Journal

Volume 13 Number 4 October-December 2022
Website:
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Indian Journal of Public Health Research & Development
EXECUTIVE EDITOR
Vidya Surwade
Associate Professor, Dr Baba Saheb Ambedkar, Medical College & Hospital, Rohinee, Delhi
INTERNATIONAL EDITORIAL ADVISORY BOARD NATIONAL EDITORIAL ADVISORY BOARD

1. Dr. Abdul Rashid Khan B. Md Jagar Din, (Associate Professor) 1. Prof. Sushanta Kumar Mishra (Community Medicine)
Department of Public Health Medicine, Penang Medical College, Penang, Malaysia GSL Medical College – Rajahmundry, Karnataka
2. Dr. V Kumar (Consulting Physician) 2. Prof. D.K. Srivastava (Medical Biochemistry)
Mount View Hospital, Las Vegas, USA Jamia Hamdard Medical College, New Delhi
3. Basheer A. Al-Sum, 3. Prof. M Sriharibabu (General Medicine) GSL Medical College, Rajahmundry,
Botany and Microbiology Deptt, College of Science, King Saud University, Andhra Pradesh
Riyadh, Saudi Arabia
4. Prof. Pankaj Datta (Principal & Prosthodentist)
4. Dr. Ch Vijay Kumar (Associate Professor) Indraprastha Dental College, Ghaziabad
Public Health and Community Medicine, University of Buraimi, Oman
5. Prof. Samarendra Mahapatro (Pediatrician)
5. Dr. VMC Ramaswamy (Senior Lecturer) Hi-Tech Medical College, Bhubaneswar, Orissa
Department of Pathology, International Medical University, Bukit Jalil, Kuala Lumpur
6. Dr. Abhiruchi Galhotra (Additional Professor) Community and Family
6. Kartavya J. Vyas (Clinical Researcher) Medicine, AII India Institute of Medical Sciences, Raipur
Department of Deployment Health Research,
7. Prof. Deepti Pruthvi (Pathologist) SS Institute of Medical Sciences &
Naval Health Research Center, San Diego, CA (USA)
Research Center, Davangere, Karnataka
7. Prof. PK Pokharel (Community Medicine)
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BP Koirala Institute of Health Sciences, Nepal
Maulana Azad Medical College, New Delhi
NATIONAL SCIENTIFIC COMMITTEE 9. Prof. Pradeep Khanna (Community Medicine)
Post Graduate Institute of Medical Sciences, Rohtak, Haryana
1. Dr. Anju D Ade (Professor)
10. Dr. Sunil Mehra (Paediatrician & Executive Director)
Community Medicine Department, SVIMS, Sri Padamavati Medical College,Tirupati,
MAMTA Health Institute of Mother & Child, New Delhi
Andhra Pradesh.
2. Dr. E. Venkata Rao (Associate Professor) Community Medicine, 11. Dr Shailendra Handu, Associate Professor, Phrma, DM (Pharma, PGI
Institute of Medical Sciences & SUM Hospital, Bhubaneswar, Orissa. Chandigarh)
3. Dr. Amit K. Singh (Associate Professor) Community Medicine, 12. Dr. A.C. Dhariwal: Directorate of National Vector Borne Disease
VCSG Govt. Medical College, Srinagar – Garhwal, Uttarakhand Control Programme, Dte. DGHS, Ministry of Health Services, Govt. of
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Belgaum Institute of Medical Sciences, Belgaum, Karnataka
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Contents www.ijphrd.com
Contents
Volume
Volume 13,13, Number
Issue 4 2 Contents April-June 2022
October-December 2022
Volume 13, Number 2 April-June 2022
1. Healthcare Service Provision Seen through Villager’s Lenses ..................................................................1

1. Alka Parikh
Healthcare Service Provision Seen through Villager’s Lenses ..................................................................1
1.2. Alka Parikh
Impact of Covid-19
Association Pandemic
of Dietary on Mental
Behaviour withHealth of Health
Demographic Care
and Workers from Factors
Socio-economic a and Physical
Tertiary Care Teaching Hospital of Northern India: A Cross-Sectional Study.............................................
Activity among Rural Adolescents: A Cross-Sectional Study.................................................................131
2. Association of Dietary
Adarshjot Kaur Behaviour
Toor, Preeti with Demographic
Padda, Jasleen Kaur, Sanjeev and Socio-economic Factors and Physical
Mahajan
Anjaliamong
Activity Kumari, Monika
Rural Jain
Adolescents: A Cross-Sectional Study.................................................................13
2. The association between works related musculoskeletal body discomfort and ergonomic
3. Anjali Kumari,
riskAssociation
level Monika
among LipidJain
offemale Profile Ratios
sewing to Diabetes
machine operatorsMellitus and Hypertension in an Indian Population .....23
in Sri Lanka................................................................... 8
ADP Perera,
Atanu Pal,HTN Fernando,
Arabinda AMCR Attanayake,
3. Association of Lipid ProfiDas
le Ratios to Diabetes Mellitus and Hypertension in an Indian Population .....23
DDI Samanwattage, HWUS Jayasinghe
4. Atanu Pal, Arabinda
Prevalence Das
of Subclinical Hypothyroidism in Metabolic Syndrome and Correlation with Its
3. Concern over career is the primary reason for poor mental
Components .............................................................................................................................................31
4. Prevalence of Subclinical
health among Hypothyroidism in Metabolic Syndrome and Correlation with Its
students.......................................................................................................................................... 14
Mahima
Agnita Rao,
Kundu, Navdeep
Sampurna Malik,
Kundu Sonu Singla, Vikram Kumar
Components .............................................................................................................................................31
4.5. Mahima
Critical Rao, Navdeep
Non Cirrhotic
Analysis Portal
of Case Malik, Sonu
Gastropathy:
Based Singla,
Learning A CaseasVikram
a Report
TeachingKumar
...................................................................................36
Learning MethodDave
Ritu Kaushik, in Medical Education..
Riya, Rajinder ............................................................................................................
Sharma, 22
5. Non
AjayCirrhotic Portal
Khade, Jyoti Gastropathy:
Wahane A Case ReportShivjeet Yadav
...................................................................................36
6. RituStudy
Kaushik, Dave Riya,ofRajinder
of Prevalence Sharma,
Depression amongShivjeet
XIth and Yadav
XIIth Class Students of Medical Stream from
5. Use of Social Networking Site and prevalence of Depression among
UrbanStudents
Medical Schools of Punjab..........................................................................................................................39
6. Study of PrevalenceinofVikarabad,
DepressionTelengana........................................................................................................
among XIth and XIIth Class Students of Medical Stream from 26
Gurshan
Ajit Singh
Mogalgiddi, Gill,
Bukya Avneet
Kalyani Singh, Sandeep Goyal
Urban Schools of Punjab..........................................................................................................................39
6.7. Gurshan Singh
Awareness
AugmentationGill,of
about Avneet
Tobacco Singh,
use
Alderfer’s among
ERG Sandeep Auto-Goyal
Needs Rickshaw Drivers
Conducive in intent to Stay of Rural CHC Doctors in
in Belagavi, North Karnataka. . ..............................................................................................................................
Tamilnadu: Structural Equation Modelling with Smart PLS ...................................................................48 32
7. Augmentation of Yogeshkumar
Amaresh P. Patil, Alderfer’s ERG S Needs Conducive in intent to Stay of Rural CHC Doctors in
J. Shanmugapriya,
Tamilnadu: Seema Mehta,
Structural Equation Tanjul
Modelling Saxena
with Smart PLS ...................................................................48
7. Students’ Perspectives on Simplified Breakout Room Approach during Video
8. J.Proctored
Shanmugapriya,
Prevalence
Online Seema Mehta,
Assessment Tanjul
of Neuroleptospirosis Saxena
in Pediatric
in COVID 19 LockAcute Encephalitis Syndrome Cases: An Experience 39
down..................................................................................
ofKumar
Anil Northern India
Reddy Tertiary Chakraborty,
Y, Montosh Care Centre....................................................................................................57
Vidya Desai Sripad,
8. Prevalence of Neuroleptospirosis in Pediatric Acute Encephalitis Syndrome Cases: An Experience
Sathianarayana,
Kanak Lata, Joy A Ghoshal,Koonwar,
Mukesh Tripathi
of Northern IndiaSciddhartha Chandra Kanta, R. K. Kalyan, Sanjeev K Verma
Tertiary Care Centre....................................................................................................57
8. Kanak
Study Lata,
on theSciddhartha
ConversionKoonwar,
of Laparoscopic Cholecystectomy
9. An Experimental Study to AssessChandra Kanta, R. K.
the Effectiveness Kalyan, on
of Nesting Sanjeev K VermaParameters and
Physiological
Owing to per Operative Complications.............................................................................................................. 44
Posture ofRaja
Annapareddy Preterm Babies
Karan inBagammagari
A Selected Hospital, New Delhi ...............................................................64
9. An Experimental Study toReddy,
Assess Raghuram
the Effectiveness Reddy
of Nesting on Physiological Parameters and
Karamjeet Kaur, A. Malar Selvi, Sherly Thomas
9. Posture of Preterm
A Clinical Study ofBabies
Hollowin Viscus
A Selected Hospital,
Injuries New Delhi
in Abdominal ...............................................................64
Trauma. ............................................................... 48
Karamjeet
BagammagariKaur, A. Malar
Raghuram Selvi,
Reddy, Sherly Thomas
Annapareddy Raja Karan Reddy
10. Eosinophilia Induced Acute Interstitial Nephritis: A Case Report ..........................................................72
Lakshya
10.10. Residual Yadav,
InducedRajinder
Cardiovascular
Eosinophilia Acute Sharma,
Risk Ritu
– A Concept
Interstitial Kaushik, Riya Report
Dave ..........................................................7252
in Evolution.................................................................................
Nephritis: A Case
Biswajit Das, Subhasish Singh
Lakshya Yadav, Rajinder Sharma, Ritu Kaushik, Riya Dave
IJPHRD / Volume 13 Issue 4 / October-December 2022

ii
11. Comparative Assessment of two behavioural risk factors

(Physical Inactivity and Unhealthy Diet) among obese Bengali women
in rural and urban areas of West Bengal, India.................................................................................................. 59
Chaitali Bose, Julekha Sultana, Oly Banerjee, Sidhhartha Singh,
Sandip Mukherjee, Alak Kumar Syamal
12. Assessment of Appropriateness of Doing CT Scan for Investigating Headache

in a Tertiary Care Hospital in Eastern India....................................................................................................... 65
Debabrata Maitra, Sharmistha Chatterjee, Sharmistha Debnath,
Dipta Kanti Mukhopadhyay, Somsubhra Chattopadhyay
13. Management of Tympanic Membrane Perforation with Cartilage Tympanoplasty in

Relation to Temporalis Fascia Graft Technique.................................................................................................. 70
Deepa Kumari , Chandresh Aggarwal , Sachin Agarwal, Sarita Gupta,
Geetanjali Jaiswani
14. Lilliputian Hallucination-An Exceptional Psychiatric Symptom.................................................................... 74

Dipankar Maiti, Nethravathi. V
15. Effect of Vaginal pH on Efficacy of Prostaglandin Gel for Labour Induction............................................... 80

B Sandhya
16. Ophthalmic Manifestations in Blood Dyscrasias - An Observational Study................................................. 85

Bhavna Dhanji Gagal, Atul A. Modesara
17. A Comparative Study of Hernioplasty With Suction Drain and

Without Suction Drain in Inguinal Hernias at Tertiary Care Hospital........................................................... 91
D. Ramesh
18. A Study of Enhanced View Total Extraperitoneal Laparoscopic

Hernioplasty (E-tep) For Inguinal Hernia In Tertiary Care Hospital............................................................. 96
D. Ramesh
19. Burden of Overweight and Obesity Among Secondary and Senior Secondary
Students of New Delhi Municipal Council Schools........................................................................................... 100
Thilagar M, Poornima Tiwari
20. Attitude of Healthcare workers towards Disaster Management

practices in a Hospital of Gujarat......................................................................................................................... 106
Kamlesh K. Patel, Manish Ramavat, Nimesh Bhojak,
Palak J. Vora
21. Study of Complications and Outcomes of Phacoemulsification

Cataract Surgery...................................................................................................................................................... 113
Gudla Vasantha
22. Perspective approach to Nutritional anemia among Medical students

using Health Belief Model: A cross sectional study in Tamil Nadu ............................................................... 117
Hanitha Rajasekar, Elangovan
23. Clinical Profile of Unilateral Disc Edema: A Cross-sectional Study............................................................... 122

Jayeshkumar C. Sadhu, Nishant Solanki
24. A Study of Effectiveness of Videolaryngoscopy and Conventional

Laryngoscopy in Adult Patients for Orotracheal Intubation............................................................................ 126
Madhavi. Mavani, Nayna Solanki, Shilpin Solanki, Hiral Solanki

iii
25. Comparative Analysis to Assess Pregnancy Related Issues

among Women over 35 Years of Age................................................................................................................... 132
Madhusudan H Gadhvi, Bhavesh M Nayak, Manish G Maheshwari
26. Diabetic Retinopathy and Typical Retinitis Pigmentosa.................................................................................. 137

Mandeep Kour
27. A Study on the Spectrum of Thyroid Abnormalities in Liver Disease

and Its Correlation with Liver Function.............................................................................................................. 140
Manju Sharma, Anju Mittal, Sangeeta Jain Sharma, Atul Kumar,
Akshay Sharma, Yatin Kumar
28. Functional Outcome of Rotating Platform Versus Fixed Platform of

Total Knee Arthroplasty - A Comparative Study.............................................................................................. 146
Mohammed Asrar M, Jassim Usman, Abhishek Shetty V,
Anna Sophia Pietsch, Imthiaz Ahammed
29. Socio-Demographic Determinants of Non-Communicable

Diseases in Assam, India........................................................................................................................................ 151
Aakanksha Agarwala, Manab Deka
30. Hemiarthroplasty in Unstable Intertrochanteric Fractures in Elderly:

A Prospective Study............................................................................................................................................... 157
Nahas R, Jassim Usman, Abhishek Shetty V, Imthiaz Ahammed
31. A Study of Clinical Profile of Patients with Traumatic Cataract..................................................................... 161

Nalini Jayanthi. B, Sujatha Asadi
32. Assessment of Various Etiological Factors of Puberty Menorrhagia ............................................................. 165
Nazima Alauddin
33. Healthy Literate Working Dynamic Life Expectancy for India and
Some of its Major States......................................................................................................................................... 170
Nazmina Hussain, Barnali Thakuria
34. Evaluation of Pradhan Mantri Jan Arogya Yojana (PM-JAY) Utilization

in a teaching hospital of Kalaburagi City, Karnataka........................................................................................ 177
Nilofer Naaz, Shantkumar Nigudgi
35. Comparative Analysis of Optical Coherence Tomographic Study of

Macula in Preoperative and Postoperative Diabetic Patients Undergoing
Small Incision Cataract Surgery............................................................................................................................ 182
Nishant Solanki, Jayeshkumar C. Sadhu
36. Correlation of D-Dimer Level with Severity of Pneumonia, Hospital Stay and
Mortality in Case of Covid-19 Infection: A Retrospective Study
an a Tertiary Care Hospital................................................................................................................................... 188
Rajashree Pradhan, Sajeeb Mondal, Somsubhra Chattopadhyay,
Sharmistha Debnath
37. A Study on Adherence of Anti-Glaucoma Medications in Adults –

An Observational Hospital based Study ............................................................................................................ 194
Ranjita Santra, Nabanita Barua, Jayanta Dutta, Pramit Ghosh

iv
38. Scoping Review on Brain Mapping Leadership and Talent Engagement...................................................... 199
Rapeerat Thanyawatpornkul, SupalakKhemthong, Winai Chatthong
39. Study of Diabetic Peripheral Neuropathy in Adults of Telangana................................................................. 205

Reyya Mohan Sundar, Makandar U.K.
40. Study of Evaluation of Maternal Side Effects and Neonatal Outcome after
Treatment with Nifedipine at Tertiary Care Hospital....................................................................................... 210
Ruchita Vajpai, Swati Gagare, Prashant Kharde
41. Fungal Infections of Paranasal Sinuses: Sequelae to 2020 Pandemic.............................................................. 213

S. Pavani, Syeda Touseef Banu, Grace, Jyothi Lakshmi, P. Shashikala Reddy
42. Study of the Future of those Recovered from COVID-19 from

Treatment centers in Guinea from March 2020 to January 2021...................................................................... 217
S. Sow, F.B. Diakité, I. Diallo, C. T. Sidibe, A. B. Diallo,
M. C. Tshikolasoni, M.O. Balde
43. Comparison of Causes of Infective and Non-Infective Epistaxis in

the Kolhan Belt Population of Jharkhand............................................................................................................ 223
Sanjay Kumar, Bhimsen Hansda, Rohit Kumar Jha
44. Falls among Elderly in a Rural Community: Incidence and Determinants .................................................. 228
Sanjay TV, Ramu P, Madhusudan M, Nandhini RC
45. Correlation of Automated cell counters RBC Histogram and

Peripheral smear in Anemias................................................................................................................................ 234
Shabahat Hussain, Mohammad Frayez
46. Impact of COVID-19 Pandemic on Medical Education; Challenges for

Faculty and Medical and Paramedical Students in a Medical
College of South Kashmir...................................................................................................................................... 238
Shaugfta Aara, Mehak Mufti, Shuaeb Bhat, Mehbooba Rasool,
Meenakshi Sharma
47. Periodontics-Prosthodontics - An Interdisciplinary Approach....................................................................... 243

Shilpa Sharma, Sameer Ahmed, Mayur Kaushik, Simran Mishra
48. Effectiveness of Planned Teaching Program on Knowledge Regarding

the Management of Hospital aquired Infections in Children.......................................................................... 250
Shivateerthayya Hiremath, Prasad Patil, Madusudhan K.G., Princely B Olickal
49. Creactive Protein as an early Predictor of acute Pancreatitis:

An Observational Study......................................................................................................................................... 258
Shivendra Dhakhda, Virendrakumar Dhakhada
50. Association of Academic Performance and load with Depression,

Anxiety and Stress among School going Students (9th-12th class) of District Amritsar:
A Cross Sectional Study. ....................................................................................................................................... 262
Simran Kaur, Sanjeev Mahajan, Manohar Lal Sharma, Preeti Padda,
Shyam Sundar Deepti
51. Emotional and Behavioural issues in children during early

Phases of school opening after Covid 19 Pandemic in Eastern India............................................................. 268
Somsubhra Chattopadhyay, Sharmistha Debnath, Rumi Gayen, Subhendu Dattta

v
52. Seroprevalence of Hepatitis C Virus in Blood Donors of

Kathua District (J & K)........................................................................................................................................... 274
Sonia Gupta, Vidhu Mahajan, Meenakshi Gupta
53. Predicting and Identifying Postpartum Blues may be the key to

implementing Preventive Approaches in Perinatal Mental Health:
Findings from a Prospective, follow up Study in India.................................................................................... 277
Sreyoshi Ghosh, Sripathy Bhat
54. Forecasting Multivariate time-series data using LSTM Neural Network

in Mysore district, Karnataka................................................................................................................................ 284
Stavelin Abhinandithe K, Madhu B, Somanathan Balasubramanian,
Sridhar Ramachandran
55. Evaluation of Vitek2 and Colistin broth disk elution test in comparison
with Micro broth dilution for Susceptibility testing of Colistin among
Carbapenem Resistant Enterobacterales. ........................................................................................................... 290
Sujatha S R, Deepashree Rajasekhar, Satyasai. Badveti,
Krishna Karthik Manthravadi
56. Periodontal Ligament: Health, Disease and Regeneration .............................................................................. 296

Surbhi Yadav, Shivi Khattri, Mayur Kaushik, Soumya Sharma
57. Application of Lean Methodology in Radiology Department of

a Multispecialty Hospital....................................................................................................................................... 302
Susmit Jain, Mahima Jha
58. Comparative evaluation of MIC of Vancomycin among methicillin

resistant Staphylococcus aureus (MRSA) isolates in tertiary care hospital.................................................... 308
Swarupa Rani, Tejashree. A, Ranjitha Shankare Gowda,
Krishna Karthik M.V.S , Eeshita Dhar, B. Satya Sai
59. Study of Perinatal Outcome in Oligohydraminos in third Trimester

of Pregnancy in Tertiary Care Hospital............................................................................................................... 313
Swati Gagare, Ruchita Vaijpai, Keerthana Meka
60. Probiotics Efficacy and Safety as add-on Therapy to Metformin in

Type 2 Diabetes Mellitus........................................................................................................................................ 317
Valishetti Manoj Kumar, Zoha Ahmed, Syed Atiq Ur Rahman
61. A Cross- Sectional Study of Prevalence of Substance Use and

Its Associated Factors Among Late Adolescents in Gadag city....................................................................... 322
Vasundara Gayakwad, Rekha Sonavane, Bhagyalaxmi Sidenur, Roopadevi V
62. Study of trimester wise effect of hypothyroidism in pregnancy and

its maternofetal outcome..................................................................................................................................... 327
Vidya Gaikwad, Pankaj Salvi, Nandini. R
63. Surgical and Oncological Outcomes of Extremity soft Tissue Sarcoma

following en bloc Resection of the Neurovascular Bundle............................................................................... 332
Haitham Fekry Othman, Reham Saied Oreaba, Marawan Yousry,
Assem Ahmed Elbrashy
64. Fertility Preservation in Young Breast Cancer Patients: a Concept Analysis................................................ 339
Hyeon gyeong Yoon, Joomin Lee

vi
65. A Study to assess the prevalence of Respiratory Morbidity among

Petrol Filling Station Employees in New Delhi, India....................................................................................... 349
Indumathy V, Gandhimathi. M., Kishore. J
66. Perceptions and Barriers to Deceased Organ Donation in Armenia:

A Qualitative Research .......................................................................................................................................... 354
Nare Ghazaryan, Miqayel Adamyan, Samvel Grigoryan, Tatevik Hovakimyan
67. Conservative Management of Acute Appendicitis in a Tertiary Care Centre............................................... 360

Ramesh Chhaganbhai Badhiya, R. M. Jitia, Haresh B. Vala
68. A cross-sectional study on Quality of life and stress among nursing

students in Central Karnataka.............................................................................................................................. 365
Rashmi. B.M. , Sindhu. B.M., Abhinandan. S.K.
69 Sleep quality and predictors of sleep disturbances among adult patients admitted
in a selected hospital, Mangaluru......................................................................................................................... 371
Amala Sibichan, Albeena Binu, Aleena Anil, Alphonsa Mathew, Amitha K Joy

Volume 13 | Issue 4 | October-December 2022
DOI: https://doi.org/10.37506/ijphrd.v14i4.18508
Impact of Covid-19 Pandemic on Mental Health of Health Care Workers

from a Tertiary Care Teaching Hospital of Northern India:
A Cross-Sectional Study
Adarshjot Kaur Toor1, Preeti Padda2, Jasleen Kaur2, Sanjeev Mahajan3

1,2
Assistant Professor, Department of Community Medicine, Government Medical College, Amritsar (Punjab, India)
3
Professor, Department of Community Medicine, Government Medical College, Amritsar (Punjab, India)
How to cite this article: Adarshjot Kaur Toor, Preeti Padda, Jasleen Kaur, Sanjeev Mahajan et al Impact of
Covid-19 Pandemic on Mental Health of Health Care Workers from a Tertiary Care Teaching Hospital of Northern
India: A Cross-Sectional Study. Volume 13 | Issue 4 | October-December 2022
Abstract
Objectives: To assess the prevalence of depression, anxiety and stress (DAS) and post-traumatic stress disorder (PTSD)
among health care workers
Methods: The present study was conducted over a period of six months (June 2020-November 2020) during which mental
health status of health care workers was assessed using semi-structured self-reporting study tool which included two
standardized and validated tools (DASS-21 and IES-R). Sociodemographic profile and occupational history were also
recorded. Health care workers of all categories who gave a written informed consent were recruited using non probability
convenience sampling technique. Minimum sample size required was this study was calculated to be 440, using 4PQ/
L2 where, power was assumed to be 80%, absolute precision of 5%, and P as 50%, after adding non-response rate of 10%.
Data was compiled and analyzed using EpiInfo07 software.
Results: Out of a total of 822 participants included in the study, 12%,13% and 16% were found to have symptoms of
depression, anxiety, and stress with the odds being higher in females. The prevalence of PTSD was 18%. Those with
education above intermediate and directly involved in COVID 19 related work and patient care were found to be at higher
risk of depression, anxiety, stress and posttraumatic stress disorder.
Conclusions: There is a need for a psychological support system for health care workers along with appropriate
administrative action to ensure shift rotation, rest and appropriate working hours. Further, in-depth knowledge of
prevention and control of the disease is necessary.
Keywords: COVID-19, Stress, Anxiety, Depression, Post-traumatic stress disorder, Health care workers
Introduction reported on 27/1/2020.3 Whereas, Punjab reported

COVID-19 was first reported in December 2019 its index case on 09/01/2020.4
from China which spread rapidly to other countries Since then, the number of cases increased putting an
and it was declared a public health emergency of overwhelming load on health care workers (HCW).
international concern by WHO on 30/01/2020 and a For control, lockdowns were imposed country-wide
pandemic on 11/03/2020.1,2 First case from India was
CORRESPONDING AUTHOR
Dr. Preeti Padda
Associate Professor
Department of Community Medicine
Government Medical College, Amritsar (Punjab, India).
Email id: [email protected]
Phone No.: +919781018838
2
and it resulted in economic slowdown adding to Assuming power of study to be 80% and an
psychological distress of population.5 absolute precision of 5%, sample size was calculated
using N= (Za/2)2 (P[1-P])/ d2, where P was taken
The morbidity and mortality due to COVID-19
to be 50% for attaining maximum sample size;
increased and HCWs are facing an uphill task in
therefore, it was planned to recruit a minimum of 440
providing services. Increased risk of contracting the
participants after adding a non- response rate of 10%
disease due to the work environment as well as innate
to the calculated sample size of 400. Non-probability
desire for a positive outcome in every patient also
convenience sampling technique was used to enroll
acts as stressor in HCWs.6-8 Increasing stress levels
the study participants.
decrease the immunity thereby increasing the risk
of contracting the disease which also stands true for The semi-structured, self-reporting study tool was
COVID-19.9 used which consisted of three sections.
The disease course and outcome due to COVID-19 Section I: Sociodemographic details (age, gender,
is associated with uncertainty and low predictability. educational status, marital status and living with
This impacts the mental health of the patients and family) and occupational details (department,
caregivers, but rates of poor mental health have been whether directly involved in COVID-19 related work
higher among HCWs.10,11 The rates are even higher or not).
among frontline workers in comparison to non-
Section II: DAS-21 scale consisted of 21 items to
frontline HCWs which has not been explored. It is
assess the symptoms of DAS on a likert scale (ranging
essential to understand the mental health effects of
from 0-3) with 7 items each allotted to one subscale
the disease in order to counter them and ensure good
(3Х7=21). After adding item specific scores for each
mental health.12-14
subscale, they were multiplied by 2 to get final scores.
Available literature shows that poor coping, The cut offs and the degree of severity for each
maladjustment and emotional disturbances have also subscale was taken as per standards.18
risen due to the pandemic.15,16 This highlights the fact
Section III: IES-R scale, which is a 22 item scale used
that not only physical but mental and social health
for recording PTSD, where each item is assessed on a
also need to be taken care of.17
likert scale (0 to 4); three subscales namely, intrusion
In view of this, the present study was carried out (8 items), avoidance (8 items) and hyperarousal (6
to assess the prevalence of depression, anxiety and items) are also assessed. Total score ranged from 0-88,
stress (DAS) and post-traumatic stress disorder where 24 was the cut-off while any individual having
(PTSD) among HCWs of our institution with the a score of 33-38 was considered to be suffering from
aim of understanding their mental health status and PTSD, while those with scores between 24-32 had
needs. partial or some symptoms of PTSD whereas, those
with scores of >39 suffered from a severe form of
Materials & Methods PTSD.19
This cross-sectional study was conducted over a period
After developing it was pilot tested for assessing
of six months (June 2020 to November 2020) in the
its completeness, sentence formation, punctuation,
Department of Community Medicine, Government
instructions, linguistic quality and aptness of duration
Medical College, Amritsar, Punjab, India. Being a
required for filling the questionnaire. This assessed
tertiary care institute, it acted as a state referral centre
face validity of the tool before it could be used in the
for seven districts (Amritsar, Gurdaspur, Jallandhar,
study.
Hoshiarpur, Pathankot, Kapurthala & Tarn Taran}.
Staff members who gave a written informed Methodology
consent were included in the study. Any study Training sessions on COVID-19 were organized
participant with a known history of psychiatric for the staff of medical college during which data
illness, intake of oral drugs causing mood disorders, collection was done. The participants were explained
alcohol dependence or illicit drug use was excluded about the objectives of study and were asked to fill in
from the study. the most appropriate responses for each item of the

90
80 84
Indian Journal
70 of Public Health Research & Development 3
Figure 1: Distribution of study participants according to severity of Depression, Anxiety & Stress
60
scales. They were requested not to leave any question 90
blank as that would lead to exclusion 50 of the study 80 84
participant. 48
70
40 60
41
Data analysis/ statistical analysis 30 50
48
37
40
Primary outcome for the present study was28 30 37
41
20 23
psychological problems in terms of DAS and PTSD 20
28
23
among HCWs. 10 10
12
17 17 17 17
10 10 0
10 10
12 5
5
The data were compiled and analyzed 0 using Depression Anxiety Stress
EpiInfo07 (CDC, USA) software. Mean ± standard Depression

Mild Moderate
Anxiety
Severe Extremely severe
Stress
deviation was calculated for continuous variables. The prevalence of PTSD was found to be 18% (146/822) among the study participants. The
Figure
Mild 1: Distribution
Moderate ofSevere study participants
Extremely severe
For categorical variables frequency and proportions distribution according to the severity of PTSD is shown in figure 2.
according to severity of Depression, Anxiety &
were calculated. Univariate logistic regression was Stress Figure 2: Distribution of study participants according to severity of PTSD (IES-R scores)
used to establish association between The presence
prevalenceofof PTSD was found to be 18% (146/822) among the study participa
DAS and PTSD with various sociodemographic and The prevalenceSeverity of PTSD of PTSD (IES-R scores)
was found to be 18%
distribution according to the severity of PTSD is shown in figure 2.
occupational variables. Linear regression was used (146/822) among the 50study participants. The
to assess association between predictor variables and distribution according 63
to the severity of PTSD is
33
Figure
mean scores of IES-R subscales. p < 0.05 on 2: Distribution
both of studyinparticipants
sides shown figure 2. according to severity of PTSD (IES-R scores)
was considered to be statistically significant.
Findings Severity of PTSD (IES-R scores)

676
A total of 822 participants were included in the
study where most of them (748;91%) were aged
50 24-32
between 31 to 60 year and their mean age± standard
<24 33-38 39 & above
33
deviation was 49.9±9.9 years. Females (457;56%) were 63
slightly higher than males (365;44%). Majority were Females were at 2.5 times higher odds of suffering from depression (OR= 2.51; 95% CI =1.55-4.04) and
diploma holders (355;43%). 13% (110/822) and 10% anxiety (OR= 2.52; 95% CI =1.59-3.98) as well as 2.94 times higher odds of suffering from stress (OR=
(85/822) had education up to graduation and post- 6

graduation level whereas, only 2% (16) were illiterate.
Most (713;87%) were married. Faculty formulated
8% (62/822) of the participants and majority were
staff nurses (43%). 35% (286/822) were involved in 676
COVID-19 related work.
Out of 822 study participants 96 (12%), 107 (13%)
and 120 (16%) were found to be having symptoms of
<24 24-32 33-38 39 & above
DAS. The mean score of DAS 21 was 5.3±8.2 ranging
from 0-57. As far as mean subscale scores were
Figure 2: Distribution of study participants
concerned, stress had the highest mean score (mean
according to severity of PTSD (IES-R scores)
±SD =4.8±6.9; range=0-38), followedFemales
by depression
were at 2.5 times higher odds of suffering from depression (OR= 2.51; 95% CI =1.55-
(mean ±SD =3.1±5.9; range=0-40) and least was for Females were at 2.5 times higher odds of suffering
anxiety (mean ±SD =2.6±4.9; range=0-38).
anxiety (OR= 2.52; 95% CI =1.59-3.98)
from depressionas(OR=
well as2.51;
2.94 95%
timesCI
higher odds of and
=1.55-4.04) suffering from str
The grading as per the severity of DAS is shown in anxiety (OR= 2.52; 95% CI =1.59-3.98) as well as 2.94
figure 1. times higher odds of suffering from stress (OR= 2.94;
95% CI =1.92-4.54) (table 1). Having an education of
more than intermediate (OR=4.95; 95% CI=2.88-8.52)
were found to be strongly related to PTSD.

4
Table 1: Univariate logistic regression analysis showing association of depression, anxiety, stress and
PTSD with sociodemographic profile of HCWs
Variable Stress Anxiety Depression PTSD

Yes No Yes No Yes (n=96) No Yes No
(n=129) (n=693) (n=107) (n=715) (n=726) (n=146) (n=676)
Sex
Female 98 358 79 377 71 386 111 346
(21%) (79%) (17%) (83%) (16%) (84%) (24%) (76%)
Male 31 335 28 338 25 340 35 330
(8%) (92%) (8%) (92%) (7%) (93%) (10%) (90%)
OR (95% CI) 2.94 (1.92-4.54) 2.52 (1.59-3.98) 2.51 (1.55-4.04) 3.03 (2.01-4.56)
Education
≥ 12th grade 105 445 91 459 80 470 130 420
(19%) (81%) (17%) (83%) (15%) (85%) (24%) (76%)
< 12 grade
th
24 248 16 256 16 256 16 256
(reference)
(9%) (91%) (6%) (94%) (6%) (94%) (6%) (94%)
OR (95% CI) 2.44 (1.52-3.90) 3.17 (1.82-5.51) 2.72 (1.56-4.76) 4.95 (2.88-8.52)
Marital status
Married 113 600 96 617 86 627 135 578
(16%) (84%) (13%) (87%) (12%) (88%) (19%) (81%)
Unmarried/ 16 93 11 98 10 99 11 98
(reference)
(15%) (85%) (10%) (90%) (9%) (91%) (10%) (90%)
OR (95% CI) 0.91 (0.52-1.61) 0.72 (0.37-1.39) 0.74 (0.37-1.46) 2.08 (1.11-3.49)
Staying with family
Yes 121 652 100 673 90 683 136 637
(16%) (84%) (13%) (87%) (12%) (88%) (18%) (82%)
No (reference) 18 41 17 42 6 43 10 39
(16%) (84%) (14%) (86%) (12%) (88%) (20%) (80%)
OR (95% CI) 1.05 (0.481-2.29) 1.12 (0.49-2.56) 1.05 (0.44-2.56) 1.12 (0.58-2.46)
Being directly involved in COVID-19 related work and working in clinical department were found to be
associated with DAS. Strength of association is shown in table 2.
Table 2: Univariate logistic regression showing association of depression, anxiety, stress and PTSD with
occupational profile of HCWs
(n=129) (n=693) (n=107) (n=715) (n=726) (n=146) (n=676)
Department
Clinical 96 434 88 442 62 356 117 413
(18.6%) (82%) (17%) (83%) (15%) (85%) (22%) (78%)
Non- Clinical 33 259 19 273 34 370 29 263
(reference) (11%) (89%) (7%) (93%) (80%) (92%) (10%) (90%)
OR (95% CI) 1.74 (1.14-2.65) 2.86 (1.70-4.8) 1.89 (1.22-2.95) 2.5 (1.7-3.9)

Indian Journal of Public Health Research & Development 5

(n=129) (n=693) (n=107) (n=715) (n=726) (n=146) (n=676)
Involved in COVID-19 related work
Yes 91 (32%) 195 (68%) 69 217 66 220 97 189
(24%) (76%) (23%) (77%) (34%) (66%)
No (reference) 38 498 38 498 30 506 49 487
(7%) (93%) (7%) (93%) (6%) (94%) (9%) (91%)
OR (95% CI) 6.11 (4.05-9.24) 4.17 (1.97-6.41) 4.17 (1.97-6.41) 5.1 (3.48-7.47)
The factors found to be associated with avoidance, hyperarousal and intrusion (IES-R subscales) were age
group, sex and involvement in COVID-19 related work (table 3).
Table 3: Linear regression analysis showing various factors associated with avoidance, hyperarousal
and intrusion.
Variable Avoidance Hyperarousal Intrusion Total
MEAN ± SD MEAN ± SD MEAN ± SD MEAN ± SD
Age group
>18-30 0.5±0.7 0.3±0.5 0.3±0.5 8.71±10.45
31-40 0.7±0.8 0.6±0.7 0.4±0.6 12.85±14.14
41-50 0.6±0.7 0.5±0.6 0.4±0.6 11.38±12.93
51-60 0.7±0.8 0.6±0.7 0.6±0.7 14.07±14.84
>60 0.4±0.6 0.2±0.6 0.2±0.5 6.05±11.54
p=0.06 p=0.000 p=0.001 P=0.005
Sex
Male 0.46±0.65 0.34±0.52 0.29±0.49 15.77±14.82
Female 0.87±0.8 0.69±0.74 0.59±0.68 8.15±11.18
p=0.000 p=0.000 p=0.000 P=0.000
Marital status
Married 0.7±0.8 0.6±0.7 0.5±0.6 12.76±14.14
Separated/widowed/di- 0.6±0.7 0.4±0.6 0.3±0.5 9.93±11.49
vorced/single
p=0.2 p=0.03 p=0.1 P=0.01
Involved in Covid-19 related work
Yes 1.1±0.9 0.8±0.8 0.8±0.7 19.93±15.83
No 0.5±0.6 0.4±0.5 0.3±0.5 8.36±10.67
p=0.000 p=0.000 p=0.000 P=0.000
Staying with family
Yes 0.7±0.8 0.5±0.7 0.5±0.6 13.2±17.4
No 0.6±0.8 0.6±0.8 0.6±0.8 12.3±13.6
p=0.35 p=0.84 p=0.89 P=0.60
Discussion found to be 12%, 13% and 16% in our study which was
The current study was conducted to assess the lower than the range of prevalence rates of depression
prevalence of psychiatric morbidity among HCWs (12.2%-50.4%), anxiety (13.0%-44.6%) and stress
and explore the factors associated with it. The overall (29.1%-71.5%) among HCWs reported from different
prevalence of depression, anxiety and stress was parts of the world.10,20-22 This lower prevalence could
be explained by the fact that our study was not

6
conducted during the peak of COVID-19 outbreak disease which further adds to the fear of morbidity
and lockdown imposed was also partially removed. and mortality associated with the disease if they
contract the same.
Among those having symptoms related to DAS,
10%, 16% and 4% had extremely severe symptoms Organisation of COVID-19 related training for
whereas majority had mild symptoms (48%, 35% enhancement of their occupational competency can
and 65%) which were similar to the results reported go a long way in relieving the stress and increasing
by a multicentric study conducted in India and job confidence.
Singapore.23,24 PTSD was found to be 18% (146/822)
Source of Funding: Self
as all had experienced a pandemic situation and
complete lockdown for the first time in their lives. Conflict of interest: None
Female gender, having intermediate & above Ethical Clearance: Ethical clearance of the current
education, working in clinical and para clinical study was obtained from Institutional Ethical
departments were found to be associated with Committee vide letter number GMC/Principal/
increased risk of having DAS and PTSD. Further being IEC/2020/GMCIEC02049 dated 25/6/2020
involved in COVID-19 related work (clinical care,
References
diagnostics, data management etc) had a very strong
association with having DAS symptomology. A study 1. Mahase, E. Coronavirus: Covid-19 has Killed More
conducted in China, also reported that females and People than SARS and MERS Combined, Despite
Lower Case Fatality Rate. BMJ 2020; 368:m641.
frontline workers were at higher risk of having DAS
during COVID-19 pandemic.25 2. WHO. Director-General’s Opening Remarks at the
Media Briefing on COVID-19—11 March 2020 [cited
Females generally take care of the family, which 2021 Sep 30]. Available from: https://www.who.
increases the fear of transmitting the infection to int/director-general/speeches/detail/who-director-
family members and if they get infected they will be general-s-opening-remarks-at-the-media-briefing-on-
unable to perform their day-to-day duties for them. covid-19---11-march-2020
These factors push them to a higher risk of having
3. Andrews MA, Areekal B, Krishnan J, Suryakala R,
DAS and PTSD.
Krishnan C, Muraly BP et al. First confirmed case of
Those involved in COVID-19 related work were at COVID-19 infection in India. Indian J Med Res 2020;
significantly higher odds of suffering from DAS and 151(5): 490-492
PTSD. This can be attributed to long working hours 4. India Today. Coronavirus outbreak: Punjab confirms
and lack of rest. Continuous exposure increases their its first positive case, patient had travelled had
chances of contracting COVID-19 and they fear of travelled to Italy. March 9, 2020 Chandigarh India
taking infection home and spreading infection to their Today [cited 2021 Sep 30]. Available from: https://
loved ones. Apprehension arising because of non- www.indiatoday.in/india/story/coronavirus-
availability of PPE, proper sanitation and required outbreak-punjab-confirms-first-positive-case-patient-
equipment contributes to the negative feelings which had-travelled-to-italy-1654059-2020-03-09
increases levels of DAS.25,26 5. Brooks, S.K.;Webster, R.K.; Smith, L.E.;Woodland,
L.;Wessely, S.; Greenberg, N.; Rubin, G.J. The
Therefore, the administration needs to configure
psychological impact of quarantine and how to reduce
appropriate working hours, periodic rest phases and
it: Rapid review of the evidence. Lancet 2020; 395:912–
rotation for all the workers during the COVID-19 920.
pandemic peak. This highlights the need of prioritising
safety of HCWs and fulfilment of their basic needs. 6. Barranco R, Ventura F. Covid-19 and infection in
Further a provision of psychological support through health-care workers: an emerging problem. Med Leg
J 2020;88:65–66.
colleagues, social media platforms and workshops
should be organised to enhance the ability to cope 7. Jin Y-H, Huang Q, Wang Y-Y, Zeng X-T, Luo L-S, Pan
with emotional challenges.26,27 Z-Y et al. Perceived infection transmission routes,
infection control practices, psychosocial changes,
Having higher education was found to be and management of COVID-19 infected healthcare
associated with higher risk of psychiatric morbidity. workers in a tertiary acute care hospital in Wuhan: a
This is because they have in-depth knowledge about cross-sectional survey. Mil Med Res 2020;7(1):24.

8. Waqas M, Hania A, Li H. Psychological Predictors 19. Christianson S, Marren J. The impact of event scale -
of Anxious Responses to the COVID-19 Pandemic: revised (IES-R). Medsurg Nurs. 2012;19.
Evidence from Pakistan. Psychiatry Investig
20. Zhang WR, Wang K, Yin L, Zhao WF, Xue Q, Peng
2020;17(11):1096-1104
M, et al. Mental Health and Psychosocial Problems
9. de Kloet E, Joëls M. Mineralocorticoid receptors and of Medical HealthWorkers during the COVID-19
glucocorticoid receptors in HPA stress responses Epidemic in China. Psychother. Psychosom.
during coping and adaptation. Oxford Research; 2020;89:242–250.
Encyclopedia of Neuroscience 2020.
21. Lu W, Wang H, Lin Y, Li L. Psychological status of
10. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors medical workforce during the COVID-19 pandemic:
associated with mental health outcomes among HCWs A cross-sectional study. Psychiatry Res. 2020; 288:
exposed to coronavirus disease 2019. JAMA Netw 112936.
Open 2020;3(3):e203976.
22. Song X, Fu W, Liu X, Luo Z, Wang R, Zhou N, et al.
11. Badahdah AM, Khamis F, Mahyijari NA. The Mental health status of medical sta_in emergency
psychological well-being of physicians during departments during the Coronavirus disease 2019
COVID-19 outbreak in Oman. Psychiatry Res epidemic in China. Brain Behav. Immun. 2020;88:60–
2020;289:113053 65.
12. Bromet E, Andrade LH, Hwang I, Sampson NA, Alonso 23. Chew NW, Lee GK, Tan BY, Jing M, Goh Y, Ngiam
J, Girolamo GP, et al. Cross-National epidemiology NJ, et al. A multinational, multicentre study
of DSM-IV major depressive episode. BMC Med on the psychological outcomes and associated
2011;9:90. physical symptoms amongst healthcare workers
during COVID-19 outbreak. Brain Behav. Immun.
13. Baxter AJ, Scott KM, Vos T, Whiteford HA. Global
2020;88:559–565
prevalence of anxiety disorders: a systematic review
and meta-regression. Psychol Med 2013;43:897–910. 24. Selvaraj P, Muthukanagaraj P, Saluja B, Jeyaraman M,
Anudeep TC, Gulati A, et al. Psychological impact of
14. Roth T. Insomnia: definition, prevalence, etiology, and
COVID-19 pandemic on health-care professionals in
consequences. J Clin Sleep Med 2007;3:S7–10.
India – A multicentric cross-sectional study. Indian J
15. Shah K, Kamrai D, Mekala H, Mann B, Desai K, Patel Med Sci 2020;72(3):141-147
RS. Focus on mental health during the coronavirus
25. Elbay RY, Kurtulmuş A, Arpacıoğlu S, Karadere E.
(COVID-19) pandemic: applying learnings from the
Depression, anxiety, stress levels of physicians and
past outbreaks. Cureus 2020;12:e7405.
associated factors in Covid-19 pandemics. Psychiatry
16. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Research 2020;290:113130
Immediate psychological responses and associated
26. Vahedian AA, Moayed MS, Rahimibashar F, Shojaei
factors during the initial stage of the 2019 coronavirus
S, Ashtari S, Pourhoseingholi MA. Comparison of
disease (COVID-19) epidemic among the general
the severity of psychological distress among four
population in China. Int J Environ Res Public Health
groups of an Iranian population regarding COVID-19
2020;17:1729.
pandemic. BMC Psychiatry 2020; 20: 402.
17. Gavin B, Lyne J, McNicholas F. Mental Health and
27. Jemal K, Deriba BS, Geleta TA. Psychological Distress,
COVID-19 pandemic. Irish Journal of Psychological
Early Behavioral Response, and Perception Toward
Medicine, (2020), 37, 156–158.
the COVID-19 Pandemic Among HCWs in North
18. Lovibond PF, Lovibond SH,. The structure of negative Shoa Zone, Oromiya Region. Front. Psychiatry
emotional states: comparison of the Depression Anxiety 2021;12:628898.
Stress Scales (DASS) with the beck depression and
anxiety inventories. Behav. Res. Ther. 1995;33(3):335–
343

The association between works related musculoskeletal body

discomfort and ergonomic risk level among female sewing
machine operators in Sri Lanka.
ADP Perera1, HTN Fernando2, AMCR Attanayake2, DDI Samanwattage2,

HWUS Jayasinghe3
1
Senior Lecturer, Department of Physiotherapy, Faculty of Allied Health Sciences,
General Sir John Kotelawala Defence University, Colombo, Sri Lanka.
2
Physiotherapy graduate, Department of Physiotherapy, Faculty of Allied Health Sciences,
3
Temporary Demonstrator, Department of Physiotherapy, Faculty of Allied Health Sciences,
How to cite this article: ADP Perera, HTN Fernando, AMCR Attanayake, DDI Samanwattage, HWUS Jayasinghe
et al The association between works related musculoskeletal body discomfort and ergonomic risk level among
female sewing machine operators in Sri Lanka. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Work related musculoskeletal discomfort can occur in any region of the body. It affects sewing machine
operator’s activities of daily living and quality of life directly or indirectly. Poor ergonomics is a major contributor to
work related musculoskeletal discomfort that develops over time. It is important to find out the association between work
related musculoskeletal body discomfort and ergonomic risk level among female sewing machine operators of selected
garment factories in western province, Sri Lanka.
Methods: A descriptive cross-sectional study was preceded, with a study population of one hundred and thirty-seven
(137) female sewing machine operators within the age of 18-50 years at selected garment factories in the western province
of Sri Lanka.
Conclusion: Of the total sample, 72.99% operators presented with musculoskeletal discomfort. Qualitative and quantitative
data were obtained using a pre-validated questionnaire; Cornell musculoskeletal discomfort questionnaire and Rapid
Entire Body Assessment (REBA). The mean age of study population was 33.55±1.64years. The highest prevalence of
discomfort was reported in neck (53.94%) and lower back (69.2%) regions. The mean ergonomic risk level was 8.42±0.16
which is 50.36% in study population. The majority of the sewing machine operators were in high ergonomic risk level
in western province of Sri Lanka and the prevalence of musculoskeletal disorders was more in the lower back and neck
regions where the ergonomic interventions should have implemented.
Keywords: Work related musculoskeletal body discomfort, ergonomic risk level, REBA, sewing machine operators
Introduction A work-related musculoskeletal discomfort

There are 300-350 apparel manufactures in Sri Lanka (WRMSD) refers to the musculoskeletal aches and
which provide direct and indirect employment for distresses that result from a work-related event2. There
over 300,000 and 600,000 employees respectively. is a prevalence of 15.5% for having musculoskeletal
It includes a considerable number of women. problems in garment factory workers in Sri Lanka3.
Dheerasinghe, reported that the garment industry According to several studies, musculoskeletal
has been Sri Lanka’s largest gross wage earner since discomfort became a major health complaint among
1986 and accounted for more than 52% of the total sewing machine operators in the apparel industry in
export earnings of the country1. Therefore, sewing South Asian countries. Work related musculoskeletal
machine operators play a major role in the economy discomfort can occur in any region of the body but the
of Sri Lanka. Therefore, it is essential to study on back pain was the most commonly reported disorder
problems regarding to them. among those who suffered from musculoskeletal
discomfort4.
Female sewing machine operators in garment Index (BMI) was calculated using mean height and
factories usually sit for more than 6 hours continuously weight values measured.
for a minimum of 6 days per week. Without adequate
The section1 of the form was consisted demographic
breaks they work in a non-ergonomically fitted
data with work related factors of the participants
work station. Literature has proved that most of the
and section 2 was consisted with Standard Cornell
female sewing machine operators are suffering from
musculoskeletal discomfort questionnaire(CMDQ).
health issues such as work-related musculoskeletal
The CMDQ is a 54-items questionnaire which has a
discomforts 5-7 .
body chart and questions on musculoskeletal ache,
As health care professionals, it is essential to pain, or discomfort occurrence in 18 body parts over
understand the work-related musculoskeletal the past week. It is calculated in accordance with the
discomfort regarding their occupational history. CMDQ scoring guidelines8.
Therefore, the current study was conducted to evaluate
Rapid ergonomic Body Assessment (REBA) was
the prevalence of the work-related musculoskeletal
used to assess ergonomic risk level. It was included
discomfort and ergonomic risk level among sewing
all body regions and considered the static force or
machine operators which is still lacking in the apparel
load score coupling score and activity scores with
industry of Sri Lanka. This study also revealed the
postural score are to achieve the final score 9. Data
association between work-related musculoskeletal
were analyzed using SPSS (Statistical Product and
discomfort and ergonomic risk level which is
Service Solution) software version 26.0.
important to make suitable adaptations to prevent
and minimize the ergonomic risk level among sewing Results
machine operators.
A majority of the participants, 100 out of 137 (72.99%)
Materials and Methods complained that they have been experiencing
The current study was designed as a descriptive, musculoskeletal body discomfort in various parts
cross-sectional study. One hundred and thirty seven of their body which indicated that there was
(137) female sewing machine operators in two large high incidence of Work-Related Musculoskeletal
scale garment factories (Kaluthara and Colombo) Discomfort.
were recruited using simple random sampling, Ergonomic risk level distribution was presented in
according to the inclusion criteria as female sewing Figure 1 under REBA category (medium risk, high
machine operators in the age category of 18 - 50 years, risk and very high risk). Based on REBA score, it is
minimum of 6 working hours, minimum working revealed that the workers are under high ergonomic
period of 6 months and participants who granted risk for musculoskeletal discomfort. No work
written informed consent. Exclusion criteria of the posture received negligible and low ergonomic risk.
study considered as participants who did not grant The results shown that only 40.88% (n=56) workers
the written informed consent, participants who were in medium risk where action level 2 i.e. further
have undergone surgeries in the spine and scoliosis investigation and change are needed, and 50.3%
and diagnosed with previous illness and diseases in (n=69) workers were in high ergonomic risk where
the musculoskeletal system and pregnant. Ethical action level 3 i.e. immediate interventions are needed.
clearance was obtained from the Ethics Review The finding shown that 8.8% (n=12) are in very high
Committee, Faculty of medicine, Kotelawala Defense risk category.
University, Sri Lanka.
Distribution of prevalence of total discomfort score
Pre-tested Interview-administrated assessment of the study population presented in the Table 1. The
form was used to collect data about work related Hundred of the subjects experienced discomfort in
musculoskeletal discomforts and demographic at least one body region in the 12 months prior to
data. Height and weight were measured using a questionnaire completion (72.99%). The work related
stadiometer 282 (Seca GmBH and Co kg, Hamburg musculoskeletal discomforts of those participants
and Germany) and a weighing scale named Tanita were evaluated according to the total discomfort
HD 318 digital weighing scale (Tanita Co-operation, score of CMDQ. It was concluded that participants
Tokyo, Japan). Three measurements were taken at the felt discomfort mostly in the neck (53.94%), lower
same time and the mean was calculated. Body Mass back (42.18%) and the right shoulder (2.79%) while

10
it was less pronounced in the left shoulder (0.28%),
Percentage (%)
upper back (0.%) and left thigh (1.62%).
Interference
Discomfort
Discomfort
Frequency
score
Body region
Upper arm-right 0 0 0 4 0.00

Upper arm-left 2 2 2 6 0.00
Lower back 43 35 33 49088 42.18
Forearm-right 0 2 3 6 0.00
Forearm-left 0 0 0 0 0.00
Wrist-right 3 6 5 90 0.07
Figure 1: Ergonomic Risk Level Distribution among Wrist-left 3 3 3 27 0.02
Participants Hip/buttock 8 7 7 392 0.34
Thigh-right 2 2 2 6 0.00
The difference between Works related
Thigh-left 5 4 4 80 0.06
musculoskeletal body discomfort employees with
Lower leg-right 5 3 2 30 0.02
Ergonomic risk level was presented in the Table 2.
Lower leg-left 0 0 0 0 0.00
An independent sample t-test was performed to
compare the mean of ergonomic risk level among Foot-right 2 1 2 3 0.02
the group with WRMSD (N=100) and group without Foot-left 3 3 4 36 0.03
WRMSD (N=37). There is no significant difference
Table 2: The difference between Works related
between mean ergonomic risk level of participants musculoskeletal body discomfort employees with
with WRMSD and mean ergonomic risk level of Ergonomic risk level
participants without WRMSD (p>0.05).
Variable Participants Participants P
The distribution between prevalence of work- with WRMSD without value
related musculoskeletal body discomfort according group WRMSD group
to body region and ergonomic risk level among N=100 N=37
participants was evaluated in Table 3. Majority of the Mean + SD Mean + SD
participants who experienced neck pain in very high- Ergonomic 8.56± 1.91 8.05± 2.08 0.183
risk category (n=14) while there were 8 participants in risk level
high risk and 3 participants in medium risk category.
There were equal number of the participants who P< 0.05, group with WRMSD VS group without
experienced lower back pain in very high risk WRMSD, Independent sample T test
and high-risk category (n=10) while there were 3 A one way ANOVA test was conducted to identify
participants in medium risk category. Majority of the association between the body regions discomfort
the participant who experienced right shoulder joint complained by the participants and the ergonomic
discomfort were in very high risk category (n=5). risk level (Table 5). Results showed that there was
Table 1: Distribution of prevalence of total no statistically significance difference between the
discomfort score of the study population ergonomic risk level and work related musculoskeletal
body discomfort (P ≥0.05).
Percentage (%)
Interference
Discussion
Discomfort
Discomfort
Frequency
score
Body region The current study results have shown that 72.9% of
the employees have experienced the Work-Related
Musculoskeletal Discomfort (WRMSD) in the past
twelve months. Similar to present study, De Silva et
Neck 44 39 37 62771 53.94
al., also explained that the prevalence was 15.5% for
Shoulder-right 15 16 14 3248 2.79
having musculoskeletal problems in garment factory
Shoulder-left 6 8 7 336 0.28
workers in Sri Lanka in 2013 10. Moreover Jahan et al.,
Upper back 7 6 6 234 0.20
in 2015 stated that the prevalence of Work-Related
Musculoskeletal Discomfort among the Bangladeshi The results of current study indicated that female
workers was about 60.7% 11 . Many research studies sewing machine operators felt most work-related
revealed that sewing machine operators were discomfort in the neck (53.94%), lower back (42.18%)
more prone to have work related musculoskeletal and right shoulder (2.79%). Similar to present study,
discomforts10,11. The prolonged exposure to Jahan et al., in 2015 has stated that the workers had
ergonomic risk factors such as force, repetition, static musculoskeletal pain in neck - 36.7%, lower back
load, awkward posture, contact stress and short - 22.2% and shoulder - 18.9%11. Several past studies
recovery time leads to Work-Related Musculoskeletal have shown that the female sewing machine operators
Discomfort12. The Work-Related Musculoskeletal had most work-related discomfort in the neck and
Discomfort incurred vast human, social and economic the lower back regions similar to the present study
losses. 9, 12-14
. Differences between studies over the years of
industry work and demographic differences may
Table 3: Distribution of Ergonomic Risk Level
and Work-Related Musculoskeletal Discomfort cause a variance in the prevalence of studies.
According to Region among study population Ilson, evaluated that neck region has high risk of
REBA Categories developing issues and discomfort than other regions
in the body 15. Further he stated that operating a sewing
Region Very
Medium High machine as an occupational risk for neck disorders.
High
Risk Risk Several studies revealed that neck has the highest
Risk
prevalence of musculoskeletal discomfort among
Neck 3 8 14
sewing machine operators and the major complaint
Shoulder-Right 0 4 5 is neck pain 12, 16-18 . The sewing machine operators
Shoulder-Left 0 2 4 have to work long hours in same in corrected static
postures with bent neck to achieve their production
Upper Back 1 4 0
targets. And also poor ergonomically designed work
Upper Arm-Right 0 2 0 environment, lack of intervals and lack of knowledge
Upper Arm-Left 1 1 0 regarding good ergonomic practices are main reasons
for the neck discomforts among sewing machine
Lower Back 3 10 10
operators. According to Kanniappan, in 2022 females
Forearm-Right 0 2 0 have higher prevalence of having neck discomforts
Wrist-Right 0 2 2 than males19. The job involves monotonous, highly
repetitive tasks performed in a sitting working posture
Wrist-Left 1 2 1
with upper back curved and head bent over the
Hip/Buttock 1 3 1 sewing machine lead for occurring musculoskeletal
Thigh-Right 0 1 1 complaints in neck.
Thigh-Left 0 3 0 Lifting heavy objects at work’ was identified as a
Lower Leg-Right 0 1 0 cause of lower back MSD was particularly high. And
also the poorly designed chairs, non-work activities,
Lower Leg-Left 0 0 1 and physical problems such as past injuries, as causes
Foot-Right 1 0 1 of lower back problems. Garment workers may
Foot-Left 0 1 3 experience a decline in back and hip pain if they are
provided height-adjustable task chairs that can swivel
Table 4: The association between the body regions 11
. It is also noted that improperly designed equipment
discomfort complained by the participants (n=137) cause the aches and symptoms around the neck, nape
and the ergonomic risk level.
and waist, and to the problems with the muscle and
Mean skeleton systems 20. A Recent study showed that the
F Sig.
Square physical burdens lead to problems at the left shoulder,
Between Groups 2.18 0.937 0.531 the neck, the back and in the lower extremities of
Within Groups sewing machine operators19. These problems either
2.33
arise from or become more pronounced when lifting
Total the weights, bending the head and body forward,

12
and by the less recovery periods while working for ergonomic interventions in the workstations.
extended periods in a seated position.
Conflicts of Interest
In present study interpreted the mean of ergonomic
risk level was 8.42±0.16.The group of subjects exposed The author(s) declare that they have no competing
to high level of risk required immediate intervention interests.
to reduce the exposure among the sewing machine Source of funding: Self
operators. Similar to present study, several
studies concluded that there was high risk level of References
musculoskeletal symptoms and it was significantly 1. Dheerasinghe, R: Garment Industry in Sri Lanka
high among female garment manufacturing Challenges, Prospects and Strategies,Staff Studies,
industry10-12 . In contrast, a study done by using 2009; 33(1), p33.
37 female sewing machine operators interpreted
2. Hima Bindu, P. and Thiruppathi, A: Work Related
that most of employees had medium level risk in Musculoskeletal Discomfort (WRMSD) among
ergonomic postures in readymade garment industry9. Physiotherapists, International Journal of Physiotherapy
The findings of the current study have disclosed ,2014;1(4), p.200.
that there was no a significant difference between 3. Lombardo, S., Vijitha de Silva, P., Lipscomb, H. and
work related musculoskeletal body discomfort with Østbye, T: Musculoskeletal symptoms among female
ergonomic risk level. In contrast to current study, garment factory workers in Sri Lanka, International
another study has recently interpreted a significant Journal of Occupational and Environmental Health ,2012;
association between prevalence of Work-Related 18(3), pp 210-219.
Musculoskeletal Discomfort and ergonomic risk 4. Jackobs, K: Ergonomics for Therapists. United States:
factors among sewing machine operators in the Mosby Elsevier.2008.
Sri Lankan textile industry21. There were limited
5. Henry, L., Jafarzadeh Esfehani, A., Ramli, A., Ishak, I.,
literature done related to association of ergonomic
Justine, M. and Mohan, V: Patterns of Work-Related
risk level and the prevalence of work related Musculoskeletal Disorders Among Workers in Palm
musculoskeletal discomfort among sewing machine Plantation Occupation,Asia Pacific Journal of Public
operators. However, one study conducted with pre- Health , 2013; 27(2), pp. 1785-1792.
cast construction workers 22 showed similar findings
6. Chandra. J, Manisha, Rajib, Sunanda, Trissa, Rahima:
and another study with nursings professionals 23
Prevalence of Musculoskeletal Disorders among the
showed contrast findings compared to the present
Bangladeshi Garments Workers,SMU Med. J ,2015;
study. 2(1), pp. 102–113.
Several factors that can create an impact on 7. Lillypet, S., Jain, T. and Joseph, B: Health problems
work related musculoskeletal diseases rather than among garment factory workers: A narrative literature
ergonomic risk level11. According to his findings, review,Journal of Occupational Health and Epidemiology
WRMD were also associated with the measure ,2017; 6(2), pp 114-121.
of command over a person’s own capacities (as
8. Çakıt: Ergonomic Risk Assessment using Cornell
colleagues, supervisors, job conflicts and working Musculoskeletal Discomfort Questionnaire in a
timetable) may prompt work environment stress. Grocery Store,Ergonomics International Journal , 2019;
3(6), pp-60-65.
Conclusion
The present study concluded the sewing machine 9. Ahmed: Ergonomic to design safe and comfort work
station of garment workers: bangladesh prespective,1st
operators suffer the neck region discomfort to
international Conference Business and Management, ,2017;
be greater in compared to other body regions.
pp 92–102.
This study also found that the majority of sewing
machine operators in western province were in high 10. Silva, M. & Lankathilake, Kantha. Living conditions
ergonomic risk level (50.36%) though, it has no impact in boarding houses and health status among female
on work related musculoskeletal discomfort. It is industrial workers in Katunayake free trade zone, Sri
Lanka. International Journal of Community Medicine
recommended to carry out future studies with larger
and Public Health. 2016; 1503-1509. 10.18203/2394-
samples to represent the whole sewing machine
6040.ijcmph20161619.
operators in Sri Lanka elite level to ensure the suitable

11. Jahan, Nusrat & Das, Manisha & Mondal, Rajib & Paul, 19. Kanniappan V, Palani V. Prevalence of Musculoskeletal
Sunanda & Saha, Trissa & Akhtar, Rahima & Khan, Disorders among Sewing Machine Workers in a
Abdul & Banik, Palash. Prevalence of Musculoskeletal Leather Industry. J Lifestyle Med. 2020;10(2):121-125.
Disorders among the Bangladeshi Garments Workers. doi:10.15280/jlm.2020.10.2.121.
SMU Medical Journal. 2015; 2. 102 - 113.
20. Kalinkara, V. Cekal, N. Akdogan, I. & Kacar, N:
12. Vihma T, Nurminen M and Mutanen P: Sewing- Anthropometric measurements related to the
machine operators’ work and musculo-skeletal workplace design for female workers employed in the
complaints,The Ergonomics journal , 1982; 25 (4): pp295 textiles sector in Denizli, Turkey,Eurasian Journal of
– 298. Anthropology , 2011;2 (2), pp102−111.
13. Maduagwu, S .Prevalence and Patterns of Work- 21. Sakthi Nagaraj, T. and Jeyapaul, R: Ergonomic Study
related Musculoskeletal Disorders among Bankers in on Work Postures of Sewing Machine Operators in
Maiduguri, Northeast Nigeria,Occupational Medicine Government Industry: A Case in Lean Environment
& Health Affairs; 2014; 02(03). Garment Industry,Ergonomic Design of Products and
Worksystems - 21st Century Perspectives of Asia, , 2017;
14. Sarder, B., Imrhan. N., & Mandahawi: Ergonomic
pp 83-101.
workplace evaluation of an Asian garment-factory.,J.
Human Ergoly , 2006; 35,pp 45–51. 22. Moussavi najarkola, s., & mirzaeir: evaluation of upper
limb musculoskeletal loads due to posture, repetition,
15. Ilson A. Effective Management of Musculoskeletal
and force by rapid upper limb assessment in a textile
Injury A Clinical Ergonomics Approach to Prevention
factory. health scope1(1), 2012; pp 18-24. https://
Treatment and rehabilitation.1st Ed, Harcourt
www.sid.ir/en/journal/ViewPaper.aspx?id=268438.
publishers, Toronto, London.; 2000.
23. Kurd, N., Omidi, M., Jalilian, M., Kazemi, M.,
16. Kaergaard A and Andersen J: Musculoskeletal
Kamalvandi, M. and Jamshidzad, M: Using of Cornell
disorders of the neck and shoulders in female sewing
measuring tool (Cornell musculoskeletal discomfort
machine operators: prevalence, incidence, and
questionnaires) for assessment of the musculoskeletal
prognosis,The Occupation and Environmental Medicine
disorders prevalence among Ilam teaching hospitals
journal, 2000; 57(8):pp 528–534.
nurses: Cross-sectional study in 2016, Annals of Tropical
17. Schibye B, Skov T, Ekner D, Christiansen JU and Medicine and Public Health , 2017; 10(6), p1729.
Sjogaard G : Musculoskeletal symptoms among sewing
machine operators,Scand Journal of Work Environment
and Health ‘ 1998; 21 (6): pp 427-434.
18. Wang P C, Rempel D M, Harrison R J,Chan J and

B R : Work-organizational and personal factors
associated with upper body musculoskeletal disorders
among sewing machine operators, Occupational and
Environmental Medicine journal 2007; 64 (1): pp 806-813.

Concern over career is the primary reason for poor mental

health among students
Agnita Kundu1 , Sampurna Kundu2

1
Assistant Professor, Department of Chemistry, Shri Shikshayatan College, 11, Lord Sinha Road,
Kolkata-700071. West Bengal, India
2
Ph.D. Research Scholar, Centre of Social Medicine and Community Health,
Jawaharlal Nehru University, Delhi-110067, India.
How to cite this article: Agnita Kundu, Sampurna Kundu et al Concern over career is the primary reason for poor
mental health among students. Volume 13 | Issue 4 | October-December 2022
Abstract
COVID-19 is the cause of a lot of concern around the world. Apart from the obvious physical distress it has contributed
significantly to elevation of mental health issues. Students who mostly have not been vaccinated are doing online
classes with severe restriction on their social lives. Survey was done with students from school, college and university
to determine their mental health status. Their mental health was evaluated with the DASS-21 questionnaire that was
distributed and collected online. The students were found to have become vulnerable to stress, anxiety and depression.
Their mental health status was found to be poor with university students being most affected. Upon Correlation studies
with relevant questions on online education and consequent change in their mode of studies and interaction with family
and friends, it was found that university students’ concern over their career led to their poor mental health
Keywords: Anxiety, COVID-19, Depression, Mental Health, Stress, Student.
Introduction in table 1. However, educational institutions were

Students represent the future generation of the not taken out of it. The decision to open education
society. The health of a society is reflected in the institutes were left to the respective states. Though
happiness of a student. Hence it is important to know some states decided to open schools and colleges
the mental health status of the students and what but unfortunately had to shut down again due to
elevates or depresses them 1. infection amongst teachers and students 2. Their
experience deterred other states from opening
Premise: The world have been combating SARS- their educational institutes. Many states closed
COV since the last 2 years. As the disease spread down school at the rise of COVID cases during the
Indian Government was forced to impose complete second wave3. As vaccination of school going age
nationwide lockdown from 24th March, 2020, initially group started since January,2022, hence, opening
for 21 days, which was extended multiple times till of educational institutions where large number of
30th of May to a total of 68 days. The lockdown was students and teachers get together was not a viable
successful as the cases in India came down and India option until recently. Therefore the students were at
started phase wise lifting of lockdown from June, 2020. home since the beginning of the lockdown on 24th
India went through 7 phases of lifting of lockdown or of March, 2020. Most of the educational institutions
unlock 1.0 to 7.0 and different establishments were were taking online classes for the students.
taken out from the ambit of lockdown as is shown
Corresponding Author:
Sampurna Kundu
Ph.D. Research Scholar, Centre of Social Medicine and Community Health,
Jawaharlal Nehru University, Delhi-110067, India.
E-mail: [email protected]
This unprecedented situation in a students’ did worsen during lockdown 15. However, there is
life led to many changes in their life. The mental not enough study on mental health of students due to
health of students was assessed and was found to pandemic and consequent lockdown in India. . This
be affected adversely. The students underwent a article takes a look at how the continuous lockdown
gamut of emotions collectively during this pandemic and online classes have affected the mental health
that hardly any student of any generation has faced of the students across the stages of our education
before. By asking the right questions it is possible to after 18 months from the start of the lockdown. Our
ascertain what affected the students’ mental health education system has three distinct stages. At the
most during the pandemic. This data can be used later onset there is Montessori schools, who were also
for the betterment of the students. taking online classes. However those students being
too small were kept out of the survey. Beyond that
Literature Survey: Studies have been done in
we have the school students ranging from nursery to
different countries in the world to see the effect of the
class 12 (students from class 9 onwards were included
pandemic and consequent lockdown on the mental
in the survey). Usually, a student then progresses to
health of the students. From a high school students
college and finally to university for postgraduation.
perspective in USA it is seen that adolescent students
Many students also opt for vocational courses. The
were specially prone to anxiety as they were missing
responsibility, worries, anxiety faced by each stage of
the social support of the school 4. Studies were done in
the students are different. Their reaction to pandemic,
Poland, where it was deduced that early intervention
lockdown also depends on their socio economic status.
is needed to prevent the psychological breakdown
Many students from poor families and rural areas
of students 5. A survey done on students of Delhi
were not able to afford a phone and sometimes they
showed that students were undergoing stress and
also do not have easily accessible internet connection.
anxiety due to the disease and its consequent loss in
The students who were able to do the classes properly
social life 6,7. The mental health issues were prevalent
have also been restricted to their houses. Active life
and even more apparent among LGBT, transgender
of playing, interaction with friends and teachers has
groups. 8. Similar study was also done in students of
been diminished. This has taken a toll on the mental
India, Bangladesh and Pakistan and was shown that
health of the students.
student s suffered from anxiety and stress because of
fear of contracting the disease 9,10. At present vaccination of the general populace is
being carried out all over the world to contain the
Students were facing all the problems that their
disease. WHO has approved of the Pfizer/BioNTech
families were facing due to unemployment or death
vaccine for use in children from 12 to 18 years of
or ill health due to COVID. The families of COVID
age, which is being used in many countries in the
warriors were especially prone to this 11. Moreover
world 16. Below 12 years no conclusive trials have
the students, were now privy to all the problems of
been done. In India vaccines are now available for
the families without the mode to escape from it in
children between 12 to18 years. Covaxine is used to
schools or sharing with friends which is putting a
vaccinate chidren between 15 to 18 years of age 17 and
strain on the relationships within the family 12. The
for children between 12 to 15 years the vaccine used is
students were also worried about their job prospects,
Corbevax manufactured by Biological E 18.
their lack of expertise in real classroom situation,
lack of experience that many used to get from intern Justification for the study: Even though the COVID
positions. Students taking their lives for not being restrictions are now over and most of the education
able to do classes is doing the rounds of social media institutes have opened, the study is still relevant
13
. The students of the government schools, who were as it tried to find out what affects the young minds
mostly from poor families were the worst affected 14. of the students the most. During the pandemic
All of these were leading to mental health problems and lockdown the students underwent a range of
in students. Continuous studies of mental health as experiences and emotions that they may never have
different stages of the lockdown and comparison experienced otherwise. They have experienced a
of mental health studies done before and after the lifetime in this 2 years, hence this lockdown however
lockdown has been done to see the effect of this unfortunate has opened up a possibility of studying
unprecedented phenomenon on our lives One such the young minds and exploring what affects them
study done in Switzerland showed that mental health most. The article takes a look at the mental health of

16
the students and also asks some pertinent questions circulated for data collection, with invitation for
causing these mental health issues. COVID-19 has participation through social media platforms, from
been a great equaliser for students of all backgrounds. 10th to 20th June, during the Covid-19 second wave
The students all faced similar situations and issues, lockdown in India. The survey was conducted in
hence the study done at 18 months after the lockdown English language, and informed consent was obtained
(when the students have experienced this new life prior to the starting of survey and were informed
for some period) has the potential to eliminate the about the purpose of the study. The total number of
background inequalities and determine what are the participants in this study is 395.
most pertinent concerns for a student.
Measures
Table 1: Phases of lockdown during Covid-19 in
India Individual characteristics: The sample characteristics
of the participants included age, gender, residence
Phase of Date Activities allowed (for
Unlock educational institutions) type, education level, type of education institution,
stream of education, and average monthly family
1 30.5.2020 Closed income of the participants.
2 29.6.2020 Closed Effect of Online mode of Education: These questions
3 29.7.2020 Closed included- Do you miss interacting with your friends?;
Do you miss interacting with your teachers?; Do you
4 29.8.2020 50% teaching and
feel that it is going to have an effect on your career?;
non-teaching and non-
Do you think you are learning as much as before?; and,
teaching staff permitted
to come to institutes Do you like that examinations are getting cancelled/
outside containment delayed?.
zones. Students may Mental health assessment: Mental health of the
come for guidance participants was assessed using the Depression,
voluntarily and upon
Anxiety and Stress Scale with 21-items (DASS-21)
parent’s consent.
(Figure 1). These are measured on a 4-point Likert
5 30.9.2020 Schools may reopen in a scale that ranges from 0 (did not apply to me at all) to
graded manner after 15th
3 (apply to me very much). Further, the mental health
October upon permission
scores can be classified as : Depression – Normal (0-
of the state government
or Union territories. 9), Mild (10-13), Moderate (14-20), Severe (21-27),
Attendance is voluntary Extremely Severe (28+); Anxiety- Normal (0-7), Mild
and subject to parental (8-9), Moderate (10-14), Severe (15-19), Extremely
consent. Severe (20+); and, Stress- Normal (0-14), Mild (15-18),
6 30.9.2020 State government Moderate (19-25), Severe (26-33), Extremely Severe
allowed to take decision (34+).
on reopening of
educational institutes. Data analysis
Descriptive statistics were employed for assessing
Source: www.mha.gov.in
the data, followed by bivariate analysis and data
Methodology: visualization. Cronbach’s alpha was used for
testing the reliability of the DASS-21 scale. Scores
Study Design and participants for depression, anxiety and stress were computed
The present study is cross-sectional and based on an and also a composite mental health index has been
online survey with quantitative approach. The survey constructed to assess the overall mental health status
was conducted in the online mode, keeping in mind of students. A generalized linear model regression,
the COVID-protocols. Information was gathered with logit link function belonging to binomial family,
regarding the mental health status of students of and the model is adjusted for the covariates that
schools, colleges and universities. Google forms were

more than Rs. 1,50,000/- 52(13.16)
Education level School 47(11.9)
College 250(63.29)
University 98(24.81)
Type of Education institution Private 185(46.84)
Government 210(53.16)
Stream of education
Indian Journal of Public Health Research & Development Science 228(57.72)
17
Humanities 73(18.48)
Commerce 62(15.7)
Others 32(8.1)
includes the sample characteristics as well as the Mental
Total health assessment N 395
other questions considered in the study. Consider Yi 1
The Cronbach’s alpha (α) of depression, anxiety, stress
as the observed binary outcome, that is, mental health 2 Mental health assessment
and composite mental health scores were found to be
indicators (making them dichotomous), for the ith 3 The Cronbach’s alpha (α) of depression, anxiety, stress and composite mental health scores
0.93, 0.86, 0.87 and 0.94, respectively, thus indicating a
were found to be 0.93, 0.86, 0.87 and 0.94, respectively, thus indicating a good internal
individual and xi’sare the covariates, the equation is 4
good internal consistency of the DASS-21 scale
5 consistency of the DASS-21 scale
given by
a. Normal Mild Moderate Severe Extremely severe
where α is the intercept βi’s are regression 21.01
coefficients. All the analysis have been done in 36.96 33.92
STATA 14.2. 10.38

23.80
13.16
20.25 20.76
Results 15.95
7.85 9.37 9.62
The sample demography is given in table 2.

26.08 26.08 24.81
Table 2: Descriptive statistics of the sample DEPRESSION ANXIETY STRESS

characteristics (N=395)
Normal Mild Moderate Severe Extremely severe
b.
Sample
N(%) 7
characteristics UNIVERSITY 22.45 6.12 15.31 28.57 27.55
STRESS
6-47 (Mean- COLLEGE 26.4 10.4 22.8 23.6 16.8
Age
20.52±3.59) SCHOOL 21.28 12.77 21.28 14.89 29.79
Gender Male 110(27.85) UNIVERSITY 22.45 8.16 16.33 10.2 42.86

ANXIETY
Female 285(72.15) COLLEGE 27.2 10.8 22.8 11.6 27.6
Residence type Urban 327(82.78)

SCHOOL 27.66 4.26 14.89 4.26 48.94
Rural 68(17.22)
UNIVERSITY 17.35 4.08 15.31 19.39 43.88
DEPRESSION
28.8 9.6 15.6 12.4 33.6

Average monthly less than
COLLEGE
89(22.53)
family income Rs.20,000/- SCHOOL 29.79 6.38 19.15 4.26 40.43
Rs. 20,001/- to
174(44.05) 1 Figure 1: Mental
Figure 1: Mental health statushealth status
of a. all students; and of a. allacross
b. students students;
school, college and
80,000/- 2 university
3 and b. students across school, college and
Rs.80,001/- to 4 Overall, the sampled students are mostly depressed, anxious and stressed (Figure 1a.). More
university
80(20.25)
Rs. 1.50,000/- 5 students had normal level of depression and anxiety than stress. Higher percentage of
6 students were extremely severely depressed than stressed. The majority of university students
more than Rs. Overall, the sampled students are mostly depressed,
52(13.16) 7 are observed to be extremely depressed (40.43%) and anxious (43%), whereas maximum
1,50,000/- 8 anxious
school students and stressed
are extremely (Figure
stressed (29.79%). More
1a.).college
The maximum studentsstudents
are found to
Education level School 47(11.9) 9 had
be mostlynormal level
having a normal mental ofhealthdepression
status (Figure 1b.). and anxiety than
College 250(63.29) 10 stress. Higher

Some pertinent questionspercentage
were asked around theofsystem
students were toextremely
of online education the students to
University 98(24.81) 11 severely depressed

determine the source than
of their poor mental stressed. The majority of
health.
Type of Education 12 university students

As observed from Figure are of observed
2, that majority to be
the students be it school, extremely
college or university,
Private 185(46.84) 13 depressed
miss interacting with (40.43%)
their friends andandteachersanxious
(>80%). The (43%), whereas
college students missed
institution interaction with teachers and friends maximally followed by university students and school
Government 210(53.16)
14
maximum school students are extremely stressed
15 students. Almost more than 80% of the students from school, college and university are
(29.79%). The maximum college students are found
Stream of educa- 16 feeling that their careers are going to be affected. The university students felt most strongly
Science 228(57.72) to bethe mostly
deficiency in having
learning in anaonline
normal mental health status
tion 17 about mode (82%), followed by college (73%) and
18 (Figure 1b.).
school students (60%). The college and university students were more bothered about
Humanities 73(18.48) 19 examinations getting cancelled or delayed.
Commerce 62(15.7) Some pertinent questions were asked around
Others 32(8.1) the system of online education to the students to 8
determine the source of their poor mental health.

