracture syndromes. Usually

associated with Distal Arthrogryposis(DA).

Paediatric Photo Quiz

DA Syndrome

Distal arthrogryposis (DA) is the sub class

in arthrogryposis syndromes. It is a multiple

congenital contracture syndrome in contrast to an

isolated contracture syndrome. Arthrogryposis

is the term used by some, with non progressive

congenital contractures in two different body

areas. DA syndrome is characterized by

distal joint involvement, limited proximal joint

involvement, reduced dominant inheritance,

and variable expressivity.

Major manifestations of DA Syndrome

- Ulnar deviation of wrist and hands.

- Camptodactyly

- Hypoplastic/Absent lexion creases

- Overriding of ingers.

- Talipes equinovarus

- Calcaneovalgus

- Vertical talus

- Metatarsus varus

Freeman and Sheldon Syndrome (FSS)

types

FSS is characterised by two or more major

manifestations of DA syndrome and the following

features.2,3

- Small pinched mouth,

- Prominent nasolabial fold,

- H shaped dimpling of chin.

There aretwo types one with classical features and

other variant.

Cause

It is due to contractures of facial muscles. It can be

sporadic. Usually autosomal dominant inheritance

has been reported. Variant FSS may be associated

with mutations in genes TPM2, TNNI 2, TNNT

3 and MYH8. They encode isoforms of troponin I

and troponin T.

Precautions before surgery

Intubation is dificult in these cases because of small mouth.

They are more prone for malignant hyperthermia.

So inhalational induction without use of

neuromuscular blocking agents, laryngoscopy

assisted intubation, use of laryngeal mask airway

and non triggering anaesthetic techniques are

some of the measures beneicial to the patient.4,5

References:

1. Stevenson DA, Carey JC, Palumbos J, Rutherford

A, Dolcourt J, Bamshad MJ, Clinical Characteristics

And Natural History of Freeman-Sheldon Syndrome.

Pediatrics 2006;117:754-62.

2. Bamshad M, Jorde LB, Carey JC. A revised and extended

classiication of the distal arthrogryposis.Am J Med Genet 1996;65:277-81.

3. Krakowiak PA, O’Quinn JR, Bohnsack JF, Watkins WS,

Carey JC, Jorde LB et al. A variant of Freeman Sheldon

syndrome maps to 11p15.5-pter. Am J Hum Genet 1997;

60:426-32.

4. Cruickshanks GF, Brown S, Chitayat D. Anesthesia for

Freeman Sheldon syndrome using a laryngeal mask

airway. Can J Anaesth 1999; 46:783-7.

5. Agritmis A, Unlusoy O, Karaca S. Anesthetic management

of a patient with Freeman-Sheldon syndrome. Pediatr

Anesth 2004; 14:874-7.

Reddy et al: Paediatric photo quiz

: 46


Fig. 3 X-ray KUB enlarged image showing calciic foci in the renal area

Radiology Quiz

Answer and Explanation

USG Findings:

Both kidneys are normal in size but shows extensive echogenic foci in the region of the medulla. Some of

these foci show posterior acoustic shadowing.

Findings are suggestive of medullary calciications which is a feature of medullary nephrocalcinosis.

Further Imaging:

1. X ray KUb (Fig.3) was done.

- X-ray image shows amorphous, coarse calciications through out both kidneys which corresponds to the shape and position of the renal pyramids.


: 47-49


Diagnosis: Medullary nephrocalcinosis

Discussion:

The term nephrocalcinosis was coined by Albright

in 1934.

Nephrocalcinosis refers to intraparenchymal renal

calciications.

The term nephrolithiasis indicates calculi within the

pelvicalyceal system.1

There are 2 types of nephrocalcinosis, cortical and

medullary. Medullary nephrocalcinosis accounts

for 90 percent of the cases.2 The term exludes

dystrophic parenchymal calciications seen in renal tuberculosis and renal cell carcinoma.3

4A

4C

4B

2. Ct scan of the abdomen was done (Fig. 4A,

4b, 4C)

- CT scan of the abdomen shows multiple calciic densities in the region of renal medullary

pyramids (renal medulla). No hydronephrosis.

Fig. 4A : Ct scan of the abdomen - Coronal section Fig.4b: Ct scan of the abdomen -Sagittal section

Fig.4C: Ct scan of the abdomen - Sagittal section


: 47-49


Common causes of medullary nephrocalcinosis

are:4

- Hyperparathyroidism

- Medullary sponge kidney

- Renal tubular acidosis

- Immobilization

- Milk-alkali syndrome

- Sarcoidosis

- Hyperoxaluria

- Glucose-galactose malabsorption

- Chronic furosemide use

Imaging features:

Nephrocalcinosis can be demonstrated on plain

radiographs, ultrasonograms, or computed

tomography (CT) scans.

