WaLaWaLKar’s - WIMJOURNALwimjournal.com/html/journal/medicalj.pdfWalawalkar’s International Medical Journal 2014 Vol:1, Issue:1 4 WaLaWaLKar’s INterNatIONaL MedIcaL JOurNaL General

Walawalkar’s International Medical Journal 2014 Vol:1, Issue:1 1

WaLaWaLKar’s

International Medical Journal Volume: 1, Issue No 1 Year 2014

www.walawalkarmedicalcollege.com

official publication of :

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WaLaWaLKar’s INterNatIONaL MedIcaL JOurNaL official publication of B.K.L Walawalkar Rural Medical College, Savarde, Ratnagiri

Editor In Chief: Dr. Suvarna N. Patil (Medical Director B.K.L Walawalkar Rural Medical College)

Editorial Board:

Chairman: Dr. Mrs Kunda M. Dandare (Principal, B.K.L Walawalkar Rural Medical College)

Advisory Editor: Dr. Shripad Banavali (Head Medical Oncology, Tata Memorial Centre)

Executive Editor: Dr. Somnath Salgar (Professor Dept of Biochemistry, B.K.L Walawalkar Rural Medical College)

Members:

Dr. Madhukar Dandare (Professor and Head Dept of P.S.M, B.K.L Walawalkar Rural Medical College)

Dr. Arvind Yadav (Professor and Head Dept of Biochemistry, B.K.L Walawalkar Rural Medical College)

Dr. Raosaheb Patil (Professor and Head Dept of Anatomy, B.K.L Walawalkar Rural Medical College)

Dr. Netaji Patil (Consultant Radiologist, B.K.L Walawalkar Rural Medical College)

Dr Alka Gogte (Professor and Head Dept of Microbiology, B.K.L Walawalkar Rural Medical College)

Dr. Abhay Desai (Assitant Professor, Dept of Surgery, B.K.L Walawalkar Rural Medical College)

Dr. Pushpa Burute (Associate Professor Dept of Anatomy, B.K.L Walawalkar Rural Medical College)

National Advisory Board:

Dr. Sanjay Oak (Vice Chancellor Dr. D.Y. Patil University Navi, Mumbai)

Dr. Sunil Nadkarni (Consultant Orthopaedic and Spine Surgeon)

Dr. Milind Sankhe (Consultant Neurosurgeon)

Dr. D.R. Kulkarni (Consultant Hepato-biliary Surgery)

Dr. Suresh Chari (Director Research and M.E.T, N.K.P Salve Institute of Medical Sciences)

Dr. Amitav Banerjee (Professor Community Medicine, Dr. D.Y Patil Medical College Pimpri)

Dr. Padmakar Pandit (Professor and Head Pharmacology B.J Medical College, Pune)

Dr. S.P Rao (Professor Community Medicine B.J Medical College Pune)

Dr Ajit Sontakke (Professor and Head Biochemistry KIMS Karad)

Dr. Kalidas Chavan (Professor and Head Forensic Medicine, Pravara Institute of Medical Sciences, Loni)

Dr. Amol Hartalkar (Associate Professor Medicine Pravara Institute of Medical Sciences, Loni)

Dr. Sushil Kachewar (Professor Radiology Pravara Institute of Medical Sciences, Loni)

International Advisory Board:

Prof. David Warrell (Professor, Emeritus, Oxford University, U.K)

Dr. Lance Cope (Radiology, U.K)

Dr. Sanjay Deshpande (Anaesthesia, U.K)

Dr. Ananda Nanu (Orthopaedics, U.K)

Dr. Nandan Kanvinde (Orthopaedics, U.K)


WaLaWaLKar’s INterNatIONaL MedIcaL JOurNaL

General Information

Walawalkar’s International Medical Journal is a peer reviewed journal, published on

behalf of the B.K.LWalawalkar Rural Medical College. This journal is published annually in

August. The journal publishes information relating to all medical disciplines. The priority

areas of publication are as follows. 1) Clinical and basic science research in all fields of

medicine. 2) Articles related to prevention, management and treatment of diseases in

developing countries. 3) Contributions are accepted in innovative health approaches, devices

and operational research in health 4) Papers are also published related to dentistry, medical

education, nursing, medical laboratory sciences, physiotherapy and other related medical

subjects. Papers are published in English. Submitted papers will be accepted after peer

review. Manuscripts accepted for publication are copy edited for grammar, punctuation, print

style, and format. Page proofs are sent to the corresponding author by e-mail only. The

corresponding author is expected to return the corrected proofs within one week. The whole

process of submission of the manuscript to final decision and sending and receiving proofs is

completed online. The journal is following the uniform requirements for Manuscripts

Submitted to Biomedical Journals available at http://www.icmje.org

Disclaimer

The information and opinions presented in the journal reflect the views of the authors and not

of the journal or editorial board or the publisher. Publication does not constitute endorsement

by the journal. Neither the Medical Journal nor its publishers nor anyone else involved in

creating or producing the Medical Journal, assumes any liability or responsibility for the

accuracy, completeness, or usefulness of any information provided in the Medical Journal of,

nor shall be liable for any direct, indirect, incidental, special, consequential or punitive

damages arising out of the use of the Medical Journal. The Medical Journal, nor its printer,

nor any other party involved in the preparation of the material contained in the Medical

Journal represents or warrants that the information contained herein is in every respect

accurate or complete, and they are not responsible for any errors or omissions or for the

results obtained from the use of such material. Readers are encouraged to confirm the

information contained herein with other sources.

Addresses

Editor in Chief: Dr. Mrs. Suvarna N. Patil

Medical Director,

B.K.L. Walawalkar Rural Medical College, Savarde,Tal. Chiplun, Dist. Ratnagiri

http://www.icmje.org/


WaLaWaLKar’s INterNatIONaL MedIcaL JOurNaL

CONTENTS

Editorial

Original Articles

1. Need for unique assessment parameters and interventional modalities in community dentistry

for school going children.

Asavari Modak, Mugdha D. Shirsath, Avinash Kondejkar

2. Effect of Ramadan Fasting on Renal Function Markers in Healthy Adults from Aurangabad

Shilpa Asegaonkar, Ishrat Kareem, Jayshree Bavikar, Avinash Pagdhune, Sunita Aghade, Anand Thorat

3. Predictive factors for successful arterio-venous access for haemodialysis.

Neemesh Lodh

4. Comparison of Vitamin B 12 Levels in Gastritis with and without H. Pylori

Shrikant Raut, Rittu Chandel

5. Study of Pulmonary Functions in Smokers and Non-Smokers in Sugarcane harvesters in Rural

Maharashtra

Rubeena Bano, Nadeem Ahmad, A.M Mahagaonkar

Reviews

1. A Ten year review of diseases in rural Konkan

Suvarna Patil

Case Reports

1. Percutaneous Approach for Mandibular Angle Fracture Using Lag Screw

Pavan Kohli, Nisheet Agni, Asawari Modak, Sunil Nadkarni, Shrikant Sangle

2. Multidisciplinary Management of Sebaceous Gland Carcinoma of Upper Eyelid with Regional Lymph

Node Metastasis

Unmesh Takalkar,Shilpa Asegaonkar,Suresh Advani, Pushpa Kodlikeri,Ujwala Kulkarni


Editorial

Shri Vitthalrao Joshi Charities Trust started

Bhaktshrestha Kamalakarpant Laxman Walawalkar

Hospital, Diagnostic and Research Centre in 1996, to

cater needy patients of rural Konkan.

This ISO certified hospital has been on a growth

trajectory & has set its sights on new objectives with

the only aim of serving the society. It now intends to

set-up a Medical College to train competent doctors,

who will be capable of serving the healthcare needs

of the poor & the downtrodden.

Today the B.K.L Walawalkar Hospital Diagnostic

and Research Centre is in the midst of expansion

from serving 300 beds capacity to 500 beds capacity

with 14 operation theatres. This hospital would soon

become a teaching hospital and would be attached to

B.K.L Walawalkar Rural Medical College. All the

operation theatres are air-conditioned and include

laparoscope, image intensifiers, different types of

monitors & ventilators. These operation theatres

would handle a range of surgeries including simple

procedures for treatment of hernia to complicated

ones like that for knee replacement, spine surgeries,

Cancer surgeries. The B.K.L.Walawalkar Hospital is

the only hospital in Konkan region with 300 beds

(expansion to 500 beds) and 6 intensive care units

like MICU, SICU, NICU, PICU, post operative

recovery room. 14 well equipped operation theatres

with laparoscopic facilities, image intensifier, endo-

urology facility. Various specialty and super-specialty

services like Medicine, Surgery, Paediatric,

Orthopaedics, Obstretrics and Gynaecology,

Ophthalmology, Oncology, ENT, Pathology, Blood

Bank, Blood Component Unit, Radiology, Endoscopy

and supportive services departments are available at

B.K.L Walawalkar Hospital.

Today, the world is witnessing the activities of

Walawalkar Hospital in its mission of serving the

poor. A tiny, neglected village like Dervan in

Ratnagiri district has now firmly established its place

on the map of India. The self-less work of the hospital

has been appreciated, especially by people from

outside India leading to students from different

countries visiting the hospital to study & learn. So

far, students from Rosalind Franklin University

(USA), Barcelona University (Spain), National

University of Singapore (Singapore) and Hamburg

University (Germany), Oxford University (U.K.) have

visited & worked at the hospital. Their stay also made

them interested in Indian culture. A dedicated group

of about 30 medical professionals from Newcastle

(UK) has been visiting Dervan every year for the past

10 years and carrying out complicated surgeries. As

the poor population of Konkan would never have the

opportunity to travel abroad for treatment,

Walawalkar Hospital has instead brought the same

treatment at their doorstep.

A medical college with 100 seats is envisaged for the

year 2014 by S.V.J.C. Trust as there is a dire

emergency to provide modern medical services to the

rural population at their door steps. Medical students

trained from this college are expected to offer their

services to the local communities. This would then

improve the overall quality of health-services in these

communities. Students will get an opportunity to

carry forward the research already going on at B.K.L.

Walawalkar Hospital.

Thus the main objectives of the Rural Medical

College would be to achieve academic growth,

provide good doctors in rural area who in turn would

serve the rural population, give an impetus to research

and thus achieve overall upliftment of the society as a

whole. Other objectives would to


produce high quality academically excellent and

research oriented doctors who would serve in rural

areas, to be an academic institution of excellence

both in the field of curative medicine and public

health, to conduct research in priority areas this

would lead to positive policy changes and

implementation and to establish strong foundation

of public health and community medicine for the

overall upliftment of the society.

Research would be the future vision of the

institution and it is intended that such research

would bring about positive policy changes which

would be implemented at field level. Thus the loop

between research, policy and implementation

would be completed. With this vision in mind

B.K.L Walawalkar Rural Medical College is

delighted to bring its first issue of Medical Journal

titled ―Walawalkar‘s International Medical

Journal‖.

I thank the editorial members for their immense

contribution.


ORIGINAL ARTICLE

Need for unique assessment parameters and interventional modalities in

community dentistry for school going children.

Asawari R. Modak, Mugdha D. Shirsath ,

Avinash.B. Kondejkar

Dept. of Dentistry

BKL Walawalkar Rural Medical College and Hospital

Address for correspondence

Dr Asavari R. Modak

Department of dentistry, BKL Walawalkar Rural Medical College

Abstract:

The present study was conducted in rural areas of

Konkan region in which a total of 5256 school

children from age group of 6 to 15 years were

screened and 4750 children (90.37%) who were

found to have dental caries were referred to the BKL

Walawalkar hospital for dental treatment. A total of

3582 school children received treatment in the

hospital. New parameters like caries teeth percentage

and functional capacity percentage were assessed

both at the time of screening and 1st follow-up. The

prevalence of caries was found to be 90.37%, at the

time of screening, the caries teeth percentage was

23.91% in group I (6years to 10years) and the caries

teeth percentage was 13.33% in group II(11years to

15years). Caries teeth percentage is the number of

caries teeth present in the mouth in relation to the

total teeth. Functional capacity percentage was

38.24% in group I (6years to 10years) and in group II

(11years to 15years) it was 58.93% at the time of

screening. After treatment at the hospital by

interventions like Glass ionomer cement (GIC),

Permanent filling (P.F), extraction and X ray, the

caries teeth percentage was brought down by 6.75%

in group I (6years to 10years) and 3.13% in group II

(11years to 15years) and functional capacity

improved by 77.34% in group I (6years to 10years)

and was improved by 82.18% in group II (11years to

15years). The data analysis was done using S.P.S.S

software and appropriate statistical tests were applied

for proving the statistical significance of results. Thus

the study proposes that the above unique assessment

tools/indicators and interventions should be used

apart from the usually

used prevalence of caries and DMFT indices.

Key Words

Prevalence of caries, Caries teeth percentage,

functional posterior teeth percentage, functional

capacity percentage, interventions.

Introduction

School going children constitute an important

fraction of the total population. School children are

also having tremendous latent potential as future

human resource of any country. The health issues

associated with school children are unique and need

special interventions. Oral hygiene is often poor

which leads to dental caries and a host of other oral

and dental problems. Nutritional status in school

children also needs attention and many of them

require nutritional supplementation. Keeping in mind

the above challenges B.K.L Walawalkar Hospital

started its School Dental Health Project with special

emphasis on oral and dental hygiene. This project

was implemented in Zilla Parishad school children so

that adequate follow-up and monitoring could be

maintained.1, 2

Objectives

To screen school children for dental

problems, to assess the prevalence of dental

caries.

Modifying the WHO dental assessment

format and including new indicators like

caries teeth percentage, functional posterior

teeth percentage and functional capacity

percentage.

Providing curative interventions like Glass

ionomer cement (GIC), Temporary filling

(Z.O.E), Permanent filling (AgF), extraction

and X ray at hospital level.

Sequential follow-up of children for keeping

a track of their dental status by maintaining

data of each tooth of each child in

appropriate database.

Materials and Methods

The study was conducted in Ratnagiri district of

Konkan region which lies in Western Maharashtra

and which consists of 9 Talukas (Administrative

Blocks).The main reason for choosing this

geographic area was the high prevalence of untreated


carious lesions and malnutrition. Dental caries were

hypothesized as both a cause and effect of

malnutrition. Poor oral and dental hygiene when

superadded with tobacco chewing increased the

chances of oral malignancies many folds.3 The

prevalence of oral malignancies in Ratanagiri district

is very high i.e. in male 9.5/ 100000 population and

4.7/100000 population.4This prompted us to consider

an oral health project targeting the school children

which would improve the oral health status and

spread awareness regarding ill effects of tobacco

chewing. Amongst 9 Talukas (Administrative

Blocks) of Ratnagiri district, 1 taluka i.e. Chiplun

Taluka was randomly selected. Chiplun taluka has an

area of 130. 31 sq kms with a total population of

2,22,735 people. It has a total of 168 villages which

have a total of 35 Kendra School‘s (Each Kendra

School consists of about 8 to 12 schools under it).

Out of the 35 Kendra Schools, 11 were selected

randomly. All the schools under these 11 Kendra‘s

i.e. a total of 118 schools were selected for the

project. All the children from 1st Standard to 7

th

Standard (i.e. 6 years to 15 years) who were present

during the screening were included for the purpose of

the project. A total of 5256 children were screened

for carious teeth, 4750 were referred and 3582 were

treated by various interventions at the hospital.

The organizational and administrative workout like

approval from authorities like chief executive officer,

district education officer, micro-planning for

selecting the schools, operational and logistic

planning, human resource allocation, monitoring and

evaluation mechanism, referral services were carried

out in a systematic manner.

A pilot screening of the project was conducted before

the start of the study with an aim to screen and assess

prevalence of caries, caries teeth percentage, loss of

functional capacity and treatment needs.