Total N 395
As observed from Figure 2, that majority of the
students be it school, college or university, miss
interacting with their friends and teachers (>80%).
The college students missed interaction with teachers

18
and friends maximally followed by university Discussion

students and school students. Almost more than 80% The overall mental health plot (figure 1a) shows that
of the students from school, college and university only 25% have normal mental health and 75% suffers
are feeling that their careers are going to be affected. from stress, anxiety and depression. It is the logical
The university students felt most strongly about reflection of the current time, as stress, depression
the deficiency in learning in an online mode (82%), and anxiety all are related to reactions to any reason
followed by college (73%) and school students (60%). that causes imbalance to our physical and mental
The college and university students were more well being 19. It was interesting to note that extreme
bothered about examinations getting cancelled or stress was less than extreme depression and anxiety.
delayed. It was reported in China that depression and anxiety
100.00 increased during COVID pandemic 20. The college
93.88
90.00 85.11
90.00 90.82
86.80
83.60 83.67
students appear to be least affected by the lockdown
82.98
80.00
80.85
situation of the pandemic. It was also observed that
70.00 students of university suffered more depression and
60.00 anxiety, though stress level of all students were the
50.00 same. Anxiety happens due to worrying over future
and depression comes from past experiences 21. As
40.43
40.00 36.17
30.00 26.80
21.60 22.45
university students have appreciable past experiences
as well as concern for the near future hence anxiety
18.37
20.00
10.00
and depression is more for them. Similar conclusions
0.00
Miss interacting with Miss interacting with Feel that it is going to Think you are learning Like that examinations were also drawn from a survey conducted with the
your friends your teachers * have an effect on your as much as before ** are getting
career cancelled/delayed * University students in Spain 22. The school students
1
School College University
due to their age and security of parents and family
2 Figure 2: Effect
Figure 2: Effect of the onlineof the
mode online
of education mode
through of education
relevant questions and less responsibility are at a better mental state in
3
4
through relevant
Regression Analysis
questions this uncertain times.
5 The regression model was run that showed all the indicators of DASS-21 questionnaire can
For further investigation we correlated the answers
6 Regression Analysis
capture the anxiety, depression and stress measure significantly well (p<0.01). Unit increase
of the questions to their state of mental health. It
7 in age caused a significant increase in depression (OR: 1.958; p<0.01), stress (OR: 1.947;
8 The regression
p<0.01), anxiety (OR: 1.021;model
p<0.01)and was runhealth
overall mental thatscoreshowed all the
(OR: 1.830; p<0.05). was seen that the strongest correlation is found for
9 indicators
Females were found ofto DASS-21
be more likely toquestionnaire canmales
have poor mental health than capture
(Depression-the the question that talks about their career. Hence for
OR: 1.170; p<0.05; Anxiety- OR: 1.239; p<0.10; Stress- OR: 1.152; p<0.05; Composite
university students as there are at the threshold of
10
11
anxiety, depression and stress measure significantly
Mental Health Score- OR: 2.5; p<0.10). With increasing average monthly family income the
12 well
mental (p<0.01). Unit thus
health status improved, increase in agevulnerability
indicating economic causedisarelated significant
to poor their career, they are suffering maximum anxiety and
13 increase in depression
mental health (Composite Mental Health (OR:
Score- OR: 1.958; p<0.01),
1.011; p<0.10). stress
In comparison (OR:
to school depression. 90% of university students also answered
14 students, the college and university students were significantly more likely to suffer from
1.947; p<0.01), anxiety (OR: 1.021; p<0.01)and overall positively when they were asked whether it is going
15 depression, anxiety, and stress. Students who felt that their careers are going to be
16 mental
affected were health score
more likely to have poor(OR: 1.830;
mental health p<0.05).
(Depression- OR: 2.609;Females
p<0.01; to affect their career (figure 2).It is interesting to
17 were found to be more likely to have poor
Anxiety- OR: 2.418; p<0.05; Stress- OR: 1.876; p<0.10; Composite Mental Health mental
Score- note that 90% of them also said they miss interacting
18
health than males (Depression- OR: 1.170; p<0.05;
OR: 2.142; p<0.05).
with their friends and teachers. However the poor
Anxiety- OR: 1.239; p<0.10; Stress- OR: 1.152; p<0.05; 9 correlation of it with mental state shows that it is not
Composite Mental Health Score- OR: 2.5; p<0.10). influencing their mental health. The 90% of university
With increasing average monthly family income students also stated that they are not learning
the mental health status improved, thus indicating adequately, however that is also not affecting the
economic vulnerability is related to poor mental mental health state. It can be concluded that for the
health (Composite Mental Health Score- OR: 1.011; students the impact that COVID will have on their
p<0.10). In comparison to school students, the college career bothers them maximally leading to high level
and university students were significantly more of depression and anxiety. Career development has
likely to suffer from depression, anxiety, and stress. a profound effect on mental health and counselling
Students who felt that their careers are going to be is suggested 23. A study on medical students of
affected were more likely to have poor mental health China and India also revealed that the pandemic
(Depression- OR: 2.609; p<0.01; Anxiety- OR: 2.418; is influencing their career choice and mental health
p<0.05; Stress- OR: 1.876; p<0.10; Composite Mental in a negative way 24,25. It was seen that with age the
Health Score- OR: 2.142; p<0.05). mental health deteriorates. Previous studies suggest

that the correlation of age with mental health is not Acknowledgement

very straight forward and many other factors need Dr. Agnita Kundu acknowledges Shri Shikshayatan
to be considered 26. Also it was seen that the female College for their support.
respondents have poorer mental health than their
male counter parts. The gender difference in mental Funding
health has been observed before and documented in
The article was written with no financial assistance
the pre pandemic era 27, and it has also been studied
and supported by study done in Austria and India
Conflict of Interest
28,29
. Therefore it is important that mental health
problems in students are addressed adequately and The authors declare no conflict of interest.
educational institutions can take a positive role in it. Ethical concerns
The students need the support of their peer group of
other students as well as their teachers. Some schools The study is an independent research and therefore
also has academic and psychological counsellor who informed consent clearance was considered. An
can help. However though education institutes have informed consent was obtained prior to the starting
opened there is still considerable opposition about of survey and the participants were informed about
sending children to school at present. A before and the purpose of the study.
after study in Italy showed that mental health of References
students was worse after the lockdown than before.
1. Rossen E, Cowan KC. Improving mental health in
However they also observed that after the lockdown
schools. Phi Delta Kappan. 2014 Dec 1;96(4):8–13.
was over students got back to their previous mental
health status 30. Therefore it is important for students 2. Times of India. 3 Kolkata schools shut as students,
to experience pre-lockdown status as much as possible teacher found Covid-19 positive | Kolkata News - Times
albeit with proper precautions. of India [Internet]. 2021 [cited 2021 Nov 11]. Available
from: https://timesofindia.indiatimes.com/city/
Conclusions kolkata/3-kolkata-schools-shut-as-students-teacher-
found-covid-19-positive/articleshow/81672017.cms
The first measure to curb COVID was imposition
of a lockdown all over the world. The educational 3. Zee Media Bureau. Schools, colleges shut in these 13
instituions deal with one of the most vulnerable states due to rise in COVID-19 cases | India News
population of the society, the chidren, the future | Zee News [Internet]. 2021 [cited 2021 Nov 29].
generation Online mode of classes had kept the Available from: https://zeenews.india.com/india/
education of the students functional however there schools-colleges-shut-in-these-13-states-due-to-rise-
in-covid-19-cases-2353855.html
was considerable lack of normalcy in their life which
leads to mental health issues. The online survey 4. Thakur A. Mental Health in High School Students at
conducted on 395 students across school, college the Time of COVID-19: A Student’s Perspective. J Am
and university to assess their mental health showed Acad Child Adolesc Psychiatry. 2020 Dec;59(12):1309–
some interesting results. Their mental health was 10.
assessed by the DASS-21 questionnaire. It was seen 5. Wieczorek T, Kołodziejczyk A, Ciułkowicz M,
that students are suffering from stress, anxiety and Maciaszek J, Misiak B, Rymaszewska J, et al. Class of
depression. University students possess very poor 2020 in Poland: Students’ Mental Health during the
mental health. The mental health also deteriorated COVID-19 Outbreak in an Academic Setting. Int J
with age. Female students showed poorer state of Environ Res Public Health. 2021 Jan;18(6):2884.
mental health than male students. The concern for 6. Chaturvedi K, Vishwakarma DK, Singh N. COVID-19
their career was found to be responsible for the poor and its impact on education, social life and mental
mental health of the students. It is suggested that health of students: A survey. Child Youth Serv Rev.
support and counselling is needed for the students 2021 Feb 1;121:105866.
of all ages even after educational institutions have 7. Schneider W, Waldfogel J, Brooks-Gunn J. The Great
opened up. Recession and risk for child abuse and neglect. Child
Youth Serv Rev. 2017 Jan 1;72:71–81.

20
8. Gonzales G, Loret de Mola E, Gavulic KA, McKay T, 17. MOHFW. Guidelines for COVID-19 vaccination of
Purcell C. Mental Health Needs Among Lesbian, Gay, children between 15-18 years and precaution dose to
Bisexual, and Transgender College Students During HCWs, FLWs & 60+ population with comorbidities
the COVID-19 Pandemic. J Adolesc Health. 2020 Nov [Internet]. 2022. Available from: https://www.mohfw.
1;67(5):645–8. gov.in/pdf/Guidelinesfor COVID19V accination of
Children between 15 to 18 years and Precaution Dose
9. Gupta R, Agrawal R. Are the concerns destroying
to HCWs FLWs & 60 population with comorbidities.
mental health of college students?: A qualitative
pdf
analysis portraying experiences amidst COVID-19
ambiguities. Anal Soc Issues Public Policy [Internet]. 18. Times of India. Covid vaccination for 12-14 age group
[cited 2021 Nov 29];n/a(n/a). Available from: https:// from March 16; comorbidity clause for 60+ removed. The
onlinelibrary.wiley.com/doi/abs/10.1111/asap.12232 Times of India [Internet]. 2022 Mar 14 [cited 2022 Apr
9]; Available from: https://timesofindia.indiatimes.
10. Sayeed A, Kundu S, Banna MdHA, Hasan MT, Begum
com/ india/ covid-vaccination-for-children-in-12-14-
MR, Khan MSI. Mental health outcomes during the
yrs-group-to-begin-from-march-16-says-union-health-
COVID-19 and perceptions towards the pandemic:
minister-mandaviya/articleshow/90198232.cms
Findings from a cross sectional study among
Bangladeshi students. Child Youth Serv Rev. 2020 Dec 19. Rehman U, Shahnawaz MG, Khan NH, Kharshiing KD,
1;119:105658. Khursheed M, Gupta K, et al. Depression, Anxiety and
Stress Among Indians in Times of Covid-19 Lockdown.
11. Dubey S, Dubey MJ, Ghosh R, Chatterjee S. Children
Community Ment Health J. 2021 Jan 1;57(1):42–8.
of frontline coronavirus disease-2019 warriors: our
observations. J Pediatr. 2020 Sep 1;224:188–9. 20. Li Y, Zhao J, Ma Z, McReynolds LS, Lin D, Chen Z, et
al. Mental Health Among College Students During the
12. Westrupp EM, Bennett C, Berkowitz T, Youssef GJ,
COVID-19 Pandemic in China: A 2-Wave Longitudinal
Toumbourou JW, Tucker R, et al. Child, parent, and
Survey. J Affect Disord. 2021 Feb 15;281:597–604.
family mental health and functioning in Australia
during COVID-19: comparison to pre-pandemic data. 21. Wheatley D. Stress, Anxiety and Depression. Stress
Eur Child Adolesc Psychiatry [Internet]. 2021 Aug Med. 1997;13(3):173–7.
21 [cited 2021 Nov 29]; Available from: https://doi.
22. Marques G, Drissi N, Díez I de la T, de Abajo BS, Ouhbi
org/10.1007/s00787-021-01861-z
S. Impact of COVID-19 on the psychological health of
13. Lathabhavan R, Griffiths M. First case of student university students in Spain and their attitudes toward
suicide in India due to the COVID-19 education Mobile mental health solutions. Int J Med Inf. 2021 Mar
crisis: A brief report and preventive measures. Asian 1;147:104369.
J Psychiatry. 2020 Oct;53:102202.
23. Herr EL. Career development and mental health. J
14. Kakodkar P. Survey: 37% poor rural students not Career Dev. 1989 Sep 1;16(1):5–18.
studying at all. The Times of India [Internet]. 2021
24. Saraswathi I, Saikarthik J, Kumar KS, Srinivasan KM,
Sep 7 [cited 2021 Nov 29]; Available from: https://
Ardhanaari M, Gunapriya R. Impact of COVID-19
timesofindia.indiatimes.com/home/education/
outbreak on the mental health status of undergraduate
news/survey-37-poor-rural-students-not-studying-at-
medical students in a COVID-19 treating medical
all/articleshow/85991577.cms
college: a prospective longitudinal study. PeerJ. 2020
15. Elmer T, Mepham K, Stadtfeld C. Students under Oct 16;8:e10164.
lockdown: Comparisons of students’ social
25. Zheng Q, Lin X, He L, Freudenreich T, Liu T. Impact
networks and mental health before and during the
of the Perceived Mental Stress During the COVID-19
COVID-19 crisis in Switzerland. PLOS ONE. 2020 Jul
Pandemic on Medical Students’ Loneliness Feelings
23;15(7):e0236337.
and Future Career Choice: A Preliminary Survey
16. WHO. COVID-19 advice for the public: Getting Study. Front Psychiatry. 2021;12:860.
vaccinated [Internet]. 2021 [cited 2021 Dec 13].
26. Gaitz CM, Scott J. Age and the Measurement of Mental
Available from: https://www.who.int/emergencies/
Health. J Health Soc Behav. 1972;13(1):55–67.
diseases/novel-coronavirus-2019/covid-19-vaccines/
advice

27. Rosenfield S, Mouzon D. Gender and Mental Health. 29. Pieh C, Budimir S, Probst T. The effect of age, gender,
In: Aneshensel CS, Phelan JC, Bierman A, editors. income, work, and physical activity on mental health
Handbook of the Sociology of Mental Health [Internet]. during coronavirus disease (COVID-19) lockdown in
Dordrecht: Springer Netherlands; 2013 [cited 2021 Austria. J Psychosom Res. 2020 Sep 1;136:110186.
Nov 29]. p. 277–96. (Handbooks of Sociology and
30. Meda N, Pardini S, Slongo I, Bodini L, Zordan MA,
Social Research). Available from: https://doi.
Rigobello P, et al. Students’ mental health problems
org/10.1007/978-94-007-4276-5_14
before, during, and after COVID-19 lockdown in Italy.
28. Chhetri B, Goyal LM, Mittal M, Battineni G. Estimating J Psychiatr Res. 2021 Feb 1;134:69–77.
the prevalence of stress among Indian students during
the COVID-19 pandemic: A cross-sectional study from
India. J Taibah Univ Med Sci. 2021 Apr 1;16(2):260–7.

Critical Analysis of Case Based Learning as a Teaching

Learning Method in Medical Education.
Ajay Khade1, Jyoti Wahane2

1
Professor, Datta Meghe Medical College, Nagpur
2
Assistant Professor, Govt. Dental College, Nagpur
How to cite this article: Ajay Khade, Jyoti Wahane et al Critical Analysis of Case Based Learning as a Teaching
Learning Method in Medical Education. Volume 13 | Issue 4 | October-December 2022
Abstract
Various teaching-learning methods are used in imparting medical education. Case Based Learning (CBL) is one of the
teaching-learning methods in which clinical cases are used for teaching. It was first used by Dr James Smith, pathologist,
in 1912 in Edinburg, wherein the students correlated the clinical records of patients with the post mortem findings. The
use of CBL in teaching medical students was extensively searched in PubMed search engine. Full text articles related to
CBL studies conducted in medical colleges were included. 6 relevant articles were selected and a critical analysis was
done. Most of the studies compare CBL with didactic lecture and found to be more effective. These studies are limited to
one college and sample size is small. CBL correlates the theory with practice. The students learn many skills like critical
thinking, higher order thinking, self-directed learning and working in a team. Thus, the learner will become a successful
Indian Medical Graduate (IMG).
Keywords: Case based learning, Medical education
Introduction In traditional medical curriculum, teaching was

Recently the National Medical Commission (NMC) given more importance but nowadays this has been
had entirely revamped the medical curriculum in shifted to learning i.e., it has become learner centric.
India. The age old traditional medical education Learning is defined as the change in behavior of
is replaced by Competency Based Medical an individual. One of the roles assigned to IMG is
Education (CBME)1. This endeavor is to bring the Lifelong Learner. Teaching facilitates learning and it
Indian Medical Graduate (IMG) at par with global is not merely for dissipating knowledge but to imbibe
standards. Competency is defined as the observable skills, communication, attitudes, values among the
activity of the health professional with a judicious learner. Here comes the role of teaching -learning
and consistent mix of knowledge, skills, attitudes methods.
and communication2. Competency forms the basis Case Based Learning (CBL)is one of the teaching
of CBME. These competencies are subdivided into learning methods and it refers to use of clinical cases
learning objectives which are matched with teaching to help teaching3. The first reference of CBL is by Dr
learning methods and assessment.
Dr. Ajay Khade
Professor (Pharmacology)
Datta Meghe Medical College, Nagpur, Maharashtra
e-mail : [email protected]
Contact No. 8019324493
James Smith Professor of Pathology at university of A cross-sectional study was conducted by Sangam
Edinburgh in 1912.The students correlated the clinical et al.in 200, 1st MBBS students of a private medical
history of patient along with signs and symptoms college in A.P. The students were exposed to CBL
with the post mortem findings and this was verified and didactic lecture on a topic in Gross Anatomy i.e.,
from patient’s clinical records. According to Axilla and Front of Thigh. Later, crossover was done.
Thistlewaite et.al, the goal of CBL is to make use of Students were divided into 5 groups of 20 each. Pre
authentic clinical cases in order to prepare students and posttest on MCQ s were conducted. Improvement
for clinical practice and CBL links theory to practice in test score was observed. This study is conducted in
as the knowledge learned is applied to the cases by a small sample size limited to 1st MBBS students of a
making use of inquiry-based learning as a method4. private medical college and 2 topics of Gross anatomy.
The students come to know what is being practiced In fact, the topics on which CBL can be conducted be
clinically or real-world situation. The method of identified and a large sample size will be required to
delivery can be live presentation by a computer or validate the advantage of CBL6.
web based.
Patrick et.al compared CBL and didactic lecture
Objectives in Pharmacology and evaluate students and faculty
perception of CBL in 140, 2nd MBBS students. Pre-
To critically review the literature related to case-based
session and post-session test of 15 MCQs was
learning and analyze it.
conducted. The CBL was conducted for Tuberculosis.
Material And Methods The long-term outcome is not assessed and the sample
size is small. A large study is required to validate the
A literature search with PubMed database was
advantages of CBL. Many topics in Pharmacology can
conducted. The use of CBL in medical education was
be clinically correlated e.g., Hypertension, angina,
searched. Keywords used were CBL and medical
anemia, malaria, etc. Even the topic of Tuberculosis
education. The full text articles related to CBL study
can be horizontally integrated with Pathology and
in medical colleges were included while the studies
Microbiology and students can learn the disease
conducted in dental, other allied subjects were
excluded. condition in a holistic manner7.
Gartmeier et al. screened 19 CBL videotapes of
Critical Analysis
Internal medicine and Surgery to analyze teacher’s
Gupta conducted a CBL study in neurophysiology question and student’s responses. It was found that
among 100 first year MBBS students.2 CBL sessions medical teachers asked closed questions reasoning
were conducted. Didactic lecture followed by a type. This study was conducted among medical
pretest (5 MCQ) was given to the students. These students in Munich Germany. The study is limited to
students were divided into 9 groups. A clinical case questions and responses asked in CBL in Medicine and
was allotted by facilitator which was followed by Surgery. It highlights the importance of questions i.e.;
group discussion, presentation, open discussion open and reasoning questions gives student freedom
and posttest. Student’s perception about the CBL to reflect and clinical thinking will be stimulated8.
was assessed by a questionnaire. Similar 2nd CBL
The study of Singhal is limited to CBL in
session was conducted after 15 days. It was found
Microbiology conducted among 100, 2nd professional
that post test scores significantly increased on both
MBBS students.4 clinical cases on Staphylococcus,
CBL and student’s perception was positive. The
Streptococcus, Enterococcus, Hepatitis A virus were
present study included only 89 students. The topics
allotted one week before. The groups were crossover
in neurophysiology is not mentioned. It is not clear
after 2 CBL session. Post test was conducted after
the significance of conducting didactic lecture session
the session and repeat after 6 weeks. Feedback
when the study does not compare CBL session and
questionnaire was sought from students as well as
didactic lecture. The pretest score was conducted after
faculty. There was improvement in scores significantly.
didactic lecture and compared with posttest score
The study is limited to bacteriology topic conducted
after CBL. The pretest SCORE might be influenced by
in small sample size among 50 students in one group.
learning in didactic lecture5.
The better post test score after 6 weeks emphasizes
the retention of the concepts learned in CBL9.

24
Vora MK conducted a CBL study in Pharmacology Proposed Implementation Plan/Translatory

topics (Iron deficiency anemia & Plasmodium Component
falciparum malaria in pregnancy) among 68 MBBS As per the NMC guidelines, various modules like
fifth semester students divided in 2 groups, CBL AETCOM module, SDL module and Pandemic
and didactic lecture. The Post test score (15 MCQs) module is included in the curriculum. The CBL can
for CBL group was more than didactic lecture group. be implemented in the SDL module and it can be
The CBL group expressed positive perception about horizontally integrated. Being a Pharmacologist, I will
learning by CBL. The CBL session was conducted try to introduce CBL in the subject of Pharmacology.
in 2 sessions and each session was allotted 2-hour Considering the entire syllabus of Pharmacology for
time and didactic lecture was taught for 1 hour. The 2nd MBBS students, the topics which can be taught on
better posttest score might be due to extensive time the basis of clinical cases and which are also common
allotted for CBL and students might have understood in Pathology and Microbiology, will be identified.
the concept better reflecting in the enhanced score. These can be Drug treatment of Tuberculosis, Malaria,
Didactic lecture has its own importance in teaching Leprosy, HIV etc. The 2nd MBBS students will be
general pharmacology. This study is conducted in a allotted clinical cases of respective disease and they
very small sample size. There are only 34 students in will learn the microbiological feature, pathological
one group. The question arises that the findings in the finding and drug treatment of these cases. Thus, the
study might be due to chance factor10. students can learn the disease condition in a holistic
Outcome of Critical Analysis manner by means of CBL.
The CBL is one of the teaching-learning method. Further, a study can be conducted to compare the
The uniqueness about CBL is that the students can CBL for individual subject and CBL that is taught in
apply the knowledge learned to the real-life cases. an integrative manner. Pretest and Post test scores
Ultimately the student is expected the same once he of both modalities will be compared by conducting
completes the course. But the students are initially MCQ based test. Additionally, feedback regarding
trained by means of CBL. This helps to better correlate CBL will be sought from the students and faculty.
the things learned in theory with the clinical aspect Prior conducting the study, a workshop will be
which was otherwise not possible. This does not organized by the medical education department in
demean the importance of didactic lecture. Didactic the college regarding the conduct of CBL. It will be
lecture has its own importance. But certain topics in a Faculty development program so that CBL can be
subject can be taught by means of CBL. This will be in better implemented.
tune with vision 2015 document of Medical Council of
Conclusion
India which stressed the need of IMG to become more
competent and better skilled. The cognitive skills Thus, many studies of CBL are conducted in different
will be enhanced if CBL methodology is used. The subjects but the sample size is small. CBL is a unique
analytical thinking, critical thinking or higher order form of teaching learning modality that links theory
thinking will be developed which will bring a change with practice. The students can learn and remember
in behavior pattern. This is nothing but learning. the concept efficiently. CBL also helps to develop
The problem-solving skills will be developed as many skills amongst the students which can make
the students discuss the clinical case. CBL is learner them a better Indian Medical Graduate.
centric and promotes active and self-directed learning.
Students learn how to make the best use of resources. Conflict of Interest: NONE
This is because of the fact that when a clinical case
is allotted to the students, they will make best use Source of Funding: Self
of resources like books, library, internet together
the information pertaining to the clinical case. Since Ethical Clearance:NA
CBL is a group activity, the student learns leadership References
quality, communication skill, working in a team. This
1. Competency Based Undergraduate Curriculum for
in turn will be helpful to incite professionalism in the
Indian Medical Graduates 2018. Available at https://
students. One of the roles attributed to IMG is lifelong www.nmc.org.in. Accessed June 3rd, 2022.
learner. CBL can lead the pathway towards achieving
this role.
2. Learning Objectives. In Tejinder Singh, Piyush Gupta, 8. Gartmeier M, Pfurtscheller T, Hapfelmeler A et al.
Daljit Singh, editors. Principles of Medical Education. Teacher questions and student responses in case-
5th ed. New Delhi: Jaypee; 2021. p. 40-41 based learning outcomes of a video study in medical
education. BMC Med Educ 2019; 19:455
3. Mclean SF: Case-based learning and its application in
medical and healthcare fields: A review of worldwide. 9. Singhal A. Case-based learning in Microbiology:
J Med Educ and Curr Dev 2016; 3:39-49 Observations from a North West Indian Medical
college. Int J App Basic Med Res 2017;7: S47-51
4. Thistlewaite JE, Davies D, Ekeocha S, et al. The
effectiveness of case-based learning in health 10. Vora MB, Shah CJ. Case-based learning in
professional education. ABEME systematic review: pharmacology: Moving from teaching to learning. Int J
BEME Guide No.23, Med Tech.2012,34:6, e421-44 App Basic Med Res 2015;5: S21-3
5. Gupta R, Grover R. Case-based learning in Authors Contribution:

neurophysiology: An educational paradigm for
preparing undergraduate medical students for better AK and JW contributed to study’s conception and
clinical acumen. Indian J Health Sci Biomed Res 2021; design. AK developed the search strategy, extracted
14:8-9 data and drafted the manuscript. JK revised the
manuscript critically and gave final approval of
6. Sangam MR, Praveen K, Vinay G et al. Efficacy of
the version to be published. The authors read and
Case-based learning in Anatomy. Cureus Dec 2016;
13(12): e20472
approved the final manuscript. The authors declare
that they have read and approved the final manuscript.
7. Patrick S, Vishwakarma K, Singh P, Matreja P. Case
based learning: An effective teaching learning method
in Pharmacology for MBBS students. Int J Health and
Clin Res 2021;4(18):378-381

Use of Social Networking Site and prevalence of Depression among

Medical Students in Vikarabad, Telengana
Ajit Mogalgiddi1, Bukya Kalyani2

1
Assistant Professor, Department of Psychiatry, Mahavir Institute Of Medical Sciences, Vikarabad.
2
Senior Resident, Department of Psychiatry, Mahavir Institute Of Medical Sciences, Vikarabad.
How to cite this article: Ajit Mogalgiddi, Bukya Kalyani et al Use of Social Networking Site and prevalence of
Depression among Medical Students in Vikarabad, Telengana. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Humans are social creatures that require the company of others in order to thrive in life. As a result,
although being socially connected with other people might help to reduce stress, anxiety, and melancholy, a lack of social
connection can put one’s mental health at danger.
Objective: To study and establish correlation between the use of Social Networking sites and depression among medical
students in a single center study.
Methods: A cross-sectional research was done among 200 medical college undergraduate students. A systematic
questionnaire was used to obtain data about medical students’ individual characteristics and use of social media sites.
The Zung Self-Rating Depression Scale were used to assess anxiety and depression. The prevalence was calculated as a
percentage, and the association was assessed using the Mann-Whitney U-test.
Results: Association between frequency of use of SNS and Depression is more in students who use 1-3 times in a day 20%
and in the students who used atleast 1hr it is 19.23% ,in students who use 4-7 times is 15.38% whereas in students who
use 8-23 times it is 17.54%. The students who were awake early morning and used SNSs often was more 25% than those
who were awake sometimes (15%) and never (18%) similarly the students who spent late nights in using SNSs was more
among who were often awake late night (25%) than those who were awake late night Sometimes (14.6%) and never (19%).
Conclusion: The current study found that SNS use was nearly ubiquitous among study participants, with the majority of
them being heavy SNS users. A large percentage of medical students show a strong preference for SNSs. Intense usage of
social media sites, especially use at unusual hours, was shown to be strongly (although not statistically significant) linked
to depression. Despite the fact that the problem is still relatively new, it is significant enough to warrant attention. To solve
the complicated relationship between social media use and mental health concerns, further study is needed.
Keywords: Addiction, Depression, Social Networking Sites , Zung Self-Rating Depression Scale
Introduction of social media sites, with 71 % of them accessing

Social networking sites (SNS) are a collection of several sites, with Facebook being the most popular
web-based apps that allow users to create and share (41 %).[2] With over one billion active Facebook users,
user-generated content. The last decade has seen a it’s easy to see how significant these sites are in our
significant shift in the area of communication, thanks everyday lives.[3]
to the rapid growth of social networking, which has SNS is a double-edged sword. They’re utilised to
had a big impact on how people engage with one help students achieve academic success. Excessive
another, and is sometimes the only means of contact.[1] usage of online social networking sites, on the other
According to a 2015 study, teenagers are heavy users hand, can lead to addiction and dependency, as well
Dr. Ramadugu Shashikumar
Professor and HOD, Department of Psychiatry, Mahavir Institute Of Medical Sciences, Vikarabad.
Email: [email protected]
as sleep disturbances and depression.[4] A correlation and/or Students using medication for any psychiatric
between online social networking and mental health illness were excluded from the study.
has been highlighted in recent studies. Because social
networking sites are becoming increasingly popular Study tools:
among today’s youth, any postulated mental illnesses 1. Structured Questionnaire for assessment of
linked to them might constitute a severe public health the use of SNSs.
hazard, possibly resulting in a global cyber-epidemic. 2. Zung Self-Rating Depression Scale.
The most worrying aspect is that most users are
already addicted to social media and are unaware of The section of a questionnaire for assessing the
its detrimental effects.[5] use of SNS and its effect on daily life was pretested
in a similar population and validated with the
According to a recent meta-analysis, 75% of help of psychiatrists, public health specialists, and
medical students use social media on a daily basis, sociologists. For assessing the use of SNSs, the
including compulsive/compensatory use, and India participants were asked whether they have any
is no exception.[6] It is generally known that medical account in any of the SNS and instant messaging
students experience much higher levels of stress, application. If yes, they were asked to state how many
which has an impact on their academics, physical times in a day, on average, they visited the site (s)
wellbeing, and psychological wellbeing. As a result,
in the last 7 days. They were also asked to state the
medical students are not impervious to depression
average duration they spent on each visit in the last
and anxiety.
7 days. They were also asked whether they wake up
In India, evidence on the extent of SNS usage and early or went to bed late to spend time in SNSs. Their
its relationship to medical students’ mental health is perceived ability to spend a day without SNSs was
limited. The current study was undertaken to analyze also enquired. Effect of spending time in SNS on their
the pattern of SNS usage, the prevalence of depression, self-confidence and their satisfaction with use were
and their association among undergraduate assessed. Zung self-rating depression scale was used
medical students in a Medical College in Vikarabad, for assessing depression.
Telengana, based on the data available.
Method of data collection:
Material and Methods The study was approved by the Institutional Ethics
Committee of the Medical College. After taking
Study design, setting and duration: informed consent, the structured questionnaire in
A cross-sectional study was conducted among the English was given to the selected students to gather
undergraduate medical students who were enrolled information regarding their sociodemographic
in college during 2016 and 2019 academic years in a characteristics such as age and gender. The pattern
Medical College in Vikarabad, Telengana enrolling of use of SNS and its effect on their daily lives was
150 students per year between June and August 2020. assessed along with screening of depression.
Sample size and technique: Statistical analysis: SPSS 22 software was used for
statistical analysis and the data was presented in the
The available literature showed that the proportion
form of tables and graphs.
of medical students using SNS ranged from 67% to
75%.[6] Considering the proportion of students using Observation and Results
one or more accounts of SNSs as 67%, observing the
confidence level of 95%, the relative precision of 10%, Characteristics of study subjects
the final sample size was 189 which was rounded off The final analysis was performed with a filled-in
to 200. The number of enrolled students was same in questionnaire of 200 medical students enrolled in
each batch (year-group), 100 students from each batch Mahavir Institute of Medical Sciences, Vikarabad,
were selected through simple random sampling as Telengana. More than half of the students aged 21–23
per Attendance Register of the College. As per the years while the mean age (± standard deviation) of
diagnosis of psychiatric diseases and/or psychotropic the sample was 21.6 (±1.8) years. Female students
drugs may alter the use of social networking sites, (54.7) outnumbered the male students (45.3)
students with clinically diagnosed psychiatric illness

28
Use of Social Networking Sites One-fourth (11.3%) students were either not sure
100% of the students used Social Networking Site. or expressed their inability to spend a day without
More than half of the students used less than three SNSs. Around 36.6% reported that they could spend
Social networking sites (54.7) and two fifths used more a day without SNSs at particular times. Only 63.3%
than three Social networking sites (45.3). “WhatsApp” felt satisfied with the use of SNSs and another 36.3%
is the most commonly used SNS (95.9%) followed were not satisfied.
by “Facebook” (89.4%) and “Instagram” (30.5%). Table 2 : Association between Use of SNS and
Communication with the friends and families was the Depression
most common (59.0%) reason for using SNSs which Variable Category n With p
was followed by entertainment (43.1%) ,education depression
and professional activities (31.4%). Depression Normal 124
Table 1 : Distribution of study participants severity
according to Use of Social Networking Sites Mild 26
depression
Variables Categories n (%)
No of SNS 0.1640
Frequency of use per Atleast hourly 26(17.3%) use
day
<3 82 11 (13.4%)
8 -23 times in a day 57 (38.0%) >3 68 15 (22.05%)
4-7 times in a day 52 (34.6%) Duration 0.9669
1-3 times in a day 15 (10.0%) of SNS use
Duration of use per Always open 13 (8.7%) (hrs)
day <2 hrs 33 5 (!5.15%)
4-23 hrs 33 (22.0%) 2-4 hrs 71 13(18.30%)
2-4 hrs 71 (47.3%) 4-23 hrs 33 5 (15.15%)
< 2hrs 33 (22.0%) Always 13 2 (15.38%)
active
Used early morning Often 4 (2.7%)
Frequency 0.9639
Sometimes 40(26.6%) of SNS use
Never 106(70.7%)
Atleast 1 hr 26 5 (19.23%)
Used late night Often 24 (16.0%)
1-3 times in 15 3 (20%)
Sometimes 89 (59.3%)
a day
Never 37 (24.6%) 4-7 times in 52 8 (15.38%)
Stated ability to Unable 24 (16.0%) a day
spend a day without 8-23 times 57 10 (17.54%)
accessing SNSs
in a day
Not sure 17 (11.3%) Used early 0.8429
Sometimes 54 (36.0%) morning
Certainly 55 (36.6%) Never 106 19 (18%)
Often 4 1 (25%)
Less than one third (17.3% )of the students, had
Sometimes 40 6 (15%)
accessed SNSs at least once in an hour, while most
Used late 0.4697
of them (38.0%) accessed at least 8 - 23 times in a
nights
day. Around one-tenth students (10.0%) accessed
Never 37 7 (19%)
SNSs 1–3 times in a day, rest were an occasional user.
Often 24 6 (25%)
Around 47.3% of the students accessed SNSs for at
Sometimes 89 13 (14.6%)
least 2 - 4 hours in a day and 8.7% students remained
Able to 0.8774
active on SNSs through out the day. One-fifth of the
spend a day
students(26.6%) in this were sometimes waking up
without
early and less than half of students (16.0%) often accessing
went to bed late night to spend time on SNSs and SNS
another 59.3% were active for sometime during night. Not sure 17 3 (17.64%)

Variable Category n With p Students who were sure that they could spend a
depression day without SNS were likely to score less on Zung
Certainly 55 9 (16.66%) self rating depression scale,the difference was not
Sometimes 54 11 (20%) statistically significant (p=0.8774).
Unable 24 3 (12.5%) Discussion
Prevalence Of Depression While social media’s communication capabilities
As per Zung Self Rating Depression scale 17.3% have positively impacted the lives of young adults all
students had Mild Depression. over the world, it also has the potential to negatively
impact young people’s development and wellness.
Association between Use of Social Networking Site The debate is on whether social media and instant
and Depression messaging apps are the reasons that cause mental
Association between use of social networking illnesses, or if increased case detection and societal
site and depression was more in the students who concern are the variables that contribute to an increase
accessed more than three SNS 22.05%, than who in the number of cases of mental disorders among
accessed less than three SNS 13.41%. Similarly, adolescents and teenagers.
students who accessed SNS for 2 - 4hrs scored more
Use of social networking sites:
on Zungs Self Rating depression scale 18.3%, students
who were always active scored 15.38% and students Face-to-screen interaction is considerably more than
who were less than 2hrs active scored 15.15%. face-to-face interaction, attributable to the growing
popularity of social networking sites. Which can
Association between frequency of use of SNS and contribute to despair, loneliness, and anxiety when
Depression is more in students who use 1-3 times in individuals around you are performing better jobs,
a day 20% and in the students who used atleast 1hr or it can assist depressed people who are socially
it is 19.23% ,in students who use 4-7 times is 15.38% isolated connect, take suggestions, and join online
whereas in students who use 8-23 times it is 17.54%. support groups.
The students who were awake early morning and
used SNSs often was more 25% than those who were In the current study, the use of SNS was ubiquitous
awake sometimes (15%) and never (18%) similarly among undergraduate medical students, with more
the students who spent late nights in using SNSs was than two-fifths of them utilizing three or more SNSs.
more among who were often awake late night (25%) WhatsApp was the most popular platform, followed
than those who were awake late night Sometimes by Facebook, with >90.0 % of study participants
(14.6%) and never (19%). using both, corroborating previous research in India.
Although the percentages of respondents who use
The Zung self-rating depression scale score was Facebook and WhatsApp were greater than in prior
greater among students who used more than three studies,[7] rates similar to those identified in our
SNSs than among students who used less than three survey have been recorded among adolescents. In
SNSs, although the difference was not statistically India[8], US,[9] medical students in Australia,[10] and
significant (p = 0.1640). Similarly, students who used UK.[11]
SNSs for 2-4 hours scored better than those who used
them for 2 hours, 4 hours, or 23 hours, although the In terms of SNS use, the medical students in this
difference was not statistically significant (p=0.9669). research were heavy users, with almost one-third of
Similarly, students who used 1–3 times per day the students using SNSs at least once per hour and
scored better than those who used at least an hour, nearly 60.0 percent using SNSs at least once every
4–7 times per day, although the difference was not day. This points to substantial and regular usage
statistically significant (p=0.9639). Students who among the participants, which is consistent with Goel
spent time in SNS early in the morning or late at night et al. and Hall et al.’s research.[12]
were more likely to have a higher Zung self-rating
The usage of social networking sites and the
depression scale score, although the difference was
probability of depression:
not statistically significant. (Early morning p=0.8429
),(Late night p= 0.4697). Affective disorders like depression have been
shown to have a bidirectional relationship with the

30
individual’s social environment, which influences Strength and Limitations

the development and persistence of disease. The This study aimed to gather empirical evidence on
social qualities of people with mental illnesses have a the correlation between SNS use and depression
direct impact on their sense of well-being. According among medical students in an Indian socio-cultural
to current mental health theories, contentment is environment, where data on the topic is limited.
not synonymous with mental disease; a full model Instead of a full clinical interview, which can lead to
of mental health necessitates not just the absence of an overestimation of the workload, the screener tool
psychopathology, but also an emphasis on positive was employed to evaluate depression in this study.
indicators of functioning such as subjective well- This cross-sectional study may be prone to reverse-
being.[13] Depression has a high rate of comorbidity, causality bias because SNS usage and depression
which can affect the size and structure of a person’s were examined at the same time.
social network. Individuals with depression have a
Conclusion
poor social network, and poor social networks, on the
other hand, are typically a risk factor for depression The current study found that SNS use was practically
because they limit access to “buffering” social support ubiquitous among study participants, with the
and increase feelings of isolation. majority of them being active SNS users. A large
percentage of medical students show a strong
Even though the number of SNSs utilised had no preference for SNSs. Intense usage of social media
effect on depression in the current study, depression sites, especially use at unusual hours, was shown to be
scores were shown to be greater in students who strongly (although not statistically significant) linked
used SNS more often and for a longer period of time. to depression. Despite the fact that the problem is
This outcome is consistent with a substantial number still relatively new, it is significant enough to warrant
of previous studies.[14] Neira et al. also observed attention. To solve the complex relationship between
a correlation between social network use and social media use and mental health complications,
depression in their study.[15] Kross et al. observed that further research is needed.
increased usage of social media exposed young people
to negative affect and decreased their feeling of well- Ethical Clearance: The ethical clearance was
being. Participants who reported being depressed obtained from Mahavir Institute of Medical
were also more likely to utilise social media to Sciences Institutional ethics committee prior to the
convey their feelings.[16] Face-to-face communication commencement of the study.
is less common among young people with emotional Source of funding: Self
problems; thus, they prefer to connect with virtual
Conflict of interest: Nil
pals.[17]
Frequent social comparison, perceived negative References
interaction, addictive/problematic usage, and 1. Kaplan AM, Haenlein M. Users of the world, unite!
rumination were the most notable social media risk The challenges and opportunities of social media. Bus
factors for depression.[18] In addition, students who Horiz. 2010;53:59–68.
reported using SNSs at odd hours, such as staying up 2. Lenhart A, Duggan M, Perrin A, Stepler R,
late at night or waking up early, or both, were more Rainie H, Parker K. Social Media and Technology
likely to have higher depression scale scores than Overview. Washington DC, USA: Pew Research
those who did not. Students who said they could go Center [Internet and American Life Project]; 2015.
a day without accessing any social media sites were 3. Pantic I. Online social networking and mental
less likely to be depressed than those who said it health. Cyberpsychol Behav Soc Netw. 2014;17:652–7.
was difficult. These showed a social media addiction
and might be the first signs of problematic SNS use. 4. Madaiah M, Seshaiyenger CT, Suresh P, Munipapanna
S, Sonappa SD. Study to assess the effects of social
Students’ circadian rhythms may be disrupted as
networking sites on medical college students. Int J
a result of working at strange hours, making them
Community Med Public Health. 2016;3:1204–8.
prone to mood problems. In conclusion, the current
study finds a statistically insignificant link between 5. Farooqi H, Patel H, Aslam HM, Ansari IQ, Khan M,
high social media usage and depression among Iqbal N, et al. Effect of facebook on the life of medical
medical students given Vikarabad, Telengana, in the university students. Int Arch Med. 2013;6:40.
current socio-cultural environment.
6. Guraya SY. The usage of social networking sites 12. Hall M, Hanna LA, Huey G. Use and views on social
by medical students for educational purposes: A networking sites of pharmacy students in the united
Meta-analysis and systematic review. N Am J Med kingdom. Am J Pharm Educ. 2013;77:9.
Sci. 2016;8:268–78.
13. Keyes CL. Mental illness and/or mental health?
7. Adithya KH, Ali K, Mahadevamurthy M. Use of Investigating axioms of the complete state model of
Social Media Among Dental Students of Farooqia health. J Consult Clin Psychol. 2005;73:539–48.
Dental College, Mysore: A Study. Bangalore, India;
14. Baxter AJ, Scott KM, Vos T, Whiteford HA. Global
2013. Presented at International Conference on open
prevalence of anxiety disorders: A systematic review
access scholarly communication reincarnated: A
and meta-regression. Psychol Med. 2013;43:897–910.
futuristic approach at Bangalore. 7].
15. Neira CJ, Barber BL. Social networking site use: Linked
8. Goel D, Subramanyam A, Kamath R. A study on the
to adolescents’ social self-concept, self-esteem, and
prevalence of internet addiction and its association
depressed mood. Aust J Psychol. 2014;66:56–64.
with psychopathology in Indian adolescents. Indian J
Psychiatry. 2013;55:140–3. 16. Hwang JM, Cheong PH, Feeley TH. Being young
and feeling blue in Taiwan: Examining adolescent
9. Statista: The Statistical Portal. Reach of Leading Social
depressive mood and online and offline activities. New
Media and Networking Sites Used by Teenagers and
Media Soc. 2009;11:1101–21.
Young Adults in the United States as of February,
2016. 2016. Available from: https://www.statista. 17. Ybarra ML, Alexander C, Mitchell KJ. Depressive
com/statistics/250172/ symptomatology, youth internet use, and
online interactions: A national survey. J Adolesc
10. Gray K, Annabell L, Kennedy G. Medical students’
Health. 2005;36:9–18.
use of facebook to support learning: Insights from four
case studies. Med Teach. 2010;32:971–6. 18. Jawaid M, Khan MH, Bhutto SN. Social network
utilization (Facebook) and e-professionalism among
11. White J, Kirwan P, Lai K, Walton J, Ross S. ‘Have you
medical students. Pak J Med Sci. 2015;31:209–13.
seen what is on facebook?’ The use of social networking
software by healthcare professions students. BMJ
Open. 2013;3 pii: e003013.

Awareness about Tobacco use among Auto- Rickshaw Drivers

in Belagavi, North Karnataka
Amaresh P. Patil 1, Yogeshkumar S2

1
MBBS, MD, DNB, PG Diploma in Environmental & Occupational Health, MNAMS, Research Officer, Women’s & Children’s Health
Research unit J. N. Medical College, KLE Academy of Higher Education and Research (KAHER)
2
Associate Professor, Department of Community Medicine, J N Medical College, KAHER, Belagavi
How to cite this article: Amaresh P. Patil, Yogeshkumar S Awareness about Tobacco use among Auto- Rickshaw
Drivers in Belagavi, North Karnataka. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Auto – rickshaws are most commonly used mode of transportation in cities where metros or application-
based cab aggregators (ABCA) are either non-existent / not available. Auto rickshaw drivers (ARD’s) are under constant
physical and mental pressure due to various factors most importantly illiteracy, poverty, lack of awareness about hazards
of addictions which lead to various habits majority being tobacco use. Studies have found that overall prevalence of
tobacco use among ARD’s is very high compared to general population.
Objectives: To know level of awareness about tobacco use among ARD’s in Belagavi, North Karnataka.
Methods: It was a cross sectional study conducted among 600 regular ARD’s of Belagavi City Corporation between
January to December 2016. Estimated sample size was 600. Two ARD’s who were last in queue were selected from 300
major auto rickshaw stands. Questionnaire was adopted from Global Adult Tobacco Survey (GATS) questionnaire. Data
was collected by personal interview after getting informed consent. Data compilation and analysis was done using SPSS
software. Study was approved by Institutional Ethics Committee of J. N. Medical College, KAHER, Belagavi.
Results: Most (88.66%) of the participants knew that tobacco in any form caused serious illness. Cancers (72.66%) were
the most commonly known illnesses. Most of the participants supported law prohibiting smoking in indoor work places
(99%) and favored increase of taxes on tobacco products (94.5%).
Conclusion: Although the awareness regarding hazards of tobacco has increased in recent days, actual practice remains
a challenge.
Keywords: Auto-rickshaw drivers, Tobacco, Awareness, Karnataka
Introduction sector in India. They are generally self-employed and

The three-wheeled motorized vehicles, popularly lack employment benefits such as health insurance
known as auto rickshaws, are a backbone to urban and social security. Income insecurity is a significant
mobility. Auto – rickshaws are still the most commonly concern for the drivers – they earn on a daily basis
used mode of transportation in Tier II & III cities leading to no fixed income. Health expenses are a big
where metros or application-based cab aggregators challenge for most of them. They suffer from serious
(ABCA) are either non-existent or not available. Auto respiratory health threats due to constant exposures
rickshaw drivers work for over 10-12 hours per day to vehicular pollution. They are also prone to road
and form an important part of the urban informal accidents given poor road infrastructure and badly
Corresponding author:
Dr. Amaresh P. Patil
MBBS, MD, DNB, PG Diploma in Environmental & Occupational Health, MNAMS
Research Officer, Women’s & Children’s Health Research unit,
J. N. Medical College, KLE Academy of Higher Education and Research (KAHER)
Belgaum-590010, Karnataka, INDIA
maintained vehicles. On the road for most of their day, b. Permanent residents of Belagavi city from the
they suffer due to the poor quality and availability of past one year.
hygienic water and sanitation facilities in the country,
Auto rickshaw drivers driving on part time basis
leading to further health issues.
were excluded.
Auto rickshaw drivers are under constant physical
and mental pressure due to irregular shifts, continuous Sampling procedure
variation in fuel prices, long waiting hours, illiteracy, As per the information form the Regional transport
poverty, lack of knowledge about hazards of tobacco office, the city had around 300 major auto rickshaw
and other socioeconomic factors which lead to various stands and among each stand two auto rickshaw
habits majority being tobacco use. [1-4] drivers who were last in the queue were selected
purposively for the study. This was to have ample
Tobacco use imposes a huge burden of disease in
amount of time for the participant to be interviewed
India and is a major global public health problem. The
for the study, which could not have been done if
tobacco epidemic is one of the biggest public health
someone else from the queue were selected as they
threats the world has ever faced, killing more than 8
had to discontinue the study if their auto rickshaw
million people a year. More than 7 million of those
was hired meanwhile.
deaths are the results of direct tobacco use while
around 1.2 million are the result of non-smokers Study tools
being exposed to second-hand smoke. [5]
Questionnaire was adopted from the Global Adult
In the Indian context, tobacco use implies a varied Tobacco Survey (GATS) questionnaire [11] and
range of chewing and smoking forms of tobacco customized as per the requirements of the study.
available at different price points, reflecting the
Methodology
varying socio-economic and demographic patterns of
consumption. [6] Investigator made visits to all the 300 major auto
rickshaw stands within the limits of Belagavi City
Cigarette smoking in any form harms nearly Corporation and participants were identified
every organ of the body, causes many diseases, and according to the sampling procedure. These
reduces the health in general. [7-8] It causes diminished participants were explained about the purpose of the
overall health, increased absenteeism from work, study and after the written informed consent, they
and increased health care utilization and cost. [7] were interviewed in the auto rickshaw stands or any
There are many diseases that are caused, increased or convenient place nearby using pre-designed and pre-
exacerbated by use of tobacco. [9] tested questionnaire adopted from GATS. [11].
Author intends to find the level of awareness about The participants were given free chance to
tobacco use among auto rickshaw drivers in Belagavi, discontinue from the study at any given point of time
a northern district of Karnataka. for any privacy, confidential or work related issues.
Materials and Methods Care was taken to make sure that the participants did
not have any hindrance in their work.
Study design
Data analysis
This was a descriptive, cross-sectional study
The data was analyzed through descriptive statistics
conducted on registered auto rickshaw drivers plying
and Chi-square test using the SPSS software. A value
in Belagavi city, in the period of January to December
of P < 0.05 was considered statistically significant.
2016. Sample size was calculated to be 597 & rounded
off to 600 based on the estimated prevalence of 84% [10] Results
and absolute error of 3%. The inclusion criteria were All the participants were male with age ranging
as follows: between 18 to 70 years and an average age of 39.71
a. Registered, regular auto - rickshaw drivers ± 11.07 years. Mean years in the present occupation
aged above 18 years. was 15.80 years ± 10.11 years and participants worked
over a mean length of 9.43 ± 1.82 hours per day.

34
Majority of them (89.83%) were married, 371 [Table 1] Most of the users (54.69%) were advised
(61.83%) stayed in nuclear families and 346 (57.67%) to quit by a health care professional in the last one
resided in pucca house. year. Among the users, 227 (60.86%) had attempted to
quit usage in the last one year and more than half of
Among the participants, 373 (62.17%) were using
them (54.63%) could sustain it for few months before
tobacco in one or the other form. Cigarettes (87.05%)
resuming usage. Self-motivation (90.75%) was the
were the most commonly smoked form while gutkha
strongest driving force to quit. Majority of the users
(54.93%) was the commonest smokeless form.
planned to quit within next one month (28.69%).
Majority of the users had initiated their habit before
20 years of age (46.38%). Mean age at initiation was [Table 2] Most of the participants (88.66%) knew
23.22 ± 8 years for smoke form and 23.36 ± 7.99 years that tobacco in any form caused serious illnesses.
for smokeless form. Mean duration of use was 15.31 Cancers (72.66%) were the most commonly known
± 10.29 years. More than half of the participants illnesses caused by tobacco.
(54.96%) used tobacco within an hour of waking up.
[Table 3] Most of the participants supported the
Almost three fourths of those using tobacco never did
law prohibiting smoking in indoor work places (99%)
it in front of their children (74.8%).
and favored increase of taxes on tobacco products
(94.5%).
Table 1. Details of tobacco quit by participants

Characteristics n (%)
Advised to quit by Health care Yes 204 (54.69)
professional in last one year No 169 (45.31)
Attempts to quit tobacco in last 1 Yes 227 (60.86)
year No 146 (39.14)
Months 124 (54.63)
Weeks 17 (7.49)
Duration of previous quit attempt Days 68 (29.95)
Less than 1 day 15 (6.61)
Don’t know 3 (1.32)
Counselling 13 (5.73)
Nicotine replacement therapy 5 (2.2)
Switching to other forms 6 (2.64)
Methods adopted to quit tobacco** Own will / self-motivation 206 (90.75)
Badesoap 8 (3.52)
Religious reasons 2 (0.88)
Chewing gum 8 (3.52)
Quit within next month 107 (28.69)
Thinking within next 12 months 82 (21.98)
Description of thinking about
Quit someday, but not next 12 months 88 (23.59)
quitting tobacco
Not interested in quitting 39 (10.46)
Don’t know 57 (15.28)
**Multiple users had adopted more than one methods to quit
Table 2. Knowledge & Practices of ARD’s related to tobacco

Characteristics n Percentage
Tobacco users (%) Non users (%) Total (%)
Does use of tobacco Yes 324 (86.86) 208 (91.63) 532 (88.66)
in any form casues
serious illness No 34 (09.12) 06 (02.64) 40 (06.67)
Don’t know 15 (04.02) 13 (05.73) 28 (04.67)

Cancers 436 72.66
Heart disease 56 9.33
Impotence 15 2.5
Premature aging 6 1
Respiratory disease 160 26.66
Gastritis/ acidity 39 6.5
Illnesses known to Weakness 37 6.16

be caused by use of Blindness 3 0.5
tobacco*
Headache 10 1.66
Hypertension 4 0.67
Diabetes mellitus 4 0.67
Tuberculosis 2 0.33
Renal diseases 8 1.33
Others 87 14.5
Don’t know 97 16.16
Home 141 37.8
Tea stall 170 45.57

Usual place of tobacco
Auto stand 288 77.21
use**
While driving 63 16.89
Others 37 9.91
Parents 12 3.21
Other family members 19 5.09
Friends 265 71.04

Motivation for tobacco
Fellow auto rickshaw drivers 148 39.67
use#
Film stars 28 7.5
Self / curiosity 28 7.5
Others 12 3.21
* Multiple participants reported more than one illness
** Multiple tobacco users used tobacco products at more than one place
# Multiple users were motivated by more than one group for use of tobacco

36
Table 3. Attitude of ARD’s regarding tobacco and its regulations
Tobacco users (%) Non users (%) Total (%)
Opinion on law prohibiting smoking in Support 373 (100) 221 (97.36) 594 (99.0)
indoor work places and public places Not sure 0 06 (02.64) 06 (01.00)
Favour 349 (93.57) 218 (96.04) 567 (94.50)
Opinion about increasing taxes on
Oppose 24 (06.43) 03 (1.32) 27 (04.50)
tobacco products
Not sure 0 06 (2.64) 06 (01.00)
Favour 334 (89.54) 191 (84.14) 525 (87.50)
Opinion on law prohibiting
Oppose 39 (10.46) 18 (07.93) 57 (09.50)
advertisements of tobacco products
Not sure 0 18 (07.93) 18 (03.00)
Yes 310 (83.11) 216 (95.16) 526 (87.67)
Are you aware about harmful effects of
No 63 (16.89) 05 (02.20) 68 (11.33)
second hand smoke
Not sure 0 06 (2.64) 06 (01.00)
Warning labels led to thinking about Yes 339 90.89
quitting No 34 9.11
In the last one month have you asked Yes 38 10.19
your children or anyone less than 18
years to buy tobacco products? No 335 89.81
Discussion Mean years in present occupation was 15.80 ± 10.11

Auto rickshaw drivers spend a considerable years whereas it was 17.70 ± 7.62 years in the study
amount of time in an environment full of pollutant done in Nagpur. [14] Mean length of working hours per
gases, noise, continuous stress, accelerations and day was 9.43 ± 1.82 hours while it was 11.52 ± 2.29
decelerations, lateral swaying from side to side hours in the study done in Nagpur. [14]
and whole-body up and down vibrations when the Prevalence of tobacco use in the present study in
vehicle is in motion. Further poor lifestyle practices any form was found to be 62.17%. The study among
like irregularity of meals, no proper rest rooms, awful auto rickshaw drivers in Gwalior showed prevalence
quality of sanitary toilets, bad posture while driving to be 84.26% [10], 64.44% among auto rickshaw drivers
and stressful occupational conditions during their in Bareily, Uttar Pradesh [15] and 69% among auto
working hours augment their health problems. Such rickshaw drivers in South Delhi. [16] The difference in
working parameters may be associated with various prevalence with Gwalior study can be attributed to the
health problems. [2, 4, 12-13] fact that the educational levels of the participants in
The present study was done to find the level of the present study was high compared to the Gwalior
awareness about use of tobacco among auto rickshaw study and both the studies have shown negative
drivers. Among the 600 study participants, all association between educational level and tobacco
were male which was consistent with other studies use. All of these studies reveal a comparatively high
conducted among similar sub groups. [10, 14] Most of the prevalence among auto rickshaw drivers with respect
participants in this study had high school education to the prevalence in Indian adults aged 15 years and
(54.50%). The educational level of participants was above which was just 28.6% according to GATS 16
higher when compared with other similar studies. [10] -17. [17] It was also noted that the prevalence in present
This increase in education level may be attributed to study was very high compared to the adults among
better literacy level among south India as compared general population in Belgaum city where prevalence
to the north. of ever use was 29.41%. [18]

This comparatively higher prevalence among days owing to mass negative advertisements, scary
auto rickshaw drivers can be attributed to various images and videos of serious health hazards which
occupational factors coupled with low levels of are continuously displayed in cinema halls, social
education, poverty, lack of knowledge about hazards, media, television advertisements and etc.
other socioeconomic factors and many unknown
In this study, around 72% of the participants knew
factors.
that tobacco in any form caused one or the other
Smokeless form was the predominant form of cancers and this was around 87% in study done in
tobacco use. Similar findings have been observed in Belgaum. [18] In general, knowledge regarding cancers
multiple studies done among similar subgroups and has increased owing to mass media advertisements
consistent with the GATS survey done among adult
In the present study, almost all the participants
Indian male. [10, 17, 19-20] This is also particularly true in
(99.0%) supported the law which prohibits smoking
auto rickshaw drivers as their hands are preoccupied
in indoor work places and public places. Whereas
in driving and hence smoking while driving would be
only 68% of the participants in the Gwalior study
cumbersome whereas chewing can be continued even
were aware about existence of such law. [10] Despite
while driving.
high level of knowledge about the law, actual
Majority (54.69%) of the users were advised to implementation is a bigger question.
quit tobacco by any health care provider in last one
Limitations and Recommendations
year. There is still a lot of potential to counsel each
& every user every time they encounter a health care Apart from recall bias, those auto rickshaw drivers
professional, which will have a deeper impact in plying exclusively during night might have been
reducing the use. missed from the study. Based on the study, we
recommend that work place tobacco cessation model
Around 61% of the study participants had tried
should be established for this group and tobacco
to quit the use in last one year. In the study done
cessation activities should be targeted at younger
in Nepal, 75.8% of long route bus drivers had tried
auto rickshaw drivers to address the early initiators
quitting [21] whereas in the Gwalior study, only 28.47%
to prevent future addictions & health hazards. There
tried to quit. [10] This difference in quit attempts can be
is a dire need for strict implementation of the tobacco
attributed to the difference in various socioeconomic
control legislations.
factors, educational level, knowledge regarding
hazards and the personality traits of the users as all Ethical clearance- Approved from Institutional
of these play an important role to quit. Majority of Ethics Committee of J. N. Medical College, KLE
those who attempted a quit could hardly sustain it University, Belagavi
for few months before resuming the use. This can be Source of funding- Self funded
attributed to various religious events (like Ramadan,
Diwali), strong peer pressure, addiction and physical Conflict of Interest - Nil
dependence along with ignorance. Self-motivation
References
was found to be the most common approach (90.75%)
by the participants to even attempt quitting. This can 1. Kaul S, Gupta AK, Sarkar T, Ahsan SK, Singh NP.
Substance abuse and depression among auto-rickshaw
be augmented by providing education and raising
drivers: A study from the national capital region of
the level of knowledge, providing emotional and
Delhi, India. Indian J Med Spec. 2019;10(3):143-8. doi:
mental support to those willing to quit. A study 10.4103/INJMS.INJMS_64_19.
conducted in Canada concluded that many smokers
may be unaware of effective cessation methods and 2. Singh SP, Misra SK, Chaudhary SS, Katyal R, Singh A,
most underestimate their benefit. Further, this lack Joshi HS. Heath status of auto rickshaw drivers plying
in Agra city, MedPulse. Int Med J. 2015;2(4):221-8.
of knowledge may represent a significant barrier to
treatment adoption. [22] 3. Melwani V, Priya A, Toppo M, Sethia S, Khan A,
Melwani S. Study to assess the socio-demographic
In the present study, around 89% of the participants profile, health status and working conditions of auto
knew that use of tobacco caused one or the other rickshaw drivers in Bhopal. Int J Community Med
serious illness. Similar findings were seen in Gwalior Public Health. 2018;5(4):1323-6. doi: 10.18203/2394-
study (89%). [10] Knowledge has increased in recent 6040.ijcmph20180971.

38
4. Kirkorowicz J, Sapukotana P, De Silva P, 13. Whitelegg J. Health of professional drivers, A Report

Noda M, de Oliveira J, Østbye T 2014. Work- for Transport and General Workers’ Union. White
related stress and substance use as risk factors for Cross, Lancaster: Eco-Logica Ltd, LA1 4XQ; 1995.
chronic disease among three-wheel drivers in Galle. Sri
14. Chaudhary SS, Nagargoje MM, Kubde SS, Gupta SC,
Lanka: A Qualitative [study]. Int J Occupational Safety
Misra SK. Prevalence of cardiovascular Diseases
and Health, 3(2), 21-4.
risk factors among auto rickshaw drivers. Indian
5. World Health Organization. Available from: J Community Health. 2011;23(1):32-4.
http://www.who.int/mediacentre/factsheets/
15. Singhal A, Agrawal P, Agrawal VK. Prevalence and
fs339/en/. WHO Media centre Factsheets,
determinants of tobacco use and oral sub mucous
Tobacco [accessed Jul 05 2021]; 2017.
fibrosis in auto-rickshaw drivers at Bareilly, Uttar
6. Imtiaz D, Kandpal SD, Juyal R, Shrotriya VP. A study Pradesh, India. Int Surg J. 2018;5(4):1449-53. doi:
on awareness about harmful effects of tobacco use 10.18203/2349-2902.isj20181128.
among rural population in Dehradun District of
16. Arora P, Kaur G, Khokar A, Jindal AK. Prevalence
Uttarakhand. Ntl. J Community Med. 2015;6 (2):137-40.
and pattern of tobacco use among auto rickshaw
7. US Department of Health and Human Services. The drivers of South Delhi: a cross-sectional study. Int J
Health Consequences of Smoking—50 Community Med Public Health. 2018;5(8):3464-8. doi:
Years of Progress: A Report of the Surgeon 10.18203/2394-6040.ijcmph20183082.
General. [accessed Jul 05 2021]. Atlanta: United States
17. World Health Organization. WHO report on the
Department of Health and Human Services, Centers
global tobacco epidemic. Available from: http://
for Disease Control and Prevention, National Center
www.who.int/tobacco/surveillance/policy/country_
for Chronic Disease Prevention and Health Promotion,
profile/ind.pdf?ua=1 [accessed Jul 05 2021]. Country
Office on Smoking and Health; 2014.
profile – India; 2017.
8. US Department of Health and Human Services. How
18. Patil AP, Patil M, Karikatti S, Halki S. Tobacco use,
Tobacco Smoke Causes Disease: What It Means to
its correlates and knowledge about its hazards
You. [accessed Jul 05 2021]. Atlanta: United States
in Belgaum urban, Karnataka. Ntl. J Community
Department of Health and Human Services, Centers
Med. 2017;8(2):52-6.
for Disease Control and Prevention, National Center
for Chronic Disease Prevention and Health Promotion, 19. Koppad R, Kumar SA, Kotur N, Umakanth AG. A
Office on Smoking and Health; 2010. cross sectional study on magnitude of risk factors of
cardio-vascular diseases among auto rickshaw drivers
9. World Health Organization. The tobacco body. World of Davangere city Karnataka, India. Int J Curr Res
Health Organization; 2019. Available from: https:// Rev. 2012;4(22):66-73.
a pps. wh o. i n t / i r i s/ r e st / b i t st r e a ms/ 1 2 30962/
retrieve. [accessed Jul 05 2021]. 20. Bawa MS, Srivastav M. Study the epidemiological
profile of taxi drivers in the background of occupational
10. Bhatia M, Mishra A, Agrawal AK. Prevalence and environment, stress and personality characteristics.
pattern of tobacco addiction among auto-rickshaw Indian J Occup Environ Med. 2013;17(3):108-13. doi:
drivers of North-Central India. Asian Pac. J Health 10.4103/0019-5278.130855, PMID 24872669.
Sci. 2014;1(4):312-18.
21. Saroj G, Chaudhuri S, Yadav AK, Yadav AK, Shrestha SR,
11. World Health Organization. Available from: http:// Baral DD. Tobacco use among long route bus drivers
www.who.int/tobacco/surveillance/en_tfi_gats_ and staffs of Dharan Eastern Nepal a KAP study.
c ore qu est i o n n a i r e w i t h o p t i o n a l q u e s t i ons_v 2_ Sci J Public Health. 2017;5(4):301-6. doi: 10.11648/j.
FINAL_03Nov2010.pdf. Global adult tobacco survey. sjph.20170504.14.
Core questionnaire with optional questions. Version
2.0; November 2010 [accessed Jul 05 2021]. 22. Hammond D, McDonald PW, Fong GT, Borland R. Do
smokers know how to quit? Knowledge and perceived
12. Saltzman GM, Belzer MH. Truck driver occupational effectiveness of cessation assistance as predictors of
safety and health: 2003 conference report and selective cessation behavior. Addiction. 2004;99(8):1042-8. doi:
literature review; 2007 (No DHHS (NIOSH) Publication 10.1111/j.1360-0443.2004.00754.x, PMID 15265101.
No. 2007- 120).

Students’ Perspectives on Simplified Breakout Room Approach during

Video Proctored Online Assessment in COVID 19 Lock down
Anil Kumar Reddy Y1, Montosh Chakraborty2, Vidya Desai Sripad3, Sathianarayana4,
Joy A Ghoshal5, Mukesh Tripathi6
Assistant Professor, Department of Anatomy, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh,
1,
2
Associate Professor, Department of Biochemistry, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh,
3
Additional Professor, Department of Biochemistry, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh,
4
Assistant Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh,
5
Professor, Department of Anatomy, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh,
6
Professor, Department of Anesthesia, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh
How to cite this article: Anil Kumar Reddy Y, Montosh Chakraborty, Vidya Desai Sripad, Sathianarayana,
Joy A Ghoshal, Mukesh Tripathi. Students’ Perspectives on Simplified Breakout Room Approach during Video
Proctored Online Assessment in COVID 19 Lock down. Volume 13 | Issue 4 | October-December 2022
Abstract:
Background: The lockdown in COVID 19 pandemic mandated the normal academic schedule in virtual mode including
e-assessments. Since the summative assessments are a mix of both selected response approach and constructed response
approach, a new method of e assessment under video surveillance by break out room approach has been tried in this
study and the student’s response with regard to the different aspects of this technology will be evaluated.
Methods: The students were asked to appear for the exams under video surveillance by zoom video conference. The
instructions and the check lists were rolled out accordingly for both the students and teachers. The students appeared for
the examination under video surveillance such that one invigilator monitors 10 students along with a guardian secondary
invigilator present by their side. A questionnaire based survey regarding the conduct of examination was conducted
amongst the students. The data was analysed by descriptive statistics. P value < 0.05 is taken as statistically significant.
All statistical analysis was performed by using the statistical software package SPSS version 21.
Results: Analysis of student’s feedback revealed that 90% are agreed that proctored clarified their queries. Majority of the
students (96%) are happy with overall experience with break out room approach in video proctored online assessment.
Conclusion: The conduct of online assessment by break out room approach is a new methodology tried in this period of
pandemic lockdown and will be evaluated for its acceptance by the students so that it can facilitate the upgradation of
e-assessment methodologies.
Key words: Assessment, Breakout room, COVID-19, Video Proctored.
Introduction: mandates a change in the academic assessments

COVID 19 pandemic has disrupted the conventional which still remains a challenge.2 Ours being an
academic activities and has ushered in a new era institute of national importance in the field of tertiary
of creative environment of online education.1 This health care also faced the brunt during COVID
*Corresponding Author:
Dr. Montosh Charkraborty,
Associate Professor, Department of Biochemistry
All India Institute of Medical Sciences, Mangalagiri, Guntur District,
Andhra Pradesh, India.
Pin Code: 522 503
Email Id: [email protected]
40
19 pandemic when the virtual platforms of online days before the examination to allay their fears and
teaching came to the rescue. We started with home the following checklist was provided to keep them
based academic assessments by selected response prepared for the examination:
approach right from the declaration of 1st lockdown • Do I have a laptop with front camera or smart
phase in our country and tried to maintain the routine phone with front and back cameras?
assessment schedule with the help of virtual platform.
But the necessity of subjective assessments was felt • Do I have a smart phone with updated
soon as the summative assessments are a right mix Firefox/safari/chrome browsers?
of both selected response and constructed response • Do I have/upgraded to 1.5 GB data/day plan
assessments. Also, the constructed response system with at least 1 Mbps upload & download
is more popular in the evaluation of all sections of speeds?
cognitive domain.3 • Did I install the Google Classroom and
Online exams can be proctored either in person ZOOM Video Conference apps on my
in a controlled exam centre or by using artificial mobile/laptop?
intelligence.4 But it usually requires a learning • Did I keep registration number as name in
management system along with a technical back up ZOOM app/software?
for support which is a costly affair in a developing
• Do I have login credentials and am able to
country like ours.5 The in person proctoring for a
login to all the above-mentioned Apps?
large group of students seems difficult and students
are apprehensive of the support for their queries • Did I identify an appropriate, well-lit, noise-
during the conduct of exams.6 The chances of cheating free place in the house with my writing table
by using internet driven sources in such home based and chair for typing answers comfortably?
online assessments requires elimination to maintain • Did I understand the question paper model
the academic integrity.7 As there is a growing concern and exam duration for each subject/paper?
among teachers about online assessment and the • Have I kept sufficient number of A4/A3/
impact of its results for accountability, monitoring Legal sized papers to write for section B and
their views on students perspective will be an C along with other stationary requirements?
important task.8
• Proctoring requirement: Students must
Here we present our experience of navigating a new understand that being visible for invigilation
terrain of conducting a home based online academic (proctoring) throughout the duration of
subjective assessment of medical students in a tertiary the exam is a mandatory. Students who do
care medical institute under video proctoring by NOT follow this rule will be marked under
using break out room approach and the students malpractice. By appearing for the exams, a
perspectives with regard to the same which has not student declares that (s) he understands these
been described in the literature before. The technique guidelines and has clarity clearly that their
involves the hand written subjective assessments to proctoring session will be video recorded and
eliminate internet driven malpractices and controlled will be used only to identify malpractices if
invigilation by primary and secondary (in-person) any during the exam.
invigilators for better monitoring and elimination
The invigilators were supposed to have the
of their apprehensions and queries with regard to
following materials ready for Invigilation:
conduct of exams.
• Laptop
Subjects & Methods:
• Earpiece with the mike
Study type: • Print out of Document for the Methodology
An online hand written subjective academic of examination
assessment of 2nd semester students was planned • Print out of the list of Contact numbers of
using break out room approach. The module was students and guardians
explained to the students in detail and their queries • Print out of Invigilator report document
were attended to. A mock test was conducted 2

Procedure of examination: Statistical analysis: The items were evaluated on

an ordinal scale and considered to be non-parametric
Students were asked to login to google classroom
in nature. The validity of the items was tested by
and zoom video conference (Zoom incorporation,
spearman’s correlation analysis. Cronbach’s α
California, USA) 20 minutes before the commencement
coefficient was used to identify the reliability status
of examination. They were asked to be seated at least
of the items. The data was analysed by descriptive
2 feet away from the camera (webcam or mobile) in
statistics. P value < 0.05 is taken as statistically
such a way that the surroundings are clear and the
significant. All statistical analysis was performed by
proctor has a clear view of the entire set up with
using the statistical software package SPSS version 21.
the application in unmuted form. Break out rooms
were created by the administrator in zoom video Results:
conference such that 1 proctor (faculty as primary
The reliability of the questionnaire was assessed by
invigilator) invigilates 10 students. 5 breakout rooms
cronbach’s coefficient α as 0.56. Students’ perspectives
were created for a total of 50 students in the ratio of 1:
on the conduct of exams by break out room approach
10. The Proctors were given the permission to record
are shown in fig 1. 66% of the students (n= 50) are of
the session for the entire period. The question paper
the opinion that the practice session of break out room
was shared by google classroom in a coordinated
approach was good. More than 90% (n=50) of the
manner. The onsite invigilation was done by the
students agreed that the proctor was available on time
guardian of the student (secondary invigilator) who
and clarified their queries during the examination.
was intimated earlier and approval was taken. The
Barring 1 student, 84% (n=50) of the students termed
student answers the question paper in the given
the technology used in the approach as user friendly.
time period by constructed response under primary
and secondary invigilation (controlled invigilation). As depicted in figure 2, 96% (n=50) of the students
After the examination is over, 20 minutes are allotted are happy with their experience of attending
for the scanning and upload of the pdf format of examination by break out room approach.
answer script in the google classroom under video
Figure 3 highlights the preferred mode of summative
proctoring. The proctors download the answer
examination by students on the basis of their present
scripts of the respective students; verify the quality
experience. Only 18% (n=50) of the students are ready
of the scanned answer sheets and once satisfied asks
to give their examination in physical presence in the
the student to leave the VC. The coordinator of the
institute in offline mode in this scenario of COVID 19
respective department will arrange the answer scripts
pandemic. Of 82% of the students who prefer online
as verified by the invigilators via online mode and
examination, 72% (n=50) would like to attend their
submit it to the respective head of the department for
examination by using home based break out room
further proceedings.
approach. 4% of the students preferred to attend the
Qualitative analysis: examination from their home by online mode without
video proctoring.
A questionnaire based survey regarding the conduct
of examination was conducted amongst the students. Most of the students (86%, n=50) liked the home
Participation in the study was voluntary and based online examination under video proctoring by
complete anonymity was ensured. The questionnaire using break out room approach (Fig 4). Poor internet
evaluated the conduct of examination, the difficulties connectivity is the major factor for dislike of this
encountered and student’s satisfaction in this new mode of examination by 10% of the students. Of the
approach of online assessment test. The questionnaire students who did not like this mode of conduct of
was validated by 3 experts in medical education on examination, poor internet connectivity is the most
a sample population, prepared in google form and important factor. The availability of invigilator for
was mailed to the participants to be submitted within clarification of doubts or queries during the conduct
a period of 2 days. The respondents were asked to of examination is the most admired reason (70%,
provide the response on an ordinal scale or to select n=50) to like the break out room approach for the
the options provided along with open comments. conduct of examination in this COVID era.

1 clarification of doubts or queries during the conduct of examination is the most admired reason (70%,
1 42doubts or queries during the conduct of examination is the most admired reason (70%,
clarification of
2 n=50) to like the break out room approach for the conduct of examination in this COVID era.
2 n=50) to like the break out room approach for the conduct of examination in this COVID era.
Discussion
Outcomes of innovation: As the world moves into
different phases of lockdowns, the online academics
and assessment is here to stay. The idea of evolving
a better assessment platform in the virtual platform
is to be as near to assessment in physical presence or
even better.9 The innovative idea of subjective online
assessment by break out room approach is a step
towards this direction. Due to the involvement of
multiple factors in this regard, the review of students
regarding various facets of this approach is necessary
to establish its credibility. Systematic feedback is a
Figure
Figure 1:1: Conduct
Conduct ofbyexams
of exams break outby breakStudents’
approach: out approach:
perspectives
Figure 1: Conduct of exams by break out approach: Students’ perspectives basic condition for the operation and development of
Students’ perspectives
any complex system.10
Inspite of the fact that 66% of the students (n=50)
appreciated the practice session for the breakout
room approach, an equal amount of students (58%)
were still nervous for the examination (Fig 1). It
might be due to the incumbent fear of performance
in the examination which is quite common even in
the exams in physical presence. The technology finds
a wider acceptance amongst students as 94% (n=50)
have termed it user friendly. The clarification of
Figure 2: Students’ experience of attending exams
Figure 2: Students’ experience of attending exams by break out room approach doubts in the conduct of examination was successfully
Figure 2: Students’ experience of attending exams by break out room approach
by break out room approach attended to due to the availability of both primary
and secondary invigilators (proctor) customised for
students. Validity and reliability of online assessment
should be established to ensure students’ achievement
of the learning objectives.11 Breakout room approach
with small group of students in each has the ability
to solve any technical obstacle met during the online
assessment.
Page66of
Page of99
96% of the students (n=50) liked the conduct of
the examination by break out room approach with
22% terming it as very good. The opinion becomes
Figure 3: Mode of summative exam as preferred by significant on the ground that the students have
Figure 3:
Figure 3: Mode
Mode of summative exam as preferred by
by students on
on the
thebasis
basisof
ofpresent
presentexperience.
students on the basispreferred
of present experience.
students experience.
been attending regular unproctored, online MCQ
assessments and have seen and experienced the
regular modes of online assessment. Alsadoon H
(2017), revealed that procedures implemented during the
online including briefing on examination procedure by
peers minimise the chance of cheating and unauthorized
collaboration.12
With the experiences garnered about the various
modes of assessments, 82% have opined to conduct
the summative examinations in online mode in the
present scenario of COVID 19 pandemic (Fig 3). Most
Figure 4:
Figure 4: Strengths
Strengths and
Figure and weaknesses
4: weaknesses
Strengths of
of conduct of
of exams
exams by
and weaknesses
conduct by breakout
ofroom
breakout approach: Students’ of them (72%, n=50) have exerted their trust on the
approach:Students’
conduct
room
of exams by breakout room approach: Students’
Perspectives. break out room approach as compared to other modes
Perspectives.
Perspectives.
1 Discussion:
1 Discussion:
2 Outcomes of innovation: As the world moves into different IJPHRD / Volume
phases 13 Issue
of lockdowns, the 4online
/ October-December 2022
2 Outcomes of innovation: As the world moves into different phases of lockdowns, the online
3 academics and assessment is here to stay. The idea of evolving a better assessment platform in the
3 academics and assessment is here to stay. The idea of evolving a better assessment platform in the
4 virtual platform is to be as near to assessment in physical presence or even better.9 The innovative idea
4 virtual platform is to be as near to assessment in physical presence or even better.9 The innovative idea
of online assessment. Availability of customised 3. McAllister D, Guidice RM. This is only a test: A
proctor for a small group of students to clarify their machine-graded improvement to the multiple-choice
doubts (70%, n=50) and user friendly technology and true-false examination. Teaching in Higher
(10%, n=50) seems to be the most important factors Education. 2012 Apr 1;17(2):193-207.
for the students to prefer this approach (Fig 4). 14% of 4. Kolowich S. Behind the Webcam’s Watchful Eye,
the students (n=50) have not liked the breakout room Online Proctoring Takes Hold. Chronicle of Higher
approach, internet issues being the most important Education. 2013 Apr 15.
slayer. Since the students are spread pan India, digital 5. Lajoie SP, Hmelo-Silver CE, Wiseman JG, Chan
divide can be the reason for performance divide.7 LK, Lu J, Khurana C, Cruz-Panesso I, Poitras E,
Simplified breakout room approach for conduction Kazemitabar M. Using online digital tools and video
of online home based video proctored assessments to support international problem-based learning.
provides students and teacher’s easy-to-use, valid, Interdisciplinary Journal of Problem-Based Learning.
and reliable assessment system. It may significantly 2014 Jun 18;8(2):60-75.
contribute to solving certain crucial problems of 6. Ray ME, Daugherty KK, Lebovitz L, Rudolph MJ,
online assessment today. With the focus and thrust Shuford VP, DiVall MV. Best practices on examination
on digital India programmes, the divide is bound to construction, administration, and feedback. American
reduce leading to wider acceptance of this mode of journal of pharmaceutical education. 2018 Dec 1;82(10).
online assessment.
7. Moore R, Vitale D, Stawinoga N. The Digital Divide
The conduct of online assessment by break out room and Educational Equity: A Look at Students with Very
approach is a new methodology tried in this period of Limited Access to Electronic Devices at Home. Insights
pandemic lockdown and has been accepted well by in Education and Work. ACT, Inc.. 2018 Aug.
the students because of its characteristic inclusive and 8. Wu H. Molnár G.(2018a). Interactive problem solving:
customised approach. assessment and relations to combinatorial and
inductive reasoning. J. Psychol. Educ. Res.;26:90-105.
Financial support: Nil
9. Goh PS, Sandars J. A vision of the use of technology
Conflicts of interest: There are no conflicts of
in medical education after the COVID-19 pandemic.
interest MedEdPublish. 2020 Mar 26;9(49):49.
Acknowledgement: The authors would like to 10. Csapó B, Molnár G. Online diagnostic assessment in
thank all respondents who participated in the study. support of personalized teaching and learning: The e
Dia system. Frontiers in psychology. 2019 Jul 3;10:1522.
Ethical Clearance: The study was approved by the
Institutional Ethical Committee AIIMS/MG/2021/ 11. Elzainy A, El Sadik A, Al Abdulmonem W. Experience
IEC-20. of e-learning and online assessment during the
COVID-19 pandemic at the College of Medicine,
References: Qassim University. Journal of Taibah University
1. Gaur U, Majumder MA, Sa B, Sarkar S, Williams A, Medical Sciences. 2020 Dec 1;15(6):456-62.
Singh K. Challenges and opportunities of preclinical 12. Alsadoon H. Students’ Perceptions of E-Assessment at
medical education: COVID-19 crisis and beyond. SN Saudi Electronic University. Turkish Online Journal of
comprehensive clinical medicine. 2020 Nov;2(11):1992- Educational Technology-TOJET. 2017 Jan;16(1):147-53.
7.
2. Murphy B. COVID-19: how the virus is impacting

medical schools. Am Med Assoc. 2020.