Plain radiographs can show both cortical and

medullary nephrocalcinosis.

Medullary nephrocalcinosis typically produces

clusters of stippled calciications, mainly within the regions of the renal pyramids.

Ultrasound reveals hyperechogenicity in renal

medullary pyramids.5

CT scanning is said to be the most sensitive imaging

modality in the diagnosis of nephrocalcinosis. CT

scans depict nephrocalcinosis at an early stage of

the disease, provide a better picture of the density

and extent of the nephrocalcinosis,

References:

1. Dahnert W, Radiology Review Manual.6th edition.

Philadelphia. Lippincott Williams and Wilkins, 2003; 893-

894.

2. David Sutton, Textbook of Radiology and Imaging. 7th ed.

Volume 2. Edinburgh. Churchill Livingstone. 2002; 976-

977.

3. Gary M. Glazer, Peter W. Callen, Roy A. Filly. Medullary

nephrocalcinosis: Sonologic Evaluation; AJR (1982)

138:55-57.

4. William E. Brant, Clyde A. Helms. Fundamentals of

Diagnostic Radiology, 2nd ed. : Philadelphia. Lippincott

Williams & Wilkins; 1999; 882-883.

5. N Reed Dunnik, Carl M Sandler, Jeffry H Newhouse,

Stephen Amis Jr. Text Book of Uroradiology, Third

edition: Philadelphia. Lippincott Williams & Wilkins, 2001;

179-182.


: 47-49


Journal of basic and Clinical Research (JbCR)

General

Manuscripts are accepted for publication with the

understanding that their contents, all or in part,

have not been published and will not be published

elsewhere, except in the Abstract form or with

the consent of the Editor. Material received for

consideration will be acknowledged. Manuscripts

will be initially reviewed by the Editor for suitability

for formal review and would then be reviewed

by peer Reviewers on originality, methodology,

scientiic content and quality, clinical importance and overall suitability for publication. Reviewer

comments will be sent to the corresponding author

for response, revision and resubmission within a

speciied time.

Authorship

All individuals designated as authors should qualify

for authorship.

An 'author' is considered to be someone who

has made substantive intellectual contributions

to a published study. Authorship credit should be

based on substantial contributions to conception

and design, acquisition of data, or analysis and

interpretation of data; drafting the article or revising

it critically for important intellectual content; and

inal approval of the version to be published. Authors should meet all the above conditions.

Participation solely in the acquisition of funding, for

the collection of data or data entry, and general

routine supervision does not justify authorship.

The order of authorship should be a joint decision

of all the co-authors. Once submitted, the order will

not be changed without written consent of all the

co-authors.

Conlicts of Interest

Authors should submit a conlict of interest statement which will be published with every

article. The purpose of the statement is to ensure

that any factors- personal relationships, inancial connections, sponsorships- that might bias the

author of an article, are declared so that readers

are aware of the potential conlict of interest and can include knowledge in the assessment of

information. Stating a conlict of interest does not disqualify an author from publication.

Plagiarism

Plagiarism is the wrongful appropriation or

purloining and publication as one's own, of the

ideas, or the expression of the ideas of another.

Plagiarism is considered by the journal as scientiic or professional misconduct and authors and

reviewers are advised to be careful to maintain

high ethical standards.

MANUSCRIPt

The manuscript should be typed in single space

throughout. Font size should be of English Arial 12

points. The identity of the author or institute should

not be revealed in the manuscript, except for the

title page. (For example, do not mention name of

institute in Methods, citing previous study as 'our

study', names on igure labels, name of institute in photographs etc).

The manuscript comprises (1) Title page, (2)

Abstract and keywords, (3) Text, (4) References,

(5) Tables, (6) Legends for illustrations and (7)

Illustrations. All these must start on separate pages

and in the above order.

(1) Title page - gives the title of the article, a short

title , type of article (original article, case report

etc), name(s) of the author(s), afiliations of author(s), place of work, names and addresses

of the authors and word count (excluding

abstract and references). Identify one author

as corresponding author and give his/her

postal address, direct telephone or mobile

number and email address. The title should

not exceed 60 characters. It should have no

abbreviations.

Guidelines for Authors: Manuscript preparation

: 50-56


(3) Abstract and Keywords - The abstract is a

synopsis of the main article in about 200 words

and gives an opportunity to the author to induce

the reader to go through the article. It should

be structured in to the headings: Background,

Methods, Results, Conclusion, giving facts

and not descriptions. Avoid abbreviations. No

abstract is required for Case Reports or Letters

to the Editor. Give not more than 6 keywords

(4) Text - The text should be divided into sections,

e.g. Introduction, Material and Methods,

Results and Discussion. Each should have

its individuality and must not be mixed with

others. Ensure that all references, tables and

igures are cited in the text. Only authorized, internationally accepted abbreviations should

be used. First time use of an abbreviation must

always be preceded by its full form except for

standard units of measurement. Abbreviations

are to be avoided in title, abstract and

keywords.