Modifications were made in the WHO dental

assessment proforma for clarity and easy

accessibility. The norms for analysis of the data were

set and only then the research project was initiated.

Proper informed consent was obtained from parents

of all school children and school teachers before

starting with the treatment procedure. The screening

of school children was carried out by a dental team

which visited each school according to schedule. Oral

examination of each child was conducted by seating

the child on a chair in day light using required

instruments. The required data for conducting

research was collected and recorded using a printed

form. A structured questionnaire proforma was used

which included questions regarding personal data,

anthropometry, etc. A modified WHO format for

recording the dentition status and treatment form was

used to generate comprehensive record of ―Each

tooth of each student‖. A session on importance of

oral health was undertaken along with an interactive

demonstration on thorough brushing and mouth

rinsing techniques. Distribution of free toothbrush

and toothpaste was done to each school child in order

to promote good oral cleaning habits.

The essential instruments used for screening were

mouth mirror, straight probe, explorer and pair of

tweezers. Sufficient numbers of instruments were

made available to have an uninterrupted examination.

At field level the used instruments were disinfected

using korsole.

Those children who required treatment were referred

to B.K.L Walawalkar hospital, here they were treated

for carious teeth and procedures were carried out to

increase their functional capacity. Scaling i.e. Oral

prophylaxis was performed to restore the normal

health of gums. Extraction was done in case of over-

retained deciduous teeth to avoid malocclusion. The

essential instruments used for referrals were, airotar

handpiece for cavity preparation, filling instruments

like round condenser, cement carrier, pedo extraction

forceps, ultrasonic scalers, to name a few. In the

hospital all instruments were sterilized by

autoclaving. Sequential follow-up of all school

children were done at 6 months and 1 year to know

the impact that the project is having on the

parameters developed.

Unique assessment parameters used for the

purpose of the study:

i. Prevalence of Caries: Number of children having

caries teeth*100/ Total number of children screened

ii. Caries Teeth Percentage (C.T %): Number of

carious teeth (C.T)*100/Total number of teeth (T.T)

iii. Total Functional Pair = Functional pair (R) +

Functional pair (L)

iv. Functional posterior teeth percentage (F.P.T %)

=

Functional posterior teeth (FPT)*100/ Total posterior

teeth (P.T)

v. Functional capacity percentage (FC %) =

Total Functional pair (TFP)*100/ Total pair (TP)

Results

Despite credible scientific advances and the fact that

caries is preventable, the disease continues to be a

major public health problem.5The research study was

carried out in zilla parishad schools of chiplun taluka.

In school going children belonging to 6yrs to 15yrs

of age group. A total of 118 schools out of 363


schools were randomly selected. Among this 3582

school children in the age group of 6 to 15 years were

treated for dental caries out of which 1725 (48%)

were males and 1863(51.9%) were females.

Table No 1(sex)

Frequency Percent

Valid

Percent

Valid Male 1725 48.1 48.1

Female 1863 51.9 51.9

Missing 2 0.1 0.1

Total 3590 100.0 100.0

For further studies like prevalence of dental caries

and functional capacity, the school children were

divided in two groups. Group I included 6years to

10years school children, that was a total of 2464

children (68.8%) and Group II included 11 years to

15 years school children, which was a total of 1118

children (31.2%).

Table No2(Age)

Frequency Percent Valid Percent

Valid 6 to 10 years 2464 68.6 68.8

11 to 15 years 1118 31.1 31.2

Total 3582 99.8 100.0

Missing System 8 0.2

Total 3590 100.0

As the study was carried out in two parts of which the

first part was screening .The school children from

both the groups were examined for dental caries and

the percentage of caries teeth was recorded i.e.

(CT%).In group I the percentage of caries found was

23.91%.

Table No 3

CARIES TEETH% (6 to 10 years age group)

N Valid 2462

Missing 2

Mean 23.91

Minimum 0

N Valid 2462

Missing 2

Mean 23.91

Minimum 0

Maximum 88

The percentage of caries teeth (CT %) in group II

school children was found to be 13.33%.Table No 4

CARIES TEETH% (11 to 15 years age group)

Hence this indicates that the percentage of carious

teeth (CT%) is decreased as the age is increased or it

can be said that prevalence of dental caries is more in

primary dentition as compared to mixed or permanent

dentition.

During mastication, tooth contact exists. These

occur most often during sliding movements in which

the direction and the origin are variable. This justifies

the concept of an occlusion field of mastication.

Centric occlusion is the occlusion most often used

during mastication. It is also the occlusion for which

the masticator y forces are greatest.6 This occlusion

determines the functional capacity(FC%), which can

be calculated by pairing posterior teeth as upper right

side with lower right side and upper left side with

lower left side. In this way we can calculate the

functional pair for each dentition. In case of primary

dentition i.e. when only deciduous teeth are present

there are only four functional pairs. During mixed

dentition when both deciduous and permanent teeth

are present there are six functional pairs. For

permanent dentition there are eight functional pairs.

By using these procedures we calculate the functional

pairs and also the percentage functional capacity for

each school children.

The percentage of functional capacity (FC %) was

done for both groups.

In group I – 6years to 10years the percentage

functional capacity (FC %) at the time of screening

was38.24%.

Table No5

FUNCTIONAL CAPACITY % (FC%) 6 years to 10

years at screening

N Valid 1118

Missing 0

Mean 13.33

Minimum 0

Maximum 75


N Valid 2462

Missing 2

Mean 38.24

Minimum 0

Maximum 133

The percentage of functional capacity in group II i.e.

11years to 15years at the time of screening was found

to be 58.93%.

Table No 6

FUNCTIONAL CAPACITY % (FC %) 11 years to 15

years AT SCREENING

N Valid 1117

Missing 1

Mean 58.93

Minimum 0

Maximum 700

This indicates that the functional capacity is less in

group I that is in 6years to 10years school children.

The studies also indicates that in primary dentition

the functional capacity is less and which can be due

to various factors like wrong feeding habits

introduced by mothers , improper brushing teeth ,

snacking and many more.

The second part of the study consists of referral. In

this phase the school children were treated for dental

caries and also other respectful treatment like scaling

and extraction was performed, for which the school

children were brought to B.K.L.Walawalkar Hospital

Dental Department.

The treatment procedure were also followed in

similar pattern in two groups that is group I 6years to

10years and group II 11years to 15years.

After treating the group I school children for dental

caries the percentage of caries teeth (CT%) was

reduced by 6.75%.Table No 7

CARIES TEETH % after treatment in 6 to 10

years age group

N Valid 2462

Missing 2

Mean 6.75

Minimum 0

Maximum 88

After treating school children in group II also showed

decrease in percentage of caries teeth(CT%) by

3.13%.Table No 8

CARIES TEETH % after treatment in 11 to 15

years age group

N Valid 1118

Missing 0

Mean 3.13

Minimum 0

Maximum 62

The study of prevalence of dental caries in school

children from 6years to15years can be better

explained by drawing a comparison in before and

after conditions that is at the time of screening and

after getting treated.

This was again done separately for both

groups.Graph No 1

Statistically Significant (P value < 0.01 using

Standard Error of Difference between two means)

The bar graph No 1 above shows the figures, that

shows the difference for percentage of caries teeth

(CT%) at screening and after treatment. Similar

assessment was also done for percentage of

functional capacity (FC%) in both groups i.e. group I

and group II. It showed increase in functional

capacity in both groups. The difference was found to

be statistically significant at 99% confidence limit

using standard error of difference between two means

test.

In group I the functional capacity(FC%) was

increased by 77.34%.

In group II the functional capacity(FC%) was

increased by 82.18%

The increase in functional capacity in group I and

Group II was found to be statistically significant (p

value < 0.01) using standard error of difference

between two means statistical test.

PRE AND POST INTERVENTION EFFECT ON

FUNCTIONAL CAPCITY % (Graph No 2)

0

5

10

15

20

25

6 to 10 years

11 to 15 years

23.91

13.33

6.75

3.13

CT%Screening

CT%1stFU




The above bar graph No 2 shows the before and after

results of increased in functional capacity(FC%).

To summaries the whole, study of prevalence of

dental caries in school children from 6years to

15years group with before and after conditions, that

is at the time of screening and after getting treated for

dental caries teeth. The percentage for caries

prevalence was drawn which showed that about 90%

of the school children had decayed teeth at the time

of screening and after getting treated for this decayed

teeth the percentage was reduced to 34.6%.

The bar graph No 3 shows the percentage of caries

prevalence before the treatment and after getting

treated for dental caries.



Hence we can conclude that the percentage of

prevalence of dental caries is decreased as the

functional capacity is increased. By increasing the

functional capacity we can also improve the centric

occlusion which is most often used for mastication.

By treating at the right time with right modalities of

treatment we also prevent malocclusion and also

restore the healthy gums.

Discussion

Dental caries is a highly prevalent dental disease

amongst school children, which is frequently

neglected by the children and parents until it reaches

terminal stages with painful consequences. Multiple

untreated carious lesions are frequently observed

among rural children because of low priority to

dental caries, lack of awareness, unavailability of

dental man power and fear towards dental treatment.

Caries is the most prevalent dental disease in both

primary and permanent dentition. [7] By assessing

the needs for dental disease among the school

children ,the greatest need was for one surface

restoration, followed by two surface restoration , pulp

restoration, extraction and other care.[7]. In this study

of prevalence of dental caries the school children

belonging from 6years to 15years were selected. For

better study they were divided in two groups. The

group I included children from 6years to 10years and

group II included from 11years to 15years. The study

showed that the percentage of prevalence of dental

caries was high in first group that is 6years to10years 8-13

. During the study it was found that the percentage

of the prevalence of dental caries was decreased in

group II 11years to 15years. 12,14-17

This showed that

as age advances the prevalence of dental caries

decrease or it can be said that the prevalence of

dental caries is more in deciduous dentition as

compared to mixed and permanent dentition.7,9,10,18

On assessment of treatment required, among two

groups it was found that group I that was 6years to

10years required more treatment. 8,19,21,22

Untreated oral diseases in children frequently lead to

serious general health, significant pain, interference

with eating and lost school time. A world health

organization [WHO] estimation of global DMFT for

12years old children reported in 188 countries

included in their data base that on global basis 200,

335, 280 teeth were decayed, filled, or missing

among just that age of group.[21]. World health

organization[WHO] continues to advocate that efforts

to improve the overall situation are still highly

indicated. 20,21

A study on oral health assessment and dental health

education of children at an early age helps in

improving preventive dental behavior and attitude

which would be beneficial for life time. It would also

help reducing amount of malocclusion and at same

time awareness for oral hygiene to reduce the risk of

oral cancer cases.

The result of this study is a pointer to the fact that

there still exist a large segment of the population who

continues to remain ignorant about the detriment

effect of poor oral health and multiple benefits

enjoyed from good oral health. One of the oral health

advocated by WHO for 2000 AD(22) was that

0

20

40

60

80

100

6 to 10 years

11 to 15

years

38.24

58.93

77.34 82.18

CT%Screening

CT%1stFU

0

20

40

60

80

100

BEFORE AFTER

91

34.6

Caries Prevelance %

Caries Prevelance %


50%for 5years to 6years olds should be free from

dental caries.20

It also points to the fact that new

indicators like caries teeth percentage, functional

posterior teeth percentage and functional capacity

percentage need to be developed and used in

community dentistry for school children.

References

1) Sogi G M, Bhaskar D J. Dental caries and oral

hygiene status of school going children in Davangere

related to their socioeconomic levels—An

epidermological study , J.Indian Soc Pedod Prev

Dent 2002;20:152-7

2) N Joshi, R Rajesh, M Sunitha. Prevalence of

dental caries among school children in kulasekharam

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ORIGINAL ARTICLE

Effect of Ramadan Fasting on Renal Function Markers in Healthy Adults

from Aurangabad

Shilpa B. Asegaonkara,Ishrat Kareemb, JayshreeS. Bavikarc,Avinash Pagdhuned,Sunita Aghadee,Anand P. Thoratf

a-Assistant Professor b,c-Associate Professor,d,e-Senior Resident f-Professor and Head

Department of Biochemistry ,Government Medical college, Aurangabad

Address for correspondence-

Dr Shilpa B. Asegaonkar

C-13 Swarsangam Society

New Shrey Nagar, Aurangabad.

Email:[email protected]

Abstract:

Background:Ramadan fasting is a religious

obligation followed by Muslims worldwide.

No intake of food and water from sunrise to

sunset often results in changed hydration

status. Generally there is belief of renal

dysfunction due to dehydration during

Ramadan fasting. However, there is scarcity of

scientific literature regarding its effects on

renal function in healthy individuals. This

study was aimed to evaluate alterations in

renal functions due to long intermittent fasting

schedule in the holy month of Ramadan.

Material and Methods:

Thirty three normal healthy volunteers (age

group 23-52 years) from the same large joint

family were enrolled in this study. Blood and

urine samples were collected twice: first, one

day before Ramadan after a 12-hour overnight

fast (baseline) and second on the 28th day of

Ramadan. Blood samples were assayed for

urea, creatinine and uric acid levels and urine

for microalbuminurea.

Results and discussion: Mean age of the

subjects was 43.8±5.4 years. There were slight

but nonsignificant reductions in blood urea,

serum creatinine, uric acid levels and

microalbuminurea of the participants (p> 0.05)

from pre Ramadan to post Ramadan state. Our

study findings revealed no significant impact

of long intermittent fast of Ramadan on renal

function markers. Mean difference between

pre Ramadan and post Ramadan values of

blood urea was 2.4 mg%, serum creatinine was

0.2 mg%, uric acid 0.6 mg% and

microalbuminurea 3 mg/dl which are

statistically not significant.

Conclusion: Among healthy individuals renal

functions are not altered due to Ramadan

fasting.

Key words: Ramadan fast, urea, creatinine,

uric acid, microalbuminurea.

Introduction

Ramadan fasting is a religious obligation

followed by Muslims worldwide. In this

month, there is no intake of food and water

from sunrise to sunset. Hence energy and

water intake is often reduced resulting in

changed hydration status. Also there is

alteration in the pattern of diet, sleep and

behavior of people practicing Ramadan

fasting. In this holiest month, two meals are

consumed, one before sunrise called Suhore

and another meal after sunset called Iftar. [1]

Islamic fasting is unique physiological model

of fasting differing from experimental fasting

because sometimes period of abstinence from

liquid and food may extend for more than 12

hours. [2]

Decreased consumption of fluids, that too only

in nocturnal period has effect on hydration

status and body mass. [3]

Generally there is

belief of renal dysfunction due to dehydration

during Ramadan fasting. However, there is

scarcity of scientific literature regarding its

effects on renal function in healthy

individuals. This study was aimed to evaluate

alterations in renal functions due to long

intermittent fasting schedule in the holy month

of Ramadan.

Materials and Methods Present study was conducted as per the

guidelines of Institutional Ethics Committee.

mailto:[email protected]


Thirty three normal healthy volunteers (age

group 23-52 years) from the same large joint

family were enrolled in this before after study.

All participants had the same diet, behavior,

culture and level of physical activity.

Participants practiced fasting from sunrise to

sunset for at least 25 days during Ramadan.

Informed consents were obtained from all the

participants.

Blood and urine samples were collected twice:

first, one day before Ramadan after a 12-hour

overnight fast (baseline) and second on the

28th day of Ramadan, just before sunset. Urine

samples were collected in sterile container. To

avoid day to day laboratory variation, all blood

and urine samples were assayed on the same

day in a single batch. After serum separation,

blood urea, serum creatinine, uric acid was

assayed using commercial kits from Erba on

fully automated chemistry analyzer from

Transasia. For microalbuminurea, its

quantitative estimation was done by

turbidimetric immunoassay using commercial

kits from AGAPPE diagnostics.