Study on the Conversion of Laparoscopic Cholecystectomy

Owing to per Operative Complications
Annapareddy Raja Karan Reddy1, Bagammagari Raghuram Reddy2

1
Assistant Professor, Department of General Surgery, Gandhi medical college and hospital, Hyderabad Telangana.
2
Professor, Assistant Professor, Department of General Surgery, Gandhi medical college and hospital, Hyderabad Telangana.
How to cite this article: Annapareddy Raja Karan Reddy, Dr. Bagammagari Raghuram Reddy et al Study
On The Conversion Of Laparoscopic Cholecystectomy Owing To Per Operative Complications. Volume 13 |
Issue 4 | October-December 2022
Abstract
Background: Laparoscopic surgery has advanced to the point that it is being performed even for malignant conditions
in the current healthcare era. Conversion to open technique is a major morbidity of laparoscopy as it loses its supremacy
over open technique once the conversion takes place.
Objectives: To study the Conversion of Laparoscopic Cholecystectomy owing to per operative complications.
Methods: There were a total of 100 patients that matched the criteria for inclusion. A comprehensive medical history
was obtained, as well as a detailed medical examination was done. Blood tests were performed as part of the admissions
process. All of the patients underwent a liver function test. Ultrasonography of the abdomen and upper GI endoscopy
were done on all patients. Patients with suspected pancreatic/common bile duct pathology underwent CECT abdomen.
Patients with increased alkaline phosphatase and dilated CBD/associated CBD pathology underwent MRCP. In all cases,
consent was obtained for conversion if necessary.
Results: Out of 100 cases, 13 cases were converted to open cholecystectomy. In majority of the cases, dense adhesion was
the reason for conversion of laparoscopic cholecystectomy to open cholecystectomy in 38.46%. Arterial injury and difficult
anatomy around calout’s was the reason for conversion in 23% of the cases each. Hepato biliary injury and technical
difficulty was the reason for conversion in 7.69% of the cases each.
Conclusion: Recognizing when a patient is at higher risk for conversion can help with preoperative counselling
and resource allocation in the operating room, can improve safety by limiting the time it takes to convert to an open
cholecystectomy, and can identify patients who would benefit from a planned open approach.
Keywords: Laparoscopic cholecystectomy, Open cholecystectomy, Gallstones, Hepato biliary injury
Introduction Every year, almost 10 lakh cholecystectomies

Laparoscopic surgery has advanced to the point that are conducted, with 96 % of them being performed
it is being performed even for malignant conditions laparoscopically.2 The most frequent laparoscopic
in the current healthcare era. Minimal access surgery, surgery performed in today’s medical age is
which evolved from minimally invasive surgery, has laparoscopic cholecystectomy. Because of advantages
given us hope that practically all procedures can now such as smaller incisions, early healing, reduced post-
be performed using laparoscopy.1 operative discomfort and hospital stay, and improved
cosmesis, laparoscopic cholecystectomy is superior
Dr. Bagammagari Raghuram Reddy
Professor, Assistant Professor, Department of General Surgery, Gandhi medical college and
hospital, Hyderabad Telangana
to traditional open cholecystectomy. Laparoscopic done on all patients. Patients with suspected
cholecystectomy, on the other hand, has its own set of pancreatic/common bile duct pathology underwent
drawbacks and complications.3 CECT abdomen. Patients with increased alkaline
phosphatase and dilated CBD/associated CBD
Conversion to open method is a key complication
pathology underwent MRCP. In all cases, consent
of laparoscopy, as it loses its hegemony over
was obtained for conversion if necessary.
open technique after conversion.4 As laparoscopic
cholecystectomy has gained more expertise and The patients who have been converted to the
the learning curve has been surmounted, the open technique are the emphasis of this study. They
indications for laparoscopic cholecystectomy were further analysed in terms of the reasons for
have been broadened, approaching those of open converting to the open method owing to per-operative
cholecystectomy.5 complications.
Laparoscopic cholecystectomy complications Statistical Analysis: The SPSS 22 software was used
have been considerably reduced. However, due to for statistical analysis and the data was presented in
technical difficulties or intraoperative complications, the form of means and percentages.
a significant number of patients will have to be
transitioned to open surgery.6 The important thing Observation and Results
to remember about conversion is that it should never Table 1: Distribution based on laparoscopic
be viewed as a complication, but rather as a valid cholecystectomy cases
surgical decision. Parameters No. of patients Percentage
Materials and Methods Male 48 48%
Study Design: Hospital-based cross-sectional Female 52 52%
study Mean Age group 42.98 + 20.02 yrs
Study Setting: Department of General Surgery, Obese 18 18%
Gandhi Medical College and hospital Pre-operative diagnosis
Duration of study: January 2021 to June 2021 Chronic
74 74%
cholecystitis
Sample size: 100 patients undergoing laparoscopic
Acute cholecystitis 16 16%
Cholecystectomy 13 cases converted to open
Cholecystectomy Low albumin 1 1%
Elevated WBC
2 2%
Inclusion Criteria: count
Elevated alkaline
• All symptomatic gallstone disease patients 1 1%
phosphatase
• Gallstone disease with no symptoms in type Elevated bilirubin 2 2%
2 diabetics
Pericholecystic fluid
4 4%
• Gallbladder polyps on usg
• Exclusion Criteria: Co-morbidity

Diabetes mellitus 18 18%
• Patients who have a history of liver disease
Thickened
12 12%
• Patients who have already had upper GI gallbladder
surgery
The female predominance was observed. The mean
There were a total of 100 patients that matched age group was 42.98 + 20 yrs. Chronic cholecystitis was
the criteria for inclusion. A comprehensive medical diagnosed in 74% of the cases and acute cholecystitis
history was obtained, as well as a detailed medical was diagnosed in 16% of the cases.
examination was done. Blood tests were performed Low albumin levels and elevated alkaline
as part of the admissions process. All of the patients phosphatase was seen in 1% of the cases each, Elevated
underwent a liver function test. Ultrasonography wbc count and elevated bilirubin levels were seen in
of the abdomen and upper GI endoscopy were

46
2% of the cases each. Pericholecystic fluid on usg was Discussion

seen in 4% of the cases. The gold standard treatment for cholelithiasis is
Diabetes mellitus was the most prevalent laparoscopic cholecystectomy. The superiority
comorbidity seen in 18% of the cases and thickened of laparoscopic cholecystectomy over open
gall bladder seen in 12% of the cases. cholecystectomy has been studied, and the results
Out of 100 cases, 13 cases were converted to open show that laparoscopic cholecystectomy is superior
cholecystectomy. to open cholecystectomy. Today, even in developing
countries like India, cholelithiasis is treated using the
Table 2: Distribution based on Gender of laparoscopic approach.6
converted cases
When the feasibility of a laparoscopic
Gender No. of patients Percentage
cholecystectomy cannot be assured, the treatment
Male 7 53.84%
must be converted to an open cholecystectomy.
Female 6 46.15%
The identification of characteristics that indicate
Total 13 13%
conversion enhances preoperative patient
Out of 13 laparoscopic cholecystectomy conversion counselling, perioperative planning, operating room
cases, 53.84% of the cases were males and 46.15% of efficiency, and the ability to prevent laparoscopic-
the cases were females. The male: female ratio was related complications by doing an open surgery when
1.16:1. necessary.
Table 3: Distribution based on Age group of According to studies from different countries,
converted cases conversion rates range from 5% to 14%. The
Age group No. of patients Percentage conversion rate in this study was 13 %. Michael Rosen
20-30 yrs 3 23% et al7, Singh Kuldip et al8, H.J.J Van Der Steeg et al9,
and Ajay Anand et al10 have all published prospective
30-40 yrs 2 15%
studies with outcomes that are identical to ours.
40-50 yrs 6 46%
50-60 yrs 2 16% It should not be deemed as failure or inexperience
of the surgeon owing to multiple and repeated
Out of 13 laparoscopic cholecystectomy conversion analyses and studies in this particular component
cases, Majority of the patients belonged to the 40 to 50 of laparoscopic cholecystectomy. Conversions
yrs age group with 46%, followed by 20 to 30 yrs age are usually done for the sake of the patient’s safety and
group with 23%, 16% belonged to the 50 to 60 yrs age well-being. As a result, the conversion of laparoscopic
group and the least belonged to the 30 to 40 yrs age cholecystectomy should be emphasised as a sign of
group with 15%. The mean age waas 45.15 + 4.54 yrs. the surgeon’s proficiency and prompt intervention.
Table 4: Distribution based on reasons for
conversion of laparoscopic cholecystectomy Conclusion
Our findings show that widely accessible preoperative
No. of
Converted Cases reason Percentage data may be used to calculate an accurate and simple
patients
Dense adhesions 5 38.46% risk estimate for conversion from laparoscopic to open
Difficult anatomy around cholecystectomy. Recognizing when a patient is at
3 23.07% higher risk for conversion can help with preoperative
Calout’s
Arterial Injury 3 23.07% counselling and resource allocation in the operating
Hepato biliary injury 1 7.69% room, can improve safety by limiting the time it
Technical difficulty 1 7.69% takes to convert to an open cholecystectomy, and can
identify patients who would benefit from a planned
In majority of the cases, dense adhesion was the
open approach.
reason for conversion of laparoscopic cholecystectomy
to open cholecystectomy in 38.46%. Arterial injury Ethical Clearance: The Ethical clearance was
and difficult anatomy around calout’s was the reason obtained from the institutional ethics committee of
for conversion in 23% of the cases each. Hepato Gandhi Medical College and hospital prior to the
biliary injury and technical difficulty was the reason commencement of the study.
for conversion in 7.69% of the cases each.

Conflict of interest: Nil 7. Rosen M, Brody F, Ponsky J. Predictive factors for

conversion of laparoscopic cholecystectomy. Am J Surg
Source of funding: Self 2002;184: 254-8
References 8. Singh K, Ohri A. Laparoscopic cholecystectomy - is there
1. Livingston E, Rege R. A nationwide study of conversion a need to convert? J Minim Access Surg. 2005 Jun;1(2):59-
from laparoscopic to open cholecystectomy. Am J Surg 62. doi: 10.4103/0972-9941.16528.
2004;188:205-11. 9. Alexander, Shandrich & Houterman, Saskia & Slooter,
2. Alponat A, Kum C, Koh B, Rajnakova A, Goh P. Predictive Gerrit & Roumen, Rudi. (2011). Risk Factors for
factors for conversion of laparoscopic cholecystectomy. Conversion during Laparoscopic Cholecystectomy
World J Surg 1997;21:629-33. — Experiences from a General Teaching Hospital.
Scandinavian journal of surgery : SJS : official organ
3. Fried G, Barkun J, Sigman H, Joseph L, Clas D, Garzon for the Finnish Surgical Society and the Scandinavian
J,et al. Factors determining conversion to laparotomy in Surgical Society. 100. 169-73.
patients undergoing laparoscopic cholecystectomy. Am J
Surg 1994;167:35-9. 10. Ajay Anand, B.S. Pathania, Gurjeet Singh. Conversion
in Laparoscopic Cholecystectomy: An Evaluation
4. Kama N, Kologlu M, Doganay M, Reis E, Atli M, Dolapci Study. JK SCIENCE 2007; 9(4): 171 - 4.
M. A risk score for conversion from laparoscopic to open
cholecystectomy. Am J Surg 2001;181:520-5.
5. Tang B, Cuschieri A. Conversions during laparoscopic

cholecystectomy: risk factors and effects on patient outcome.
J Gastrointest Surg 2006;10:1081-91.
6. Bulbuller N, Ilhan Y, Baktir A, Kirkil C, Dogru O.

Implementation of a scoring system for assessing difficult
cholecystectomies in a single center. Surg Today 2006;
36:37-40.

A Clinical Study of Hollow Viscus Injuries in Abdominal Trauma
Bagammagari Raghuram Reddy1, Annapareddy Raja Karan Reddy2

1
Professor, Assistant Professor, Department of General Surgery, Gandhi medical college and hospital, Hyderabad Telangana.
2
How to cite this article: Bagammagari Raghuram Reddy, Annapareddy Raja Karan Reddy et al A Clinical Study of
Hollow Viscus Injuries in Abdominal Trauma. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Blunt abdominal trauma results in injury to the bowel and mesenteries in 3—5% of cases. The injuries are
polymorphic including hematoma, seromuscular tear, perforation, and ischemia. They preferentially involve the small
bowel and may result in bleeding and/or peritonitis. The main diagnostic challenge is to promptly and correctly identify
injuries that require surgical repair.
Objectives: To study the incidence, management and outcome of Hollow Viscus Injuries in Abdominal Trauma
Methods: A comprehensive history was obtained from 50 patients attendants, including the patient’s demographic
characteristics, the type of injury (whether blunt or penetrating), the symptoms with which the patient presented, and the
time elapsed from injury to admission. All patients underwent baseline tests such as haemoglobin, platelet count, blood
urea, blood glucose levels, serum electrolytes, and blood grouping. Ultrasound and CT scans of the abdomen were not
performed on all patients. Patients whose x-rays or clinical examinations were inconclusive had USG and CT scans.
Results: Male predominance was observed with 72% and females were 28%. The male: female ratio was 2.57:1.Out of the
50 cases with these kinds of injuries 56% of the cases underwent primary closure of perforation. 20% cases had resection
and anastomosis. 14% of the cases had Omental patch closure of perforation and 10% cases with serosal tear underwent
simple repair
Conclusion: Many predictors of morbidity and mortality have been identified, and treatment delays have been identified
as a strong indication of morbidity that has a substantial impact on the post-operative path.
Keywords: Hollow viscus injury, trauma, blunt, Omental patch
Introduction injuries and are just as serious, resulting in higher

In today’s modern mobile world, trauma is the blood loss and contaminated bowel injury.3
significant cause of morbidity and mortality. After Intestinal and mesenteric injuries are less prevalent
head and chest injuries, abdominal organ injuries are in acute abdominal trauma than solid organ injuries
the third most prevalent type of injury.1 In hospital (liver, spleen), but they frequently pose diagnostic
emergency rooms, both blunt and penetrating injuries challenges that might cause therapeutic delays.4
are prevalent.2
Hollow viscus injuries occur when the oesophagus
Solid viscera are the most typically injured is injured from the cervical section to the anus, the
organs in trauma, and numerous studies have been liver and biliary tract, and the lower genitourinary
undertaken upon them. Hollow viscus injuries, on tract. A serosal tear to a full transection of the gut or
the other hand, are just as prevalent as solid visceral tracts are instances of injury patterns.5
Annapareddy Raja Karan Reddy
Despite modern tools and technologies such as Patients whose x-rays or clinical examinations were
ultrasound, CT scan, MRI scan, and endoscopy, inconclusive had USG and CT scans.
the nature of the injury, a clear clinical history,
Statistical Analysis: The SPSS 22 software was used
a comprehensive clinical examination, and basic
for statistical analysis and the data was presented in
radiographs can aid in identifying many patients
the form of means and percentages.
with hollow visceral injuries with decent accuracy.
Any delay in diagnosis will increase morbidity and Observation and Results
mortality in the long-term.6
Table 1: Distribution based on Gender
As a result, a general surgeon should be able to
Gender No. Of patients Percentage (%)
clinically detect and treat trauma, particularly those
Male 36 72%
involving abdominal hollow visceral injuries, which
Female 14 28%
are becoming increasingly common. In this study,
efforts were undertaken to study about the prevalence Male predominance was observed with 72% and
of abdominal trauma, the numerous intra-abdominal females were 28%. The male: female ratio was 2.57:1.
organs injured in penetrating and blunt abdominal Table 2: Distribution based on age group
injuries, and their varied outcomes. Age group (yrs) No. Of Percentage
Materials and Methods patients (%)
<20 11 22%
Study Design: Hospital-based cross-sectional
21-30 17 34%
study
31-40 13 26%
Study Setting: Department of General Surgery, 41-50 4 8%
Gandhi Medical College and hospital >50 4 8%
Duration of study: July 2021 to December 2021 Total 50 100%
The majority of the patients belonged to the age
Sample size: 50 Patients with Hollow abdominal
group of 21 – 30 years with 34%, followed by 31 to
viscus injury
40 yrs age group with 26%, <20yrs age group had
incidence of 22%, the least no. of patients belonged
Inclusion Criteria:
to the age group of 41 – 50 yrs and >50 years of age
• All patients hospitalised with abdominal group with 8% each.
pain, either blunt or penetrating, who have
hollow viscus injuries (contusion, serosal tear Road traffic accidents was the most prevalent
or perforation) on clinical or radiographic caused of hollow abdominal viscus injury in 60% of
examination or intraoperative findings. the cases, followed by fall from height in 24% of the
cases, Train accidents and stab injuries accounted for
Exclusion Criteria: 8% of the cases each. The significant injury associated
in trauma was Polytrauma with 26% followed by
• Patients with abdominal pain owing to
orthopedic injuries constituting 24%, Head injuries in
trauma who did not have radiological or
15% and the least being the thoracic injuries seen in
intraoperative indications of hollow viscus
8% of the patients.
injuries were excluded from the study.
Table 3: Distribution based on time taken for
A comprehensive history was obtained from surgery after hollow viscus injury
50 patients attendants, including the patient’s
demographic characteristics, the type of injury Hours No. of patients Percentage (%)
(whether blunt or penetrating), the symptoms with 0-12 33 66%
which the patient presented, and the time elapsed 12-24 15 30%
from injury to admission. All patients underwent 24-48 1 2%
baseline tests such as haemoglobin, platelet count, >48 1 2%
blood urea, blood glucose levels, serum electrolytes, The majority of the patients around 66% were
and blood grouping. Ultrasound and CT scans of operated within 12 hours of the injury. Around 30%
the abdomen were not performed on all patients. were operated with 24 hrs of the injury. Around 2% of

50
the cases each were operated between 24 to 48 hrs and Competent clinical judgement, rapid decisions,
more than 48hrs after the injury due to conservative good and appropriate surgical procedures, and
management as the risk was more complicated. adequate postoperative care are all required for the
successful management of traumatic hollow viscus
Table 4: Distribution based on type of management
injuries. Regardless of how far technology has
No. of Percentage progressed, a trained surgeon’s competence is by
Hours
patients (%) far the most important aspect in managing a hollow
Primary closure of viscus injury.10
28 56%
perforation In brief, abdominal trauma is a significant category
Omental patch closure of severe injuries that a surgeon encounters in the
7 14%
of perforation emergency room. The clinical appearance of these
Repair of serosal tear 5 10% injuries varies widely depending on the site and
severity of the injury, and also differentiates between
Resection and blunt and penetrating injuries. It might range
10 20%
anastomosis from a seemingly normal look after a blunt injury
Commonest repair methods performed for to a collapsed and lifeless state after hypotensive
gastrointestinal injuries include primary closure of shock. Other solid organ damage may complicate
perforation, omental patch closure of perforation, matters at times. When dealing with hollow viscus
serosal tear repair and resection and anastomosis. injuries that are coupled with other severe injuries,
Out of the 50 cases with these kinds of injuries 56% of the management modality should prioritise life-
the cases underwent primary closure of perforation. threatening injuries first, followed by other injuries.
20% cases had resection and anastomosis. 14% of the Even though most studies suggest that penetrating
cases had Omental patch closure of perforation and abdominal trauma increases the risk of hollow viscus
10% cases with serosal tear underwent simple repair injuries, this study reveals that blunt abdominal
Table 5: Distribution based on mortality of patients trauma causes the majority of hollow viscus injuries,
based on reporting to the hospital after injury highlighting the need of effective trauma care.11
Mortality No. of patients Percentage In all cases of blunt abdominal trauma, a hollow
Presentation <24 hrs 3 6% viscus injury should be assumed. For accurate
diagnosis and to avoid delays in appropriate
Presentation >24 hrs 6 12%
surgical intervention, multiple clinical examinations
The mortality rate for patients admitted more than with thorough monitoring and repeat imaging are
24 hours after the injury was significantly greater than required in uncertain patients. The mode of repair is
those admitted within 24 hours of the trauma. determined by the condition of the patient, degree of
contamination with intestinal contents, concomitant
Discussion injuries, and overall condition. Above all, it is
Primary repair, or resection and anastomosis dependent on the surgeon’s clinical expertise as well
without a diversion colostomy, is preferable for as the trauma centre’s facilities.
individuals with colonic or intraperitoneal rectal
injuries.7 In individuals with extraperitoneal rectal
Conclusion
injuries, proximal diversion colostomy alone may be Although early diagnosis of gastrointestinal injuries
adequate. Because of the increased risk of anastomotic from blunt abdominal trauma might be difficult
leak, patients with stomach rupture should have a in some circumstances, it is critical because of the
gastrectomy and an intra-abdominal drain placed potential for life-threatening complications. The
at the location of the esophagojejunal anastomosis patient’s age, anatomical location, and time of
rather than no drainage. Drains are not recommended manifestation are probably the most important
for other gastrointestinal injuries after repair.8 The prognostic markers. Many predictors of morbidity
abdominal wall may need to be temporarily closed and mortality have been identified, and treatment
after an exploratory laparotomy for trauma so that a delays have been identified as a strong indication of
second look surgery may be performed later.9 morbidity that has a substantial impact on the post-
operative path.

Ethical Clearance: The Ethical clearance was 6. Elton C, Riaz AA, Young N, Schamschula R,
obtained from the institutional ethics committee of Papadopoulos B, Malka V. Accuracy of computed
Gandhi Medical College and hospital prior to the tomography in the detection of blunt bowel and
commencement of the study. mesenteric injuries. Br J Surg 2005;92(8):1024—8.
7. Nural MS, Yardan T, Güven H, Baydin A, Bayrak IK,

Kati C. Diagnostic value of ultrasonography in the
Source of funding: Self evaluation of blunt abdominal trauma. Diagn Interv
Radiol. 2005;11(1):41–4.
References
8. Killeen KL, Shanmuganathan K, Poletti PA, Cooper
1. Watts DD, Fakhry SM, EAST Multi-Institutional
C, Mirvis SE. Helical computed tomography of bowel
Hollow Viscus Injury Research Group. Incidence of
and mesenteric injuries. J Trauma. 2001;51(1):26–36.
hollow viscus injury in blunt trauma: an analysis from
trauma admissions from the East multi-institutional 9. Miller LA, Shanmuganathan K. Multidetector CT
trial. J Trauma 2003;54(2):289—94. evaluation of abdominal trauma. 2005;43(6):1079–viii.
2. McNutt MK, Chinapuvvula NR, Beckmann NM, et al. 10. Khan I, Bew D, Elias DA, Lewis D, Meacock LM.
Early surgical intervention for blunt bowel injury: the Mechanisms of injury and CT findings in bowel and
Bowel Injury Prediction Score (BIPS). J Trauma Acute mesenteric trauma. Clin Radiol. 2014;69(6):639–47
Care Surg 2015;78(1):105—11.
11. Scaglione M1, de Lutio di Castelguidone E, Scialpi M,
3. Bhagvan S, Turai M, Holden A, Ng A, Civil I. Predicting Merola S, Diettrich AI, Lombardo P, et al. Blunt trauma
hollow viscus injury in blunt abdominal trauma with to the gastrointestinal tract and mesentery: is there a
computed tomography. World J Surg 2013;37(1):123—. role for helical CT in the decision-making process? Eur
J Radiol. 2004;50(1):67–73
4. Stuhlfaut JW, Lucey BC, Varghese JC, Soto JA. Blunt
abdominal trauma: utility of 5-minute delayed CT with
a reduced radiation dose. Radiology 2006;238(2):473—
9.
5. Alsayali DMM, Atkin C, Winnett J, Rahim R,

Niggemeyer LE, Kossmann T. Management of blunt
bowel and mesenteric injuries: experience at the Alfred
hospital. Eur J Trauma Emerg Surg 2009;35(5):482—8.

Residual Cardiovascular Risk – A Concept in Evolution
Biswajit Das1, Subhasish Singh2

1
Associate Professor SCB Medical College, Cuttack, Odisha,
2
Assistant Professor MKCG Medical College, Berhampur, Odisha.
How to cite this article: Biswajit Das, Subhasish Singh et al Residual Cardiovascular Risk – A Concept in Evolution.
Abstract
The commonest cause of mortality worldwide is cardiovascular disease.The contemporary evidence based therapy targets
known risk factors like LDL cholesterol,hypertension and hyperglycemia.Still,the current treatment protocols prevent
only half of the CVD deaths.Scientific research is constantly providing newer options to mitigate unfavourable outcomes
in those with persistent risk.This review discusses the multiple potential targets of therapy and the drugs available to fill
this unmet need.
Keywords: atherosclerosis, cardiovascular risk, inflammation
Introduction conventional risk factors is labelled as “residual

The recent past has seen remarkable developments in risk” that encompasses all etiological entities that are
the field of therapy for atherosclerotic cardiovascular underrecognized and hence,undertreated.
disease(ASCVD).Substantial inroads have been Lipids
made in the identification and control of important
Raised LDL-C is a conventional established etiological
conventional predisposing factorsincluding raised
agent for atherosclerosis and its reduction has been
low-density -cholesterol (LDL-C).The widespread
unequivocally found to improve outcomes.Allaying
use of statins,as part of an aggressive LDL lowering
fears of cognitive dysfunction,”lower the better”
strategy,has substantially reduced morbidity and
approach has been vindicated by high potency lipid
mortality associated with ASCVD.1Newer drugs
lowering therapy The 2019 ESC/EAS guidelines
like PCSK9 inhibitors have made possible reducing
recommend LDL-C< 70 mg/dl in high risk and <55
LDL to drastically low values.There is robust
mg/dl in very high-risk patients.The first drug of
evidence that lower LDL is not only better but also
choice remains statins followed by ezetimibe if target
safe.Importantly,such tremendous decrease of LDL
level is not reached and then,PCSK9 inhibitors in
translated to a fall of absolute risk by a meagre 1.5%
selected patients.While ezetimibe is an efficacious
and a 3 year MACE approached 10% in the two
and affordable drug,PCSK9 inhibitors are a highly
landmark PCSK9i trials(FOURIER and ODYSSEY
efficacious but expensive option.PCSK9 inhibitors are
OUTCOMES).This persistent elevated propensity
human monoclonal antibodies that attach to PCSK9
of adverse outcomes in the face of rigid control of
protein preventing degradation of LDL receptors
Dr Subhasish Singh
Assistant Professor, MKCG Medical College, Berhampur, Odisha.
Address:Department of Cardiology, MKCG Medical College, Berhampur, Odisha.
on hepatocytes.Enhanced uptake of LDL-C from related primates.Apo(a) is synthesized in the liver

the bloodstream results in a fall of LDL-C by about but its fusion with LDL may occur either in liver or
60%.FOURIER and ODYSSEY OUTCOMES with a plasma.
cumulative pool of about 50,000 patients documented
Lp(a) is vulnerable to oxidative damage leading
the clinical benefit of PCSK9 inhbitors.2Adverse
to production ofdamaged molecular complexes
effects are minor such as injection site erythema
recognised by “oxidation specific epitopes”(OSE).This
and pharyngitis.siRNA therapy,inclisiran,has made
complex consists of LDL,phospholipids,sterols(all
possible halving of LDL levels with six monthly
oxidised) and apoptotic cells.The KIV repeats
injections.The ORION 4 is a safety and efficacy study
contain certain specific regions that mediate
that will clarify the role of inclisiran in high risk
inflammatione.g.oxidised phospholipids(oxPLs) of
patients.
which Lp(a) is the primary carrier.Cytokines that
A large body of population and gene based promote inflammation like IL1,IL6 and TNFα are
studies support the causative role of triglycerides stimulated by Lp(a) which can also enhance release
in CVD and the prime culprit in TG-rich particles of IL-8 and monocyte chemotactic protein from
is cholesterol.Disease risk has been correlated with macrophages.Human vascular endothelial cells are
alteration in apoB level regardless of its presence in stimulated by Lp(a) to secrete monocyte chemotactic
LDL-C or chylomicron/VLDL.Disappointingly,trial activity.Also,Lp(a) is a strong chemoattractant for
data do not support CVD-lowering effect of fibrates. human monocytes mediated by a cGMP dependent
The REDUCE-IT trial concluded that 4g of omega-3 mechanism.PET/CT based studies reveal augmented
fatty acid,icosapent ethyl(on a background of statin metabolic activity in the arterial wall in patients with
therapy) caused significant reduction in CV events raised Lp(a).The oxPLs promote transendothelial
.3However,the modest magnitude of TG reduction movement of monocytes.Lp(a) has been found to
and disputability over use of mineral oil as placebo promote monocyte adhesion and migration,possibly
cast doubts on the results.With the STRENGTH study by higher PFKFB-3 and ICAM activity.10In patients
showing negative results,other pleiotropic effects of with coronary artery spasm(CAS),Lp(a) and
EPA,rather than TG-lowering, are conjenctured to be macrophage numbers are increased.An inflammatory
the main mechanism of its action.Pemafibrate is being pathophysiology is indicated by raised α7-nAChR/
studied in diabetics with combined dyslipidemia IL-6/p38 MAPK signalling in such macrophages
for both primary and secondary prevention in the which is inhibited by tocilizumab.Also,Lp(a)
PROMINENT study. stimulates CD80+ macrophage polarisation and
inhibits NO synthase expression,reducing levels of
The molecule Lp(a) has generated considerable
the vasodilatory NO.11
interest. The molecule has two components-one
consisting of LDL attached with apo B-100 and the A Danish study of 3 cohorts of white individuals
other apo(a) covalently linked by a single disulphide revealed a causal association between elevated Lp(a)
bond on KIV9 situated close to the LDL receptor and increased risk of MI.The hazard ratio was 1.22
binding region of apoB.4Apo(a) is a large glycoprotein for every two fold increase in Lp(a) levels.12Clarke
molecule with molecular weight ranging from et al studied about 50,000 single nucleotide
400 to 800 kDa and consisting of multiple kringle polymorphisms(SNPs) in 2100 candidate genes and
IV subunits,akringle V and a proteolytic subunit. found that the LPA gene had the strongest association
There are 10 kinds of kringleIV repeats with one with risk of CAD.They identified 2 LPA variants that
each of KIV1 and KIV3-10 and multiple number of were strongly associated with an increased level
KIV2 .Circulating Lp(a) levels are determined by of Lp(a) and a greater risk of CAD.Joint analysis
the genetic variability of apo(a) mediated through concluded that the 2 variants account for 36% of the
KIV2 representation.The number of KIV-2 repeats variation in Lp(a) levels whereas stepwise regression
correlates inversely with levels of lipoprotein(a).5The identified 7 SNPs that together contributed to
LPA gene encoding apo(a) is situated on chromosome 40% of the total variation.13A metanalysis of 26
6q26.Of note,thekringle V and the proteolytic entities prospective cohort studies and 10 nested case control
of Lp(a) share structural homology with plasminogen. studies revealed that Lp(a) correlated weakly with
However,while the PLG gene is ubiquitous in animal established risk factor for CHD .However,in contrast
species ,the LPA gene is present only in humans and to earlier postulations of steep threshold effect, it

54
had a continuous association with risk of CAD with GLP-1RA act as ligands to the widely distributed
a relative risk(RR) of 1.16 for every 3.5 times rise in GLP-1 receptors but when in islets of Langerhans
Lp(a).The findings were replicated in subanalyses stimulate insulin and inhibit glucagon.Gastric motility
of coronary death and nonfatal MI.This continuous, is retarded and anorectic effect is also noted leading
independent and specific correlation was shown to to weight loss.An anti-inflammatory effect has also
be limited to vascular outcomes.14The biracial ARIC been identified.A total of 55,000 odd patients studied
study found Lp(a) levels to be positively associated over six CV outcome trials showed an improvement
with CAD and ischemic stroke.Xu et al investigated in outcome including CV mortality,nonfatal MI and
the impact of Lp(a) on severity of CAD and found nonfatal stroke.
that Lp(a) was independently correlated with
intermediate to high SYNTAX score.15An analysis of Inflammation
data from about 4000 patients revealed a statistically Apart from controlling LDL-C ,HMG-CoA reductase
significant relation between Lp(a) and coronary inhibitors have numerous other mechanisms of action
artery calcification(CAC) with a causal link between including inhibition of inflammation.Multiple trials
the two.Also,the LPA SNP rs 10455872 was associated incriminate inflammation as etiological in ASCVD
with higher Lp(a) and CAC.In so much as CAC by revealing that reduced inflammation results in fall
provides a measure of atherosclerotic burden and of subsequent CV outcomes.The pathophysiology
future CV events,this particular SNP may by raising of atherosclerosis starts with deposition of apoB
Lp(a) contribute to development of atherosclerosis.16 rich lipoproteins in the subendothelium of blood
Lp(a) levels positively correlate with plaque volume vessels.They are subjected to multiple structural
and unfavorable plaque composition in patients of changes (such as glycation and oxidation) leading
ischemic heart disease. In ACS patients subjected to the genesis of foam cells.The oxidised LDL inflict
to PCI,a synergistic effect of GRACE risk score and damage by endothelial cell injury,promotion of
Lp(a) level was observed in prediction of adverse adhesion molecules and localised inflammation
outcomes.This could help select the candidates for via accumulation of white blood cells.Theintensity
aggressive reduction of Lp(a).17 of this inflammation is strongly dependent on the
apoBsubtype,the effect of which is again influenced by
Diabetes other factors like liver triglyceride content or genetic
Type 2 diabetes mellitus is animportant etiological susceptibility.Oxidised LDL is also proinflammatory
agent for CVD but apart from metformin,no by promoting formation of intracellular crystalline
conventional antidiabetic has been shown to confer cholesterol and damage-associated molecular pattern
cardiovascular benefit.The newer drugs,namely molecules.The biochemical consequence of these
SGLT2 inhibitors and GLP-1RA,have been shown molecular processes is a rise in blood levels of hs-
to improve cardiovascular outcomes independent CRP and IL-6 which have been proven by numerous
of their glucose-lowering effect.While SGLT2i studies to be an efficient marker of future ASCVD.The
primarily improve heart failure prognosis,GLP- ubiquitous presence of mild,long term inflammation
1RA protect against atherosclerosis related events. in the pathogenesis of atherosclerosis provides a
Multiple trials substantiate the protective effect of promising target for prevention and treatment of
SGLT2i on MACE,heart failure hospitalisation and ASCVD.
mortality in high risk diabetics.While CANVAS and
The connection between inflammation and
EMPA-REG demonstrated 14% decrease in clinical
dyslipidemia was first uncovered by the landmark
endpoint,DECLARE TIMI 58 and VERTIS CV showed
statin trials wherein use of statin was associated
no benefit.18Irrespective of diabetic status,upto 35%
with fall in hsCRP which in turn was correlated
fall in hospital admission for HF was noted.Also,the
with improved CV outcomes. The change in LDL-C
renoprotective effect was demonstrated as a 40-60%
and hsCRP was comparable and had an additive
reduction in fall of GFR,ESRD or mortality due to
salutary effect on clinical events. Amongst patients
renal causes.EMPA-REG also revealed a 40% fall in
taking statins,a sizeable one-third have heightened
CV death.Contemporary societal guidelines consider
hsCRP with lipid targets achieved. Notably, the
SGLT2i as preferable in diabetics with HFrEF or CKD.
potent hypolipidemic PCSK9 inhibitors have been
Adverse effects include increased susceptibility to
consistently found to be ineffective in lowering hsCRP.
genital ingections and diabetic ketoacidosis.
In further support of the inflammation hypothesis,

hsCRP was found to be a predictor of future events The inflammasome acts by stimulating caspase-1
even in patients whose LDL-C levels were reduced to activity resulting in increased production of IL-1β
less than 20 mg/dl with statins. which serves to attract inflammatory cells, primarily
macrophages and T cells.It also promotes IL-6/IL-18
Consequently,multiple potential targets of
generation and thereby, increases hepatic production
therapy have been identified and explored.The IL-1β
of proinflammatory proteins like CRP, fibrinogen and
antibody,canakinumab,was tested in a trial of post-
plasminogen.The persistent low grade inflammation
MI patients with raised hsCRP(inspite of maximal
sustains the evolution of atherosclerosis from foam
statin therapy).The drug halved the hsCRP and IL-6
cells to fatty streaks to the full blown obstructive
levels and also,lowered the overall major adverse
plaques.
clinical events by 15% and an even more impressive
25% in patients achieving hsCRP concentration below Inflammation has also been proposed to be a
2 mg/dl.This was comparable to the benefit accrued controller of lipid metabolism in the liver.VLDL
in prominent PCSK9 inhibitor trials.Methotrexate,on particles rich in apo-C3 and Lp(a) particles rich in
the other hand,proved to be a disappointment.A oxidised phospholipids can promote inflammation.
study on post MI patients or diabetics with Raised TNF-α results in augmented lipogenesis,efflux
multivessel coronary artery disease who were of VLDL into circulation and lesser apoB breakdown.
already receiving all recommended drugs showed Teleologically,increased circulating lipids in response
that weekly methotrexate provided no clnical(5 year to inflammation serves to provide sufficient energy
MACE) or biochemical(hsCRP reduction) benefits.A for efficient tissue healing.However,over the
recent upsurge in interest in colchicine is the result long term,it may prove detrimental by fostering
of the COLCOT study.4755 post-MI patients were development of metabolic syndrome or diabetes.The
randomised to 0.5 mg daily dose of colchicine or concept of thromboinflammation entails a two way
placebo.A 23% and 48% reduction in ischemic relationship between thrombosis and inflammation.
ASCVD events was noted in patients enrolled within Inflammation promotes thrombosis by increasing
30 days or 3 days of MI,respectively. These results platelet activation,fibrinogen,PAI-1 and tissue factor.
were replicated on a cohort of stable angina patients Conversely,thrombosis also stimulates inflammation.
in the LoDoCo2 study wherein the verum group had The influence of lipids on platelet function has
a 31% lesser relative risk of MACE over a follow up been increasingly elucidated by lipidomics. Many
of about two and half years. However, the correlation lipid moieties like oxidised LDL and Lp(a) increase
with inflammation could not be established as no thrombosis.Rosuvastatin putatively retards
inflammatory parameters were measured in these thrombosis by decreasing platelet membrane
studies. cholesterol and reducing tissue factor,factor VII
and factor X.Laboratory evidence indicates that
The NLRP3 inflammasome has emerged as a crucial
the PCSK9 molecule facilitates platelet dysfunction
and possibly,exclusive pathway in the inflammatory
and thrombosis.Lab mice with PCSK9 deletion had
genesis of atherosclerosis.Canakinumab acts by
decreased incidence of vascular thrombi and those
modulating IL-1β without any effect on IL-1α whereas
with increased expression had higher thrombin-
colchicine is nonselective as it prevents microtubule
antithrombin and lower protein C.To add another
assembly.It also inhibits caspase-1 thereby reducing
dimension,lipoproteins also modulate inflammation
IL1β level.Methotrexate prevents conversion of
and thrombosis by yet undefined mechanisms.
5-aminoimidazole-4-carboxamide ribonucleotide
(AICAR) to formyl-AICAR by the enzyme ATIC Therefore,dyslipidemia and inflammation are
leading to accumulation of adenosine,a potent anti- both etiologically associated with atherosclerosis.
inflammatory.Yet,it showed no benefit in clinical The dynamics of their mutual interaction are not
trials,indicating that atherosclerosis is mediated by fully clear but definitely,the long term probability
the NLRP3 inflammasome.In consonance with this of MACE is more accurate when both are taken into
hypothesis , multiple lipid molecules like oxidised account.Ridker et al in a study of 4786 stable but high
LDL and apoC3 modulate the NLRP3 complex by risk patients revealed that IL-6 and LDL-C together
multiple pathways including upregulating toll-like was thrice more accurate in predicting MACE than
receptors,increased potassium efflux and enhanced either parameter alone.The HR of the highest quartile
oxidative damage. relative to the lowest was 6.4 whereas the same

56
value for hsCRP and LDL-C was 4.9.For individual increased risk of MACE.The corresponding figure for
parameters,the HR was 1.79 for hsCRP,2.11 for IL-18 was 15% inspite of no change in IL-18 levels.A
IL-6 and 2.38 for LDL-C.Considering that all trial number of NLRP-3 inflammasome inhibitors that
participants were on standard therapy,these data decrease both IL-1β and IL-18 are under investigation
highlight the sizeable residual risk in a high risk but its potential widespread immunosuppressive
population.Also,it underlines the importance of actions warrant caution . In CANTOS,a significant
both factors( inflammatory and dsylipidemic) to increase in life-threatening infections was noted
this residual risk.In consequence,the importance of possibly due to direct inhibition of IL-1β and
a holistic principle targeting both these components hence,selective targeting of IL-6 appears to be a
is in order because use of PCSK9 inhibitors or anti- more prudent approach.Investigative IL-6 inhibitor
inflammatory agents individually decreased MACE molecules are tocilizumab(monoclonal antibody
by a meagre 20-30% leaving a large burden of against IL-6 ) and sarilumab(monoclonal antibody
residual risk.In the absence of trial data,it remains against IL-6 receptor).RESCUE is an ongoing study
to be seen if a combination of both ,on a background of ziltivekimab(IL-6 monoclonal antibody) in CKD,a
of conventional therapy,proves to be synergistic or group of patients where colchicine is contraindicated.
even superadditive in their efficacy to prevent future
Of equal importance is the identification of
events.
appropriate high risk patient population who will
The selection of candidate drugs for such a study benefit the most from aggressive therapy.The preferred
is an important decision.PCSK9 inhibitors are suitable biomarker for patient selection is yet to be pinpointed.
by way of their neutral effect on hsCRP but the cost In CANTOS,hsCRP was used as the discriminator
is prohibitive.A combination of bempedoic acid and whereas in COLCOT,hsCRP was measured in a small
ezetimibe is as efficacious as moderate dose statins percentage of patients.The median concentration of
and its effect on clinical endpoints still unknown. 4 mg/l was comparable to CANTOS but whether it
Inclisiran,a small interfering RNA,is an option as it could be generalized to the entire trial is questionable.
halves PCSK9 synthesis and requires injection every In contrast,CIRT found median hsCRP to be much
6 months.The NLTP-3 inflammasome is the lynchpin less(1.5 mg/l).CANTOS showed that reduction in
of the inflammatory component of atherosclerosis clinical events was maximal(25%) in patients with
but as compared to the gamut of hypolipidemics on-treatment hs-CRP less than 2 mg/l.The correlation
available,canakinumab and colchicine are the was stronger for IL-6 with a 32% reduction for those
only two drugs proven to have clinical benefit. with level less than 1.65 ng/l.19
No comparative study between the two has been
Other contentious matters include threshold
undertaken and would be beset with many practical
for starting treatment and duration of therapy.
hindrances including striking difference in cost and
The duration of therapy neeed to extract maximum
route of administration.Colchicine with its oral route
clinical benefit is undetermined.Also,a rebound of
of administration,previous safety data,fast action
clinical events after treatment discontinuation cannot
and low cost is clearly the front runner for any trial.
be excluded.A secondary analysis of CANTOS was
Its myriad actions beyond the NLRP3 inflammasome
performed to measure the total number of CV events
include a fall in multiple other inflammatory mediators
since initiation of therapy.Divergent from primary
like myeloblastin,CEA-related CAM8,azurocidin
trial results,a marked decrease of total events was
and myeloperoxidase.It also increases concentration
seen in all patients,irrespective of drug dosage.The
of beneficial factors like fibroblast growth factor
drug was found to confer protection even without
and insulin-like growth factor binding protein.
significant fall in hsCRP or IL-6.The COLCHINE-
However the superior clinical efficacy as compared to
PCI study revealed that prePCI intake of 1.8 mg of
canakinumab is still unproven.
colchicine reduced immediate increase in IL-6 and
CANTOS participants underwent measurement hsCRP without any effect on clinical events over 30
of both IL-6 and IL-18 before and after starting day followup.These data point towards need for long
canakinumab and were followed up for a mean term therapy to obtain clinical benefit.
of 3.7 years.An impressive 43% reduction of IL-6
Optimum timing of initiation of therapy is
notwithstanding,each tertile rise in IL-6 ,measured 3
undetermined.Canakinumab has been tried in
months after drug initiation,was associated with a 42%

patients with history of MI at least 30 days prior to 3. Bhatt DL, Steg PG, Miller M, et al. Cardiovascular
initiation but colchicines has been found useful in risk reduction with icosapent ethyl for
both post MI and stable CAD patients.Bouabdallaoui hypertriglyceridemia.NEnglJMed. 2019;380:11–22.
et al showed that clinical benefit was significantly 4. Dubé J. B., Boffa M. B., Hegele R. A., Koschinsky M. L.
higher when colchicine was started within 3 days as 2012. Lipoprotein(a): more interesting than ever after
compared to 4-7 days after MI. 50 years. Curr. Opin. Lipidol. 23: 133–140
Apart from drugs,the old school doctrine of 5. Utermann G. Lipoprotein(a). In: Scriver CR, Beaudet
lifestyle modification continues to be an effective AL, Sly WS, Valle D, eds. The Metabolic and Molecular
strategy.a combination of weight loss, abstinence Bases of Inherited Disease. 2001 ed. New York, NY:
from smoking, regular exercise and diet modification McGraw-Hill Professional; 2006:2753-2787
has been shown to reduce hsCRP to less than 2mg/l 6. Boffa M, Marcovina SM, Koschinsky ML (2004)
in upto 40% of CAD patients.A putative mediator is Lipoprotein(a) as a risk factor for atherosclerosis and
β-hydroxybutyrate (BHB).Circulating levels rise with thrombosis: mechanistic insights from animal models.
exercise and diet restriction. The compound impedes Clin Biochem 37: 333–343
the formation of the NLRP-3 inflammasome and 7. Yeang C, Witztum JL, Tsimikas S. Novel method
hence,production of IL-1β and IL-6.Carbohydrate for quantification of lipoprotein(a)-cholesterol:
restricted diets promote ketosis and inhibit implications for improving accuracy of LDL-C
inflammation in insulin resistance as evidenced by measurements. J Lipid Res. 2021;62:100053.
the fall in biomarkers of atherosclerosis.20 doi:10.1016/j.jlr.2021.100053
Conclusion: 8. Enas EA, Varkey B, Dharmarajan TS, Pare G, Bahl VK.

Lipoprotein(a): an independent, genetic, and causal
The recent past has brought to light ,sometimes factor for cardiovascular disease and acute myocardial
serendipitously, the marked salutary effects of infarction. Indian Heart J. 2019;71(2):99–112. https://
multiple drugs on cardiovascular outcomes.The doi.org/10.1016/j.ihj.2019.03.004.
practical application of this knowledge is impeded
9. Buechler C, Ullrich H, Ritter M, Porsch-Oezcueruemez
by apparent randomness in choosing from this array
M, Lackner KJ, Barlage S, et al. Lipoprotein (a) up-
,mostly decided by the prescriber’s personal discretion regulates the expression of the plasminogen activator
rather than patient candidacy.The need of the hour is inhibitor 2 in human blood monocytes. Blood.
a set of clear cut guidelines that assist a physician to 2001;97(4):981–6
rationally individualise therapy for high risk patients
10. Schnitzler JG, Hoogeveen RM, Ali L, et al. Atherogenic
wherein conventional therapy may not be enough.
Lipoprotein(a) Increases Vascular Glycolysis,
While they may represent a minority in daily clinical
Thereby Facilitating Inflammation and Leukocyte
practice,the substantial benefit accrued from these Extravasation. Circ Res. 2020;126(10):1346-1359.
ancillary drugs should be enough motivation for doi:10.1161/CIRCRESAHA.119.316206
scientic societies and caretakers alike to handpick the
11. Lin YK, Yeh CT, Kuo KT, et al. Apolipoprotein (a)/
drugs that maximise favourable outcomes.
Lipoprotein(a)-Induced Oxidative-Inflammatory α7-
Ethical clearance - Taken from Ethical clearance nAChR/p38 MAPK/IL-6/RhoA-GTP Signaling
committee MKCG Medical College,Berhampur Axis and M1 Macrophage Polarization Modulate
Inflammation-Associated Development of Coronary
Source of funding - Self Artery Spasm. Oxid Med Cell Longev. 2022;2022:9964689.
Conflict of interest - None Published 2022 Jan 19. doi:10.1155/2022/9964689
12. Kamstrup PR, Tybjaerg-Hansen A, Steffensen R,

References
Nordestgaard BG. Genetically elevated lipoprotein(a)
1. Dhindsa DS, Sandesara PB, Shapiro MD, et al. The and increased risk of myocardial infarction. JAMA
evolving understanding and approach to residual 2009;301:2331-9
cardiovascular risk management. Front Cardiovasc
Med 2020;13;7:88. https://doi. org/10.3389/ 13. Clarke R, Peden JF, Hopewell JC, Kyriakou T, Goel A,
fcvm.2020.00088; PMID: 32478100. Heath SC, et al. Genetic variants associated with Lp(a)
lipoprotein level and coronary disease. N Engl J Med
2. SabatineMS,GiuglianoRP,KeechAC,etal. Evolocumab 2009;361:2518-28
and clinical outcomes in patients with cardiovascular
disease.NEnglJMed. 2017;376:1713–22.

58
14. Emerging Risk Factors Collaboration, Erqou S, 18. Zinman B, Wanner C, Lachin JM, et al.
Kaptoge S, Perry PL, Di Angelantonio E, Thompson Empagliflozin,cardiovascular outcomes, andmortality
A, et al. Lipoprotein(a) concentration and the risk in type 2 diabetesNEnglJMed. 2015;373:2117–28.
of coronary heart disease, stroke, and nonvascular
19. Ridker PM, MacFadyen JG, Everett BM, et al.
mortality. JAMA 2009;302:41
Relationship of C-reactive protein reduction to
15. Xu N, Tang XF, Yao Y, Jia SD, Liu Y, Zhao XY, cardiovascular event reduction following treatment
Chen J, Gao Z, Yang YJ, Gao RL, Xu B, Yuan JQ. with canakinumab: a secondary analysis from
Lipoprotein(a) levels are associated with coronary the CANTOS randomised controlled trial. Lancet
severity but not with outcomes in Chinese patients 2018;391:319–28. https://doi.org/10.1016/S0140-
underwent percutaneous coronary intervention. 6736(17)32814-3; PMID: 29146124.
NutrMetab Cardiovasc Dis. 2020 Feb 10;30(2):265-273.
20. Bhanpuri NH, Hallberg SJ, Williams PT, et al.
doi: 10.1016/j.numecd.2019.09.020. Epub 2019 Sep 26.
Cardiovascular disease risk factor responses to a type
PMID: 31740238.
2 diabetes care model including nutritional ketosis
16. Pechlivanis S, Mahabadi AA, Hoffmann P, et al. induced by sustained carbohydrate restriction at
Association between lipoprotein(a) (Lp(a)) levels 1 year: an open label, non-randomized, controlled
and Lp(a) genetic variants with coronary artery study. Cardiovasc Diabetol 2018;17:56. https://doi.
calcification. BMC Med Genet. 2020;21(1):62. Published org/10.1186/s12933-018-0698-8; PMID: 29712560
2020 Mar 27. doi:10.1186/s12881-020-01003-3
17. Hu C, Liu J, Han H, et al. A Synergistic Effect of

Lp(a) and GRACE Score on Cardiovascular Risk in
Acute Coronary Syndrome Patients Undergoing
Percutaneous Coronary Intervention: A Cohort Study
From China. Front Cardiovasc Med. 2021;8:637366.
Published 2021 Feb 19. doi:10.3389/fcvm.2021.637366

Comparative Assessment of two behavioural risk factors

(Physical Inactivity and Unhealthy Diet) among obese Bengali women
in rural and urban areas of West Bengal, India
Chaitali Bose1, Julekha Sultana2, Oly Banerjee3, Sidhhartha Singh4,

Sandip Mukherjee5, Alak Kumar Syamal6
Research Fellow, Post Graduate Department of Physiology, Hooghly Mohsin College, University of Burdwan, West Bengal-732101, India.
1,2
M.Sc., Research Fellow, Department of Physiology, Serampore College, 9 William Carey Road, Hooghly, West Bengal-712201, India.
3,4
5
Associate Professor, Department of Physiology, Serampore College, 9 William Carey Road, Hooghly, West Bengal-712201, India.
6
Post Graduate Department of Physiology, Hooghly Mohsin College, University of Burdwan, West Bengal: 732101, India.
How to cite this article: Chaitali Bose, Julekha Sultana, Oly Banerjee, Sidhhartha Singh, Sandip Mukherjee,
Alak Kumar Syamal et al Comparative Assessment of two behavioural risk factors (Physical Inactivity and
Unhealthy Diet) among obese Bengali women in rural and urban areas of West Bengal, India. Volume 13 | Issue 4 |
Abstract
This study was aimed to assess dietary pattern and unhealthy dietary factors and to determine the prevalence of
physical inactivity among obese Bengali women in rural and urban areas of West Bengal. This study was conducted in
Hooghly district of West Bengal, India and 150 female subjects of 20-50 years age group were recruited for the study
considering inclusion and exclusion criteria. Different physical, anthropometric and socio-demographic variables were
documented and dietary information was collected using questionnaire. Global Physical Activity Questionnaire was used
to collect information about physical activities. Daily energy comes mainly from carbohydrate in the diet of both groups.
Consumption of animal protein and dairy products, fruits, visible fat and sugar were significantly higher in urban group
whereas dietary fibre, green leafy and other vegetables, pulses and nuts intake was significantly high in rural group.
Physical inactivity prevalence was 64.0% in rural and 78.7% in urban and there was significant differences between rural
and urban group regard to all the anthropometric indices.
In summary, the behavioural risk factors are undoubtedly apprehensive and anthropometric indices are pointing out
towards associated possible metabolic risks which were poorer in urban group than rural. Further clinical investigation
along with proper intervention measure is indispensible.
Keywords: adiposity, food habit, non communicable diseases, sedentarism.
Introduction infectious diseases to chronic diseases which were

Unhealthy eating, physical inactivity and obesity not infectious or transmissible`1. Like the other low
are the trio, amongst many others to heighten the or middle income counties, India is also a witness of
ubiquity of Non Communicable Diseases (NCDs) such transition and these led to the development of
for the last few decades worldwide. Since the late ‘Lifestyle Diseases’ [also called non-communicable
nineteenth century the pattern of diseases and the diseases, NCD] which are the by-products of ‘fast-
cause of mortality of the then developed countries paced modern lifestyle’. According to report of
had started to take a shift from communicable World Health Organization (WHO), amongst all
Dr. Alak Kumar Syamal
Associate Professor
Post Graduate Department of Physiology, Hooghly Mohsin College, University of Burdwan, West Bengal : 732101
Email : [email protected]
60
global deaths 71.0% is accountable to NCDs2,3. Disease suffering from chronic diseases or are on certain
burden of NCDs is rising by leaps and bounds every medications. Total 150 (n) obese females were selected
year in India as well. As per WHO report 2014, India from both rural (n1=75) and urban (n2=75) areas. Data
contributes two- third of all deaths from NCDs occur were collected during January 2017 to January 2018.
in south East Asia region of world health organization.
Dietary Information
The behavioural risk factors (unhealthy diet;
24 hour recall method on multiple, non-consecutive
physical inactivity; tobacco and alcohol consumption)
days was done avoiding days of fasting or feasting.
interact with one’s genetic make-up and lead to
Dietary diversity on week days or on weekends also
metabolic changes and provide the complex aetiology
considered. Mean consumption of different nutrients
behind the commencement of NCDs4. The scenario
and foods under various food groups were calculated
of NCDs among Indian is quite distressing. Age
using Diet Cal software (which used nutritive values
standardized prevalence of obesity, hypertension
of Indian foods).
and hyperglycaemia have raised by 22.0%, 10.0%
and 9.0% respectively among both sexes (age group Physical Activity
≥18 years) within four years i.e. 2010-2014. So, Global Physical Activity Questionnaire (GPAQ)
India which is facing ‘double burden of diseases’ developed by WHO (2012)7 and was standardised and
(both non-communicable and infectious diseases), validated in nine countries8 was used in the study to
time to time monitoring and surveillances on the collect information on physical activities of subjects.
behavioural and metabolic risk factors among Metabolic Equivalent (MET) scores was calculated
people residing in different states or regions of the and used for physical activity classification.
country, are utmost important for making health care
policies and programmes. Further, 54.4% Indians Anthropometric Measurement
are physically inactive5 and it is more prevalent in Body weight, height, waist circumference (WC)
urban than rural and among women than men; and and hip circumference (HC) were measured using
urban people are more hypertensive than rural7. So standardized protocols and instruments9. Body
Indian women, who have been kept in the centre of Mass index (BMI), ratio of waist circumference to
Sustainable Development Growth (2015-30) need hip circumference and waist circumference to body
more surveillances to lessen their burden of NCDs. height i.e. Waist to Hip Ratio (WHR) and Waist to
West Bengal also follows the similar trends as Height Ratio (WHtR) were respectively calculated
prevalence of overweight or obesity in female has as well. Cut off of BMI, WC and WHR as normal for
risen from 11.4% (NFHS-3, 2005-6) to 19.9% (NFHS- Indian women were considered according to Bhalerao
4, 2015-16) and in every cases urban women were et al (2014)10. WHtR>0.5 is seen as strong predictor of
more prevalent than rural6. So, this study was aimed cardio-metabolic risk in obesity11.
to assess dietary and physical activity pattern among
Statistical Analysis
obese women in both the selected rural and urban
parts of West Bengal to make a comparison between Descriptive statistics like mean, standard deviation
these two groups. (S.D.) was done and to compare the mean values
between the groups two tail, unpaired t-test was
Materials and Methods performed. P<0.05 was considered as significant.
Study Population
Results
This study was a community based cross sectional
study of urban and rural areas of Hooghly district Dietary Profile
in West Bengal. As inclusion criteria, all the females
were Bengali (Hindu), permanent residents in those Mean intake of calorie/day by rural subjects is
households, age group were 20-50 years and with 1941.5±168.9 kcal and urban is 2027.4±166.3 kcal and
a body mass index (BMI) between 25-30 kg/m2 and this difference is significant (Table 1). In contrast,
free from any clinically diagnosed NCDs; also, they mean daily dietary fibre intake is significantly higher
never consumed any form of tobacco or alcohol. in rural females than their urban counterparts.
As exclusion criteria, those, who were physically, However, no significant difference was observed
mentally challenged or non-ambulatory; already between rural and urban groups regarding the mean
consumption of whole and refined cereals and the root

Whole grain+refined cereals (gm) 314.7± 29.1 310.2±21 ≥0.05
Dairy products (gm) 64.1± 23.9 84.2±23.4 0.0001
Pulses (gm) 30.3 ±4.7 28.0±7.2 0.02
Root & tubers (gm) 100.2 ±26.6 99.7±9.9 ≥0.05
Egg/meat/fish/poultry (gm) 23.5± 7.7 30.6±10.3 0.0001
Green
Indian Journal of Public leafy
Dairy
Health vegetables
products
Research (gm) (gm) 22.1
64.1±
& Development ±8.4
23.9 15.7±8.4
84.2±23.4 61 0.00010.0001
Other
Root &vegetables(gm)
tubers (gm) 100.274.1±10
±26.6 50.7±11.2
99.7±9.9 ≥0.050.0001
and tuber groups which is mostly potato. Significant Fruits (gm) (gm)
Variables
Green leafy vegetables
21.8±6.7
Rural 25.2Level
22.1 ±8.4 Urban 15.7±8.4
±7.3 of 0.0001
0.004
difference between rural and urban groups in terms Visible fats & oils 38.7±
(Mean 7.4
(Mean 42.4±7.9
Significance 0.003
Other vegetables(gm) 74.1±10 50.7±11.2 0.0001
of having other food groups like dairy products Nuts& oilseeds(gm) ±S.D.)2.2 ±1 ±S.D.) (<0.05)
1.7±1
Fruits (gm) 21.8±6.7 25.2 ±7.3 0.004 0.001
and other animal protein food group(p=0.0001),VisibleNuts& fats & oils 2.2 ±1
38.7± 7.4 1.7±1 42.4±7.9 0.001 0.003
visible fats(p=0.003), fruits(p=0.004) and addedAddedoilseeds(gm)
sugar (gm) 31.5 ±6.2 34.5±8.1 0.01
Added
Nuts& Salt (gm)
oilseeds(gm) 10.1
2.2 ±1± 1.6 9.8±1.6
1.7±1 0.001 ≥0.05
sugar(p=0.01) were observed. Alternatively, mean Added sugar 31.5 34.5±8.1 0.01
daily intake of food groups like pulses(p=0.02), greenAdded(gm)
sugar (gm) 31.5 ±6.2
±6.2 34.5±8.1 0.01
Added
leafy vegetables or other vegetables (p=0.0001) andA. Added Salt (gm)
Salt 10.1±± 1.6 9.8±1.6 9.8±1.6 ≥0.05
10.1 ≥0.05
nuts and oil seeds(p=0.001), rural women showed (gm) 1.6
significantly higher intake than urban women. NoA.
A.
significant difference was found between both the
group regards to dietary salt intake (mean intake of
rural subject 10.1±1.6 gm and in urban 9.8±1.6gm).
Data of mean percentage of energy/day derived
from macronutrients like carbohydrate (carb), protein,
fat and saturated fat showed rural subjects derive
more energy from carbohydrate than urban subjects.
Figure 1A has represented the mean consumption of
percentage of energy from those nutrients along with
its S.D. values.
Table 1. Average nutrient consumption of study
participants B.
B. B.
Variables Rural Urban Level of
(Mean (Mean Significance
±S.D.) ±S.D.) (<0.05)
Calorie (Kcal) 1941.5 2027.4 ± 0.002
±168.9 166.3
Dietary fibre 19.5± 16.5±4.4 0.0003
(gm) 5.5
Consumption of food groups
Whole 314.7± 310.2±21 ≥0.05
grain+refined 29.1 Figure 1. [A] Mean percentage of energy derived 6
cereals (gm) from nutrients. [B] Percentage of inactivity in
Pulses (gm) 30.3 28.0±7.2 0.02 leisure domain (age wise)
±4.7
Physical Activity
Egg/meat/ 23.5± 30.6±10.3 0.0001
fish/poultry 7.7 Data revealed that 64.0% of rural subjects and 78.7%
(gm) of urban subjects are physically inactive i.e., MET
Dairy products 64.1± 84.2±23.4 0.0001 scores was <600; percentage of active females (MET
(gm) 23.9 score 600-1200) is 32 and 21.3 in rural and urban areas
Root & tubers 100.2 99.7±9.9 ≥0.05 respectively; whereas only 4.0% rural female subjects
(gm) ±26.6 are highly active (MET score≥1200) and unfortunately
Green leafy 22.1 15.7±8.4 0.0001 among urban subjects that is nil considering all the
vegetables (gm) ±8.4 domains of activity, shown in Table 2.
Other 74.1±10 50.7±11.2 0.0001
vegetables(gm)
Fruits (gm) 21.8±6.7 25.2 ±7.3 0.004
Visible fats & 38.7± 42.4±7.9 0.003
oils 7.4

62
Table 2. Sample distribution on total energy expenditure on low/ moderate/ vigorous activity/week
BASED ON TOTAL ENERGY EXPENDITURE

MET VALUE RURAL n1=75(%) URBAN n2=75(%)
PHYSICALLY INACTIVE <600 48 (64.0%) 59 (78.7%)
ACTIVE 600- 1200 24 (32.0%) 16 (21.3%)
HIGHLY ACTIVE ≥1200 3 (4.0%) 0
BASED ON PHYSICAL INACTIVITY
DOMAIN RURAL n1=75(%) URBAN n2=75(%)
WORK 45(60.0%) 57(76.0%)
TRAVEL 38(50.6%) 44(58.7%)
RECREATION 52(69.3%) 49(65.3%)
Table 2 also has depicted that among the subjects in both the areas prevalence of physical inactivity in
particular domains were also assessed and it was found that among rural subjects, most was inactive in
recreational domain (69.3%) and lowest percentage of inactivity was seen in travel domain (50.6%). On the
other hand among urban female subjects mostly was inactive in occupational domain (76.0%) and least in travel
domain (58.7%). Age group-wise distribution indicated that subjects belong to the 36-50 yrs of age group was
more inactive than the age group of 20-35 yrs in both the areas (Figure 1B).
Mean time/ day spend on various domains with vigorous to moderate intensity activity was also calculated
(Table 3). No significant differences were found regard to mean time spent on vigorous work and recreation
but differences were significant in terms of travel and moderate intensity occupational work domains. Urban
obese subjects spend more time on sitting than rural and the difference was significant (p=0.03).
Table 3. Mean time spend on different activities/day (Mean ±S.D.) and level of significance
ACTIVITY DOMAIN Rural Urban Level of Significance <0.05

VIGOROUS WORK 9.61±40.1 1.4±3.21 ≥0.05
RECREATION 0.61±1.9 0.83±1.64 ≥0.05
MODERATE WORK 16.6±35.6 6.5±12.3 0.02
TRAVEL 8.9±10.1 5±6.8 0.005
RECREATION 3.09±5.4 3.12±5.1 ≥0.05
SITTING 327.7±99.9 366.5±117 0.03
Anthropometric Profile
Anthropometric indices of urban obese female subjects had significantly higher values than their rural
counterparts (Table 4). Body weight and BMI which indicates generalised obesity among both urban and rural
females. WC and WHR value were also significantly higher in urban group. WHtR was 0.57±0.02 for rural and
0.58±0.02 for urban group and was significantly different (p=0.04).
Table 4. Anthropometric profile of rural and urban samples (Mean ±S.D.)
Variables RURAL URBAN Level of significance <0.05
Body weight (kg) 69.5±5.05 71.6±5.9 0.01
BMI(kg/m2) 27.4±1.4 28±1.6 0.008
WC (cm) 91.7±3.4 93±3.4 0.02
WHR 0.89±0.02 0.9±0.02 0.001
WHtR 0.57±0.02 0.58±0.02 0.04

Discussion The subjects from both the rural and urban

In our study, two major behavioural factors like areas were found obese i.e. BMI >25 kg/m2 and
unhealthy diet and physical inactivity of NCDs along all the selected anthropometric parameters were
with anthropometric parameters among the obese significantly higher in urban females than their rural
Bengali women (20-50 years of age) from selected counterparts indicating higher obesity in urban
parts of both rural and urban groups were studied. females. These findings are well in line with earlier
Previous study on changed dietary pattern of Indians studies18,19. Thus, we hypothesised that such lofty
has noted that consumption of dietary fibre, fruits and parameters are indicators of different health issues
vegetables are gradually decreasing whereas intake of like cardio-vascular diseases, insulin resistance,
visible fats and added sugar are escalating rapidly12. diabetes mellitus, metabolic syndrome, reproductive
Consumption of plant and animal protein was lower hassles, different cancer and so on among both the
than the recommended value in both groups. Urban groups.
obese group was having more animal protein, dairy Conclusion
products, fruits, visible fat and oil and added sugar
This study reported unhealthy diet in both the rural-
than rural group whereas rural group was consuming
urban groups whereas physical activity profile was
more pulses, green leafy and other vegetables and nuts
worse in urban females than the rural group. Lifestyle
and oil seeds. Our study also revealed that most of the
modification through dietary intervention and
daily energy is coming from carbohydrate, possibly
recommendation of enough physical activity can be
be a reason behind increasing diabetes in India. Poor
beneficial to cut down the risk factors which could be
consumption of dairy products and animal protein
investigated in future as well.
especially in rural group as reported in this study is in
line with the reporting of Sharma et al. (2020)13 differs Conflict Of Interest
from the observations of Shetty (2002) 12.
The author declared no conflict of interest.
Physical activity which has been measured in this
Source of Funding
study, another behavioural risk factor for lifestyle
diseases was also not satisfactory as well. More than Self
half of all subjects, in both groups were inactive i.e.
Refe Rences
MET score <600. Urban obese women were more
inactive (78.7%) than rural group (64.0%). Across all 1. McKeown RE. The epidemiologic transition: changing
the domains, urban subjects were mostly inactive in patterns of mortality and population dynamics. Am J
Lifestyle Med 2009; 3:19S-26S.
occupational domain whereas highest percentage
of inactivity among rural subjects was found in 2. Tabish SA. Lifestyle diseases: consequences,
recreational domain. Age group wise participation in characteristics, causes and control. J Cardiol Curr Res
leisure activity was measured and emerged that older 2017; 9:00326.
age group was less active in leisure among both the 3. GBD 2015 Risk Factors Collaborators. Global,
groups. regional, and national comparative risk assessment
of 79 behavioural, environmental and occupational,
Ample researches have been done on physical
and metabolic risks or clusters of risks, 1990–2015: a
activity pattern among adults (both sexes) in
systematic analysis for the Global Burden of Disease
different regions covering both the rural-urban
Study 2015. Lancet 2016; 388:1659-1724.
parts across India and most of them specified more
physical inactivity amongst urban females than 4. Esmailnasab N, Moradi G, Delaveri A. Risk factors
their rural counterparts, which also goes with our of non-communicable diseases and metabolic
syndrome. Iranian J Pub Health 2012; 41:77-85.
observation14. In contrast, other studies15,16 found
no significant differences between rural and urban 5. NFHS-4. National Family Health Survey, (2015–16),
females regarding diet, physical activity and obesity India fact sheet, International Institute for Population
in North India population. Whereas, Newtonraj et al. Sciences (IIPS) & Macro International. Mumbai: IIPS,
(2019)17 noted lesser percentage of physical inactivity 2017.
in rural females than urban which was 22.5%, almost 6. Sharma M, Kishore A, Roy D, Joshi K. A comparison
comparable to the prevalence of global physical of the Indian diet with the EAT-Lancet reference
inactivity i.e. 27.5%. diet. BMC Public Health 2020; 20:1-13.

64
7. World Health Organization. Global physical activity 14. Anjana RM, Pradeepa R, Deepa M, Datta M, Sudha
questionnaire (GPAQ) analysis guide, Geneva: World V, Unnikrishnan R. Prevalence of diabetes and
Health Organization, 2012; 1-22. Available from: prediabetes (impaired fasting glucose and/or impaired
http://www.who.int/chp/steps/resources/GPAQ_ glucose tolerance) in urban and rural India: Phase
Analysis_Guide.pdf I results of the Indian Council of Medical Research–
INdiaDIABetes (ICMR–INDIAB) study. Diabetologia
8. Bull FC, Maslin TS, Armstrong T. Global physical
2011; 54:3022-3027.
activity questionnaire (GPAQ): nine country reliability
and validity study. J Phys Act Health 2009; 6, 790-804. 15. Tripathy JP, Thakur JS, Jeet G, Chawla S, Jain S, Prasad
R. Urban rural differences in diet, physical activity and
9. Sengupta P, Chaudhuri P, Bhattacharya K. Screening
obesity in India: are we witnessing the great Indian
obesity by direct and derived anthropometric indices
equalisation? Results from a cross-sectional STEPS
with evaluation of physical efficiency among female
survey. BMC Pub Health2016; 16:1-10.
college students of Kolkata. Annals Med Health Sci
Res 2013; 3:517-522. 16. Devamani, Oommen AM, Mini GK, Abraham VJ,
George K. Levels of physical inactivity in rural and
10. Bhalerao SD, Somannavar M, Vernekar SS, Ravishankar
urban Tamil Nadu, India: a cross-sectional study. J
R, Goudar SS. Risk factors for type 2 diabetes mellitus
Clin Prev Cardiol 2019; 8:13-17.
in rural population of North Karnataka: A community-
based cross-sectional study. Int J Pharm Med and Biol 17. Newtonraj A, Vincent A, Gowtham PJ, Haritha S,
Sci 2014; 3:1-4. Ilaveyini S. Level of insufficient physical activity
among adults in a rural area of South India: A
11. Rajput R, Rajput M, Bairwa M, Singh J, Saini O, Shankar
population-based cross-sectional study. J Curr Res
V. Waist height ratio: A universal screening tool for
Scientific Med 2019; 5:105-109.
prediction of metabolic syndrome in urban and rural
population of Haryana. Ind J Endocrinol Metab 2014; 18. Krishnan A, Asadullah MD, Roy A, Praveen PA, Singh
18:394-399. K, Amarchand R. Change in prevalence of Coronary
Heart Disease and its risk between 1991-94 to 2010-12
12. Shetty PS. Nutrition transition in India. Pub Health
among rural and urban population of National Capital
Nutri 2002; 5:175-182.
Region, Delhi. Ind Heart J 2020; 72:403-409.
13. Sharma SK, Vishwakarma D, Puri P. Gender disparities
19. Pradeepa R, Anjana RM, Joshi SR, Bhansali A, Deepa
in the burden of non-communicable diseases in
M, Joshi PP. Prevalence of generalized & abdominal
India: evidence from the cross-sectional study. Clin
obesity in urban & rural India-the ICMR-INDIAB
Epidemiol and Glob Health 2020; 8:544-549.
Study (Phase-I)[ICMR-INDIAB-3]. Ind J Med Res 2015;
142:139-150.

Assessment of Appropriateness of Doing CT Scan for Investigating

Headache in a Tertiary Care Hospital in Eastern India
Debabrata Maitra1, Sharmistha Chatterjee2, Sharmistha Debnath3,

Dipta Kanti Mukhopadhyay4, Somsubhra Chattopadhyay5
Assistant Professor, Department of Radiodiagnosis, College of Medicine & Sagore Dutta Hospital, Kamarhati, Kolkata-700058
1
2
Assistant Professor, Department of Biochemistry, College, of Medicine & SagoreDutta Hospital, Kamarhati, Kolkata-700058
3
Associate Professor, Department of Oncopathology, Medical College & Hospital, Kolkata
4
Professor & Head, Department of Community Medicine, College of Medicine & Sagore Dutta Hospital, Kamarhati, Kolkata-700058
5
Associate Professor, Department of Psychiatry, College of Medicine &SagoreDutta Hospital, Kamarhati, Kolkata-700058
How to cite this article: Debabrata Maitra, Sharmistha Chatterjee, Sharmistha Debnath, Dipta Kanti Mukhopadhyay,
Somsubhra Chattopadhyay et al Assessment of Appropriateness of Doing CT Scan for Investigating Headache in a
Tertiary Care Hospital in Eastern India. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Headache is one of the most common presenting symptoms encountered in day to day clinical practice.
A computed tomography is often the most common imaging modality to diagnose the underlying causes of headache,
majority of which turns out to be normal. The objective of this research is to study the morbidity patterns in the CT scan
reports of patients presenting with headache in the population attending a tertiary care hospital in Eastern India.
Method: The study was a retrospective analysis of all the CT scan reports performed in a tertiary care government hospital
performed for diagnostic evaluation of headache referred from different clinics and included all patients regardless of the
age during the time period December 2018 to November 2019.
Results: All the patients were classified into two groups traumatic and non- traumatic depending on the history. Out of
a total 1142 patient evaluated, 649 patients (56.83%) did not yield any positive findings on CT scan, i.e. the reports were
normal. In fact, a routine CT scan is not advised for all headache complaints even by the ACR (American College of
Radiology) appropriateness criteria. The difference between the number of patients with normal CT scan and abnormal
CT scan in both the groups was statistically significant (p< 0.05).
Conclusion: In concordance with the previous similar studies, it may be concluded that in evaluation of headache, CT
scan should be advised only in selected cases as recommended by ACR Appropriateness Criteria® Headache or any other
guidelines that may be developed for this purpose.
Keywords: Headache, Computed Tomography Scan, CT scan findings.
Introduction Though there may be regional variations, yet headache

Headache is one of the most common presenting disorders are a worldwide problem, affecting people
symptoms encountered in day to day clinical practice. of all ages, ethnicities, socio-economic status and
According to WHO estimates, the prevalence of geographical areas. A computed tomography is often
headache among adults is about 50%.1 Unfortunately, the most common imaging modality to diagnose the
there are insufficient statistics for the prevalence of underlying causes of headache. Previous studies have
headache in India and other developing countries.2 shown that in most of these cases, CT findings turned
Dr. Somsubhra Chattopadhyay
Associate Professor, Psychiatry
College of Medicine &SagoreDutta Hospital, Kamarhati, Kolkata- 70005
M: 9836145175
E Mail: [email protected]
66
out to be normal. 3,6 The objective of this research is to The CT scan findings were classified into
study the morbidity patterns in the CT scan reports of 26 categories: Normal, Mild diffuse cerebral
patients presenting with headache in the population atrophy, Diffuse cerebral atrophy, Periventricular
attending a tertiary care hospital in Eastern India. ischemic changes, Lacunar infarcts, Focal gliosis,
Encephalomalecic changes, Chronic ischemic changes,
Materials & Methods Sub acute infarct, Intracranial haemorrhage, Intra-
The study was aretrospective analysis of all the axial calcification, Hydrocephalous, Neoplasm, Intra-
CT scan reports performed in the Department of axial lesion other than neoplasm, Extra axial lesion,
Radiology College of Medicine and SagoreDutta Mega cisterna magna, Extra axial collection, Infection,
Hospital (CoMSDH), Kamarhati, Kolkata – a tertiary asymmetrical dilatation of lateral ventricle, Osteoma,
care government hospital and Medical College, from Contusion, Scalp hematoma , Extra axial calcification,
December 2018 to November 2019. It was basically a Metastasis, Deviated nasal septum, Sinusitis.
secondary data analysis carried out on the information
The data thus collected was compiled and tabulated
retrieved from the CT scan reports of the patients who
and checked for consistency and outliers. The
underwent CT scan of head for diagnostic evaluation
proportions of CT scan with and without abnormality
of headache referred from different clinics and
are expressed in percentages. The distribution of the
included all patients regardless of the age.
morbidity patterns among the abnormal CT scan
The study was carried out in accordance with the according to different population groups are also
guidelines of the Institutional Ethics Committee expressed in percentages.
(Registration No. ECR/1210/Inst/WB/2019 issued
under Rule 122 DD of the Drugs and Cosmetics Rules, Results:
1945) at the College of Medicine and SagoreDutta A total of 1142 patient’s CT scan reports were evaluated
Hospital. in our study.Out of them 32.2% (n=368/1142) of the
patients were males, the rest 67.8% (n= 774/1142)
CT scan reports of all patients referred for CT
were females. The mean age of the patients was 37.92
scan of head for evaluation of headache at CoMSDH
with a standard deviation of 16.67. The median age
for a period of 1 year was included in the analysis.
was 36. From the histories obtained from these 1142
A structured checklist was used for the analysis and
patients, who’s CT Scans were evaluated, the patients
the information collected was based on the following
were classified under two groups, namely traumatic
parameters:
27.4 % ( n=313/1142) and non-traumatic 72.5%( n=
Individual: Age in completed years/ Gender/ 829/1142). In the non-traumatic category, 54.28 %
History of trauma in completed days/other associated of patients (n=450/ 829) had normal findings on CT
symptoms like vomiting/loss of consciousness/ scan. In the traumatic category, 63.5% (n=199/313)
vertigo. of the patients showed no abnormal findings on CT
Radiological: The CT scans were carried out on scan. Out of the total 1142 patients included in the
16-slice spiral CT scanner (GE MEDICAL SYSTEM, study, 649 patients (56.83%) did not yield any positive
OPTIMA CT540) in Department of Radiology CMSDH. findings on CT scan, i.e. the reports were normal.
5 mm contagious slices were taken from foramen The results obtained on statistical analysis are
magnum to the vertex, which were reconstructed into summarised in the following tables (Table 1 -3):
1mm slices both in soft tissue and bone window.
Table 1: Distribution of findings in both groups:

CT Scan findings Non-trauma Trauma Grand total
Normal 450 199 649
Mild diffuse cerebral atrophy 62 17 79
Diffuse cerebral atrophy 16 1 17
Periventricular ischemic changes 33 5 38
Lacunar infarcts 71 13 84
Focal gliosis 18 3 21

CT Scan findings Non-trauma Trauma Grand total

Encephalomalecic changes 2 0 2
Chronic ischemic changes 2 0 2
Sub acute infarct 5 1 6
Intracranial haemorrhage 2 0 2
Intra-axial calcification 12 4 16
Hydrocephalous 3 1 4
Neoplasm 0 0 0
Intra-axial lesion other than neoplasm 1 0 1
Extra axial lesion 6 1 7
Mega cisterna magna 5 6 11
Extra axial collection 4 1 5
Infection 0 0 0
Asymmetrical dilatation of lateral ventricle 5 1 6
Osteoma 3 1 4
Contusion 0 3 3
Scalp hematoma 0 4 4
Extra axial calcification 1 0 1
Metastasis 0 1 1
Deviated nasal septum 193 67 260
Sinusitis 90 18 108
Grand Total 829 313 1142
Table-2: Distribution of findings according to gender:

Category CT Scan Findings Gender
F M Total
1 Normal study 454 (70.0) 195 (30.0) 649
2 Mild diffuse cerebral atrophy 41 (51.9) 38 (48.1) 79
3 Diffuse cerebral atrophy 10 (58.8) 7 (41.2) 17
4 Periventricular ischemic changes 22 (57.9) 16 (42.1) 38
5 Lacunar infarcts 56 (67.5) 27 (32.5) 83
6 Focal gliosis 16 (76.2) 5 (23.8) 21
7 Encephalomalecic changes 1 (50.0) 1 (50.0) 2
8 Chronic ischemic changes 2 (100.0) 0 2
9 Sub acute infarct 1 (16.7) 5 (83.3) 6
10 Intracranial hemorrhage 1 (50.0) 1 (50.0) 2
11 Intra-axial calcification 14 (87.5) 2 (12.5) 16
12 Hydrocephalous 3 (75.0) 1 (25.0) 4
13 Neoplasm 0 0 0
14 Intra-axial lesion other than 1 (100.0) 0 1
neoplasm
15 Extra axial lesion 4 (57.1) 3 (42.9) 7
16 Mega cisterna magna 8 (72.7) 3 (27.3) 11
17 Extra axial collection 3 (60.0) 2 (40.0) 5

68
Category CT Scan Findings Gender

F M Total
18 Infection 0 0 0
19 Asymmetrical dilatation of lateral 3 (50.0) 3 (50.0) 6
ventricle
20 Osteoma 3 (75.0) 1 (25.0) 4
21 Contusion 0 3 (100.0) 3
22 Scalp hematoma 3 (75.0) 1 (25.0) 4
23 Extra axial calcification 1 (100.0) 0 1
24 Metastasis 1 (100.0) 0 1
25 Deviated nasal septum 169 (65.0) 91 (35.0) 260
26 Sinusitis 65 (60.2) 43 (39.8) 108
Total 774 (67.8) 368 (32.2) 1142
Table 3: Table showing the results of the Chi square test.