(5) References - Responsibility of accuracy of

the references lies entirely with the authors.

The authors are encouraged to use the facility

available for checking the correctness of

references online. References should be in the

style described in examples. References should

be listed in the order in which they are cited in

the text. Only relevant and recent references are

encouraged. They should be indicated in the text

by Arabic numerals superscripted with word or

punctuation. Ensure that all the references cited in

the text are included in the list and vice versa. List

all authors, surname followed by initials when six

or less; when seven or more, give only irst three and add et al. Do not use full stops in abbreviations

of journal names.

Representative examples, based on formats

used by NLM in Index Medicus are given below.

Please refer to ICMJE guidelines for other types of

references.

Examples of Reference Formats

i) Standard Journal Articles - You CH, Lee KY,

Chey RY, Menguy R. Electrogastrographic

study of patients with unexplained nausea,

bloating and vomiting. Gastroenterology 1980;

79: 311-314.

ii) Organization as Author - The Royal Marsden

Hospital Bone-Marrow Transplantation Team.

Failure of syngeneric bone marrow graft

without preconditioning in post-hepatitis

marrow aplasia. Lancet 1977; 2 : 242-244.

Guidelines regarding maximum permissible size of text as well as number of tables,

Figures and References. Articles not adhering to the above

speciications are likely to be rejected.

Type of Article Text (in words) Tables and igures References

Review 4000 8 30

Original Article 3000 8 30

Contemporary Issue 2000 4 10

Editorial 1500 - 10

Short Communication 1500 2 10

Case Report 1000 4 10

Methods in medicine 1000 4 5

Guidelines for Authors

: 50-56


iii) No Author Given - Coffee drinking and cancer

of the pancreas [editorial]. BMJ 1981; 283 :

628.

iv) Volume with Supplement - Magni F, Rossoni

G, Berti F. BN-52021 protects guinea-pig from

heart anaphylaxis. Pharmacol Res Commun

1988; 20 Suppl 5 : 75-78.

v) Issue with supplement - Gardis G, Cole JO,

Haskell D, Marby D, Paine SS, Moore P. The

natural history of tardive dyskinesia. J Clin

Psychopharmacol 1988; 8 (4 Suppl) : 31S-

37S.

vi) Type of article indicated as needed - Spargo

PM, Manners JM. DDAVP and open heart

surgery [letter]. Anaesthesia 1989; 44 : 363-

364.

vii) Journal Paginated by Issue - Seaman WB.

The case of the pancreatic pseudocyst. Hosp

Pract 1981; 16 [Sep] : 24-25.

books and Other Monographs

viii) Personal Authors - Eisen HN. Immunology

: an introduction to molecular and cellular

principles of the immune response. 5th ed.

New York : Harper and Row, 1974.

ix) Editor(s), compiler as Author - Dausset J,

Colombani J, editors. Histocompatibility

testing 1972. Copenhagen : Munksgaard,

1973.

x) Chapter in a Book - Weinstein L, Swartz

MN. Pathogenic properties of invading

microorganisms. In : Sodeman WA Jr,

Sodeman WA, editors. Pathologic physiology

: mechanisms of disease. 3rd ed. Philadelphia

: WB Saunders, 1974; 457-472.

xi) Conference Papers - Harley NH. Comparing

radon daughter dosimetric and risk models.

In: Gammage RB, Kaye SV, editors. Indoor

air and human health. Proceedings of the

Seventh Life Sciences Symposium; 1984 Oct

29-31; Knoxville (TN). Chelsea: Lewis, 1985 :

69-78.

xii) Conference proceedings - Vivian VL,

editor. Child abuse and neglect : A medical

community response. Proceedings of the First

AMA National Conference on Child Abuse and

Neglect; 1984 Mar 30-31; Chicago. Chicago :

American Medical Association, 1985.

xiii) Scientiic or technical report - Akutsu T. Total heart replacement device. Bethesda (MD)

: National Institute of Health, National Heart

and Lung Institute; 1974 Apr. Report No. :

NIH-NHLI-69-2185-4.

xiv) Dissertation or Thesis - Cairns RB. Infrared

spectroscopic studies of solid oxygen

[dissertation]. Berkeley, Univ. of California :

1965.

xv) Newspaper Articles - Rensberger B, Specter

B, CFCs may be destroyed by natural process.

The Washington Post 1989 Aug 7; Sect. A : 2

(col. 5).

xvi) Magazine Articles - Roueche B. Annals of

medicine : the Santa Claus Culture. The New

Yorker 1971 Sep 4; 66-81.

xvii) Journal article on the internet - Abood S.