Statistical Analysis

Data was compiled and analyzed using

SPSSv10 software package. It was expressed

as mean +/- S.D. (standard deviation).

Student‘s paired‗t‘ test was used to compare

pre and post Ramadan status variables. Cut off

value for significant p values considered was

0.05.

Results

Mean age of the subjects was 43.8+/-5.4

years. There were slight but nonsignificant

reductions in blood urea, serum creatinine,

uric acid levels and microalbuminurea of the

participants (p> 0.05) from Pre Ramadan to

post Ramadan state. This data pertaining to

the effect of fast on renal function markers has

been summarized in the following table.

Table 1: Presentation of biochemical

parameters before and after Ramadan among

studied participants.

Variables Before Ramadan Mean± S.D.

After Ramadan Mean± S.D.

Difference in Mean

P value

Blood Urea mg%

24.6±

3.8

22.4±

2.2

2.4

mg%

0.062

NS

Serum Creatinine mg%

1.1±0.3 0.92±

0.2

0.2

mg%

0.059

NS

Serum Uric acid mg%

5.8±1.2 5.2±1.

2

0.6

mg%

0.063

NS

Microalbuminurea mg/dl

32±12 29±8 3 units 0.06

NS

NS- Not significant

Discussion

Present work was aimed to ascertain whether

fasting in Ramadan has beneficial or

detrimental effect on renal function due to

restricted intake of fluids for long period. Our

study findings revealed no significant impact

of long intermittent fast of Ramadan on renal

function markers. Mean difference between

pre Ramadan and post Ramadan values of

blood urea was 2.4 mg%, serum creatinine was

0.2 mg%, uric acid 0.6 mg% and

microalbuminurea 3 mg/dl which are

statistically not significant. Confounders‘

effects were kept minimal by including all

subjects from same family for recording

baseline and post Ramadan samples.

Changed dietary pattern, not only with respect

to quantity but quality also with no fluid intake

in day time and altered lifestyle is expected to

alter functioning of kidney. There are

conflicting results about effects of Ramadan

fasting on renal functioning. [4]

Saada A

observed significant rise in blood urea and

serum creatinine levels while Indral et al found

significant reduction in urea and creatinine

values in Ramadan fasting group. [5,6]

Nomani

et al. reported a significant increase in blood

urea level by the end of Ramadan. [7]

Azizi in

their study stated that during long-term hunger


pangs, serum uric acid increases abnormally,

which may be caused by Glomerular filtration

and release of uric acid. [8]

Effect of Ramadan

fast on renal function has been wisely studied

in patients of hypertension, type 2 diabetes

mellitus and among individuals performing

physical exercise demonstrating no harmful

effects. [9]

Zahid observed low levels of serum

uric acid without any difference in urea in his

56 Muslim healthy subjects practicing

Ramadan fasting. [10]

Various researchers studied the effect of

fasting on renal function tests -blood urea,

serum creatinine and albumin in healthy

individuals. They reported small but

statistically not significant changes on these

parameters. The results of our study are

consistent with the previous studies [10, 11, 12]

.

Beneficial effect of insignificant reductions in

blood urea, creatinine and urinary ACR were

observed in a study by Ola A. [13]

Progressive

rise in the blood urea nitrogen and reduction in

creatinine, but within normal range was

observed with the advancement of fasting

period in healthy subjects. This could be

attributed to dehydration, excessive break

down of nucleic acids especially RNA in

tissues and restricted energy intake. [14]

Creatinine which is synthesized endogenously

in muscles is better marker to assess function

of kidney. It is neither absorbed nor secreted

by renal tubules. While blood urea levels

depend on dietary protein intake. Uric acid is

an end product of purine metabolism and

excreted by kidney. Microalbuminuria is an

early marker of renal dysfunction. [15]

Khaled

Trabelsi and colleagues studied effect of

Ramadan fast on renal function after rugby

seven matches. They concluded that renal

response to matches was not different

statistically. [16]

In one of the Malaysian study,

tubular dysfunction was observed for

temporary period during Ramadan fasting. [17]

We investigated effect of Ramadan fasting on

renal function markers in healthy young

individuals which was not significant. Hence

practicing Ramadan fast can be advocated in

healthy individuals.

Conclusion Among healthy individuals renal functions are

not altered due to Ramadan fasting. Many

factors can influence the effects of Ramadan

fasting on biochemical and physiologic

parameters like diet, daily activity, sleep

pattern, the season of fasting, socio-economic

factors, geography and climate. Hence large-

scale coordinated multi-centre studies, with

standardized methodology, to explore the issue

more extensively are warranted.

Conflicts of interests There is no conflict of interest among all

authors of the study.

References:

1. Azizi F. Islamic fasting and health.

Ann Nutr Metab. 2010; 56:273-282.

2. Hadi Abdul Ridha Hadi Khafaji,

Abdulbari Bener, Mohammed Osman,

Ajayeb Al Merri, Jassim Al Suwaidi.

The impact of diurnal fasting during

Ramadan on the lipid profile, hs-CRP,

and serum leptin in stable cardiac

patients. Vascular Health and Risk

Management 2012;8:7–14.

3. Trabelsi et al.: Effect of fed- versus

fasted state resistance training during

Ramadan on body composition and

selected metabolic parameters in

bodybuilders. Journal of the

International Society of Sports

Nutrition. 2013;10:23.

4. Attarzadeh Hosseini SR, Sardar MA,

Hezaji K, Farahati S et al. The effect

of Ramadan fasting and physical

activity on Body Composition, serum

Osmolarity Level and Some

Parameters of electrolyte in Females

Int J Endocrinol Metab. 2013; 11(2):

88-94.

5. Saada A, Selselet attou G, Belkacemi

L, Ait chabane O, Italhi M, Bekada

AM, et al. Effect of Ramadan fasting

on glucose, glycosylated haemoglobin,

insulin, lipids and proteinous

concentrations in women with non-

insulin dependent diabetes mellitus.

African J Biotech. 2010;9(1):87-94

6. Indral M, Satumanl L, Widodo E,

Tinny E, Endang S, Soemardini S.

Study of some biochemical parameters

in young men as effected by Ramadan

Fasting. J Kedokteran Yarsi.

2007;15(1):6-12.

7. Nomani M. Dietary Fat, Blood

cholesterol and Uric Acid Levels


during Ramadan Fasting. Int J

Ramadan Fasting Res.1997;1(1):1-6.

8. Azizi F. Research in Islamic fasting

and health. Ann Saudi

Med.2002;22(3-4):186-91.

9. JB Leiper, AM Molla and AM Molla.

Effects on health of fluid restriction

during fasting in Ramadan European

Journal of Clinical Nutrition.

2003;57:Suppl 2, S30–S38

10. Zahid J. Mohammed The Influence of

Ramadan Fasting on Some

Hematological and Biochemical

Parameters in Healthy Adult Males

Iraqi National J. for Nursing

Specialties. 2011;24(1):45-51.

11. Yousef B, Bassam B, Raafat AH.

Fasting Ramadan in kidney transplant

is safe. Saudi J kidney Dis Transpl

2009;20(2):198-200.

12. Aksungar FB, Eren A, Ure S, Teskin

O, Ates G. Effect of intermittent fasting on

serum lipid levels, coagulation status and

plasma homocysteine levels. Ann Nut

Metab2005; 49: 77-82.

13. Ola A. El-Gendy M. Rokaya, Hassan

E. El-Batae, Salwa Tawfeek.Ramadan

Fasting Improves Kidney Functions and

Ameliorates Oxidative Stress in Diabetic

Patients. World Journal of Medical

Sciences.2012;7(1): 38-48.

14. S.A. Nagra, N. Shaista, M.Z.A.

Nomani, and A. Ali. Effect of Ramadan

Fasting on Serum Protein Concentrations

in Male and Female University

Students.Canadian Journal of Applied

Sciences. 2011; 1(2): 29-42.

15. Inass Taha Renal diseases and

Ramadan: A review of the literature. Life

Science Journal 2013;10 (3):450-8.

16. Khaled Trabelsi, Haithem Rebai, ,

Kais el Abed, , Stephen Stannard, ,

Choumous

Kallel, , Zouheir Sahnoun, , Ahmed

Hakim, , Nicole Fellman, , Zouheir Tabka.

Effect of ramadan fasting on renal

function markers and serum electrolytes

after a rugby sevens match. IOSR Journal

of Pharmacy.2012;2(5):42-50.

17. Cheah S.H., CH‘ng S.L, Hussain R.

and Duncan M.T. Effects of fasting during

Ramadan on urinary excretion in

Malaysian Muslims. Br. J.

Nutr.1990;63(2): 329-337.


ORIGINAL ARTICLE

Predictive factors for a successful arterio-venous access for haemodialysis.

Lodh Neemesh Manohar Corresponding Author:

Dr Neemesh Manohar Lodh, Department of Surgery,B K L Walawalkar Rural Medical College,Sawarde,

Taluka Chiplun, District Ratnagiri.Pin:415606.Maharashtra, India.e-mail address: [email protected]

Abstract

Background: This study, aimed to model

associations between multiple predictor variables

and arteriovenous fistula (AVF) maturation,is

based on post-surgery data from 80 patients that

received an AVF construction for the first time by a

single surgeon. Using these data the factors

associated with successful AVF that may have an

important role in improving AVF patency rates are

elucidated.Methods: This prospective study

included 80 patients undergoing an AVF

construction for the first time by a single surgeon,

& followed them up till ascertainment of successful

AVF maturation. Multivariable logistic regression

methods were used to model associations between

multiple predictor variables and AVF maturation.

We constructed receiver operating characteristic

(ROC) curves, by plotting sensitivity versus

specificity of our model predicting AVF

maturation. We used the area under the ROC curve

(AUC) and odds ratio for predicting optimum

venous & arterial diameters for AVF construction.

Results: With an overall AVF patency rate of 60

%, the highest patency rates were observed in

brachiobasilic AVFs (89.50%), while

brachiocephalic & radiocephalic AVFs had patency

rates of 47.10% & 55.60% respectively. Distal

venous diameter (ROC cut off) > 2.2mm was a

significant predictor of a successful AVF. Using

odds ratio, a vein having a diameter of ≥ 2.2mm

was 4 times more likely to yield a patent fistula.

Proximal arterial diameter (ROC cut off) > 3mm

was a significant predictor of a successful AVF.

Using odds ratio, an artery having a diameter of ≥ 3

mm was 3 times more likely to yield a patent

fistula. Previous central venous catheterization,

brachial artery diameter, proximal cephalic vein

diameter and distal basilic vein flow velocity are

significant predictors of a working AVF as the final

outcome. The type of AVF constructed carries no

significance as far as prediction of a working AVF

is concerned. The age, sex, End Stage Renal

Failure (ESRF), Hypertension, Diabetes Mellitus &

duration of disease had no significance in

predicting a successful AVF. Conclusion: As per

our study, the chances of a working AVF were

higher in patients with no previous central venous

catheterization, a distal venous diameter of ≥

2.2mm and a proximal arterial diameter of ≥3mm.

Key Words: Arteriovenous fistula (AVF),

Haemodialysis (HD), Receiver Operating

Characteristics curve (ROC).

INTRODUCTION

With a population over a billion, and an

exponential rise in the cases of diabetes, India is

fast becoming the leading nation of patients with

(ESRF). Approximately 1 million new cases are

detected each year, out of which 90 % never see a

nephrologist. Of the 10 % who do see a

nephrologist, Renal Replacement Therapy (RRT)

in the form of haemodialysis, peritoneal dialysis or

renal transplantation is initiated in 90 % patients.

The remaining 10% are simply unable to afford the

prohibitive cost of therapy. [1]

HD is an integral part

of RRT, and constitutes a short- term measure to

cover the run-up to renal transplantation without

overt uremic symptomatology. [2]

In such a

scenario, it is even more pertinent to have a

working AVfistula. A study of the various factors

which could have a predictive role in the successful

maturation and patency of an AV fistula was hence

undertaken.

MATERIALS& METHODS

Subjects & Data:

We conducted a prospective study of predictive

factors for a successful AVF maturation. In all 80

patients were chosen for the study as per the

inclusion and exclusion criteria laid down prior to

the study. The study was a prospective one for a

period of 2 years, from February 2007 to February

2009 and included male and female patients of all

ages with ESRF, planned for an AVF for the first

time. The study was commenced after due approval

from the hospital ethics committee. Patients with a

prior history of fistula surgery, those with vessels

unsuitable for a primary AVF, those with arm

oedema, especially with a history of prolonged

central venous catheterisation & those who were

candidates for primary AV graft procedures were

excluded from this study. All AVFs were


constructed by the same surgeon, under uniform

operating conditions.

Only the first surgical AVF construction during the

follow- up period was considered for each study

subject. Study variables, including such

demographics as age, race, and sex and the

presence of various comorbid conditions, such as

hypertension and diabetes, were recorded from

available medical records. Additionally, cause and

length of ESRF and time on dialysis therapy before

the surgery were ascertained for each subject.

Preoperative AV mapping was carried out in all

patients to assess the most suitable vessels for AVF

construction.

AV mapping:

The Colour Doppler imaging was carried out using

a Philips Envisor machine with a linear phased

array dual high frequency probe of 3- 12

Megahertz.

Method: The patient was seated with the arm

uncovered & outstretched on a pillow.

The veins were mapped along their natural course,

at three places; namely the cephalic vein at the

wrist & the cubital fossa, & the basilic vein along

the medial aspect of the arm upto the subclavian

vein, to see for the patency of the proximal central

veins. The depth, diameter of the vessels & the

flow across the veins was recorded.

Veins which were thin walled, varied in size with

respiration, collapsed completely on compression

with the transducer probe and augmented with

distal compression were chosen for AVF

construction. Any thickening or thrombosis was

duly observed and noted.

The arteries were similarly mapped; the radial

artery at the wrist & the brachial artery along the

medial aspect of the arm. The ulnar artery was not

routinely mapped in the presence of an adequate

radial artery flow. The depth, diameter & flow

were noted across the arteries. A note was made of

any excessive calcification or irregularity of the

vessel wall. A site for the access procedure was

then chosen after correlating the clinical findings

with the visual impression as seen on the Duplex

scan.

The AVF construction was carried out by the same

vascular surgeon, under optimum conditions.

Patients were then followed up in the post-

operative period upto the time of successful AVF

cannulation for Haemodialysis, wherein the AVF

was termed successful.

Statistical methods:

The distribution of the various predictor variables

was analyzed using tabular displays and histograms.

We used the odds ratios (with 95% confidence

intervals) to compare these variables and the chi-

square test to determine the compatibility of data

with hypotheses of no association. Multivariable

logistic regression methods were used to model

associations between multiple predictor variables

and AVF maturation. We constructed Receiver

Operating Characteristic (ROC) curves by plotting

sensitivity versus specificity of our model

predicting AVF maturation. The area under the

ROC curve and the odds ratios were utilized for

predicting optimum venous & arterial diameters for

AVF construction.

RESULTS:

A total of 80 patients were included in the study,

out of which 43 were male and 37 female.

The mean age was 49.68 years, with a minimum

age of 18 and a maximum of 78 yrs.

Age, sex, ESRF, HTN, DM & duration of disease

had no significance in predicting a successful

AVF.Proximal brachiocephalic AVF construction

was carried out in 34 patients while distal

radiocephalic AVF construction was done in 27

patients. In addition, brachio-basilic vein

transposition AVFs were constructed in 19 patients.

The overall AVF patency rate was 60 %. Patency

rates were highest in brachiobasilic AVFs

(89.50%), while brachiocephalic & radiocephalic

AVFs had patency rates of 47.10% & 55.60%

respectively. Using Pearson‘s Chi- Square test

(with continuity correction), no significant

association was found between final outcome and

vein diameter in each type of AVF. Also, the type

of AVF constructed was not a significant predictor

of successful AVF, when compared using binary

logistic regression.