Groups Normal Abnormal Marginal Row Totals
Traumatic 199 (176.56) [2.85] 165 (187.44) [2.69] 364
Non-traumatic 450 (472.44) [1.07] 524 (501.56) [1] 974
Marginal Column Totals 649 689 1338 (Grand Total)
Chi-square: 7.609; p= 0.005808.
OR=1.404
(95% CI) (1.103-1.788)
According to the results of the Chi-square test given In a similar study reported from Nigeria, the authors
above, the difference between the number of patients opined that the yield of significant abnormalities
with normal CT scan and abnormal CT scan in both on CT scans did not justify the huge number of CT
the groups was statistically significant (p< 0.05). Scans performed for the diagnosis of headache. 4 An
analysis of about 2500 patients with headache from
Discussion: Chandigarh reported a poor yield of positive findings
A careful consideration of the above table (Table 1) too. 5
throws up some interesting results. Majority (almost
CT scan is almost routinely prescribed for
57%) of the patients with complaints of headache, who
investigation of chronic headache and has quite a
went for a CT scan, came back with normal reports.
few advantages. It is easily and widely available in
Even among patients in the traumatic category, a
many places, easy to perform and inexpensive. But,
sizeable portion of the patients (about 63.5%) showed
many studies have shown the futility of routinely
normal findings on CT. Our findings have been
prescribing Computed tomography to all patients
corroborated by other studies conducted in various
with chronic headache. In most of these cases, either
parts of India and abroad also. But, the proportion
no serious intracranial pathology was found, or the
of patients with abnormal findings in our study was
CT scan findings did not significantly alter the clinical
higher than other studies. It has been further noted
or therapeutic jurisdiction. So, our findings are in
that even those who had abnormal findings on CT
agreement with other studies where similar findings
scan, most of them were deviated nasal septum and
have been reported. Whenever there has been an audit
sinusitis and not any significant intracranial lesions.
of CT Scans prescribed for headache, the findings
Our study has included the findings of the visualized
have been interestingly similar. In fact, a routine CT
paranasal sinuses which can be a potential cause of
scan is not advised for all headache complaints even
headache in patients and evaluation of paranasal
by the ACR 6 appropriateness criteria. 7
sinuses was not reported in the previous studies. 4,5

The concurrence of findings in similar studies References

drives home the point that not all headaches reported 1. Atlas of headache disorders and resources in the
to the outdoor and emergency for consultation merits world 2011.A collaborative project of World Health
a prescription for a CT scan, for it may not yield a Organisation and lifting the burden.
positive finding. Even those patients who reported
2. Mateen FJ, Dua T, Steiner T, Saxena S. Headache
a positive finding, the diagnosis were mostly benign
disorders in developing countries: Research over the
causes like sinusitis. Therefore we recommend past decade. Cephalalgia 2008; 28: 1107-14.
reporting of pathology of the visualized paranasal
and deviated nasal septum, if any in every CT scan 3. Frishberg BM. The utility of neuroimaging in the
referred for evaluation of headache as it may yield a evaluation of headache in patients with normal
neurologic examination. Neurology 1994; 44: 1191–1197.
potential cause.
http://tools.aan.com/professionals/practice/pdfs/
The retrospective nature of our study is the gl0088.pdf (2010, accessed 20 April 2014).
main limitation as the referrals requisitions were 4. Onwuchekwa CR, Onwuchekwa AC. The role of
occasionally incomplete in clinical information. computed tomography in the diagnostic work-up
In concordance with the previous studies our study of headache patients in Nigeria. Headache 2010 Sep;
reiterated that in evaluation of headache, CT scan 50(8): 1346-135252.
should be advised only in the cases of sudden severe 5. Vivek Gupta,N Khandelwal, AnujPrabhakar, A
headache, new headache with optic disc edema and Satish Kumar, Chirag K Ahuja, and Paramjeet Singh.
with worsening headache in patients with history Prevalence of normal head CT and positive CT findings
of trauma and MRI with or without contrast should in a large cohort of patients with chronic headaches.
be the preferred imaging modality in other cases as Neuroradiol J 2015; 28(4): 421-425.
recommended by ACR Appropriateness Criteria® 6. Matthew J Neff. Evidence-based guidelines in the
Headache. 8 This recommendation is however not primary care setting: Neuroimaging in patients with
followed in lot many cases because of the demand nonacute headache. American family Physician 2005;
of the patients as such or the patient’s relatives. 71(6): 1219-22
There should be structured recommendations for 7. Nawaz M, Amin A, Qureshi AN, Jehanzeb M.
the treating physicians as to when a CT scan should Audit of appropriateness and outcome of computed
be advised; otherwise it would be just a waste of tomography brain scanning for headaches in paediatric
resources. age group. J Ayub Med Coll Abbottabad 2009 Jan-
Mar;21(1): 91-93.
Acknowledgments: The contributions of Mrs
PiyaliMoitra and Mrs Basanti Das in data entry and 8. Expert Panel on Neurologic Imaging, Whitehead
data processing are highly appreciated. MT, Cardenas AM, Corey AS, Policeni B, Burns J,
Chakraborty S, Crowley RW, Jabbour P, Ledbetter LN,
Conflict of interest: Lee RK, Pannell JS, Pollock JM, Powers WJ, Setzen G,
Shih RY, Subramaniam RM, Utukuri PS, Bykowski
None declared. J. ACR Appropriateness Criteria® Headache. J Am
CollRadiol. 2019 Nov; 16(11): 364-377.
Funding:
None declared.

Management of Tympanic Membrane Perforation with Cartilage

Tympanoplasty in Relation to Temporalis Fascia Graft Technique
Deepa Kumari1 , Chandresh Aggarwal 2 , Sachin Agarwal 3, Sarita Gupta3 ,

Geetanjali Jaiswani 4
1&3
Resident, Department of ENT, Saraswathi Institute of Medical Sciences, Hapur
2
Professor and HOD, Department of Ent, Saraswathi Institute of Medical Sciences, Hapur
4&5
Assistant Professor, Department of ENT, Saraswathi Institute of Medical Sciences, Hapur
How to cite this article: Deepa Kumari, Chandresh Aggarwal, Sachin Agarwal, Sarita Gupta, Geetanjali Jaiswani et al
Management of Tympanic Membrane Perforation With Cartilage Tympanoplasty in Relation to Temporalis Fascia Graft
Technique. Volume 13 | Issue 4 | October-December 2022
Abstract
An Observational Study was undertaken at Department of Otorhinolaryngology,. The aim of this study was to observe
the outcome of cartilage tympanoplasty for tubotympanic type of CSOM. All the patients attending ENT OPD at SIMS
within the age group of 11-60 years, irrespective of sex with tubotympanic CSOM either unilateral or bilateral were
included in this study. In our study of 80 patients, 40 patients had graft uptake after disease clearance and 8 had failure
of graft uptake without chronic otorrhoea and 2 had failure with chronic otorrhoea. Through this study we concluded
that cartilage tympanoplasty for tubotympanic type of CSOM is an excellent technique for complete removal of disease
especially frominaccessible areas of middle ear cleft.
Keywords: Tympanoplasty, Temporalis fascia, Endoscopic Tympanomastoidectomy, Pure tone audiometery, Impedence
audiometry.
Introduction reconstruction of the middle ear hearing mechanism

The Tympanic Membrane (TM) plays a significant that has been impaired or destroyed by chronic ear
role in the physiology of hearing as well as in the disease.In 1953, the Zeiss operating microscope
pathophysiology of chronic inflammatory middle became available commercially and, in the same year,
ear diseases. The TM perforations significantly Wullstein and Zöllner launched their tympanoplasty
impair the quality of life for millions of patients. methods with a split-thickness skin graft.(7) In 1956,
(1)
The term ‘chronic ear disease’ includes a wide Zöllner successfully used autologous fascia lata.(8)
range of clinical entities, including chronic otitis Heermann was the first to introduce the cartilage
media, chronic suppurative otitis media (with palisade technique, in 1962. (4,5)
and without cholesteatoma), chronic mastoiditis,
In the Heermann’s technique of palisade
tympanosclerosis, and cholesterol granuloma.(2)
tympanoplasty, the cartilage strips with
The term Tympanoplasty was introduced in 1953 perichondrium preserved on the outer surface were
by Wullstein to describe surgical techniques for placed parallel to the malleus until the middle-
Corresponding author :
Dr Deepa Kumari
Resident, Department of Ent, Saraswathi Institute Of Medical Sciences, Hapur
ear cavity was covered.(4,9)Six groups of cartilage 3) Congenital hearing disorder

tympanoplasty have been proposed in the literature
4) Chronic otitis media with predominant
by Mirko Tos. The choice of technique is determined
sensorineural hearing loss
by the surgeon’s preference, size of the perforation,
integrity of the ossicular chain, and the presence of 5) Isolated serous otitis media
cholesteatoma. 6) Active intracranial complication of chronic
Aim: otitis media
1. To compare success rate between type 7) Patients with history of diabetes mellitus, HIV
1 cartilage tympanoplasty and type 1 and TB
temporalis fascia tympanoplasty within the
8) Radical mastoidectomy
period of October 2021 to September 2022.
9) Patients who did not turn up regularly for
2. To compare post-operative failures using
follow up.
both these techniques
3. To compare post-operative hearing status Study design Hospital-based, two arm, prospective,
using both these techniques comparative study
Material and Methods Results

The study was carried out in the Department of The study consists of 80 patients with tubotympanic
Otorhinolaryngology, SARASWATHI INSTITUTE chronic suppurative otitis media who were analysed
OF MEDICAL SCIENCES, Hapur (U.P). Total of 80 taking into consideration a number of parameters.
Patients were evaluated who attended the OPD of The following are the observations made during
ENT during the period of October 2020 to September our study:
2022. The cases for the study were selected on the
basis of following criteria - In our study patient age varied from 11 yrs. to 40
yrs. as shown above in table. Themaximum incidence
All the patient attending the Department of was 43 percent in the third decade than 31 percent
Otorhinolaryngology in Saraswathi Institute of in second decade and followed by 26 percent in the
Medical Sciences, Hapur (U.P) with chronic ear fourth decade. The mean age in this study was 24
disease. years.
Criteria for Patients Selection In our study the most common symptom
encountered was otorrhoea in 86% patients for which
Inclusion Criteria we managed conservatively and managed, followed
1) Chronic otitis media by impairedhearing in 82%. Otalgia and tinnitus were
seen in 17% and 11.5% patients respectively. Vertigo
2) Small, medium, large, subtotal, total and attic
was seen in 11.5% patients.
perforations
In our study 46% patients had CSOM in the
3) Traumatic perforations
active stage with persistent ear discharge. 42%
4) Atelectatic ear patients presented with occasional discharge and
11.5% presented with no discharge, we treated
5) Tympanosclerotic patches
conservatively for discharging ear for 3 weeks before
6) Retraction pockets operating.
7) Patient willing to participate in the study 44/50 patients presented with complaints of
discharge. Out of these 44 patients, 39 presented with
Exclusion Criteria some degree of hearing impairment. As shown in
1) Acute otitis media table longer duration of otorrhoea more is the severity
of the disease and more the hearing impairment.
2) Otosclerosis

72
In our study complete visualization of the tympanic Degree of hearing improvement is from 10-14dB in
membrane without any manipulation was possible in 36% of cases and 15-19 dB in 34% of the cases and
50% of the cases and visualization after manipulation 20-25 dB in 2% of the cases and 25- 30 dB in 1% of the
was possible in 34% of the cases. However partial cases at the end of the study period. When the degree
visualizationeven after manipulation was seen in 17% of hearing improvement was compared at 1, 3 and 6
cases. months follow up it was observed that endoscopic
tympan mastoidectomy had a positive effect on post
18 patients showed perforation in more than one
operative degree of hearing improvement (p value<
quadrant and out of these 11 patients (22%) showed
0.05).
medium size while 7 patients (14%) showed total
perforation. Discussion
In 55% of the cases the diseased ear showed retracted The management of CSOM is one of the most
pars tensa with the TM. 14% patients showed same challenging tasks in otologic surgeryas the chances of
side central perforation and 31% showed normal TM. residual disease and the morbidity of the conventional
On the contralateral side retraction was noticed in procedures involved in treatment are high. With
40% of the cases, perforation in9% and about 51% had incorporation of endoscopes in theotologic field much
normal TM. of the recidivism and morbidity of the procedures has
been reduced.
Out of 50 cases B/L sclerosis was noted in about
31% and U/L sclerosis on the affected side in 37%. As stated by Takahashi (2000) middle ear pressure is
B/Lly Pneumatised mastoid was noted in 26%. The maintained by two routes, the Eustachian tube and the
cavitary mastoid diagnosed in only 6%. middle ear mucosal gas exchange. Ventilation through
Eustachian tube is quick and active mechanism that
Pure CHL implies > 25db air conduction loss and helps in adapting to transient fluctuations in middle
A-B gap > 20db and in the mixed variety the bone ear pressure. The middle ear mucosal gas exchange
conduction loss > 25db and A-B gap > 20db. In our is passive and constant phenomenon, that functions
study 66% showed Pure conductive hearing loss and even during sleep v/s the Eustachian tube which
33% showed mixed hearing loss. closes during sleep, helps in continuous maintenance
The disease was seen extending to the attic and of middle ear pressure .In our present study apart
aditus as well in 26% of the cases,spreading further to from the eradication of disease and reconstruction
mastoid antrum in 26 % of the cases and involving of the middle ear much importance has been given
both the posterior mesotympanum and aditus ad to the preservation of middle ear cleft mucosa and
antrum was seen in 40% of the cases. restoration of ventilation of middle ear and mastoid.
On the basis of extent of the disease different Jacob and sade (1992) stated that csom ears usually
surgical procedures were used, 100% cortical possess poorly pneumatised or non pneumatised
mastoidectomy with tympanoplasty. temporal bones, in our study about 67% of our patient
had sclerosed mastoid, that reduces the middle ear
While assessing the post-operative graft uptake it buffering capacity.
was observed that successful graft uptake was seen
In our study we have not used silicon sheets in any
in 94% cases while graft uptake was unsuccessful
of the patients instead we usedcartilage in the middle
in 6% cases after 6 months of follow up. At routine
ear to augment the myringoplasty versus Takashi in
follow ups of 1, 3 and 6 months it was observed that
2000 who used tympanostomy tube in patients and
the chances of graft uptake decreased as the post op
0.5mm silicon sheets in the tympaniccavity and found
time period increased (p<0.05).
no significance in the recovery of mastoid aeration
While assessment of post op chronically discharging with tympanostomy tubes.
ear it was observed that only 2% of the cases had
Advantages of the cartilage tympanoplasty is that it
chronic discharge at 6 month follow up period. The
helps in restoration of the middle ear air space enabling
above table shows that chronically discharging ear
the drainage of blood clot and other collection from
is negatively associated with post operative time
attic, aditus, antrum, anterior epitympanum via the
period(p<0.005). As time progresses the rate of
middle ear into the Eustachian tube to the pharynx.
chronically
The tympanic membrane gets perforated when

cartilages other than handle of malleus comes into References

direct contact with it but in cartilage tympanoplasty 1. Anisur Rahman. Healing of tympanic membrane
where the composite cartilage placed between the perforation : an experimental study by. From
ossicular graft and tympanic membrane overcomes Karolinska Institute And University Hospital
this disadvantage. Stockhole Sweden 2007, ISBN 978-91-7357-243-9.
So far in our 6month follow up we have not 2. Committee on Conservation of Hearing of the
encountered any residual, recurrent disease just 1 American Academy of Ophthalmology and
chronically discharging ear, also the healing time Otolaryngology. Standard classification for surgery
(period for complete epithelization of cavity) was of chronic ear infection. Arch Otolaryngol Head Neck
also less in 27+/-10 days compared to Takahashi 2000 Surg 1964;81:204-5
where it was 31.5+/-19days. All our procedures were 3. Sunil S Nichlani et al. Reconstruction of the Tympanic
done exclusively with endoscopes where the need Membrane with Partial Tragal cartilage Graft Versus
for bone removal for accessing is less compared to Temporalis Fascia Graft. Bombay Hospital Journal,
the Takahashi (2000) procedures which were done vol.52, No.2, 2010
exclusively with microscopes, excessive bone and 4. Heermann J, Heermann H, Kopstein E. Fascia and
mucosal. cartilage palisade tympanoplasty. Arch Otolaryngol
1970; 91:228–41.
Conclusion
5. Heermann J. Auricular cartilage palisade tympano-
The success of Tympanoplasty in terms of graft
,epitympano-, antrum- and mastoid-plasties. Clin
uptake and hearing improvement is better in patients Otolaryngol 1978;3:443–6
with lesser duration of disease, less preoperative Air
bone gap and with medium sized perforations when 6. Mirko Tos.:Cartilage Tympanoplasty: Classifications of
comparedto subtotal perforations. methods—techniques--Results :Edition I, Thieme,2009
7. Wullstein H. Funktionelle Operationen im Mittelohr

The success of cartilage tympanoplasty in terms of
mit Hilfe des freien Spalt-lappen-Transplantates. Arch
graft uptake and hearing improvement is better in
Ohren-Nasen-u Kehlkopfh 1952; 161:422.
patients with lesser duration of disease and less pre-
operative Air bone gap. 8. Zollner F. Panel of myringoplasty. Second workshop
on reconstructive middle ear surgery. Arch Otol
In post-operative evaluation of patients with 1963;78:301.
unilateral hearing loss, application of Belfast rule
9. Milewski C. Composite graft tympanoplasty in the
of thumb enables the actual hearing benefit ofthe
treatment of ears with advanced middle ear pathology.
patient.
Laryngoscope 1993;103:1352–6
Ethical clearance: taken from ethical committee of
institute
Consent: taken from of patients
Conflict of interest: no
Source of funding: self

Lilliputian Hallucination-An Exceptional Psychiatric Symptom
Dipankar Maiti1, Nethravathi. V2

1
Nursing Tutor, Sushrutha College of Nursing, Rajiv Gandhi University of Health Sciences, Karnataka, India
2
Principal, Sushrutha College of Nursing, Department of Obstetrics & gynaecological Nursing, Rajiv Gandhi University of Health
Sciences, Karnataka, India
How to cite this article: Dipankar Maiti, Nethravathi.V, et al Lilliputian Hallucination-An Exceptional Psychiatric
Symptom. Volume 13 | Issue 4 | October-December 2022
Abstract
As in normal cases in Psychiatry we have seen so many types of hallucination like tactile, auditory, visual, gustatory. But in
this review article reader will get to know about a very rare &and unique type or category of hallucination i.e., Lilliputian
Hallucinations. The AIWS is a clinical presentation of distorted body images and/or objects surrounding the subject
experiencing the syndrome. Several medical conditions have been accompanying to this unique type of hallucinatory
disease condition, the exact cause of which is yet unknown. AIWS can also be described as a set of symptoms with
alteration of body image. An amendment of visual perception is found in that way that the sizes of body parts or sizes
of external objects are professederroneously. The causes may be epilepsy, stroke, brain tumor, Head trauma, Migraines,
Infection etc. The exact treatment modality is still not unknown.The finest way to treat this condition is simply by helping
the patient become more comfortable. For example, if the problem is caused by migraines, the treatment of the migraine
itself may be the best way to assuage Alice in Wonderland Syndrome symptoms.
Keywords: Alice in Wonderland syndrome, Todd’s syndrome,dysmetropsia,temporal lobe epilepsy, Epstein-Bar virus
Introduction (micropsia) or larger (macropsia), or appearing to

AIWS is a rare neurological syndrome characterized be nearer (pelopsia) or farther (teleopsia) away than
by misrepresentations of visual perception, the body they actually are. Spin may also occur for senses other
image, and the experience of time. People may see than vision.2
things smaller than they are, feel their body alter in AIWScan also be described as a set of symptoms
size or experience any of the syndrome’s numerous with amendment of body image. Avariation of visual
other indications. 1 perception is found in that way that the sizes of
AIWS, also recognized as Todd’s body parts or sizes of exterior objects are perceived
syndrome or dysmetropsia, erroneously. The most common perceptions are
is a neuropsychological at night. The causes for AIWS are still not known
illness that roots a distortion precisely. Typical migraine, temporal lobe epilepsy,
of perception. People may brain tumours, psychoactive drugs toEpstein-Barr
experience falsifications in virus are causes of AIWS. AIWS has no confirmed,
visual perception of objects effective treatment. The treatment plan entails of
such as seeming smaller migraine prophylaxis and migraine diet.3
Dipankar Maiti
Nursing Tutor,Sushrutha College of Nursing, Rajiv Gandhi University of Health Sciences, Karnataka, India
Email Id: [email protected]
Methodology Migraines-Todd’ssyndrome may be a type of aura,

We performed a PubMed quest in April,2022 by or a sensory warning of a coming migraine. Some
using the phrases “AIWS,” “AIWS pathophysiology,” doctors also believe that Todd’ssyndrome may be a
“AIWS treatment,” and “Lilliputian Hallucination.” subtype of migraines.
The search bornealmost 46 papers, including reviews, Infections-AWS episodes may be an early
case reports, case series, and small clinical studies. symptom of the EBV. This virus may cause infectious
After excluding the 16 non-English reports without mononucleosis, or mono.
an English abstract, we encompassed the remaining
Genetics-family history of migraines and AWSmay
30, irrespective of publication date.
have a higher risk for experiencing this rare condition.
History
Common Causes
AIWS is also known as Todd’s syndrome.This
Still the causes of AWS, but doctors are working to
symptom was first identified in the 1950s by Dr.
better understand this unique condition. They do
John Todd, a British psychiatrist. He noted that the
know that AWS isn’t a problem with the patient’s
symptoms and recorded anecdotes of this syndrome
eyes, a hallucination, or a mental or neurological
closely resembled episodes that the character Alice
illness.
Liddell experienced in Lewis Carroll’s novel “Alice’s
Adventures in Wonderland.”4 Researchers believe unusual electrical activity in the
brain causes abnormal blood flow to the parts of the
Background brain that process our environment and experience
The syndrome is sometimes termed as Todd’s visual perception. This infrequent electrical bustle
syndrome, in reference to apersuasive description of may be the result of several causes. Even if more
the condition in 1955 by Dr. John Todd (1914–1987), a research is needed, migraine is painstaking the leading
British consultant psychiatrist at High Royds Hospital cause for AWS in adults. Infection is painstaking the
at Menston in West Yorkshire.Dr. Todd discovered primary cause for AWS in children. Other possible
that several of his patient’sveteran severe headaches causes include:
causing them to see and perceive objects as greatly
• infection
out of proportion. In addition, they had altered sense
of time and touch, as well as slanted perceptions of • brain tumours
their own body. Despite having migraine headaches, • stress
none of these patients had brain tumours, damaged
• cough medicine
eyesight, or mental illness that could have accounted
for these and similar symptoms. • use of hallucinogenic drugs
• epilepsy
Dr. Todd speculated that Carroll had used his own
migraine experiences as a source of encouragement • stroke
for his famous 1865 novel Alice’s Adventures • head trauma
in Wonderland. Carroll’s diary discloses that in
• migraines
1856 he consulted William Bowman, arenowned
ophthalmologist, about the visual manifestations of • brain tumour
the migraines he habituallyexperienced. In Carroll’s • acute Disseminated Encephalomyelitis4,7
diaries, he often wrote of a “bilious headache” that
came attached with severe nausea and vomiting. In Pathophysiology
the year of 1885, he wrote that he had “experienced, The TPO junction connects the temporo-occipital,
for the second time, that odd optical affection of seeing parieto-occipital, and temporo-parietal junctions is
moving fortifications, shadowed by a headache”.5,6 where visual and somatosensory dataare integrated
to generate the inner and external representation of
Anothewr Name-AIWS, Todd’ssyndrome,
self. Other intricate perception can be professed by
Lilliputian hallucinations, dysmetropsia
the patient if other areas of the brain are involved,
Risk Factors - Several conditions are linked to evolving into complex somatosensory disorder.
Todd’ssyndrome. The following may increase the risk AIWS has been ascribed to the migrainous cortical
for it: dysfunction of the non-dominant parietal lobe.
76
Various studies have publicized that electrical • Quick-motion phenomenon

stimulation of the parietal lobe chiefs to distortion in • Dysmorphopsia – lines and contours look as
the size and length of the image perceived. Decreased if wavy
perfusion to the non-dominant parietal lobe during an
attack leads to discernment of symptoms. Generally, • Feeling of derealization, depersonalization,
symptoms of AIWS can precede or accompany a somatopsychic duality
migraine attack.9 • Alteration in judgement of time7
Symptomatic Types
Obligatory
Types Facultative symptoms
symptoms
Aschematia:partial
Derealization,
or total macro-
depersonalization,
somatognosia
A somatopsychicduality,
or micro-
aberration in
somatognosia;
judgement of time
paraschematia
Macro- and
micropsia and/or
tele- and pelopsia.
When micropsia
and telopsia seems
B at the same time
Symptoms and for the same
• AIWS disorder may cause various numbers object:porropsia
Lilliputianism
of symptoms like-
(people appearing
• Dysmorphopsia: Straight lines or edges smaller)
appear to be wavy. Type A + type B
C
symptoms
• Macrosomatognosia: A person’s own body
feels much bigger than it is. Diagnostic Evaluation
• Microsomatognosia-A person’s own body • One or more episodes of self-experienced
feels much smaller than it is. body schema illusion or metamorphopsia
• Visual hallucinations • Duration < 30 min
• Metamorphopsia - visual distortions • Accompanied by headache or a history of
• Macropsia - seeing images larger than normal migraine
• Micropsia – seeing images smaller than • MRI, CSF analysis, andEEG all normal.
normal However, visual evoked potentials may be
abnormal
• Achromatopsia – inability to perceive colour
The below picture shows different scanned photos of
• Teleopsia – seeing farther than normal
MRI in case of AIWS affected patients-
• Pelopsia – seeing nearer than normal
• Micropsia: Objects seems much smaller than
they really are
• Macropsia: Objects seems much larger than
they are in real life
• Teleopsia: Objects seem further away than
they are
• Pelopsia: Objects looks closer than they are
• Partial/total body macro/micro-matognosia

Treatment of symptoms since the resection of the arteriovenous

There is no particular treatment for AIWS still. The malformation.11
superlative way to treat this condition is simply by Report No. 2-A 69-year-old Thai man without an
helping the patient develop more comfortable with the underlying illness presented with multiple episodes
perceptual problem which does not exists in reality. of transient visual disturbances of macropsia (seeing
For instance, if the problem is caused by migraines, things larger than they are) including enhanced
the treatment of the migraine itself may be the best stereoscopic vision (an exaggeration of the depth
way to assuageLilliputian hallucination and detail of visually alleged objects). The visual
At present condition (2017), Lilliputian symptoms continued for a few seconds and were
hallucination has no identical treatment plan.Since escorted by impairment of awareness, which his
symptoms of Alice in Wonderland syndrome often daughter described as not responding to others,
disappear, either spontaneously on their own, or with for nearly a minute. He was seen chewing even
treatment of the underlying disease, most clinical and nevertheless there was no food in his mouth. He has
non-clinical AIWS cases are considered to be benign. confronted those events 2 or 3 times per day for a
This unique condition is caused by underlying twosome of months and more often in a week before
chronic disease, nevertheless, symptoms tend to he came to our hospital. He sometimes howled of
reappear during the active phase of the fundamental palpitations as “rapid heartbeat” presently during the
cause (e.g., migraine, epilepsy). If treatment of Alice event. He did not reminiscence any dizziness, chest
in Wonderland Syndrome is determined essential and pain, shortness of breath, fever, headache, numbness,
useful, it should be engrossed on treating the suspected or weakness prior to each occurrence. He had not
underlying disease. Treatment of these underlying ever had symptoms like these before. He testifiedas
conditions mostly involves remedial medications a 35 pack-year times past and social drinking. He
such as antiepileptics, migraine prophylaxis, deprived of over-the-counter medication misuse, food
antivirals, or antibiotics. Antipsychotics are seldom and drug allergy, and a family history of unexpected
used in treating Todd’ssyndromesymptoms due to cardiac death or epilepsy.10
their minimal effectiveness. Report No. 3-A case of 78-year-oldemeritus
male – with comorbid condition of diabetes and
Reported Cases
hypothyroidism – was referred to the psychiatric
Report No. 1-A case of 24-year-old man with a department in Kolkata Medical collegefrom
identified cerebral vascular anomaly and seizures ophthalmology of the same hospital for VH of 1-year
presented with a two-week history of visual and time period. The patient had the previous history
perceptual instabilities. Described visual disturbances of unembellished depressive episode 2 years back
comprise a physician “coming through a portal like and had not taken any psychotropic medications or
Doctor Strange” to the patient’s left side and the psychoactive substances for more than 1 year. He too
same physician’s right shoulder and arm growing had a history of bilateral cataract, which had led to
in size while the left hand was shrinking in size. deterioration in his visual acuity over the last few
Other perceptual disturbances contained within cars years. He checked to his ophthalmologist 1 year ago,
floating, people morphing into other people, and reporting VH. The ophthalmologist supposed CBS,
experiencing jamais vu. EEG proved nonconvulsive and he was successfully operated for his cataract;
position epilepticus that was resilient to antiepileptic however, the VH persisted.11
therapy with levetiracetam, phenytoin, and
valproic acid. MRI of the brain revealed a right Report No. 4-A 44-year-old gentleman, wedded
parietal cavernous deformity that increased in size and unemployed, had a history of bullous lesions over
as associated to prior imaging. A right parieto- the tongue, palate and buccal mucosa. Dermatological
occipital craniotomy with microdissection was assessment revealed bullae and crusted erosions over
made to separate the malformation from the normal the forehead scattering toward the chest, abdomen,
brain parenchyma. Mutually gross and histological and ventral aspects of thighs. He respondedunwell
neuropathology were steady with an arteriovenous to dapsone (100 mg/day), prednisolone (20 mg/day)
malformation. The patient was discharged from the and azathioprine (100 mg/day)for 10 weeks. While
hospital on levetiracetam and has had no reappearance doing the MSE, athought-provoking phenomenon

78
noted was the fruition of tiny Lilliputian hallucinations Conflict of Interest- Have no conflict of interest
into gigantic Brobdingnagian hallucinations (size relevant to this article
of 10 feet) on treatment with the combination of
The authors affirm that the research was conducted
steroids. The illumination of the visuals could not
in the absence of any profitable or monetary
fit dysmegalopsia or visual imagery. His tedious
relationships that could be interpreted as a potential
blood investigations and CT scan of the brain were
conflict of interest.
within the normal bounds. A diagnosis of organic
depression with psychotic indications was made by Ethical Clearance - Not required
consultation–liaison psychiatry team and in progress
Bibliography
on oral escitalopram up to 20 mg and risperidone up
to 4 mg/day. Within a week of treatment, the size 1. Naarden T, ter Meulen BC, van der Weele SI, Blom
of hallucinations abridged back to tiny people (from JDi. Alice in wonderland syndrome as a presenting
manifestation of Creutzfeldt-Jakob disease. Frontiers
10 feet to 2 feet) while conserving the shape of them
in Neurology. 2019;10(MAY):473.
and completely resolved by the end of 2 weeks. His
depression amended at the time of releasing from the 2. Lanska DJ, Lanska JR. The Alice-in-Wonderland
department backed by MSE and drop in the Hamilton Syndrome. Frontiers of Neurology and Neuroscience
Depression Rating Scale which scores from 18 to 6.12 [Internet]. 2018 [cited 2022 Apr 29];42:142–50.
Available from: https://www.karger.com/Article/
Conclusion FullText/475722
Lilliputian hallucination is a very rare as well as 3. Weissenstein A, Luchter E, Stefan Bittmann MA.
exceptionalcategory of mental disorder but can be Alice in Wonderland syndrome: A rare neurological
observed and scared by seeing various social media manifestation with microscopy in a 6-year-old child.
footages in you tube, Facebook and other sites. So, Journal of Pediatric Neurosciences [Internet]. 2014 Oct
we, authors have tried to cover the allied information 1 [cited 2022 Apr 29];9(3):303. Available from: /pmc/
regarding the rarely known disorder. We expect articles/PMC4302569/
that the readers will get enough information as well 4. Blom JD. Alice in Wonderland syndrome A systematic
as interest about this special and unique type of review. Neurology: Clinical Practice. 2016 Jun
hallucination. 1;6(3):259–70.
List of Abbreviations 5. Todd, J (1955). “The syndrome of Alice in Wonderland”.

Canadian Medical Association Journal. 73 (9): 701–4.
AIWS-Alice in Wonderland syndrome PMC 1826192. PMID 13304769.
MSE-Mental status examination 6. Lanska, John; Lanska, Douglas (2013). “Alice in
Wonderland Syndrome: somesthetic vs visual
EBV- Epstein-Bar virus
perceptual disturbance”. Neurology. 80 (13): 1262–4.
CBS-Corticobasal syndrome doi:10.1212/WNL.0b013e31828970ae. PMID 23446681.
S2CID 38722468.
VH-Visual hallucinations
7. Alice in Wonderland Syndrome | Symptoms &
TPO-Temporo-parieto-occipital Treatment [Internet]. [cited 2022 Apr 29]. Available
MRI-Magnetic resonance imaging from: https://share.upmc.com/2016/10/alice-in-
wonderland-syndrome/
CSF-Cerebrospinal fluid
8. Evans RW, Rolak LA. The Alice in Wonderland
EEG-Electroencephalogram Syndrome. Headache. 2004;44(6):624-625. doi:10.1111/
j.1526-4610.2004.446013.x
TPO-Thyroid peroxidase
9. Blom, Jan Dirk (2016). “Alice in Wonderland
CT-Computed tomography syndrome”. Neurology: Clinical Practice. 6 (3): 259–
Source of Funding 270. doi:10.1212/CPJ.0000000000000251. ISSN 2163-
0402. PMC 4909520. PMID 27347442.
Self(review aticle), No financial support was provided
relevant to this article.

10. Panpruang P, Wongwandee M, Rattanajaruskul N, 12. Sutar R, Patra S, Siddiqui F, DIwan S, Rajan A. A
Roongsangmanoon W, Wongsoasu A, Angkananard rare case report of Lilliputian and Brobdingnagian
T. Alice in Wonderland Syndrome-Like Seizure hallucinations in a case of pemphigus vulgaris.
and Refractory Supraventricular Tachycardia. Case Indian Journal of Psychiatry [Internet]. 2020 Jul 1
Reports in Neurology [Internet]. 2021 Nov 2 [cited [cited 2022 Apr 29];62(4):435–6. Available from:
2022 Apr 29];13(3):716–23. Available from: https:// https://journals.lww.com/indianjpsychiatry/
www.karger.com/Article/FullText/519509 Fulltext/2020/62040/A_rare_case_report_of_
Lilliputian_and.15.aspx
11. Chatterjee SS, Khonglah D, Mitra S, Garg K. Gulliver’s
world: Persistent lilliputian hallucinations as
manifestation of Charles Bonnet syndrome in a case of
cataract and normal pressure hydrocephalus. Indian
Journal of Psychiatry [Internet]. 2018 Jul 1 [cited 2022
Apr 29];60(3):358. Available from: /pmc/articles/
PMC6201671/

Effect of Vaginal pH on Efficacy of Prostaglandin Gel for Labour Induction
B Sandhya
Assistant Professor, Department Of Obstetrics And Gynecology, Niloufer Hospital For Women And Children,
Osmania Medical College, Hyderabad
How to cite this article: B Sandhya et al Effect of Vaginal pH on Efficacy of Prostaglandin Gel for Labour Induction.
Abstract
Background: Inducing Labour Is A Procedure Intended To Trigger Artificial Contractions Of The Uterus That Generally
Involve Progressive Erasure And Dilation Of The Cervix. This Will Hopefully Lead To The Birth Of A Baby Through The
Vaginal Route.
Objective: To Assess The Effect Of Vaginal Ph On Efficacy Of Prostaglandin Gel For Labour Induction
Methods: A Total Of 200 Women With An Unfavourable Cervix Were Enrolled In This Retrospective Study. In Group I,
There Were 100 Cases With Vaginal Ph Of ≤4.5 And In Group Ii, 100 Cases With Vaginal Ph Of > 4.5. Patients With Minimal
Change In Bishop Score, Received Up To 3 Doses Of Prostaglandin Gel Intracervically, 6 Hours Apart. Women Who Had
No Change In Bishop Score At The End Of Induction With 3 Doses Of Prostaglandin Gel, Were Further Reassessed.
Results: In Terms Of Maternal Age, Parity, Gestational Age, And Initial Bishop Score, There Was No Significant Difference
Between The Two Groups. Prior To Induction Of Labour, The Average Bishop Score Was 3.6±0.9 In Group I And 4±1.0 In
Group Ii. Out Of 200 Cases, 33% Cases Required Oxytocin Infusion In Group I And 13% In Group Ii.
Conclusion: Parity Has A Major Impact On The Pre-Induction Of The Bishop Score And The Ph Itself Has A Vaginal
Influence. Knowing The Pre-Induction Vaginal Ph May Also Be A Helpful Method For Determining The Outcome Of
Pge2 Induction.
Keywords: Vaginal ph, Labour, Induction, Pge2 Gel
Introduction Ranges Between 6 And 7. The Ph Of The Vaginal Fluid

Labour Induction Is A Procedure That Artificially Is Regulated Between 3.8 And 4.8.3 Lactobacillus Is
Induces Uterine Contractions, Culminating In A Healthy Vaginal Flora That Generates Lactic Acid,
Cervical Effacement And Dilation. This Should Which Causes An Acidic Vaginal Ph. Lower Genital
Ideally Culminate In The Baby Being Born By Vaginal Tract Infections, Ruptured Membranes, Douching,
Delivery.1 And Other Factors Might Affect Vaginal Ph During
Pregnancy.4
One Of The Most Prevalent Obstetrical Interventions
Is Induction Of Labour. The Most Routine Way Of Prostaglandins Are Organic Acids With A Low
Inducing Labour Is Using Prostaglandins. Induction Ph And Limited Solubility In Aqueous Solution.
Of Labour In An Unfavourable Cervix Has A Varied The Acidity Of The Vaginal Mucosa May Affect
Response To Pge2.2 The Ph Of The Vaginal Fluid Is The Drug’s Release, Resulting In A Varying Clinical
Hypothesised To Play A Role In Inducing Labour. Reaction. The Effectiveness Of Intravaginally
During Pregnancy, The Ph Of The Cervix Normally Administered Prostaglandins May Be Affected
Dr. Bushra Fatima
Assistant Professor, Department Of Obstetrics And Gynecology, Niloufer Hospital For Women And Children,
Osmania Medical College, Hyderabad
By Vaginal Ph. Various Potential Causes Include Parameters: Cervical Dilation, Cervical Deletion,
Changes In Prostaglandin Uptake And Metabolism.5 Cervical Continuity, Cervical Location, Foetal
Station. A Score Of 0-2 Or 0-3 Was Given To Each
The Influence Of Vaginal Ph On The Efficiency Of
Part. The Highest Possible Score Was 13 And <5 Is
Intracervical Prostaglandin Gel Administration In
Unfavourable If Induction Is Necessary.
Preinduction Cervical Ripening Is Ambiguous, And
There Is A Paucity Of Research On The Topic. That’s All Women Were Induced With The Initial Dose
Why This Study Was Undertaken. Of Intracervically Placed Prostaglandin Gel (0.5 Mg).
The Patient Was Advised To Stay Reclusive For A
Materials and Methods Period Of 30 Minutes After Application. A Repeat
Study Design: Random Prospective Observational Score From The Bishop Was Done After Initial 6
Study Hours Of Cervical Maturation. All Participants Were
Exposed To The Uniform Intrapartum Care Regimen.
Study Population: Both Pregnant Women Aged 18-
Those Women With Minimal Change In Bishop
35 Who Had Been Admitted Into Safe Confinement
Score, Received Up To 3 Doses Of Prostaglandin Gel
In The Department Of Obstetrics And Gynecology
Intracervically, 6 Hours Apart. Women Who Had No
And Were Between 37 And 42 Weeks Of Gestation
Change In Bishop Score At The End Of Induction
Were Enrolled. All Participants Had A Diagnostic Or
With 3 Doses Of Prostaglandin Gel, Were Further
Obstetric Indication For Labour Induction.
Reassessed. Women Who Had Any Improvement In
Sample Size: 200 Women Divided Equally Into 2 Bishop Score But Are Not In Sufficient Labour Got
Groups Oxytocin Infusion For Improvement. The Shift In
Bishop’s Score Over 6 Hours, Induction-Active Step
Inclusion Criteria:
Interval, Induction-Interval Of Delivery, Mode Of
• Pregnant Women With Singleton Pregnancy
Delivery And Neonatal Outcome Is Recorded For
With Foetus In Vertex Presentation >37
Both Groups.
Weeks Of Gestation With Unfavourable
Bishop’s Score ≤5 Were Included. Statistical Analysis: Spss 22 Software Was Used
For Statistical Analysis. The Data Was Presented In
Exclusion Criteria: The Form Of Means And Percentages. P<0.05 Was
• Women With Following Conditions Such Considered Statistically Significant.
As Cephalopelvic Disproportion, Ruptured
Membranes, Suspected Chorioamnionitis, Observations and Results
Abnormal Vaginal Discharge, Parity >4, Table 1: Distribution Based On Baseline
Previous Lscs Or H/O Uterine Surgery, Characteristics
Severe Iugr, Severe Pre-Eclampsia, Abruptio
Characteristics Group - I Group - p-value
Placenta And Abnormal Nst Were Excluded
(mean ± II (mean
From The Study
SD) ± SD)
Prior To The Commencement Of Study Informed Maternal age 26.5±4.5 25.7±4.1 0.911
Consent Form Was Obtained. Once The Patient Who (in years)
Required Induction Was Admitted In Labour Room, Gestational age 39.3±0.9 38.8±1.4 0.954
Vaginal Ph Was Measured Prior To Per Vaginal (in weeks)
Examination. A Speculum Analysis Was Performed
Vaginal pH 4.1±0.2 5.1±0.3 <0.001
To Each Participant; And The Ph-Value Of The
Initial Bishop score 3.6±0.9 4.0±1.0 0.884
Vaginal Was Measured Using A Wide And Narrow
Ph Paper. The Participants Were Classified Into Two The Age Group Ranged From 18 To 35 Yrs And
Subgroups As Group I And Group Ii Depending On The Mean Age In Group I Was 26.5 Years And Group
Their Vaginal Ph. Group I Comprised Patients With Ii Was 25.7 Years. The Majority Of Patients Were
Vaginal Ph ≤4.5 And Group Ii Included Vaginal Ph Having 37 To 41 Weeks Of Gestational Age The Mean
>4.5 And Discrepancies Within Groups With Regard Gestational Age Was 39.3 Weeks In Group I And
To Menstrual Age, Parity, Gestational Age Were 38.8 Weeks In Group Ii. There Was No Statistically
Recorded. After Ph Measurement, The Bishop Score Meaningful Correlation Between The Two Classes
Was Calculated On The Basis Of The Following With Regard To Maternal Age, Gestational Age,

82
Parity And The Original Bishop Scores. Around 60% Outcome Group - I Group - II P-
In Group I And 37% In Group Ii Had A Pre-Induction value
Bishop Score Of 4. The Mean Bishop Score Before
Augmentation 33.3% 13.3% -
Labour Induction Was 3.6±0.9 In Group I And 4±1.0 required (%)
In Group II.
Induction- Active 390 420 0.771
Table 2: Comparison Of Vaginal ph With Various phase interval in (240–630 (300–720)
Factors minutes
Maternal Age Group - I Group - II (Median time, (Q1
≤25years (n, %) 49(49%) 46(46%) to Q3)
>25years (n, %) 51(51%) 54(54%) Induction delivery 510 580 0.976
interval in minutes (390–855) (312–870)
Parity (Median
Primi 68 (68%) 62(62%)
Q1 to Q3)
Multi 32 (32%) 38(38%)
Number of induc- In Group II, Bishop’s Score Changes Over 6 Hours
tions After The Start Of The First Intracervical Prostaglandin
Gel Were Significantly Higher Than Those In Group I
One 53(53%) 70(70%)
(23 Vs 10 Cases. No Significant Correlation Has Been
Two 27(27%) 23(23%)
Identified Between Vaginal Ph And Induction-Active
Three 20(20%) 7(7%) Step Interval, Induction-Delivery Interval. Out Of
Induction-Active 200 Cases, 33% Cases Required Oxytocin Infusion In
phase interval Group I And 13% In Group II.
≤6 hours 40(40%) 60(60%)
Table 3: Neonatal Outcome.
>6 hours 60(60%) 40(40%)
Neonatal Group - I Group - II P - value
Mode of delivery
Outcome
Vaginal delivery 90(90%) 87(87%)
Birth weight
LSCS 10(10%) 13(13%) 3.05±0.5 3.06±0.4 0.996
(in kgs)
No Significant Correlation Has Been Identified 5min APGAR
Between Vaginal Ph And Maternal Age. Patients 0 0 -
score < 7
With A Higher Vaginal Ph (>4.5) Required Higher NICU
Number Of Inductions Compared To Patients With admission 7(7%) 10(10%) 0.466
Lower Vaginal Ph, But This Observation Was Not (n %)
Statistically Significant. Majority Of The Patients In
Both Groups Required Only One Dose Of Pge2 To The Average Birth Weight, Apgar Score At 5
Initiate Labor. The Number Of Vaginal Deliveries Minutes, Need For Nicu Admission Outcomes Were
Was Comparable In Both Categories, 90% In Group Nearly Similar In Both The Groups. Total 17 Babies
I And 87% In Group Ii. The Caesarean Section Was Required Nicu Care, Of Which 7 Were From Group I
Comparable In Both Groups (10% Vs 13%). There And 10 From Group Ii. Most Common Indication For
Was No Substantial Variation Between Groups In The Nicu Admission Was Respiratory Morbidity In Both
Mode Of Delivery. The Groups. All Babies Were Discharged Within A
Week. No Perinatal Morbidity In Both The Groups.
Table 3: Comparison of Labour Outcomes
Discussion
Outcome Group - I Group - II P-
value There Was No Statistically Significant Difference
Bishop score 10(1-9) 23(2-9) 0.023 In Bishop’s Score Changes Between The Two Groups
changes over 6 Following The First Dosage Of Prostaglandin Gel.
hours (Median There Was No Statistically Significant Correlation
Between The Number Of Gels Required To Ripen
Q1 to Q3)
The Cervix And Vaginal Ph. The Duration From

Induction To Active Labour, Rupture Of Membranes, The Effectiveness Of Prostaglandin Gel In Cervical
And Vaginal Delivery Did Not Differ Substantially Maturation And Labour Induction. However, Our
Between The High And Low Vaginal Ph Groups. In Research’s Observational Evidence Indicates That
Individuals With Varied Vaginal Ph, There Was No Vaginal Ph Is Unlikely To Impact The Effectiveness
Significant Variation In Mode Of Delivery. Of Prostaglandin Gel.
Few Previous Studies Have Shown Contradictory Ethical Clearance: The Ethical Clearance Was
Results.6,7 A Study Of The Influence Of Vaginal Ph Obtained From The Institutional Ethics Committee
On Intracervical Prostaglandin Gel Administration Prior To The Commencement Of The Study.
Found That Individuals With High Vaginal Ph Had
Conflict Of Interest: Nil
A Considerably Higher Bishop’s Score Prior To
Induction And Had Higher Vaginal Delivery Rates.8 Source Of Funding: Self
Similar Research Using Intracervical Prostaglandin References

Gel Found A Statistically Significant Difference In 1. Rcog. Royal College Of Obstetricians And
Labour Result Between Vaginal Ph Groups. There Gynaecologists. Induction Of Labour. 2008;1:1- 12,5:45-
Was A Shorter Time To Active Labour, Full Cervical 68
Dilation, And Delivery In Individuals With A High
2. Basirat Z, Barat S, Ghanbarpour A, Golsorkhtabar-
Vaginal Ph.9
Amiri M. 2012. Does Vaginal Ph Affect The Efficacy Of
According To Studies On Pg Vaginal Inserts, Dinoprostone In Cervical Ripening/ Labor Duration.
Vaginal Ph Had An Influence Solely On The Change Clinical And Experimental Obstetrics And Gynecology
In Bishop’s Score Following The First Dosage 39:522–525.
Administration.10,11 They Found No Difference In 3. Choudhury A, Das S, Kar M. 2011. A Review On
Other Outcomes With A Change In Vaginal Ph.12 Novelty And Potentiality Of Vaginal Drug Delivery.
International Journal Of Pharmtech Research 3:1033–
The Findings Of This Study Reveal That Changes
1044.
In Vaginal Ph Have No Influence On The Efficacy Of
Pg Intracervical Administration. Since The Cervical 4. Goswami J, Choudhury Ss, Deka G. 2015. Effect Of
Ph In Pregnant Women Ranges Between 6 And 7, Vaginal Ph In Cervical Ripening With Dinoprostone
Triacetin-Based Pge2 Preparations Are Appropriate Gel. The New Indian Journal Of Obgyn 2: 32–36.
For Intracervical Administration As Vaginal Ph Is 5. Johnson Ta, Greer Ia, Kelly Rw, Calder Aa. 1992. The
Unaffected. Instead Of A Preset Induction Approach Effect Of Ph On Release Of Pge2 From Vaginal And
For All Women, Evaluating Cervical And Vaginal Endocervical Preparations For Induction Of Labour:
Ph For Each Patient And Selecting The Optimal An In-Vitro Study. British Journal Of Obstetrics And
Prostaglandin Preparation For Their Ph Will Aid In Gynaecology 99:877–880.
Effective Induction. 6. Kurian Mj, Rao B, Rao A, Shameem V. 2016. Effect Of
Vaginal Ph On Efficacy Of Dinoprostone Gel For Labour
Strengths and Weakness: Induction. International Journal Of Reproduction,
• Our Study’s Strength Is Its Big Sample Contraception, Obstetrics And Gynecology 5:1196–
Size. In Our Study, Strict Exclusion Criteria 1201.
Were Applied, Which Helped To Eliminate 7. Lyrenas S, Clason I, Ulmsten U. 2001. In Vivo
Confounding Bias. Controlled Release Of Pge2 From A Vaginal Insert
• Cervical Ph, On The Other Hand, Could (0.8 Mm, 10 Mg) During Induction Of Labour. British
Have Been Measured, Which Would Have Journal Of Obstetrics And Gynaecology 108:169–178.
Aided In Comparing Vaginal And Cervical 8. Onen S, Ozaks¸It G, Yilmaz B, Gungor T, Bilge U, Sut
Ph With Pge2 Efficacy And Labour Progress. N, Et Al. 2008. The Role Of Vaginal Ph On Efficacy Of
This May Have Shed Further Insight On The Controlled-Release Dinoprostone Vaginal Insert For
Research. Cervical Ripening/Labor Induction: A Prospective
Doubleblind Study. Journal Of The Turkish-German
Conclusion
Gynecological Association 9:206–211.
Our Research Showed That The Vaginal Ph
Doesn’t Seem To Have A Significant Impact On

84
9. Ramsey Ps, Ogburn Pl, Harris Dy, Heise Rh, Ramin 11. Singh U, Mehrotra S, Gupta H, Dhakad A, Jain V. 2011.
Kd. 2002. Effect Of Vaginal Ph On Efficacy Of The A Prospective Double Blind Trial Investigating Impact
Dinoprostone Gel For Cervical Ripening/ Labor Of Vaginal Ph On Efficacy Of Prostaglandin Gel For
Induction. American Journal Of Obstetrics And Cervical Ripening And Course Of Labour. Journal Of
Gynecology 187: 843–846. Obstetrics And Gynaecology 31:217–219.
10. Ramsey P, Ogburn P, Harris D, Heise R, Dimarco C, 12. Kudagi B.l, Sailajai L, Kumari Rp, Babu Cr Et Al. A
Ramin K. 2003. Effect Of Vaginal Ph On Efficacy Of Comparative Study Of Intracervical Misoprostol With
The Controlled-Release Dinoprostone Vaginal Insert Intracervical Dinoprostone Gel For Induction Of Labor
For Cervical Ripening/Labor Induction. The Journal In Pregnancy. Asian J Pharm Clin Res, 2013;6 (2):174-
Of Maternal-Fetal And Neonatal Medicine 13:250–253. 178.

Ophthalmic Manifestations in Blood Dyscrasias - An Observational Study
Bhavna Dhanji Gagal1, Atul A. Modesara2

1
Assistant Professor, Department of Ophthalmology, Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat
2
Associate Professor, Department of Ophthalmology, Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat
How to cite this article: Bhavna Dhanji Gagal, Atul A. Modesara Ophthalmic Manifestations in Blood Dyscrasias -
An Observational Study. Volume 13 | Issue 4 | October-December 2022
Abstract
Aim: The present study was conducted to study the spectrum of ophthalmic manifestations in blood dyscrasias and to
assess the prevalence of ocular manifestations between acute and chronic blood malignancies.
Material and Methods: The Present observational study was conducted on a total of 200 patients diagnosed with blood
dyscrasias at the Department of Ophthalmology, tertiary care hospital, Bhuj, during the study period of 2 years. Detailed
history and examination were conducted, and findings were noted. All relevant haematological investigations were also
done.
Results: Out of 200 patients, anemia was the most common diagnosis observed in 70 (35%) cases, followed by sickle cell
anemia 54 (27%). Out of 70 patients with anemia, the majority of cases, i.e. 33, had iron deficiency anemia followed by
13 and 5 cases with megaloblastic and aplastic anemia, respectively. Retinal Veinous Tortuosity was the most common
finding in Thalassemia. In contrast, Veinous Fullness and Tortuosity and sub - conjunctival bleeding were the most
common finding in patients with leukemia and coagulation disorders, respectively.
Conclusion: The ocular changes of blood dyscrasias are not uncommon as is proved by various clinical and pathological
studies. These changes in the eye are due to the hemorrhagic effect of the blood disorders or due to the infiltration of the
ocular tissues by malignant cells. Ophthalmic manifestations are commonly observed in patients with blood dyscrasia.
Keywords: Anemia, Blood dyscrasias, Retinal Veinous Tortuosity, Sub - conjunctival bleeding
Itroduction increase or decrease in the total number of red cells

The blood is common to every tissue, and its disorder in a given patient is referred as polycythaemia or
can affect any part of the body. Anemia is the most anemia respectively.3 A large population of atypical
common haematological disorder in India, which the or neoplastic white blood cells within the blood
pallor of palpebral conjunctiva can identify, although constitutes leukemia. A subnormal number of
not a highly accurate index of severity of anemia. platelets in the circulating blood or loss of normal
Damage by anemia can be an indicator for retinal platelet function can lead to bleeding disorders or
damage manifesting as haemorrhage or pallor.1 As coagulopathies.4
the disease progresses, haemorrhages, exudates, The ocular fundus examination offers a unique
distended tortuous retinal veins and ultimately even opportunity for direct observation of small blood
papilloedema may occur in the ocular fundus.2 vessels and vascular lesions. In any systemic
The word dyscrasia comes from the Greek condition, fundus examination helps in the diagnosis
language and means”bad temperament”. An and/or prognosis of the condition.5 Besides the skin
Dr. Atul A. Modesara
Associate Professor,
Department of Ophthalmology, Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat
86
and mucous membranes, where blood dyscrasias Science, Bhuj were included in the study for the
can sometimes produce visible symptoms, the retina duration of 2 years. Sample size was 200 patients
presents our best early diagnostic opportunity. Indeed, diagnosed with blood dyscrasias.
significant ocular manifestations are not uncommon
Ethical approval was taken from the institutional
in these disorders and vision related issues may be the
ethical committee and written informed consent was
presenting symptom.6 However, since patients may
taken from all the participants.
often present without symptoms, a review of retinal
signs associated with blood dyscrasias is warranted. Inclusion criteria: All the patients diagnosed with
blood dyscrasias, including anaemia, thalassaemia,
Changes in the retina are the most common clinical
leukaemia and bleeding disorders; belonging to an
manifestation of Leukemic involvement of the eye.
age group of fewer than 70 years and giving consent
These manifestations include vascular sheathing and
for the complete ophthalmic examination.
tortuosity, pallor, haemorrhages and exudates, cotton
wool spots and neovascularization at the periphery Exclusion criteria: whereas pregnant females;
of the disc.7 The presence of ocular involvement is patients with the known ocular disorder; with a
associated with poor prognosis in acute childhood history of any ocular trauma due to RTA/head
leukaemia.8 Coagulative disorders such as Purpuras injury/ocular injury and not giving consent for the
can present with haemorrhages involving the whole study.
of the retina and vitreous in young girls, especially Detailed history regarding sociodemographic
those who suffer from Idiopathic thrombocytopenic variables such as age, gender, socioeconomic status
purpura.9 Sickle cell disease can present with lid etc., was obtained and entered the questionnaire.
edema, conjunctival sickling sign, iris atrophy, and
Clinical history regarding the blood dyscrasias,
iris neovascularisation and angioid streaks. In the
presence of ocular symptoms, time since diagnosis,
sickle cell, Thalassemia exudative and haemorrhagic
chemotherapy received, and other relevant information
changes have been found in the retina.10 Notably,
was obtained from all the study participants and
the incidence of proliferative retinopathy is highest
documented. The examination of the eyes was
in patients with HbSC or S-beta Thal, while patients
carried out at the bedside or in the eye department.
with HbSS have a 3% incidence of proliferative
Visual acuity was recorded using Snellen charts,
retinopathy.11
and refractive error was assessed. Anterior segment
Various reports indicate that there exists a examination was done using a slitlamp. Intrao-ocular
link between haematological abnormality and pressure was measured using schiotz tonometer and
ocular manifestations.8 Ocular manifestations applanation tonometer. Fundus examination was
of thrombocytopenia included papilloedema, done by slit-lamp biomicroscopy, binocular indirect
extraocular muscle palsies and visual field defects, ophthalmoscopy. Fundus Fluorescein angiography
which usually result in concomitant CNS findings. and fundus photography were done wherever
Retinal findings consist of hemorrhages, vascular indicated. Additional procedures including Fundus
occlusions and serous detachments. Fluorescein Angiography (FFA) and OCT, B- SCAN
of the eyes, central nervous system examination was
The present study was conducted to study the
done in cases suggested.
spectrum of ophthalmic manifestations in blood
dyscrasias and to assess the prevalence of ocular Further, all relevant hematological investigations
manifestations between acute and chronic blood like Hb%, TLC, DLC, peripheral smear, reticulocyte
malignancies. The study also aimed to correlate count, serum iron studies, bleeding and coagulation
ophthalmic findings in anaemia, thalassaemia, profile, serum iron studies were done in all the cases.
leukaemia, lymphomas and other bleeding disorders. Other routine investigations like serum electrolytes,
urine routine microscopy, blood sugar profiles
Material and Methods
were ordered wherever indicated. And appropriate
Patients with blood dyscrasias referred for complete hematological/ histopathological investigations
ophthalmic examination from the Department like bone marrow studies were ordered whenever
of Medicine and Paediatrics to Department of indicated.
Ophthalmology, Gujarat Adani Institute of Medical

Statistical analysis The majority of cases were males in our study

The recorded data was compiled and entered in a (52%). The mean age of patients was 27.8 years, and
spreadsheet computer program (Microsoft Excel the majority of patients belonged 0 to 10 years (29%),
2007) and then exported to data editor page of SPSS followed by 30 to 40 years (22%). (Table 1)
version 15 (SPSS Inc., Chicago, Illinois, USA). For all In patients with anemia, 57.14% of cases had normal
tests, confidence level and level of significance were results, whereas 37.14% had conjunctival pallor.
set at 95% and 5% respectively. However, in sickle cell anemia, conjunctival pallor
and comma sign was observed in 61.1% of cases each.
Results
Retinal Veinous Tortuosity was the most common
Out of 200 patients, anemia was the most common finding in Thalassemia. In contrast, Veinous Fullness
diagnosis observed in 70 (35%) cases, followed and Tortuosity, and subconjunctival hemorrhage
by sickle cell anemia 54 (27%). Out of 70 patients were the most common findings in patients with
with anemia, the majority of cases, i.e. 33, had iron leukemia and coagulation disorders, respectively.
deficiency anemia followed by 13 and 5 cases with (Table 2)
megaloblastic and aplastic anemia, respectively.
However, anemia secondary to other causes was The above table suggests that the most common
observed in 19 cases. Out of 54 patients with sickle findings in blood dyscrasias were pallor of the fundus
cell anemia, Sickle Cell Anaemia (Homozygous) Hb- and veinous tortuosity/ fullness. Both these findings
SS was seen in 27 (50%), Sickle Cell Trait (SC-As) in were observed in maximum proportions of cases with
18, Sickle Cell Disease-Thalassemia (ScThal) in 7 and anemia, sickle cell anemia and Thalassemia. However,
HbD (Punjab variant) were noted in 2 cases. Among retinal hemorrhages were the most common finding
18 patients, AML, ALL, CML and CLL were observed in leukemia, whereas Veinous Tortuosity/ Fullness
in 5, 3, 9 and 1 cases, respectively. were the most common finding in coagulation
disorders.
Table 1: Distribution of study participants according to sociodemographic variables

Variables Number Percentage (%)
Male 104 52
Gender
Female 96 48
0-10 58 29
11-20 44 22
21-30 46 23
Age (years) 31-40 44 22
41-50 30 15
51-60 6 3
>60 2 1
Table 2: Ophthalmic manifestations in various blood dyscrasias

Blood dyscrasias Ophthalmic finding Number Percentage (%)
Normal 40 57.14
Conjunctival Pallor 26 37.14
The pallor of fundus, Veinous Tortuosity/venous Fullness 25 35.7
Anemia (n=70) Flame Shaped Haemorrhages With White Centres 20 28.5
Superficial Haemorrhages With Cotton Wool Spots 7 10
Neo- Vascularisation 4 5.71
Subhyaloid Haemorrhage 3 4.2

88
Blood dyscrasias Ophthalmic finding Number Percentage (%)

Conjunctival Pallor 33 61.1
Conjunctival Sign (Comma Sign) 33 61.1
Normal 20 37.03
The pallor of fundus, Veinous Tortuosity/venous Fullness 32 59.25
Sickle cell anemia
Flame Shaped Haemorrhages With White Centers 26 48.1
(n=54)
Cotton Wool Spots 15 27.7
Retinitis Proliferans with Neovascularisation 3 5.5
Black Sunburst Sign 1 1.85
Vitreous Haemorrhage 3 5.55
Normal 19 47.5
Dry eye 4 10
Lenticular Opacities 3 7.5
Thalessemia Retinal Veinous Tortuosity 13 32.5
(n=40) Retinal Pigment Epithelium Changes(Degeneration/ 11 27.5
Mottling)
Defective Color Vision 3 7.5
Defective Visual Field 2 5
Normal 5 27.7
Orbital Involvement 1 5.5
Sub-Conjunctival Haemorrhage 1 5.5
Veinous Fullness and Tortousity 13 72.2
Leukemia (n=18)
Flame Shaped Haemorrhage with White Centers 9 50
Cotton Wool Spots 3 16.6
Pre-Retinal Haemorrhage 5 18
Papilloedema with Neo-Vascularisation Over Disc 3 16.6
Discussion and haemorrhages with central pallor suggestive of

Many studies and case reports highlighting the ocular Roth spots. It has been documented in the literature
manifestations of different blood dyscrasias are that fundus findings have been associated with a
present in the literature. However, the results shown profound fall of haemoglobin, and a critical level of
by them are not uniform and the significance of these 50% fall has been described by Ballantyne et al.14
changes and their relationship with hematological Out of 54 patients with sickle cell anemia, 33(61.1%)
parameters has been reported differently by various patients had conjunctival sign positive in them, and
studies.9-11 There are, however, certain common 20 of them belonged to SS, had AS, and 5 were cases
denominations in these diseases which predispose to of sickle- thalassemia trait. Cordon et al 15 reported
the formation of retinal lesion.12 corkscrew-like dilated conjunctival vessels in 74 out
The maximum number of patients had iron of 76 SS patients. They correlated this finding with
deficiency anemia which is a common factor in our irreversibly sickled cells.
country. Anemia was observed in patients with a mean The authors described retinitis proliferans to
age of 27.8 years with a slightly high male: female ratio. be common in HbC (SC) and auto- infarction in
In our study, around 39% of cases with anemia had homozygous (SS) disease. Meurs et al16 observed
retinopathy. Similarly, 28.35% and 22.5% of patients proliferative retinopathy in 2% of SS patients and 50%
had retinopathy in a survey by Rubenstein et al.12 and of SC patients. It led to vitreous hemorrhage in 18%
Merin et al13, respectively. The subsequent common and RD in 8% of cases.
finding comprised of flame-shaped haemorrhages

In this study, 18 cases with leukaemia were Ethical approval was taken from the institutional
enrolled, of which chronic leukaemia was found ethical committee and written
more in number than acute leukaemia. About 75% of
Informed consent was taken from all the
subjects had venous fullness and tortuosity, 50% of
participants.
patients had flame-shaped hemorrhage with white
centres, however, 16.6% had neovascularisation on Source of funding - Nil
the disc and cotton wool spots in the general fundus, Conflict of Interest: None declared
and 16.6% had bilateral papilloedema. Retinopathy
in leukemia was observed in 56% of Kataria et al17 References
and 44% cases by Holt et al18. The wide variation in 1. Pandharinath, Jakkal Tapan, Shitole Satish
incidence of ocular involvement in these studies may Chandrakant, and Jakkal Darpan Pandharinath.
be ascribed to majority of them being pathological Ophthalmic Manifestations Of Common
studies whereas ours was a clinical study. The figures Haematological Disorders. Journal of Evolution of
of retinal hemorrhages in all types of leukemia are Medical and Dental Sciences. 3;42(2014): 10510- 10517.
43% by various studies.19-21 [Crossref][PubMed][Google Scholar]
Most common ocular finding in patients with 2. Mosby’s dental dictionary, 2nd edition. 2008 elsevier,
Thalassemia was retinal veinous tortuosity followed inc.
by retinal pigment epithelium changes. Similar 3. API textbook of medicine, 9th edition, volume I,
findings were observed by Jafari et al.22in which section 15, chapter 2 (anemia- A clinical approach, pg
ocular findings such as the dry eye, cataract, retinal 922, authors- Renu Saxena, M Mahapatra.
pigment epithelium degeneration, colour vision 4. Singh AD. The prevalence of ocular disease in chronic
deficiency and visual field defects were detected lymphocytic leukaemia Eye (Lond). 2003;17:3–4.
in 69% of the thalassemic group. Barteselli et al.23
5. Russo V, Scott IU, Querques G, Stella A, Barone A, Delle
reported ocular fundus abnormalities characteristic
Noci N. Orbital and ocular manifestations of acute
of pseudoxanthoma elasticum (PXE) in 70 of 255
childhood leukemia: Clinical and statistical analysis of
patients (27.8%) with Thalassemia. These findings 180 patients Eur J Ophthalmol. 2008;18:619–23.
were supported by Sodhi et al24, in which the authors
stress subconjunctival bleeding as the first presenting 6. Omoti CE, Awodu OA, Bazuaye GN. Chronic lymphoid
clinical feature in ITP. Retinal hemorrhages were leukaemia: Clinico-haematological correlation and
outcome in a single institution in Niger Delta region of
noted in around 44 % of the cases in our study. This
Nigeria Int J Lab Hematol. 2007;29:426–32.
was in agreement with several studies. 11,25
7. Eze BI, Ibegbulam GO, Ocheni S. Ophthalmic
Conclusion manifestations of leukemia in a tertiary hospital
The ocular changes of blood dyscrasias are not population of adult Nigerian Africans Middle East Afr
uncommon as is proved by various clinical and J Ophthalmol. 2010;17:325–9.
pathological studies. These changes in the eye are 8. Omoti AE, Omoti CE, Momoh RO. Ocular disorders in
due to the hemorrhagic effect of the blood disorders adult leukemia patients in Nigeria Middle East Afr J
or due to the infiltration of the ocular tissues by Ophthalmol. 2010;17:165–8.
malignant cells. Ophthalmic manifestations are 9. Lang GE, Spraul CW, Lang GK. Okuläre Veränderungen
commonly observed in patients with blood dyscrasia. bei hämatologischen Grunderkrankungen [Ocular
The routine ocular examination must be conducted changes in primary hematologic diseases]. Klin Monbl
in blood dyscrasias; especially posterior segment Augenheilkd. 1998 June;212(6):419-27. German. doi:
evaluation should be mandatory in severe anaemia/ 10.1055/s2008-1034925 [Crossref][PubMed][Google
sickle cell haemoglobinopathy and leukaemia, which Scholar]
is both diagnostic and prognostic of the severity of this 10. Srinivasan M, Chakrabarti A, Chakrabarti M. Expulsive
disease. Also, there is a need to develop a standard haemorrhage in a case of thrombocytopenic purpura.
referral protocol between the haematology clinic and Indian J Ophthalmol. 1996 Mar;44(1):44-5. [Crossref]
the eye clinic so that blood dyscrasia patients can [PubMed][Google Scholar]
have periodic evaluations.