Quality improvement initiative in nursing

homes : the ANA acts in an advisory role. Am

J Nurs (serial on the internet). 2002 Jun (cited

2002 Aug 12); 102 (6) : (about 3 p). Available

from http://www.nursingworld.org/AJN/2002/

june/Wawatch.htm. Accessed on mm/yy.

(6) Tables - are to be typed on separate pages.

They should be serially numbered in arabic

numerals (Table 1, Table 2) and a short title

should specify the contents. Horizontal lines

in the body of the table except between a

column heading and its sub-headings should

be avoided. The vertical lines separating the

columns should be totally omitted. A table

should not exceed a page in length, and

should not contain less than four lines of data.

Tables should be self-explanatory and should

not duplicate the data in the text.


: 50-56


(7) Figures / Illustrations / Photographs- Illustra-

tions should be clear enough and of appropriate

size (5 inch x 7 inch or larger) for better

reproduction. If illustrations are scanned, then

they should be scanned at minimum of 300 dpi.

Colour images must be CMYK. Line art drawing

must have a minimum resolution of 1200 dpi.

Photographs and X-rays should be sent as

black and white glossy prints. Photographs

may be submitted as 'jpg', or 'tiff ' iles in a zipped folder. In clinical photographs, identity

of the subjects should be suitably masked; in

case this is not possible, a written permission

from the concerned person should accompany

the manuscript. Permission to reproduce any

borrowed illustration must be obtained from

the author and the publisher.

(8) Legends to Figures - The Figure number

(numbered consecutively in Arabic numerals),

title and explanations of the Figures should

appear in the legend (not on the Figure). Type

the legends on a separate page. Enough

information should be included to interpret the

Figure without reference to the text.

(9) Units - All measurements must be in metric

units, preferably with corresponding SI units in

parentheses. No periods, no plural form (eg.

'10 cm' not '10 cms').

Miscellaneous:

Use 'radiograph', 'radiographic' and 'radiographical'

not 'X-ray', 'skiagram' and 'roentgenogram'.

'Signiicant' should be reserved for use in the statistical sense. Avoid duplication and repetition

of material in results and discussion, in Tables and

Text, and in Text and Legends.

Ethics

Do not use names and initials of the patients or

hospital numbers, especially in illustrative material.

When informed consent for the same has been

taken from the subject, it should be mentioned

in the manuscript. Any report of experimental

investigation on human subjects must contain

evidence of informed consent by the subjects and

of approval by the institutional ethics committee.

Manuscript for various types of articles

Original Articles

These are scientiic communications from research workers engaged in the ield of medicine and include randomized controlled trials, intervention

studies, studies of screening and diagnostic tests,

outcome studies, cost effective analyses, case

control studies and surveys with high response

rate.

Format - Abstract (Structured) & Keywords;

Introduction; Material & Methods; Results;

Discussion.

Case Reports:

A case report should communicate a message

that transcends the individual patient and should

describe rare interesting facets of a particular

disease or an unusual entity.

Format - Keywords; Introduction; Case Report;

Discussion.

Discussion should highlight unusual features of the

report and it should not be a review of literature.

Review Article, Update Article

These are invited from experts in the ield. Prospective authors are requested to consult the

Editor in- Chief for prior approval of their topic.

Contemporary Issue

These are articles of topics of current interest,

authored preferably by experienced practitioners.

Short Communication

This article describes briely a research study or a case series to highlight speciic or peculiar aspects.

Format - Introduction; Results; Discussion.

Methods in Medicine (including Drug and

Equipment Update)


: 50-56


These are brief descriptions of a speciic technique or procedure, modiication of a technique, or equipment of interest and should be supported

by relevant diagrams and results of clinical and/or

ield trials.

book Review

Title of the book; name of the editor/authors; name

and address of the publisher; year of publication;

number of pages; number of illustrations; hard

bound or soft bound; price, ISBN number, text of

review. As a policy we do not encourage submission

of reviews of books that are more than a year old.

Others

These include Editorials, Guest Editorials and

Symposia, which are solicited by the Editorial

Board.


Undertaking by Authors

We, the undersigned, give an undertaking to the

following effect with regard to our article entitled

...............................................................................

...............................................................................

...............................................................................

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submitted for publication in the Journal of Basic

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Important

(i) All the authors are required to sign independently

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case an author has left the institution/country

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senior author may sign on his/her behalf taking

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(iii) If the authorship is contested at any stage,

the article will be either returned or will not

be processed for publication till the issue is

solved.

: 50-56



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: 50-56



All editorial correspondence should be sent to

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v. 3-5 key words

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: 50-56


Notes


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