RRT was already being carried out in 55 patients

(either HD or PD) at the time of creation of the

fistula. HD was being carried out by Internal

Jugular Vein (IJV) catheterization in 53 Dialysis

(CAPD). However, 25 patients were not on any

form of dialysis. Of those being dialyzed, 55

patients (68.8%) gave history of previous central

venous catheterization (CVC). This is significant in

view of central venous stenosis caused by prior

CVC, which may lead to venous outflow

obstruction. A history of prior central venous

catheterization was obtained in 68.8 % patients.

Studies [3]

have found subclavian and internal

jugular stenosis in patients on temporary HD

catheters. This is an important cause of venous

outflow obstruction and subsequently, AVF failure.

Majority of the patients had ESRF, Hypertension

(HTN) and Diabetes Mellitus (DM). However, no

significant association was found between these


comorbid illnesses and the final outcome as per

binary logistic regression.

Previous central venous catheterization, brachial

artery diameter, proximal cephalic vein diameter

and distal basilic vein flow velocity were found to

be significant predictors of a successful AVF using


Using the ROC curves (Table 1), it was found that

a distal vein diameter of ≥ 2.2 mm was a

significant predictor of a working AVF, with a

95% confidence interval of 0.547 to 0.895, and an

area under the ROC curve of 0.750. Positive

likelihood ratio was 2.8, while negative likelihood

ratio was 0.1, which was significant.The odds ratio

derivatives suggest that, a vein having a diameter

of ≥ 2.2mm was 4 times more likely to yield a

patent fistula.

Furthermore, using the ROC curve, it was found

that a proximal arterial diameter ≥ 3mm was found

to be a significant predictor of the final outcome,

with 95% Confidence intervals of 0.566 to 0.824 &

an area under the ROC curve of 0.707. Positive


ratio was 0.39, which was significant. Using odds

ratio, an artery having a diameter of ≥ 3 mm was 3

times more likely to yield a patent fistula.

DISCUSSION:

1).Sex-wise AVF maturation differences:

Women usually have smaller arteries and veins

and, therefore, this may be the reason for poorer

maturation and survival rates of vascular access in

them. However, the literature remains

contradictory. Some studies have shown that there

was no difference in the arterial and venous

diameters between males and females, with similar

maturation and 1- year patency rates; whereas

others have shown that that female gender was

associated with an increased use of grafts and a

higher number of access revisions. [4-10, 17]

However, our study showed no significant

association between sex and the final outcome

(successful AVF maturation), as confirmed by


2). Age- wise distribution:

The mean age was 49.68 years, with a minimum

age of 18 and a maximum of 78 yrs. Age may have

an influence on post-operative blood flow in newly

created autogenous fistulae, which results in a

slightly higher failure rate as compared with young

patients.[9]

No significant association was found between age

and the final outcome, as per binary logistic

regression.

Arterial Diameter - mm

3). Comorbid illnesses (Diabetes Mellitus,

Hypertension, ESRF, Others):

The combination of age and diabetes does have an

impact on fistula outcome with significantly higher

failure rates and an increased percentage of grafts

in elderly patients. [10- 12]

Our study did not show

any significant association between the two and the

final outcome.

The presence of diabetes and hypertension may

have an additional negative impact on the chance


of successful access creation. These patients

usually have poor, thickened and calcified arteries

with proximal and/or distal vessel obstruction.[12-15]

Access creation is more difficult, and the risk of

symptomatic ischaemia of the upper and lower

extremity due to access-induced steal syndrome is

significant.

Hypotension is a well-known cause of thrombosis

of a vascular access. In some studies, hypertension

was found to be protective against AVF failure [13]

.

In a retrospective study of 191 patients, Thomsen et

al16

described a greater early failure rate (first 4

weeks after placement) in patients with low

perioperative systolic blood pressure (110 mm Hg;

53% versus 24%; P <0.02). These findings suggest

that consideration should be given to evaluating

strategies in which antihypertensive therapy is

deintensified around placement of an AVF.

In this study, Diabetes Mellitus and Hypertension

did not affect the final outcome. Also, no

significant association was found between Diabetes

Mellitus and the final outcome in each category of

venous diameter. No discernible cause was found.

However, more cases need to be included to study

this causal association.

4). Association between Final Outcome and Vein

diameter:

Preoperative vascular mapping has shown to

substantially increase the total proportion of

patients dialyzing with fistulae [17-19]

. Several

studies support the 2.0- to 2.5-mm vein diameter

threshold for successful creation of a fistula.

Radiocephalic fistulae constructed in veins with a

less than 2.0-mm diameter had only 16% primary

patency at 3 months compared with 76% for those

with veins greater than 2.0 mm17

. In a pivotal study [9]

, a threshold of 2.5 mm vein diameter assessed by

duplex ultrasound was used. This resulted in an

increase in fistula creation of 63% compared with a

retrospective 14% rate in the absence of vascular

mapping [20]

. A similar study using the same duplex

ultrasound criteria showed a fistula increase from

34% in historical controls to 64%. Importantly, in

this study, duplex ultrasound altered the surgical

plan based entirely on the surgeon's clinical

evaluation, resulting in increased placement of

fistulae21

.

Although angiography remains the standard for

evaluating the central veins, they may be assessed

indirectly by using duplex ultrasound12

. Compared

with invasive venography, duplex ultrasound had a

specificity of 97% and sensitivity of 81% for

detecting central vein occlusion20

. Alternatively,

Magnetic Resonance Angiography may be used for

evaluation of central venous occlusion21, 22

.

In our study, an overall AVF patency of 60 % was

achieved, with brachiobasilic vein transposition

fistulae having the maximum patency rates of

89.50% (17 working out of 19), while

radiocephalic AVFs had a patency rate of 55.60 %(

15 working out of 27). Brachiocephalic AVFs had

the poorest patency rate of 47.10 % (16 working

out of 34).

In the present study, a distal vein diameter of ≥ 2.2

mm was a significant predictor of a working AVF,

with a 95% confidence interval of 0.547 to 0.895,

& an area under the ROC curve of 0.750. Positive


ratio was 0.1, which was significant.

The odds ratio for distal venous diameter was

4.008, which meant that an AVF created using a

venous diameter ≥2.2mm was 4 times more likely

to succeed as compared to that using a vein with

lesser diameters.

Also, a proximal arterial diameter ≥ 3mm was

found to be a significant predictor of a working

AVF, with confidence intervals of 0.566 to 0.824 &

an area under the ROC curve of 0.707. Positive


ratio was 0.39, which was significant.

An odds ratio of 3.02 signified that arterial

diameter of ≥ 3mm was 3 times more likely to

produce a patent AVF.

This study showed no significant association

between the final outcome and vein diameter in

each type of AVF.

Also, the type of AVF was not a significant

predictor of the final outcome (working AVF).

This study showed that previous central venous

catheterization, brachial artery diameter (mm),

proximal cephalic vein diameter (mm) & distal

basilic vein flow velocity (cm/sec) were significant

predictors of working as final outcome.

Table 1 ROC Curve for vein diameter (mm) as a

predictor of final outcome (working AVF):

Variable Vein diameter

(mm)

Classification Variable Final outcome

Select 1

Positive group

Final outcome = 1

Sample size 15

Negative group

Final outcome = 0

Sample size 12

Disease prevalence (%) unknown

Area under the ROC curve 0.750

Standard error 0.094

95% Confidence interval 0.547 to 0.895

Significance level P (Area=0.5) 0.0079


Table: 2

Association between Final Outcome and Vein

diameter (mm)

Final Outcome

Vein diameter (mm)

(ROC cut-off) Total

>2.2 2.2

Working No. 41 7 48

% 68.30% 35.00

% 60.00

%

Not working

No. 19 13 32

% 31.70% 65.00

% 40.00

%

Total No. 60 20 80

% 100.00% 100.00

% 100.00

%

Chi-square Tests

Value df p-

value Association

is-

Pearson Chi-Square

6.944 1 0.008 Significant

Continuity Correction

5.625 1 0.018 Significant

Risk Estimate Value

95% Confidence

Interval

Upper

Lower

Odds Ratio for Final Outcome (Working / Not working)

4.008 1.378 11.658

For cohort Vein diameter (mm) (ROC cut-off) ≥ 2.2

1.439 1.056 1.96

For cohort Vein diameter (mm) (ROC

cut-off) 2.2

0.359 0.161 0.801

Table: 3

ROC Curve for proximal arterial diameter

(mm) as predictor of final outcome (working

AVF):

Variable Arterial diameter (mm)

Classification variable Final outcome

Select 1

Positive group

Final outcome = 1

Sample size 33

Negative group

Final outcome = 0

Sample size 20

Disease prevalence (%) unknown

Area under the ROC curve 0.707

Standard error 0.071

95% Confidence interval 0.566 to 0.824

Significance level P (Area=0.5) 0.0037

Table: 4

Association between Final Outcome and

Arterial diameter (mm)

Final

Outcome

Arterial

diameter (mm)

(ROC cut-off) Total

>3 3

Working No

. 26 22 48

% 74.30% 48.90% 60.00%

Not working No

. 9 23 32

% 25.70% 51.10% 40.00%

Total No

. 35 45 80

% 100.00

%

100.00

%

100.00

%

Chi-square

Tests Value df

p-

value

Association

is-

Pearson Chi-

Square 5.291 1 0.021 Significant

Continuity

Correction 4.286 1 0.038 Significant

Risk Estimate Val

ue

95%

Confidence

Interval

Upp

er

Low

er

Odds Ratio for Final

Outcome (Working / Not

working)

3.0

2 1.16

7.86

6

For cohort Arterial

diameter (mm) (ROC cut-

off) ≥ 3

1.9

26

1.04

4

3.55

2

For cohort Arterial

diameter (mm) (ROC cut-

off) 3

0.6

38

0.43

8

0.92

9

CONCLUSION:

Pre- operative Colour Doppler imaging of the

arteriovenous system, coupled with utilization of

optimal arterial & venous cut- off diameters can be

helpful in improving the success rate of AV

Fistulae.


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ORIGINAL ARTICLE

Comparison of Vitamin B12 Levels in Gastritis with and without

H.pylori

Shrikant S. Rauta ,Rittu S Chandel

b,

a,b-Postgraduate resident

Dept of Biochemistry, Grant Government Medical College and Sir JJ

Group of Hospitals,Mumbai

Address for Correspondance-

Dr Shrikant S. Raut, 5/501,Mangalmurti Annexe,S.K.Bole road, Agar Bazzar,Dadar (W),

Mumbai -400028,Maharashtra, E-mail - [email protected]

Abstract

Background: H. pylori infection is widespread in developing nations, prevalence is more than 80% among middle-aged adults.It may play an important role in impairment of vitamin B12 absorption.Itis almost invariably associated with the presence of gastritis in India. The classical sign of vitamin B12 deficiency is megaloblastic anemia which, occurs in only 50 % of vitamin B12-deficient subjects. Other signs are psychiatric and neurodegenerative changes. Aim: To study the status of vitamin B12 in gastritis with and without H.pylori.

Methods and Material : Prospective study carried out at tertiary care hospital in Mumbai between June to December 2013

Ninety gastritis suspected patients who underwent gastroscopy were enrolled. Rapid urease test was used to diagnose H.pyloriinfection.Chemiluminescent immunoassay based Immulite 1000 analyzer was used for analysis of vitamin B12.

Statistical analysis used: The mean serum levels of vitamin B12 in H.pylori-positive and H.pylori-negative gastritis groups of patients were compared by independent sample „t‟ test.

Results: Serum vitamin B12 levels were significantly lower in patients with H.pylori positive gastritis than in those with H.pylori negative gastritis ( 261.2 ±89.2 ; 382.7 ± 164.9respectively, p = 0.0001 )

Discussion: The study shows serum vitamin B12 levels to be lower in H.pyloripositive as compared to H.pylori negative gastritis.

Key-words: H.pylori gastritis, vitamin B12, gastroscopy , rapid urease test, chemiluminescence

Introduction The epidemiology of H. pylori infection in developing countries, such as India is characterized by a rapid rate of acquisition of the infection such that approximately 80% of the population is infected by the age of 20 yrs

1,2,3 because the disease is

most often acquired in childhood.4-8

In developing countries the prevalence of infection peaks in the 20 to 30 year old age group. H.pylori is recognized as a major etiologic agent for chronic active gastritis.

9 Asymptomatic carrier state is

common in H.pylori infection10

and if left untreated H. pylori infection is lifelong.

11 It

has been suggested that H. pylori infection may play an important role in impairment of folate and vitamin B12 absorption owing to diminished acid secretion, lower ascorbic acid levels in gastric juice and reduced secretion of intrinsicfactor.

12 Studies have

been published where Vitamin B12 was compared between H.pylori positive and H.pylori negative gastritis.

13

Subjects and Methods:

We conducted our study at Biochemistry laboratory in collaboration with Department of Surgery, at a tertiary care hospital in Mumbai. It was conducted over a period of six months from June 2013 to December 2013. A complete medical history and informed consent was obtained from all participants included in the study . Ninety symptomatic patients, in the age group 20-60 yrs of either sex, suspected of gastritis were subjected to upper gastrointestinal endoscopy and enrolled in the study. On confirmation of gastritis by endoscopy, biopsy was taken from the gastric antrum to diagnose the presence of H.pylori infection with Rapid Urease Test.

Text


Inclusion criteria : Patients of age group 20-60 yrs. Patients of either sex. Patients diagnosed as gastritis with or without H.pylori by rapid urease test on gastric antral biopsy specimen taken during endoscopy.

Exclusion criteria : Patients with previous H.pylori eradication therapy in last 6 months. Renal failure. Liver diseases. Use of drugs affecting plasma vitamin B12 and folic acid levels. Patients with history or presence of other causes of vitamin malabsorption. Pregnant women.

Of the Ninety patients ten were excluded on the basis of exclusion criteria. CASES : Forty patients in the age group 20-60 yrs of either sex diagnosed as H.pylori associated gastritis by positive rapid urease test on gastric antral biopsy specimen taken during endoscopy. CONTROL : Forty patients in the age group 20-60 yrs of either sex diagnosed as gastritis other than H.pylori associated gastritis, by negative rapid urease test on gastric antral biopsy specimen taken during endoscopy. All the patients enrolled in the study, who underwent upper gastrointestinal endoscopy were subjected to gastric antral biopsy for diagnosis of H.pylori infection so as to categorize them into gastritis with and without H.pylori infection. H.pylori infection was diagnosed by Pylo-dry test, ( manufactured and marketed by Halifax Research Laboratories, Kolkata, India ) which is a rapid urease test. Procedure For Rapid Urease Test : Written and informed consent was taken for the procedure Patients subjected to upper gastrointestinal endoscopy were nil by mouth for 8 hours. Local anaesthesia with Lidocaine Topical Aerosol ( LOX 10% spray ) was given.A flexible, fiber-optic, endoscope ( PENTAX EG – 2770K (2.8) ) was manoeuvred into the stomach.Patients with gastritis were subjected to a biopsy from the pyloric antrum.The biopsy specimen was transferred from the biopsy forceps onto the exposed yellow media of the Pylo-dry test kit.One drop of distilled water was added onto the yellow media containing the

biopsy specimen. Urease enzyme of H.pylori, if present, reacts with urea of the media and changes the colour from yellow to red or pink altering the pH to make it alkaline. The change in the colour of the media from yellow to red or pink was taken as a positive test ,thus the patients were categorized as cases and controls. Analysis of Vitamin B12 A fully automated enzyme amplified chemiluminescent immuno assay based Immulite 1000 analyzer was used for quantification of vitamin B12 . Commercial kits from Siemens Medical Solutions Diagnostics, Los Angeles, CA, USA were used. The reference serum level of :

Vitamin B12 = 160 – 800 pg/ml Independent sample t-test was used to compare the difference of means. In this analysis, variables showing p-value less than 0.05 were considered to be statistically significant.