90
11. Majji AB, Bhatia K, Mathai A. Spontaneous bilateral 19. M. Baccarani. European LeukemiaNet
peripapillary, subhyaloid and vitreous hemorrhage recommendations for the management of chronic
with severe anemia secondary to idiopathic myeloid leukemia Blood, 2013 122 (2013), pp. 872-884.
thrombocytopenic purpura. Indian J Ophthalmol. 2010
20. Rane PR, Barot RK, Gohel DJ, Bhagat N. Chronic
May-Jun;58(3):234-6. doi: 10.4103/0301-4738.62651
Myeloid Leukaemia Presenting as Bilateral Retinal
[Crossref][PubMed] [Google Scholar]
Haemorrhage with Multiple Retinal Infiltrates.
12. Serjeant GR, Serjeant BE, Condon PI. The J Clin Diagn Res. 2016;10 ND04-05. doi:10.7860/
conjunctival sign in sickle cell anemia, A relationship JCDR/2016/18215.7822.
with irreversibly sickled cells. JAMA. 1972 Mar
21. Rudolph G, Haritoglou C, Schmid I, Hochhaus F,
13;219(11):1428-31. [Crossref][PubMed][Google
Kampik A. Visual loss as a first sign of adult-type
Scholar]
chronic myeloid leukemia in a child. Am J Ophthalmol.
13. Merin S, Freund M. Retinopathy in severe anemia. Am J 2005;140:750–1.
Ophthalmol. 1968 Dec;66(6):1102-6. doi: 10.1016/0002-
22. Jafari R, Heydarian S, Karami H, Shektaei MM,
9394(68)90818-0 [Crossref] [PubMed][Google Scholar]
Dailami KN, Amiri AA, et al. Ocular abnormalities in
14. Ballantyne, Arthur James, and Isaac Chesar multi-transfused beta-thalassemia patients. Indian J
Michaelson. Textbook of the Fundus of the Eye. Ophthalmol. 2015 Sep;63(9):710-5. doi: 10.4103/0301-
Churchill Livingstone. 1970. [Crossref][PubMed] 4738.170986 [Crossref][PubMed] [Google Scholar]
[Google Scholar]
23. Barteselli G, Dell’arti L, Finger RP, Charbel Issa P,
15. Condon PI, Serjeant GR, Ikeda H. Unusual chorioretinal Marcon A, Vezzola D, et al. The spectrum of ocular
degeneration in sickle cell disease, Possible sequelae alterations in patients with β-thalassemia syndromes
of posterior ciliary vessel occlusion. Br J Ophthalmol. suggests a pathology similar to pseudoxanthoma
1973 Feb;57(2):81-8. doi: 10.1136/bjo.57.2.81 [Crossref] elasticum. Ophthalmology. 2014 Mar;121(3):709-18.
[PubMed] [Google Scholar]
24. Sodhi PK, Jose R. Subconjunctival hemorrhage:
16. van Meurs JC. Visusbedreigende oogafwijkingen the first presenting clinical feature of idiopathic
bij patiënten met sikkelcelziekte op Curaçao thrombocytopenic purpura. Jpn J Ophthalmol.
[Visionthreatening eye manifestations in patients with 2003 May-Jun;47(3):316-8. doi: 10.1016/s0021-
sickle cell disease on Curaçao]. Ned Tijdschr Geneeskd. 5155(03)00017-0 [Crossref][PubMed][Google Scholar]
1990 Sep 15;134(37):1800-2. Dutch [Crossref][PubMed]
25. Turaka K, Shields CL, Bianciotto C, Shields JA. Vitreous
[Google Scholar]
hemorrhage as the initial manifestation of idiopathic
17. Kataria VC, Audich KL, Narang SK, Khamar BM. thrombocytopenic purpura. Retin Cases Brief Rep. 2012
The fundus findings in blood dyscrasias. Indian Winter;6(1):16-8. doi: 10.1097/ICB.0b013e3181f7f75d
J Ophthalmol. 1983;31 Suppl:899-902. [Crossref] [Crossref][PubMed] [Google Scholar]
[PubMed][Google Scholar]
18. Holt JM, Gordon-Smith EC. Retinal abnormalities
in diseases of the blood. Br J Ophthalmol. 1969
Mar;53(3):145-60. doi: 10.1136/bjo.53.3.145 [Crossref]

A Comparative Study of Hernioplasty With Suction Drain and

Without Suction Drain in Inguinal Hernias at Tertiary Care Hospital
D. Ramesh
Associate professor, Department of General surgery, Osmania general hospital, Hyderabad
How to cite this article: D. Ramesh et al A Comparative Study of Hernioplasty With Suction Drain and Without
Suction Drain in Inguinal Hernias at Tertiary Care Hospital. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Inguinal hernia occurs in about 15% of adult population and inguinal hernia repair is one of the most
commonly performed surgical procedure. In the era of minimal invasive surgery, hernia repair has seen a paradigm shift
from open to laparoscopic technique.
Objectives: To assess the outcome of drain placement Vs no drain use, in patients undergoing open mesh repair of
inguinal hernias.
Methods: This is a prospective study comprising of 50 patients of inguinal hernia over a period of 23 months. The patients
were randomized into 2 groups – With and without the use of drains. The patients underwent open inguinal hernia mesh
repair by a standardized method. The outcome of seroma formation, hematoma formation, infection at surgical site, and
duration of hospital stay was recorded and analyzed.
Results: In the present study 16% of cases in drainage group and 20% in non-drainage group developed post operative
wound infection. P value is insignificant. The mean post operative hospital stay in drainage group was 9.7 days and in
non-drainage group was 6.7 days.
Conclusion: The early post operative complications like seroma, hematoma, wound infection rates are similar in both
drainage and non-drainage groups. So, it appears that suction drain usage can be restricted in Lichtenstein’s tension free
mesh repair in simple inguinal hernias unless hernia is complicated or there is extensive dissection
Keywords: Hernioplasty, Inguinal Hernias, Seroma, Lichtenstein
Introduction of inguinal hernias has equalled to the technological

Hernia is defined as a protrusion of a viscus or a developments in this field. The most significant
part of a viscus through an abnormal opening in the advances to impact inguinal hernia repair have been
walls of its containing cavity.1 Most commonly seen the addition of prosthetic materials to conventional
in the inguinal region followed by paraumbilical/ tissue repairs.2
incisional hernia. Inguinal hernia occurs in about The laparoscopic inguinal hernia repair includes
15% of adult population and inguinal hernia repair Totally Extraperitoneal approach (TEP)/Trans
is one of the most commonly performed surgical Abdominal Preperitoneal approach(TAPP).3
procedure. In the era of minimal invasive surgery, Following introduction of mesh for hernia repair,
hernia repair has seen a paradigm shift from open to newer measures focus on post hernioplasty pain
laparoscopic technique. Evolution in the treatment syndrome, quality of life and return to normal
B. Moksha prasuna,
92
activities .They show although laparoscopic operation Inclusion Criteria:

takes longer to perform, proven advantages are 1. Age >18 years of age
reduced pain both following surgery, more rapid
2. Patients giving consent for participation in
return to full activity and reduced chance of wound
the study.
complications. They commonly occur due to pre-
existing risk factors which include age, obesity, 3. Patients fit for surgery.
chronic obstructive pulmonary disease (especially 4. All patients with reducible non obstructive
emphysema), diabetes mellitus, smoking, drug direct or indirect inguinal hernia
intake around the time of surgery (like steroids),
infection at the surgical incision site. The prosthetic Exclusion criteria:
materials available for inguinal hernia repair may be
1. Patients not willing to participate in the study
of Biological or Synthetic type. Because of various
factors, like the increased cost and non- availability, 2. Patients not fit for surgery.
the biological mesh use is very less. The synthetic 3. All the patients with irreducible or obstructed
materials are used more frequently.4 or recurrent inguinal hernias.
Available synthetic meshes include polypropylene All patients fitting the inclusion criteria for the
(Prolene, Marlex),expanded PTFE (Gore-tex) and study were. Data collection was done in the ward.
polyester Prolene mesh is the most commonly used The patients were planned for an ultrasound between
material in our institute for open repair of inguinal 7-10 days, and necessary arrangements done.
hernias. Regardless of the technique employed in
In order to assess the outcome of patients
open repair of inguinal hernias the use of drains
undergoing open inguinal hernia mesh repair, with
is almost universal, especially for large hernias.
and without the use of drains, the patients were
Insertion of drain is usually to evacuate the blood and
randomized into 2 groups – With and without the
fluid collection, which might happen in the potential
use of drains. The patients underwent open inguinal
space created, and to allow tissue apposition and
hernia mesh repair by a standardized method. The
better healing. Hence traditional teaching tells us
outcome of seroma formation, hematoma formation,
that drains reduce the accumulation of fluid and
infection at surgical site, and duration of hospital stay
blood, which reduce the incidence of postoperative
were recorded and analyzed.
hematoma, seroma and wound infection, and thereby
reduce the recurrence of inguinal hernia.5
Intraoperative procedure
However, many have found no discernable benefit – Open Inguinal Hernia repair.
of the insertion of drains, while others have in fact
found a better outcome without the insertion of – Polypropylene Mesh (Ethicon) used.
drains. The proponents of no-drain insertion also – Skin to be closed by 3-0 Prolene.
argue that the complications of inserting a drain can
Postoperatively, they were followed up in the ward
be avoided.
by examination of the wound following dressing
Materials and Methods removal prior to discharge. In the out-patient
Study design: Comparative study. department, they were reviewed at the first outpatient
department visit. An ultrasound examination was
Setting: Department of General Surgery, Osmania done for patients who did not have wound gaping or
General Hospital, Hyderabad. Study population: intervention or a clinically obvious seroma.
Patients admitted to department of General Surgery
during the period of the study. Statistical methods: Data entry was done using the
Epidata software version 3.1. Descriptive statistics
Study period: 18 months From 14th october 2019 to were computed with use of the SPSS software (version
5th december 2021. 21). Sample size was calculated. Data Analysis
Sample size: This is a prospective study comprising was done using SPSS software and p values were
of 50 patients of inguinal hernia over a period of 23 computed with Pearson’s Chi square.
months

Observation and Results TYPE HEMA- NO PER-

Table 1: Distribution based on Age group TOMA HEMATO- CENT-
MA AGE
AGE GROUP NO. OF CASES PERCENTAGE
Non-drainage 1 24 4%
10-20 1 2% group
21-30 8 16%
TYPE SERO- N0 SEROMA
31-40 8 16% MA
41-50 10 20% Drainage group 3 22 12%
51-60 15 30%
Non-drainage 3 22 12%
61-70 7 14% group
71-80 1 2%
In our study 0% and 4% of patients developed
Over the period of study only male patients hematoma in drainage and non-drainage group. The
presented with inguinal hernia. The age of patients difference was statistically insignificant (p-value>
ranged between 18 to 80 years. In the study majority 0.05)
of patients presented between 50-60 years of age.
Table 5: Distribution based on Post-operative
complications and hospital stay
Table 2: Type and location of Hernia
TYPE INFEC- NO IN- PERCENT-
TYPE NO.OF CASES PERCENTAGE TION FECTION AGE
DIRECT 21 42% Drainage
4 21 16%
INDIRECT 29 58% group
BOTH 0 0% Non-drainage
5 20 20%
LOCATION group
RIGHT 25 50% Hospital stay
LEFT 22 44% Average
9.1 6.7
hospital stay
BOTH 3 6%
In the present study 16% of cases in drainage group
In the present study 42% cases were of direct type
and 20% in non-drainage group developed post
and 58% cases were of indirect type. In present study
operative wound infection. P value is insignificant.
56% cases had right sided hernias and 44% had left
sided. In the present study, patients in drainage group
mean post operative hospital stay is 9.7 and in non-
Table 3: Distribution based on pain
drainage group is 6.7 days.
TYPE C/O OF No Percentage
PAIN Significant Discussion
pain The use of drains in elective surgery appears to
Drainage group 8 17 32% be a never ending story. The increasing use of
Non-drainage 2 23 8% minimally invasive techniques for hernia repair
group has raised new interest in reducing discomfort after
open hernia repair. Such discomfort may be in part
In drainage group pain was seen in 8 patients as
may be due to insertion of drains into wound area.
compared to 2 in non-drainage group.
Another though slightly minor issue is the need for
Table 4: Distribution based on Hematoma and drains regarding to treatment cost. Finally may be
Seroma group undesirable when surgery needs to be performed as
an outpatient procedure. On the other hand all of us
TYPE HEMA- NO PER-
TOMA HEMATO- CENT- recall patients with large and unpleasant seromas and
MA AGE hematomas following hernia repair. Such seromas
and hematomas may cause considerable discomfort
Drainage group 0 25 0%
and embarrassment to the surgeon. PAIN Residual

94
neuralgia following Lichtenstein meshplasty complications are comparable. In our present study
represents the mosting vexing complication in the the mean hospital stay in case of drainage group is
inguinal region. In some cases, the post operative 9.1days whereas in non-drainage group is 6.7days
pain can be debilitating requiring re-exploration
In a previous study, post operative hospital stay is
and divising of the nerves. In the present study
2.9 days in drainage group and 1.48 days in the non-
only immediate post operative pain was evaluated.6
drainage group which is statistically significant.10
32% of patients in the drainage group complained
of pain whereas 8% of patients complained of pain Conclusion
in non drainage group. P value being less than 0.05, The early post operative complications like pain,
difference was significant. In a previous study, mean post operative stay in hospital is increased in
there was no significant difference in pain following Lichtenstein’s with drainage group. The early post
Lichtenstein mesh hernioplasty with and without operative complications like seroma, hematoma,
drains(95%vs90%). Here p value is insignificant.7 wound infection rates are similar in both drainage
Hematoma: Bleeding from either artery or vein and non-drainage groups. So, it appears that suction
may result at all anatomic levels during an inguinal drain usage can be restricted in Lichtenstein’s tension
hernia repair resulting in hematoma formation. In our free mesh repair in simple inguinal hernias unless
study 0% and 4% of patients developed hematoma in hernia is complicated or there is extensive dissection
drainage and non-drainage group respectively. The Ethical Clearance: The ethical clearance was
difference was insignificant (p value >0.05). obtained from Osmania Medical College and General
Seroma: In the present study 12% of patients Hospital prior to the commencement of the study.
in drainage group developed seroma and 12% of Conflict of Interest: Nil
patients in non-drainage group developed seroma.
Studies concerning post operative drainage to
prevent seroma are contradictor. In two RCTs of References
patients following open intervention, no advantage 1. Lichtenstein IL, Shulman AG, Amid PK, Montllor
was observed. The risk of seroma is rarely big MM. The tension-free hernioplasty. Am J Surg.
enough to necessitate leaving a drain, except in a 1989;157(2):188-93.
case of excessive diffuse blood loss or patients with
2. Palanivelu C. Result of hand sutured laparoscopic
coagulopathies.8 hernioplasty: an effective method of repair. Indian
Infection: Infection represents a dreaded Journal of Surgery 2000;62(5):339-41.
complication for all types of surgeries and it is no 3. Simchen E, Rozin R, Wax Y. The Israeli Study of
difference in inguinal hernia surgeries. Inguinal hernia Surgical Infection of drains and the risk of wound
surgeries complicated by infections have a higher rate infection in operations for a hernia. Surg Gynecol
of recurrence as the repairs are destroyed along with Obstet. 1990;170(4):331-7.
the tissues. Furthermore, it is important to recognize 4. Kuo YC, Mondschein JI, Soulen MC, Patel AA, Nemeth
superficial from deep infections as deep infections are A, Stavropoulos SW et al. Drainage of collections
ominous and requires removal of mesh. In the present associated with hernia mesh: is it worthwhile? J Vasc
study 16% of cases in the drainage group and 20%of Interv Radiol. 2010;21(3):362-6 Oonwala ZG. Inguinal
patients in the non-drainage group developed post Hernia Repair: Past & Present. Pak J Surg 2005; 21(2):
operative superficial wound infection. None of the 54-55.
patients required removal of mesh. 5. Moro ML, Carrieri MP, Tozzi AE, Lana S, Greco D,
The risk increased with increased duration of Risk factors for surgical wound infections in clean
wound drainage. In a previous study presence of risk surgery: a multicenter study. Italian PRINOS Study
factors for wound infection based on surgery are the Group. Ann Ital Chir. 1996;67(1):13-9.
use of drains and the use of antibiotic prophylaxis.9 6. Mohammad S, Molaei H, Jalali A. The effects of
Hemovac on short term outcomes of Lichtenstein
Post operative hospital stay: In the fast paced life
herniorrhaphy. Med Sci J Islamic Azad University.
of today, duration of mean hospital stay after surgery 2011;21(1):44-9.
may be the determining factor when the rates of other

7. Mahmudlu R. Investigating the short-term 9. Saratzis A, Soumian S, Willetts R, Rastall S, Stonelake

complications of drainage appliance post inguinal PS. Use of multiple drains after mastectomy is
hernia repair operation with Lichtenstein’s method in associated with more patient discomfort and longer
patients admitted to surgery ward of Imam Khomeini postoperative stay. Clin Breast Cancer. 2009;9(4):243-6
hospital. Urmia Med J. 2011;22(1):48-52.
10. Rodrigues AJ Jr, Jin HY, Utiyama EM, Rodrigues CJ.
8. Perkins SW, Williams JD, Macdonald K, Robinson EB. The Stoppa procedure in inguinal hernia repair: to
Prevention of seromas and hematomas after face-lift drain or not to drain. Rev Hosp Clin Fac Med Sao
surgery with the use of postoperative vacuum drains. Paulo. 2003;58(2):97-102
Arch Otolaryngol Head Neck Surg. 1997;123(7):743-5

A Study of Enhanced View Total Extraperitoneal Laparoscopic

Hernioplasty (E-tep) For Inguinal Hernia In Tertiary Care Hospital
D. Ramesh
How to cite this article: D. Ramesh et al A Study of Enhanced View Total Extraperitoneal Laparoscopic Hernioplasty
(E-tep) For Inguinal Hernia In Tertiary Care Hospital. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Generally, TAPP and TEP has been done, but it gives both technically less space to surgery and there is a
need to suture the mesh. In our new study we get more space to operate and no sutures required.
Objectives: To study enhanced view total extraperitoneal laparoscopic hernioplasty (e-tep) for inguinal hernia
Methods: The data for this prospective study was obtained from 21 patients undergoing Laparoscopic hernioplasty
(21 from E-TEP) in Osmania General Hospital, Hyderabad, Telangana between November 2019 to May 2021 inclusive
of a follow up period of 6 months. Consent for the procedure was obtained. E-TEP procedure were performed using
Polypropylene mesh.
Results: Minor complication rate was 26.66% for ETEP group. There was one case of converted from ETEP to TAPP
method. The recurrence in E-TEP is zero. The hospital stay in E-TEP was 2.27 days.
Conclusion: ETEP is the best method of hernioplasty for a primary inguinal hernia. However largescale study and long
term follow up studies are required.
Keywords: ETEP, TEP, Lichenstein Meshplasty, Inguinal Hernia.
Introduction avoidance of chronic pain have become the most

Inguinal hernia the most common abdominal wall important considerations in hernia repair.3
hernia and consequently inguinal hernia repair rank Approximately 70% of femoral hernia repairs are
among one of the most often performed surgical performed in women; however, inguinal hernias
procedure. It is estimated that more than 20 million are five times more common than femoral hernias.
groin hernia repairs are performed every year The most common subtype of groin hernia in men
worldwide.1 Despite the frequency of this procedure and women is the indirect inguinal hernia. Inguinal
no surgeon has ideal results and complications such hernias form because of a defect in the myopectineal
as postoperative pain, infection, early return to work, orifice that allows intra-abdominal contents to
recurrence remain.2 protrude into the groin. The anatomy can be difficult
Advancements in perioperative anesthesia and to grasp, however, before performing inguinal
operative technique have made this an outpatient hernioplasty, the surgeon must understand inguinal
ambulatory operation with low recurrence rates and anatomy to avoid complications such as chronic pain
morbidity. Given this success, quality of life and the and recurrence.4
B. Moksha prasuna
Five laparoscopic techniques are currently Table 1: Distribution based on Age Distribution.
available for repairing an inguinal hernia: totally
Age Distribution Number(n) Percentage
extraperitoneal (TEP) repair, extended view totally
(yr) (%)
extraperitoneal (ETEP), transabdominal preperitoneal
21-30 6 28.57%
(TAPP), intra-peritoneal on lay mesh (IPOM), and
reduction of the sac with or without closure of the 31-40 3 14.2%
ring.5 It is our philosophy that surgeons interested 41-50 4 19.04%
in a laparoscopic approach should be skilful in all of 51-60 3 14.2%
the available techniques to accommodate the needs 61-70 3 14.2%
of all patients and to be able to convert to a different
>70 2 9.52%
technique when necessary.
Total 21 100%
Materials and Methods
The cumulative prevalence of inguinal hernia
Study design: Prospective observational study. in males is 28.56% for age 21-30yrs,14.2% for age
Study setting: Upgraded department of general 31-40yrs,19.04% for age 41-50yrs ,14.2% for age 51-
surgery, Osmania general hospital. 60yrs,14.2% for age 61-70yrs, 9.52% for age >70yrs.
Inguinal hernias occurs eight time as often in men as
Duration of study: 18 months. in women and consequently approximately 90% of all
Sample size: 21 inguinal hernias repair performed in male patients.
Table 2: Distribution based on Side and type of
Inclusion criteria:
hernia
1. All age groups in males.
Side of Hernia Number(n) Percentage (%)
2. All inguinal hernias include. Rt. Side 12 57%
a) Direct & indirect Lt. Side 9 43%
b) Complete and incomplete Type of Hernia
c) Reducible Direct 6 29%

Indirect 15 71%
Exclusion criteria:
Among 21 cases studied 12 cases were found to
a) Patients who are unfit for general anesthesia. have inguinal hernia whereas 9 cases were left sided
b) Previous history of pelvic surgeries. hernia.
The data for this prospective study was obtained Among 21 cases studied, 15 cases had Indirect
from 21 patients undergoing Laparoscopic inguinal hernia and 6 had direct inguinal hernia.
hernioplasty (21 from E-TEP) in Osmania General Although all cases were preoperatively evaluated
Hospital, Hyderabad, Telangana between November most of the diagnosis on the type of hernia was made
2019 to May 2021 inclusive of a follow up period intra operatively.
of 6 months. Consent for the procedure was
Diabetes was the common comorbidity in the
obtained. E-TEP procedure were performed using
present study group, other comorbidities include
Polypropylene mesh.
systemic hypertension
Statistical analysis: The SPSS 22 software was used
to analyze and the data was presented in the form of Intraoperative complications:
means and percentages. Intraoperative complications like major vessel injury
or bladder injury were observed. No intraoperative
Observation and Results complications were encountered during the study
The study was conducted at Osmania general hospital period in the above 21 cases.
from November 2019 to May 2021 in Department of
general surgery. The study involved 21 male patients
Duration of surgery:
who satisfied inclusion criteria. 21 patients were The Duration of surgery was observed to be longer for
subjected to ETEP repair. indirect hernia and shorter in direct hernia. Shortest

comorbidities include systemic hypertension
Intraoperative complications:
Intraoperative complications like major vessel injury or bladder injury were
observed. No intraoperative complications were encountered during the study
period in the above 21 cases.
98
Duration of surgery:
The Duration of surgery was observed to be longer for indirect hernia and shorter
duration recorded is 90 minutes and longest is around
in direct hernia. Shortest duration recorded is 90 minutes and longest is around
significant lifetime incidence and variety of successful
120 minutes.
120 minutes. Mean
Mean duration duration
of surgery ofissurgery
in ETEP in ETEP is 100
100 minutes. treatment modalities. Advancements in perioperative
minutes. anaesthesia and operative technique have made
Post operative pain
this an outpatient ambulatory operation with low
recurrence rates and morbidity. Given this success,
quality of life and the avoidance of chronic pain have
become the most important considerations in hernia
repair.
Approximately 75% of abdominal wall hernias
Patients in serial number occur in the groin. The lifetime risk of inguinal
Figure 1: Post operative pain hernia is 27% in men and 3% in women.6 Of inguinal
Figure 1: Post operative pain
The post-operative pain was measured using Visual Analog Scale (VAS) 6 hours
hernia repairs, 90% are performed in men and 10% in
The
after the post-operative
surgery. The patient waspain
given was
a dosemeasured using Visual
of Injection Tramadol 100mg in women.7 The incidence of inguinal hernias in males
Analog
after the surgery. Scale
The next(VAS) 6 hourswasafter
dose of analgesic given the
basedsurgery.
on the VAS The
score. has a bimodal distribution, with peaks before the first
ETEP patient
procedurewas
mean given a dose
post operative ofisInjection
pain Tramadol
5.76 which is usually less. 100mg year of age and after age 40. Abramson demonstrated
in after the surgery. The next dose of analgesic was the age dependence of inguinal hernias in 1978.8
Seroma
given based Number(n)
on the VAS Percentage (%)
score. ETEP procedure mean Those age 25 to 34 years had a lifetime prevalence rate
Seroma 2 10%
post operative
Normal pain is 5.76
19 which is usually
90% less. of 15%, whereas those age 75 years and over had a
Table 3: Distribution based on Seroma rate of 47%.9
Table 3: Distribution based on Seroma
Primary unilateral inguinal hernias without
Seroma Number(n) Percentage (%) complications can be treated with ETEP.10 Although
Seroma 2 10% no major intraoperative complications were noticed
Normal 19 90% in present study, literature shows evidence of major
vessel organ damage, even mortality following
Post operative seroma was observed only in 2 cases.
laparoscopic procedure. ETEP has lesser complication
This cause prolonged hospital stays and prolonged
rates and early discharge and early return to work
antibiotic usage and late return to work. Seroma was
and less post operative pain.11 Hence according to the
subsided within 1 month completely.
present study ETEP is the best method of hernioplasty
Hematoma: Post operative hematoma were for a primary inguinal hernia. However, large scale
observed. There is no post operative hematoma seen. studies and long-term follow-up studies are required
to evaluate for the chronic pain, recurrence rates
Port site infection: Post operative port site infection
and learning curve in laparoscopic hernia repair.12
were observed. There is no single case of port site
Our study supports the view that ETEP repair of
infection seen.
inguinal hernia is safe and efficacious, but long-term
Length of hospital stay (time of discharge): Length Randomised Control Trials with enhanced sample size
of hospital stay usually less in ETEP procedure with and reduced confounding factors are still required to
mean duration is 2.28 days. In ETEP we can discharge standardize the procedure of ETEP.
early.
Conclusion
Time to return to work: Time taken to return for
ETEP is the best method of hernioplasty for a primary
work is depend on variable factors like profession
inguinal hernia. However largescale study and long
and patient related factors. ETEP mean time taken to
term follow up studies are required.
return for work is 7.7 days.
Ethical Clearance: The ethical clearance was
Recurrence: Post operative recurrence were
obtained from Osmania Medical College and General
observed. there is no single of recurrence is seen in
Hospital prior to the commencement of the study.
follow up period.
Conflict of Interest: Nil
Discussion
Inguinal hernia repair is one among the most
commonly performed operation in India, owing to a

References 7. Daes J. The enhanced view-totally extraperitoneal

technique for repair of inguinal hernia. Surg Endosc.
1. Mitura K, Skolimowska-Rzewuska M, Rzewuska
2012;26:1187–9.
A, Wyrzykowska D. Is mesh always necessary in
every small umbilical hernia repair? Comparison of 8. Radu VG, Lica M. The endoscopic retromuscular
standardized primary sutured versus patch repair: repair of ventral hernia: the eTEP technique and early
retrospective cohort study. Hernia. 2020 Mar 19; results. Hernia. 2019;23:945–55.
2. Mitura K, Skolimowska-Rzewuska M, Garnysz K, et 9. Ramana B, Arora E, Belyansky I. Signs and landmarks
al. Outcomes of bridging versus mesh augmentation in eTEP Rives-Stoppa repair of ventral hernias. Hernia.
in laparoscopic repair of small and medium midline 2020 May 18;
ventral hernias. Surg Endosc. 2017;31:382–8
10. Sikar H, Çetin K. The influence of mesh removal
3. Rives J, Pire JC, Flament JB, et al. Treatment of large during laparoscopic repair of recurrent ventral hernias
eventrations (apropos of 133 cases) Minerva Chir. on the long-term outcome. Videosurgery Miniinv.
1977;32:749–56. 2019;14:366–73.
4. Stoppa RE. The treatment of complicated groin and 11. Blatnik JA, Brunt LM. Controversies and techniques
incisional hernias. World J Surg. 1989;13:545–54. in the repair of abdominal wall hernias. J Gastrointest
Surg. 2019;23:837–45.
5. Belyansky I, Zahiri HR, Park A. Laparoscopic
transversus abdominis release, a novel minimally 12. Fiori F, Ferrara F, Gobatti D, et al. Surgical treatment of
invasive approach to complex abdominal wall diastasis recti: the importance of an overall view of the
reconstruction. Surg Innov. 2016;23:134–41. problem. Hernia. 2020 Jun 20;
6. Belyansky I, Reza Zahiri H, Sanford Z, et al. Early
operative outcomes of endoscopic (eTEP access)
robotic-assisted retromuscular abdominal wall hernia
repair. Hernia. 2018;22:837–47.

Burden of Overweight and Obesity Among Secondary and Senior

Secondary Students of New Delhi Municipal Council Schools
Thilagar M1, Poornima Tiwari2

1
Post Graduate Student, Dept. Of Community Medicine, VMMC & Safdurjung Hospital, New Delhi
2
Director Professor, Department of Community medicine, VMMC & Safdurjung hospital
How to cite this article: Thilagar M, Poornima Tiwari et al Burden of Overweight and Obesity Among Secondary and
Senior Secondary Students of New Delhi Municipal Council Schools. Volume 13 | Issue 4 | October-December 2022
Abstract
Introduction: Obesity is an emerging global public health problem of concern. Importantly, 50 to 80 percent of obese
children grow up to be obese adults, and all adult obesity issues are exacerbated if obesity begins in childhood. This study
was done to assess the prevalence of obesity among adolescents and the influence of the risk factors causing obesity.
Methodology: This was a cross-sectional study of 244 students of grade 9th to 12th in schools under NDMC. WHO BMI
growth charts were used to categorize the BMI. Statistical analysis was using licensed SPSS software version 21.0.
Results: The mean BMI among the participants was found to be 19.8 kg/m2 (SD+3.89). Majority (153, 62.7%) had a
normal BMI, 29(11.9%) were overweight and 7(2.9%) were obese. The prevalence of obesity/overweight among study
participants was lower in vegetarians. Students who skip their meals daily were at increased risk of being obese as
compared to those who skip rarely or never and the results were statistically significant (AOR 3.165 CI 1.173 – 8.544 p=
0.023).The mean physical activity score of the overweight/obese was 2.21(SD±0.804) as compared to the mean score of
2.27(SD±0.745) among the non-obese/overweight.
Conclusion: The result of this study indicates that the overweight and obesity is highly prevalent among adolescents.
There was an significant association between type of diet, skipping of meals, religion, mother’s education and overweight/
obesity.
Keywords: childhood, obesity, overweight, physical activity, adolescence.
Introduction and increasing urbanization. Childhood obesity is not

Obesity is an emerging global public health problem only restricted to industrialised countries, as even the
of concern. Obesity is defined “as a condition of developing countries also experience a higher rates of
abnormal or excessive fat accumulation in adipose the condition. Over the last few decades, substantial
tissue, to the extent that health may be impaired”.1 socioeconomic changes and new behavioural patterns
The fundamental root of obesity and overweight is have evolved in developing countries, affecting
the energy disparity between calories consumed and nutritional patterns. Few of the studies have reported
calories burnt. Globally, it has been observed that an that BMI is 25–40% heritable.2 The genetic factor
increased consumption of energy-dense foods that accounts for less than 5% of childhood obesity.2
are rich in fat and carbohydrates and an decrease in Nevertheless , genetic susceptibility commonly needs
physical activity due to the evolving sedentary nature to be coupled with behavioural and environmental
of many forms of work, changing modes of transport, factors in order to alter weight.2
Dr. Thilagar M,
Post Graduate student, Dept. Of Community Medicine, VMMC & Safdurjung Hospital, New Delhi,
e-mail id: [email protected]
Against this background, this study was conducted data and dietary practices such as type of diet,
in New Delhi to assess the prevalence of obesity skipping of meals, coffee/tea intake, intake of fruits
among adolescents and the influence of the risk and vegetables, junk foods and soft drinks was
factors causing obesity. We had also determined the obtained. Then briefing about the self-administered
modifiable factors and preventive measures of obesity physical activity questionnaire was given and doubts
at the end of the study. were clarified. The students were given 15 mins of
time to fill the questionnaire. Finally anthropological
Materials and Methods measurements were taken along with physical
The study was conducted in New Delhi school examination and at the end of the session, all the
students of 9th to 12th grade and aimed to find out the students were made aware of ill effects of consuming
prevalence of obesity along with factors associated junk foods and the importance of physical activity and
with it. healthy food intake. If the student were categorised
under obesity or overweight he/she was given proper
Study Design, Sampling:
health education, dietary recommendation and was
The study was a school based cross-sectional study advised for medical management if it was needed.
carried out among adolescents including 9th to 12th
WHO BMI growth charts were used to categorize
grade students in the schools under New Delhi
the students. These growth curves are closely aligned
Municipal Council from November 2019 to April
with the WHO Child Growth Standards at 5 years,
2021. Pretesting, modification of the questionnaire
and the recommended adult cut-offs for overweight
and ground work for data collection was done within
and obesity at 19 years. It fills the gap in growth
this period. The study population was selected
curves and provide an appropriate reference for the
using simple random sampling. According to the
5 to 19 years age group.4 The operational definitions
study conducted by Melissa H Stigler in Delhi the
combined prevalence of overweight and obesity was used in the study are enlisted: BODY MASS INDEX:
16.6%.3 So, taking the prevalence as 16.6%, the sample a person’s weight in kilograms divided by the
square of the person’s height in metres (kg/m2).4.
size according to the formula 4pq/l2 and taking
OVERWEIGHT: Students with BMI cut-off greater
the relative error of 20%, was 536. Due to COVID
than +1SD (Equivalent to BMI 25kg/m2 at 19 years) will
pandemic, the sample size was recalculated and
be classified as overweight.4 OBESITY: Students with
reduced by taking the absolute error of 5%, the sample
BMI cut-off greater than +2D (Equivalent to BMI 30
size was calculated to be 244. Out of the nine senior
kg/m2) will be classified as obese.1 Socio-demographic
secondary schools with co-education, one school was
data were analysed based on Kuppuswamy socio-
randomly selected using lotter method and complete
economic status scale 2021. SKIPPING OF MEAL:
enumeration was done with all the available students.
“Meal skipping is the omission or lack of consumption
The study included all school students of grade 9th to
of one or more of the traditional main meals (breakfast,
12th and excluded students whose parents did not give
lunch or dinner) throughout the day”5. JUNK FOOD:
consent and those who were not contactable during
The term ‘Junk food’ was coined in 1972 by Michael
the entire data collection period.
Jacobson, director of Center for sciences. Junk
Data Collection and Measurement: food are those which contains high level of refined
After initial rapport building, briefing was given to sugar, white flour, trans fat, polyunsaturated fat
all the class teachers about the study and its purpose. salt and numerous food additive such as mono
The consent forms was distributed to all the students sodium glutamate(MSG) and tartrazine, and lacking
for getting consent signed from the parents. The in protein, vitamin and fibre.6 Type of junk food:
students submitted the duly signed /thumbprint Various types of junk food is available in market
form to the class teacher. The forms was collected by out of which the most popular and locally available
the investigator on the next visit. junk food includes samosa, kachori, pakoda, chips,
namkeen, cake, pastry, pizza, burger, French fries,
The school arranged a classroom for conducting noodles, corn flakes, soup powder, chaat, gol guppa
one-to-one interview, self-administered questionnaire and chowmein were included in the questionnaire.
on physical activity, anthropological measurements Physical activity questionnaire: The Physical Activity
and examination for signs of nutritional deficiency. questionnaire for Adolescent (PAQ-A) has been
First the interview regarding the sociodemographic designed by Kowalski, Crocker, & Kowalski7. Each of

102
the 9 (PAQ-A) questionnaire items is scored between The mean BMI of participants was found to be 19.8
1 (low) and 5 (high physical activity). The mean score kg/m2 (SD+3.89). Majority (153, 62.7%) had a normal
of all items gives the overall PAQ score. PAQ-A has BMI, only 29(11.9%) were overweight and 7(2.9%)
high validity and reliability and captures the child’s were obese. Almost one-fourth 55(22.6%) were either
physical activity during the last 7 days. thin or severely thin(Figure 1).
Statistical Analysis Bivariate Analysis of Factors Affecting Overweight

The data was entered in Microsoft Excel and cleaned and Obesity
for errors and missing values. Data analysis was
Table 1 shows bivariate analysis of factors affecting
done using licensed SPSS software version 21.0. Data
overweight and obesity. Religion, mother’s education,
was presented in the form of tables and appropriate
type of diet had significant association with
diagrams. Qualitative data was summarised as
overweight and obesity (p<0.005). But consumption
proportions while quantitative data as mean, median
of vegetables, fruits, junk foods and soft drinks were
and appropriate measures of dispersion including
not significantly associated with overweight and
confidence intervals. Quantitative data was analysed
obesity.
using t-test and qualitative data by chi-square /Fisher
Exact test. P < 0.05 was taken as significant. Table 1: Bivariate Analysis of Factors Affecting
Overweight & Obesity
Results
Variable Overweight Non obese / Total p
The study was conducted among 244 students of & Obese overweight Number value
grade 9th to 12th studying in schools under New Delhi Number(%) Number (%)
Municipal Council. The response rate was 100%. The (%)
mean age of the participants is 15.74 (SD ± 1.31). Out RELIGION
of 244 study participants, the maximum number of Christian 1(25) 3(75) 4(100)
students i.e. 79(32.4%) were under the age group of 16
Hindu 27(13) 180(87) 207(100)
years. Majority of the study population i.e., 67.2% were
males. More than three-fourth of the study population Muslim 6(19.4) 25(80.6) 31(100)
0.005*
i.e.207( 84.8%) were Hindus and Christians, Muslims Sikh 2(100) 0 2(100)
and Sikhs contributed the rest. 86.9% were nuclear MOTHER’S EDUCATION
family. The socio-economic status was analyzed Illiterate 15(22.1) 53(77.9) 68(100)
using Kuppuswamy socio-economic status scale and Primary 3(7) 40(93) 43(100)
were categorized accordingly. 3(1.2%) were Upper Middle 8(9.3) 78(90.7) 86(100)
0.034*
(I) class, 228(93.4%) were Upper middle(II) class and High
(5.3%)13% were lower middle class(III). School & 10(21.3) 37(78.7) 47(100)
Above
BMI categories:
BMI categories: TYPE OF DIET
Vegetarian 6(6.0) 94(94.0) 100(100)

0.001*
Mixed diet 30(20.8) 114(79.2) 144(100)
CONSUMPTION OF VEGETABLES IN
A TYPICAL WEEK
Everyday 18(13.4) 116(86.6) 134(100)
3 to 6
times/ 10(14.7) 58(85.3) 68(100)
week
1 to 2 0.778*
times / 8(19.5) 33(80.5) 41(100)
week
Rarely or
Figure 1: Distribution of study participants 0 1(100) 1(100)
never
according to body mass index(BMI) (N=244)
Figure 1: Distribution of study participants according to body mass index(BMI) (N=244)
2(
The mean BMI of participants was found to beIJPHRD
19.8 kg/m SD+3.89).
/ Volume Majority
13 Issue 4 /(153,
62.7%) had a normal BMI, only 29(11.9%) were overweight and 7(2.9%) were obese. Almost
overweight/obese as compared to vegetarians and

CONSUMPTION OF FRUITS IN A TYPICAL WEEK
the results are statistically significant(AOR 5.777 CI
Everyday 9(15.8) 48(84.2) 57(100) 1.962 – 17.008 p= 0.001). Students who skip their meals
3 to 6 daily are at increased risk of being obese as compared
times/ 16(17.0) 78(83.0) 94(100) to those who skip rarely or never and the results are
week statistically significant (AOR 3.165 CI 1.173 – 8.544 p=
1 to 2 0.023).
0.623*
times / 10(13.3) 65(86.7) 75(100)
week Table 2: Multivariate logistic regression analysis
Rarely or assessing the relationship between various
1(5.6) 17(94.4) 18(100) independent variables and overweight/obesity.
never
CONSUMPTION OF JUNK FOODS IN Adjusted p-value
A TYPICAL WEEK Variables
OR(95% CI)
Everyday 1(10) 9(90.0) 10(100) Male 1.483(0.571 – 0.419
3 to 6 Gender 3.850)
times/ 6(12.2) 43(87.8) 49(100) Female rf
week Hindu rf
1 to 2 0.811*
Muslim 2.240(0.191– 0.521
times / 24(16.6) 121(83.4) 145(100) Religion 26.335)
week
Christian 1.423(0.475- 0.529
Rarely or
5(12.5) 35(87.5) 40(100) 4.261)
never
Illiterate rf
CONSUMPTION OF SOFT DRINKS IN A
TYPICAL WEEK Primary 0.172(0.034- 0.035
0.880)
Everyday 2(15.4) 11(84.6) 13(100) Mother’s
Middle 0.435(0.164- 0.094
3 to 6
Education
1.154)
times/ 2(6.9) 27(93.1) 29(100) High School 1.219(0.444- 0.700
week
0.569* and Above 3.347)
1 to 2
times / 16(14.4) 95(85.6) 111(100)
Mixed Diet 5.777(1.962- 0.001
Type of
week 17.008)
Diet
Rarely or Vegetarian rf
16(17.6) 75(82.4) 91(100)
never Rarely/ rf
never
Multivariate Logistic Regression Analysis Frequency 1-2 days/ 1.722(0.559- 0.344
Table 2 shows the multivariate logistic regression of week 5.305)
analysis results examining the associations of Skipping 3-6 days/ 0.530(0.109- 0.432
overweight/obesity adjusted for variables such as of meals week 2.584)
gender, religion, education of mother, type of diet, Daily 3.165(1.173- 0.023
frequency of skipping of meals. Adjusted odds ratio 8.544)
(AOR) and corresponding 95% confidence intervals Discussion
(CI) are presented. Males are tend to be overweight/
obese relative to females though not statistically In our study, overweight and obesity was observed to
significant(AOR 1.483; CI 0.571 – 3.850 p=0.419). be 11.9% and 2.9% respectively (Table 1). Studies done
Muslim and Christian students were p0sitively by Gautam et al and Kumar AP et al in government
associated with overweight/obese relative to Hindu schools of Udupi, Karnataka and Vijayawada has
students (for Muslim, AOR 2.240; CI 0.191 – 26.335, reported prevalence of overweight and obesity similar
p = 0.521), for Christian, (AOR 1.423; CI 0.475 - 4.261, to ours.8,9 The prevalence of overweight and obesity
p = 0.529). Students of mother with education level among different religion was studied and the higher
high school are at increased risk of being overweight/ prevalence was among Sikhs (100%) and Christians
obese relative to students of illiterate mothers (for (25%) followed by Muslims(19.4%). The religion and
high school and above AOR 1.219 ; CI 0.444 – 3.347, obesity prevalence were statistically significant in
p = 0.070). Students with mixed diet are tend to be the bivariate analysis(Table 1), but when examined

104
under multivariate logistic regression adjusted for The association between consumption of vegetables
gender, mother’s education, type of diet and skipping in a typical week and the prevalence of overweight
of meals, the results were not significant for Muslims and obesity was studied, and the results were not
and Christians in relative to Hindu participants(Table statistically significant, but prevalence of overweight
2). Similarly, in a study done by Gautam et al at and obesity was high (19.5%) in those who took
Karnataka, the prevalence was more among Muslims vegetables 1 to 2 times/week and was comparatively
(26.8%) followed by Christians (25.5%).8 Obesity was less (13.4%) in those who took vegetables daily. In
shown to be less common among Hindus, possibly our study, the association between consumption of
due to the Hindu nutritional culture, which places fruits and prevalence of overweight and obesity was
a greater emphasis on vegetables rather than meat. also not statistically significant, whereas other Indian
Nevertheless, other factors also may come into play. studies report lesser prevalence of obesity with higher
The prevalence of overweight and obesity depending intake of fruits. The association between consumption
on the socio-economic status was also studied and of junk foods and prevalence of overweight and
the results were not statistically significant. This obesity was studied and the results were not
may be because very less number of participants statistically significant(Table 1). Also in a study
fall under upper and lower middle (i.e. 1.2% and done in Kurukshetra by Goel et al in the year 2013,
5.3% respectively) compared to the upper middle there was no association found between junk foods
class(93.4%) and also there were no students coming and obesity/overweight prevalence. 12 In our study,
under lower and upper lower socio-economic groups. the association between consumption of soft drinks
and the prevalence of overweight and obesity was
From our study, it was observed that the mother’s
studied and the results were found to be statistically
education was significantly associated with the
insignificant. The importance of physical activity
prevalence of obesity/overweight(Table 1). The
was studied in relation to prevalence of overweight
students whose mother with primary education
and obesity. The mean physical activity score of the
( aOR-0.172, p=0.035) were less likely to be obese
overweight/obese was 2.21(SD±0.804) as compared
compared to illiterate mothers(Table 2). Similar
to the mean score of 2.27(SD±0.745) among the non-
kind of findings were observed in a study conducted
obese/overweight. Also there was no significant
by Tomar et al at Madhya Pradesh in the year 2014
difference observed between the mean physical
among 184 that over-weight and obese were higher
activity score among boys and girls in our study. A
in children of illiterate mothers and the age group of
Dehradun based study by Bhargava et al in the year
students were between 14-17.10 This can be explained
2013 found a significant association between the lack
by the fact that educated mothers tend to be more
of physical activity and overweight and obesity in
cautious about the diet of their children comparing
school-going children.13
the illiterate mother. The association between
skipping of meals and prevalence of obesity/ Conclusion
overweight was studied but there was no significant
The result of this study indicates that the overweight
difference with or without skipping of meals. In our
and obesity is highly prevalent among adolescents.
study, the prevalence of overweight and obesity
There was a significant association between
was more among adolescents who were on mixed
prevalence of overweight/obesity and religion where
diet i.e. 30(20.8%) than adolescents on vegetarian
Muslims and Christians tend to be obese in relative
diet (Table 1,2). Sivakumar et al. conducted a similar
to Hindus. The students of literate mothers are less
study in Kerala and observed that the majority of
likely to be overweight/obese as compared to the
overweight and obese children (16.10 percent) ate
student of illiterate mothers. The type of diet was
a non-vegetarian diet, which is consistent with our
also significant with the prevalence of overweight/
findings.11 The most important difference between
obesity, participants with mixed diet are more likely
vegetarian and non-vegetarian diet is that the former
to be obese compared to vegetarians. There was a
contains large amount of dietary fibre. Furthermore,
significant prevalence of overweight/obesity among
non-vegetarian meals are high in cholesterol, which
the participants who skip their breakfast daily. There
could explain why the mixed diet participants had a
association between overweight/obesity and rest
higher prevalence.
of the variables like gender, socioeconomic status,

coffee/tea intake, fruit and vegetable consumption, 6. Bhaskar R. JUNK FOOD: IMPACT ON HEALTH.
junk food and soft drink consumption, physical JDDT. 14May2012 [cited 23Sep.2021];2(3).
activity. Although not statistically significant there 7. Kowalski KC, Crocker PR, Donen RM. The physical
was an increase in prevalence of overweight/obesity activity questionnaire for older children (PAQ-C) and
among participants. adolescents (PAQ-A) manual. College of Kinesiology,
University of Saskatchewan. 2004 Aug;87(1):1-38.
Ethical Approval:
8. Gautam S, Jeong HS. Childhood obesity and its
Ethical clearance was obtained from Institute Ethics
associated factors among school children in Udupi,
Committee of Vardhman Mahavir Medical College Karnataka, India. Journal of lifestyle medicine. 2019
& Safdarjung Hospital, New Delhi. Each eligible Jan;9(1):27.
student was explicitly explained about the purpose of
9. Kumar AP, Faisal MG. Prevalence and determinants of
the study by the investigator and an informed written
overweight and obesity among affluent adolescents in
consent was obtained from the parent/guardian,
Vijayawada city, Andhra Pradesh, India. International
prior to inclusion. The privacy of subjects and
Journal of Medical Science and Public Health. 2015
confidentiality of information was also maintained. Mar 1;4(3):408-14.
Source of Funding : Self 10. Tomar SP, Kasar PK, Tiwari R. Study of lifestyle
Conflict of Interest : Nil determinants of overweight and obesity among school
going adolescents in urban Jabalpur, Madhya Pradesh,
References India. International Journal of Community Medicine
and Public Health. 2017 Feb;4(2):554.
1. Inge TH, King WC, Jenkins TM, Courcoulas AP,
Mitsnefes M, Flum DR, et al,The effect of obesity in 11. Sivakumar CP, Joseph J, Manjula VD. Dietary correlates
adolescence on adult health status. Pediatrics. 2013 of overweight and obesity among adolescents during
Dec 1;132(6):1098-104. the current nutrition transition: A cross sectional
study in Kerala. Int J Community Med Public Health.
2. Sahoo K, Sahoo B, Choudhury AK, Sofi NY, Kumar
2017;4:3140-4.
R, Bhadoria AS. Childhood obesity. Causes and
consequences. J Family Med Prim Care 4 (2): 187–192. 12. Goel S, Kaur T, Gupta M. Increasing proclivity for junk
food among overweight adolescent girls in district
3. Stigler MH, Arora M, Dhavan P, Shrivastav R, Reddy
Kurukshetra, India. Age (in years). 2013;16:17.
KS, Perry CL. Weight-related concerns and weight-
control behaviors among overweight adolescents in 13. Bhargava, M., Kandpal, S. D., & Aggarwal, P.
Delhi, India: A cross-sectional study. International (2016). Physical activity correlates of overweight
Journal of Behavioral Nutrition and Physical Activity. and obesity in school-going children of Dehradun,
2011 Dec;8(1):1-6. Uttarakhand. Journal of family medicine and primary
care, 5(3), 564–568
4. World Health Organization. Obesity: preventing and
managing the global epidemic. https://www.who.
int/tools/growth-reference-data-for-5to19-years/
indicators/bmi-for-age. DOA: 12/09/2020
5. Pendergast FJ, Livingstone KM, Worsley A,

McNaughton SA. Correlates of meal skipping in
young adults: a systematic review. International
Journal of Behavioral Nutrition and Physical Activity.
2016 Dec;13(1):1-5.

Attitude of Healthcare workers towards Disaster Management

practices in a Hospital of Gujarat
Kamlesh K. Patel 1, Manish Ramavat2, Nimesh Bhojak3,

Palak J. Vora4
1
Head of the Department, Department of Hospital Management, Hemchandracharya North Gujarat University, Patan
2
Medical superintendent, G.M.E.R.S. Medical college & Hospital, Dharpur, Patan
3
Asst. Professor, Department of Hospital Management, Hemchandracharya North Gujarat University, Patan
4
Department of Hospital management, Hemchandracharya North Gujarat University, Patan, Gujarat, India PIN-384265.
How to cite this article: Kamlesh K. Patel, Manish Ramavat, Nimesh Bhojak, Palak J. Vora et al Attitude of
Healthcare workers towards Disaster Management practices in a Hospital of Gujarat. Volume 13 | Issue 4 |
Abstract
Background: Effective management of a disaster requires preparedness and appropriate attitude of healthcare workers.
Attitude of the healthcare workers will impact their response during any emergency situation coping. This study was
conducted to assess overall attitude towards disaster management among the healthcare staff of 650 bedded hospital in
North Gujarat region.
Methodology: This is a cross sectional survey study carried out on 201 healthcare staff of the hospital under study. The
data was collected through an online questionnaire consisting the demographic details of the participants and followed
by questions regarding the attitude of participants toward disaster management and disaster management practices in the
hospital. Data was coded and analysed with MS Excel and SPSS.
Result: From the responses we received, it was conclude that 45.8% staff of the study hospital have taken the training
for disaster management and 44.8% staff have faced disaster during their work experience at the hospital. Among the
respondents, majority are students (56.2%), nursing staff (25.4%), doctors (11.9%) and others (6.5%). Looking to their
perception, 39.3% staff believes that the disaster preparedness in the hospital is sufficient, 22% says it is insufficient while
38.8% have neutral response.
Conclusion: Attitude of health care workers towards disaster management is very important as it impacts their response
during any emergency situation. Study showed the awareness regarding the disaster occurrence and vulnerability of the
hospital and health care workers’ attitude requires improvement. Which can be positively impacted by trainings, mock-
drills, making them aware about their roles during a disaster and disaster policy related information.
Keywords: Disaster management, Attitude, Perception, preparedness
Introduction will impact their response during any emergency

A disaster is an unexpected event either natural or situation handling.
man-made origin which can cause great destruction Preparedness for any disaster requires
of property, environment and human life. 1,2 Effective implementation of various practices in the hospital
management of a disaster require preparedness and and willingness of the healthcare workers to actively
appropriate attitude. Attitude of the healthcare staff participate in the disaster management process. This
Correspondence Author:
Dr. Palak J. Vora
Department of Hospital management, Hemchandracharya North Gujarat University, Patan, Gujarat, India PIN-384265.
practices of disaster preparedness should be a part of Likert scale from 1 = disagree to 5 = strongly agree.
routine functioning of the hospital which allows the
The study was carried out on the staff during
hospital to provide standardized care and efficient
the period of 5th may to 15th June 2021. The data as
resource utilization during the disaster.3
collected through online questionnaire consisting the
There have been a lot of researches conducted demographic data and questions regarding disaster
across the globe about assessing the knowledge, management. The questionnaire sent to 400 staff,
attitude and practice regarding disaster management among which 201 responded. Both male and female
and disaster preparedness4–7 among different gender responded nearly equal percentage. Majority
healthcare workers like physician, nursing staff, of participants fall in the age group of 21-30 years of
emergency staff etc.8–10 Factors impacting the disaster age group.
preparedness11–13 which showed the staff requires
We selected doctors, nursing staff, medical
adequate knowledge, ability to take the decision
and nursing students, administrative staff, other
quickly7 during any critical condition, knowing the
paramedical staff working in the hospital including
disaster plan, effective communication within the
staff of isolation wards and ICU departments also.
hospital, ethical issues9 and attitude to take a lead for
effective Disaster management. Perception regarding Data was collected and statistical analysis was done
disaster preparedness of a healthcare worker is with the help of MS excel and SPSS V.20. Descriptive
influenced by training, experience, and support12. statistics and frequency analysis were done. Reliability
Proper education regarding disaster management, of data was checked with Cronbach’s alpha test as
knowing their role during emergency might improve shown in Table 2.
the disaster preparedness by improving coordination Table 1: Details of the participants
among the healthcare workers8.
Demographics Category Frequency
Currently world is facing the complex disaster (Percentage
of SARS Cov-2 virus pandemic, even though the (%)
number of cases have been showing the variations,
Male 99(49.3%)
the hospitals need to be more resilient not only to Gender
fight with impact of Covid-19 pandemic but also as Female 102(50.7%)
a part of preparation for upcoming challenges also.14 <20 years 05(2.5%)
Improving the overall attitude of health care worker 21-30 years 166(82.6%)
towards disaster preparedness is also important along Age 31-40 years 26(12.9%)
with strengthening the healthcare system, improving 41-50 years 04(2%)
communication and technological aspects.
>50 years 00(0%)
This study has been conducted to understand School 11(5.5%)
overall attitude towards disaster management among
Educational Diploma 33(16.4%)
the healthcare workers of a 650 bedded hospital in
Qualification Graduation 142(70.6%)
North Gujarat region.
Post- Graduation 15(7.5%)
Method: OT 13(6.5%)
This is a cross sectional survey study. The self – OPD 23(11.4%)
constructed questionnaire was prepared and sent ICU 41(20.4%)
through online mode i.e. Via Google form. Pilot Wards 36(17.9%)
survey was conducted to test the questionnaire. Isolation ward 6(3%)
Informed consent was obtained in first part of the Work Emergency 5(2.5%)
questionnaire itself. Other part consists of participant Department
Others
details including name, age, gender, work department, (Labour room/
educational qualification, history of facing disaster, DEIC/Covid
training status about disaster management etc. Third 77(38.3%)
registration/
part of questionnaire consists of questions regarding Dental/
attitude of participants towards managing the Physiotherapy)
disasters. All the questions were based on five-point

108
Demographics Category Frequency (45.8%) had taken training for disaster management.
(Percentage 44.8% participants have faced disaster and 13.9% staff
(%) are not sure about they have faced any disaster or not.
Doctor/ Attitude towards disaster management includes
24(11.9%)
consultant knowing their responsibility during disaster, the
Nursing staff 51(25.4%) importance of mock drills, willingness to attend fire
Administrative safety training, feeling that the hospital is having
Designation 2(1%)
staff sufficient preparedness for disaster, occurrence of
Paramedical disaster etc. Are included in the calculation. Total
9(4.5%)
Staff 16 questions were taken in consideration which had
Others 2(1%) responses in five-point Likert scale from 1 (disagree)
Students 113(56.2%) to 5 (strongly agree). Descriptive statistic of studied
items is described in Table no.3
<1 year 122(60.7%)
1-5 years 46(22.9%) 47.3% staff (n =95) had neutral, 24.9% staff had
Work
5-10 years 23(11.4%) negative and 22.4% had positive attitude towards
Experience
disaster management and preparedness. This
>10 years 10(5%) survey was conducted during the ongoing Covid-19
No 109(54.2%) pandemic.
Training
Received Yes 92(45.8%) Table 2: Alpha Reliability of data
Unmarried 152(75.6%) Cronbach’s Alpha [ Number of items
Marital status Married 49(24.4%) Alpha reliability]
Separated 00(0%)
0.8205 16
Yes 90(44.8%)
Faced Disaster No 83(41.3%) The data was validated with Cronbach’s alpha
Not sure 28(13.9%) which was 0.8205, which showed the data was reliable
and it is having good internal consistency.
Result
Among the respondents, ~ 60% had less than 1-year
experience of working in the hospital. 92 respondents
Table 3: Attitude towards disaster management practices
Items studied Mean Std. Kurtosis

Deviation
1 Do you think disaster occurs only due to natural causes 3.56 1.248 -.870
2 Perceived requirement of disaster management policy 4.55 1.095 5.030
3 I should know about disaster management policy 4.61 0.921 6.644
4 Our hospital is safe from disaster 2.49 1.297 -.739
5 Nothing can be done for the disaster 2.59 1.294 -.809
6 I should know about disaster management committees 4.63 0.886 8.120
7 Do you think mock drill helps in effective disaster management 4.35 0.959 1.842
8 Perceived requirement of mock drill for all staff 4.5 0.895 3.285
9 Perceived Requirement fire safety training for all staff 4.73 0.794 10.713
10 Perceived requirement for regular disaster management training 4.63 0.816 6.675
11 You should Know about your responsibility during disaster 4.71 0.83 10.155

Items studied Mean Std. Kurtosis

Deviation
12 Staff experience helps in better management of disaster 4.6 0.879 5.561
13 Need for Upgradation of disaster management policy 4.6 0.861 6.178
14 Can we take uninformed leave during disaster? 2.2 1.518 -.754
15 Do you think the disaster preparedness in your hospital is 3.25 1.174 -.567
sufficient?
16 Will you give First aid when a disaster Strikes? 4.53 0.944 4.677
Discussion
There have been limited researches about disaster preparedness among healthcare workers in India emphasizing
on educating health worker, better resource allocation, training, capacity building, psychological preparedness,
communicating effectively and developing effective training tools for training of the healthcare worker and
infrastructure development in India.15-18
Hospital staff working in the hospital should know the susceptibility or vulnerability of a hospital for type of
disasters possible to occur, so they can be prepared in advance for coping up the emergency situation. Regular
fire safety trainings, mock drills will keep health care workers prepared for unexpected crisis. Knowing their
roles during disaster management practice and previous experience will aid the better management of disaster.
Hospital should have updated disaster management plan and policy and health care worker working in the
hospital should be aware of them.
Table 4: Responses of questions regarding disaster management practices
Items Studied 1 (Strongly 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly
Disagree) Agree)
Do you think disaster occurs only 14 21 (10.4%) 73 (36.3%) 25 68 (33.8%)
due to natural causes (7%) (12.4%)
Perceived requirement of disaster 13 (6.5%) 3 8 13 (6.5%) 164 (81.6%)
management policy (1.5%) (4%)
I should know about disaster 6 6 7 22 (10.5%) 160 (79.6%)
management policy (3%) (3%) (3.5%)
Our hospital is safe from disaster 62 (30.8%) 38 64 15 (7.5%) 22 (10.9%)
(18.9%) (31.8%)
Nothing can be done for the 47 61 (30.3%) 45 24 (11.9%) 24 (11.9%)
disaster (23.4%) (22.4%)
I should know about disaster 7 (3.5%) 1 10 24 (11.9%) 159 (79.1%)
management committees (0.5%) (5%)
Do you think mock drill helps in 4 6 27 (13.4%) 42 (20.9%) 122 (60.7%)
effective disaster management (2%) (3%)
Perceived requirement of mock 3 (1.5%) 6 19 (9.5%) 33 (16.4%) 140 (69.7%)
drill for all staff (3%)
Perceived Requirement fire safety 4 4 7 13 (6.5%) 173 (86.1%)
training for all staff (2%) (2%) (3.5%)
Perceived requirement for regular 3 (1.5%) 5 10 28 (13.9%) 155 (77.1%)
DM training (2.5%) (5%)

110
Items Studied 1 (Strongly 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly

Disagree) Agree)
You should Know about your 5 4 6 15 (7.5%) 171 (85.1%)
responsibility during disaster (2.5%) (2%) (3%)
Staff experience helps in better 4 5 14 22 (10.9%) 156 (77.6%)
management of disaster (2%) (2.5%) (7%)
Need for Upgradation of disaster 4 5 11 27 154
management policy (2%) (2.5%) (5.5%) (13.4%) (76.6%)
Can we take uninformed leave 104 (51.7%) 29 (14.4%) 24 (11.9%) 11 33
during disaster? (5.5%) (16.4%)
do you think the disaster pre- 20 24 78 (38.8%) 44 35 (17.4%)
paredness in your hospital is (10%) (11.9%) (21.9%)
sufficient?
Will you give First aid when a 6 4 16 27 148 (73.6%)
disaster Strikes? (3%) (2%) (8%) (13.4%)
Providing information about disaster management programmes along healthcare workers or students
practices, actions allotted to them during emergency, will aid gaining the knowledge and acquire the skill,
regular mock-drills and trainings will significantly but practical implications are limited and requires
enhance the attitude of health care workers towards constant monitoring and evaluation of participants’
better disaster management. response during an emergency situation.28,29
Studies have shown that there are insufficient Current study showed that 23.8% staff believes
knowledge among healthcare workers about that nothing can be done for any disaster. Among the
the disaster management and about their roles respondents [45.8% trained for disaster management
during emergencies will negatively impact their and 44% faced disaster in past] showed that there
responses.19–21. The knowledge can be improved with was requirement of effective training of disaster
emphasising more on teaching and practical training management to all the staff. 90% staff agrees that
sessions regarding disaster management during they should know about the hospital’s disaster
learning phase of health professionals. Preparations of management policy. 39.3% staff believes that the
to be doctors and nursing staff for better responding disaster preparedness in the hospital is sufficient,
to healthcare crisis can be achieved by specific 22% says it is insufficient while 38.8% have neutral
curriculum inclusion in the medical curriculum response. This perception will also impact their
itself.22 When medical students are not exposed response during the disaster. Healthcare workers of
with disaster management training, this may affect the hospital showed positive attitude towards giving
community health once their independent practices first aid whenever a disaster strikes (87%) internally
starts.23 For combating the upcoming challenges, it is or during an external disaster also. While some health
beneficial to have pandemic preparedness subject in care worker believes that they can take un-informed
medical curricula to strengthen the resilience among leave during the disaster (21.9%).
frontline healthcare workers. 20,22,24,25
Limitation of the study is that, it was conducted in
Effective training which include simulation a single tertiary care hospital. And the questionnaire
trainings, mock drills, evaluating the improvement was based on individual perceptions, which might
among health care worker by trainings through also be influenced by personal factors or work-related
assessing knowledge and preparedness are essential factors also.
for providing timely care to the patients during
crisis.26 One study conducted in Tanzanian regional
Conclusion
hospitals, gap found in disaster preparedness of Disasters are sudden and inevitable for any hospital
health professionals and their response during or community, hospital’s response to which becomes
emergencies.27 Conducting disaster training crucial to save human lives during the critical time.
Attitude of health care workers towards disaster

management is very important as it impacts their 6. Al-Wathinani AM, Alakeel A, Alani AH, Alharbi
response during any emergency situation. Looking M, Almutairi A, Alonaizi T, et al. A cross-sectional
to the overall attitude of the staff, 22.4% were having study on the flood emergency preparedness among
positive attitude, 24.9% health care staff had negative healthcare providers in Saudi Arabia. Int J Environ Res
Public Health. 2021;18(3):1–21.
attitude, and 47.9% staff were having neutral response.
The Study showed the awareness of healthcare workers 7. Alzahrani F, Kyratsis Y. Emergency nurse disaster
regarding the disaster management policies and preparedness during mass gatherings: A cross-
their role during the disaster, requires improvement sectional survey of emergency nurses’ perceptions in
at the study hospital. Their willingness to provide hospitals in Mecca, Saudi Arabia. BMJ Open. 2017;7(4).
urgent care in critical time is strongly on positive side 8. Donelan K, DesRoches CM, Guzikowski S, Dittus RS,
showing their dedication of work even in challenging Buerhaus P. Physician and nurse practitioner roles in
situations. Still, there is a need of conducting more emergency, trauma, critical, and intensive care. Nurs
trainings and continuous observation studies for Outlook. 2020;68(5):591–600.
disaster preparedness in the hospital. 9. Al Thobaity A, Plummer V, Williams B. What are the
Declaration: This research is a part of a major most common domains of the core competencies of
research project of corresponding author for Masters in disaster nursing? A scoping review. Int Emerg Nurs.
2017;31:64–71.
Hospital Management course at Hemchandracharya
North Gujarat University, Patan, Gujarat. 10. Zawiah M, Al-Ashwal FY, Saeed RM, Kubas M, Saeed
S, Khan AH, et al. Assessment of Healthcare System
Ethical Clearance: Not required as it was a cross
Capabilities and Preparedness in Yemen to Confront
sectional online survey study. The identity of the Novel Coronavirus 2019 (COVID-19) Outbreak: A
participants and hospital have not been disclosed Perspective of Healthcare Workers. Front Public Heal.
anywhere in the study. 2020;8(July).
Source of Funding: Nil 11. Al-Hunaishi W, Hoe VCW, Chinna K. Factors
associated with healthcare workers willingness to
Conflicts of interest: Nil
participate in disasters: A cross-sectional study in
References Sana’a, Yemen. BMJ Open. 2019;9(10):1–9.
1. Government of India. National Disaster Management 12. Lim GH, Lim BL, Vasu A. Survey of Factors
Plan (NDMP). Gov policy [Internet]. 2016;1–192. Affecting Health Care Workers’ Perception Towards
Available from: http://ndma.gov.in/images/ Institutional and Individual Disaster Preparedness.
policyplan/dmplan/National Disaster Management Prehosp Disaster Med. 2013;28(4):353–8.
Plan May 2016.pdf
13. Nafar H, Tahmazi Aghdam E, Derakhshani N, Sani’ee
2. Government of India. The Disaster Management Act N, Sharifian S, Goharinezhad S. A systematic mapping
2005 [Internet]. India; 2005 p. 29. Available from: review of factors associated with willingness to work
http://www.ndma.gov.in/sites/default/files/PDF/ under emergency condition. Hum Resour Health.
DM_act2005.pdf 2021;19(1):1–10.
3. Orsini E, Mireles-Cabodevila E, Ashton R, Khouli H, 14. Mishra PK. COVID-19, Black Swan events and the
Chaisson N. Lessons on Outbreak Preparedness From future of disaster risk management in India. Prog
the Cleveland Clinic. Chest. 2020;158(5):2090–6. Disaster Sci. 2020;8(November):100137.
4. Beyramijam M, Khankeh HR, Farrokhi M, Ebadi A, 15. Meghana A, Aparna Y, Chandra SM, Sanjeev S.
Masoumi G, Aminizadeh M. Disaster Preparedness Emergency preparedness and response (EP&R) by
among Emergency Medical Service Providers: pharmacy professionals in India: Lessons from the
A Systematic Review Protocol. Emerg Med Int. COVID-19 pandemic and the way forward. Res Soc
2020;2020:1–5. Adm Pharm. 2021;17(1):2018–22.
5. Nofal A, Alfayyad I, Khan A, Aseri Z Al, Abu-shaheen 16. Phalkey R, Dash SR, Mukhopadhyay A, Runge-
A. Knowledge, attitudes, and practices of emergency Ranzinger S, Marx M. Prepared to react? Assessing the
department staff towards disaster and emergency functional capacity of the primary health care system in
preparedness at tertiary health care hospital in central rural Orissa, India to respond to the devastating flood
Saudi Arabia. 2018;39(11):1123–9. of september 2008. Glob Health Action. 2012;5(1):1–10.

112
17. Gandhi S, Sahu M, Govindan R, Nattala P, Gandhi 24. O’Byrne L, Gavin B, McNicholas F. Medical students
S, Sudhir PM, et al. Psychological Preparedness for and COVID-19: The need for pandemic preparedness.
pandemic (COVID-19) Management: Perceptions J Med Ethics. 2020;46(9):623–6.
of nurses and Nursing students in India. PLoS One
25. Gillani AH, Izham M, Ibrahim M, Akbar J. Evaluation
[Internet]. 2021;16(8 August):1–13. Available from:
of Disaster Medicine Preparedness among Healthcare
http://dx.doi.org/10.1371/journal.pone.0255772
Profession Students : A Cross-Sectional Study in
18. Babu M V., Arumugam MK, Debnath DJ. Simulated Pakistan.
patient environment: A training tool for healthcare
26. Goniewicz K, Goniewicz M, Burkle FM, Khorram-
professionals in COVID-19 era. Adv Med Educ Pract.
Manesh A. Cohort research analysis of disaster
2021;12:579–85.
experience, preparedness, and competency-based
19. Yllmaz TE, Yllmaz T, Örnek Büken N, Özkara A, training among nurses. PLoS One [Internet].
Altlntaş KH. Awareness of family physician residents 2021;16(1):e0244488. Available from: http://dx.doi.
of their roles in disaster health management: A cross- org/10.1371/journal.pone.0244488
sectional study in Turkey. Prim Heal Care Res Dev.
27. Koka PM, Sawe HR, Mbaya KR, Kilindimo SS, Mfinanga
2020;21.
JA, Mwafongo VG, et al. Disaster preparedness and
20. Achora S, Kamanyire JK. Disaster preparedness: Need response capacity of regional hospitals in Tanzania:
for inclusion in undergraduate nursing education. A descriptive cross-sectional study. BMC Health Serv
Sultan Qaboos Univ Med J. 2016;16(1):e15–9. Res. 2018;18(1):1–7.
21. Martono M, Satino S, Nursalam N, Efendi F, Bushy 28. Parra Cotanda C, Rebordosa Martínez M, Trenchs
A. Indonesian nurses ’ perception of disaster Sainz de la Maza V, Luaces Cubells C. Impact of a
management preparedness. Chinese J Traumatol disaster preparedness training programme on health
[Internet]. 2019;22(1):41–6. Available from: https:// staff. An Pediatría (English Ed. 2016;85(3):149–54.
doi.org/10.1016/j.cjtee.2018.09.002
29. Ashcroft J, Byrne MHV, Brennan PA, Davies RJ.
22. Scott LA, Maddux PT, Schnellmann J, Hayes L, Tolley Preparing medical students for a pandemic: A
J, Wahlquist AE. High-fidelity multiactor emergency systematic review of student disaster training
preparedness training for patient care providers. Am J programmes. Postgrad Med J. 2021;97(1148):368–79.
Disaster Med. 2012;7(3):175–88.
23. Corte FD ell. Italian medical students and disaster

medicine: awareness and formative needs. Am J
Disaster Med. 2013;8(2):127–36.

Study of Complications and Outcomes of Phacoemulsification

Cataract Surgery
Gudla Vasantha
Assistant Professor, Department of ophthalmology, Government Medical College, Nizamabad.
How to cite this article: Gudla Vasantha et al Study of Complications and Outcomes of Phacoemulsification
Cataract Surgery. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: It’s unknown if surgical complication rates and long-term visual acuity results differ between patients who
had phacoemulsification cataract surgery.
Objective: To study the complications and outcomes of phacoemulsification cataract surgery
Methods: Out of numerous cataract surgeries performed at the hospital, around 50 patients had developed intra-operative
and post-operative complications for phacoemulsification. The operations were carried out under local anaesthetic. The
intraoperative problems, as well as the operational step in question, were recorded. Visual acuity and a full anterior and
posterior segment evaluation were reported postoperatively.
Results: Male predominance was observed with 54% and females were 46%. The male: female ratio was 1.17:1. The mean
age was 52.34 + 6.71 yrs. Majority of the cases around 92% had visual outcome of 6/12 or Better Around 6% had visual
outcome of < 6/12 but ≥ 6/60 and 2% had visual outcome of < 6/60.
Conclusion: Although the risk of problems from cataract surgery using the phacoemulsification technique is lower,
anticipating of these risks, as well as preparation and preventative measures, may help to reduce the risk of difficulties.
Keywords: Phacoemulsification, Cataract, Intra-operative complications, Post- operative complications
Introduction as their preferred procedure. Improved intraocular

Despite the fact that cataracts may be quickly and lens materials and designs have accompanied these
affordably repaired with a conventional procedure, advancements, making them particularly well
they remain the most common cause of blindness adapted for usage with tiny incisions.3
globally. Cataract surgery is one of the most common More than 20 years ago, phacoemulsification was
procedures performed in the world. The operation proposed as a procedure for removing a cataractous
restores eyesight to the large proportion of individuals lens.4 The popularity of phacoemulsification has
who have crystalline lens opacification.1 risen dramatically as procedures and equipment
Cataract surgery procedures and outcomes have have improved, resulting in improved safety and
evolved considerably during the last three decades. efficiency.5
In the United States, intracapsular cataract extraction Phacoemulsification had been a breakthrough
has largely given way to almost entirely extracapsular in cataract surgery. Prior to the development of
procedures.2 Smaller incisions have become the norm, phacoemulsification, surgeons would remove the
with most surgeons opting for phacoemulsification entire lens and capsule.6 It was difficult to place
Dr. Gudla Vasantha
Assistant Professor, Department of ophthalmology, Government Medical College, Nizamabad.
Email Id:- [email protected]
114
an intraocular lens because of this. The eye’s lens Table 1: Distribution based on Gender
provides a significant amount of focusing power.7
Phacoemulsification is usually done at an outpatient
Gender Frequency Percentage
surgical centre, and there is no need to stay in the Male 27 54%
hospital. Local anaesthetic or topical anaesthesia are Female 23 46%
used during cataract surgery.
Total 50 100%
Materials and Methods Male predominance was observed with 54% and
Study setting: Department of Ophthalmology females were 46%. The male: female ratio was 1.17:1.
Sample size: 50 patients with complications for Table 2: Distribution based on Age group
phacoemulsification
Age Frequency Percentage
Inclusion Criteria: 41 -50 6 12%
51 – 60 25 50 %
• Consecutive phacoemulsification cataract
surgeries. 61 – 70 18 36%
>70 years 1 2%
• Age between 40 years to 75 yrs.
Majority of the patients belonged to the age group
Exclusion Criteria: of 41 to 50 yrs with 50% frequency, followed by
• Age < 40 years or > 75 years 36% belonging to the age group of 61 to 70 yrs, 12%
belonged to the age group of 41 to 50 yrs and 2%
• Mature and Hypermature cataract
belonged to the age group of >70 yrs. The mean age
• Inability to give informed consent was 52.34 + 6.71 yrs.
• Previous intra ocular injury, inflammation or
Table 3: Distribution based on Visual outcome
surgery after management
Out of numerous cataract surgeries performed Visual outcome Frequency Percentage
at the hospital, around 50 patients had developed after management of
intra-operative and post-operative complications for complications
phacoemulsification (after 1 month)
Uncontrolled diabetes, uncontrolled hypertension, 6/12 or Better 46 92 %
and active infection in any part of the body. Details < 6/12 but ≥ 6/60 3 6%
about the patient’s demographics and medical history < 6/60 1 2%
were obtained. Blood pressure was taken, and regular Total 50 100%
blood and urine tests were performed. Each patient
had a full anterior segment examination, posterior Majority of the cases around 92% had visual
segment examination, intraocular lens powering, and outcome of 6/12 or Better Around 6% had visual
intraocular pressure measurement performed prior to outcome of < 6/12 but ≥ 6/60 and 2% had visual
surgery. outcome of < 6/60.
The specifics of the pre-operative, operational, Table 4: Distribution based on Intra-operative

and post-operative procedures were recorded. The complications
operations were carried out under local anaesthetic. Intra-operative No. of Percentage
The intraoperative problems, as well as the operational Complication patients
step in question, were recorded. Visual acuity and a (n=23)
full anterior and posterior segment evaluation were Posterior capsule rupture 8 34.78%
reported postoperatively. with vitreous loss
Posterior capsule rupture 4 17.39%
Observation and Results without vitreous loss
50 patients had developed complications for Zonular Dialysis 3 13.04%
phacoemulsification cataract surgery

Intra-operative No. of Percentage Randleman JB et al. reported phacoemulsification

Complication patients under topical anaesthetic done by resident surgeons.
(n=23) A BCVA of 20/40 or greater was reached in 86.6 % of
Descemet’s Membrane 3 13.04% patients. The rate of postoperative complications was
Detachment 9.9%. In 4.1 % of patients, there was vitreous loss.8
Failure to implant lens 2 8.69 % Aravind et al, also reported the similar outcomes.9
Iris Prolapse 1 4.34% A first-day postoperative (POD1) visit is
Capsulorrhexis Extension 1 4.34% recommended by the American Academy of
Broken Haptic 1 4.34% Ophthalmology in functionally monocular patients
Intraoperative complications like Posterior capsule who have experienced intraoperative problems or
rupture with vitreous loss was seen in 34.78% of who are at high risk of immediate postoperative
the cases, 17.39% of the cases had Posterior capsule issues such as an increase in intraocular pressure
rupture without vitreous loss. Descemet’s Membrane (IOP).10 A follow-up appointment should be planned
Detachment was seen in 13% of the cases. Failure within 48 hours for people who do not pose these
to implant lens was seen in 8.69% of the cases. Iris concerns. In contexts where follow-up is inadequate,
prolapse, Capsulorrhexis Extension and Broken early vision evaluation for all patients and follow-up
Haptic was seen in 4.34% of the cases. examination just for patients who return to the clinic
without prompting are appropriate indicators of
Table 5: Distribution based on Post-operative
complications surgical quality. A progressive training path in which
adequate expertise with big incision ECCE comes
Post-operative No. of patients Percentage before learning manual SICS, and phacoemulsification
Complication (n=27) is taught only after manual SICS (which includes
Corneal oedema 10 37.03% capsulorhexis) is mastered.11 The cost of the Phaco
Wound Leak 6 22.22 % machine, maintenance and improvements to
Secondary 4 17.39% the equipment and facilities, personnel pay, and
Glaucoma consumables are all related with high expenses in
phacoemulsification surgery. Phacoemulsification,
Epithelial defect 3 13.04%
on the other hand, may be taught to residents with
Hyphaemia 2 8.69 %
satisfactory aesthetic outcomes and a similar risk of
Retained cortical 1 4.34% significant surgical problems.
matter
Decentred IOL 1 4.34% Conclusion
Although the occurrence of problems associated
Post-operative complications like Corneal oedema
with cataract surgery using the phacoemulsification
was seen in 37% of the cases, wound leak was seen
technique is low, anticipating of these issues, as well
in 22.22% of the cases, Secondary glaucoma was seen
as preparation and preventative measures, may
in 17.39% of the cases, epithelial defect was seen in
reduce the incidence of these complications.
13% of the cases, Hyphaemia was seen in 8.69% of
the cases, Retained cortical matter and decentred IOL Ethical Clearance: Ethical clearance was obtained
was seen in 4.34% of the cases each. from Government Medical College, Nalgonda, prior
to the commencement of the study
Discussion
Source of funding: Self.
Following cataract surgery, phacoemulsification
provides desired anatomical and functional results, Conflict of interest: Nil
and it has become the gold standard technique in
industrialised nations. It is so reassuring that early References
best corrected visual acuity correlates equally well 1. El-Shafy E, El-Sayed S, El-Sobky H, Badawy N.
with later best corrected vision in these instances as Phacoemulsification versus manual small incision
in those with more recent surgery that uses smaller cataract surgery for treatment of cataract. Menoufia
Med J. 2015;28(1):191.
incisions.

116
2. Shah R. Anesthesia for cataract surgery: Recent trends. 8. Randleman JB, Srivastava SK, Aaron MM.
Oman J Ophthalmol. 2010;3(3):107. Phacoemulsification with topical anesthesia
performed by resident surgeons. J Cataract Refract
3. Ahmad N, Zahoor A, Motowa S, Jastaneiah S, Riad
Surg 2004;30:149-154.
W. Satisfaction level with topical versus peribulbar
anesthesia experienced by same patient for 9. Aravind Haripriya, David F. Chang, Mascarenhas
phacoemulsification. Saudi J Anaesth. 2012;6(4):363–6. Reena, Madhu Shekhar, Complication rates of
phacoemulsification and manual small-incision
4. Naeem B-A, Raja A, Bashir R, Iftikhar S, Akhtar KN.
cataract surgery at Aravind Eye Hospital, Cataract
Comparison of Peribulbar Vs Topical Anaesthesia for
Refract Surg 2012; 38:1360–1369.
Phacoemulsification. 2007;11(2):79–82.
10. Mehta R, Punjabi S, Bedi N, Nagar CK. Comparison
5. Singh P, Jadon A, Singh B. Single Injection versus
of peribulbar anesthesia and topical anesthesia on
Double Injection Peribulbar Anaesthesia in Eye Camp
outcome of phacoemulsification. Int J Res Med Sci.
Surgery: a Comparative evaluation of Akinesia and
2017;5(6):2608.
Anaesthesia. Internet J Anesthesiol. 2012;18(2):2–6.
11. Zulfiqar-ud-Din Syed, Tariq M Malik, Aamir M Malik,
6. Joseph B, Thampi B, Joosadima A, Bhaskaran J,
Dilshad Alam Khan, Umar Ejaz AFP. Peribulbar Versus
Raghavan R. Comparison of topical versus peribulbar
Topical Anesthesia for Cataract Surgery; Patient’s
anaesthesia for manual small incision cataract surgery
Satisfaction. Pak J Ophthalmol. 2014;30(2):63–7.
with intraocular lens implantation. Int J Res Med Sci.
2016;4(11):4862–6.
7. Dole K, Kulkarni S, Shisode K, Deshpande R, Kakade N,

Khandekar R, et al.. Comparison of clinical outcomes,
patient, and surgeon satisfaction following topical
versus peribulbar anesthesia for phacoemulsification
and intraocular lens implantation: A randomized,
controlled trial. Indian J Ophthalmol. 2014;62(9):927–
30.

Perspective approach to Nutritional anemia among Medical

students using Health Belief Model: A cross sectional study
in Tamil Nadu
Hanitha Rajasekar1, Venmathi Elangovan2

1
Senior Resident, Department of Community Medicine, Bhaarath Medical College and Hospital, Bharath Institute of higher
education and Research, Selaiyur, Tamil Nadu.
2
Assistant Professor, ESIC Medical college and PGIMSR, Ashok Pillar main Road, KK Nagar, Chennai, Tamil Nadu
How to cite this article: Hanitha Rajasekar, Elangovan et al Perspective approach to Nutritional anemia among
Medical students using Health Belief Model: A cross sectional study in Tamil Nadu. Volume 13 | Issue 4 |
Abstract
Introduction: Anemia is one of the major public health problem more commonly encountered in both developed as well as
developing countries1. Various causes for anaemia are nutritional deficiencies, infectious diseases and chronic blood loss.
Nutritional anemia is the most widespread nutritional disorder in the world affecting 500 million to 1 billion individuals4.
The most vulnerable population for nutritional anaemia is Adolescents aged 10-19 years. Most of the anemia initiatives
are directed towards maternity and early childhood, there is not much attention shown towards adolescent population.
This study was conducted to throw light on attitude towards nutritional anemia among undergraduate medical students
by using Health belief model.
Study Methodology: This study was conducted in a private medical college at Chengelpet district of Tamil Nadu. 122
students from first year were selected by using universal sampling method. A self administered questionnaire comprising
of two parts was used to collect data, first part was general information about the participants and second part were
questions under five factors of Health benefit model.
Result:Mean value of perceived benefit was 3.2+1.54, perceived barrier was 1.7+0.47, perceived self efficacy was 2.69+1.14
interpersonal influence was 2.45+0.73 and situational influence was 2.26+1.2. Nearly 82.8% had perceived benefit on
highest scale, 76.2% had perceived barrier on a moderate scale and 52.5% had perceived self efficacy on a moderate scale.
Conclusion: The study participants with high self efficacy were able to overcome the barriers and perceive benefit of
reduced risk in acquiring nutritional anaemia.
Keywords: Nutritional Anemia. Health Belief Model
Introduction: subsequently their oxygen-carrying capacity) is

Anemia is one of the major public health problem insufficient to meet physiologic needs. The function
more commonly encountered in both developed of Hemoglobin is to carry oxygen to the tissues
as well as developing countries1. It is defined as and this explains the common clinical symptoms
a reduced absolute number of circulating RBCs\ associated with anemia like fatigue, shortness
or a condition in which the number of RBCs (and of breath, bounding pulses or palpitations, and
conjunctival and palmar pallor2. Various causes for
Hanitha Rajasekar
Senior resident
Department of Community Medicine, haarath Medical college and Hospital, Bharath Institute of higher education and research,
Selaiyur, Tamil Nadu.
Contact No. : +91 9551177736
E-mail – [email protected]
118
anaemia are nutritional deficiencies, particularly influences and situational influences. Health Belief
iron deficiency, folate and vitamins B12, infectious model is a theoretical model used to guide health
diseases, chronic blood loss and hemoglobinopathies3. promotion and disease prevention programs. The
Some trace elements like copper and zincfound in the Key elements of Health Belief Model primarily focus
structures of enzymes that act on iron metabolism are on individual beliefs about health conditions and
also associated with anemia. Copper may contribute predicts individual health-related behaviours. The
to anemia through reductions in erythropoietin (EPO) model defines the key factors that influence health
thus increasing oxidative stress and reducing RBC life behaviours as an individual’s perceived threat to
span2. Nutritional anemia result when concentrations sickness or disease (perceived susceptibility), belief
of hematopoietic nutrients which are involved in RBC of consequence (perceived severity), potential
production or maintenance are insufficient to meet positive benefits of action (perceived benefits),
the demand2.It is the most widespread nutritional perceived barriers to action, exposure to factors that
disorder in the worldaffecting 500 million to 1 billion prompt action (Perceived barriers), and confidence
individuals4. The most vulnerable population for to succeed (self-efficacy)7. To facilitate response from
nutritional anaemia is Adolescents aged 10-19 years the participants, the questions were standardised
and they constitute about 21% of India’s population to a five point Likert scale ranging from 0 (strongly
which in absolute numbers translates to 253 million. disagree) to 4 (strongly agree). The content validity
Adolescents suffer from nutritional anemia because of of questions were evaluated by panel of experts from
social factors like erratic lifestyle, structural poverty, field of preventive medicine, nutrition and Paediatrics
social discrimination, negative social norms, and poor and their comments were also incorporated. Before
eating habits5.In 2012, the World Health Assembly starting this study the questionnaire was also pilot
(WHA) approved a Comprehensive Implementation tested among 15 higher secondary school students in
Plan on Maternal, Infant and Young Child Nutrition Kancheepuram district. Mean value of each sub-scale
that identified six global targets related to priority was evaluated by dividing total points by number
nutrition outcomes to be achieved by 2025. Following of items in the sub-scale. Depending on the scores in
this initiative in 2014, Member States approved the each sub-scale attitude towards each factor among the
Global Nutrition Monitoring Framework (GNMF) study participants was categorised as mild, moderate
on Maternal, Infant and Young Child Nutrition that and severe. The data collected was entered in excel
included six global targets6. Most of the anemia sheet and statistical analysis was done by using IBM
initiatives are directed towards maternity and SPSS software. The scores in each sub-scale of health
early childhood and there is not much attention benefit model was expressed by mean value and
shown towards adolescent population. This study Pearson correlation was used to find the association
was conducted to throw light on attitude towards between each of the sub-scales.
nutritional anemia among undergraduate medical
students by using Health belief model Result
This study was done to evaluate the attitude of
Study Methodology adolescents towards nutritional anemia and to
This study was conducted in a private medical college understand their needs to overcome a major health
in Chengelpet district of Tamil Nadu. Total number issue like anemia. Anemia unlike any other disease
of students studying first year were 250 and among does not have major symptoms unless there is severe
them 122 students were selected by using universal decrease in Hemoglobin and remains unnoticed
sampling method. The study was initiated among the especially in adolescent age group because of the other
study participants after explaining in detail about the social factors more common during this age group.
purpose of study and getting an informed consent Medical undergraduate students were selected since
to participate in the study. A self administered they are the future of healthcare and it is important
questionnaire comprising of two parts was used to address their positive outcome towards any health
to collect data, first part was general information ailment. Among 122 participants selected majority
about the participants like name, age, sex and second were girls 64.8% and the remaining were boys 35.2%.
part were questions under five factors of Health As mentioned earlier 5 factors in health belief model
benefit model namely perceived benefits, perceived was used and their mean values were obtained by
barrier, perceived self efficacy, interpersonal using Likert scale from 0-4 for each questions in

the factor. Accordingly mean value of perceived

benefit was 3.2+1.54, perceived barrier was 1.7+0.47,
perceived self efficacy was 2.69+1.14 interpersonal
influence was 2.45+0.73 and situational influence was
2.26+1.2. A frequency distribution table was made to
know the number of participants who had perceived
more belief on the factor concerned and it was found
that nearly 82.8% had perceived benefit on highest
scale, 76.2% had perceived barrier on a moderate scale
and 52.5% had perceived self efficacy on a moderate
scale. With regards of interpersonal and situational
influences 82% of individuals had faced interpersonal
influence on moderate scale and 77.9% had faced
situational influence on moderate scale. According to
the Health Belief Model Perceived barriers were the
most powerful single predictor of preventive health
behavior across all behaviours and perceived severity
was the least powerful predictor8. The most common
barrier perceived by medical students were that most
of the students stay away from their hometown and
second common barrier was skipping breakfast for
want of time. There was also a positive association
found with Pearson correlation between perceived
benefit with self efficacy and perceived self efficacy
with interpersonal influences. These associations
were also found to be statistically significant.
Table 1: Mean value of HBM constructs
HBM Constructs Mean+SD
Perceived benefit 3.2+1.54
Figure 1: Scatter plot showing positive correlation
Perceived barrier 1.7+0.47 between self efficacy to personal benefit and
Perceived self efficacy 2.69+1.14 interpersonal influences
Interpersonal influences 2.45+0.73
Situational influences 2.26+1.2
Table 2: Correlation between HBM Constructs

HBM Constructs Perceived Perceived Perceived self Interpersonal Situational
benefit barrier efficacy influences influences
Perceived benefit + -.114 .92** .177 .164
Perceived barrier + + .121 -.092 -.183*
Perceived self efficacy + + + .64** .042
Interpersonal influences + + + + -.053
Situational influences + + + + +
Discussion effective tool over years in evaluating several health

Most of the previous study done by using Health programs. It proposes that people are most likely
Belief Model was interventional studies using to take preventative action only if they perceive the
education as a tool and it primarily focussed on effect threat of a health risk to be serious and feel that they
of health education. Health Belief Model has been an are personally susceptible. Health Belief Model could

120
function as a causal chain, It is referred to as serial study participants were having more self confidence
mediation, for example, campaign exposure could to perceive benefit in order to overcome the health
increase self-efficacy, self-efficacy could influence ailment.
perceived barriers, and perceived barriers could
Hamideh Mohaddesi15 studied effect of intervention
predict behavior9. This study takes into account the
based on health belief model on the change in
demographic, socio-psychological, and structural
nutritional behaviour of pregnant mothers with
variables which affect an individual’s perceptions of
iron deficiency anemia referred to health centres
dietary change and thus indirectly influence his or her
and the results showed that there was no significant
ability to sustain new eating behaviors10.
difference between the two intervention and control
In a study done by Mirzaei Hamed et11 on groups in terms of the health belief constructs and
Application of Health Belief to promote preventive nutritional behavior before the intervention. It was
behaviour against iron deficiency anemia among also suggested that based on independent t-test, the
female students, the students were divided into mean scores of knowledge, model constructs, self-
intervention and control group and education on efficacy and nutritional behavior after intervention
iron deficiency was given. The study suggested that were significant compared to the control group (P
following education there was a significant difference <0.001). In our study self efficacy had significant
in the mean score of perceived susceptibility, severity, association with perceived benefit and interpersonal
benefits, barriers, perceived self-efficacy, practice influences. Marshall H Becker16 in his study on
guidance and health performance and this was prediction of dietary compliance by using Health
found to be statistically significant. In present study Belief Model which was a prospective experimental
association between the factors of health belief model design evaluated the ability to predict and explain
was analysed inorder to guide the health care workers mothers’ adherence to a diet prescribed for their obese
to focus on the factor which will provoke beneficiary children. The result of this study suggested significant
effect in the participants. Khadije Baharzadeh12 correlations between each major dimension of the
study on health belief model to promote preventive Model and the outcome measures, and findings
behaviors against iron deficiency anemia among from multiple regression analyses also supported the
pregnant women was also an interventional study usefulness of the Model as a whole.
in the form of health education. The highest score
belonged to the structure of perceived susceptibility Conclusion
63.12 before intervention and 97.1 after intervention Health Belief Model is a psychological model that
and this was found to be statistically significant. In attempts to explain and predict health behaviors by
our study nearly 82.8% had perceived benefit on a focusing on the attitudes and beliefs of individuals10.
highest scale and the mean value of this factor was The study concludes that 82.8% of participants had
15.7. Naseh Ghaderi13 study on effect of education perceived benefit on highest scale, 76.2% had perceived
on anemia preventive behaviours among Iranian girl barrier on a moderate scale and 52.5% had perceived
students by using HBM was a quasi experimental self efficacy on a moderate scale. It also suggested
study conducted among 128 students. This study had that the study participants with high self efficacy will
highest score for perceived benefit before and after be able overcome the barriers and perceive benefit of
intervention which was similar to our study. reduced risk in acquiring nutritional anaemia.
Marziye Reisi14 did a cross sectional study for Recommendation

Investigating of Mothers’ Behavior Based on the Health The Health belief model is likely to be influential
Belief Model about using iron Supplementation in 6 when used by health practitioners especially doctors
to 24 month old children. This study concluded that in a clear and specific manner, when it is placed in
awareness, sensitivity and perceived severity and the context of overall risk for diseases, and dietary
also perceived benefits of most studied cases (59%) change recommendations can be linked prospectively
were acceptable but the attitude of a considerable to tangible risk reduction10. According to RMNCH+A
number of the cases (41%) towards removing the strategy all interventions are aimed at reproductive,
barriers (perceived barriers) was found to be poor. In maternal, newborn, child, and adolescent health
our study there was a significant positive association under a broad umbrella focusing on the strategic
between perceived benefit and self efficacy. The lifecycle approach17. Hence adolescent health should

be of primary concern and everyone in the chain of life 10. Health Belief Model[Internet].[cited 3 May 2020].
cycle including the adolescents should understand Available from; www.sciencedirect.com
their responsibility to lead a healthy life. 11. Mirzaei Hamed, et al.Application of Health Belief
Ethical clearance: Obtained for IHEC (Institute of Model to promote preventive behaviours against
iron deficiency anemia among female students of
Human Ethics Committee, CHRI)
high school Fereydan city: A quasi-experimental
Source of funding: None study..Journal of Health Education and Health
promotion.2018;5(4):260-269
12. Khadije Baharzadeh1, Tayyebe Marashi2, Amal Saki3,
References Ahmad Zare Javid4, MarziehAraban.Using of health
1. Nipura A.Vibhute et al. Prevalence and awareness of belief model to promote preventivebehaviors against
nutritional anemia among female medical students in iron deficiency anemia amongpregnant women.
Karad, Maharashtra, India: A cross-sectional study.J Journal Research & Health.2017; 7(2): 754- 762.
Family Med Prim Care. 2019 Jul; 8(7): 2369–2372. 13. Naseh Ghaderi et al.Effect of education based on the
2. Camila M. Chaparro. Parminder S. Suchdev.Anemia Health Belief Model (HBM) on anemia preventive
epidemiology, pathophysiology, and etiology in low- behaviors among iranian girl students.International
and middle-income countries.Ann N Y Acad Sci. 2019 Journal of Pediatrics.5(6):5043-5052
August ; 1450(1): 15–31. 14. Marziye Reisi et al.Investigating of Mothers’ Behavior
3. Anemia[Internet].[cited 28 April 2020].Available Based on the Health Belief Model about Using Iron
from:www.who.int Supplementation in 6 to 24- Month Old Children in
Shahrekord City, Iran.British Journal of Medicine &
4. Hercberg S, Rouaud C.Nutritional anemia. Child Trop. Medical Research.2015;5(9): 1140-1146
1981;(133):1-36
15. Hamideh Mohaddesi, Parivash Alizadeh Rashakani,
5. Vani Srinivas, Ranjit Mankeshwar.Prevalence and Alireza Didarloo, Hamidreza Khalkhali.Effect of
determinants of nutritional anemia in an urban area Intervention based on Health Belief Model on the
among unmarried adolescent girls: A community- change in nutritional behaviour of pregnant mothers
based cross-sectional study.International Journal of with iron deficiency anemia referred to Urmia Health
Medicine and Public health.2015;5(4) Centres.Pharmacophore.2017;8(6S);Pages 6
6. Global nutrition monitoring framework: operational 16. Marshall H Becker, Lois A Maiman, John P Kirscht,
guidance for tracking progress in meeting targets Don P Haefner, Robert H Drachman. The Health
for 2025[Internet].[cited 28 April 2020].Available Belief Model and prediction of dietary compliance:
from:www.who.int A field experiment.Journal of Health and social
7. The Health Belief Model[Internet].[cited 28 April behaviour;1977.Volume 18(December):348-366.
2020].Available from; www.ruralhealthinfo.org 17. National Health Mission components>RMNCH+A.
8. Christina L Jones et al.The Health Belief Model as an [Internet].[cited 4 May 2020].Available from; www.
Explanatory Framework in Communication Research: nhm.gov.in
Exploring Parallel, Serial, and Moderated Mediation.
Health Commun. 2015; 30(6): 566–576.
9. Hayes JA. PROCESS: A versatile computational tool

for observed variable mediation, moderation, and
conditional process modeling.[Internet].[cited 3 May
2020].Available from;http://www.afhayes.com/
public/process2012.pdf.