Results:

Serum vitamin B12 levels were significantly lower in patients with H.pylori positive gastritis than in those with H.pylori negative gastritis

Table 1 Vitamin B12 levels in H.pylori positive and H.pylori negative gastritis

Parameters

H.pylori positive gastritis

H.pylori negative gastritis

p value Mean ± SD

Mean ± SD

Vitamin B12 (pg/ml)

261.2 ± 89.2

382.7 ± 164.9 0.0001

Discussion: Vitamin B12 is a water-soluble molecule that functions as an essential coenzyme for two enzymes in the human body : cytoplasmic methionine synthase which catalyzes methylation of homocysteine to methionine; and methylmalonyl-CoA mutase, which catalyzes the conversion of methylmalonyl-CoA to succinyl-CoA in the mitochondrion. The methionine synthase reaction, which also involves folate is essential for a high number of methyl-transfer reactions and is also, therefore, indirectly involved in nucleotide synthesis. The methylmalonyl-CoA mutase reactions are involved in digestion of different organic compounds, including branched amino acids and odd-


chain fatty acids. Once referred to as “ nature‟s most beautiful cofactor ”

14 the red-

coloured B12 is a tetrapyrrole that occurs in several active and inactive forms.

15-20 A

complex 30-step pathway of vitamin B12 biosynthesis is confined to certain prokaryotes, humans are completely dependent upon a dietary source of the vitamin.

21It has been suggested that H.

pylori infection may play an important role in the reduction of acid production, reduced intrinsic factor secretion and therefore the development of vitamin B12 deficiency. However, development of vitamin B12 deficiency occurs slowly due to the low requirement ( 2 µg/day ), the enterohepatic cycle of cobalamin and the liver stores of the vitamin that have been built up during life and that are about 2–3 mg of cobalamin by the age of 60 years.

22 The

classical sign of vitamin B12 deficiency is megaloblastic anemia which, however, occurs in only 50 % of vitamin B12-deficient subjects. Other signs of vitamin B12 deficiency which are often overlooked are psychiatric and neurodegenerative changes.

23

Shuval-Sudai and Granot24

investigated 133 patients in Israel for H.pylori infection and cobalamin and folate status and reported a significant association of H. pylori infection and prevalence of low cobalamin and folate concentrations. In the present study, serum vitamin B12 levels were significantly lower in patients with H.pylori positive gastritis as compared to those without. The mechanisms of vitamin B12 and folic acid malabsorption by H.pylori infection are unclear, but the following explanations are possible. First, hypochlorhydria associated with atrophic gastritis may lead to failure in splitting of vitamin B12 from food binders and its subsequent transfer to R-binder (haptocorrin) in the stomach.

12 Second,

decreased secretion of ascorbic acid and secretory dysfunction of the intrinsic factor in the backdrop of H.pylori infection could possibly lead to a decrease in vitamin B12 and folate absorption.

24,25

Conclusion :

In our study serum levels of vitamin B12 were significantly lower in H.pylori positive gastritis as compared to H.pylori negative gastritis.

References: 1. Graham DY, Adam E, Reddy GTet al. Seroepidemiology of Helicobacter pylori

infection in India. Comparison of developing and developed countries. Dig Dis Sci 1991; 36: 1084-1088. 2. Megraud F, Brassens-Rabbe MP, Denis F et al. Seroepidemiology of Campylobacter pylori infection in various populations. J Clin Microbiol 1989; 27: 1870-1873. 3. Al-Moagel MA, Evans DG, Abdulghani ME et al. Prevalence of Helicobacter (formerly Campylobacter) pylori infection in Saudi Arabia: and comparison of those with and without upper gastrointestinal symptoms. Am J Gastroenterol 1990; 85: 944-948. 4. Malaty HM & Graham DY. Importance of childhood socioeconomic status on the current prevalence of Helicobacter pylori infection. Gut 1994; 35: 742-745. 5. Malaty HM, Kim JG, Kim SD et al. Prevalence of Helicobacter pylori infection in Korean children: inverse relation to socioeconomic status despite a uniformly high prevalence in adults. Am J Epidemiol 1996; 143: 257-262. 6. Malaty HM, Graham DY,WittingtyWA et al. Helicobacter pylori acquisition in childhood: a 12-year followup cohort study in a bi-racial community. Clin Infec Dis 1999; 28: 279-282. 7. Malaty HM, Graham DY, Logan ND et al. Helicobacter pylori infection in preschool and school age minority children attending day care centers: effect of socioeconomic indicators and breast feeding practice. Clin Infec Dis 2001; 32: 1387-1392. 8. Malaty HM, ElKasaban AB, Graham DYet al. Age of acquisition of Helicobacter pylori infection: a follow-up study from infancy to adulthood. Lancet 2002; 359: 931-935. 9. Farinha, P. & Gascoyne, R. D. Helicobacter pylori and MALT Lymphoma. Gastroenterology. 2005;128:1579–1605. 10. Peterson, A. M. & Krogfelt, K. A. Helicobacter pylori: an invading micro-organism? A review. FEMS Immunol. Med. Microbiol. 2003;36:117–126. 11. Czinn, S. J. Helicobacter pylori infection: detection investigation and management. J. Pediatr. 2005;146:S21–S26. 12. Del Corral A, Carmel R. Transfer of cobalamin from the cobalamin- binding protein of egg yolk to R binder of human saliva and gastric juice. Gastroenterology 1990; 98: 1460–6. 13. Rasool S, Abid S, Iqbal MP, Mehboobali N, Haider G. Relationship between vitamin B 12 , folate and homocysteine levels and H . Pylori infection in patients with functional dyspepsia: A cross-section study. BMC Research Notes. 2012; 5:206.


14. Stubbe, J. Binding site revealed of nature‟s most beautiful cofactor. Science. 1994;266:1663–1664. 15. Rickes, E. L., Brink, N. G., Koniuszy, F. R., Wood, T. R. & Folkers, K. Crystalline vitamin B12. Science.1948;107:396–397. 16. Rickes, E. L., Brink, N. G., Koniuszy, F. R., Wood, T. R. & Folkers, K. Vitamin B12, a cobalt complex. Science. 1948;108: 134. 17. Smith, E. L. Purification of anti-pernicious anaemia factors from liver. Nature. 1948;161:638. 18. Kamper, M. J. & Hodgkin, D. C. Some observations on the crystal structure of a chlorine-substituted vitamin B12. Nature. 1955;176:551–553. 19. Lindstrand, K. Isolation of methylcobalamin from natural source material. Nature. 1964;10:188–189. 20. Hodgkin, D. C. et al. Structure of vitamin B12. Nature. 1956;178:64–66.

21. Martens, J. H., Barg, H., Warren, M. J. & Jahn, D. Microbial production of vitamin B12. Appl. Microbiol. Biotechnol.2002;58:275–285. 22. Carmel R: Cobalamin, the stomach and aging. Am J Clin Nutr 1997;66:750–759. 23. Nexo E, Hansen M, Rasmussen K, Lindgren A, Grasbeck R: How to diagnose cobalamin deficiency. Scand J Clin Lab Invest Suppl 1994; 219:61–76. 24. Shuval-Sudai O, Granot E: An association between Helicobacter pylori infection and serum vitamin B12 levels in healthy adults. J Clin Gastroenterol 2003;36:130–133. 25. Appelmelk BJ, Simoons-Smit I, Negrini R, et al. Potential role of molecular mimicry between Helicobacter pylori lipopolysaccharide and host Lewis blood group antigens in autoimmunity.Infect Immun 1996;64:2031–40.


ORIGINAL ARTICLE

Study of Pulmonary Functions in Smokers and Non-Smokers in Sugarcane

harvesters in Rural Maharashtra

Rubeena Banoa, Nadeem Ahmad

b, AM Mahagaonkar

c

a-Associate Professor,Dept. of Physiology,

Integral Institute of medical Sciences & research, IIMSR, Integral University, Lucknow

b-Professor,Dept. of Community Medicine


c-Professor.,Dept. of Physiology

Pravara Institute of medical Sciences PIMS, Pravara University, Loni, Maharashtra

Corresponding Author:

Dr. Rubeena Bano

Associate Prof.,Dept. of Physiology


Abstract

Background: In India smoking is a common habit prevalent in both urban and rural areas. Cigarette and bidi smoking has extensive effects on respiratory function and is clearly implicated in the etiology of a number of respiratory diseases. Objectives: 1. To study and compare the pulmonary function tests among smokers and non-smokers in a rural area. 2. To study the role of possible associated factors and relation of type, quantity and duration of smoking on the pulmonary function tests. Setting: Pravara Rural Hospital, Loni, District Ahmednagar, Maharashtra. Study design: Cross sectional study. Materials &Methods: The pulmonary function tests were assessed on computerized spirometer in 400 male sugarcane harvesters comprising of 200 smokers and 200 non smokers and results were compared. Statistical analysis: SPSS Statistical Software. Results & Conclusion: Almost all the pulmonary function parameters were significantly reduced in smokers and obstructive pulmonary impairment was commonest. Thus by spirometry a spectrum of lung disorders may be detected at an early stage and subsequent morbidity can be minimized. Key words: Smoker, Spirometry, Pulmonary functions, rural area

Introduction

Cigarettes kill an estimated 5 million people annually world wide

1. The World Health

Organization reported that tobacco smoking killed 100 million people worldwide in the 20th century and warned that it could kill one billion people around the world in the 21st century

2.

By the early 2030, tobacco related death would increase to about 10 millions a year

3.

Tobacco smoking rates have decreased in industrialized countries since 1975, but there has been a corresponding 50% increase in smoking rates in low- income countries

4.

In India smoking is a common habit prevalent in both urban and rural areas irrespective of mode of smoking i.e. cigarettes, bidis, pipes, cigar, hookah etc. In India, tobacco is consumed mainly in the form of bidis (54%), followed by smokeless tobacco (27%) and cigarettes (9%)

5.

Bidi smoke may be more injurious because bidi contains unrefined form of tobacco as compared to cigarettes

6,7. Cigarette smoking

has extensive effects on respiratory function and is clearly implicated in the etiology of a number of respiratory diseases, particularly chronic bronchitis, emphysema, and bronchial carcinoma

8.

Materials and Methods:

The present cross sectional study was conducted in Pravara Rural Hospital of Rural Medical College, PIMS, Loni, in district Ahmednagar, Maharashtra from January 2007

http://en.wikipedia.org/wiki/World_Health_Organization




to August 2008. The study population included 400 male sugarcane harvesters comprising of 200 smokers and 200 non smoker controls aged between 30-60 years. Individuals with history of smoking cigarettes / bidis daily for at least one year were considered as smokers

9.

Ex-smokers or past smokers were excluded from the study. For the control group, 100 healthy non smokers of almost same age and matching other characteristics were selected. The materials used in the study were a computerized RMS Med-spirometer, weighing machine, measuring tape and Blood Pressure set. To evaluate dose and duration response relationship, quantification of tobacco smoking was performed by calculating smoking index for smokers.

Smoking Index: It is equal to multiplication of the average number of cigarettes/bidis smoked per day and duration (in years) of tobacco smoking

10, 11.

Habit Smoking Index (Frequency x

duration)

Non-smokers 0

Light smokers 1-100

Moderate smokers 101-200

Heavy smokers More than 200

The observations of the study were analyzed by statistical methods like percentages, chi square test and t-test of significance.

Observations: In the present study it was observed that there was no significant difference in the mean physical parameters like age, height, weight, body mass index and body surface area by calculating mean and standard deviation in smokers and non-smokers (Table 1). Most of the smokers smoked only bidi (62.0%) followed by both cigarette and bidi mixed (24.0%) and only cigarettes (14.0%) (Table 2). Most smokers were light smokers (42.0%) followed by moderate smokers (32.0%) and heavy smokers (26.0%) based on the criteria of smoking index (Table3). Majority of the light smokers were in the age group of 41-50 years (51.85%), moderate smokers in 51-60 years (46.66%) and heavy smokers, 51-60 years (75.0%) (Table 4).

All Pulmonary function parameters like FVC, FEV1, FEV1/FVC, PEFR, FEF25-75% and MVV showed statistically highly significant association between smokers and non-smokers by applying unpaired t-test of

significance (p < 0.001) (Table 5). The association between smoking and impaired PFT was statistically highly significant. The smokers had 17.3 times more risk of having impaired pulmonary functions as compared to non-smokers (Table 6). The obstructive lung changes were most common and were observed predominantly in bidi smokers (72.22%) (Table 7).

Table 1: Physical Characteristics of Smokers and Non-Smokers.

Variables Smokers Mean ± 2 S.D.

Non-smokers Mean ± 2 S.D.

Age (years) 48.26 ± 10.09 48.10 ± 10.54

Height (m) 1.66 ±0.11 1.67 ± 0.12

Weight (Kg) 65.4 ± 8.8 64.4 ± 11.5

Body Mass Index (BMI)

23.52 ± 3.20 23.80 ± 3.37

Body surface area (m

2)

1.71 ± 0.06 1.74 ± 0.14

S.D. = Standard Deviation Table 2: Type of Tobacco Smoking in Smokers.

Type of smoking

No. %

Only Bidi 124 62.0

Both cigarette/ bidi

48 24.0

Only Cigarette 28 14.0

Total 200 100.0

Table 3: Distribution of Grade of Smoking in Smokers.

Grade of smoker

Number of

smokers (%)

Light smoker 108 54.0

Moderate smoker

60 30.0

Heavy smoker

32 16.0

Total 200 100.0


Table 4: Age Wise Distribution of Grade of Smoking.

Age group (years)

Light Smoker No. (%)

Moderate smoker No. (%)

Heavy smoker No. (%)

Total No. (%)

31-40 28 (25.92)

8 (13.33)

0 (0.0) 36 (18.0)

41-50 56 (51.85)

24 (40.0)

8 (25.0)

88 (44.0)

51-60 24 (22.22)

28(46.66)

24(75.0)

76 (38.0)

Total 108 (100.0)

60 (100.0)

32 (100.0)

200 (100.0)

Table 5: Pulmonary Function Tests among Smokers and Non-Smokers.

Pulmonary Function Tests (PFTs)

Smokers Mean ± 2 S.D

Non-smokers Mean ± 2 S.D

**

Significance*

p value

FVC 2.98 ± 1.06

3.13 ± 0.98

0.03242 (S)

FEV1 2.48 ± 1.02

2.81 ± 0.86

0.000692 (HS)

FEV1/FVC 83.93 ± 23.98

89.49 ± 10.54

0.003808 (HS)

PEFR 5.30 ± 3.46

6.80 ± 3.44

0.000034 (HS)

FEF25-75% 2.99 ± 2.02

3.59 ± 1.74

0.00196 (HS)

MVV 86.1 ± 44.22

103.6 ± 33.66

0.00002 (HS)

Significance has been calculated by unpaired t test (p < 0.001).

Table 6: Interpretation of PFT results in smokers and non-smokers.