Clinical Profile of Unilateral Disc Edema: A Cross-sectional Study
Jayeshkumar C. Sadhu1, Nishant Solanki2

1,2
Assistant Professor, Department of Ophthalmology, Shri M.P.Shah Government Medical College, Jamnagar, Gujarat
How to cite this article: Jayeshkumar C. Sadhu, Nishant Solanki et al Clinical Profile of Unilateral Disc Edema:
A Cross-sectional Study. Volume 13 | Issue 4 | October-December 2022
Abstract
Background and Aim: Optic disc swelling is due to arrest or obstruction of axoplasmic flow at the lamina cribrosa.
It may be due to various pathological conditions like ischemia, infiltration, inflammation, compression, metabolic and
toxic damage. In this study, the clinical profile of each case of unilateral disc edema was analysed in relation to age of
presentation, gender, systemic association, risk factor and prognosis.
Material and Methods: The present study was done in the department of ophthalmology, medical college and hospital.
The patients with the unilateral disc edema were included in the study. Visual acuity was measured using Snellen’s acuity
chart and converted to logmar for the purpose of statistical analysis. Intraocular pressure was recorded. Colour vision
was recorded using ishihara chart. Routine blood investigations were done. Radiological imaging was done.
Results: Females are affected more commonly compared to males in the study group. The commonest cause for unilateral
disc edema is nonarteritic AION and the next common cause is optic neuritis. Compressive disc edema, inflammatory disc
edema and neuroretinitis are the other conditions causing unilateral disc edema. In this study 60 % of the persons showed
disc pallor on follow up and 40 % of person showed normal fundus. 66.67 % of patients of NAION had disc pallor on
follow up. MRI BRAIN in NAION showed small vessel ischemic changes in 6.67% of persons which indicates the ischemic
change were also noted in brain.
Conclusion: If a patient with unilateral disc swelling presents to neuroophthalmology clinic, NA-AION and ON should
be considered first in the differential diagnosis. Other causes of disc edema should not be missed.
Keywords: Compressive disc edema, Intraocular pressure, Ophthalmology, Optic disc swelling
Introduction The management and prognosis depends upon the

Disc edema is a common manifestation of variety etiology of the disc edema.2, 3
of disorders. The disc edema can be unilateral or Optic disc swelling is due to arrest or obstruction
bilateral. Unilateral disc edema can be inflammatory, of axoplasmic flow at the lamina cribrosa. It may be
ischemic, compressive or infiltrative. It may also be an due to various pathological conditions like ischemia,
eye opener for detection of certain systemic diseases. infiltration, inflammation, compression, metabolic
Hence, it is very essential for an ophthalmologist to and toxic damage.4, 5
clinically evaluate and differentiate the causes of disc
Ophthalmoloscopically, the early disc edema
edema.1
usually presents as superior and inferior margin blur
The presenting signs and symptoms will be and the increasing swelling can obscure the blood
different depending upon the cause of the disc edema vessels at the disc margin. Hyperemic disc with
and the work up for that also should be individualized absent spontaneous venous pulsation may be seen. In
based on the history and the examination finding. the stage of fully developed disc edema, intra retinal
Dr. Jayeshkumar C. Sadhu,
Department of Ophthalmology,
Shri M.P.Shah Government Medical College, Jamnagar, Gujarat
hemorrhages, infarcts leading to soft exudate and Intraocular pressure was recorded. Direct and
hard exudates may be seen.6-8 Indirect Ophthalmoscopy was done. Colour vision
was recorded using ishihara chart. Routine blood
In the long course, after several months, the
investigations were done. Radiological imaging
hemorrhages and hard exudates may resolve and
was done. Follow up was done at regular intervals.
the hyperemia is replaced by milky gray appearance
Various parameters were checked on follow up to
due to gliosis. The presence of optociliary shunt, neo
check the Improvement in visual activity.
vascular membrane with subretinal hemorrhages
and serous fluid are also not uncommon. The final Data collected were entered in Excel Spread
fate of any optic nerve disease is atrophy. The type sheet and analyzed using STATA statistical
of atrophy in any disc edema is secondary with dirty software package release 11. We used the two sided
yellow colour disc with ill defined disc margin with independent-samples t test to compare means
surrounding vascular sheathing. Once the atrophy across dichotomous variables (i.e. men v. women);
develops, the optic nerve does not swell.9, 10 the one-way ANOVA test for comparison of means
across multilevel variables. Simple calculations like
In most cases the vision can be preserved with
Percentages, Proportions and Mean values were
appropriate and prompt treatment. If the disc
derived. A type I error of 0.05 was considered in all
edema is left untreated it can lead to permanent and
analyses.
irreversible blindness due to optic atrophy.11 In this
study, the clinical profile of each case of unilateral Results
disc edema was analysed in relation to age of
Total of 60 cases diagnosed with unilateral disc
presentation, gender, systemic association, risk factor
edema were included in the study with each case of
and prognosis.
unilateral disc edema were analysed in relation to
Materials & Method age of presentation, gender, systemic association, risk
factor and prognosis. The mean age of presentation of
The present study was done in the department of
NAION is 51 years and the mean age of presentation of
ophthalmology, medical college and hospital. The
optic neuritis is 30 years. This indicates the association
study was done was for the period of one year. The
of systemic disease with NAION as it affects the age
ethical committee was informed about the study and
group between 40 to 50 years and the association of
the ethical clearance certificate was obtained prior to
demyelination with optic neuritis as it affects the age
the start of the study. Both male and females were
group between 20 to 30 years. In general females are
included in the study.
affected more commonly compared to males in the
‘The age range of the included patients was from 20 study group.
– 65 years. The patients with the unilateral disc edema
It is evident from the study, the commonest cause
were included in the study. The exclusion criteria for
for unilateral disc edema is nonarteritic AION and the
the study as follow: Patient with bilateral presentation
next common cause is optic neuritis. Compressive disc
and papilledema and patient with age < 20 years.
edema, inflammatory disc edema and neuroretinitis
The patients reported to the ophthalmology are the other conditions causing unilateral disc edema.
department were registered for the study. The All the cases in our study had unilateral affection of
patients were informed about the study, and the the disease.
written informed consent was obtained prior to the
In this study, Fundus examination of uninvolved
start of the study. The patients who did not provided
eye showed normal fundus in 50% of cases. Other
the informed consent were excluded from the study.
50% of cases showed some findings which helped in
The included patients were evaluated and followed
diagnosing the condition. ‘At risk’ crowded disc was
up during the study period.
seen in 6.67% of persons, hypertensive and diabetic
The detailed history of the present illness was changes were noted in 10% of cases.
recorded. Visual acuity was measured using Snellen’s
There is no specificity of the eye involved. Both eyes
acuity chart and converted to logmar for the purpose
are equally affected in the study group. In this study
of statistical analysis. Slit lamp bio microscopy of
60 % of the persons showed disc pallor on follow up
anterior segment, fundus with +90D lens was used.
and 40 % of person showed normal fundus. 66.67 % of

124
patients of NAION had disc pallor on follow up. All

Disc pallor Present Absent
the patients of optic neuritis had disc pallor on follow
up even though the vision was good. Neuroretinitis OPTIC NEURITIS 10 0
disc edema and inflammatory disc edema usually Total 36 24
resolved without producing any disc pallor.
Discussion
MRI imaging was needed only in 40 % of the patients. Jong Jin Jung, Seung-Hee Baek12 and et al conducted
It was 100% useful in compressive neuropathy the study called Analysis of the Causes of Optic
and also aided in diagnosing optic neuritis in some Disc Swelling and its result showed that the most
patients. It also helped in diagnosing longitudinally common cause with optic disc edema was NAAION
extensive transverse myelitis which was an important and the second most common cause was ON. There
sign in diagnosing neuromyelitis optica. MRI BRAIN was no case of arteritic AION in this study. The NA-
in NAION showed small vessel ischemic changes in AION was diagnosed at an older age in this study
6.67% of persons which indicates the ischemic change and the common type of field defect in NA-AION
were also noted in brain. was an inferior altitudinal defect. Optic neuritis was
Table 1: Different causes of unilateral disc edema associated with a better prognosis than NA-AION.
The compressive optic neuropathy causing disc
Diagnosis Frequency edema is only 6.1%. In our study also NAION is the
NAION 32 most common cause of unilateral disc edema and the
INFLAMMATORY NEUROPATHY 6 second is optic neuritis.
OPTIC NEURITIS 10 Preechawat P13, Bruce BB, et al studied the
COMPRESSIVE NEUROPATHY 6 characteristics of AION in patients younger than 50
NEURORETINITIS 6 years. They concluded that AION in younger patients
TOTAL 60 is not uncommon and it represents 23% of AION
patients. In this study, AION was also common in age
Table 2: Different fundus findings in group between 40 to 50 years.
uninvolved eye
MRI imaging was needed only in 40 % of the
Other eye fundus Frequency patients. It was very much useful in compressive
GIII HT RETINOPATHY 2 neuropathy. MRI Brain in NAION showed small
vessel ischemic changes in 6.67% of persons which
ARTERIOLAR ATTENUATION 12
indicates that the ischemic change were also noted
DM RETINOPATHY 4 in the brain.14 In NAION, disc showed sectoral pallor
HIGH MYOPIC 2 in 100% of patient, disc haemorrhages in 93.75%
NO VIEW 2 of patients. Fellow eye fundus of NAION patient
DISC AT RISK 4 showed small crowded disc [disc at risk] in 6.67% of
patients.
ROTH SPOTS 2
PALLOR 2 Fellow eye involvement was seen in 12.5% of
NORMAL 30 patients with NAION. 66.7% of the NAION patients
showed disc pallor on follow up and all cases of optic
TOTAL 60
neuritis showed temporal pallor on follow up. The
TABLE 3: Disc pallor on follow up visual prognosis of NAION is very poor even with
prednisolone treated group and with only control
Disc pallor Present Absent of systemic factors without oral prednisolone. All
NEURORETINITIS 0 6 cases of optic neuritis showed improvement with
intravenous steroids but it did not alter natural course
INFLAMMATORY 0 6
DISC EDEMA of the disease.
AION 24 8 Conclusion
COMPRESSIVE OPTIC 2 4 If a patient with unilateral disc swelling presents
NEUROPATHY to neuroophthalmology clinic, NA-AION and ON

should be considered first in the differential diagnosis. 7. Rosen ES: Photographic Studies on the Fundus of the
Other causes of disc edema should not be missed. A Human Eye: The University of Manchester (United
detailed history taking, visual field, color-vision and Kingdom), 1969.
imaging tests should be performed for each and every 8. Hayreh SS: Pathogenesis of optic disc edema in raised
case of unilatreal disc edema. Regular follow-up intracranial pressure. Progress in retinal and eye
examination would be necessary for all cases to look research 2016, 50:108-44.
for visual recovery and recurrence.
9. Scott IU, Ip MS: Retinal Venous Occlusive Disease.
Ethical approval was taken from the institutional Albert and Jakobiec’s Principles and Practice of
ethical committee and written Informed Consent was Ophthalmology 2022:3019-61.
taken from all the participants. 10. Chitra G: Clinical Profile of Idiopathic Intracranial
Hypertension in a Tertiary Eye Care Centre in South
Sources of funding: Nil.
India. Aravind Eye Hospital, Madurai, 2016.
Conflict of interest: None declared
11. Luneau K, Newman NJ, Biousse V: Ischemic optic
References neuropathies. The neurologist 2008, 14:341-54.
1. Hata M, Miyamoto K: Causes and prognosis of 12. Jung JJ, Baek S-H, Kim US: Analysis of the causes of
unilateral and bilateral optic disc swelling. Neuro- optic disc swelling. Korean Journal of Ophthalmology
Ophthalmology 2017, 41:187-91. 2011, 25:33-6.
2. Figueira L, Fonseca S, Ladeira I, Duarte R: Ocular 13. Preechawat P, Bruce BB, Newman NJ, Biousse V:
tuberculosis: Position paper on diagnosis and treatment Anterior ischemic optic neuropathy in patients younger
management. Revista Portuguesa de Pneumologia than 50 years. American journal of ophthalmology
(English Edition) 2017, 23:31-8. 2007, 144:953-60.
3. Abdelhakim A, Rasool N: Neuroretinitis: a review. 14. Secades JJ, Lorenzo JL: Citicoline-pharmacological and
Current Opinion in Ophthalmology 2018, 29:514-9. clinical review, 2006 update. Methods and findings in
experimental and clinical pharmacology 2006, 28:1-56.
4. Trobe JD: Papilledema: the vexing issues. Journal of
Neuro-ophthalmology 2011, 31:175-86.
5. Xie JS, Donaldson L, Margolin E: Papilledema: a

review of etiology, pathophysiology, diagnosis, and
management. Survey of Ophthalmology 2021.
6. Abinaya K: A study on clinical profile of unilateral disc

edema. Madras Medical College, Chennai, 2018.

A Study of Effectiveness of Videolaryngoscopy and Conventional

Laryngoscopy in Adult Patients for Orotracheal Intubation
Madhavi.Mavani1, Nayna Solanki2, Shilpin Solanki3, Hiral Solanki4

1
Assistant Professor, Department of Anaesthesia, GMERS Medical College and Hospital, Sola, Ahmedabad, Gujarat
2
Professor, Department of Anaesthesia, GMERS Medical College, Vadnagar, Gujarat
3
Assistant Professor, Department of Anaesthesia, GMERS Medical College, Dharpur, Gujarat
4
Senior Resident, Department of Anaesthesia, SVP Hospital, Ahmedabad, Gujarat
How to cite this article: Madhavi.Mavani1, Nayna Solanki2, Shilpin Solanki3, Hiral Solanki4 et al A Study
of Effectiveness of Videolaryngoscopy and Conventional Laryngoscopy in Adult Patients for Orotracheal
Intubation. Volume 13 | Issue 4 | October-December 2022
Abstract
Aim: Present study was carried out to evaluate and compare the laryngeal view and intubation by direct laryngoscope
using macintosh blade with video laryngoscope in adult patients requiring endotracheal intubation.
Material and Methods: This prospective study was carried out at our institute - GUJARAT CANCER SOCIETY MEDICAL
COLLEGE, HOSPITAL AND RESEARCH CENTER. Total 100 adult patients for elective surgery under general anaesthesia
were included in this study. Patients were randomly divided in two groups. Each group included 50 patients. Group A:
Videolaryngoscopy, Group B : Conventional Laryngoscopy. Hemodynamic changes and SpO2 were noted and recorded
during the procedure at various intervals.
Results: Cormack Lehane glottis view is better with videolaryngoscope than conventional Macintosh laryngoscope and
is significant statistically. The mean tracheal intubation time was higher, in Group B as compared to Group A. But the
differences were statistically not significant. The mean rate of failure to intubate was almost similar among both the
groups. The difference was statically not significant. No statistically significant difference was observed in mean arterial
BP between the two study groups, at any point time.
Conclusion: video laryngoscope offers a better laryngeal view, minimum external maneuvers, less attempts for intubation
and provides better hemodynamic response during laryngoscopy and intubation as compare to direct laryngoscopy with
Macintosh blade.
Keywords: Intubation, Laryngoscope, Pulse rate, Videolaryngoscope
Introduction respiratory tract from digestive tract, allows control

Airway Management, an essential skill forms the of breathing, and facilitates administration of oxygen,
central pillar of the practice of anaesthesiology, anaesthetic gases and drugs. Proper view of glottis
resuscitation, critical care and emergency medicine. is either by direct or indirect laryngoscopy. An ideal
Maintaining a free airway during general anaesthesia laryngoscopy must provide adequate visualisation
is primarily achieved by cannulation of trachea of glottis to allow correct placement of endotracheal
via orotracheal route, a technique recognised as tube with the minimum effort, less elapsed time and
endotracheal intubation. Intubation isolates the minimal potential for injury to the patient.
Dr Hiral Solanki,
Department of Anaesthesia, SVP hospital, Ahmedabad, Gujarat
Tel: 98253 82822
Direct laryngoscopy (DL) relies on the formation Group B : Conventional Laryngoscopy ( Macintosh
of a “line-of-sight” between the operator and the Blade)
laryngeal inlet, success depends on proper head
positioning and consistent anatomy. When the above Inclusion Criteria
conditions are not met, for example in poor tissue • Informed consent of patient.
mobility, restricted mouth opening, or large tongue,
the failure rate of intubation with conventional direct • Age ≥ 18years
laryngoscopy increases.1,2,3 • Patients scheduled for elective surgeries
requiring oral tracheal intubation.
The King Vision videolaryngosope is a fully
portable and wireless video laryngoscope with high • Mouth opening ≥ 2 or 2 and half fingers.
blade angulation allowing best visualization of • Mallam Patti Grade 1 and 2
larynx indirectly through small portable flat screen
• ASA grade 1 and 2.
monitor. Laryngoscopy and intubation is noxious
stimulus which results in sympathetic response Exclusion Criteria
leading to hypertension and tachycardia, which
can in turn produce adverse cardiovascular events, • Patient refusal
especially in patients with cardiac comorbidities. The • Emergency surgeries.
hemodynamic response is due to the oropharyngeal • Age ≤ 18 years
stimulation produced by laryngoscopy and
• Mallam Patti Grade 3 and 4
larymgotracheal stimulation due to tube insertion.
Videolaryngoscopes do not require the alignment • Patient with airway pathology. (Oral,
of oral, tracheal and laryngeal axes for glottic Pharyngeal, Laryngeal Carcinoma)
visualization and hence may cause less oropharyngeal • Patients with nil mouth opening
stimulation and airway trauma. Pre Operative Assessment
So present study was carried out to evaluate and It was done one day before the surgery. Any
compare the laryngeal view and intubation by direct significant past, family and personal history were
laryngoscope using macintosh blade with video taken. General physical examination was done,
laryngoscope in adult patients requiring endotracheal vitals and investigations were noted. A meticulous
intubation. airway assessment was done to exclude patients with
difficult airway by giving attention to Inter Incisor
The king Vision videolaryngosope is a fully
gap, Modified Mallampati airway classification, Neck
portable and wireless video laryngoscope with high
movements, Thyromental distance, Sternomental
blade angulation allowing best visualisation of larynx
distance and examination of dentition.
indirectly.
Patients were kept NBM for 6 hours prior to surgery.
Material and Methods
This prospective study was carried out at our
Patient preparation
institute - GUJARAT CANCER SOCIETY MEDICAL On the day of surgery, the patients were taken to the
COLLEGE, HOSPITAL AND RESEARCH CENTER. operating room, 18 G intravenous cannula inserted
Ethical permission was obtained from the ethical and I.V. fluid started. Multipara monitor was attached
committee of GCSMCH & RC. Informed written and baseline pulse rate, blood pressure and SpO2
consent was obtained from each patient and the were recorded. All patients were pre-oxygenated for
procedure was explained to the patients. 3 min before induction.
Total 100 adult patients of either Sex, Age ≥ 18 Premedication: Inj. Ondansetron 4 mg I.V.
years, having ASA grade I/II posted for elective Inj.Glycopyrrolate 0.2 mg I.V.
surgery under general anaesthesia were included in
Inj. Fentanyl 2µg/kg I.V.
this study. Patients were randomly divided in two
groups. Each group included 50 patients. Induction: Inj. Propofol 2 mg/kg I.V.
Group A : Videolaryngoscopy (King Vision - Inj. Succinylcholine 2 mg/kg I.V.

Channeled Blade )

128
Intubation Monitoring:
Procedure was performed by a senior anesthetist who • Pulse/min
has experience of 2 years. Endotracheal tubes; Size
• Blood pressure in mmHg
7.0–7.5 mm tracheal tubes for females and size 8.0–
8.5mm in males were used. • EtCO2
Group A (n=50): patients were intubated using • ECG monitoring
King Vision video laryngoscope. CHANNELLED
• SPO2
BLADE
• Hemodynamic changes (Pulse rate and blood
Group B (n=50): patients were intubated using
pressure) and SpO2 were noted and recorded
direct laryngoscope with Macintosh blade.
during the procedure (Laryngoscopy and
Intubation) at various intervals.
Procedures of Video Laryngoscopy and Direct
laryngoscopy ■ Pre op- Baseline
All patients were kept in supine position with head ■ Before laryngoscopy and intubation
in neutral position in group A and in sniffing position
■ After laryngoscopy and intubation
in group B.
■ 0,5,10 ,15 minutes after intubation.
In group A After adequate depth of anaesthesia, King
Vision laryngoscope with proper size CHANNELLED Statistical Analysis
blade (no.3/4) premounted with appropriate size The socio-demographic parameters were compared
slightly lubricatd endotacheal tube was introduced between the two study groups, using frequencies
in the midline, superior to the tongue and advanced and percentages for categorical variables, mean and
towards the larynx until the epiglottis was visualized. standard deviation for quantitative variables. The
On visualization of the cords, Cormack- Lehane grade statistical significance was assessed by independent
(CLG) was noted. Proper size of ET tube was inserted sample student t-test. IBM SPSS Version 26 and © 2018
from the angle of the mouth to the trachea. Graph Pad Software was used for stastical analysis.
In group B, direct laryngoscopy was performed with
Results
Macintosh blade in a usual way with head in sniffing
position. The blade tip is inserted into the valleculla. This clinical study comprised of 100 adult patients.
The Cormack- Lehane grade (CLG) was noted. The They were divided into two groups. Each group
maneuvers required facilitating the intubation like included 50 patients.
external laryngeal manipulation, use of stylet or Table 1: Demographic Data
bougies were noted. After successful intubation, the
patients were mechanically ventilated for the surgical VARIABLE GROUP A GROUP B P-VALUE
procedure and anaesthesia was maintained with AGE (YEARS) 0.58
42 15.3 43 12.5
sevoflurane in a mixture of nitrous oxide and oxygen
GENDER (M:F) 21:29 26:24 NA
in a 1:1 ratio with muscle relaxant as per requirement
of the surgery. WEIGHT (KG) 0.108
58 10.6 56 6.2
ASA GRADE 0.120
Total time taken for intubation:- 1.36 0.48 1.36 0.48
( I/II)
During the procedure, time was noted by an assistant MOUTH 1.00
from introducing the laryngoscope into the mouth till 3.0 0.0 3.0 0.0
OPENING
the appearance of firstsquare wave capnography on MALLAM PATTI 0.008
EtCO2 monitor and bilateral chest movement during 1.3 0.46 1.2 0.38
GRADE
manual ventilation, this time was considered as the
total time taken for intubation. The predictors of difficult intubation were also

comparable in both groups.Cormack lehane Grade VARIABLE GROUP GROUP P

I and II (A) was found in 99% and 1% respectively A B VALUE
of patients in Group A, 72% and 28% respectively of
Post 82.62 9.9 84.62 0.641
patients with Group B. intubation 8.33
Table 2: Total Time Taken For Intubation (after 10
min.) Pulse
VARIABLE GROUP GROUP P-VALUE Rate
A B
No statistically significant difference was observed
Time 25 7.3 35 6.7 0.197 in heart rate between the two study groups, at any
Taken for
point time. No statistically significant difference was
intubation
observed in mean arterial BP between the two study
No. of 1 0.0 1.14 0.000 groups, at any point time.
Attempts 0.35
Table 5: Complications
The mean tracheal intubation time was higher,
COMPLICATIONS GROUP A GROUP B
in Group B as compared to Group A. But the
differences were very minimal and were statistically SOFT TISSUE 4 7
not significant. All the cases in the Group A were INJURY
intubated in first attempt, but some of the patients TOOTH INJURY 0 0
in Group B had required more than 1 attempt, which SORE THROAT 0 0
resulted in higher mean number of attempts. HOARSNESS OF 0 0
Table 3: Maneuvers Required Facilitating VOICE
Intubation No significant differences in complications were
VARIABLE GROUP GROUP P-VALUE seen in all two groups.
A B Discussion
BURP 1.28 0.141 1.98 0.45 0.000 Present study was carried out to evaluate and
Manoeuver
compare the laryngeal view and intubation by
Use of 0.030 direct laryngoscope using macintosh blade with
1.94 0.240 1.88
BOUGI/ videolaryngoscope in adult patients requiring
0.331
STYLET endotracheal intubation. Total 100 adult patients
of age 18 to 65 years of either sex, ASA grade I/II
Table 4: Comparision Of Pulse Rate posted for elective surgery under general anaesthesia
VARIABLE GROUP GROUP P were included in this study.
A B VALUE Group A included 21 males and 29 females patients
Baseline 92 13.7 90.5 0.655 and Group B included 26 males and 24 females.
Pulse Rate 12.5 Demographic data were comparable in both groups.
Pulse Rate 86.9 11.4 87.02 0.966 All subjects in Group A showed vivid, wide,
before 10.6 magnified, true colour and binocular view of vocal
intubation folds without using greater retraction force. In Group
Post 0.693 B 72% subjects had Cormack Lehane grade 1 view,
87.14 11.2 88.76
intubation 11.04 38% with grade 2a, laryngeal view. Jungbauer,
(o min.) Pulse M. Schumann, V. Brunkhorst, et al6 concluded
Rate that Videolaryngoscopy when compared to direct
Post 83.78 10.5 85.2 0.805 laryngoscopy for difficult intubations provides a
intubation 9.09 significantly better view of the vocal cords, a higher
(after 5 min.) success rate, faster intubations and less need for
Pulse Rate optimizing maneuvers. Griesdale DE et al11 cocnluded
that Video laryngoscopy resulted in successful glottic

130
visualisation in 85% of patients compared to only 30% References

in direct laryngoscope group. 1. Prathima Padavarahalli Thammanna, Kavya
In our study the mean tracheal intubation time Marasandra Seetharam*, Tejesh Channasandra
(TTI) was 25 seconds in Group A and 35 seconds in Anandaswamy, Prapti Rath, Geetha Chamanhalli
Rajappa, Jancy Joseph, Comparison of Haemodynamic
Group B. Akbar SH, Oioi JS et al9, compared the
Response to Intubation with KingVision and
intubation profile and hemodynamic fluctuations
C-MAC® Videolaryngoscope in Adult,Archives of
between C-MAC video laryngoscope and Macintosh Anesthesiology and Critical Care (Spring 2020); 6(2):
direct laryngoscope with immobilised cervical spine. 65-70.
Murphy LD, Kovacs GJ, Reardon PM, Law JA et al14
also found similar findings. 2. Qazi Ehsan Ali, Syed Hussain Amir, Sarfraz Ahmed
et al,A comparative evaluation of King Vision video
The heart rate in both groups decreased from laryngoscope (channelled blade), McCoy, and
basal value after premedication with fentanyl and Macintosh laryngoscopes for tracheal intubation in
midazolam and lowered further after induction with patients with immobilized cervical spine, Ali et al. Sri
Propofol. Both groups were comparable and found Lankan Journal of Anaesthesiology: 25(2):70-75(2017)
not significant. 3. David W Healy, Oana Maties, David Hovord and
In both groups Systolic, diastolic and mean blood Sachin Kheterpal, A Systemic review of the role
of videolaryngoscopy in successful orotracheal
pressure decreased to lower value from basal to
intubation, Healy et al. BMC Anaesthesiology 2012,
premedication and to post induction. After intubation
12:32
they all increased to basal value from post induction
value at PT0 then started declining to remain stable 4. Jain D, Bala I, Gandhi K. Comparative effectiveness of
by about 5 minutes after intubation. Prathima McCoy laryngoscope and CMAC ® videolaryngoscope
Padavarahalli Thammanna et al1found that the in simulated cervical spine injuries. J Anaesthesiol Clin
Pharmacol 2016;32:59-64
hemodynamic responses to laryngoscopy and
intubation with King Vision videolaryngoscope were 5. Guyette F, Carlson JN, Callaway CW, Phrampus
similar when used in normotensive patients with P. Comparison of VideoLaryngoscopy and Direct
normal airway.1 Laryngoscopy in a Critical Care Transport Service.
Prehospital Emergency Care. April/June 2012; 2.
4 patients in Group A and 7 patients in Group B had
airway trauma. No patients had cuff perforation or 6. Jungbauer A, Schumann M, Brunkhorst V, Borgers
A et al. Expected difficult tracheal intubation: a
hypoxia in both the groups. Our study was conducted
prospective comparison of direct laryngoscopy and
in patients with normal airway and hence it cannot
video laryngoscopy in 200 patients. British Journal of
be applied to difficult airway management. For this Anaesthesia. 2009: 102(4): 546–50.
further study is required.
7. Ahmad N1, Zahoor A1, Riad W2, Al Motowa S3.
Conclusion Influence of GlideScope assisted endotracheal
From present study, we concluded that intubation on intraocular pressure in ophthalmic
patients. Saudi J Anaesth. 2015 Apr-Jun; 9(2):195-8
videolaryngoscope offers a better laryngeal view,
minimum external maneuvers, less attempts for 8. Amini S1, Shakib M2. Hemodynamic changes
intubation and provides better hemodynamic following endotracheal intubation in patients
response during laryngoscopy and intubation as undergoing cesarean section with general anesthesia:
compare to direct laryngoscopy with Macintosh application of glidescope® videolaryngoscope versus
blade. direct laryngoscope. Anesth Pain Med. 2015 Mar 30;
5(2):e21836.
Conflict of Interest: none
9. Akbar SH, Ooi JS. Comparison between C-MAC video-
Source of Support: Nil laryngoscope and Macintosh direct laryngoscope
during cervical spine immobilization. Middle East J
Anaesthesiol. 2015 Feb; 23(1):43-50.

10. Jones BM1, Agrawal A, Schulte TE. Assessing the 16. Platts-Mills TF1, Campagne D, Chinnock B, Snowden
efficacy of video versus direct laryngoscopy through B, Glickman LT, Hendey GW. A comparison of
retrospective comparison of 436emergency intubation GlideScope video laryngoscopy versus direct
cases. J Anesth. 2013 Dec; 27(6):927-30. laryngoscopy intubation in the emergency department.
Acad Emerg Med. 2009 Sep; 16(9):866-71.
11. Griesdale DE1, Liu D, McKinney J, Choi PT.
Glidescope® videolaryngoscopy versus direct 17. Van Zundert A1, Maassen R, Lee R, Willems R,
laryngoscopy for endotracheal intubation: a systematic Timmerman M, Siemonsma M, Buise M, Wiepking M. A
review and meta-analysis. Can J Anaesth. 2012 Jan; Macintosh laryngoscope blade for videolaryngoscopy
59(1):41 reduces stylet use in patients with normalairways.
Anesth Analg. 2009 Sep; 109(3):825-31.
12. Boedeker BH1, Berg BW, Bernhagen M, Murray WB.
Direct versus indirect laryngoscopic visualization 18. Kanchi M1, Nair HC, Banakal S, Murthy K, Murugesan
in human endotracheal intubation: a tool for virtual C. Haemodynamic response to endotracheal intubation
anesthesia practice and teleanesthesiology. Stud in coronary artery disease: Direct versus video
Health Technol Inform. 2008; 132:31-6. laryngoscopy. Indian J Anaesth. 2011 May; 55(3):260-5.
13. Akihisa Y., Maruyama K., Koyama Y., Yamada 19. Ke J1, Xu Q. [Comparison the applications of tracheal
R., Ogura A., Andoh T, Comparison of intubation intubation with GlideScope video laryngoscope and
performance between the King Vision® and Macintosh Macintosh direct laryngoscope in snoring patients].
laryngoscopes in novice personnel: a randomized, [Article in Chinese] Lin Chung Er Bi Yan Hou Tou Jing
crossover manikin study. Anaesth 2014; 28:51-7. Wai Ke Za Zhi. 2013 May; 27(9):468-70.
14. Murphy LD, Kovacs GJ, Reardon PM, Law 20. El-Tahan MR1, Doyle DJ, Khidr AM, Abdulshafi M,
JA.Comparison of the King Vision video laryngoscope Regal MA, Othman MS. Use of the King Vision™
with the Macintosh laryngoscope. Anaesth 2014; video laryngoscope to facilitate fibreoptic intubation
47:239-46. in critical tracheal stenosis proves superior to the
GlideScope®.Can J Anaesth. 2014 Feb; 61(2):213-4.
15. Qazi Ehsan Ali; Syed Hussain Amir; ShaistaJamil;
Sarfaraz Ahmad. Airtraq and King Vision video
laryngoscope as an intubating aid in adult patients.
Acta Anaesth. Belg 2015; 66: 81-85.

Comparative Analysis to Assess Pregnancy Related Issues

among Women over 35 Years of Age
Madhusudan H Gadhvi1, Bhavesh M Nayak2, Manish G Maheshwari3

1,2
Senior Resident, Department of Obstetrics & Gynecology, Banas Medical College & Research Institute, Palanpur, Gujarat
3
Assistant Professor, Department of Obstetrics & Gynecology, Banas Medical College & Research Institute, Palanpur, Gujarat
How to cite this article: Madhusudan H Gadhvi, Bhavesh M Nayak, Manish G Maheshwari et al Comparative
Analysis to Assess Pregnancy Related Issues among Women over 35 Years of Age. Volume 13 | Issue 4 |
Abstract
Background and Aim: Advanced maternal age (AMA) is seen by patients and healthcare professionals, to be correlated
with poorer outcomes to pregnancies. This is largely because of the higher incidence of chronic medical conditions among
older women. The present study has been conducted to reckon the strength of the association between maternal age and
obstetric issues pertaining to women.
Material and Methods: The present study was conducted in the Department of Obstetrics and Gynecology, tertiary care
institute of India. A total number of patients included in the study were 280 which were divided into two groups based
on age of patients. Group A consists of 200 pregnant women aged < 35 years and group B consists of 80 pregnant patients
aged ≥35 years. Routine antenatal examination along with some additional lab investigations like KFT; LFT etc. were
performed.
Results: The difference in number of cesarean sections, assisted pregnancies and early pregnancy loss between group A
and group B was statistically significant. We found a significant difference between group A and group B with respect to
early pregnancy loss, C-section, antepartum, intrapartum and postpartum complications (p<0.001).
Conclusion: Advanced maternal age is linked with disastrous pregnancy issues. Without any doubt, extreme maternal
age invites a catastrophe of pregnancy related complications that include antenatal, intrapartum and postpartum
complications. Natural conception becomes all the more challenging and hence the role assisted pregnancies comes into
play.
Key Words: Advanced maternal age, Gynecology, Postpartum Complications, Pregnancy,
Introduction has fallen 61% from 1991. Maternal age has become
Maternal age at childbearing has dramatically all the more important factor to determine the
shifted in the last decades due to a broad range of severity of complications associated with pregnancy.
social and cultural determinants. In Italy the mean However, there is no universal definition of advanced
age at delivery rose from 25.2 years in 1981 to 31.7 reproductive age in women, in part because the
in 2015.1,2 This trend toward delayed childbearing effects of increasing age occur as a continuum, rather
is reported worldwide (e.g. USA or China)3-5, and than as a threshold effect. Fertility clearly declines
comes, in parallel, with a decline in pregnancies at with advancing age, especially after the mid-30s, and
a younger age, so that these are increasingly rare in women who conceive are at greater risk of pregnancy
developing countries. The teen birth rate in the USA complications.1
Dr Madhusudan H Gadhvi
Department of Obstetrics & Gynecology, Banas Medical College & Research Institute, Palanpur, Gujarat
The risks related to pregnancy in those over 35 the study were evaluated for different parameters at
years old, especially primiparity, can be understood outpatient department of obstetrics and gynecology.
from two perspectives: first, the actual medical risks, Routine antenatal examination along with some
and second, the acceptability of the risks as defined additional lab investigations like KFT; LFT etc. were
through social discourse among different groups performed. All women who qualified the inclusion
within society.6,7 Medical risks are related to an ageing criteria were asked for monthly follow-up till 28
reproductive system and an ageing body, whereas weeks and then fortnightly follow was advised to
social discourse prescribes the way in which older these patients up to 36 weeks and thereafter weekly
pregnant women are regarded as mothers, and when follow-up was recommended to them.
it is “considered” that women “should have” children.
It has been said that pregnant women and healthcare Statistical analysis
providers understand the risks differently: pregnant The recorded data was compiled and entered in a
women evaluate the risks subjectively, through their spreadsheet computer program (Microsoft Excel
own experiences, whereas healthcare providers assess 2007) and then exported to data editor page of SPSS
the risks in an apparently more objective way.6 version 15 (SPSS Inc., Chicago, Illinois, USA). For all
tests, confidence level and level of significance were
Advanced maternal age (AMA) is seen by patients
set at 95% and 5% respectively.
and healthcare professionals, to be correlated with
poorer outcomes to pregnancies. This is largely Results
because of the higher incidence of chronic medical Table 1, show that there were 200 women aged< 35
conditions among older women. Women of AMA years and 80 women aged ≥35 years. The difference
are often treated as if they are in need of the level of in number of cesarean sections, assisted pregnancies
care necessary for any high-risk pregnancy; and they and early pregnancy loss between group A and group
are treated differently even if there is no scientific B was statistically significant. Evidently, out of 200
basis for different treatment and there are no medical women in group A, (35%) had cesarean section, (6%)
problems evident.8 women had early pregnancy loss and (2.5%) had
There are multifaceted factors that encourage assisted conception. On the other hand, in group B
women to delay pregnancy process which includes out of 80 patients, (38.7) patients had cesarean section,
financial goals, longer life expectancy, higher (16.2%) had early pregnancy loss and (11.2%) women
education, pursuit of career and sometimes due to had assisted conception.
miscalculations women halt the pregnancy process
We observe that out of 200 women in group A,
and subsequently invite major complications like;
74 had antepartum complications, of them (12%)
chromosomal abnormality, miscarriages, ectopic
had preterm delivery, (10%) had induced labour,
pregnancies and congenital anomalies, pre-
(7.5%) had hypertensive disorder of pregnancy, (7%)
eclampsia, gestational diabetes, intrauterine growth had gestational diabetes mellitus and (0.6%) had
restriction and antepartum hemorrhage.9-13 There placenta previa. However, in B out of 80 women, 60
are some studies that have explored the association developed antepartum complications, of them (20%)
between maternal age and pregnancy outcome. had hypertensive disorder of pregnancy, (23.75%)
Cesarean sections, instrumental assisted deliveries had preterm delivery, (8.75%) had induced labour,
are more commonly adopted procedures among (8.75%) had gestational diabetes mellitus and (1.2%)
these women.14 developed placenta previa. Statistically, found that
Material and Methods both groups differ significantly from one another
with respect to each and every antepartum, intra and
The present study was conducted in the Department
postpartum complication except for induced labour
of Obstetrics and Gynecoogy, tertiary care institute of
and vaginal trauma.
India. A total number of patients included in the study
were 280 which were divided into two groups based We observe that both the groups are statistically
on age of patients. Group A consists of 200 pregnant comparable with respect to NICU admission with
women aged < 35 years and group B consists of 80 a p=0.15 which means that the proportion of NICU
pregnant patients aged ≥35 years. Women who meet admissions in both the groups is comparable.
inclusion criteria and agreed to willfully participate in

134
Table 1: Comparison of various parameters In all developed countries, the deep social and
economic transformations of recent decades have led
Variables Group A Group B P
to higher life standards together with a deferment of
(200) (80) value
parenthood.2,3,16 This phenomenon is due to multiple
No % No %
determinants: global aging of population with an
Assisted 5 2.5 9 11.2 0.05* increasing prevalence of women aged between 35
conception and 45 years, the change in social customs with a rise
Early 12 6 13 16.2 0.001* in divorces and second marriages, improvements to
pregnancy women’s educational and professional outlooks as
loss well as the diffusion of contraception. The availability
Cesarean 70 35 31 38.7 0.02* of contraception has made women protagonists of
section their childbearing options. Asked to explain the
* indicates statistically significance at p≤0.05 main determinants of their pregnancy plan, a survey
group of women mentioned educational and career
Table 2: Comparison of antepartum, intrapartum
and postpartum complications between the groups achievements, financial goals and emotional stability,
illustrating how individual readiness seems to be an
Variables Group A (200) Group B (80) P essential factor in guiding childbearing options.16,17
No % No % value
Out of a total of 280 women patients, 200 were<
Antepartum complications 35 years and 80 women were ≥35 years. So, the
Hypertensive 15 7.5 16 20 0.003* classification of patients with respect to age threshold
disorder of of 35 year was made. The patients were divided in
pregnancy two groups; group A consists of 200 women with
Gestational 14 7 7 8.75 0.05* age< 35 years and group B consists of 80 women with
diabetes age ≥35 years. The difference in number of cesarean
mellitus sections, assisted pregnancies and early pregnancy
Placentia 1 0.5 1 1.2 0.003* loss between group A and group B was statistically
previa significant. Evidently, out of 200 women in group A,
Preterm 24 12 19 23.75 0.001* (35%) had cesarean section, (6%) women had early
delivery pregnancy loss and (2.5%) had assisted conception.
Induced 20 10 7 8.75 0.9 On the other hand, in group B out of 80 patients,
labour (38.7) patients had cesarean section, (16.2%) had early
pregnancy loss and (11.2%) women had assisted
Intrapartum and postpartum complications
conception. Contemporary to the research, Pawde et
Vaginal 7 3.5 7 8.75 0.25
al reported that women with 35 years of age and above
trauma
had significantly higher rates of assisted conception
Postpartum 4 2 11 13.75 0.001* (12.6%) compared to (3.5%) in women with 35 years
hemorrhage old which in consonance to our observation, similarly
* indicates statistically significance at p≤0.05 they reported higher rates of early pregnancy (18.9%)
in women with 35 years of age and beyond compared
Discussion to (10.5%) in women with< 35 years of age.17 Several
In the Western world, the average age at which authors have reported the similar kind of observations
first time mothers give birth is continually rising.15 with regard to early pregnancy loses and assisted
Complications and risks associated with pregnancy conceptions.16,17
among women of AMA have been addressed in
Several authors have reported the similar kind of
numerous studies from different viewpoints, mostly
observations with regard to early pregnancy loses
focusing on the medical risks associated with higher
and assisted conceptions.16,17 We analyzed patients
maternal age. The purpose of this research was to
for antepartum intra and postpartum complications
profile how women over 35 years and the associated
and observed that 74 had antepartum complications,
pregnancy-related risks have been described in
of them (12%) had preterm delivery, (10%) had
previous research.
induced labour, (7.5%) had hypertensive disorder of

pregnancy, (7%) had gestational diabetes mellitus and conception becomes all the more challenging and
(0.6%) had placenta previa. However, in B out of 80 hence the role assisted pregnancies comes into play.
women, 60 developed antepartum complications, of
them (20%) had hypertensive disorder of pregnancy,
ethical committee and written Informed consent
(23.75%) had preterm delivery, (8.75%) had induced
was taken from all the participants.
labour, (8.75%) had gestational diabetes mellitus and
(1.2%) developed placenta previa. In tune with our Source of funding : Nil
observations, most of the authors have also reported Conflict of Interest : None declared
higher incidence of hypertensive disorders in women
aged 35 years and above.18,19 Pawde et al also reported References
significantly higher rates of hypertension (17.54%), 1. Loghi M, Crialesi R, editors. La salute riproduttiva
preterm delivery (17.5%), gestational diabetes della donna. Roma: Istituto Nazionale di Statistica;
(10.52%) in women aging 35 years or above compared 2017.
to hypertension (7.23%), preterm delivery (10.3%),
2. Sabbadini L. Gravidanza e parto. Roma Istat. 2001;12.
gestational diabetes (6.43%) in women less than
35 years of age.14 Similar to our observations, some 3. Sobotka T. Post-transitional fertility: childbearing
authors have also reported significant difference postponement and the shift to low and unstable fertility
between the two groups with respect to placenta levels. Vienna: Vienna Institute of Demography
Working Papers 01/2017; 2017.
previa, gestational diabetes.12,20
4. Shan D, Qiu PY, Wu YX, Chen Q, Li AL, Ramadoss
In present study we found that the difference in
S, et al. Pregnancy outcomes in women of advanced
number of intrapartum and postpartum complications maternal age: a retrospective cohort study from China.
is statistically significant in favor of group A. We Sci Rep. 2018;8:12239.
observed that out of 200 women in group A, (3.8%)
had vaginal trauma and (1.9%) had postpartum 5. Hamilton BE, Martin JA, Osterman MJK, Curtin SC,
Matthews TJ. Births: final data for 2014. Natl Vital Stat
hemorrhage. However, in group B, out of 80 women,
Rep. 2015;64:1–64.
(9.5%) had vaginal trauma and (12.9%) had postpartum
hemorrhage and the difference was significant with 6. Carolan M, Nelson S. First mothering over 35 years:
respect to postpartum hemorrhage but insignificant questioning the association of maternal age and
with respect to vaginal trauma. Labri et al have also pregnancy risk. Health Care Women Int 2007; 28(6):
reported a significant difference between the two 534-55.
groups with respect to vaginal trauma and postpartum 7. Carolan MC. Towards understanding the concept of
hemorrhage.21 However, Pawde et al reported that risk for pregnant women: some nursing and midwifery
(5.26%) of women with 35 years of age and above implications. J Clin Nurs 2009; 18(5): 652-8.
had intrapartum complications compared to (0.9%) 8. Braveman FR. Pregnancy in patients of advanced
in women with less than 35 years of age, reportedly maternal age. Anesthesiol Clin 2006; 24(3): 637-46.
there was a significant difference in intrapartum
9. Hansen JP. Older maternal age and pregnancy
complications between the 2 groups, however, they
outcome: A review of the literature. Obstet Gynecol
found that both the groups are comparable with
Surv. 1986;41:726-42.
respect to postpartum complications.14
10. Carolan MC. Towards understanding the concept of
The reason for the insignificance between the groups risk for pregnant women: some nursing and midwifery
with respect to NICU admission can be attributed to implications. J Clin Nurs. 2009;18(5):652-8.
the management and timely intervention of health
11. Shimrit SY, Amalia l, Arnon W. A significant linear
care workers.
association exists between advanced maternal age
Conclusion and adverse perinatal outcome. Arch Gynecol Obstet.
2011;283(4):755-9.
Advanced maternal age is linked with disastrous
pregnancy issues. Without any doubt, extreme 12. Yogev Y, Melamed N, Haroush B. Pregnancy outcome
maternal age invites a catastrophe of pregnancy at extremely advanced maternal age. Am J Obstet
related complications that include antenatal, Gynecol. 2010;203:558:e1-7.
intrapartum and postpartum complications. Natural

136
13. Ales KL, Druzin ML, Santini DL. Impact of advanced 18. Delbaere I, Verstraelen H, Goetgeluk S. Pregnancy
maternal age on the outcome of pregnancy. Surg outcome in primiparae of advanced maternal age.
Gynecol Obstet. 1990;171:209-16. EJOG. 2007;135:41-6.
14. Pawde Anuya A, Kulkarni Manjiri P, Jyothi U. 19. Jacobsson B, Ladfors L, Milsom I. Advanced maternal
Pregnancy in women aged 35 years and above: a age and adverse perinatal outcome. Obstet Gynecol.
prospective observational study. J Obstetr Gynecol 2004;104:727-33.
India. 2015;65(2):93-6.
20. Carloan MC, Davey M, Biro M. Very advanced
15. Zasloff E, Schytt E, Waldenstrom U. First time mothers’ maternal age and morbidity in Victoria, Australia: a
pregnancy and birth experiences varying by age. Acta population-based study. BMC Pregnancy Childbirth.
Obstet Gynecol Scand 2007; 86(11): 1328-36. 2013;13:80-9.
16. Cooke A, Mills TA, Lavender T. ‘Informed and 21. Larbi RKT, Buchmann EJ, Matshidze PR. Pregnancy
uninformed decision making’– women’s reasoning, outcome in urban black South African women aged 35
experiences and perceptions with regard to advanced years and older. J Obstet Gynaecol. 2000;20:259-62.
maternal age and delayed childbearing: a meta-
synthesis. Int J Nurs Stud. 2010;47:1317–29.
17. Leridon H. Can assisted reproductive technology

compensate for the natural decline in fertility with
age? A model assessment. Hum Reprod. 2004;19:1548-
53.

Diabetic Retinopathy and Typical Retinitis Pigmentosa
Mandeep Kour1
1
Senior Resident, Department of Ophthalmology, Adesh Institute of Medical Sciences, Bathinda, Punjab
How to cite this article: Mandeep Kour et al Diabetic Retinopathy and Typical Retinitis Pigmentosa. Volume 13 |
Issue 4 | October-December 2022
Abstract
A 39-year-old woman with typical retinitis pigmentosa (RP) for 9 years and a positive family history of night blindness
was diagnosed with diabetes mellitus (DM). She developed proliferative diabetic retinopathy (PDR) during the course
of disease. She was promptly managed with pan retinal photocoagulation (PRP). PDR developing in a case of typical
RP is extremely rare and has not been reported in the literature to date. Recognition of this rare, vision threatening
complication, points out a definite need to further look deep into the pathogenesis of diabetic retinopathy.
Keywords: Diabetic, Recognition, Retinal, Retinitits
Introduction illness and family history of systemic diseases was

Diabetic retinopathy is an important cause of unremarkable.
preventable blindness and retinitis pigmentosa is an A detailed ocular examination was performed.
ocular condition known to have a protective effect Visual acuity was 20/30 in both eyes and intraocular
against development of diabetic retinopathy.1 We pressure 20 mm Hg by non-contact tonometer.
describe a case of a 39-year-old woman with typical Anterior segment evaluation of both eyes showed
retinitis pigmentosa who developed proliferative early posterior sub capsular cataract (P1-P2 by LOCS
diabetic retinopathy. To the best of our knowledge, III classification). The patient did not have evidence
this is the first case to be reported of proliferative of anterior segment inflammation on slit lamp
diabetic retinopathy in a case of typical retinitis examination. A detailed fundus examination of both
pigmentosa. eyes revealed typical bony spicule pigmentation in
the mid-peripheral region, arteriolar attenuation and
Presentation
pallor of the disc. In addition, micro aneurysms were
A 39-year-old woman presented with painless seen in both eyes and neovascularisation of the disc
progressive loss of vision of 1 year duration, more in was noted in the left eye . There was no evidence of
the left than the right eye. She had night blindness vitreous floaters/opacities, retinal vascular sheathing,
for 9 years and a significant positive family history retinal holes, tears, retinal telangiectasia or subretinal
of night blindness, with her father and two siblings exudation. A clinical diagnosis of bilateral typical
having similar symptoms. She was a diabetic on retinitis pigmentosa with mild non–proliferative
treatment with oral hypoglycaemic agents and insulin diabetic retinopathy of the right eye and proliferative
for 2 years. There was no history of other systemic diabetic retinopathy of the left eye was made.
Corresponding author
Dr mandeep Kaur
Senior resident
AIMSR
Mob: 9464780122
138
Automated perimetry with a Humphrey field have shown a negative coincidence of DR and RP. They
analyser revealed bilateral constriction of visual suggested that attenuation of the blood vessels and
field, which was correlating with the finding of RP the presence of early posterior vitreous detachment
. Fluorescein angiography was carried out, which prevented the progression to proliferative stage.1
revealed the presence of multiple point hyper- Arden et al, in their detailed survey of patients with
fluorescent areas in the perifoveal region of both eyes DM and RP, showed that there was no evidence of
with leak in the late phase and blocked fluorescence proliferative changes in the retina in patients with RP.
caused by the bony spicule pigmentation in the They explained that the possible loss of rods decreased
mid-periphery. In addition, there was also, in the the severity of hypoxia and production of vascular
left eye, hyper-fluorescence at the disc, which endothelial growth factor, thereby preventing the
increased in the mid to late phase suggestive of changes of diabetic retinopathy from developing in
definite neovascularisation at the disc. Fluorescein patients with RP.4 Spalton et al5 explained the role of
angiography confirmed the clinical diagnosis of inflammation due to degeneration of photoreceptors
proliferative diabetic retinopathy (PDR) in the left and retinal pigment epithelium in the development of
eye with neovascularisation of the disc along with retinal oedema.
presence of microaneurysms and thickening of
There are anecdotal reports of retinal vascular
the macula not involving the centre, and mild non-
abnormalities previously described in RP patients and
proliferative diabetic retinopathy in the right eye.
include a Coats-type RP, sub retinal exudation, retinal
The systemic investigations revealed an detachment, and neovascularisation of disc and
uncontrolled hyperglycaemic status with fasting periphery. In all these reported cases, loss of receptor
blood glucose of 240 mg% and glycated hemoglobin cells, RPE dysfunction, altered metabolic environment
8.4%. The patient’s blood urea was 23 mg% and of the retinal vasculature and capillary non perfusion
serum creatinine was 0.9 mg%. Her biochemical and were identified as possible causes. These cases were
haematological investigations were unremarkable not associated with diabetes mellitus.6 7 Hotta and
except for uncontrolled hyperglycaemia. Hotta8 described an isolated case of diabetic macular
oedema in an RP patient that was managed with
The patient was promptly managed with pan
trans-Tenon’s retrobulbar triamcinolone infusion.
retinal photocoagulation (PRP) of the left eye in three
sittings, and strict glycaemic control. At the end of Our patient was a case of typical retinitis
1 year follow-up, the patient had a stable disease in the pigmentosa with characteristic fundus appearance.
left eye post PRP. The right eye showed progression The form of inheritance in this patient is unlikely
of the diabetic retinopathy to proliferative stage, to be of an X linked recessive nature considering
with appearance of neovascularisation, which was that she was a female. The possibility of autosomal
confirmed by fluorescein angiography . The patient dominant or recessive inheritance remains, although
was managed with PRP of the right eye in three we could not perform genetic tests because of
sittings. logistic and financial constraints. The case under
discussion was a known case of RP with uncontrolled
After 2 years follow-up, the patient has stable
hyperglycaemia. She did not have evidence of anterior
disease in both eyes post PRP with absence of leak
segment inflammation on slit-lamp examination. On
in the fluorescein angiography . Visual acuity was
detailed fundus examination, there was no evidence
maintained at 20/40 in both eyes.
of vitreous floaters/opacities, retinal vascular
Discussion sheathing, retinal holes, tears, retinal telangiectasia
Diabetic retinopathy and retinitis pigmentosa are two or subretinal exudation. Her biochemical and
common conditions not shown to coexist in the same haematological investigations were unremarkable
individual. In a large population based study, Chen et except for the uncontrolled hyperglycaemia. The
al2 clearly showed that retinitis pigmentosa reduces presence of microaneurysms and new disc vessels
the risk of proliferative diabetic retinopathy. Tarr et in addition to presence of uncontrolled DM led us
al3 have given a detailed description of the various to consider PDR in this case. Arden4 suggested that
interconnecting pathways and key contributors to the the degree of functional retina at the time of onset of
development of diabetic retinopathy. Sternberg et al DM could influence the development of DR in cases

of RP, which can be considered in our case as well, 4. Arden GB. The absence of diabetic retinopathy in
considering the age of our patient, the duration of RP patients with retinitis pigmentosa: implications
and the duration of DM. for pathophysiology and possible treatment. Br J
Ophthalmol 2001;85:366–70. 10.1136/bjo.85.3.366
Ethical Clearance : Taken From Ethical Committee [PMC free article] [PubMed] [CrossRef] [Google
of Institute Scholar]
Interest of Conflict: none 5. Spalton DJ, Bird AC, Cleary PE. Retinitis pigmentosa
and retinal oedema. Br J Ophthalmols 1978;62:174–82.
Funding: self
10.1136/bjo.62.3.174 [PMC free article] [PubMed]
References [CrossRef] [Google Scholar]
1. Sternberg P Jr, Landers MB III, Wolbarsht M. The 6. Khan JA, Ide CH, Strickland MP. Coats’-type retinitis
negative coincidence of retinitis pigmentosa and pigmentosa. Surv Ophthalmol 1988;32:317–32.
proliferative diabetic retinopathy. Am J Ophthalmol 10.1016/0039-6257(88)90094-X [PubMed] [CrossRef]
1984;97:788–9. 10.1016/0002-9394(84)90518-X [Google Scholar]
[PubMed] [CrossRef] [Google Scholar] 7. Uliss AE, Gregor ZJ, Bird AC. Retinitis pigmentosa
2. Chen YF, Chen HY, Lin CC et al. . Retinitis pigmentosa and retinal neovascularization. Ophthalmology
reduces the risk of proliferative diabetic retinopathy: a 1986;93:1599–603. 10.1016/S0161-6420(86)33539-5
nationwide population-based cohort study. PLoS ONE [PubMed] [CrossRef] [Google Scholar]
2012;7:e45189 10.1371/journal.pone.0045189 [PMC 8. Hotta K, Hotta J. Cystoid macular edema related to
free article] [PubMed] [CrossRef] [Google Scholar] diabetic retinopathy with Retinitis pigmentosa. Jpn J
3. Tarr JM, Kaul K, Chopra M et al. . Pathophysiology Ophthalmol 2006;50:390–2. 10.1007/s10384-005-0332-7
of diabetic retinopathy. ISRN Ophthalmol [PubMed] [CrossRef] [Google Scholar]
2013;2013:343560 10.1155/2013/343560 [PMC free
article] [PubMed] [CrossRef] [Google Scholar]

A Study on the Spectrum of Thyroid Abnormalities in Liver Disease

and Its Correlation with Liver Function
Manju Sharma¹, Anju Mittal², Sangeeta Jain Sharma³, Atul Kumar4,

Akshay Sharma5, Yatin Kumar6
1
Assistant Professor, Dept of biochemistry, Muzaffarnagar medical college,
2
Associate Professor, Dept of Biochemistry, Muzaffarnagar medical college,
3
Assistant Professor, Dept of Community Medicine, Muzaffarnagar Medical College,
4
Associate Professor, Dept of Microbiology, Muzaffarnagar Medical College,
5
Assistant Professor, Dept of Medicine, Muzaffarnagar Medical College,
6
Senior Resident, Dept of Medicine, Muzaffarnagar Medical College
How to cite this article: Manju Sharma, Anju Mittal, Sangeeta Jain Sharma, Atul Kumar, Akshay Sharma,
Yatin Kumar6. A Study on the Spectrum of Thyroid Abnormalities in Liver Disease and Its Correlation with
Liver Function. Volume 13 | Issue 4 | October-December 2022
Abstract
Introduction: liver diseases are associated with endocrine disturbances and secondary dysfunction of endocrine organ
which apparent hormonal imbalance. This study aims to find out the correlation between the levels of FT3, FT4, TSH and
severity of liver disease in Chronic Liver Disease patients.
Materials and Method: A total of 100 subjects with Chronic Liver disease satisfying inclusion and exclusion criteria
visiting medicine OPD and admitted in IPD of Muzaffarnagar Medical College during the period of 18 months was taken
for study which was a Cross Sectional Observational Study.Thyroid function tests which includes FreeT3, FreeT4, TSH
was done for all patients and tests such as Anti-TPO antibodies, USG neck, Doppler thyroid, FNAC thyroid was done
wherever indicated The liver function tests including total and direct bilirubin, total protein and albumin, AST and ALT,
APTT, PT, INR was done for all patients and USG abdomen and Oesophago-gastro-duodenoscopy was done wherever
indicated.
Results: The mean duration of liver disease in our study population was 5.92 ± 4.61 years (range 1-26 years). The mean
FT3 levelwas 2.3059 ± 0.8883 p Mol/L. The mean FT4 level was1.1689 ± 1.0806 ng/dL . The mean TSH level was 3.3198 ±
1.0173 m IU/mL The mean total bilirubin was 8.445 ± 4.3438 mg/dL .
Conclusion: Thyroid dysfunction forms important part of spectrum of Chronic liver disease. Patients with liver disease
should be evaluated for thyroid dysfunction periodically.
Keywords: Child-Pugh-Turcott score, FT3,FT4 ,TSH,Chronic liver disease
Introduction (NAFLD) is the leading cause of chronic liver

Cirrhosis and chronic liver disease are the leading disease in the western world [2] . In India, the overall
causes for mortality and morbidity in the whole prevalence of Non-Alcoholic Fatty Liver disease is
world [1] . As a consequence of increasing prevalence 5-30% [3] . The functions of liver include 1. Metabolism
of obesity, Non-Alcoholic Fatty Liver Disease 2. Biosynthesis 3. Detoxification and excretion 4.
Storage.
Manju sharma
Assistant Professor
Muzaffarnagar Medical College, 207, Rambagh Road, Muzaffarnagar, UP - 251001
E-Mail: [email protected]
Liver diseases are associated with endocrine College . Inclusion criteria: 1. Patients with clinical,
disturbances and secondary dysfunction of endocrine biochemical and radiological evidence of Chronic
organ. This results in signs of apparent hormonal Liver Disease. 2. Patients who himself or his/her
imbalance [4,5]. Thyroid hormone is necessary for relatives gave consent 3. Above 18 years.Exclusion
normal growth, development, energy balance, criteria: 1. Patients with diabetes. 2. Pregnant subjects.
and metabolism of the individual. It plays a role 3. Patient with prior h/o thyroid disease. 4. Patient
in determining the height of the individual by receiving drugs that may interfere with thyroid
determining the skeletal growth [6]. It is also essential hormone metabolism and function. 5. Patients with
for neural tissue growth and development, lung any other chronic illness. 6. Below 18 years of age.
maturation, maintenance of hepatocytes [7], renal Sample size calculation- Confidence Interval:95% (Z),
tubular cells, cardiovascular function regulation and Precision of study :15% of P(d) Prevalence(P) : 61% [15]
hemodynamics. The risk of cardiovascular mortality .
Formula :4×P(1-P)/d2 Sample size :100 . Informed
and atrial fibrillation is higher in individuals with consent was taken from the subjects who were
subclinical hypo or hyperthyroidism [8]. Thyroid included in the study. Socio- demographic details
hormones influence hepatic lipid homeostasis was recorded. Thyroid function tests which includes
through stimulation of free fatty acid delivery to liver FreeT3, FreeT4, TSH was done for all patients and
and increase in beta oxidation of fatty acid. Through tests such as Anti-TPO antibodies, USG neck, Doppler
these mechanisms, thyroid hormones affect hepatic thyroid, FNAC thyroid was done wherever indicated.
fat accumulation which leads to Non-Alcoholic Fatty The liver function tests was done for all patients and
Liver Disease [9]. Individuals with hypothyroidism are tests such as USG abdomen and Oesophago-gastro-
1.5-2 times more likely to have Chronic Liver Disease duodenoscopy was done wherever indicated. The
[10]
. Liver plays an important role in maintaining the relationship between the levels of Free T3, FreeT4, and
level of thyroid hormone. Thyroid gland secretes TSH with severity of liver disease in patients having
Thyroxine (T4) and Tri-Iodo Thyronine (T3) with T4 chronic liver disease was analysed using appropriate
at the rate of 90 microgram/day and T3 at the rate statistical tests. Study tools Self-made questionnaire
of 6.4 microgram/day. 100% of the total T4 and 20% containing questions on socio-demographic details,
of the total T3 is secreted by thyroid gland [11]. Liver age, gender, education, socio economic status, age
contributes about 30-40% of peripheral conversion of of onset, duration of illness, smoking, alcoholism,
T4 to T3 [12] . The thyroid hormone is inactivated by exposure to risk factors, family history of thyroid
D3 deiodinase in liver [13] . 80% of T3 and 97.5% of disorders, drug history was sought. All relevant
rT3 is produced by deiodination in peripheral tissue. investigations were noted. Child-Pugh-Turkot score
Liver plays an important role in thyroid hormone to classify the degree of cirrhosis. It ranges from 5 to
metabolism [14,15] This study aims to find out the 15.
correlation between the levels of FT3, FT4, TSH and
Statistical analysis- After completing the data
severity of liver disease in Chronic Liver Disease
collection, data was entered and analysed using
patients.
MSExcel and epi info. Quantitative variables were
Aims and Objectives expressed in mean and standard deviation. Qualitative
variables were expressed in fractions, percentage and
AIMS AND OBJECTIVES AIM To evaluate the
proportion. The data of the quantitative variables
Thyroid functions in patients with liver disease.
was analysed by using chi-square test and qualitative
OBJECTIVE To assess the severity of liver dysfunction
variables by using appropriate ‘t’ test.
in relation with interpretation of thyroid functions
MATERIALS AND METHODS : A total of 100 Results
subjects with Chronic Liver disease satisfying A hospital based cross-sectional study was done on
inclusion and exclusion criteria visiting medicine chronic liver disease patients admitted in department
OPD and IPD of MMCH, during the period of 18 of General Medicine in Muzaffarnagar medical
months was taken for study.(2020-21) .After clearance college and hospital, Muzaffarnagar.
from ethical committee ref no MMC/IEC/2020/70
Mean duration of liver disease The mean duration
dated 27/01/2020 the research work was started
of liver disease in our study population is 5.92 ±
in Muzaffarnagar medical college. Cross Sectional
4.61 years (range 1-26 years). Free T3 The mean FT3
Observational Study in Muzaffarnagar Medical

142
level in patients included in our study is 2.3059 ± FREE T4 AND CPT Class
0.8883 p Mol/L (range 0.14-5.7 p Mol/L). Free T4 Among the study population, 27 patients (27%) had
The mean FT4 level in our patients included in the reduced FT4, 69 patients had normal FT4(69%) and 4
study is 1.1689 ± 1.0806 ng/dL (range 0.45-12.2 had increased FT4 (4%). Among the CPT-A patients,
ng/dL). TSH The mean TSH level in the patients 1 patient (25%) had reduced FT4, 3 (75%) had normal
included in our study is 3.3198 ± 1.0173 m IU/mL FT4. Those patients with CPT class B, 09 (20.93%)
(range 0.4-5.11 m IU/mL). Total bilirubin The mean patients had reduced FT4, 31 patients (72.09%) had
total bilirubin in the chronic liver disease patients in normal FT4 and 3 (6.98%) had increased FT4. In CPT
our study is 8.445 ± 4.3438 mg/dL (range 1.4-20.8 ) class C patients, 17 (32.07%) patients had reduced
Of the various etiologies studied, alcohol and other FT4, 35 patients (66.03%) had normal FT4 and 1 (1.9%)
hepatotoxic drugs accounts for 81% of liver disease. had increased FT4. P value is found to be 0.5217 and is
19% of liver disease is caused by viral etiology Of the statistically insignificant.
100 patients, 97 (97%) had signs of liver cell failure.
Correlation: TSH AND CPT
29% and 19% of the patients had upper GI bleed
and hepatic encephalopathy respectively. 59% had FIG 1
hepatosplenomegaly, 53% of our patients had CPT
Class C (advanced, decompensated liver disease) and
43% of the patients had CPT Class B (moderate liver
disease) and 4% had CPT Class A (well compensated
liver disease)
TSH & CPT Class

Among the study population, 22 patients (22%) had
increased TSH and 78 had normal TSH (78%). Among
the CPT-A patients, 3 had increased TSH (75%) and
1 had normal TSH (25%). Those patients with CPT
class B, 35 patients (81.39%) had normal TSH and 8 TSH level is found to be negatively correlated with
(18.61%) had increased TSH. In CPT class C patients, Child-Pugh-Turcott score with correlation co-efficient
42 patients (79.24%) had normal TSH and 11 (20.76%) of -0.062 but it is found to be statistically insignificant
had increased TSH. In our patients, none had reduced with P value 0.119086.
TSH to suggest hyperthyroidism. CPT class C patients
had more prevalent hypothyroidism than CPT-B. Correlation: FREE T3 AND CPT
P value is found to be 0.0332 and is statistically FIG 2
significant.
FREE T3 AND CPT Class

Among the study population, 84 patients (84%)
had reduced FT3 and 16 had normal FT3 (16%).
Among the CPT-A patients, 1 had reduced FT3 and
3 had normal FT3 (25% and 75% respectively). Those
patients with CPT class B, 34 patients (79.06%) had
reduced FT3 and 09 (20.94%) had normal FT3. In CPT
class C patients, 49 patients (92.45%) had reduced FT3
and 4 (7.55%) had normal FT3. In our patients, none
had increased FT3 to suggest hyperthyroidism. More
number of CPT class C patients had reduced FT3 than FT3 level is found to be negatively correlated with
CPT-B patients. P value found to be 0.0008 and is Child-Pugh-Turcott score with correlation co-efficient
statistically significant of -0.674 and it is found to be statistically significant
with P value 0.007797.

Correlation: FREET4 AND CPT been reported. This is proposed to be due to varied
etiology and severity. This is in consistent with the
FIG 3 study by Sandeep Kharb et al [18], K.V.S. Hari Kumar
et al [19] , G Deepika et al [1]. This is in consistent with
Punekar et al [20] , and Joeimon JL et al [21] , El-Feki MA
et al , Antonelli A et al [22] . In the study by Punekar et
al [20] , 20% patients had increased TSH and in the study
by Joeimon et al [21], 21.6% patients had increased TSH.
But this finding does not correlate with the studies
by Patira NK et al [23] and Mobin A et al [24] in which
62%, 2.63% patients had increased TSH. Among the
study population, 84 patients (84%) had reduced FT3
and 16 had normal FT3 (16%). This is in correlation
with the studies by Punekar et al [20] , and Mobin A
et al [24] where 71% and 76.3% of the patients showed
FT4 level is found to be negatively correlated with reduced FT3 levels respectively. This finding also
Child-Pugh-Turcott score with correlation co-efficient goes in consistency with D Costa L et al [25], Saleem
of -0.212 but it is found to be statistically insignificant WM et al [26] , Kayacetin E et al [27] , El Sawy AA et al
with P value 0.315042.
[28]
. Among the study population, 27 patients (27%)
had reduced FT4, 69 patients had normal FT4(69%)
Discussion and 4 had increased FT4 (4%). This result goes in
In our study 100 patients with chronic liver disease correlation with Punekar et al [20] and Kayacetin E et
were enrolled after getting informed consent from al [27]. This study shows that significant decrease in
the subjects. Thyroid function tests which include FT3, insignificant change in FT4 and mild increase in
FreeT3, FreeT4, TSH were done for all patients. The TSH levels. This is in agreement with Hussein Awad
liver function tests were done for all. Liver cirrhosis- Mousa et al [29], who found that a significant decrease
was diagnosed based on standard clinical features. level of T3 and an insignificant change in TSH and
After diagnosis, was classified according to standard T4 levels. Takahashi et al [30] concluded that serum
Child-Pugh score. Free T3 (FT3) levels reduced in CLD. These findings
do not go with the study conducted by G Deepika et
The mean duration of illness in our study al [1] showed that there was a significantly increased
population is 5.92 ± 4.61 years (range 1-26 years). The TSH and slightly decreased T3 and T4 levels. These
mean FT3 level in patients included in our study is findings are not in agreement with Mohamed Abdel-
2.3059 ± 0.8883 p Mol/L (range 0.14-5.7 p Mol/L). Fattah ElFeki et al [31]. Several lines of evidence suggest
The mean FT4 level in our patients included in the a reduced dopaminergic tone as a consequence of the
study is 1.1689 ± 1.0806 ng/dL (range 0.45-12.2 ng/ accumulation of false neurotransmitters, which might
dL). The mean TSH level in the patients included be responsible for raised basal TSH concentrations, as
in our study is 3.3198 ± 1.0173 m IU/mL (range 0.4- dopamine has been shown to exert an inhibitory effect
5.11 m IU/mL). These results are in consistency with in the regulation of TSH secretion [22] . Antonelli, A., et
study by Punekar et al [16] . The mean total bilirubin al [22] result is consistent with our study who found that
in the chronic liver disease patients in our study is the level of TSH was significantly higher in patients
8.445 ± 4.3438 mg/dL (range 1.4-20.8 mg/dL). This is with chronic hepatitis C. In our study, Increase in T4
in consistent with the study of Bianchi et al [17] . In our has been observed in patients with acute and chronic
study population, patients had exposure to various liver disease is due to increase in Thyroxine Binding
hepatotoxic factors such as hepatotoxic drugs, alcohol, Globulin levels, which is synthesized as acute phase
indigenous medications, viral causes. Of these, the reactant. It can be stated that in the initial state of
majority includes hepatotoxic drugs, and alcohol. acute liver diseases the T4 production increases
Of the 100 patients, 97 patients (97%) had signs of and subsequently as liver function is worsen it will
liver cell failure. 29%). In this study, 22% patients (25 be reduced due the higher and low concentration
patients) with CLD have hypothyroidism. . Among of TBG. In our patients, none had reduced TSH to
thyroid hormone abnormalities, hypothyroidism was suggest hyperthyroidism. TSH level is found to be
more frequently seen, and hyperthyroidism has also
144
negatively correlated with Child-Pugh-Turcott score hormone, such as thyroid-binding globulin (TBG),
with correlation co-efficient of -0.062 but it is found Transthyretin, and albumin. It is also the major site
to be statistically insignificant with P value 0.119086. of thyroid hormone peripheral metabolism such as
This is not in agreement with Oren R et al [32] who conjugation, biliary excretion, oxidative deamination
found a significant negative correlation was found and the, extra thyroidal deiodination of thyroxin
between thyroid-stimulating hormone blood levels (T4) to tri-iodo-thyronine (T3) and to reverse T3. The
and both functional and synthetic liver function tests. thyroid hormone is also important to normal hepatic
In our patients, none had increased FT3 to suggest function and bilirubin metabolism
hyperthyroidism. P value is found to be 0.0008 and
As liver abnormalities worsen the T3 production
is statistically significant. FT3 level is found to be
from T4 is also reduced. It is believed this reduction
negatively correlated with Child-Pugh-Turcott score
of T3 which mainly correspond to even lower basic
with correlation co-efficient and it is found to be
metabolism rate, can be useful due to preventing
statistically significant with P value 0.007797. This
energy consumption. Free T3 concentration
is in agreement with Fariborz Mansour-Ghanaei et
corresponding with the state of liver disease and it
al , Patira NK et al reported that there is a negative
seems the serum T3 concentration directly related to
correlation was found between Child-Pugh scores
liver abnormalities progress. In conclusion, thyroid
and serum T3 level. Also concluded that serum T3
dysfunction forms important part of spectrum of
concentration is a good index of hepatic function,
Chronic liver disease. Patients with liver disease
decreasing by the severity of liver damage. This goes
should be evaluated for thyroid dysfunction
in agreement with Hussein Awad Mousa et al [29], M
periodically
Borzio et al who evaluated thyroid function in 33
patients with liver disease and found that T3, FT3 and Bibliography
T3/thyroxine binding globulin and thyrotropin after 1. Deepika G, Veeraiah N, PN Rao, Nageshwar Reddy.
thyrotropin releasing hormone were significantly Prevalence of hypothyroidism in liver cirrhosis among
reduced. Takahashi H et al conducted a study on Indian patients. International journalof pharmaceutical
thyroid hormones in different categories of liver and medical research.2015;3:4.
disease and concluded that Serum Free T3 level is
2. Loomba R, Sanyal AJ. The global NAFLD epidemic.
reduced in CLD. This is in agreement with Sandeep Nat RevGastroenterology Hepatic.2013;10:686-90.
Kharb et al who studied thyroid function in 75
patients with liver disease concluded that there was 3. Pagadala MR, Zein CO, Dasarathy S, Yerian L, Lopez R,
significantly lower T3 level. This result goes with Sanu McCollougg AJ. Prevalence of hypothyroidism in non-
alcoholic fatty liver disease. Dig Did sci.2012;57:528-34.
A et al who found that serum T3 and FT3 showed an
inverse correlation with serum bilirubin and positive 4. Maheshwari A, Thuluvath P. Endocrine Diseases and
correlation with serum albumin. the Liver. Clinics inLiver Disease.2011;15(1):55-67.
Limitations of the Study Our study data 5. Zietz B, Lock G, Plach B, Drobnik W, Grossmann J,
derived from a small group of patients do not give Schölmerich J et al. Dysfunction of the hypothalamo-
enough evidence to suggest that the observed pituitary-glandular axis and relation to ChildPugh
classification in male patients with alcoholic and virus-
endocrinopathies are merely coincidental or due to
related cirrhosis. European Journal of Gastroenterology
the underlying cirrhosis. Further largescale studies
& Hepatology.2003;15(5):495-501.
with a greater number of patients are required to
confirmthe findings observed in our study. 6. Riukees SA, Bode HH, Crawford JD. Long term growth
in juvenile acquired hypothyroidism: The failure to
Funding : self achieve normal adult stature. N English J Med.1988;
Conflict of interest: there was no conflict of interest 318:599-60
7. Malik R, Mellor N, Selden C, Todgson H. Tri-iodo

Conclusion thyronine enhances the regenerative capacity of the
The present study revealed that cirrhotic patients liver following partial hepatectomy. Hepatology.2003
had more prevalent thyroid dysfunction specially ;37:79-8.
hypothyroidism. The liver has important role 8. Hernando VV, Eliana MS. Role of thyroid hormones in
in thyroid hormone metabolism because it is different aspects of cardiovascular system. Endocrinol
the manufacturer of protein that bind thyroid Metabolism Syndrome.2015;4:166.