PFT Results

Smokers No. (%)

Non-smokers No. (%)

Total No. (%)

Obstructive 72 (36.0)

8 (4.0) 80 (20.0)

Restrictive 4 (2.0) 0 (0.0) 4 (1.0)

Mixed 8 (4.0) 0 (0.0) 8 (2.0)

Normal 116 (58.0)

192 (96.0)

308 (77.0)

Total 200 (100.0)

200 (100.0)

400 (100.0)

Chi square value = 20.84, p < 0.001, highly significant.(Odds‟ ratio = 17.3)

Table 7: Relation of Type of smoking with Pulmonary Function tests Type of smoking

PFT interpretation

Total Obstructive

Restrictive

Mixed Normal

Only Bidi 52(72.22) 0 (0.0) 8 (100.0)

64(55.17)

124 (62.0)

Both cigarette/ bidi

16(22.22) 4 (100.0) 0 (0.0)

28 (24.13)

48 (24.0)

Only Cigarette

4 (5.55) 0 (0.0) 0 (0.0)

24(20.68)

28 (14.0)

Total 72 (100.0)

4 (100.0) 8 (100.0)

116 (100.0)

200 (100.0)

Discussion:

In the present study it was observed that there was no significant difference in the mean physical parameters like age, height, weight, body mass index and body surface area thereby showing proper matching of smokers and non-smokers (Table 1). None of individuals smoked tobacco in any form other than bidis or cigarettes. Most smokers were bidi smokers (62.0%) (Table 2). Also the cigarette smokers usually smoked non-filter cigarettes since they are cheap and easily available in rural areas. In the present study most smokers were light smokers (Table 3) in the age group of 41-50 years (51.85%). Similarly, Burrows et al

12 reported that there is

quantitative significant relationship between impaired ventilatory function and duration and frequency of smoking (Table 4). All Pulmonary function parameters showed statistically highly significant association between smokers and non-smokers by applying unpaired t-test of significance (p < 0.001). Similar, observations showing lung function impairment in smokers were reported by Burrows et al

12, Pandya et

al13

, and Gupta et al14

.

However, several researchers like Angelo15

and Mahajan et al

16 observed no change in

FVC in smokers and non-smokers (Table 5). The association between smoking and impaired PFT was statistically highly significant. The smokers had 17.3 times more risk of having impaired pulmonary functions as compared to non-smokers (Table 6). The fall in FEV1, PEFR and other flow rates indicate obstructive lung changes and fall in FVC indicates restrictive lung changes. Padmavathy

17 in a study concluded that the

pulmonary function tests are more affected in bidi smokers than in cigarette smokers (Table 7).


Conclusion:

The pulmonary function tests were assessed on a computerized spirometer in 400 male subjects comprising, 200 smokers and 200 non smoker controls. The present study reveals the effect of type, duration and pattern of smoking on the pulmonary functions in smokers. Bidi smoking was most common as the study setting was in rural India. Almost all the pulmonary function parameters were significantly reduced in smokers as compared to non smoker controls and obstructive pulmonary impairment was commonest in smokers. By screening smokers, by computerized pulmonary function testing, the early changes in airflow obstruction may be detected and special emphasis is to be recommended on smoking cessation strategies.

References:

1. Bulletin of the WHO, International Journal of Public Health, June 2006, Vol. 84, No. 6; 495.

2. WHO Report: Tobacco Could Kill One Billion by 2100, Science Daily; Aug 2008; 24: 71.

3. Yach D. Partnering for better lung health: Improving tobacco and tuberculosis control. Int J Tuberc Lung Dis 2000; 4: 693-7.

4. Yu JJ, Shopland DR. Cigarette smoking behavior and consumption characteristics for the Asia- Pacific region. World Smoking Health 1989; 14: 7-9.

5. Anonymous. IUALTD: The world tobacco situation. IUALTD News Bull Tobacco Health 1998; 11: 19-21.

6. World Health Organisation. Health Situation in South East Asia region 1999; 12: 83.

7. Pakhale SS, Jayant K, Bhide SV. Chemical analysis of smoke of Indian

cigarettes, bidis and other indigenous forms of smoking, levels of phenol, hydrogen cyanide and benzopyrene. Indian J Chest Dis Allied Sci 1990; 32: 75-81.

8. WHO; World tobacco epidemic; 1993; 2nd Edition; p-47.

9. World Health Organization. Guidelines for controlling and monitoring the tobacco epidemic. WHO, Geneva, 1998; 76-101.

10. S.K. Gupta; Respiratory disorders among workers in a railway workshop; Ind. J Tub., 1995, 42, 161.

11. Sanjay P. Zodpey and Suresh N. Ughade. Tobacco Smoking and Risk of Age-related Cataract in Men..Regional Health Forum; WHO South-East Asia Region; September 2006; Vol. 3: 336-46.

12. Burrows B, Khudson R.J, Martha Jeline, Lebowitz M.D. Quantitative relationship between cigarette smoking and ventilatory function. Amer. Review. Resp. Dis. 1977; Vol. 115, 195-205.

13. Pandya KD, Dadhani AC, Chandwani S. Effect of age, sex, posture and smoking on peak flow rates; Indian. J. Physiol & Pharmacol 1984; 28: 3, 38.

14. Gupta P, Dhir VS, Sharma K. Cardiorespiratory function in healthy smokers and non-smokers. Ind. Jr. Physio. And Pharm. 1984; Vol. 28:5-30.

15. Angelo MT, Silva D, Paul Hamosh. Effect of smoking cigarettes on small airways. Jour. Appl. Physio. 1973; Vol. 34; 3: 361-365.

16. Mahajan BK, Raghunandan V, Maini BK, Mahajan SK. Effect of cigarette smoking smoking on airways. 1983; 27:1-37.

17. Padmavathy KM. Comparative study of pulmonary function variables in relation to type of smoking. Indian J Physiol Pharmacol; 2008; 52 (2): 193-196.

http://www.sciencedaily.com/releases/2008/02/080210092031.htm




REVIEW

A TEN YEAR REVIEW OF DISEASES IN RURAL KONKAN Dr Suvarna N. Patil Address for correspondence: Medical Director, BKL Walawalkar Rural Medical College, Kasarwadi, Savarde.

Abstract: An analysis of 11,984 cases admitted in an intensive care unit or general ward under general medicine department over a period of 10 years (2003 to 2013) at a rural secondary care Hospital in Ratnagiri was performed. Out of these 7670 (64%) were males and 4314 (36%) were females. 7294 patients got admitted in Intensive CareUnit (60.86%) and 4690 (39.13%) were admitted in wards. Analysis showed that largest group of patients had cardio vascular system related problems 3831 (31.96%), followed by 2559 (21.35%) having central nervous system related problems, Respiratory diseases 1402 (11.69%), infections 993 (8.28%), gastro intestinal 985 (8.21%), diabetes 804 (6.70%), renal disorders 517(4.31%), poisoning 296 (2.46 %), snake bites 288 (2.40%,) and scorpion bites 309 (2.57 %). Cardio vascular disease form a sizable majority of non communicable medical illness .This analysis indicates that the prevalence of coronary artery disease is increasing in rural India and there is an urgent need for development and implementation of accessible and approachable primary and secondary prevention and treatment approach for control of this epidemic. It also indicates that there is a need for development of nephrological services in rural area. Snake and scorpion bites were the diseases prevalent in this area, but mortality was lowest in this group because of goodICU back up. Overall mortality in 11984 patients was 6.14%.Highest mortality was seen in renal disorders that are 8.12%, in spite of having hemodialysis facility.

Introduction: This paper discusses a need for secondary level hospitals in rural India. In rural India there is severe shortage of ICU‟s for effective critical care. Because of lack of knowledge, poverty, illiteracy, low socioeconomic status, patients present very late to the hospitals and delayed presentations reduce the chance of survival. It also increases the economical burden on them. Most of the primary health centers and government hospitals in rural areas lack the facilities which are required to treat critically ill

patients. So in this paper we have studied the disease pattern of the patient admitted to the hospital under general medicine department. We categorize the patients according to the final diagnosis, they were classified system wise. Overall mortality and system wise mortality was noted. This shows that burden of CAD is increasing and it is equal to urban areas. Different class of disease conditions like snake and scorpion bite were identified which were prevalent in this areas.

Aim: To Study the pattern of various medical diseases seen during specialist medical rural practice.

Materials and Methods: We have done retrospective analysis of 11,984 patients from their case paper records between December 2003 to December 2013. According to the severity of the disease condition patients were admitted in either wards or ICUs. Patients were classified into coronary artery disease, respiratory,Central Nervous System CNS, Poisoning, renal disorders,Diabetes Mellitus DM, Infectious disease ,snake bites and scorpion stings . System wise mortality was studied. Patients were provided with the facilities like ICU, multipara monitors, ventilators, Arterial Blood Gas analysers, temporary pace makers, haemodialysis, CT scanner, Ultrasound, 2 D echoes, pathology lab and blood bank.

Results: Data of 11,984 patients were analyzed. Out of these 7670 patients were male (64%) and 4314 (36%) patients were females. System wise classification was done from the final diagnosis written on the case paper. They were classified in following systems. 1) Cardio vascular system (3831 patients), 2) Respiratory system (1402), 3) Gastro intestinal system (985), 4) Renal disorders (517), 5) Diabetes Mellitus (804), 6) Infections (993), 7) Poisoning (296), 8) Central Nervous System (2559), 9) Snake bite (288), 10) Scorpion stings (309).Thus percentage wise the highest morbidity was for CVS (31.96%), followed by


Mortality

7

(2.66%)

8

(2.77%)

17

(5.74%)

26

(3.24%)

42

(8.12%)

43

(4.33%)

169

(6.60%)

44

(4.46%)

79

(5.63%)

302

(7.88%)

0

50

100

150

200

250

300

350

CVS

R/S

GIT

CNS

Inf

Nephr.

DM

Poison

Snak

ebite

Sco

rpionbite

CNS (21.35%), Respiratory system (11.69%), Infections (8.28%), GIT (8.21%), DM (6.70%), Renal disorders (4.31%), Poisoning (2.46%), Scorpion stings (2.57%) and Snake bite (2.40%) in that order. Out of 11,984 patients 737 patients expired thus mortality was 6.14 %. Cardiovascular diseases mortality was found to be 7.88%, Respiratory was 5.63%, CNS (6.6%), GIT (4.46%), Infections (4.33%), Renal diseases (8.12%), DM (3.24%), Poisoning (5.74%), Snake bite is 2.77% and scorpion sting was 2.66% Out of 11984 patients, 7294 i.e.60.86 % patients were admitted in ICU in critical condition and 4690 i.e.39.15% were admitted in wards.

(Graph 1): System wise classification.

(Graph 2): Overall mortality,

(Graph 4): Gender wise classification.

(Graph 5): ICU and Ward wise admission analysis

(Grap (Graph 3): System wise mortality

(Graph 3): System wise mortality

3831

1402985

2559

993517

804296 288 309302

79 44 169 43 42 26 17 8 70

500

1000

1500

2000

2500

3000

3500

4000

4500Patients

4314(34%)

7670(64%)

0

2000

4000

6000

8000

10000

Male Female

4690

(39.13%)

7294

(60.86%)

0

1000

2000

3000

4000

5000

6000

7000

8000

ICU WARD

11984

737(6.14%)

0

2000

4000

6000

8000

10000

12000

14000

Total Pt Mortalities


Graph 6): System wise Contribution to Overall Mortality Out of 737 Deaths

It is evident from the tables that coronary artery disease patients constitute highest percentage. Snake and scorpion sting conditions though constitute smaller group of patients, these are prevalent conditions of this area and one of the reason of mortality in rural population.

Discussion: Most of our countries population lives in rural areas and most of the rural people are devoid of basic necessities of life like food, water and shelter. Health is not priority at all. They are caught in the vicious cycle of poverty and illiteracy and in Kokan they are dependent on money order economy. Most of people in our country suffer from twins scourge of large population with rest numbers living in dire poverty and subhuman living conditions. Most of the population lives below the poverty line which leads to neglecting of health and most of the disease are considered physiological. Other prevalent disadvantages are complexity of living into deep interiors of country side. Where means of transport are not existent, health care centers are far away, modern medical care is a distant dream, and mere survival is boon from the god. Villagers are often confused as to where to seek medical relief even if convinced of its effectiveness due to illiteracy, ignorant of the miracles which modern medicine can perform, suspicious of new experiments to be conducted by strangers and misguided by the indigenous quacks. All these factors leads to limited attention to health and they thus land up in complicated health problems and invariably get admitted in ICUs. In our study 60.86 % patients got admitted in ICU as they were in critical condition. Unfortunately there is a shortage of secondary and tertiary care level hospitals in rural areas, so these patients have no option than to die. Percentage of patients getting admitted in ICU was 60.86% i.e. higher than patients

admitted in wards because diseases are considered physiological and there is delay in diagnosis and seeking medical help due to poor economic status, illiteracy and difficult geographic terrain with no means of transport. Percentage of males getting admitted to the hospital is more than female patients may be because it is a male dominant community which gives importance to males in the families with least priority to females in Konkan region. In our study 31.96% patients had CAD. This shows that prevalence of CAD is significant in rural areas. Indian studies indicate that coronary risk factor and coronary artery prevalence are higher among wealthy communities

1-6

Surrotham & Berry (1) reported that CAD was more prevalent among high income group without giving any explanation. Other workers emphasized that people engaged in physically demanding work such as farming were less likely to develop CAD than people with sedentary occupation

2-3.

Raman Kutty etal.from south Indian suburban village reported that coronary disease prevalence was highest in higher socioeconomic group

6. This indicates that

detailed study is required to understand the risk factors of CAD in rural Indian population. Chronic kidney disease is major health problem for the under developed countries of south east Asia

7

True incidence & prevalence in the region is not known but the estimate suggests that prevalence may be more than that reported in western societies. The looming epidemic of diabetes and hypertension is likely to further

7(0.94%)

8

(1.08%)

17 (2.30%)

26

(3.52%)

42

(5.69%)

43

(5.68%)

169

(22.9%)

44

(5.9%)

79

(10.71%)

302

(40.97%)

0 50

100

150

200 250

300 350

CVS R/S GIT CNS Inf Nephr.

DM Poison

Snakebite

Scorpionbite

Mortality


add to the disease burden. A large population of patients presents late with advanced kidney failure and multiple complications. Management is hampered by lack of health care services in rural area

7.

Facility of dialysis is not available in the rural areas and most of patients die of complications. In our study highest mortality was seen in renal patients i.e. 8.12%. This indicates that there is a urgent need to develop CKD detection and prevention program. Various etiological factors should be found out, so that prevention programs can be targeted appropriately. Snake and scorpion sting are the conditions prevalent in this area and constitute 4.97 % and with the mortality 2.02%. This shows that while treating such conditions one needs to understand the pathophysiology and develop treatment protocols. Our analysis gave a brief idea about the disease pattern in rural hospitals. Study indicates that prevalence of CAD is increasing in rural India and there is urgent need for development and implementation of accessible and approachable primary and secondary prevention and treatment approach for this control of this epidemic.

References: 1) Survotharan S. G., Berry J. N.:Prevalence

of coronary artery disease in urban population in North India. Ciculation 1968; 37: 839-46.

2) Gupta S.P., Malhotra K.G.: Urban rural trends in epidemiology coronary heart disease. J. Ass. Phy India 1975; 23: 885-9.

3) Jajoo U.N, Kalantri S. P., Gupta O.P., Jain A.P., Gupta A. k., The prevalence of coronary artery disease in rural population from central India 1998: 36: 689-93.

4) Sing R.B., Niaz M.A., Ghosh Setav. E. Epidemiological study of coronary Arterial disease & its risk factors in an elderly urban population of North India. J. Am Coll Nutr 1995; 14: 628-34.

5) Chandha S.L., Radhakrishnaan S., Ramchandran K., Kaul U, Gopinath N., Epidemiological study of coronary heart disease in an urban population of Delhi. Ind. J Med Res1990; 92:424-30.

6) Raman Kutty V., Balakrishnan K.G., Jayashree A.K., Thomas J. Prevalance of coronary heart disease in rural population of Thiruvananthapuram District, Kerala, India. Ind. J. Cardiol. 1993; 39:59-70.

7) Jha V., Current status of chronic Kidney disease care in south East Asia. Semin Nephrol : 2009 Sep: 29(5):487-96.