9. Van Horngiven, Wind L, Dullaart RPF. Low normal 22. Antonelli A, Ferri C, Fallabi P, Giuggioli D, Nesti
thyroid function as a determinant of increased large C, Longombardo G, et al. Thyroid involvement in
VLDL particles. Clin Biochemical.2015;58:489- 94 patients with overt hepatitis C virus related mixed
cryoglobulinemia. QJM Int J Med.2004;97:499-506.
10. Chung GE, Kim D, Kim W, Yim JY, Park MJ, Kim
YJ, et al. Non-alcoholic fatty liver disease across the 23. Patira NK, Salgiya N, Agrawal D. Correlation of
spectrum of hypothyroidism. J Hepatic.2012;57:150-6. thyroid function tests with severity of liver dysfunction
in cirrhosis of liver. J Med Sci Clin Res.2017;5:21921-7.
11. Jameson, Fauci, Kasper, Hauser, Longo, Loscalzo.
Harrison’s principles of internal medicine.20thed. 24. Mobin A, Haroon H, Shailch H, Qureshi S, Ali M.
New York: McGraw-Hill Education;2018. p.2695. Decompensated cirrhosis; Thyroid hormone levels in
patients. Prof Med J.2016;23:34-8.
12. Shlomo M, Richard J, Allison B. Ronald J, Clifford
J. Williams textbook of endocrinology. 14thed. 25. D’Costa L, Dhume CY. Assessment of thyroid
Philadelphia: Elsevier Inc;2020. p.343. parameters inAlcoholic Liver Disease. Int J Pharm Bio
Sci.2016;7:771-6
13. Greg Kelly. Peripheral metabolism of thyroid
hormones: A review. AlternMed Rev.2000;5(4):306- 26. Saleem WM, Wadea FM. Evaluation of thyroid
333. dysfunction in Egyptian chronic hepatitis C virus
cirrhotic patients complicated with portalhypertension.
14. Malik R. The relationship between the thyroid gland
Int J Sci Res.2016;5:595-600
and the liver. QJM. 2002;95(9):559-569.
27. Kayacetin E, Kisakol G, Kaya A. Low serum Total
15. Bandyopadhyay SK, Moulick A, Saha M, Dutta A,
thyroxine and Free T3 in patient with hepatic
Bandyopadhyay R, Basu AK. A study on endocrine
encephalopathy due to non-alcoholic cirrhosis. Swiss
dysfunction in adult males with liver cirrhosis. J Indian
Med Weekly.2003;133:210-3.
Med Assoc.2009;107:866–9.
28. El-sawy AA, Tawfik M. low serum free and total
16. Punekar P, Ashvanee Kumar Sharma, Jain A. A
T3 hormones as possible prognostic factors in liver
study of thyroid dysfunction in cirrhosis of liver and
cirrhosis patients because of chronic hepatitis C. Tanta
correlation with severity of liver disease. Indian J
Med J.2015;43:46-51
Endocrinol Metab.2018;22(5):645-650.
29. Hussein Awad M, Husham O, NassrEldin M, Amna O.
17. Bianchi GP, Zoli M, Marchesinia, Volta U, Vecchi
Serum Thyroid Hormone Levels in Sudanese Patients
F, Lervese T, Bonazzi C, Pisi E. Thyroid gland size
with Liver Cirrhosis. IOSR Journal of Pharmacy and
and function in patients with cirrhosis of liver.
Biological Sciences (IOSR-JPBS).2016;11:14-18.
Liver.1991;11:71-78.
30. Takahashi H, Yamada S. Studies on changes of thyroid
18. Garg M, Puri P, Brar K, Pandit A, Srivastava S, Kharb
hormones in various liver diseases. Usefulness of
S. Assessmentof thyroid and gonadal function in
free thyroid hormones as liver function test. Japanese
liver diseases. Indian Journal of Endocrinology and
Journal of Medicine.1989;28(3):297-302.
Metabolism.2015;19(1):89.
31. El-Feki M, Abdalla N, Atta M, Ibrahim A. Serum
19. Kumar KH, Pawah AK, Manrai M. Occult endocrine
Level of Thyroid Hormones in Patients with Chronic
dysfunction in patients with cirrhosis of liver. J Family
Hepatitis C Virus Infection. Open Journalof Endocrine
Med Prim Care.2016;5:576-80.
and Metabolic Diseases.2016;06(03):126-134
20. Punekar P, Ashvanee Kumar Sharma, Jain A. A
32. Oren R, Brill S, Dotan I, Halpern Z. Liver
study of thyroid dysfunction in cirrhosis of liver and
Function in Cirrhotic Patients in the Euthyroid
correlation with severity of liver disease. Indian J
Versus the Hypothyroid State. Journal of Clinical
Endocrinol Metab.2018;22(5):645-650.
Gastroenterology.1998; 27(4):339-341.
21. Joeimon JL, Mohanraj K, Karthikeyan R, Solomon
RT, Aravind A,Selvi CK, et al. Thyroid dysfunction
in patients with liver cirrhosis. IOSR J Dent Med
Sci.2017;16:18-22.

Functional Outcome of Rotating Platform Versus Fixed Platform of Total

Knee Arthroplasty- A Comparative Study
Mohammed Asrar M1, Jassim Usman2, Abhishek Shetty V3, Anna Sophia Pietsch4,
Imthiaz Ahammed5
1
PG, Orthopaedics, Yenepoya Medical College, Mangalore, Karnataka
2
Assistant professor, Department of Orthopaedics, Yenepoya Medical College, Mangalore, Karnataka
3
Associate professor, Department of Orthopaedics, Yenepoya Medical College, Mangalore, Karnataka
4
Intern, Orthopaedics, Charité- Medical University of Berlin, Berlin, Germany
5
Professor and Hod, Yenepoya Medical College, Mangalore, Karnataka
How to cite this article: Mohammed Asrar M, Jassim Usman, Abhishek Shetty V, Anna Sophia Pietsch,
Imthiaz Ahammed et al Functional Outcome of Rotating Platform Versus Fixed Platform of Total Knee
Arthroplasty- A Comparative Study. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Total knee arthroplasty (TKA) has shown to be a successful and reliable procedure for older, debilitated
patients with knee osteoarthritis. TKA’s indications were widened to include younger and more active patients after its
initial success.
Objectives: To compare the functional outcome of rotating vs fixed platform of total knee arthroplasty
Methods: All patients who are fit to undergo total knee arthroplasty like advanced stages of osteoarthritis and rheumatoid
arthritis in age group of 50-70 years . We compared the functional outcome between rotating platform versus fixed
platform of Total Knee Arthroplasty. Clinical and radiological follow-up was performed at 1, 3, 6 months and 1year after
the operation. Pre-operative and follow-up ratings according to Knee Society Scoring system were obtained for all the
patients. In addition, a visual analogue scale was used to specially assess the severity of the pain
Results: In group A and group B there were 6 males (30%) and 14 females (70 %). In both the groups the mean post
operative range of movements were significantly improved for the follow-up at every 3months with the mean ROM of
120° achieved at 1year follow-up. The ROM has significantly improved from 90° at 3rd month follow- up to 120° at 1year
follow-up. The mean KSS knee and functional score were gradually improved in post operatively in 3rd, 6th and 1year
follow-up compared to the pre operative KSS score.
Conclusion: The post-operative range of motion and the Knee Society functional score were similar in both groups. There
was no significant statistical difference between the two groups of Total Knee Arthroplasty in terms of post-operative
range of motion and functional outcomes.
Keywords: Total knee arthroplasty, KSS score, rotating platform, fixed platform
Introduction TKA’s indications were widened to include younger

In the last 30 years, total knee arthroplasty (TKA) has and more active patients after its initial success. The
shown to be a successful and reliable procedure for emergence of mobile-bearing polyethylene surfaces
older, debilitated patients with knee osteoarthritis.1 reflects efforts to reduce wear while coping with
complicated function and kinematics.2
Dr. Abhishek Shetty V
Associate Professor
Department of Orthopaedics, Yenepoya Medical College, Mangalore, Karnataka
The wear of the bearing surface is linked to long- osteoarthritis and rheumatoid arthritis in age
term TKA survival, which has been extensively group of 50-70 years.
documented in the orthopaedic literature. TKA
wear patterns differ from total hip arthroplasty wear Exclusion Criteria:
patterns in that delaminating and pitting occur. The • Patients with rheumatoid arthritis and
shear force causes bigger particles to form. However, patients undergoing revision arthroplasty,
significant submicron polyethylene debris is still requiring tibial component augmentation
formed, which can cause osteolysis.3 or a femoral component augmentation or a
This can cause the implant to loosen and eventually constrained prosthesis were excluded.
fail. Engineers and orthopaedic surgeons have We compared the functional outcome between
long sought a “better” knee design with longer rotating platform versus fixed platform of Total
survivorship despite strong long-term survival. The Knee Arthroplasty. Clinical and radiological follow-
mobile-bearing knee was designed to take advantage up was performed at 1, 3, 6 months and 1year after
of the reduced stress found in conforming designs, the operation. Pre-operative and follow-up ratings
minimising polyethylene wear while reducing according to Knee Society Scoring system were
implant stress and lessening the danger of tibial obtained for all the patients. In addition, a visual
component loosening.4 analogue scale was used to specially assess the
Furthermore, the mobile design was thought severity of the pain
to more nearly resemble natural knee kinematics. Statistical Analysis: The SPSS 22 software was
However, while selecting the most appropriate used for statistical analysis. The data outcome was
implant for his or her patient, the orthopaedic surgeon presented in the form of tables with means and
must be wary of the likelihood of a market push as percentages.
new and “better” implants are introduced. Total knee
arthroplasty (TKA) is a popular procedure for treating Observation and Results
severe osteoarthritis of the knee joint.5,6 Table 1: Distribution based on Gender and age
group
The objective, on the other hand, was to see if
patients who received a rotating platform implant Gender Group A Group B
had a better functional result than those who had
fixed bearing implants. The goal of this study is to Male 6(30%) 6(30%)
produce an evidence-based evaluation that compares Female 14(70%) 14(70%)
fixed bearing with mobile–bearing TKA in terms of
survival and clinical outcomes. Total 20 20
Materials and Methods Age Group
Patients were included if they were eligible for Mean + S.D 63.75 ± 6.138 yrs 62.75 ± 7.860 yrs
treatment with a complete knee replacement system
In group A and group B there were 6 males (30%)
with either fixed or movable bearings and had given
and 14 females (70 %).
written informed consent. After receiving approval
from the hospital’s Ethical Committee, the current In group A, The mean age was 63.75 ± 6.138 years.
study will be carried out at Yenepoya medical college
In group B, The mean age was 62.75 ± 7.860 years.
hospital. A well-structured and well-prepared case
The clinical history, physical examination findings, Gender Group A Group B
and investigation findings will all be included on a
proforma. B/L 9(45%) 3(15%)
Duration of study: June 2018 to July 2020 LT 3(15%) 7(35%)

RT 8(40%) 10(50%)
Inclusion criteria:
• All patients who are fit to undergo total
knee arthroplasty like advanced stages of

148
Table 3: Statistics of group A

Post_op_ Post_6M Post_ Knee_ Knee_ Post_op_ Fun_ Fun_ Fun_
rom_3M op 1 yr score_ score_ knee_ score_3M score_6M score_1yr
3M 6M 1year
N Valid 20 20 20 20 20 20 20 20 20
0 0 0 0 0 0 0 0 0
Mean miss-
95.00 108.50 120.50 64.00 69.65 73.90 72.00 84.00 94.50
Median ing
Mini- 95.00 110.00 120.00 61.00 69.00 74.00 70.00 85.00 90.00
mum 80 100 110 46 54 58 55 70 90
Maxi- 110 120 130 77 78 85 80 90 100
mum 90.00 100.00 112.50 59.00 66.00 70.75 70.00 80.00 90.00
Percen-
95.00 110.00 120.00 61.00 69.00 74.00 70.00 85.00 90.00
tiles 25
50 100.00 117.50 130.00 70.00 75.00 78.00 80.00 90.00 100.00
75
10 17.50 17.5 11 9 7.25 10 10 10
IQR
In Group A patients, the mean post operative range of movements were significantly improved for the follow-
up at every 3months with the mean ROM of 120° achieved at 1year follow-up. The ROM has significantly
improved from 90° at 3rd month follow- up to 120° at 1year follow-up. The mean KSS knee and functional score
were gradually improved in post operatively in 3rd, 6th and 1year follow-up compared to the pre operative KSS
score. The KSS Knee score corresponds to the patient’s objective score and hence there is an improvement in the
objective score and patient’s were relieved of symptoms.
Table 4: Statistics of Group B
Post_ Post_op Post_op_ Knee_ Knee_ Knee_ Fun_ Fun_ Fun_
op_3M 1year 3M 6M 1yr 3M 6M 1Yr
_6M
20 20 20 20 20 20 20 20 20
N Valid 25 0 0 0 0 0 0 0 0 0
Missing 50 97.00 109.50 122.00 60.05 66.25 72.00 73.75 83.25 91.50
Mean Median 100.00 110.00 120.00 60.00 67.00 71.50 75.00 80.00 90.00
Minimum 90 100 110 49 50 57 55 70 80
Maximum 110 120 130 69 78 84 80 90 100
Percentiles
90.00 102.50 120.00 59.00 63.50 69.25 70.00 80.00 90.00
75 100.00 110.00 120.00 60.00 67.00 71.50 75.00 80.00 90.00
IQR 100.00 110.00 130.00 64.75 68.00 75.00 80.00 90.00 100.00
10 7.5 10 5.75 4.5 5.75 10 10 10
In Group B patients, the mean post operative range of movements were significantly improved for the follow-
up at every 3months with the mean ROM of 120° achieved at 1year follow-up.The ROM has significantly
improved from 97° at 3rd month follow-up to 122° at 1year follow-up. The mean KSS knee and functional score
were gradually improved in post operatively in 3rd ,6th and 1year follow-up compared to the pre operative
KSS score. The KSS Knee score corresponds to the patient’s objective score and hence there is an improvement
in the objective score and patient’s were relieved of symptoms.

Table 5: Statistical analysis of both groups

Test Statistics
Post_ Post_ Post_ Knee_ Knee_ Post_op_ Fun_ Fun_ Fun_
op_r 6M op sco sco scor scor scor
knee_1ye
om_3M re_3M re_6M e_3M e_6M e_1yr
_1Y ar
Mann-
172.000 183.500 178.500 143.500 138.000 163.000 176.500 187.000 158.000
Whitney U
393.5
Wilcoxon W 382.000 388.500 353.500 348.000 373.000 386.500 397.000 368.000
00
Z -.838 -.480 -.630 -1.546 -1.688 -1.007 -.697 -.386 -1.262
Asymp. Sig.
.402 .631 .528 .122 .091 .314 .486 .699 .207
(2- tailed)
Exact Sig.
[2*(1-tailed .461b .659b .565b .127b .096b .327b .529b .738b .265b
Sig.)]
a. Grouping Variable: Groups
b. Not corrected for ties.
Since P value >0.05 for Post op ROM 3M,6M,1Year in terms of overall knee score, postoperative range of
there is no significant difference between Group A motion, or survival rate.
and Group B. P value>0.05 Knee Score 3M,6M,1year
In both groups, 90% had excellent or good
there is no significant difference between Group A
outcomes. In both groups, some patients experienced
and Group B.
stiffness. Following a fall, one patient had a patellar
P value>0.05 Fun Score 3M,6M,1 year there is no tendon rupture, which was subsequently repaired.
significant difference between Group A and Group B. In revolving platforms, no spin off or dislocation has
happened.
Discussion
Despite the fact that their designs are different, Post
In total knee arthroplasties, both mobile-bearing and
et al. observed that both mobile-bearing and fixed-
fixed-bearing prostheses were compared in terms
bearing implants exhibited comparable kinematic
of performance and survival, with overall revision
patterns in terms of posterior femoral translation and
rates of about 1% per year for both types of implants.
tibiofemoral rotation in experimental research. They
In terms of clinical function or longevity, no prior
proposed that the movable tibial insert stops moving
controlled comparison has been able to establish any
at <90° degrees of flexion and that the prosthesis
benefit for a mobile-bearing complete knee prosthesis
thereafter functions effectively as a fixed-bearing
over a fixed-bearing total knee prosthesis.7,8 The
implant.9
goal of this study was to compare the individual
performance of fixed-bearing versus mobile-bearing Delport et al. observed similar findings.10 The
knee replacements in the same clinical context while current study’s clinical findings are in line with the
controlling for characteristics including age, weight, findings of these experimental trials. Both the fixed-
and activity level. bearing and mobile-bearing groups showed similar
postoperative ranges of motion, suggesting that their
The senior surgeon conducted all of the procedures.
in vivo kinematics are similar.
Patients were blinded to the kind of implant used
in each knee when doing the clinical evaluation. With every movable bearing, dislocation is a
As a result, patient-related bias was reduced. Both possible problem. Knee replacement is no exception,
arthroplasties yielded similar clinical outcomes. and the LCS prosthesis is no exception. In our series,
Based on the size of the series, there was no benefit of some individuals in both groups had knee stiffness.
the mobile bearing knee over the fixed-bearing knee Following a previous fall, one patient’s patellar

150
tendon ruptured. In rotating platform knees, there is 3. Delport HP, Vander Sloten J, Bellemans J Comparative
no spin off or dislocation of the knee. gravimetric Wear Analysis in mobile versus fixed-
bearing posterior stabilized total knee prostheses. Acta
With the figures provided, there was no significant Orthop Belg 2010; 76: 367-73.
difference in the rates of survival between the two
4. Kettlekamp DB, Pryor P, Brady TA. Selective use of the
prostheses. Because of the limited number of patients
variable axis knee. ClinOrthopRelat Res 1979; 3:301-2
analysed and the short duration of the investigation,
this study may suffer from a lack of statistical power. 5. Jacobs WC, Christen B, Wymenga AB, Schuster A,
With the figures provided, no advantage of the van der Schaaf DB, ten Ham A, Wehrli U. Functional
mobile-bearing design over the fixed-bearing design performance of mobile versus fixed bearing total knee
could be proven. prostheses: a randomised controlled trial. Knee Surg
Sports Traumatol Arthrosc. 2012 Aug; 20(8):1450-5.
Conclusion 6. Hanusch B, Lou TN, Warriner G, Hui A, Gregg P.
The post-operative range of motion and the Knee Functional outcome of PFC Sigma fixed and rotating-
Society functional score were similar in both groups. platform total knee arthroplasty. A prospective
Because of the short term research of one year, there randomised controlled trial. Int Orthop. 2010 Mar;
was no significant statistical difference between the 34(3):349-54.
two groups of Total Knee Arthroplasty in terms 7. Luna JT, Sembrano JN, Gioe TJ. Mobile and fixed-
of post-operative range of motion and functional bearing (all-polyethylene tibial component) total knee
outcomes. The long-term follow-up will evaluate arthroplasty designs: surgical technique. J Bone Joint
whether either group has an increased rate of wear Surg Am. 2010 Sep; 92 Suppl 1 Pt 2:240-9.
or loosening. 8. Woolson, S., Epstein, N. and Huddleston, J. (2011).
Ethical Clearance: The ethical clearance was Long-Term Comparison of Mobile-Bearing vs. Fixed-
obtained from the Yenepoya Medical College Bearing Total Knee Arthroplasty. The Journal of
Arthroplasty, 26(8), pp.1219-1223
institutional ethics committee prior to the
commencement of the study 9. Post ZD, Matar WY, van de Leur T, Grossman EL,
Austin MS. Mobile- bearing total knee arthroplasty:
better than a fixed-bearing? J Arthroplasty. 2010 Sep;
Source of Funding: Self 25(6):998-1003
10. Delport, H. (2013). The Advantage of a Total

References
Knee Arthroplasty with Rotating Platform is
1. Buechel FF, Pappas MJ. The New Jersey low-contact Only Theoretical: Prospective Analysis of 1,152
stress knee replacement system: biomechanical Arthroplasties. The Open Orthopaedics Journal, 7(1),
rationale and review of the first 123 cemented cases. pp.635-640
Arch Orthop Trauma Surg 1986; 105:197.
2. Goodfellow JW, O’Connor J. Clinical results of the

Oxford knee: surface arthroplasty of the tibiofemoral
joint with a meniscal bearing prosthesis. Clin Orthop
1986; 205:21.

Socio-Demographic Determinants of Non-Communicable

Diseases in Assam, India
Aakanksha Agarwala1, Manab Deka2

1
DST INSPIRE Junior Research Fellow, Department of Statistics, Gauhati University, Gopinath Bordoloi Nagar,
Jalukbari, Guwahati-781014, Assam, India
2
Associate Professor, Department of Statistics, Arya Vidyapeeth College, Gopinath Nagar, Guwahati-781016, Assam, India.
How to cite this article: Aakanksha Agarwala, Manab Deka et al Socio-Demographic Determinants of
Non-Communicable Diseases in Assam, India. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Located to the south of the eastern Himalayas along the Brahmaputra and Barak River valleys, Assam is the
gateway to north east India. Covering an area of 78,438 km sq., the state is inhabited by a multi-ethnic, multi-linguistic
and multi-religious society. In the present study we intend to throw some light on the prevalence of non-communicable
diseases (NCDs) in this most important state of north-east.
Method: The main objective was to examine the effect of socio-demographic characteristics, lifestyle behaviour, household
status and contextual characteristics among adults (aged 30 and above) of Assam. We used data from Indian Human
Development Survey (IHDS II). Logistic regression was applied to attain the study objective.
Conclusion: Age and gender; education, smokeless tobacco consumption were found to be significantly associated with
the presence of NCDs. A lot of research has been carried out to understand the prevalence of NCD in India, but the
effect of various factors remains somewhat unexplained at the state level. There is need of more in depth studies to solve
the ever-growing burden of NCDs at the state level. The present study and its findings could be effectively utilized to
consider conducting similar studies for other Indian states as well.
Keywords: logistic regression, NCD, IHDS
Introduction factors; the risk factors mainly being behavioral and

In the past few years, non-communicable diseases metabolic. 75% of premature adult death was caused
(NCDs) have taken over infectious diseases as the by NCDs which implies that NCDs do not target the
primary cause of death. The growing epidemic of older population alone. Also, unlike the common
NCDs are now the leading cause of death worldwide old belief that NCDs is a disease of affluence, it is
affecting the global health scenario and socio-economic now emerging both in poorer countries and among
development; the worst sufferers being the low and the poorer population in richer countries. This rapid
lower middle-income countries, who fail to avail rate of change poses a major threat to the world and
services for timely diagnosis and necessary treatment. at the same time demands immediate and effective
In 2016, NCDs were responsible for 41 million of the measure for prevention and control.
world’s 57 million deaths, which is equivalent to 71% India, one of the largest economies of the world
of the total deaths. The main types of NCDs behind also faces the NCD burden. 63% of total deaths in
these deaths are cardiovascular diseases (such as the country in 2016 were attributed to NCDs. The
heart attacks and stroke), cancer, chronic respiratory country is presently experiencing a phase of rapid
diseases (such as chronic obstructive pulmonary health transition wherein the mounting magnitude
disease and asthma) and diabetes. According to World of NCDs is gaining prominence with substantial
Health Organization (WHO), NCDs, also known as repercussion on health and economic productivity
chronic diseases, are diseases of long duration and which implies there is an urgent need to prioritize
slow progression and the result of a combination of NCD control techniques.(WHO, 2018). The epidemic
genetic, physiological, environmental and behavioral of NCDs poses devastating health consequences for
152
individuals, families and communities, and threatens Choudhury et al2, 2009, studied the influence of
to overwhelm health systems. The socioeconomic socio economic and demographic factors on the
costs associated with NCDs make the prevention and risk of chronic diseases in Guwahati,Assam.The
control of these diseases’ imperative. authors carried out logistic regression to examine the
relationship between different risk factors and NCDs
A number of studies on NCDs have since been
and hence identified the significant factors affecting
carried out worldwide, the basis of most of which
the same.
is identification of risk factors-modifiable (or
behavioral) and metabolic. Majority of NCDs are due Deka, et al3, 2012 put forward Bayesian approach to
to lifestyle and behavior, and therefore, be prevented outline the probability of an individual being afflicted
to a great extent. The rise of NCDs have been driven by chronic disease. The data source used in this study
by primarily four major risk factors: tobacco use, was a primary one collected through a household
physical inactivity, the harmful use of alcohol and survey conducted in Guwahati, the state capital as
unhealthy diets.According to WHO, in 2014 there well as largest city of the state of Assam.
were 346 million smokeless tobacco users – 7% of the
Mishra P, Mini GK and Thankappan KR4, 2014,
world’s population. 80% of these users resided in the
carried out a survey to assess the prevalence of NCD
South-east Asian region, and were at an increased risk
risk factors among Mishing tribes in Assam using the
of oral cancers.
WHO STEPs approach. A total of 332 individuals
In India too, researchers have attempted modeling of the Mishing tribe (men 54%) aged 25-64 year
of chronic diseases at various levels. A lot of similar were selected from Tinsukia district by multistage
research has been carried out on NCDs for entire cluster sampling. Using the WHO STEPs approach
India. But when we look into the state scenario, lesser information was collected on demographics, STEP
number of studies have been conducted for individual 1 variables (tobacco, alcohol, physical activity, diet)
states and for the state of Assam, we came across only and measured STEP 2 variables (weight, height,
very few numbers of such studies. Hence in our study waist circumference and blood pressure).The authors
we intend to throw some light on the prevalence concluded that Tobacco use, alcohol use and unhealthy
of NCDs in this most important state of north-east diet habits were high among men and women in this
India. Assam is the second largest northeastern population and were major NCD risk factors.
state in terms of area, covering an area of 78,438 km2
Medhi et al5, 2015, carried out a cross-sectional
(30,285 sq miles). The state is bordered by Bhutan
study among elderly individuals (≥60 yr) in two
and Arunachal Pradesh to the north; Nagaland,
randomly selected wards of Dibrugarh urban area of
Arunachal Pradesh and Manipur to the east;
Assam. Pre-tested questionnaire was used to collect
Meghalaya, Tripura, Mizoram, and Bangladesh to the
data on self-rated health (SRH), sociodemographic
south; and West Bengal to the west. As per the Census
and other information. The findings indicated that
2011, the total population of Assam is 3.12 crores.
diabetes was a significant contributor of poor SRH
India’s gateway to the northeast, Assam is inhabited
among elderly individuals. The authors emphasized
by a multi-ethnic, multi-linguistic and multi-religious
the need for developing urgent strategies for
society. Lowry et al1 (1996) have opined that the effect
preventing/postponing diabetes in the population in
of socio-economic and demographic factors on health
order to improve quality of life at old age.
outcomes particularly prevalence of NCDs may result
from a variety of social and individual factors that Singh PK, Singh L, Dubey R et al6., 2019, used
vary by social class and adoption of lifestyle behavior multilevel logistic regression analysis to examine
that are associated with prevalence of NCDs. This is the effect of individual, household and contextual
another reason for choosing to study about Assam characteristics on chronic diseases among older Indian
and investigating the relationship between NCDs and adults. The authors highlighted the need to consider
the various variables or factors affecting it. more contextual variables to examine chronic health
status among the growing older population of India.
Literature Review
A number of studies on NCDs have been carried out Materials and Mehods
worldwide, however not much significant research The study utilized data from the second round of the
has been done on the state Assam, the gateway to Indian Human Development Survey (IHDS;2011-
northeast India. 12) conducted by the National Council of Applied
Economic Research, New Delhi and University of (47%). A significant percent had never attended any
Maryland. IHDS II is a nationally representative multi- school (28.5%). 66.5% were Hindus, followed by 31%
topic survey of 42152 households in 1503 villages and Muslims, and around 2% belonging to other religions.
971 urban neighborhoods across India. We extracted Nearly 50% respondents belonged to general
the data for Assam to carry out our analysis. This data category, followed by around 17% in OBC and SC
set consisted of 4651 individuals. Since the prevalence category each; 13% belonged to ST category. Overall
of chronic disease among individuals below age 30 prevalence of NCDs in state was 4%.
was insignificant, we carried out the analysis only
Table 1: ariables in the research
on those aged above 30. Hence the reduced sample
size was 2123, out of which 1094 were males and 1029 VARIABLES FREQUENCY VALID %
females. IHDS asked about the presence of chronic SEX
morbidity among all household members. Three set male 1094 51.5
of responses were recorded “yes”,”no” and “cured”.
female 1029 48.5
Our study considered the response ‘yes’ and ‘cured’
to define that the member was diagnosed with chronic AGE GROUP
morbidity or suffering from the disease during the 30-44 1016 47.9
time of the survey. 45-59 745 35.1
We carried out logistic regression to examine 60 & above 362 17.1
the relationship between various socio economic, CURRENT
demographic, contextual level variables and different MARITAL
risk factors with chronic diseases. Socio demographic STATUS
characteristics (age, sex, marital status and education), married 1785 84.1
lifestyle behavior (tobacco and alcohol use) 5.7
unmarried 120
household status (social group, religion) were taken
widow/ 217 10.2
as the independent variables. Each respondents’
separated/
marital status was categorized as married, widowed/
divorced
separated/divorced and unmarried.Education was
measured as highest level attained-never attended, EDUCATION
below primary, below secondary and secondary or never attended 606 28.6
higher. The respondents’ use of tobacco (smoked below
cigarette, chewed gutka/tobacco, drink alcohol) primary(1-4) 186 8.8
was categorized as never, sometimes and daily user. below
Hindu, Muslim, Christian and others (Jain, Sikh and secondary(5-8) 328 15.5
others) were 4 broad categories of religion and caste
secondary and 998 47.1
groups were categorized into General, OBC, SC, ST above(>=9)
and others.
RELIGION
The dependent variable in our analysis is Hindu 1411 66.5
individuals suffering from NCDs (no/yes).
Muslim 660 31.1
Result and Discussion Others 52 2.4
CASTE
Descriptive Statistics
General 1072 51.2
Table 1 shows the sample description of the present
OBC 375 17.9
study. Our analysis was carried out on 2123
respondents out of which 51.5% were males and SC 373 17.8
48.5% females. Nearly 48% belonged to the age group ST 274 13.1
30-44, followed by 35% in the group 45-59 and 17%
elderly, i.e., aged 60 and above. Majority of people
had attained secondary level education or beyond

154
Table 4: Results of Logistic Regression

VARIABLES FREQUENCY VALID %
B P- ODDS 95% C.I. FOR
SMOKE
VALUE RATIO (OR) OR
CIGARRETE
LOW- UP-
Never 257 39.7 ER PER
SEX
Sometimes 298 46.1 MALE -1.597 .037 .202 .045 .908
Daily 92 14.2 FEMALE(R)
CHEW AGE GROUP .005
TOBACCO/ 30-44 -2.012 .001 .134 .039 .453
GUTHKA 45-59 -.664 .167 .515 .200 1.322
60 &
Never 255 39.4
ABOVE(R)
Sometimes 263 40.6 MARITAL
.559
STATUS
Daily 129 19.9 MARRIED 1.291 .281 3.637 .349 37.953
DRINK UNMARRIED -17.019 .998 .000 .000 .
ALCOHOL WIDOWED/
SEPARATED/
Never 360 55.6 DIVORCED(R)
Sometimes EDUCATION .034
252 38.9 NEVER
Daily -1.239 .033 .290 .093 .908
35 5.4 ATTENDED
BELOW
Analysis PRIMARY(1-4)
-.083 .894 .920 .271 3.127
As per the Classification table (Table 2), the overall BELOW

SECOND- -2.423 .023 .089 .011 .717
correct percentage of 69.3% is quite satisfactory. ARY(5-8)
Table 2: Classification table SECONDARY
AND ABOVE
Observed Predicted >=9 (R)
RELIGION .894
NSD Percentage
HINDU 17.656 .998 46541964.340 .000 .
ABSENT PRESENT Correct
MUSLIM 17.906 .998 59760549.342 .000 .
NCD ABSENT 416 193 68.3 OTHERS(R)
PRESENT 3 26 89.7 SMOKE
.334
CIGARETTES
Overall Percentage 69.3 NEVER -.328 .612 .720 .203 2.562
Hosmer-Lemeshow test of goodness of fit was SOMETIMES .418 .466 1.519 .493 4.681
DAILY(R)
conducted to check the appropriateness of the model.
CHEW
We obtained a significant value of 0.717 which TOBACCO
.034
suggests that the logistic regression model fits the NEVER -.106 .851 .899 .297 2.723
data well. SOMETIMES -1.366 .036 .255 .071 .912
DAILY(R)
Table 3: Hosmer Lemeshow test
DRINK
.197
Chi-square df Sig. ALCOHOL
NEVER -.005 .997 .995 .107 9.257
5.376 8 .717
SOMETIMES .855 .449 2.352 .257 21.511
We examined the association between various DAILY(R)
CASTE .109
characteristics and chronic illness using logistic
GENERAL .792 .280 2.208 .524 9.300
regression technique and also computed odds ratio
OBC -1.192 .232 .304 .043 2.145
for different categories with corresponding 95%
SC -18.143 .996 .000 .000 .
confidence intervals; the results have been presented ST(R)
in the Table 4. CONSTANT -19.312 .998 .000

It was seen that there is a significant association never consumed smokeless tobacco stood at 20%
between socio-demographic characteristics age, fewer chance of having any chronic illness.
gender and chronic illness. We observed that as
We also observed a significant association between
compared to females, males have 20% less chance of
education level of an individual and prevalence of
being afflicted by a chronic morbidity. Similar results
NCD. However, it was seen that those who attained
were obtained by Patra S, Bhise M7 (2016). According
education below the secondary level(OR 0.089) had
to their study, prevalence of NCD was higher among
lesser chance of being afflicted as compared to those
women as compared to men among the Indian states
who were more educated, which is an unexpected
Himachal Pradesh and Uttaranchal; whereas among
and surprising result and needs further in-depth
the union territories Daman and Diu showed the
investigation to reveal possible factors responsible for
widest gap in the prevalence of NCDs between men
it.
and women. Sharma S, Vishwakarma D, etal8.(2019)
in their study also concluded that there exist marked Conclusion
gender differences in NCD prevalence among the Our present study is an attempt to fill the void that
adults in India. In contrast to studies conducted in the exits when it comes to studying about the prevalence
past few years, many recent studies claim that women of NCDs in the state of Assam. It provides insight into
in India possess more burden of NCD compared to the association between various socio demographic
men. NCDs affect women inequitably. They have characteristics, lifestyle behaviors, household status
been the leading cause of death among women and chronic illness among the adults of Assam.
globally for at least the past three decades and are Our findings suggest that characteristics like age,
now responsible for two in every three deaths among sex, education, smokeless tobacco consumption
women each year. This burden is expected to increase had significant effect on prevalence of chronic
substantially in the coming decades, especially in diseases. However, no association was observed
Low- and Middle-income Countries (WHO). between characteristics like marital status, caste,
Individuals below age 60 had less chance of having religion, alcohol consumption and presence of non-
any chronic illness as compared to those aged 60 communicable disease.
and above (OR 0.134). This finding is at par with Chronic diseases are largely preventable diseases.
many similar studies conducted in the past. With the While age, sex and genetic susceptibility are non-
ageing population, the older are likely to face various modifiable, many of the risks associated with age and
health conditions and disease risk. According to the sex are modifiable. Such risks include behavioral factors
Longitudinal Ageing Survey of India also, prevalence (e.g., diet, physical inactivity, tobacco consumption);
of single morbidity and multi-morbidity conditions biological factors (e.g., hypertension, overweight etc.)
increases with age. 75% of the elderly people suffer and finally societal factors which include a complex
from one or the other chronic disease. It was found mixture of interacting socio-economic, cultural and
that the prevalence of multi-morbidity conditions other environmental parameters. Thus, prevention
among the elderly i.e. aged 60 and above was much and early diagnosis should be the prime concern of
higher in the states/UTs of Kerala Chandigarh, the hour, seeking participation from multiple sectors
Lakshadweep, and Andaman & Nicobar Islands. of government, industry, medical field and society.
Lifestyle characteristic (chewing tobacco/gutka) Fundings: None
was noted to be significantly associated with the
prevalence of NCD. The likelihood of chronic illness Conflict of Interest: No conflict of interest was
was lower among those adults who chewed tobacco/ reported by the authors.
gutka sometimes as compared to those who did so Ethical Clearance: No ethical clearance/approval
on daily basis. It is worth mentioning that Singh PK, was needed for this study.
Singh L, Dubey R et al6(2019) also obtained similar
results while analyzing data for entire India. They
concluded from their study that older adults who

156
References: 5. Medhi GK, Sarma J, Bhattacharyya H, Pala S, Visi V,

Bora PJ. Sociodemographic variations in health-related
1. Lowry, R., Laura K., Collins J.L, Kolbe L.J. The Effect
quality of life (HRQOL) among elderly individuals in
of Socioeconomic Status on Chronic Disease Risk
an urban locality in India. J Family Med Prim Care.
behaviors among US adolescents. JAMA. 1996: 276(10).
2019 ;8(7):2473-2477.
2. Choudhury, L, Choudhury, A, Deka, M. Influence of
6. Singh, P.K, Singh, L., Dubey, R., Singh, S. and
Socio-Economic and Demographic Factors on the Risk
Mehrotra, R. (2019). Socioeconomic determinants of
of Chronic Diseases in Guwahati- The Premier City of
chronic health diseases among older Indian adults: a
North East India. Demography India. 2009; 38(1):85-
nationally representative cross-sectional multilevel
101.
study. BMJ Open. 2019; 9e028425.
3. Deka, M., Choudhury, L. and Choudhury, A. Health
7. Bhise MD, Patra S. Prevalence and correlates of
Scenario of Urban set up of Assam in regard to Chronic
hypertension in Maharashtra, India: A multilevel
Diseases., Indian Journal of Public Health Research &
analysis. PLoS One. 2018;13(2):e0191948.
Development. 2012; 3(4):110-115.
8. Sharma,S, Vishwakarma, D, Parul,P .Gender
4. Misra PJ, Mini GK, Thankappan KR. Risk factor profile
disparities in the burden of Non-Communicable
for non-communicable diseases among Mishing tribes
Diseases in India: Evidence from the cross-sectional
in Assam, India: results from a WHO STEPs survey.
study. Clinical Epidemiology and Global Health. 2019;
Indian J Med Res. 2014;140(3):370-8.
8(2): 544-549

Hemiarthroplasty in Unstable Intertrochanteric Fractures in Elderly:

A Prospective Study
Nahas R1, Jassim Usman2, Abhishek Shetty V3, Imthiaz Ahammed5

1
PG, Orthopaedics, Yenepoya Medical College, Mangalore, Karnataka
2
Assistant professor, Department of Orthopaedics, Yenepoya Medical College, Mangalore, Karnataka
3
Associate professor, Department of Orthopaedics, Yenepoya Medical College, Mangalore, Karnataka
4
Intern, Orthopaedics, Yenepoya Medical College, Mangalore, Karnataka
5
Professor and Hod, Yenepoya Medical College, Mangalore, Karnataka
How to cite this article: Nahas R, Jassim Usman, Abhishek Shetty V, Imthiaz Ahammed et al Hemiarthroplasty in Unstable
Intertrochanteric Fractures in Elderly: A Prospective Study. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Grossly comminuted intertrochanteric fractures in osteoporotic bones are highly unstable and difficult to
treat. Hemiarthroplasty is a popular choice because it provides stability and enables for immediate complete weight
bearing.
Objectives: The goal of this trial was to see how effective cemented hemiarthroplasty was at treating proximal femoral
fractures in older people with severe osteoporosis.
Methods: Thirty patients who had bipolar hemiarthroplasty for unstable intertrochanteric fractures were studied
prospectively. The posterior (Moore’s) technique was used to treat all of the patients with cemented bipolar prostheses.
The average time of follow-up was 12 months. The modified Harris hip score was used to evaluate the patients.
Results: Abductor weakness was present in 5 of the individuals. At the 12-month follow-up, 21 cases (70%) had bad
results, while three cases (10%) had poor results. The average length of stay in the hospital was 10.9 days. Excellent to fair
results were observed in 24 patients, as measured by the modified Harris hip score.
Conclusion: In older individuals with significant osteoporosis, the therapy of unstable intertrochanteric fractures differs
from the treatment of other proximal femoral fractures. Internal fixation is not as effective as cemented hemiarthroplasty
in treating these fractures. This approach has a clear advantage in terms of early full weight bearing and recovery. Hips
that have undergone cemented hemiarthroplasty are stable and mobile. Weight bearing can begin earlier than with other
treatment approaches, avoiding any recumbency-related problems.
Keywords: Intertrochanteric fracture, primary bipolar hemiarthroplasty, Harris hip score, Moore’s technique
Introduction In these people with poor bone quality, fractures

Intertrochanteric fractures are becoming increasingly are commonly accompanied with issues such as
prevalent in older people worldwide. Trochanteric nonunion, metal failure, and femoral head perforation.
fractures are the most frequent proximal femur The majority of fractures are caused by minimal
fractures, typically affecting the elderly and ranking trauma. An intertrochanteric fracture is defined as a
among the most hazardous injuries in the elderly. fracture that extends from the extracapsular basilar
This is due to individuals living longer lives and neck area to the lesser trochanter region before the
osteoporosis.1 establishment of the medullary canal.2
Dr Abhishek Shetty V.
Associate Professor
Department of Orthopaedics, Yenepoya Medical College, Mangalore, Karnataka
158
Fractures in the posteromedial cortex that have Inclusion criteria:

comminution are considered unstable. Internal 1. Patient above 60 years of age.
fixation produces reliable results for treating stable
2. Elderly patients with non-united trochanteric
trochanteric fractures. The best way to treat an
fractures
unstable osteoporotic fracture is still up for debate. In
the past, utilising a fixed blade plate and an enders 3. Patients with trochanteric fractures treated by
nail to treat unstable fractures resulted in a high rate internal fixation which has gone for failure.
of cut through and fracture displacement.3
Exclusion criteria:
Sliding hip screws were then successfully used, and
they have subsequently become the most prevalent 1. Patient less than 60 years.
means of treating these fractures. Even with this 2. Polytrauma patients.
technology, due to uncontrolled telescoping, metal 3. Compound intertrochanteric fracture
fracture, and screw cut out through the skull, early
complete weight bearing mobility of an unstable Boyd and Griffin classification was used to classify
osteoporotic fracture can produce rotational deformity fractures. The posterior (Moore’s) technique was
and limb lengthening.4 used to treat all of the patients with cemented bipolar
prostheses.
Early weight bearing following internal fixation
of comminuted trochanteric fractures by different Statistical Analysis: The SPSS 22 software was
methods leads to fixation failure and unsatisfactory used for statistical analysis. The data outcome was
outcomes in physically elderly and osteoporotic presented in the form of tables with means and
persons. As a result, a time of restricted movement percentages.
is indicated for this patient, which might lead to Observation and Results
complications such atelectasis, bed sores, pneumonia,
Table 1: Distribution based on Gender
and deep vein thrombosis.5
Intramedullary interlocking devices are proving Gender Frequency Percentage
to be more effective in treating unstable fractures. Male 17 56.66%
However, the long-term effects of these gadgets have Female 13 43.33%
yet to be identified. Endoprosthetic replacements
The average age of the patient was 74.4 years [60-
have recently been found to result in early patient
90 years]. The study covered both male and female
mobilisation and long-term success. However, before
patients. There were 17 males and 13 females among
a judgement can be formed, further prospective
the patients. All of the patients had suffered a fracture
randomised studies are required.6
as a result of a minor accident.
As a result, the appropriate treatment technique
Table 2: Distribution based on fracture
for an unstable intertrochanteric fracture remains a
classification
point of contention. This research looks at the role
of primary hemiarthroplasty in the treatment of Fracture Classification Frequency Percentage
unstable intertrochanteric fractures in the elderly and
TYPE 1 0 0%
physically aged.
TYPE 2 24 80%
Materials and Methods TYPE 3 4 13.33%
Study Design: Random Prospective study TYPE 4 2 6.67%
Study setting: Department of Orthopaedics, A total of 14 patients suffered a left-sided fracture.
Yenepoya medical college, Mangalore, Karnataka A total of 16 patients suffered from a right-sided
Study duration: December 2017 to march 2019. fracture.
30 elderly and physiologically elderly patients Boyd and Griffin Type II intertrochanteric fracture
with comminuted trochanteric fractures who met the was sustained in 24 patients, Boyd and Griffin Type III
inclusion criteria were studied prospectively. intertrochanteric fracture was sustained in 4 patients,

and Boyd and Griffin Type IV intertrochanteric Table 5: Distribution based on Complications
fracture was sustained in 2 patients.
Complications Frequency Percentage
Table 3: Distribution based on singh index Superficial infection 2 6.66%
Singh index Frequency Percentage Abductor weakness 5 16.66%
Grade 1 2 6.67% Limb shortening 13 43.33%
Grade 2 9 30% Bed ridden 0 0%
Grade 3 14 46.66% The most common complication in our study is
Grade 4 3 10% post-operative shortening of the Limb.
Grade 5 2 6.67% Discussion
Grade 6 0 0% Internal fixation with a dynamic hip screw is the
The majority of the patients in our study have Grade treatment of choice for stable intertrochanteric
3 or less osteoporosis according to Singh’s index. fractures. However, the situation is different when it
comes to treating an unstable fracture. Internal fixation
Three patients died within eight months of surgery, of unstable fractures has a failure rate of up to 56%.
out of a total of thirty. The remaining 17 patients In physiologically normal individuals, early weight
were followed up on at six weeks, three months, six bearing following various modalities of internal
months, and twelve months after surgery. repair of communited trochanteric fractures. In
The mean time from injury to surgery was 12 days. elderly and osteoporotic individuals, fixation failure
All the cases were treated with cemented bipolar and unsatisfactory outcomes are prevalent. Because
prosthesis. Tension band wiring of greater trochanter it offers stability and allows for early total weight
was done in 3 cases to hold the fragments together. bearing, hemiarthroplasty is a common operation.
Calcar reconstruction using cement was done in 15 The bulk of the problems related with internal fixation
cases. are eliminated when prosthetic replacement is used.
Hemiarthroplasty was originally only used to treat
The mean day of full weight bearing was on the
failed intertrochanteric fracture repairs.
6th post operative day. Postoperatively two patients
had superficial infection which was treated with I.V. Stern and Goldstein, who used the Leinbach
antibiotics. prosthesis to treat 22 intertrochanteric fractures,
found that early ambulation and rehabilitation to pre-
13 patients had shortening of the operated limb,
injury status was a substantial advantage.6 Grimsurd
of which 11 had less than 2 cms, so they were given
et al showed a minimal incidence of complications in
a heel raise. They walked with the help of a cane,
39 patients with unstable intertrochanteric fractures
1 patient had shortening more than 2 cm, he had a
treated with cemented bipolar hip arthroplasty. There
limp.5 patients (25%) had abductor weakness at 12
were no issues like pressure sores, pneumonia, or
months of following.
deep vein thrombosis in our trial since the majority of
Table 4: Distribution based on HARRIS hip score our patients were mobile right after surgery.7
Kiran kumar et al found that 20% of patients had
HARRIS HIP Score Frequency Percentage
a shortening of less than 2cm, whereas 10% of cases
Excellent 7 23.33% had a shortening of more than 2cm. Eight of the cases
Good 6 20% in our research had a shortening of less than two
centimetres, whereas one had a shortening of more
Fair 11 36.66% than two centimetres.8
Poor 3 10% According to our findings, we had good to
The functional results were graded according to extraordinary results 75% of the time. As a result,
Harris Hip Scoring System. In our study, 7 patients the outcomes of hemiarthroplasty in the treatment of
had excellent results, 6 patients had good results, 11 intertrochanteric fractures are highly promising.
patients had fair results, 3 cases had poor result. In Post-operative death rates varied from 5.4 % to 48.8
our study ,15 cases (70%) had excellent to fair result. %. The prosthetic group has a slightly higher mortality

160
rate than the internal fixation group, according to the Conflict of interest: Nil
majority of comparison studies.9,10
Kesmezacare et al, observed a 48.8% post-op
mortality rate in patients treated with endoprosthesis
References
after a mean of 6 months.11 Only two patients out of 1. Kannus P, Parkkari J, Sievanen H, Heinonen A, Vuori
37 (5.4 %) died within six months following surgery, I, Jarvinen M. Epidemology of hip fractures. Bone
according to Sanchetti et al.12 The most prevalent 1996;18:57S-63S.
cause of post-operative death and morbidity, they 2. Koval KJ, Zuckerman JD. Hip fractures are an
predicted, is treatment delay. increasingly public health problem. Clin Orthop
RelatRes1998;348:2.
The mean number of days spent by the patient in
the hospital in the postoperative period was 12 days. 3. Rockwood PR, Horne JG, Cryer C. Hip fractures: A
At the end of 12 months 4 patients walked without future epidemic? J Orthop Trauma1990;4:388-393.
any support, 11 patients walked with the help of a 4. Laros, G. S. and Moore, J. F.: Complications of fixation in
cane, 4 patients complained of occasional anterior intertrochanteric fractures, Clin. Orthop.1994;101:110.
thigh pain on long distance walking, which was
5. Jensen, J. Steen, Tondevold, E. & Sonne-Holm.:
relieved on taking rest and analgesics , 3 patients died Unstable trochanteric fractures. A comparative analysis
due to unrelated causes. There was no incidence of of four methods of internal fixation. Actaorthop.
deep vein thrombosis, pneumonia, pressure sores sand.1980;51,949-962.
or cardiovascular complication in the early post
6. Stern MB, Anger man A: Comminuted Inter trochanteric
operative period.
fractures treated with a Leinbach prosthesis. Clin
Bipolar Stem was fitted in valgus position in 3 cases orthop.1987 May (218): 755-780.
, varus position in 2 patient, whereas the position 7. Chris Grimsrud,Raul J.Monzon,Jonathan Richman
of the stem was centre (normal) in 25 patients. and Michael D.Ries:Cemented Hip Arthroplasty
Cement filling was adequate in 22 cases, whereas it is With a Novel Cerclage Cable Technique for Unstable
inadequate in 4case. Intertrochanteric Hip Fractures.J Arthroplasty
2005Apr;337-343.
There was no prosthetic dislocation, stem loosening,
acetabular erosion or periprosthetic fracture after a 8. Kiran Kumar GN , Sanjay meena, Vijaya Kumar ,
period of 12 months follow up in our series. Manjunath S, Vinaya raj MK.: Bipolar Hemiarthroplasty
in Unstable Intertrochanteric Fractures in Elderly: A
Conclusion Prospective Study. Journal of Clinical and Diagnostic
When standard approaches were employed, Research 2013;7(8):1669-71.
this therapy resulted in good pain-free mobility, 9. Tronzo RG. The use of an endoprosthesis for severely
uncomplicated rehabilitation, and a quick return communited intertrochanteric fractures. Orthop Clin
to functional level. The adaptability of the bipolar North Am1974;5:679-681.
prosthesis is demonstrated by its ability to function 10. Pho RW, Nather A, Tong GO, Korku CT.
in a variety of settings. This demonstrates the Endoprosthetic replacement of unstable, communited
technique’s effectiveness. Extended immobilisation, intertrochanteric fracture of the femur in the elderly. J
long rehabilitation, significant residual abnormalities, Trauma1981;21:792-797
and revision procedures were all minimised with
11. Kesmezarcar H, Ogut T, Bilgili MG, Gokay S,
bipolar hemiarthroplasty. In older patients with
Tenekecioglu Y.: Treatment of intertrochanteric
femur intertrochanteric fractures, the surgery fractures in the elderly patients. Internal fixation
enhanced mobility, hastened recovery to pre-injury (or) hemiarthroplasty. Acta Orthop Traumatol Tur
levels, increased quality of life, and provided a long- 2005;39:287-294.
term solution.
12. Sancheti et al.: Primary hemiarthroplasty in elderly
Ethical Clearance: The ethical clearance was unstable osteoporotic intertrochanteric fracture. Indian
obtained from the Yenepoya Medical College J orthop 2010;44(4):428-434.
institutional ethics committee prior to the
commencement of the study

A Study of Clinical Profile of Patients with Traumatic Cataract
Nalini Jayanthi. B1, Sujatha Asadi2

Assistant professor of Ophthalmology, Govt. Medical college Nalgonda
1
2
Assistant Professor, Osmania medical college and Osmania General Hospital, Hyderabad
How to cite this article: Nalini Jayanthi. B1, Sujatha Asadi2 et al A Study of Clinical Profile of Patients with Traumatic
Cataract. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Traumatic cataracts cause a significant amount of vision loss and blindness in the general population,
particularly in underdeveloped nations. It’s associated with a variety of ocular injuries.
Objectives: To study the clinical profile of traumatic cataract patients.
Methods: A total of 50 patients who satisfied the inclusion criteria were recruited for the study, and a comprehensive
history was obtained. A thorough slit lamp examination was performed using a torch light under diffuse lighting.
Results: In majority of the patient’s total cataract was done in 86% of the cases. Among the associated ocular damage,
corneal injury was seen in 62% of the patients, And associated ocular complication was Lens matter in anterior chamber
reported in 22% of the cases, Uveitis in 8% of the cases and Glaucoma was reported in 6% of the cases.
Conclusion: Traumatic cataracts result in considerable vision impairment, psychological distress, and a major financial
burden. To avoid vision loss in traumatic cataract patients, a better knowledge of these injuries is required. Appropriate
health awareness education, as well as early prevention, is required among the population.
Keywords: Trauma, Cataract, Slit lamp, Glaucoma
Introduction are the most prevalent victims of sports and work-

Ocular trauma is considered one of the most serious related eye injuries, followed by accidents caused by
public health issues in the globe. It is the world’s youngsters participating in high-risk sports lacking
single most common cause of acquired monocular supervision or protective measures.4
blindness. Ocular damage causes around 1.6 million Cataracts can be caused by both penetrating and
individuals to go blind across the world.1 Ocular traumatic injuries. The visual prognosis of traumatic
trauma is thought to be responsible for around 40% of cataract is determined by the type of ocular trauma,
monocular blindness.2 Cataract advancement occurs the level of lenticular involvement, and any ocular
as a result of trauma. After a variety of ocular insults, structural damage. The time of intervention has been
including blunt and penetrating trauma, a traumatic stressed that for a better prognosis, cataract surgery
cataract can occur. Infrared energy, ionising radiation, should be performed within a year of the initial
and UV radiation are all rare causes of traumatic procedure in adults and within six months of the
cataract.3 initial surgery in children.5
Domestic injury is the most prevalent type of injury Traumatic cataract has a physiological, social, and
in children, which occurs most frequently while monetary impact on the quality of life of younger
they are playing at home or at school. Young people people, thus it’s crucial to understand the clinical
Dr. Nalini Jayanthi. B
Assistant professor of Ophthalmology, Govt. Medical college Nalgonda
162
profile for proper treatment. The purpose of this Table 2: Distribution based on type, cause and
study was to look at the clinical characteristics of duration of trauma
individuals who had traumatic cataracts.
Type of trauma Number of cases Percentage
Materials and Methods Blunt 13 26%
Type of Study: Retro prospective Cross-sectional Penetrating 37 74%
study.
Cause of trauma
Study Setting: Department of Ophthalmology.
Rod/ stick 27 54%
Sarojini Devi eye hospital
Stone 7 14%
Study Duration: 2 years, 2019 to 2021
Glass 2 4%
Inclusion Criteria:
Wired fence 10 20%
• Traumatic cataract patients
Ball 4 8%
• Exclusion Criteria:
Total 50 30
• Those unwilling to participate in the study.
Duration of
A total of 50 patients who satisfied the inclusion trauma
criteria were recruited for the study, and a < 1 week 2 4%
comprehensive history was obtained. A thorough slit
< 1 month 16 32%
lamp examination was performed using a torch light
under diffuse lighting. Where applicable, intraocular < 1 year 25 50%
pressure was measured using Goldmann applanation >1 year 7 14%
tonometry.
Total 50 100%
Statistical analysis: The data was analysed using
SPSS 22 software and the outcome was presented in In majority of the cases, it was penetrating
the form tables with percentages. trauma reported in 74% of the cases and
blunt trauma was seen in 26% of the cases.
Observation and Results Most common cause of trauma was due to rod/stick
Table 1: Distribution based on demographics in 54% of the cases, followed by wired fence in 20%
of the cases, stones in 14% of the cases, ball in 8% of
Gender No of patients Percentage the cases and glass in 4% of the cases. Majority of the
Male 34 68% patients around 50% presented within a year after
Female 16 32% trauma, 32% of the cases presented within a month of
Age group (years) trauma, 14% took more than a year after trauma for
11-20 6 12% cataract and only 4% of the cases presented within a
week of trauma.
21-30 14 28%
31-40 13 26% Table 3: Distribution based on type of cataract
41-50 12 24% Type of cataract No of patients Percentage
51-60 5 10% Total cataract 43 86%
Male predominance was seen with 68% and females Soft cataract 3 6%
were 32%. The male: female ratio was 2.1: 1. Subcapsular
2 4%
cataract
Majority of the patients belonged to the age group
Rosette cataract 2 4%
of 21 to 30 yrs with 28% followed by 31 to 40 yrs with
26%, 24% belonged to the age group of 41 to 50 yrs Total 50 100%
age, 12% belonged to the age group of 11 to 20 yrs and In majority of the patients total cataract was done in
the least belonged to the age group of 51 to 60 yrs. The 86% of the cases, soft cataract was done in 6% of the
mean age was 34.17 + 4.37 yrs. cases, subcapsular and rosette cataract was done in
4% of the cases each.

Table 4: Distribution based on associated ocular The kind of damage and the form of the cataract
damage were also found to have statistical relevance. In this
Associated Ocular No of study, Majority had total cataract surgery, while Shah
Percentage et al observed soft cataract in the majority of cases.10
Damage patients
Corneal injury 31 62% The most common related ocular morbidity was
Iris injury 16 32% corneal involvement. These findings backed with
Vitreous haemorrhage 2 4% previous research that found corneal impairment to
be the most prevalent related injury. According to
Associated Ocular
Memon et al., 2012, the interval between damage and
Complication
cataract surgery had no effect on the ultimate visual
Lens matter in anterior 11 22% result of traumatic cataract patients, and that these
chamber
patients, if treated appropriately, had a satisfactory
Uveitis 4 8% visual prognosis.
Glaucoma 3 6%
Trauma can be reduced with awareness and
Total 30 100%
caution. Because corneal involvement is one of the
Among the associated ocular damage, corneal most prevalent morbidities associated with traumatic
injury was seen in 62% of the patients, Iris injury was cataract, the need of early reporting and proper
seen in 32% of the cases, Vitreous haemorrhage was follow-up, particularly those suffering from traumatic
seen in 6% of the cases. cataract, must be emphasised.
The associated ocular complication was Lens Conclusion

matter in anterior chamber reported in 22% of the In India, traumatic cataracts result in considerable
cases, Uveitis in 8% of the cases and Glaucoma was vision impairment, psychological distress, and a major
reported in 6% of the cases. financial burden. To avoid vision loss in traumatic
Discussion cataract patients, a better knowledge of these injuries
is required. Appropriate health awareness education,
The most prevalent cause of unilateral cataract is
as well as early prevention, is required among the
trauma. A primary repair of a corneal, iris, or scleral
population.
wound, as well as a comprehensive evaluation of
injury to the intraocular structures, may be required Ethical Clearance: The ethical clearance was
at the time of presentation following an eye injury. obtained from Government Medical College prior to
Prior to surgery, a comprehensive assessment of the the commencement of the study.
nature and degree of the ocular injury, meticulous Source of funding: Self
planning, and counselling are critical to the successful
management of these cases.6
The incidence of trauma in this study age group was References
more in the teenage years compared to other studies 1. Negrel AD, Massembo-Yako B, Botaka E: prevalence
who reported in children since they were paediatric et causes de la ceciteou Congo. Bull WHO. 1990;68:237.
studies who focussed on the study population while 2. Johns KJ, Feder RS, Bowes Hamill M. Lens and cataract,
this study had included patients with all age groups. AAO basic and clinical science course series. San
In previous studies, the incidence of traumatic Francisco: the foundation for the American Academy
cataract was shown to be higher in the younger age of ophthalmology, 2001;50-54:213-216.
group. Daljit Singh has a similar age demographics.7
3. Zaman M, Sofia I, Muhammad DK. Frequency and
In this study 54% of the cases had trauma due to visual outcome of traumatic cataract. J Postgrad Med
stick/ rod. Injury occurred as a result of their regular Inst. 2006;20:330-4.
activities, such as playing with or handling such 4. Irivine JA, Smith RE, Lens Injuries in trauma. CV
things at home or in their neighbourhood, which is Mosby.1991;126-135
similar to previous studies by Krishnamachiary M et
5. Maida JM, Mathers K, Alley CL. Pediatric
al8 and Memon MN et al reported that 54.7 % and 44
ophthalmology in the developing world. Curr Opin
% of patients, respectively, sustained stick injury.9
Ophthalmol. 2008;19:403–8.

164
6. Gilbert C, Muhit M. Eye conditions and blindness 9. Menon M N, Narsani AK, Nizamani NB. Visual
in children: priorities for research, programs, and outcome of unilateral traumatic cataract. Journal of
policy with a focus on childhood cataract. Indian J College of physicians and surgeons Pakistan 2012;
Ophthalmol. 2012;60:451–5. 22:497-500.
7. Singh D, Singh K, Singh J, Sood R. The role of intraocular 10. Shah MA, Shah SM, Shah SB, Patel CG, Patel UA.
lens in traumatic cataract. Indian J Ophthalmol. 1983 Morphology of traumatic cataract: does it play a
May;31(3):294-7 role in final visual outcome? BMJ Open. 2011 Jul
29;1(1):e000060.
8. Krishnamachary M, Rathi V. Management of traumatic
cataract in children. J Cat Refract Surg 1997;23:681-7

Assessment of Various Etiological Factors of Puberty Menorrhagia
Nazima Alauddin
Associate Professor, Department of Obstetrics and Gynecology, Dr. Patnam Mahender Reddy Institute of medical sciences,
Chevella, Ranga Reddy district. Telangana.
How to cite this article: Nazima Alauddin et al Assessment of Various Etiological Factors of Puberty Menorrhagia.
Abstract
Background: Puberty menorrhagia is characterized with lengthy bleeding that occurs between menarche and the age
of 19. From menarche to menstruation, it takes 5-8 years for a regular menstrual cycle to develop, and during this time,
teenagers may have menstrual irregularities. Puberty menorrhagia poses a significant challenge to the gynecologist when
it is associated with serious systemic complications like anemia and hypoproteinemia.
Objectives: To analyze the various causes for puberty menorrhagia
Methods: A total of 82 Adolescent girls attending outpatient department were selected after meeting the inclusion criteria.
Informed consent from parents/guardian and consent from patient and consent from adolescent if she is above 18yrs of
age. Identification of underlying cause and prevalence rates. Diagnosis will be made based on the investigations.
Results: The mean age 14.92 + 2.16. Severe anemia was seen in 41.46% of the cases, moderate anemia was seen in 43.90%
of the cases and Mild anemia was seen in 14.63% of the cases. The ultrasound findings were normal in 88% of the cases,
PCO was detected in 10% of the cases, Intramural fibroid was seen in 2% of the cases. Anovulatory cycle were seen in
79.26% of the cases, PCOS was the most common etiology in 9.75% of the cases, Hypothyroidism was diagnosed in 8.53%
of the cases, Uterine fibroids were diagnosed in 2.43% of the cases.
Conclusion: Puberty menorrhagia is an aggravating condition that can escalate into serious complications and necessitate
a blood transfusion. The majority of instances are caused by anovulatory cycles with immature hypothalamo-pituitary-
ovarian-endometrial axis. The present child obesity epidemic may exacerbate the symptoms of polycystic ovarian
syndrome, emphasizing the necessity of early and accurate diagnosis with a focus on lifestyle change.
Keywords: Anovulatory cycle, PCOS, Anemia, Hypothyroidism
Introduction Menorrhagia has a substantial impact on teenage

Adolescent gynecological issues occupy a unique quality of life, academic performance and peer
place in the spectrum of gynecological disorders relationships. Many teenagers delay consulting
of all ages. Several researchers have investigated a gynecologist, putting them at risk for problems
in adolescent gynecological issues, with menstrual including severe anemia and hypoproteinemia.
abnormalities being the most prevalent. Adolescents It is critical to rule out pregnancy in all cases of
with gynecological problems require sensitive puberty menorrhagia, particularly incomplete
intervention because dealing with these concerns can abortion and ectopic pregnancy. Anovulatory cycles,
be embarrassing for them and is still considered taboo coagulation disorders, platelet function disorders,
in our society today.1 Adolescent girls are a vulnerable hypothyroidism, polycystic ovarian syndrome,
demographic, especially in developing nations such genital tuberculosis, and pelvic tumors are the most
as India, where female children are often neglected. In common causes.4
India, adolescents account for about 21.4 %.2 Because Menstruation does not always imply ovulation;
of the turmoil of adolescence that they confront as in fact, the majority of early menstrual cycles are
a result of the many phases of growth that they go anovulatory. It may take several years for menstrual
through, the various situations that they encounter, cycles to return to normal. Without ovulation,
their various demands and difficulties, this age group estrogen has an unopposed impact on progesterone,
need specific care.3 leading in endometrial growth that outgrows its
166
blood supply and architectural supports, resulting in Adolescent girls attending outpatient department
partial disintegration and irregular shedding. Anemia were selected after meeting the inclusion criteria.
is a possible side effect of puberty menorrhagia. As a Informed consent from parents/guardian and
corollary, it is critical to confirm the correct diagnosis consent from patient and consent from adolescent if
before initiating any therapy.5 she is above 18yrs of age. Identification of underlying
cause and calculation of prevalence rates. Diagnosis
Materials and Methods was made based on the investigations.
Study design: Random Prospective Observational
study Statistical Analysis
Study site: Hospital based Study, Outpatient Statistical analyses were done using SPSS 22 software.
department of OBG Data was presented in the form of mean and
percentages.
Study Population: Adolescent girls attending
hospital OPD Observation and Results
A total of 82 patients with Puberty menorrhagia were
Inclusion criteria
included for the study.
• All Adolescent girls attending OPD of Gynecology
Table 1: Distribution based on Age group and BMI
department with complaints of prolonged heavy
bleeding Age group
Frequency Percentage
(In years)
Exclusion criteria
11 - 13 22 26.82%
• Adolescent girls with obstetric causes of bleeding 14 - 16 39 47.56%
• Adolescent girls with genital structural 17 - 19 21 25.60%
abnormality
BMI
Sample size: 82 <18.5 20 24.39%
18.5 – 24.9 51 62.19%
Method
25.0 – 29.9 11 13.41%
Young girls with prolonged heavy bleeding from age
of menarche till 19 years of age are recruited after Total 82 100%
taking informed consent from their parents and If the The majority of the patients around 47.56%
girl is above 18years of age, consent was taken from belonged to the age group of 14 to 16 yrs., followed by
her. 11 to 13 yrs. age group with 26.82% and 17 to 19 yrs.
Detailed history was taken including, bleeding age group with 25.60%. The mean age 14.92 + 2.16.
disorders, drug intake, menstrual, Age of Menarche, Around 62% of the patients had a normal BMI,
Regularity of Cycles in past and present, Duration of 24.39% were underweight and 13.41% of the patients
Flow, Passage of Clots, No. of Pads Used per day and were overweight. The mean BMI was 20.85 + 3.36
per cycle, Dysmenorrhea and Last Menstrual Period
was noted. Detailed general physical examination Table 2: Distribution based on Hemoglobin and
TSH levels
was also done
Hemoglobin (g/dl) Frequency Percentage
Investigations
<5 34 41.46%
1. Complete Blood Picture
5.0 – 8.0 36 43.90%
2. Blood Grouping and Typing
8.1 – 10.0 12 14.63%
3. PT,APTT,INR TSH (mIU/L)
4. Thyroid Assay 0.5 to 5.0 74 90.24%
5. USG of Abdomen and pelvis with Full Bladder if >5.0 8 9.75%
necessary

All patients were suffering from anemia. Severe Ultrasound Pelvis

anemia was seen in 41.46% of the cases, moderate Frequency Percentage
Findings
anemia was seen in 43.90% of the cases and Mild PCOS 8 9.75%
anemia was seen in 14.63% of the cases. The mean Total 82 100%
Hemoglobin levels were 5.75 + 1.55.
PCOS was detected in 10% of the cases, Intramural
TSH levels were normal in 90.24% of the cases. In fibroid was seen in 2% of the cases.
9.75% of the cases the TSH levels were High. In 1
patient TSH levels were >100. The mean TSH levels Anovulatory cycle were seen in 79.26% of the cases,
were 5.15 + 5.04. PCOS was the most common etiology in 9.75% of the
cases, Hypothyroidism was diagnosed in 8.53% of the
Table 3: Distribution based on Prothrombin cases, Uterine fibroids were diagnosed in 2.43% of the
time, activated partial thromboplastin time and
International normalized ratio cases.
Prothrombin Time Discussion

(in seconds) Puberty menorrhagia generally described as heavy
11.0 – 12.5 49 59.75% bleeding in the amount of >80ml or duration of
>12.5 33 40.24% >7 days between menarche and the age of 19. The
Activated partial onset of puberty and its progression differs from
thromboplastin time person to person, and is thus largely affected by
(in seconds) genetics. Menstruation begins as the hypothalamic-
<25 4 4.87% pituitary-ovarian axis matures, which is impacted
25.0 – 35.0 78 95.12% by genetics, diet, body weight, and the development
International of the hypothalamic-pituitary-ovarian axis. It might
normalized ratio (INR) take up to two years for the axis to fully mature.
0.80 -1.10 64 78.04% Adolescents frequently appear with menorrhagia
>1.10 18 21.95% during this period. In teenage females, abnormal
The prothrombin time was normal in 60% of the bleeding accounts for almost half of all gynecological
cases and in the rest 40% of the cases Prothrombin consultations, with symptoms ranging from minor
time was high. The mean prothrombin time was 12.24 spotting to heavy bleeding.
+ 0.72. Girls under the age of 20 make up about a quarter of
The aPPT was normal in 95% of the cases and in the population in developing nations. It is typical for
5% of the cases it was slightly low 24.3 in 2 cases, 24.6 individuals to appear with symptoms of menstrual
in 1 case and 22.3 sec in 1 case. The mean aPPT was abnormalities at this time. Initially, postmenopausal
28.70 + 2.13 cycles are anovulatory. Endogenous progesterone
cannot counteract the estrogen impact in the absence
The International Normalized Ratio(INR) was
of ovulation, resulting in endometrial growth and
normal in 78% of the cases. The INR was 1.20 in 22%
eventually excessive monthly bleeding. As a result,
of the cases. The mean International Normalized
puberty menorrhagia is a very frequent gynecological
Ratio(INR) was 1.00 + 0.14.
condition in adolescence, and it can occasionally lead
Table 4: Distribution based on Ultrasound Pelvis to a life-threatening occurrence.
findings and Etiology
Immaturity of the hypothalamic-pituitary ovarian
Ultrasound Pelvis axis, which causes anovulation, is the most prevalent
Findings cause of abnormal bleeding in teenagers, followed
Normal 72 87.80% by PCOS, endocrine, or hematological problems,
PCOS 8 9.75% all of which require specific diagnostic tests. The
Intramural Fibroid 2 2.43% prognosis is better if irregular uterine bleeding occurs
Etiology after a period of regular menstruation rather than at
Anovulatory cycle 65 79.26% menarche. Each case must be handled individually,
Uterine Fibroid 2 2.43% with a comprehensive history, physical examination,
Hypothyroidism 7 8.53% baseline workup, and timely hospitalization.

168
Etiology Anovulatory cycles Uterine Fibroid Hypothyroidism PCOS

This study 79.26% 2.43% 8.53% 9.75%
Laksmi et al 6
61.53% 5.76% 13.46% 19.23%
Gupta D et al 7
72.9% 4.3% 10.0% 12.9%
Nusrat et al 8
53.33% - 13.33% 16.66%
Prameela et al9 68.7% - 18.7% 12.5%
Mandal et al 10
72% 2.0% 8.5% 10.5%
Ashraf et al 11
69.2% 15.3% 11.5% 15.3%
Koranne et al 12
80% - 5.7% 5.7%
The immaturity of the HPO axis is responsible for References

95% of instances of anovulation in teenagers. Despite 1. Lakshmi Rachkonda, Savita Kadam, Swati Shiradkar.
adequate follicular estrogen levels, these teenagers Study of evaluation of puberty menorrhagia. MedPulse
lack the positive feedback mechanism required to – International Journal of Gynaecology. July 2017; 3(1):
initiate an LH surge and subsequent ovulation. We 30-33.
did not come across any bleeding diathesis during
2. Mohammad, S. (2012). Puberty menorrhagia: Causes
our research. We found a significant relationship and management. Journal of Medical Sciences
between age and final diagnosis (p=0.001) in our (Peshawar). 20. 15-18.
study, indicating that the final diagnosis is based on
the age of the adolescent girls. 3. A. Shanti Sri, Ayesha Jehan. “Pubertal Menorrhagia:
Evaluation and Management”. Journal of Evolution
Reassurance and treatment for adolescent girls of Medical and Dental Sciences 2015; Vol. 4, Issue
and their parents about menstruation physiology 30, April 13; Page: 5198-5203, Gillani S, Mohammad
are critical for treating puberty menorrhagia. When S. Puberty Menorrhagia: causes and management.
patients do not react to routine supportive care, Journal of Medical Sciences (Peshawar). 2012 Jan;
progesterone-only or a combination of hormone 20(1):15-8.
therapy with OCP is an essential treatment. A balanced 4. Joshi S, Chella H, Shrivastava D. Study of puberty
diet, regular follow-up, and iron supplementation are menorrhagia in adolescent girls in rural set-up. Journal
required in all girls having puberty menorrhagia. of SAFOG. 2012; 4(2):110-2
Conclusion 5. Patel NK, Patel S, Damor R, Pandya MR. Comparison of

the efficacy and safety of norethisterone vs. combined
Puberty menorrhagia is an aggravating condition oral contraceptive pills for the management of puberty
that can escalate into serious complications and menorrhagia. Int J Basic Clin Pharmacol 2012;1:191-5
necessitate a blood transfusion. The most prevalent
6. Lakshmi Rachkonda, Savita Kadam, Swati Shiradkar.
cause of puberty menorrhagia is immature
Study of evaluation of puberty menorrhagia. MedPulse
hypothalamic-pituitary-ovarian axis, which results
– International Journal of Gynaecology. July 2017; 3(1):
in anovulation. Around 20% of teenagers have an 30-33.
underlying endocrine or hematological disease that
need specific examination and treatment. Anatomical 7. Gupta D, Agrawal S, Gupta S. Assessment of various
abnormalities such as fibroid or polyp should also be etiological factors of puberty menorrhagia in rural
central India. The New Indian Journal of OBGYN.
evaluated. Once a diagnosis has been determined,
2021; 7(2): 190-95
medical or surgical intervention should be provided
as needed. 8. Ummul Nusrat Zahan, Sufia Begum Shampy, Syeda
Akhter Jahan,Ferdous Ara Suchi , G.W.M.Zahidul
Ethical Clearance: Ethical Clearance was obtained Hasan, Incidence of puberty Menorrhagia - A Case
from the institutional ethics committee of Dr. Patnam Study in Dhaka, Bangladesh, JMSCR Volume – 2, Issue
Mahender Reddy Institute of Medical Sciences prior – 9, Page 2140-2147, September-2014.
to the commencement of the study.
9. Prameela, Syeda Mohsina Iffath, Study of Puberty
Source of Funding: Self Menorrhagia in Inpatient Admissions, Sch. J. App.
Med. Sci., 2015; 3(3A):1060-1063

10. Mandal RC, Bhar D, Mahapatra C et al. Etiological 12. Koranne PS, Wahane AR. Puberty menorrhagia in
factors and management of puberty menorrhagia in a modern era: analysis in a tertiary care centre. Int J
rural medical college of South Bengal: A prospective Reprod Contracept Obstet Gynecol 2014;3:622-6
study. Int J Health Sci Res. 2015; 5(12):81-88.
11. Ashraf S, Afzal A, Nigeen W, Nabi N. Study of puberty

menorrhagia - Causes and management. Int J Med Sci
Public Health 2017;6(11):1594-1597.