CASE REPORT

Percutaneous Approach For Mandibular Angle Fracture Using Lag Screw. Pavan Kohli

a, Nisheet Agni

b, Asawari Modak

c, Sunil Nadkarni

d, Shrikant Sangle

e

a-Associate Professor, Dept. of Orthopaedics, BKL Walawalkar Rural Medical College b,c- Department of dentistry ,BKL Walawalkar Rural Medical College d- Consultant Orthopaedic Surgeon,BKL Walawalkar Hospital e-Resident doctor , BKL Walawalkar Rural Medical College

Address for Correspondance- Dr Pavan Kohli Associate Professor, Dept. of Orthopaedics BKL Walawalkar Rural Medical College, Savarde Abstract Mandiubular fracture are among the most common injuries to the facial skeleton with 6:2 proportion between mandibular and zygomatic fractures.

1 Facial injuries are clinically highly

significant as the face provides anterior protection for the cranium, statistics shows that the maxillofacial injuries makes upto 48% of all forms of injuries of which road accidents and assaults are the most common causes.

2

The therapeutic goal of Mandibular fracture treatment is the restoration of anatomic form, function, with particular care to reestablishment of occlusion and facial esthetics, with least patient discomfort. This article describes the new intervention and effectiveness of lag screw in the treatment of mandibular angle fracture using extraoral percutaneous approach. Keywords :- Mandibular angle fracture, Percutaneous approach, Lag screw. Introduction :- Fracture of the mandibular angle are plagued with the highest rate of complication of all mandibular fracture. Over the past years various forms of treatment for this fracture were performed. Hippocrates first described direct reapproximation of fractured segments with use of circumdental wires and external bandages, splints, circummanidibular wiring, extraoral pins. Semirigid fixation with transoessous wiring to rigid fixation and more lately back to semirigid fixation with miniplates

3In recent years the treatment of

mandibular fractures has led to the use of operative as well as conservative methods. The traditional way of treating mandibular angle fracture involves either close reduction with MMF or open reduction and internal fixation with or without MMF. The current trend involves use of miniplates with monocortical screw in the treatment of mandibular angle fracture.

Although many studies have shown two miniplates to be more stable than a single miniplate, whether one or two miniplates should be used at the mandibular angle fracture is still debatable.

4,5,6

Extraorally, the approach, to open reduction and internal fixation was through a skin incision in the submandibular region. It has disadvantage of leaving scar and also puts facial nerve at the greater risk, though the advantage was better exposure and direct application of fixation plate.

7

Another approach is, Transbuccal approach, the main advantage is that it result in no external scarring and also allows visualization and confirmation of desired occlusion during placement of bone plate.

8

With all these different modalities of treatment of mandibular angle fracture, the aim of our study is to evaluate the effectiveness of a new technique of minimal approach using Lag screw for stabilization by compression that relies on bony butterssing of the fracture to help stability. Other reason why mandibular body is suited to lag screw fixation is the thickness of the bony cortices which provides extremely secure fixation when screw are properly inserted, providing interframmmentary compression. Review Of Literature 1) Paul G Tiwana et al done an analysis on

102 patients who underwent lag screw fixation of fracture of anterior mandible. Lag screw osteosynthesis of anterior mandibular fracture is a sensitive, facial, predictable and relatively in expensive method for internal fixation of indicated fractures.

2) Ellis E and Ghali GE (1991) reviewed 41patients who had lag screw placed for anterior mandibular fractures and showed that it is provides rigid internal fixation.


3) Ellis E and Ghali GE(1991) treated 30 patients who had lag screw placed for mandibular angle fracture, showed that it is an extremely useful, but technique-sensitive, method of providing rigid internal fixation.

4) Zachariades N, Mezitis M and Papademetriou I (1996) retrospectively evaluated 30 patients, treated with lag screw and concluded that 30% of patients developed complications which were minor, transient or both.

5) Ellis E (1996) showed that treating fractures of mandibular body using lag screw alone or with bony plates, concluded that it is a reliable technique when there is sufficient obliquity of fracture.

6) Kallela I, Ilzuka T, Laine, Lindquist C (1996) studied to evaluate clinical and radiological results after lag screw fixation of mandibular parasymphyseal and angular fractures, concluded that it is practical and effective way of fixing such fractures internally.

Case Report A case of RTA reported to ER of the B.K.L.Walawalkar.Hospital. Radiological and clinically the patient was diagnosed with displaced, unilateral, right side mandible angle fracture and also undisplaced intraarticular left side fracture of calvicle. While the fracture of the clavicle was managed conservatively with strapping and immobilization, the fracture of angle of mandible was managed by novel technique using a cannulated, cancellous lag screw. Complete case history was taken. General examination was done to rule out any other injury present. Local examination was done to look for jaw opening, tenderness at fracture site, teeth in line of fracture and presence of infection. Required investigation as complete blood count, random blood sugar was done. X-rays as PA mandible, lateral oblique both right and left side of mandible, CT mandible. Surgical technique:- Patient was taken to the operation theatre, were he was scrubbed and draped as per routine. After intubation, antibiotic ointment was put in both eyes and sterile gauze pack was placed. The site of insertion was marked with Bonny‟s ink about 1.5-2cms below and parallel to the inferior border of mandible. Surgical site was infiltrated with local anaesthetic solution containing 2% lignocaine with 1:80,000 adrenaline. Application of this technique relies on tension band principle which can be

achieved by the placement of interdental wire and resistance of intercusp relationship of teeth after intermaxillary fixation. In this case, interdental wiring was done using eyelet for intermaxillary fixation to restore primary occlusion. A 1cm long incision was made at previously anticipated location, so as to drill the cortex. Proximal segment of bone was drilled with drill bit and a guiding wire was passed through the hole to access proper insertion path of lag screw. Drilling the cortex is the most important step in this technique. The factors to be considered are that -1)Drill bit should always be intraosseous.2)Point of drill should be equidistant from fracture line so that the threaded part of the screw engages the other fragment and produce static interfragmentary compression and satisfactory fixation of fracture.

1 3)Angulation and depth

must be in such a way that-a)should not disturb the underlying mandibular nerve and facial artery. b) Should not interfere with the bony structures such as mandibular canal, tooth roots. c) Should not breach lingual cortext beyond its limits. d) Should be always at right angle to the line of fracture. For angle fracture an extraoral approach that is submandibular, gliding hole was made just 2mm below the apices of the posterior teeth in relation with first molar and drill was performed, selection of proper point of entry for drill bit in the buccal cortext was placed sufficiently away from fracture line so that ample amount of bone is present between the head of screw and the fracture line after drill and counter-sink. A proper care was taken not to disturb the underlying structures as mentioned above. Through the hole a guiding „k‟ wire was inserted to guide the path of insertion of lag screw. The path of insertion is predicted by securing the terminal screw threads in bone that is dense enough to provide rigid fixation. The proper angulations and path of insertion of lag screw is determined by using „k‟ wire and taking X-rays during procedure. Drilling through the second fragment was the next step, with the drill bit seated in near fragment to obtain same angulations as in first. A „k‟ wire was inserted through drilled hole and screw length was determined. The hole in the far segment was tapped using long tap. After selecting the appropriate length of screw, it was inserted on a screw driver into the screw hole. The outer hole was free of threads so that screw slips through until it contacts the threads in far segment. Thus when tightened the screw would compress the two segments of bone together.


Once the adequate fixation was achieved the skin was closed with a single suture. The MMF was released and patient was maintained on soft diet. The following X-ray was taken prior to the surgery to determine the site of fracture.

Following are the photographs that were taken during operative procedure. Fig (1) shows the extra oral percutaneous approach used for the insertion of lag screw.

Fig(2) shows the insertion of guiding wire that would determine the path of insertion of lag screw.

Radiographic view of path of insertion of lag screw using „k‟ wire as guiding wire.Fig (3)

X-Rays showing the proper placement of lag screw after surgery Fig. (4)

Discussion:- Management of mandibular angle fracture is often challenging and results in the highest complication rate among fracture of the mandible. Optimal treatment for angle fracture remains controversial.

6 historically, treatment

of mandible fracture includes intraoperative maxillomandibular fixation (MMF) along with rigid internal fixation. More recently, non compression manipulates which produces only relative stability, have gained popularity. The absolute necessity of intraoperative MMF as an adjunct to internal fixation has also became controversial.

911. The use of single non

compression miniplate for treatment for mandibular angle fracture had a high complication rate.

9, 11

When mandibular angle fracture, treated with two miniplates complication rates was 2.1% as


compared to treated with one miniplate with 26.3% complication rate.

12

When two mini dynamic compression plates were placed through transoral incision without MMF, complication rate found was 29% and results are unpredictable.

14. Any tooth in

fracture line was removed if it was infected, fractured or was interferring with reduction.

16,17

The complication rates were within acceptable limits even when treated after 24 hours of injury, proving no correlation between time, or injury and treatment given.

18

The present study describes a new intervention and management of mandible angle fracture using lag screw. The approach used was percutaneous with minimum or just a small hole type incision for insertion of screw. The various advantages that were achieved by using this technique are :- 1) the most important was the cosmetic approach of no scar formation caused because of incision.2) innovative drilling and tapping lag screw ensures superior compression across the fracture site providing proper stability.3) Low profile head of the lag screw prevents soft tissues irritation and also preserves blood supply.4) Comprehensive system requires minimal instrumentation while reducing the operative time for surgeon.5) Less post-operative complication hence the hospital stay of patient is reduced. Last but not the least the technique is financially affordable.

References

1) Sanjay Jadwani and Snehal Bansod.Lag screw fixation of fracture of the anterior mandible.A new minimal access technique. J.Oral.Maxillofac.Surg Jun2011;10(2):176-180 2) Bochylogyros NP. A retrospective study of 1521 mandibular fracture. J.Oral Maxillofac Surg 1985;43:597-599 3) Fonseca Raymond J and Robert V Walter.Oral and Maxillofac Trauma, Pennsylvania, W.B.Saunders Company,1997;2

nd edition vol-1:474-478

4) Kroon HM et al. The use of miniplates in mandibular fracture. An in vitro study.J.Cranio Maxillofac Surg 1991;91:199-204 5) Choi BH, Kim KN, Yoo JH and Kang HS. Stability test of two miniplates fixation technique for mandibular angle fractures. As in

vitro study. Journal of cranio Maxillofac Surg 1995;23:122-125 6) Gear AJ, Apasova E, Schmitz JP, Suhubert W. J. Oral Maxillofac Surg 2005 may 63(5):0555-63 7) Vincent S.Toma et al. Transoral versus extraoral reduction of mandible fractures : A comparison of complication ratesand other factors. Otolaryngology.Head and Neck surgey 2003;18:215-219 8) Eric J.Dierks: Transoral approach to fracture of the mandible. Laryngoscope 1987;97:4-6 9) Ellis Edward III. Treatment methods for fractures of the mandibular angle. Int.J.Oral Maxillofac Surg 1999;28:243-252 10) Niederdellmann.H, Akuamoaboateng E, Uhling G. Lag screw osteosynthesis: Anew procedure for treating fracture of mandibular angle. J.Oral Maxillofac Surg 1981;9:938-940 11 )ElliS E, Walker LR: Treatment of mandibular angle fracture using one non compression miniplate .J.Oral Maxillofac Surg 54:864,1996 12) Levy FE et al. Monocortical miniplate fixation of mandibular angle fracture. Arch Orolaryngol Head Neck Surg 1991;117:149-154 13) Ellis Edward III and GE Ghali et al. Lag screw fixation of mandibular angle fracture. J.Oral Maxillofac Surg 1991;49:234-243 14) Ellis Edward III and M Karas et al. Treatment of mandibular angle fracture using two mini dynamic compression plates. J Oral Maxillofac Surg 1992;50:958-963 15) Ellis Edward III et al. Treatment of mandibular angle fracture using AO reconstruction plate. J Oral Maxillofac Surg 1993;51:250-254 16) Nakamura S, Yashuharu T, Masuichiro O. Complication of miniplates osteosynthesis for mandibular fracture. J Oral Maxillofac Surg 1994;32:233-239 17) Stefan Berg, Hans Dieter Pape.Teeth in fracture line. Int J Oral Maxillaofac Surg 1992;21:145-146 18)Pradeep Pattar, Sujith Shetty, Saikrishna Degala. A prospective study on management of mandibular angle fracture.J Oral Maxillofac Surg 2013


CASE REPORT Multidisciplinary Management of Sebaceous Gland Carcinoma of Upper Eyelid with Regional Lymph Node Metastasis

Unmesh Takalkar, Shilpa Asegaonkar,Suresh Advani, Pushpa Kodlikeri,Ujwala Kulkarni Corresponding Author-

Dr. Takalkar Unmesh Vidyadhar M.S.FAIS F.U.I.C.C. Fellow Johns Hopkins Chief Consultant Cancer, general and endoscopic surgeon United CIIGMA Hospital Aurangabad, Maharashtra

Email: [email protected]

Abstract: Sebaceous gland carcinoma (SGC) of ocular adnexa is a highly malignant, multifocal in origin seen in elderly. SGCs are known to have highly virulent course of progression with more tendency to metastasize locally and systemically resulting in poor outcome. We managed a case of SGC in 55 years old with multimodality treatment consisting of surgical excision, chemotherapy for tumor bulk reduction and radiotherapy. This offered her long disease free survival. Aggressive behavior of SGC for early metastasis is associated with high mortality. Hence high index of suspicion for diagnosing SGC in ophthalmic practice is the key for better survival of the patient. Key words: sebaceous gland carcinoma, eyelid, chemotherapy, radiotherapy, metastasis. Introduction: Sebaceous gland carcinoma (SGC) of ocular adnexa is a highly malignant but relatively rare condition. It is multifocal in origin seen in elder population with female predisposition with reported incidence less than 1% of all skin malignancies.

[1] It accounts for 1-5.5% of all

eyelid malignancies with more predilections for upper eyelid.

[2] Predisposing factors reported

are advanced age, female gender, Asian race, prior irradiation to head and neck, genetic predisposition to Muir-Torre syndrome or familial retinoblastoma.

[1]

SGC may originate from the meibomian glands in the tarsus, zeis glands at the eyelid margin or sebaceous glands at caruncle or eyebrows.

[3] SGCs are known to have highly

virulent course of progression with more tendency to metastasize locally and systemically resulting in poor outcome. Usually the condition is diagnosed in late stage because it mimics various benign ocular conditions like chalazion, chronic blepharoconjuctivitis, papilloma,

keratocanthoma, dermoid cyst and benign or sessile keratosis.

[4]

Herein, we describe clinical course and management of a patient with SGC of upper eyelid with metastasis and recurrence. Case Report: A 60 year old hypertensive woman was referred to our centre for nonhealing ulcer on right eyelid and swelling on right cheek. She gave history of excision of nodular lesion on right eyelid 6 month back at her local place. Otherwise, her personal and family history was unremarkable. But 3 months after excision of nodule, she had ulcerative lesion at the site of excision and swelling over parotid area on right side. On examination, ulcer was of 0.7 x 0.8 cm in dimension with everted edges, firm and bleeding on touching. Lymph node was palpable over parotid region. First fine needle aspiration cytology of lymph node was performed which revealed secondary deposits of poorly differentiated adenocarcinoma. So patient underwent right upper eyelid excision with lower eyelid flap reconstruction and right sided total parotidectomy. Histologically case was diagnosed as poorly differentiated sebaceous adenocarcinoma of right upper eyelid. After healing of the wounds, 6 cycles of systemic chemotherapy (Taxol, cisplatin and 5 Fluorouracil) were administered followed by radiotherapy. Patient tolerated these therapies without any adverse events. She was on regular follow up initially every three months for 1 year, then semiannually. But after six years of disease free survival state, our patient again presented with regional submandibular and preauricular lymph node metastasis on the same side. PET scan revealed secondaries in regional lymph nodes. Again she received radiotherapy followed by chemotherapy (Carboplatin, Docitaxel and Gefitinib).

mailto:[email protected]


Discussion: Present case is reported to describe clinical profile and management of a patient presented with malignant eyelid tumor. Many times SGC is mistaken as chalazion, the most common ophthalmic condition in practice. Same might have occurred in our case when she underwent excision of nodule for the first time and her diagnosis was delayed. But with multimodality approach, she had disease free survival of six years. It has been reported that about 18.6% cases of SGC have been diagnosed by general physician and 50% by ophthalmologists in practice.

[5]

Present case report emphasizes thorough diagnostic work up for painless growth on eyelid with suspicion of SGC. Continuous surveillance is necessary for early detection of the secondary and recurrence of the lesion throughout the management. SGC has high tendency to metastasize locally and systemically. Husain A et al studied retrospectively clinical records of 4 patients with metastatic eyelid SGC and observed that metastasis can occur late as 5 years after treatment. In our case we discovered metastasis 6 years after completion of the treatment.

[6] Our patient has time length of 84

months from initial lesion to metastasis. Murthy R and colleagues reported role of neoadjuvant chemotherapy with radiotherapy with eyelid sparing orbital exenteration.

[7]

Several case reports suggested multimodality management of SGC to prevent metastasis. [8,9]

Shields JA et al described their experience of 60 cases with SGC of eyelid and concluded that only 32% cases diagnosed during initial evaluation and 50% on histopathological examination. With the aid of modern therapeutic approach, procedure of exenteration can be avoided.

[10]

Conclusion: Aggressive behavior of SGC for early metastasis is associated with high mortality. Hence high index of suspicion for diagnosing SGC in ophthalmic practice is the key for better survival of the patient. References:

1. Shurti Singh, Swarn Kaur, , Alok Mohan, Sunder Goyal. Sebaceous carcinoma of right upper eyelid: case

report and literature review. International Journal of Cancer Therapy and Oncology.2013;1(3):1-3.

2. Gardetto A, Rainer C, Ensinger C, Baldissera I, Piza-Katzer H. Sebaceous carcinoma of the eyelid: A rarity worth considering. Br J Ophthalmol.2002;86:243–4. [PMCID: PMC1770994] [PubMed: 11815355]

3. Meenu Gill, Shilpa Garg, Rajnish Kalra, Rajeev Sen. Sebaceous carcinoma of the eyelid diagnosed on fine needle aspiration cytology. J Cytol.2012;29(1):75–76.

4. Upender K. Wali and Abdullah Al - Mujaini Sebaceous gland carcinoma of the eyelid Oman J Ophthalmol.2010;3(3):117–121.

5. Frank S. Hwang, Aneesh Neekhra,Mark J. Lucarelli, Thomas F. Warner, Stephen N. Snow, and Daniel M. Albert. Ophthal Plast Reconstr Surg.2010;26(3):208–210.

6. Husain A, Blumenschein G, Esmaeli B.Treatment and outcomes for metastatic sebaceous cell carcinoma of the eyelid.Int J Dermatol.2008;47(3):276-9. doi: 10.1111/j.1365-4632.2008.03496.x.

7. Murthy R, Honavar SG, Burman S, Vemuganti GK, Naik MN, Reddy VA. Neoadjuvant chemotherapy in the management of sebaceous gland carcinoma of the eyelid with regional lymph node metastasis.Ophthal Plast Reconstr Surg.2005;21(4):307-9.

8. Priyadarshini O, Biswas G, Biswas S, Padhi R, Rath S. Neoadjuvant chemotherapy in recurrent sebaceous carcinoma of eyelid with orbital invasion and regional lymphadenopathy.Ophthal Plast Reconstr Surg.2010;26(5):366-8. doi: 10.1097/IOP.0b013e3181c32515.,

9. Rizvi SAR, Maheshwari V. Advanced Upper Eyelid Sebaceous Gland Carcinoma with Deep Orbital Extension. JSCR. 2010;1:5

10. Shields JA, Demirci H, Marr BP, Eagle RC, Jr, Shields CL. Sebaceous carcinoma of the eyelids: Personal experience with 60 cases.Ophthalmology.2004;111:2151–7. [PubMed: 15582067]

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hypothesis); (study question, study design, data collection, analysis and interpretation); Interpretation and implications in the context of the totality of evidence (is there not, could one be reasonably done here and now?, what this study adds to the available evidence, effects on patient care and health policy, possible this study; and Future research directions (for this particular research collaboration, underlying mechanisms, clinical research). Do not repeat in detail data or other material given in the Introduction or the Results section. In particular, contributors should avoid making statements unless their manuscript includes economic data and analyses. Avoid claiming priority and alluding to work that has not been completed. New hypotheses they should be clearly labeled as such. About 30 references can be included. These articles generally should not have more than six authors. Review Articles: It is expected that these articles would be written by individuals who have done substantial work on the subject or are considered experts in the field. the contributor(s) in the field of review should accompany the manuscript. The prescribed word count is up to 3000 words excluding tables, references and abstract. The manuscript may have about 90 references. The manuscript Abstract (250 words) representing an accurate summary of the article. The section titles would depend upon the topic reviewed. Authors submitting review describing the methods used for locating, selecting, extracting, and synthesizing data. These methods should also be summarized in the abstract. The journal expects the contributors to give post-publication updates on the subject of review. The update should be brief, covering the advances in the article and should be sent as a letter to editor, as and when major development occurs in the field. Case reports: New, interesting and rare cases can be reported. They should be unique, describing a great diagnostic or therapeutic challenge and providing a learning clinical significance or implications will be given priority. These communications could be of up to 1000 words (excluding Abstract and references) and Abstract (unstructured), Key-words, Introduction, Case report, Discussion, Reference, Tables and Legends in that order.

The manuscript could be of up to 1000 words (excluding references and abstract) and could be supported with up to 10 references. Case Reports could Letter to the Editor: These should be short and decisive observations. They should preferably be related to articles previously published in the Journal or views expressed preliminary observations that need a later paper for validation. The letter could have up to 500 words and 5 references. It could be generally authored Other: Editorial, Guest Editorial, Commentary and Opinion are solicited by the editorial board. References References should be numbered consecutively in the order in which they are first mentioned in the text (not in alphabetic order). Identify references in numerals in superscript with square bracket after the punctuation marks. References cited only in tables or figure legends should be numbered in accordance by the first identification in the text of the particular table or figure. Use the style of the examples below, which are based on the formats used by the NLM journals should be abbreviated according to the style used in Index Medicus. Use complete name of the journal for non-indexed journals. Avoid using from manuscripts submitted but not accepted should be cited in the text as "unpublished observations" with written permission from the source. The commonly cited types of references are shown here, for other types of references such as newspaper items please refer to ICMJE Guidelines (http://http://www.nlm.nih.gov/bsd/uniform_requirements.html). Articles in Journals 1. Standard journal article (for up to six authors): Parija S C, Ravinder PT, Shariff M. Detection of hydatid antigen in the fluid samples from hydatid R.Soc. Trop. Med. Hyg.1996; 90:255–256. 2. Standard journal article (for more than six authors): List the first six contributors followed by et al. Roddy P, Goiri J, Flevaud L, Palma PP, Morote S, Lima N. et al., Field Evaluation of a Rapid Immunochromatographic Assay for Detection of Trypanosoma Blood. J. Clin. Microbiol.2008; 46: 2022-2027. 1. Volume with supplement: Otranto D, Capelli G, Genchi C: Changing distribution patterns of canine vector borne diseases in Italy: leishmaniosis 2009; Suppl 1:S2.


Books and Other Monographs 1. Personal author(s): Parija SC. Textbook of Medical Parasitology. 3rd ed. All India Publishers and Distributors. 2008. 2. Editor(s), compiler(s) as author: Garcia LS, Filarial Nematodes In: Garcia LS (editor) Diagnostic Medical Parasitology ASM press Washington 3. Chapter in a book: Nesheim M C. Ascariasis and human nutrition. In Ascariasis and its prevention and control, D. W. T. Crompton, M. C. Nesbemi, Taylor and Francis,London, U.K.1989, pp. 87–100. Electronic Sources as reference Journal article on the Internet: Parija SC, Khairnar K. Detection of excretory Entamoeba histolytica DNA in the urine, and detection of E. histolytica DNA abscess pus for the diagnosis of amoebic liver abscess .BMC Microbiology 2007, 7:41.doi:10.1186/1471-2180-7-41. http://www.biomedcentral.com/1471-Tables • Tables should be self-explanatory and should not duplicate textual material. • Tables with more than 10 columns and 25 rows are not acceptable. • Number tables, in Arabic numerals, consecutively in the order of their first citation in the text and supply a brief title for each. • Place explanatory matter in footnotes, not in the heading. • Explain in footnotes all non-standard abbreviations that are used in each table. • Obtain permission for all fully borrowed, adapted, and modified tables and provide a credit line in the footnote. • For footnotes use the following symbols, in this sequence: *, †, ‡, §, ||,¶ , **, ††, ‡‡ • Tables with their legends should be provided at the end of the text after the references. The tables along with their number should be cited at the Illustrations (Figures) • Upload the images in JPEG format. The file size should be within 1024 kb in size while uploading. • Figures should be numbered consecutively according to the order in which they have been first cited in the text. • Labels, numbers, and symbols should be clear and of uniform size. The lettering for figures should be large enough to be legible after reduction • Symbols, arrows, or letters used in photomicrographs should contrast with the background and should be marked neatly with transfer type or by • Titles and detailed explanations belong in the legends for illustrations not on the illustrations themselves. • When graphs, scatter-grams or histograms are submitted the numerical data on which they are based should also be supplied.

• The photographs and figures should be trimmed to remove all the unwanted areas. • If photographs of individuals are used, their pictures must be accompanied by written permission to use the photograph. • If a figure has been published elsewhere, acknowledge the original source and submit written permission from the copyright holder to reproduce appear in the legend for such figures. • Legends for illustrations: Type or print out legends (maximum 40 words, excluding the credit line) for illustrations using double spacing, with Arabic illustrations. When symbols, arrows, numbers, or letters are used to identify parts of the illustrations, identify and explain each one in the legend. (magnification) and identify the method of staining in photomicrographs. • Final figures for print production: Send sharp, glossy, un-mounted, color photographic prints, with height of 4 inches and width of 6 inches at the manuscript. Print outs of digital photographs are not acceptable. If digital images are the only source of images, ensure that the image has minimum 1600 pixels in TIFF format. Send the images on a CD. Each figure should have a label pasted (avoid use of liquid gum for pasting) on its back running title, top of the figure and the legends of the figure. Do not write the contributor/s' name/s. Do not write on the back of figures, scratch, • The Journal reserves the right to crop, rotate, reduce, or enlarge the photographs to an acceptable size. Protection of Patients' Rights to Privacy Identifying information should not be published in written descriptions, photographs, sonograms, CT scans, etc., and pedigrees unless the information the patient (or parent or guardian, wherever applicable) gives written informed consent for publication. Authors should remove patients' names from figures written informed consent from the patients. When informed consent has been obtained, it should be indicated in the article and copy of the consent should letter. Sending a revised manuscript The revised version of the manuscript should be submitted online in a manner similar to that used for submission of the manuscript for the first time. When submitting a revised manuscript, contributors are requested to include, to point clarification at the beginning in the revised file itself. In addition, they are expected to mark the changes as underlined or colored text in the article.


Copyrights The entire contents of the Walawalkar‟s International Medical Journal are protected under Indian and international copyrights. The Journal, however, grants worldwide, perpetual right of access to, and a license to copy, use, distribute, perform and display the work publicly and to make and distribute derivative reasonable non-commercial purpose, subject to proper attribution of authorship and ownership of the rights. Checklist Covering letter • Signed by all contributors • Previous publication / presentations mentioned • Source of funding mentioned • Conflicts of interest disclosed Authors • Last name and given name provided along with Middle name initials (where applicable) • Author for correspondence, with e-mail address provided • Number of contributors restricted as per the instructions • Identity not revealed in paper except title page (e.g. name of the institute in Methods, citing previous study as 'our study', names on figure labels, etc.) Presentation and format • Double spacing • Margins 2.5 cm from all four sides • Page numbers included at bottom • Title page contains all the desired information • Running title provided (not more than 50 characters) • Abstract page contains the full title of the manuscript • Abstract provided (structured abstract of 250 words for original articles, unstructured abstracts of about 150 words for all other manuscripts excluding • Key words provided (three or more) • Introduction of 75-100 words • Headings in title case (not ALL CAPITALS) • The references cited in the text should be after punctuation marks, in superscript with square bracket. • References according to the journal's instructions, punctuation marks checked • Send the article file without „Track Changes‟ Language and grammar • Uniformly American English • Write the full term for each abbreviation at its first use in the title, abstract, keywords and

text separately unless it is a standard unit of measure. • Numerals at the beginning of the sentence spelt out • Check the manuscript for spelling, grammar and punctuation errors • If a brand name is cited, supply the manufacturer's name and address (city and state/country). • Species names should be in italics Tables and figures • No repetition of data in tables and graphs and in text • Actual numbers from which graphs drawn, provided • Figures necessary and of good quality (colour) • Table and figure numbers in Arabic letters (not Roman) • Labels pasted on back of the photographs (no names written) • Figure legends provided (not more than 40 words) • Patients' privacy maintained (if not permission taken) • Credit note for borrowed figures/tables provided • Write the full term for each abbreviation used in the table as a footnote Contributors' form (to be modified as applicable and one signed copy attached with the manuscript) Manuscript Title: __________________________________________________________________________ I/we certify that I/we have participated sufficiently in contributing to the intellectual content, concept and design of this work or the analysis and interpretation as well as writing of the manuscript, to take public responsibility for it and have agreed to have my/our name listed as a contributor. I/we believe that the manuscript represents valid work. Neither this manuscript nor one with substantially similar content under my/our authorship has been submitted for publication elsewhere, except as described in the covering letter. I/we certify that all the data collected during the study is presented in this manuscript or will be published separately. I/we attest that, if requested by the editors, I/we will provide the data/information or will cooperate fully in obtaining on which the manuscript is based, for examination by the editors or their assignees. Financial interests, direct or indirect, that exist or may be perceived in connection with the content of this


paper have been disclosed in the cover letter. Sources of outside support of the project are named in the covering. I/We hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership, including any and all rights incidental thereto, exclusively to the Medical College, in the event that such work is published by the Walawalkar‟s International Medical Journal. 1. Copyright; 2. The right to grant permission to republish the article in whole or in part, with or without fee; 3. The right to produce preprints or reprints and translate intouages other than English for sale or free distribution; and 4. The right to republish the work in a collection of articles in any other mechanical or electronic format. We give the rights to the corresponding author to make necessary changes as per the request of the journal, do the rest of the correspondence on our guarantor for the manuscript on our behalf. All persons who have made substantial contributions to the work reported in the manuscript, but who are not contributors, are named in the Acknowledgment written permission to be named. If I/we do not include an Acknowledgment that means I/we have not received substantial contributions from non-contributors omitted. Name Signature Date signed 1 --------------- --------------- --------------- 2 --------------- --------------- --------------- 3 --------------- --------------- --------------- 4 --------------- --------------- --------------- (up to 4 contributors for case report/ images/ review)

5 --------------- --------------- --------------- 6 --------------- --------------- --------------- (up to 6 contributors for original studies)

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WaLaWaLKar’s - WIMJOURNALwimjournal.com/html/journal/medicalj.pdfWalawalkar’s International Medical Journal 2014 Vol:1, Issue:1 4 WaLaWaLKar’s INterNatIONaL MedIcaL JOurNaL General