Healthy Literate Working Dynamic Life Expectancy for India and

Some of its Major States
Nazmina Hussain1, Barnali Thakuria2

1
Research Scholar, Department of Statistics, Gauhati University, Guwahati, Assam, India
2
Assistant Professor, Department of Statistics, Pandu College, Guwahati, Assam, India
How to cite this article: Nazmina Hussain, Barnali Thakuria et al Healthy Literate Working Dynamic Life
Expectancy for India and Some of its Major States. Volume 13 | Issue 4 | October-December 2022
Abstract
The absence of disease or disability, good level of education and active involvement in society are considered as essential
dimensions for a long and fulfilling life. To assess these concepts, we propose a new indicator the Healthy Literate Working
Dynamic Life Expectancy that associates health, literacy level and employment status along with the changing mortality
scenario in India and some of its major states for the census year 2011 based on the rates of change of probabilities of death
over the previous 10 years i.e.2001. Since dynamic life table considers the mortality changes prevailing in a population,
therefore it might provide a more realistic and accurate picture of the healthy, literate and working population under
consideration. The analysis reveals higher values of healthy literate working dynamic life expectancy at birth for India
and all the major states as compared under usual consideration. Further, different inequalities and a number of particular
cases are obtained from the above proposed index.
Keywords: Dynamic life expectancy, Health, India, Literacy, Mortality, Working.
Introduction families and are more likely to depend on additional

Over the last Century, India has witnessed a drastic means such as social assistance or food stamps4. As
improvement in the overall life expectancy (LE). such, to get proper medical facilities and for acquiring
Several studies in the recent years have pointed out a healthy life, people should be well paid for their
that declining death rates among adults and elders work.
in India have contributed significantly towards Research during the past several studies have shown
improved LE1. However, a question that could be that literacy, employment and health condition of a
raised in this context is that whether this increased person in a society are demographically measured by
life expectancy has really improved the quality of life literate life expectancy5, working life expectancy6 and
in India. During second half of twentieth century, disability-free or healthy life expectancy7 respectively.
WHO noted that the fundamental objective of human Moreover, various previous demographic studies
activity should include both long life as well as good carried out in the areas of health, literacy and
health2. Additionally, the scientific literature on working life expectancy8-10 are mostly conducted by
health inequalities has repeatedly demonstrated a using the period life table method which assumes
strong association between lower levels of education that the mortality experience of a population will
and poorer health outcomes3. Further, in terms of remain constant. However, Denton and Spencer11
employment, those with low literacy skills often have showed an alternative approach of period life table,
difficulty finding jobs that pay more than a living named as ‘dynamic’ extension, that contradicts the
wage and thus they face difficulties supporting their assumption of constant mortality of period life table
Nazmina Hussain
Research Scholar, Department of Statistics, Gauhati University, Guwahati, Assam, India
and unambiguously allow for the likelihood of further then the expression for healthy literate working life
changes in mortality rates. Although the requirement expectancy (HLWLE) as developed by Thakuria18,
of dynamic life table is particularly important for which represents the expected number of years
analyzing the changes in mortality rates for India12-13, remaining healthy as well as literate and working life
one can also have a thought to measure the life simultaneously of an individual at age x is given by
expectancy under dynamic scenario with addition to
the three most important socio demographic factors 1ϖ
viz health, literacy and working. hlwe0 = ∑ P * L  (3.1)
x l  n hlwx n x 
x x
Empirical evidences suggests that health, literacy
Where n Lx denotes the total number of years lived
and working play a significant role in reducing
mortality rates, which in turn is associated with
an increase in life expectancy14-17. Hence, if we by a cohort in the age group [x, x+n) and ω represents
compute dynamic literate working life expectancy the highest age category i.e., 80+.
by considering simultaneous changes in mortality,
morbidity, literacy and working, then the resultant Now, for constructing dynamic life table as per the
indicator would expect to give an absurd value, method given by Denton and Spencer, we need two
which might not be acceptable in real situation. period life tables for a particular region. The most
Consequently, to compute dynamic literate working recent period could be taken as the reference period.
life expectancy one can consider only the changing Similarly, the required expression for healthy
mortality scenario prevailing in a population and the literate working dynamic life expectancy, denoted by,
current level of health, literacy and working. With hlwe0 is 1 ϖ 
= then∑derived as follows:
xx l  n Phlwx * n Lxy 
this, the paper mainly concentrates on the dynamic xx y
extension of period life table and attempts to develop
1 ϖ
a new indicator viz. healthy literate working dynamic hlwe0 = ∑ P * L 
xx l  n hlwx n xy 
life expectancy (HLWDLE) in order to portray the xx y (3.2)
affects of health, literacy and working on mortality
0 in
1 ϖ  
India.
hlwe =
xx l
∑ P
y
Wn h e r e* n Lxy (the dynamic analogue of L x column)
hlwx
xx
Objectives stands for the number 1 of

ϖ person years lived by
hlwe0 = * L 
The main objectives as outlined in the present study survivors of the l xx
xx cohort
l
∑ P
y
in the
n interval
hlwx n y
xyto
 y+1, ω
xx
are:
represents the highest age category i.e., 80+ and n Phlwx
To develop the formula for Healthy Literate
Working Life Expectancy (HLWLE) under dynamic represents the age-specific proportions of healthy,
set up of life table and to derive different inequalities literate as well as working persons of the reference
and a number of particular cases from the above period. The healthy literate working dynamic life
index. expectancy could then be used to represent the
To apply these indices in India and some of its expected number of years lived on an average by a
major states for the census year 2011 based on the person in a healthy, literate as well as in working state
rates of change of the probabilities of death over the when mortality changes over the years under
previous ten years i.e., 2001. consideration provided that the current situation of
health, literacy and working remains same.
Methods and Materials
Development of a proposed indicator-Healthy Particular Cases
Literate Working Dynamic Life Expectancy The proposed indicator is a generalized one in the
(HLWDLE): sense that from equation 3.2, numerous particular
cases can be persued. If the proportion of working
Let n Phlwx denote the age-specific proportions of
persons are not considered in equation (3.2) then we
get healthy-literate dynamic life expectancy (HLDLE)
healthy, literate as well as working persons
at various ages under current health and literacy
simultaneously at age group [x, x+n) respectively
state but under changing mortality pattern. Again

172
by ignoring the literate proportions in equation Similarly, if there is no continuation in the rates of
(3.2) gives healthy-working dynamic life expectancy change of probabilities of death, then all the above
(HWDLE) and by ignoring the healthy proportions inequalities will reduce to ordinary life expectancies.
we get the literate-working dynamic life expectancy
An important point to be noted here is that as the
(LWDLE). Likewise, ignoring the proportions of both
quantity of factors implicated in the life expectancy
literacy and working persons in the proposed index,
reduces, there is an increase in the corresponding
we get healthy dynamic life expectancy (HDLE) at
value of the index which is quite obvious.
various ages under current health scenario but under
changing mortality pattern. In a similar manner, we Application
can obtain literate dynamic life expectancy (LDLE) and As stated in the objective, here we tried to estimate
working dynamic life expectancy (WDLE). Moreover, healthy literate working dynamic life expectancy
if all the three factors health, literacy and working are (HLWDLE) for India and some of its major states
ignored in equation (3.2), then we get dynamic life for both sexes for the census year 2011. For this,
expectancy at various ages. Furthermore, if there is the age specific proportions of healthy, literate
no continuation in the rates of change of probabilities as well as working persons together needs to be
Particular Cases:
of death, then all the above indicators will reduce to combined with the dynamic life table. The Sample
ordinary life Theexpectancies. Thus,
proposed indicator is athe above discussion
generalized one in the senseRegistration
that from equation
System3.2, (SRS) based abridged life tables
clearly illustrates that the proposed indexIf viz.
numerous particular cases can be persued. the proportion
healthy of of working persons are not
India and its selected states for the period 2009-
considered in equation (3.2) then we get healthy-literate dynamic life expectancy (HLDLE) at
literate working dynamic life expectancy (HLWDLE) 2013 and
various ages under current health and literacy state but under changing 1999-2003
mortality pattern. are considered for the purpose.
is seemed
Again to
by be a more
ignoring the generalized one.in equation (3.2) gives The
literate proportions healthy-working
required dynamic
information regarding the literate and
life expectancy (HWDLE) and by ignoring the healthy proportions we get the literate-
Inequalities
working dynamic life expectancy (LWDLE). Likewise, ignoringworking population
the proportions of both by age and sex, for India and
literacy and working persons in the proposed index, we get healthyall the major
dynamic states, are provided by the population
life expectancy
One can
(HDLE)derive various
at various agesinequalities as shown
under current health below:
scenario but under changing mortality pattern.
In 0a similar manner, we can
census, which is the main source of demographic data
obtain 0literate dynamic life expectancy (LDLE) and working
0 0
hlwe ≤ hle ≤ he ≤ e
dynamic life expectancy (WDLE). Moreover, if all the three factors
xx
working xx
are ignored xx
in equation
in India.
health,For the and
literacy
xx then we get dynamic life expectancy at various ages.
(3.2),
factor health, since we do not have
morbidity data, as such for the present study, data on
Furthermore, if there is no continuation in the rates of change of probabilities of death, then
0 0 0 0 disability were taken from the table C20 of the 2011
hlwe ≤ hle ≤ le ≤ e
all the above indicators will reduce to ordinary life expectancies. Thus, the above discussion
clearly
xx illustrates
xx that thexx proposed
xx index viz. healthy literate Census
workingofdynamic
India. life
Using the above information, one

expectancy (HLWDLE) is seemed to be a more generalized one. can thus calculate the healthy proportions, literate
0 0 0 0
hlwe
≤ hlexx ≤ wexx ≤ exx
Inequalities:
xx
proportions and working proportions by age and sex
wise respectively. However, Census of India do not
0
One can derive
0
various
0
inequalities
0
as shown below: provide information on healthy, literate and working
hlwe

xx
≤ lwexx ≤ lexx hlwe
≤ exx  hle 0
 hexx  exx
0 0 0
persons simultaneously. As such, we have attempted
xx xx
0 0 0 0 to find the values of the proposed indicator HLWLE

0 0 0hlwe xx 0 hlexx  lexx  e xx
hlwe

xx
≤ lwe xx
≤ we xx
≤ e
0 xx
by using the random number generation method. In
hlwe  hle 0 0
 we  e
0
the process, we have also generated very compact and
xx xx xx xx
0 0 0 0 user friendly R programs for calculating the values
hlwe

xx
≤ lwexx ≤ hexxhlwe
≤ xx0exx lwexx0  lexx0  exx0 using the above technique. An interesting point to be

0 0 0
hlwexx  lwexx  wexx  exx
0
noted here is that if we take the product of healthy,
0 0 0 0
hlwexx ≤ hwexx ≤ hexxhlwe
≤ 0exx lwe 0  he 0  e 0 literate and working proportions simultaneously i.e
xx xx xx xx by assuming all the three factors as independent,
0 0 0 0
then the values obtained are very near to the values
≤ hwexx ≤ wehlwe
≤ e xxhwe  hexx  exx
0 0 0 0
hlwe

xx xx
xx xx
obtained by using the random number generation
0 0 0 0
hlwe xx  hwe xx
 we xx  e xx method18.
0 0 0 0
hlwe

xx
≤ hwexx ≤ lexxhlwe
≤ xxe0 xx hwexx0  lexx0  exx0 Finally, the age specific proportions of healthy,

literate as well as working persons together are
Where 0 0 0 0 0 0
represents
Where hexx , lexx, wexx , hlexx, hwexx and lwexx represents healthy calculated for India and 17 of its major states and
dynamic life expectancy,
healthy dynamic
literate dynamiclife
lifeexpectancy, literate
expectancy, working dynamic
dynamic life consequently,
life expectancy, healthy literate dynamic
healthy literate working dynamic life
life expectancy,
expectancy, working healthy workinglife
dynamic dynamic life expectancy
expectancy, healthyand literate working dynamic life
expectancy of an individual at age x respectively. Similarly, if there is no continuation in constructed
expectancies are the and presented in Table
literate dynamic life expectancy, healthy working 1 and 2 below
rates of change of probabilities of death, then all the above inequalities for to
will reduce both the sexes for the period 2011
dynamic life life
ordinary expectancy and literate working dynamic by taking the period 2009-13 (centered at 2011) as
expectancies.
life expectancy of an individual at age x respectively. reference period and 1999-2003 (centered at 2001)
as the previous period. Various other social indicators, viz, healthy literate dynamic life expectancy, healthy
working dynamic life expectancy, literate working dynamic life expectancy, healthy dynamic life expectancy,
literate dynamic life expectancy and working dynamic life expectancy are also presented in the same tables.
Looking into the constraints of time and space, the estimates are presented only at birth. Moreover, literate and
healthy life expectancy is usually calculated at age zero while working life tables are generally constructed
from age 15 onwards but in the present study to maintain the uniformity we have calculated all the indicators
mentioned above from age zero onwards.
Table 1: Values of HLWDLE at birth and various other indicators along with period and
dynamic life expectancy at birth (MALES)
Period Dynamic Dynamic Period Dynamic
STATES hlwe0 0
hlwe 0
00 Difference hle 0
00 hwe 0
00 lwe 0
00 he0
00 le0
00 we0
00 e0
0 e00 0 Difference
India 29.06 30.96 1.90 46.80 41.79 31.94 68.70 48.27 43.18 65.83 70.90 5.07
Jammu & Kashmir 25.88 26.77 0.89 42.31 40.33 27.89 68.66 44.01 42.27 70.56 71.74 1.18
Himachal Pradesh 35.34 35.36 0.02 51.46 41.62 36.46 67.35 53.04 43.04 68.96 69.57 0.61
Punjab 29.14 29.62 0.48 45.97 39.97 30.54 68.44 47.36 41.26 69.10 70.57 1.47
Haryana 28.36 27.79 -0.57 42.81 34.97 28.57 59.31 43.93 35.99 65.81 60.86 -4.95
Rajasthan 27.48 27.86 0.38 41.02 40.16 28.81 64.35 42.48 41.79 65.37 67.07 1.70
Uttar Pradesh 25.93 25.68 -0.25 38.63 36.79 26.40 59.60 39.65 37.86 62.54 61.17 -1.37
Bihar 25.69 26.97 1.28 40.13 43.50 27.87 68.43 41.40 45.0 67.34 70.58 3.24
Assam 27.49 29.20 1.71 42.37 40.15 29.84 63.25 43.26 41.06 61.94 64.56 2.62
West Bengal 30.7 32.29 1.59 50.47 41.89 33.26 70.95 52.04 43.19 68.46 73.10 4.64
Odisha 28.7 31.51 2.81 48.58 41.39 32.87 69.96 50.93 43.29 63.78 73.45 9.67
Madhya Pradesh 27.23 28.75 1.52 41.61 40.96 29.66 63.89 42.88 42.36 62.29 65.89 3.60
Gujarat 32.12 34.06 1.94 51.07 42.48 34.91 70.29 52.40 43.59 66.02 72.14 6.12
Maharashtra 33.84 37.15 3.31 57.28 44.57 38.53 75.77 59.41 46.28 69.37 78.58 9.21
Andhra Pradesh 24.96 26.49 1.53 42.25 41.01 27.46 69.26 43.79 42.64 65.50 71.96 6.46
Karnataka 30.41 31.78 1.37 47.25 41.95 32.65 67.70 48.53 40.96 66.37 69.53 3.16
Kerala 35.44 37.47 2.03 66.23 39.29 38.66 77.27 68.57 40.56 71.80 79.91 8.11
Tamil Nadu 32.88 34.96 2.08 54.32 43.22 35.72 73.29 55.48 44.19 68.16 74.84 6.68
Table 2: Values of HLWDLE at birth and various other indicators along with period and dynamic life expectancy
at birth (FEMALES)
Difference Difference
STATES hlwe 0
0 hlwe 0
00 hle0
00 hwe 0
00 lwe 0
00 he 0
00 le 0
00 we 0
00 e00 e00 0
India 9.84 10.36 0.52 35.80 19.97 10.60 73.55 36.68 20.50 69.28 75.74 6.47
Jammu & Kashmir 6.06 6.12 0.06 27.51 14.87 6.29 71.30 28.34 15.45 73.96 74.52 0.56
Himachal Pradesh 20.94 21.33 0.39 42.44 33.62 21.77 73.95 43.33 34.61 73.06 76.34 3.28
Punjab 7.15 7.35 0.20 40.81 12.16 7.51 74.29 41.73 12.46 73.43 76.22 2.79
Haryana 5.75 5.81 0.06 33.41 10.64 5.93 66.42 34.08 10.88 70.91 68.12 -2.79
Rajasthan 9.46 9.71 0.25 24.49 27.21 9.92 70.08 25.14 28.15 69.99 73.67 3.68
Uttar Pradesh 5.10 5.43 0.33 27.29 14.38 5.55 69.40 27.88 14.75 65.25 71.18 5.93
Bihar 5.69 5.97 0.28 25.20 17.34 6.11 70.71 25.77 17.78 68.02 72.50 4.48
Assam 8.68 9.29 0.61 35.11 17.31 9.46 70.75 35.84 17.72 65.08 72.67 7.58
West Bengal 7.80 8.09 0.29 41.63 13.18 8.27 75.17 42.65 13.50 71.56 77.25 5.69
Odisha 9.81 10.25 0.44 33.75 18.94 10.54 69.43 34.85 19.60 65.88 72.45 6.58
Madhya Pradesh 10.38 10.92 0.54 29.03 25.61 11.14 69.05 29.66 26.27 65.52 71.02 5.50

Some Important Observations:
1. The highest dynamic HLWLE at birth during a 10-year interval is observed in Kerala for
males with 37.47 years and Himachal Pradesh for females with 21.33 years. The same is also
174 true in case of usual consideration.
2. The lowest dynamic HLWLE at birth during a 10-year interval is in Uttar Pradesh for both
the sexes with 25.68 years for males and 5.43 years for females.
Difference 3. Among all the indicators, the values of healthy literate life expectancyDifference
(HLLE) at birth are
STATES hlwe 0
0 hlwe 0
00 hle 0
00 hwe 0 0 tolwe
0
found
0
he
be highest
00 0 0 Indiale
0
for
0
wefor
as0 0 well as
0
e00 selected states
0 0 all the e00 0 under study whereas the
values of working life are found to be much lower for both the sexes under both the
Gujarat 9.87 10.09 0.22 39.06 16.75 10.31 71.26 39.92 17.14
procedures. 70.49 73.02 2.53
Maharashtra 15.31 16.16 0.85 47.12 24.79 16.58 life
4. The working 79.84 48.42people
of Keralian 25.49 73.42
are found to be much82.28 8.86to the other
poor as compared
states. The gap between LE at birth and WLE at birth under dynamic scenario is found to be
Andhra Pradesh 11.39 11.69 0.30 31.93 25.35 11.99
39.35 years 71.96
in Kerala, 32.81gap 26.12
the highest 70.42
in comparison 74.41
to all other states. 3.99
Karnataka 12.70 12.89 0.19 37.05 22.32 13.15 Bihar,
5. Meanwhile, 68.16 37.82
the state 22.80 quite
which records 70.78
low values69.66 -1.12
in terms of HLE at birth (68.43
years) and extremely low values in terms of LLE at birth (41.4 years) as compared to Kerala,
Kerala 11.66 12.0 0.34 65.99 13.20
records 12.29 83.32in the68.03
second highest list after13.53 77.79
Maharashtra 86.06
with regard 8.27
to WLE at birth and HWLE at
Tamil Nadu 13.99 14.77 0.78 45.62 birth. 15.01
24.06 80.43 46.36 24.47 72.33 81.86 9.53
6. Further, inspite of low literacy and health status of the females of Rajasthan, Andhra
Pradesh and Madhya Pradesh, their working status are found to be extremely good.
Results and Discussion Sex Difference:
Sex Difference:
Some Important Observations Gender Gap in HLWLE at birth in India and Major States
40
1. The highest dynamic HLWLE at birth during
Healthy Literate Working Life Expectancy at birth

35
30
a 10-year interval is observed in Kerala for 25
males with 37.47 years and Himachal Pradesh 20
15
for females with 21.33 years. The same is also 10 Male HLWDLEB
5
true in case of usual consideration. 0
Female HLWDLEB
Haryana
Uttar Pradesh
Himachal Pradesh
Kerala
West Bengal
Punjab
Rajasthan
Karnataka
Madhya Pradesh
Andhra Pradesh
Gujarat
Jammu & Kashmir

Bihar
India
Odisha
Assam
Maharashtra
Tamil Nadu
2. The lowest dynamic HLWLE at birth during
a 10-year interval is in Uttar Pradesh for both
the sexes with 25.68 years for males and 5.43
years for females. Figure 1: Gender disparity in Healthy Literate Working Dynamic Life Expectancy at birth
Figure 1: Gender disparity
for India in states,
and its major Healthy2011. Literate
3. Among all the indicators, the values of
Working Dynamic Life Expectancy at birth for
healthy literate life expectancy (HLLE) at India and its major states, 2011.
birth are found to be highest for India as
well as for all the selected states under study 40 Gender Gap in HLWLE at birth in India and Major States
Healthy Literate Working Life Expectancy at birth
whereas the values of working life are found 35

30
to be much lower for both the sexes under 25
both the procedures. 20
15
4. The working life of Keralian people are found 10
Male HLWLEB
to be much poor as compared to the other 5

Female HLWLEB
states. The gap between LE at birth and WLE 0

Kerala
Haryana
Assam
Uttar Pradesh
Rajasthan
West Bengal
Bihar
Jammu & Kashmir
Gujarat
Punjab
Maharashtra
Karnataka
Madhya Pradesh
Himachal Pradesh
India
Andhra Pradesh
Odisha
Tamil Nadu
at birth under dynamic scenario is found to

be 39.35 years in Kerala, the highest gap in
comparison to all other states.
Figure 2: Gender disparity in Healthy Literate Working Life Expectancy at birth for India
5. Meanwhile, Bihar, the state which records
Figure 2: Gender disparity in Healthy
and its major states, 2011. Literate
quite low values in terms of HLE at birth Working Life Expectancy at birth for India and its
(68.43 years) and extremely low values in Some Important Observations:
major states, 2011.
terms of LLE at birth (41.4 years) as compared 1. Among the states under consideration, the highest gap in gender variation with regard to
HLWLE at birth is found to be in Kerala under both dynamic and usual consideration with
to Kerala, records second highest in the list almost 25 years and 24 years respectively. One of the possible reason for this might be the
Some Important Observations:
after Maharashtra with regard to WLE at lower work participation of females compared to males.
birth and HWLE at birth. 1. Among

2. Subsequently, after Kerala, the states
all other under
states also consideration,
exhibits high gender dispartity in the
terms of
dynamic HLWLE at birth. A closer inspection reveals that although the gender gap in LLE is
highest gap in gender variation with regard
found to be high in India as well as across all its major states except Kerala (0.54 years)
6. Further, inspite of low literacy and health however, this gaptois found
HLWLE to be muchat more
birth withisregard
found to work
to female be participation
in Kerala in the
status of the females of Rajasthan, Andhra labour force.
under both dynamic and usual consideration
Pradesh and Madhya Pradesh, their working Conclusion:
The studywith almosta 25
puts forward newyears and 24indicator
and innovative yearshealthy
respectively.
literate working
status are found to be extremely good. dynamic life expectancy by combining four essential dimensions of life: health, the literacy
level and the employment status along with the mortality scenario in India and some of its
major states, by incorporating the rates at which the probabilities of death have been
changing over the previous years. Due to tremendous improvement in mortality rates during
the last decade, the values of dynamic HLWLE at birth for all the major states are more or
less higher as compared under usual consideration. The result of this indicator reveals that in
most of the states, a higher value of healthy literate working life expectancy (HLWLE) is
mainly correlated with longer health, higher literacy and with longer periods of working for
IJPHRD / Volume 13 Issueboth
4 / males
October-December
and females under 2022
both dynamic and usual consideration. However, some states
viz. Kerala, Bihar, Rajasthan, Andhra Pradesh and Madhya Pradesh are an exception. Inspite
of showing highest literacy levels in the nation as well as enjoying much more healthier lives,
the Kerala state fails to engage its active population in labour force. Meanwhile, despite
having very low literacy level and poor health condition, males of Bihar and females of
One of the possible reason for this might References

be the lower work participation of females 1. Thomas MB, James KS, Sulaja S. Does Living Longer
compared to males. mean living healthier/ Exploring disability-free
2. Subsequently, after Kerala, all other states also life expectancy in India: The Institute for Social and
exhibits high gender dispartity in terms of Economic Change (Bangalore, India); 2014. ISEC
dynamic HLWLE at birth. A closer inspection Working Paper 322.http://www.isec.ac.in/WP%20
322%20-%20Benson%20Thomas%20et%20al.pdf
reveals that although the gender gap in LLE
is found to be high in India as well as across 2. Molla MT, Wagener DK, Madans JH. Summary
all its major states except Kerala (0.54 years) measures of population health: Methods for calculating
however, this gap is found to be much more healthy life expectancy. Hyattsville, Maryland:
with regard to female work participation in Department of Health & Human Services, National
the labour force. Center for Health Statistics; 2001 Aug. Healthy People
Statistical Notes, no. 21.
Conclusion
3. HeideI V, Wang J, Droomers M, Spreeuwenberg P,
The study puts forward a new and innovative Rademakers J, Uiters E. The Relationship Between
indicator healthy literate working dynamic life Health, Education, and Health Literacy: Results From
expectancy by combining four essential dimensions the Dutch Adult Literacy and Life Skills Survey.
of life: health, the literacy level and the employment Journal of Health Communication 2013; 18sup1:172-
status along with the mortality scenario in India 184. DOI: 10.1080/10810730.2013.825668
and some of its major states, by incorporating the 4. Mboko Ibara SB, Ikiemi CBS. Effects of Functional
rates at which the probabilities of death have been Illiteracy on the Living Conditions of Households in
changing over the previous years. Due to tremendous Congo. Modern Economy 2021 March; 12:576-596.
improvement in mortality rates during the last https://doi.org/10.4236/me.2021.123030
decade, the values of dynamic HLWLE at birth for all 5. LutzW.Literate life expectancy. Popnet 1995;
the major states are more or less higher as compared 26(winter):1-5, Laxenburg, Austria: International
under usual consideration. The result of this indicator Institute for Applied System Analysis.
reveals that in most of the states, a higher value of
6. Swee-Hock S. Malaya: Tables of male working life,
healthy literate working life expectancy (HLWLE)
1957. Journal of the Royal Statistical Society. Series A
is mainly correlated with longer health, higher (General) 1965; 128 (3): 421-438. DOI: 10.2307/2344209
literacy and with longer periods of working for both
males and females under both dynamic and usual 7. Sanders B S. Measuring community health levels. Am
consideration. However, some states viz. Kerala, J Public Health Nations Health 1964 July; 54(7): 1063-
1070.doi: 10.2105/ajph.54.7.1063
Bihar, Rajasthan, Andhra Pradesh and Madhya
Pradesh are an exception. Inspite of showing highest 8. Choudhury L, Sarmah GR, Sarma R. Literate Life
literacy levels in the nation as well as enjoying much Expectancy for Females of Assam and Selected States
more healthier lives, the Kerala state fails to engage of India: A District Level Analysis of the 2001Census
its active population in labour force. Meanwhile, Data.Journal of Population and Social Studies. 2013
despite having very low literacy level and poor health July; 21Suppl 2: S-88-S-98.
condition, males of Bihar and females of Rajasthan, 9. Kpedekpo GMK. Working Life Tables for Males
Andhra Pradesh and Madhya Pradesh showed active in Ghana, 1960. Journal of the American Statistical
involvement in work participation. Association. 1969 March; 64(325):102-110.
Conflict of Interest: Nil 10. Lievre A, Jusot F, Barnay T, Sermet C, Brouard N,

Robine JM, Brieu MA, Forette F. Healthy Working
Source of Funding: None Life Expectancies at Age 50 in Europe. The Journal of
Ethical Clearance: Ethical clearance was not Nutrition, Health & Aging. 2007 Aug; 11(6):508-514.
required in this study. 11. Denton FT, Spencer BG. A Dynamic extension of the
period life table. Demographic Research 2011 June;
24(34):831-854. DOI:10.4054/DemRes.2011.24.34

176
12. Sharma M, Chouhury L, Sarma R. Dynamic Life 16. Oyedele O. Child Mortality and Female Labour
Tables for India and Some of Its Major States.Journal Participation in Nigeria. Int. Eco. Res 2017; 8(5):74 – 84.
of Population and Social Studies 2017; 25(4):343 – 357.
17. Tulasidhar VB. Maternal education, female labour
DOI: 10.25133/JPSSv25n4.00
force participation and child mortality: evidence from
13. Sharma M. Literate Life Expectancy under Dynamic the Indian census. Health Transition Review 1993;
set up with Applications to Indian Data. International 3(2):177 - 190.
Journal of Research in Social Sciences 2018; 8(12): 729-
18. Thakuria B. Some aspects of life tables in India a
745.
district wise study. [dissertation on the internet]. India:
14. Grosse RN, Auffrey C. Literacy and health status in Gauhati University; 2020. Available from: http://hdl.
developing countries. Annu. Rev. Public Health 1989; handle.net/10603/267718.
10:81-97.
15. Shetty A, Shetty S. The Impact of Female Literacy on

Infant Mortality Rate in Indian States. CurrPediatr Res
2014;18 (1):49-56.

Brief Research Article Indian Journal of Public Health Research & Development
Evaluation of Pradhan Mantri Jan Arogya Yojana (PM-JAY) Utilization

in a teaching hospital of Kalaburagi City, Karnataka
Nilofer Naaz1, Shantkumar Nigudgi2

Postgraduate Student of MD Community Medicine, Sedam Road, M.R medical college, Kalaburagi-585105, Karnataka, India
1
2
Professor, Mahadevappa Rampure Medical College, Kalaburagi, Karnataka
How to cite this article: Nilofer Naaz, Shantkumar Nigudgi et al Evaluation of Pradhan Mantri Jan Arogya
Yojana (PM-JAY) Utilization in a teaching hospital of Kalaburagi City, Karnataka. Volume 13 | Issue 4 |
Abstract
Introduction : Ayushman Bharat PM-JAY is the largest health assurance scheme in the world which aims at providing a
health cover of Rs.5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crores poor and
vulnerable families. A timely assessment at various hospitals will help to evaluate the impact of this public health policy.
Aim : 1. To assess the utilization of Pradhan Mantri Jan Arogya Yojana (PM-JAY) insurance scheme in Basaveshwar
teaching and General hospital Kalaburagi city, Karnataka.2. To assess the reasons for rejection of certain claims.
Settings and design: This is an observational study conducted at Basaveshwar teaching and general hospital which is a
800 bed tertiary care empaneled private hospital attached to M R medical college, Kalaburagi.
Methods and material: Duration of study is 10 months (January to October -2021). Data was collected using semi-
structured questionnaire from the designated Arogya Karnataka office in the hospital. After the entry of data, the
descriptive statistics was presented in frequency tables and graph.
Results: From January to October -2021, 1791 patients claimed the PM-JAY benefits. April being the highest due to second
wave of Covid-19, 327 patients claimed PM-JAY insurance. Few claims were rejected for various reasons. NCD burden
was seen during the study. Conclusion: Creating awareness among the needy population is necessary, modification in
the hospital infrastructure claim processing also plays a key role.
Keywords : PM-JAY, Claims, Insurance, Scheme, Benefits
Introduction socioeconomic strata. To address to this growing

The health profile report released by WHO in 2014 concern a health initiative by name Pradhan Mantri
states that in India because of high out of pocket Jan Ayogya yojana or Ayushman Bharat scheme
expenditure annually about 3.2% Indians fall was launched on 23rd September 2018.Ayushman
below the poverty line and also threefourth Indians Bharat is the largest health insurance scheme in the
spending their entire income on health care and world which aims at providing a health cover of Rs.5
purchasing drugs.4 lakhs per family per year for secondary and tertiary
care hospitalization to over 10.74 crores poor and
High out of pocket expenditure makes health vulnerable families that form the bottom 40% of the
care services inaccessible to significant proportion Indian population.
of Indian households particularly from the low
Dr. Shantkumar Nigudgi
Sedam Road, M.R medical college, Kalaburagi-585105, Karnataka, India
E-mail - [email protected]
Telephone number – 9741294261
178
Around 1,350 medical and surgical procedure

are included under the scheme which is claimed to
include almost all secondary and most of the tertiary
care procedures. It allows the beneficiaries to avail free
services from either public or an empaneled private
hospital. All preexisting diseases are also covered,
and the hospital is not allowed to charge any fee.5
The execution of PMJAY scheme is authorized by
the state government. The state is allowed to continue
their existing programs parallel to national program
or coordinate them with the new scheme. The states
can either cover services directly as in Andhra Pradesh
or mix the existing scheme of the state with PMJAY as
in Tamil Nadu and Gujarat.6 Objectives
In Karnataka PMJAY is merged with Arogya To assess the functioning and utilization of Pradhan
Karnataka scheme which also has Yeshaswini Mantri Jan Arogya Yojana (PM-JAY) insurance
Scheme, Rajiv Arogya Bhagya Scheme, Rashtriya scheme in Basaveshwar teaching and general hospital
SwasthayaBimaYojana (RSBY) including RSBY for Kalaburagi city, Karnataka.
senior citizens, RashtriyaBalaSwasthayaKaryakram Methodology
(RBSK), MukhyamantriSantwana Harish Scheme,
Study Design : Observational Data based study
Indira Suraksha Yojane, Cochlear Implant Scheme
etc.converged under this new Arogya Karnataka Sampling Technique - Data was collected using
Scheme. The scheme is made available across all the semi-structured questionnaire from the designated
government and empanelled private hospitals. But Arogya Karnataka office in the hospital. After the
one of the pre requirements required to avail this entry of data, the descriptive statistics was presented
service is Arogya Karnataka health card.8 in frequency tables and graph. Analysis is done using
Microsoft Excel program.
Currently 62 lakh families are getting benefitted
under this scheme. Place of Study : Basaveshwar teaching and general
hospital (800 bed tertiary care empaneled private
Advantage Of Arogya Karnataka
teaching hospital attached to M R medical college,
In an emergency situation, the patients need not Kalaburagi, Karnataka)
wait for the card or the referral by the government
Duration : 10 months ( Jan – October -2021)
hospital doctors. They can get admitted to any private
hospital which is empanelled. Inclusion Criteria : All claims during the study
duration
Short Coming Of Arogya Karnataka
• Only BPL families are provided with free Exclusion Criteria : Rejected claims
treatment. APL card holders need to pay 70% Ethical Clearance : The study proposal was
of the hospital bills. approved by the Institutional Ethical Committee
• There is no provision for daily expenses. of Mahadevappa Rampure Medical College and
Hospital. Informed consent was obtained from all
• Government hospitals are allowed to refer
the study participants before administering the study
only those patients who can’t be treated at the
questionnaire.
government facility.9
Hence a study is done to evaluate the functioning Results
and impact of the public health policy like Ayushman • The data was divided into two quarters
Bharat at the Basaveshwar teaching and general January to May and June to October 2021,
hospital of Kalaburagi City in Karnataka. Second wave of Covid-19 was between
March to May 2021 in the City. During

January to May 484 patients claimed the PM- Consultant fees, etc.
JAY insurance, April being the highest due to • Anesthesia, Blood Transfusion, Oxygen, O.T.
second wave of Covid 327 patients claimed Charges, Cost of Surgical Appliances, etc.
PM-JAY insurance.
• Medicines and Drugs.
• Non-Covid insurance claims from month of
January to October 2021 were 1437. • Cost of Prosthetic Devices, implants.
• Total Claims from January to October 2021 • Pathology and Radiology tests.
were 1791 including both Covid and Non- • Food to patient.
Covid Cases. • Pre and Post Hospitalization expenses:
• Total Number of Rejected Claims from Expenses incurred for consultation, diagnostic
January-2021 to October-2021 were 72. tests and medicines before the admission of
Reasons for Rejection were - Diseases which the patient in the same hospital, and up to 15 days
could not be treated by the hospital, certain of the discharge from the hospital.
beneficiaries card limit was exhausted due to Table 1. Total number claims from January
previous admissions during the same year. 2021 – October 2021
• Another finding was that Non Communicable
PM-JAY Jan – May June - Oct Rejected
diseases claims were maximum in the
Claims (2021) (2021) Claims
Department of Medicine accounting to 55%
of the total Cases which shows the presence Non-Covid 484 953 -
of NCD burden among the people from low Covid 354 0
socioeconomic strata as well.
Total 838 953 72
• Stroke, hypertension, Diabetes, Respiratory
illnesses were among the NCDs commonly Grand Total Jan-Oct 838 + 953 = 72 Page |7
2021 1791
seen.
A proper coded list as per the Arogya Karnataka OTHERS 8%
guidelines is made by the hospital to categorize the OBS/GYN 17%
eligibility for these claims. The 100 % Claims package PEDIATRICS 16%
for BPL card holders includes: SURGERY 12%
• Registration charges. ORTHO 5%
• Bed charges (General Ward). MEDICINE 42%
• Nursing and Boarding charges.

Chart 1. Department wise claims ratio
• Surgeons, Anesthetists, Medical Practitioner,
Chart 1. Department wise claims ratio
Table 2. Department wise number of cases who claimed PMJAY insurance scheme
Department Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Total
Medicine 55 58 86 26 39 38 64 83 93 78 620
Covid 04 04 19 327 Department Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- 354 Oct- Total
OBG 23 27 17 21 11 21 28 21 21
37 21 23 21 21
28 21 2621 21
241 21
Medicine 55 58 86 26 39 38 64 83 93 78 620
Pediatrics 08 15 08 09 Covid 01 04 11 04 27
19 32740 62 42 223 354
NeuroSurgery 11 18 13 04 OBG 23 12 27 17
19 21 14 11 28
13 37 1423 28
118 26 241
Pediatrics 08 15 08 09 01 11 27 40 62 42 223
Orthopedics 04 07 05 01 NeuroSurgery 11 10 18 16
13 04 11 07
12 19 14
14 75 14
13 118
Gen.Surgery 03 04 08 05 Orthopedics 04 07 07 12
05 01 05 09 16 0411
10 57 14
07 75
Gen.Surgery 03 04 08 05 07 12 05 09 04 57
Ped.Surgery 02 03 04 02 Ped.Surgery
03 02 03
07
04 02
07 03 08 07 0407 40 04
08 40
Plastic Surgery 06 05 03 Plastic Surgery 06 05 01
03 04 03 01 0404 26 04
03 26
ENT
ENT 02 02 02 02 02
05 01 02
01 05 0101 01
14 01 14
Burns 01 07 01 02 11
Burns 01 07 Urology 01 02 02
02 02 02 11 08
Urology 02 02 Ophthalmology 01 02 01
02 02 08 04
Grand Total 113 144 136 68 54 109 192 190 224 187 1791
Ophthalmology 01 02 01 04
Grand Total 113 144 136 68 54 109 192 190 224 187 1791
Table 2. Department wise number of cases who claimed PMJAY insurance scheme

180
Page |8
Gastroenterology
Declaration of patient consent - The authors certify
Cardiology
12%
3% that they have obtained all appropriate participant
consent forms.
Renal Diseases
8% Financial support and sponsorship - Nil.
Conflicts of interest - There are no conflicts of
NCD
55% interest.
Infectious Diseases
22%
References
1. Reddy NKK, Bahurupi Y, Kishore S, Singh M, Aggarwal
P, Jain B. Awareness and readiness of health care
NCD Infectious Diseases Renal Diseases Cardiology Gastroenterology workers in implementing Pradhan Mantri Jan Arogya
Yojana in a tertiary care hospital at Rishikesh. Nepal J
Chart 2. Case distribution in Department of Epidemiol. Jun 30 2020;10(2):865-70. doi: 10.3126/nje.
Medicine, Non Communicable diseases accounted
Chart 2. Case distribution in Department of Medicine, Non Communicable diseases v10i2.27941, PMID 32874700.
to the
accounted to themaximum
maximum aboutabout 55%
55% of the of the
insurance insurance claims.
claims.
2. Sriee G VP, Maiya GR. Coverage, utilization, and
Conclusion impact of Ayushman Bharat scheme among the
rural field practice area of Saveetha Medical College
The
Conclusion most important benefit of this scheme is that
and Hospital, Chennai. J Fam Med Prim Care.
beneficiaries
The most important benefitcanof thismake use
scheme is that of services
beneficiaries anywhere
can make use of services
2021;10(3):1171-6. doi: 10.4103/jfmpc.jfmpc_1789_20,
anywhere in India. During Covid-19 Pandemic it has been a boon to the underprivileged.
in India. During Covid-19 Pandemic it has been a
Creating awareness in the community is necessary, modification in the hospital infrastructure PMID 34041146.
boon to the underprivileged. Creating awareness more
claim processing also plays a crucial role. The APL card holders can be given some
benefits as healthcare burden is also significant among them. Due to which they ignore certain3. 4Ved, Rajani RR et al.. India’s health and wellness
in the community is necessary, modification in the
treatable conditions as they are unable to pay out of pock expenses for the treatment. At times the
centres: realizing universal health coverage through
hospitaldoes
State Government infrastructure claim
not release the funds on timeprocessing also plays
which causes financial burden ona these
empaneled private hospitals. comprehensive primary health care. WHO South East
crucial role. The APL card holders can be given some
Non communicable diseases are becoming a major health concern among the poor section of the Asia J Public Health. 2019;8(1):18-20. doi: 10.4103/2224-
more benefits as healthcare burden is also significant
community. India needs a major policy agenda to tackle the escalating burden of Non 3151.255344, PMID 30950425.
among
communicable them.
diseases. Due
Poverty to which
is a strong association they ignoreriskcertain
to the increasing of NCDs like
Stroke, Respiratory illnesses, Hypertension and Diabetes to name a few.
treatable conditions as they are unable to pay out of 4. Dhaka R, Verma R, Agrawal G, Kumar G, Yojana
A timely assessment at various hospitals and health centers will help to evaluate and assess the
pock expenses for the treatment. At times the State AB. Ayushman Bharat Yojana: A memorable health
impact of such public health policies which help to improvise the services and enhance the health
initiative for Indians. Int J Community Med Public
Government
care benefits does
to the marginalized not release the funds on time which
community.
Health. 2018;5(8):3152-3. doi: 10.18203/2394-6040.
causes financial burden on these empaneled private
ijcmph20183043.
hospitals.
5. Bharat-PMJAY A [internet]. New Delhi: Ministry of
Non communicable diseases are becoming a Health and Family Welfare, Government of India; 2020
major health concern among the poor section of the [cited Aug 14 2020]. Available from: https://www.
community. India needs a major policy agenda to pmjay.gov.in.
tackle the escalating burden of Non communicable
6. Ghosh A. Health cover scheme: who, how [internet].
diseases. Poverty is a strong association to the
New Delhi: The Indian Express; 2018 [cited Aug 14 2020].
increasing risk of NCDs like Stroke, Respiratory Available from: https://indianexpress.com/article/
illnesses, Hypertension and Diabetes to name a few. explainedational-healthmission-ayushman-bharat-
A timely assessment at various hospitals and health health-mission-jp-nada-healthbudget-5216382/.
centers will help to evaluate and assess the impact of 7. Joseph J, Sankar D H, Nambiar D. Empanelment
such public health policies which help to improvise of health care facilities under Ayushman Bharat
the services and enhance the health care benefits to Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in
the marginalized community. India. PLOS ONE. May 27. 2021;16(5):e0251814. doi:
10.1371/journal.pone.0251814, PMID 34043664.
Acknowledgement - The authors sincerely thank
all the faculty of department of community medicine 8. Available from: https://arogya.karnataka.gov.in/
at M.R medical college and supportive staff at Arogya Forms/Aboutus.aspx.
Karnataka office in the Basaveshwar Teaching and 9. Available from: https://www.karnataka.com/govt/
General hospital. arogya-karnataka/.

10. Keshri VR, Ghosh S. Health Insurance for Universal 11. Debnath DJ, Kakkar R. Modified BG Prasad socio-
Health Coverage in India: A Critical Examination economic classification, Updated −2020. Indian J
[internet]. Patna: ADRI. p. 40; 2019p. Available Community Health. 2020;32(1):124-5. doi: 10.47203/
from: https://www.adriindia. org/images/ IJCH.2020.v32i01.024.
paper/1557397831HealthInsuranceforUniver
salHealthCoverageinIndia.pdf.

Comparative Analysis of Optical Coherence Tomographic Study of Macula

in Preoperative and Postoperative Diabetic Patients Undergoing Small
Incision Cataract Surgery
Nishant Solanki1, Jayeshkumar C. Sadhu2

1,2
Assistant Professor, Department of Ophthalmology, Shri M.P.Shah Government Medical College, Jamnagar, Gujarat
How to cite this article: Nishant Solanki, Jayeshkumar C. Sadhu et al Comparative Analysis of Optical Coherence
Tomographic Study of Macula in Preoperative and Postoperative Diabetic Patients Undergoing Small Incision
Cataract Surgery. Volume 13 | Issue 4 | October-December 2022
Abstract
Background and Aim: Macular oedema (ME) occurs in a variety of pathological conditions and accounts for different
degrees of vision loss. Early detection of ME is therefore critical for diagnosis and management. Optical Coherence
Tomography (OCT) is particularly useful and accurate for measuring retinal nerve fiber layer (RNFL) thickness and
macular thickness. This study is undertaken to evaluate the quantitative changes in macular thickness using spectral
domain optical coherence tomography in diabetic patients undergoing cataract surgery pre and post operatively and its
relation with diabetic retinopathy.
Material and Methods: Study participants included 100 diabetic patients irrespective of presence or absence of retinopathy
who underwent cataract surgery. Each eye underwent fundus examination with indirect ophthalmoscopy and OCT of
macula i.e.,preoperatively and at postoperatively at day 1, 1 week, 4 weeks and at 12 weeks. Best-corrected visual acuity
(BCVA) was recorded at each visit.
Results: Visual acuity improved postoperatively at 4th and 12th week after small incision cataract surgery to 6/12 and 6/9
in majority of the patients. Post operatively 1 month 75% patients achieved vision of 6/6– 6/12. Mean values of central
subfield macular thickness at preoperatively was 268.9 µm which increased to 278.2 µm at postoperative day 1, 281.6 µm
at postoperative 1 week, 286.1 µm at postoperative 4 weeks and 297.2 µm at postoperative 12 weeks.
Conclusion: There was no difference in median macular thickness between the groups, and no cases in either group had
an increase in macular thickness to reach this threshold. diabetic macular edema generally worsens after cataract surgery,
and that the worsening of macular edema is more prominent in eyes with DR.
Keywords: Best-corrected visual acuity, Cataract, Macular oedema, Optical Coherence Tomography
Introduction to opacity of any part of the crystalline lens which

Cataract is the leading cause of blindness in the is normally almost completely transparent. Cataract
world and the most prevalent ocular disease. accounts for 47.8% of the world’s roughly 37 million
With the advancement in surgical methods and blind individuals. Of note, approximately 90% of
instrumentation, the visual outcome following cataract the contribution of cataract to blindness was seen in
surgery has become much better. Phacoemulsification developing countries. The visual outcome of cataract
and implantation of a foldable intraocular lens (IOL) surgery depends upon various factors like condition
is currently the preferred technique of surgery of the cornea, type of cataract, manipulation of
among cataract surgeons.1 The term cataract refers iris, presence of pre-existing ocular conditions like
chronic uveitis, any associated systemic disease, and
Dr. Nishant Solanki
Department of Ophthalmology, Shri M.P.Shah Government Medical College, Jamnagar, Gujarat
occurrence of intra-operative complications and also surgery pre and post operatively and its relation with
experience of the surgeon.2 diabetic retinopathy.
Optical Coherence Tomography (OCT) was Material and Methods
introduced in 1991 and since then it has become an
It was a prospective comparative study on 110 patients
invaluable tool in the diagnosis and management
for the duration of 1 year. Ethical approval was taken
of different retinal disorders. OCT is a method
from the institutional ethical committee and written
of analysing the in-vivo retinal architecture. It is
informed consent was taken from all the participants.
particularly useful and accurate for measuring retinal
nerve fibre layer (RNFL) thickness and macular The exclusion criteria were those with intraocular
thickness.3 OCT uses light reflectance signal from the pressure >21mmHg, previously diagnosed glaucoma,
retina to measure its thickness. Macular oedema (ME) high refractive errors – more than 5D of spherical
occurs in a variety of pathological conditions and equivalent refraction or 3D astigmatism, macular
accounts for different degrees of vision loss. Early diseases and very poor signal strength (<2) of OCT.
detection of ME is therefore critical for diagnosis All Type 2 diabetic patients irrespective of duration
and management. OCT has been routinely used in of diabetes of age group 55-75 years with senile
measuring retinal thickness for the evaluation of immature cataract with varying levels of retinopathy
ME caused by diseases such as age-related macular
including absence of retinopathy underwent
degeneration, diabetic retinopathy, central serous
uncomplicated small incision cataract surgery done
retinopathy, hereditary retinal degenerations, retinal
by an experienced surgeon were included in the
vein occlusion, after cataract surgery, epiretinal
study.
membrane (ERM) and uveitis.
Preoperative evaluation
Cataract surgery is known to cause increased
levels of inflammatory mediators. Clinical studies are 1. Visual acuity testing for distance and near
inconclusive as to the effect of cataract surgery on the using Snellen’s distant chart and near vision
onset of diabetic macular oedema (DMO).4 Macular chart respectively.
oedema (ME) occurs in a variety of pathological 2. Refraction and correction where ever
conditions and accounts for different degrees of vision required.
loss. Early detection of ME is therefore critical for 3. External ocular examination
diagnosis and management. A higher incidence of ME
after cataract surgery is reported to occur in eyes with 4. Slit lamp bio microscopic examination done
diabetic retinopathy (DR), and worsening of ME often with dilated pupil
occur after surgery in eyes with pre-operative diabetic 5. Tonometry using applanation tonometer
macular edema (DME).5 In diabetic macular edema 6. Lacrimal patency test
(DME), ME is induced by hyperglycemia-induced
7. Keratometry
oxidative stress, deposition of advanced glycation
end products (AGES), impaired blood flow, hypoxia, 8. A-scan and Intraocular lens power calculation
pericyte loss, endothelial cell loss, up regulation of by SRK-2 formula
vesicular transport, down regulation of glial cell– 9. Fundus examination with indirect
derived neurotropic factor and inflammation. Where ophthalmoscopy with 20D Lens after
as in Pseudophakic cystoids macular edema (PCME), dilatation.
which is thought to be caused by Pro-inflammatory
The level of diabetic retinopathy was recorded as
cytokine release.
No, mild, moderate, and severe non proliferative;
OCT is a method of analysing the in-vivo retinal or proliferative, as described in the early treatment
architecture. It is particularly useful and accurate for diabetic retinopathy study. Other investigations
measuring retinal nerve fiber layer (RNFL) thickness included: RBS, FBS, PPBS, HBA1C. Optical coherence
and macular thickness. This study is undertaken tomography testing was done preoperatively and
to evaluate the quantitative changes in macular repeated at the POD day1, POD1 week, and 4th and
thickness using spectral domain optical coherence 12th week postoperative visits. Best-corrected visual
tomography in diabetic patients undergoing cataract acuity (BCVA) was recorded at each visit. Fundus

184
photographs of retina were taken with CANON CF-1 macular edema is seen in 4 patients. Preoperatively
Digital retinal camera. Optical coherence tomography 93% patients had a vision of 6/60 or lesser. Over all
testing was performed and images were generated visual acuity improved postoperatively at 4th and
with the use of Macular cube 512*128 in 6 mm 12th week after small incision cataract surgery to 6/12
square grid according to the manufacturer protocol and 6/9 in majority of the patients. Post operatively
as described in the user’s manual. CIRRUS software 1 month 75% patients achieved vision of 6/6– 6/12.
identifies the Fovea location automatically by looking By Postoperative 3 months 90% patients achieved a
for the reduced reflectivity below the retina. We can vision of 6/6 – 6/12. Mean central subfield macular
also change the Fovea location manually which will thickness on OCT in diabetic patients of all grades of
update the data table and the ETDRS grid thickness DR is increased with higher statistical significance at 1
measurements. Macular Thickness OU Analysis and 3 months post operatively compared to 1st week
provides interactive scan images, as well as the postoperatively. The central subfield means thickness
Fundus image with a scan cube overlay for both eyes in all patients irrespective of diabetic retinopathy
together and includes: increased 17.4µm and 29µm at 1 month and 3 months
follow up. A statistically significant increase could be
1. Colored thickness maps.
detected in central subfield macular thickness though
2. OCT Fundus image, including the identified the increase was mild. (P<0.05) Mean Pre op CSMT
fovea location with a red dot. of all patients is 266.8±17.2µm. Mean Central subfield
3. The ETDRS grid maps with normative data. thickness increased to 284.12±41.8 at 1 month and
4. A table containing central subfield thickness, to 297.1±54.8 µm at 3 month follow up with P-value
average thickness and volume Measurements 0.001* among all the diabetic cases. In this study,
for the entire cube taken. level of diabetic retinopathy was associated with
increased foveal thickening. The study group with
Statistical analysis no diabetic retinopathy developed increases in foveal
The recorded data was compiled and entered in a thickening, of 15.3 um and 21.4 um at 4th and 12th
spreadsheet computer program (Microsoft Excel week after surgery, respectively. Among patients
2007) and then exported to data editor page of SPSS with no diabetic retinopathy developed thickening
version 15 (SPSS Inc., Chicago, Illinois, USA). For all from a preoperative mean value of 256.2±12.4 to
tests, confidence level and level of significance were 278.3±13.4µm at 3rd month of follow up with a
set at 95% and 5% respectively. P-value of 0.04*.
Results The worse the level of diabetic retinopathy at

baseline, the more likely the foveal thickness increased
Out of 110 patients 7 were lost to follow-up. 3
at 4th and 12th week after surgery. The group with
patients in the DR group had pseudophakic bullous
mild non proliferative diabetic retinopathy had
keratopathy, did not appear for examination because increase in center point thickness—of 4.5 um and 8.5
of hazy media. Therefore, 100 patients completed the um at 4th and 12th week after surgery respectively
3 months follow-up and were included for analysis. with low level of significance. But it is not statistically
The mean age of the study population was 65.2 ±6.4 significant in mild and moderate NPDR cases due to
years. Among the 100 patients 60 patients (60%) small number of patients. The group with moderate
were males and 40 (40%) were females. Among the non proliferative diabetic retinopathy with macular
100 study group patients of type II diabetes mellitus edema had largest increase in foveal thickness 57.9
patients, most of the patients are with DM ≤5 Years um and 137 um at 4th and 12th week after surgery
duration of about 67% patients. Mean Age duration respectively. This increase in foveal thickness was
of DM is 4.7±2.8 yrs. 54 patients (54%) were systemic correlated inversely with VA improvement.
hypertensives. Right eye cataract surgery was
performed in 49 patients and left eye cataract surgery In eyes with preoperative moderate NPDR with
was performed in 50 patients. No Diabetic retinopathy macular edema the mean change of central subfield
was detected preoperatively in 44% of diabetic macular thickness was 137 µm at 3 months follow
eyes. 31 patients had Mild NPDR, 14 patients had up. The patients who developed macular edema had
Moderate NPDR comprises 14% of diabetics. Severe decrease in visual acuity. In eyes with preoperative
NPDR With macular edema in 2 patients and pre op macular edema the mean change of central subfield

macular thickness was 28 µm at 3 months follow up. phacoemulsification and phacoemulsification

Severity of DR was not significantly correlated to ME complicated with posterior capsule rent. But there are
because of limitation in sample size. No statistical not many studies comparing these changes following
difference in macular thickness was revealed through manual SICS which is a commonly performed type
severity of DR. of cataract surgery in developing countries like India.
The present study compares the macular changes on
Mean values of central subfield macular thickness at
OCT following uneventful and complicated (with
preoperatively was 268.9 µm which increased to 278.2
posterior capsule rent) manual small incision cataract
µm at postoperative day 1, 281.6 µm at postoperative
surgery.
1 week, 286.1 µm at postoperative 4 weeks and 297.2
µm at postoperative 12 weeks. The mean ±SD in In this study OCT has been able to demonstrate a
microns foveal thickness in all the patients groups are moderate correlation between retinal thickness and
shown in and Table 2. best corrected visual acuity, and it has been able to
demonstrate 3 basic structural changes of the retina,
Table 1: Gender wise Distribution of Study
Participants i.e., diffuse retinal swelling, cystoid macular edema,
and serous retinal detachment.
Gender Number Percentage (%)
Most of the studies in the literature showed6–8 that
Male 60 60
mean CMT is statistically significant increase at 1
Female 40 40 month after cataract surgery, which was maintained
Total 100 100 after 3 months, pointing out a possible leakage. Also,
baseline CMT was thicker in eyes developing PCME,
Duration of DM suggesting that increased CMT thickness may be a
predisposing factor for Pseudophakic Cystoid Macular
Edema (PCME) or the presence of subclinical PCME,
7% which may not be detected by OCT imaging systems.
26% This is witnessed in one of our patients. Inflammatory
less than 5 years
mediators may increase vascular permeability
6-10 years
67% leading to an increase in macular thickness and cyst
more than 10 years
formation.9–11 Now a day’s use of SD-OCT provides
quicker, more objective, and noninvasive assessments
of retinal thickness compared to FA. Compared to
Graph 1: Distribution of cases according to time domain OCT, SD-OCT offers more accurate
duration of DM
measurements, higher repeatability, and a lower rate
Graph 1: Distribution of cases according to duration of DM
Table 2: Distribution of OCT according to POD of errors and falsenegatives. Duker et al. showed that
Table 2:all
among Distribution
cases of OCT according to POD among all cases SD-OCT has enabled ophthalmologists to visualize
Total cases Mean SD SD
and monitor the vitreomacular interface with better
Total Mean MeanMean
SD SD P P value
cases value accuracy and repeatability. 12
OCT Pre op 268.9 15.4 POD1 278.2 44.6 0.02*
Hayashi et al. have shown that the foveal thickness
central
Pre op POD 268.9
1 278.215.4
44.6 POD 1 wk
POD1 281.6278.2
39.2 44.6
0.12 0.02*
and macular volume in diabetic patients increases
sub field POD 1 281.6 39.2 POD 4 wk 286.1 41.9 0.001*
OCT centralthickness
POD 1 wk 278.2 44.6 POD 1 wk 281.6 39.2 after
0.12 small incision cataract surgery in eyes both
sub field POD 4 286.1 41.9 POD 12 297.2 56.3 0.005* with and without DR: the percent increase from
POD 1 wkwk 281.6 39.2 POD
wk4 wk 286.1 41.9 0.001*
baseline was greatest at 3 months after surgery,
thickness
* indicates statistically
POD 4 wk 286.1 significance
41.9 POD at12 p<0.05
wk 297.2 56.3 and then decreased gradually. Furthermore, the
0.005*
Discussion increase in foveal thickness was greater in eyes with

* indicates statistically significance at p<0.05
DR than in eyes without DR. These results indicate
Discussion
CME has been the most common cause of unexpected that, on average, diabetic macular oedema worsens
poor visual acuity after cataract surgery. The incidence after cataract surgery, and the worsening is more
CME has been the most common
increases when cause of unexpected
the degree poor visual acuityincreases
of inflammation after cataract surgery.
pronounced in eyes with DR.13
as in cataract surgery complicated with posterior
The incidence increases when the degree of inflammation increases as in cataract surgery
capsule rent. There have been studies comparing This study showed similar significant correlation
complicated with posterior capsule rent. There have been studies comparing macular thickness between levels of retinopathy, foveal thickness.
macular thickness changes following uneventful
changes following uneventful phacoemulsification and phacoemulsification complicated with
186
Alastair K Denniston, Usha Chakravarthy et al14 2. Minassian DC,Mehra V. 3.8 million blinded by cataract
reported that rate of developing treatment-requiring each year: projections from the first epidemiological
DMO increases sharply in the year after cataract study of incidence of cataract blindness in India.
surgery for all grades of retinopathy, peaking in the British Journal of Ophthalmology1990; 74:341-343.
3–6 months’ postoperative period. 3. Liu Y, Simavli H, Que CJ, Rizzo JL, Tsikata E, Maurer
R, et al. Patient characteristics associated with artefacts
In the present study the measurements on the
in spectralis OCT imaging of RNFL in glaucoma. Am J
day of surgery and first and third postoperative
Ophthalmol. 2015;159(3):565- 76.
week were compared, the release of inflammatory
mediators inducing disturbed blood retinal barrier 4. Denniston AK, Chakravarthy U, Zhu H, Lee AY, Crabb
permeability with vessel leakage are factors that DP, Tufail A. The UK Diabetic Retinopathy Electronic
Medical Record (UK DR EMR) Users Group. Br J
could affect the thickness measurements. These
Ophthalmol. 2017;2(12):1673–81.
factors are highly individual to the patient. Upto 3-5
weeks post surgery these factors can play a role in 5. Baker CW. Macular Edema After Cataract Surgery in
the OCT measurements.3,4 There is improvement in Eyes Without Preoperative Central-Involved Diabetic
visual acuity after 1 and 3 months postoperatively in Macular Edema. JAMA Ophthalmol. 2013;131(7):870.
patient with no DR than those with DR. this finding 6. Rossetti L, Autelitano A. Cystoid macular edema
is consistent with the fact of deficient blood retinal following cataract surgery. Curr Opin Ophthalmol.
barrier function in those patients with more advanced 2000;11(1):65–72. doi:10.1097/00055735-200002000-
vascular changes resulting from DR.14 Many previous 00010.
studies15 showed the high risk of developing macular 7. Copete S, Martí-Rodrigo P, Muñiz-Vidal R, Pastor-
edema in patients with diabetic retinopathy but most Idoate S, Rigo J, Figueroa MS, et al. Preoperative
of the studies included the patients with preoperative vitreoretinal interface abnormalities on spectral
high macular thickness like ours. domain optical coherence tomography as risk factor
for pseudophakic cystoid macular edema after
Conclusion phacoemulsification. Retina. 2019;39(11):2225–32.
There was no difference in median macular thickness doi:10.1097/iae.0000000000002298.
between the groups, and no cases in either group 8. Anastasilakis K, Mourgela A, Symeonidis C,
had an increase in macular thickness to reach this Dimitrakos SA, Ekonomidis P, Tsinopoulos I. Macular
threshold. diabetic macular edema generally worsens Edema after Uncomplicated Cataract Surgery: A Role
after cataract surgery, and that the worsening of for Phacoemulsification Energy and Vitreoretinal
macular edema is more prominent in eyes with Interface Status? Eur J Ophthalmol. 2015;25(3):192–7.
DR. and the change in patients without diabetic doi:10.5301/ejo.5000536
retinopathy is subclinical without affecting the visual 9. Jagow B, Ohrloff C, Kohnen T. Macular thickness
acuity. To provide patients with DR the benefits of after uneventful cataract surgery determined by
cataract surgery and avoiding the progression of optical coherence tomography. Graefes Arch Clin Exp
macular edema it is advised that all patients with DR Ophthalmol. 2007;245:1765–71. doi:10.1007/s00417-
should be evaluated with OCT, particularly in the 007-0605-6.
early postoperative period to detect macular changes,
10. Biro Z, Balla Z, Kovacs B. Change of foveal and
so that early diagnosis timely adequate management perifoveal thickness measured by OCT after
can be ensured. All diabetic patients need close phacoemulsification and IOL implantation. Eye.
observation for at least 6 months following surgery 2008;22(1):8–12.
to intervene with laser photocoagulation and anti
11. Gulkilik G, Kocabora S, Taskapili M, Engin G. Cystoid
VEGF as and when required to prevent visual loss
macular edema after phacoemulsification: risk
from diabetic maculopathy and other consequences
factors and effect on visual acuity. Can J Ophthalmol.
of diabetic retinopathy. 2006;41(6):699–703. doi:10.3129/i06-062
References 12. Duker JS, Kaiser PK, Binder S, de Smet M, Gaudric
1. Dandona R, Dandona L. Review of findings of the A, Reichel E, et al. The International Vitreomacular
Andhra Pradesh Eye Disease Study: policy implications Traction Study Group Classification of Vitreomacular
for eye-care services. Indian J Ophthalmol 2001; 49:215. Adhesion, Traction, and Macular Hole. Ophthalmology.
2013;120(12):2611–9. doi:10.1016/j.ophtha.2013.07.042

13. Hayashi K, Igarashi C, Hirata A, Hayashi H. Changes 15. Horozoglu F, Yanyali A, Aytug B, Nohutcu AF,
in diabetic macular oedema after phacoemulsification Keskinbora KH. Macular thickness changes after
surgery. Eye. 2009;23(2):389–96. phacoemulsification in previously vitrectomized eyes
for diabetic macular edema. Retina. 2011;31(6):1095–
14. Chu CJ, Johnston RL, Buscombe C, Sallam AB,
1100. doi:10.1097/iae.0b013e3181f98cd5
Mohamed Q, Yang YC. Risk Factors and Incidence
of Macular Edema after Cataract Surgery.
Ophthalmology. 2016;123(2):316–23. doi:10.1016/j.
ophtha.2015.10.001.

Correlation of D-Dimer Level with Severity of Pneumonia, Hospital Stay

and Mortality in Case of Covid-19 Infection: A Retrospective Study
an a Tertiary Care Hospital.
Rajashree Pradhan1, Sajeeb Mondal2, Somsubhra Chattopadhyay3, Sharmistha Debnath4

1
Associate Professor, Department of Pathology, College of Medicine & Sagore Dutta Hospital, Kamarhati, Kolkata, West Bengal.
2
Associate Professor, Department of Pathology, Rampurhat Government Medical College & Hospital, Birbhum, West Bengal.
3
Associate Professor, Department of Psychiatry, College of Medicine & Sagore Dutta Hospital, Kamarhati, Kolkata, West Bengal.
4
Associate Professor, Department of Onco, Pathology, Medical College & Hospital, Kolkata, West Bengal.
How to cite this article: Rajashree Pradhan, Sajeeb Mondal, Somsubhra Chattopadhyay, Sharmistha Debnath et al
Correlation of D-Dimer Level with Severity of Pneumonia, Hospital Stay and Mortality in Case of Covid-19 Infection:
A Retrospective Study an a Tertiary Care Hospital. Volume 13 | Issue 4 | October-December 2022
Abstract
Introduction: Worldwide there was a pandemic of novel corona virus infection in which one of the major concern was the
risk of thrombosis and the mortality associated with it.
Aim: In this study our aim was to observe the changes in D-dimer levels during disease progression and its correlations
with severity of Pneumonia, duration of hospital stay and mortality of COVID-19 patients.
Materials & Methods: In this study we reported the clinical, radiological and pathological laboratory results of 432 cases
of confirmed COVID-19 infection. In these patients their clinical presentation, concentration of D-dimer, coagulation
parameters, CBC, severity of Pneumonia on HRCT, hospital stay and higher mortality were retrospectively analyzed.
Result: All the statistical variables were expressed in % and compared withx2 test. Out of the 432 cases in 45 cases (10.41%)
the D-dimer values were >2.4µg/ml and in 15 cases the value were very high (3.47%). When correlated these patients
found to have severe degree of pneumonia, longer hospital stay and higher mortality rate in comparison to patients with
D-dimer level of <2.4 µg/ml.
Conclusion: D-dimer level could be used as an early marker for the clinical classification, risk stratification and improved
management of COVID-19 patients.
Keywords: COVID-19, D-dimer , pneumonia, hospital mortality.
Introduction COVID-19 (Corona Virus disease 2019) by World

Worldwide there was a pandemic of a novel member Health Organization(WHO).
of human corona virus which is newly identified in It is typically spread via respiratory droplets and
Wuhan, China. It is officially named as severe acute during close contact. The main clinical manifestation
respiratory Syndrome corona virus -2 (SARS-CoV-2) is lung injury. 4,5 COVID-19 is usually characterized
by International Committee on taxonomy of viruses, by symptoms of fever, dry cough and dyspnoea
ICTV.1-3 SARS-CoV-2 belongs to the beta-corona similar to the other two diseases caused by Corona
virus 2 and is a new strain of RNA Virus. Recently viruses, severe acute respiratory syndrome(SARS)
the disease caused by SARS-CoV-2 is named as and Middle East Respiratory Syndrome, MERS. 6,7
Dr Sharmistha Debnath
Associate Professor, Department of Onco Pathology, Medical College & Hospital, Kolkata, West Bengal.
Mobile: 9836145175.
E mail: [email protected].
Most of the patients have a favourable prognosis but committee (IEC) of our institute. In this retrospective
some rapidly progress to severe and critical cases study the data collected involves no potential harm
with respiratory distress syndrome, coagulation to the patients and there was no link between the
dysfunction ,multi-organ failure etc. 8,9 The reported researcher and the patients.
overall case fatality rate (CFR) for COVID-19 by now
was 2.3% but in cases of aged individuals (70-79 Clinical Classification of the patients :
years) had an 8% CFR and in cases of aged 80 years All the COVID-19 patients are clinically categorized
and older had a 14.8% CFR. 10 It has been reported into four groups, mild, moderate, severe and critical.
that about 50% of the patients had increased D-dimer 1) Mild cases - Mild clinical symptoms of fever
levels and abnormal D-dimer levels are associated with no features of Pneumonia in imaging.
with poor prognosis.4,9 It has been reported that
2) Moderate cases - Fever, respiratory symptoms
markedly elevated D-dimer levels were observed in
like cough and there is features of Pneumonia
non-survivors. 11
in imaging and Spo2 more than equality 90%
One of the key issues in this outbreak of COVID-19 in room air.
infection is very high number of patients presenting to
3) Severe cases - They have severe respiratory
hospitals and health centres leading to overwhelming
distress, RR> 30 breaths/min, the oxygen
of human & mechanistic capacity available specially
saturation is < 90% at resting state in room air
the need for critical care support. For this reason risk
and on imaging >50% lesion in the lung.
stratification of the COVID-19 patients is absolutely
helpful for better management of patients. 9,4 Therefore 4) Critical cases - These patients have any of the
early and effective predictors of clinical outcomes are following.
urgently needed for risk stratification. Respiratory failure with requirement of mechanical
ventilation,
Aim
The aim of our study was to compare the D-dimer or shock or multi-organ failure that require
level with that of the severity of Pneumonia, with monitoring in the CCU.
inflammatory and coagulation markers and duration The outcome of illness were divided into four
of hospital stay along with mortality in COVID-19 categories -
patients.
1. Hospital discharge.
Materials and Methods 2. Improved
Study design 3. Exacerbation.
This is a retrospective study done in a tertiary care 4. Death.
hospital (CMSDH, Kolkata) of West Bengal.
Laboratory investigation
Duration Laboratory interventions were done at the following
The study was conducted from 30th June 2020 to 30th point of time and the data were analysed.
June 2021.
First - Within 24 hours of admission into the
General Covid Ward the following assays were done.
Participants
Blood samples were collected for - CBC, D-dimer,
Inclusion Criteria - The patients having a positive PT/APTT.
result of SARS-CoV2 by RT-PCR are included in the
Routine biochemical tests were sent to the Central
study.
Laboratory of our hospital.
Exclusion Criteria - Patients with absent/negative
SARs-CoV-2 RT-PCR test are excluded from the ECG and HRCT of thorax were simultaneously
study. done.
The study was approved by the Institutional Ethics Second - After initial evaluation then all the Blood
tests and HRCT repeated after 5-6 days and again

190
evaluated for the outcome as follows - -> All the data were retrospectively analyzed from
the records in the Radio-diagnosis department of our
1. Hospital discharge.
hospital.
2. Improved.
-> Categorization of covid Pneumonia basing on
3. Exacerbation.
CTSS were as follows Mild( Score < 7 or = 7}, Moderate
4. Death. ( Score 8- 17) and Severe ( > 18 or = 18).
Out of these only in improved cases the laboratory Results
assay repeated while they continued to stay at the
general Covid ward. All the categorical variables were expressed as
number(%) and compared by x2 test.
The third laboratory assay: We used IBM SPSS software version 20.0 for
It is done in CCU segment of our hospital. The statistical analysis.
laboratory assay includes those patients which P values <0.0001 were considered statistically
are very critical at the initial time of assay and significant Association of D-dimer level with severity
immediately shifted to CCU and also those patients of Covid Pneumonia on HRCT of thorax were studied.
which were exacerbated in the general Covid ward
and then shifted to CCU. D-dimer levels were correlated with hospital stay
and mortality.
The following parameters were evaluated.
D-dimer levels also correlated with the levels of
1. CBC (Complete blood count) done from inflammatory markers and coagulation parameters.
peripheral venous blood by automated cell
counter 5 part (Sysmex Xs-800i) and were Table 1: Basic clinical parameters of Covid-19
studied for increased leukocyte counts as a patients at the time of admission
surrogate marker of Pneumonia. n= 432
2. Inflammatory markers (IL6 &hs-CRP) were (A ) AGE & SEX

analyzed by full auto biochemistry analyzer Age( In years) Male Female
ERBAXL 640, Germany.
hs-CRP (N-range) 0.5 to 10 mg/L. >80 06 ( 2.4%) 02 (1.1%)
3. D-dimer levels & coagulation parameters 60-80 136 ( 53.9%) 100 (55.5%)
(PT-INR, APTT) were estimated by fully 40 -59 90 ( 35.7%) 74 (41.1%)
automated coagulation analyzer STA satellite
Max, stago, France by utilizing CL89050422. 20-39 18 (7.1%) 06 ( 3.3%)
4. HRCT Routinely in all COVID-19 patients (B) Clinical Number Of %

HRCT of thorax were done to assess the Presentation Cases
severity of involvement of lungs by organizing
Fever 402 93
Pneumonia and fibrosis. Reporting were done
basing on the CT severity score. (CT-SS). Cough 380 87
Left lobe and right lobe of lungs were divided into Shortness Of 350 81
10 segments each. Basing on the severity of Pneumonia Breath
in each segment scoring were done, as follows
Myalgia 180 41
Score 0 ( No involvement of the parenchyma), Score
1( < 50% of parenchymal involvement) and Score 2 ( Diarrhea 54 12
> 50% of parenchymal involvement). Joint Pain 38 8.7
Lowest Score - 0
Highest Score - 40

Table-2 : D -dimer level, CT- severity Score and D dimer value

Categories of patients (WHO guidelines) at the
time of Admission. < 2.4 ug >2.4 ug/ P value
n=432 / ml ml
B. Coagulation
D-dimer level Number of cases % Parameter
0.4-1 µg/ml 234 54.1% PT-INR(>20secs)/ 362 72 <0.0001
1-2.4 µg/ml 138 31.9% (>1.2)
>2.4 µg/ml 45 10.41% Hospital Stay
Very high level 15 3.47% >4 weeks 10 59 <0.0001
CT Severity Score <4 weeks 362 1 <0.0001
CT severity score No of cases % Non survivor 1 24 <0.0001
< or =7 (Mild 238 55.09%
( Mortality)
8-17(Moderate) 136 31.48%
> or = 18 (Severe) 58 13.42% Discussion
Categories of Patients ( WHO guidelines) Covid-19 is an acute infections disease caused by a
according to severity novel member of human Corona Virus (SARS-Cov-2).
Mild 240 55.55% Clinically the patient presents with fever mild or
Moderate 132 30.55% severe in few cases. 8,2,3
Severe 42 9.72 %
In contrary in severe cases the disease progress
Critical 18 4.16 % very rapidly and patient develops septic shock, multi
Table-3: Comparison of D-dimer level with severity organ failure and die. 12,13,14,15
of Pneumonia by HRCT.
An important observation is that in many of the
n=432 severe, critical and deceased patients have significant
D-dimer level CT severity P. coagulation abnormalities. 4,5,8,9
score value In our study the primary observation was
(Cut off value <7, 8-17, > associated of higher D-dimer value with that of
2.4µg/ml.) or= 18 severity of Pneumonia and with mortality rate.
< 2.4 µg/ 238, 132, 2 D-dimer elevation is one of the commonest
ml.(n-373) < 0.0001 laboratory findings noted in Covid-19 patients
> 2.4 µg/ 1 3 56 requiring hepatization.
ml.(n=59) < 0.0001
Guan and colleagues found the non-survivors had
Table 4: Comparision of D-dimer value with a significantly higher D-dimer (Median : 2.12 µg/
Inflammatory markers, coagulation parameters , ml) than that of survivors (Median : 0.61 µg/ml) (9).
hospital stay and mortality Ming T et al observed markedly elevated D-dimer
D dimer value in deaths with Covid-19(16). Huang and colleagues
< 2.4 ug >2.4 ug/ P value showed D-dimer levels on admission were higher in
/ ml ml patients needing critical care support.
A. Inflammatory Now coming to the mechanism of elevation of
Marker D-dimer level in Covid-19 patients.
i. hs-CRP
First- Virus (SARS- CoV-19) infection leads
<20.44 ug / ml 368 02 <0.0001 to aggressive pro-inflammatory response and
>or = 20.44 ug/ml 4 58 <0.0001 insignificant anti-inflammatory response 17 which
might induce endothelial dysfunction resulting in
ii. IL-6
excess thrombin generation. 18
>37.65pg/ml 372 60 <0.0001

192
Second-Hypoxia induced by severe Covid-19 References

infection stimulate thrombosis through hypoxia- 1. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et
inducible transcription factor dependent signaling al. Epidemiological and clinical characteristics of 99
pathway and increasing blood viscosity. 19,20 cases of 2019 novel coronavirus pneumonia in Wuhan,
China: a descriptive study. The Lancet. 2020 Feb
Third-Hospitalized patients having elder age,
15;395(10223):507–13.
underlying co-morbidity conditions, long term bed
rest and invasive treatment etc.All are associated with 2. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al.
increased rick for thrombosis or hyper-coagulation. Clinical features of patients infected with 2019 novel
21,22,23 coronavirus in Wuhan, China. The Lancet. 2020 Feb
15;395(10223):497–506.
Fourth-Some patients develop sepsis-induced
3. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al.
coagulopathy like DIC . 11,24
Clinical Characteristics of 138 Hospitalized Patients
In our study it was found that patient who had with 2019 Novel Coronavirus-Infected Pneumonia
higher D-dimer levels at the time of admission in Wuhan, China. JAMA - Journal of the American
(cut off value > 2.4 µg/ml) had severe Pneumonia Medical Association. 2020 Mar 17;323(11):1061–9.
as correlated with CT severity score. In addition 4. Guan W jie, Ni Z yi, Hu Y, Liang W hua, Ou C quan,
the result of this study also showed that patients He J xing, et al. Clinical Characteristics of Coronavirus
with higher D-dimer levels had a significant higher Disease 2019 in China. New England Journal of
value of other inflammatory markers and markers Medicine. 2020 Apr 30;382(18):1708–20.
forincreased risk of thrombosis. 5. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A
Out of 432 cases in total 60 cases D-dimer level were Novel Coronavirus from Patients with Pneumonia in
elevated. (45 cases with D-dimer >2.4 µg/ml and 15 China, 2019. New England Journal of Medicine. 2020
cases with very high level of D-dimer >20 µg/ml). A Feb 20;382(8):727–33.
total of 25 deaths occurred all of which had a higher 6. A Cluster of Cases of Severe Acute Respiratory
D-dimer level at the time of admission. Syndrome in Hong Kong [Internet]. Vol. 348, N Engl J
Med. 2003. Available from: www.nejm.org
Another interesting observation was that patients
with moderate clinical presentation but having higher 7. Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah
D-dimer level had higher duration of hospital stay in FA, Al-Hajjar S, Al-Barrak A, et al. Epidemiological,
comparison to the patients having low D-dimer level demographic, and clinical characteristics of 47 cases of
Middle East respiratory syndrome coronavirus disease
with same clinical presentation.
from Saudi Arabia: A descriptive study. The Lancet
Conclusion Infectious Diseases. 2013 Sep;13(9):752–61.
The results of this study showed that elevated D-dimer 8. Han W, Quan B, Guo Y, Zhang J, Lu Y, Feng G, et al.
level at the time of admission could effectively predict The course of clinical diagnosis and treatment of a
the severity of Pneumonia and mortality in patients case infected with coronavirus disease 2019. Vol. 92,
with Covid-19 infection. Journal of Medical Virology. John Wiley and Sons Inc.;
2020. p. 461–3.
To conclude D-dimer level could be used as an early
9. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation
marker for the clinical classification and improved
parameters are associated with poor prognosis in
management of Covid-19 patients. patients with novel coronavirus pneumonia. Journal of
Thrombosis and Haemostasis. 2020 Apr 1;18(4):844–7.
Conflict of interest
10. Wu Z, McGoogan JM. Characteristics of and
None. Important Lessons from the Coronavirus Disease 2019
(COVID-19) Outbreak in China: Summary of a Report
Contribution from the author: of 72314 Cases from the Chinese Center for Disease
Control and Prevention. Vol. 323, JAMA - Journal of
All authors have equal contribution for the paper.
the American Medical Association. American Medical
Funding - Self , No Financial support received Association; 2020. p. 1239–42.

11. Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, 18. Levi M, van der Poll T. Coagulation and sepsis. Vol.
Levi M, et al. ISTH interim guidance on recognition 149, Thrombosis Research. Elsevier Ltd; 2017. p. 38–44.
and management of coagulopathy in COVID-19.
19. Gupta N, Zhao YY, Evans CE. The stimulation of
Journal of Thrombosis and Haemostasis. 2020 May
thrombosis by hypoxia. Vol. 181, Thrombosis Research.
1;18(5):1023–6.
Elsevier Ltd; 2019. p. 77–83.
12. Wan Y, Shang J, Graham R, Baric RS, Li F. Receptor
20. Tang N, Bai H, Chen X, Gong J, Li D, Sun Z.
Recognition by the Novel Coronavirus from Wuhan:
Anticoagulant treatment is associated with decreased
an Analysis Based on Decade-Long Structural Studies
mortality in severe coronavirus disease 2019 patients
of SARS Coronavirus. Journal of Virology. 2020 Mar
with coagulopathy. Journal of Thrombosis and
17;94(7).
Haemostasis. 2020 May 1;18(5):1094–9.
13. Kowalczuk S, Bröer A, Tietze N, Vanslambrouck JM,
21. Harper PL, Theakston E, Ahmed J, Ockelford P.
Rasko JEJ, Bröer S. A protein complex in the brush-
D-dimer concentration increases with age reducing
border membrane explains a Hartnup disorder allele.
the clinical value of the D-dimer assay in the elderly.
The FASEB Journal. 2008 Aug;22(8):2880–7.
Internal Medicine Journal. 2007 Sep;37(9):607–13.
14. Gates B. Responding to Covid-19 — A Once-in-a-
22. Barbar S, Noventa F, Rossetto V, Ferrari A, Brandolin
Century Pandemic? New England Journal of Medicine.
B, Perlati M, et al. A risk assessment model for the
2020 Apr 30;382(18):1677–9.
identification of hospitalized medical patients at risk
15. Zhou T, Liu Q, Yang Z, Liao J, Yang K, Bai W, et al. for venous thromboembolism: The Padua Prediction
Preliminary prediction of the basic reproduction Score. Journal of Thrombosis and Haemostasis. 2010
number of the Wuhan novel coronavirus 2019- Nov;8(11):2450–7.
nCoV. Journal of Evidence-Based Medicine. 2020 Feb
23. Hess K, Grant PJ. Inflammation and thrombosis
1;13(1):3–7.
in diabetes. Thrombosis and Haemostasis.
16. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical 2011;105(SUPPL. 1):43–54.
course and risk factors for mortality of adult inpatients
24. Iba T, Levy JH, Warkentin TE, Thachil J, van der Poll
with COVID-19 in Wuhan, China: a retrospective
T, Levi M. Diagnosis and management of sepsis-
cohort study. The Lancet. 2020 Mar 28;395(10229):1054–
induced coagulopathy and disseminated intravascular
62.
coagulation. Journal of Thrombosis and Haemostasis.
17. Wong JP, Viswanathan S, Wang M, Sun LQ, Clark GC, 2019 Nov 1;17(11):1989–94.
D’elia R v. Current and future developments in the
treatment of virus-induced hypercytokinemia. Future
Medicinal Chemistry. 2017 Feb 1;9(2):169–78.

A Study on Adherence of Anti-Glaucoma Medications in Adults – An

Observational Hospital based Study
Ranjita Santra1, Nabanita Barua2, Jayanta Dutta3, Pramit Ghosh4

1
Associate Professor, Department of Pharmacology. Deben Mahata Govt Medical College, Purulia.
2
Assistant Professor, Dept. of Ophthalmology. Deben Mahata Govt Medical College, Purulia.
3
Associate Professor, Dept. of Ophthalmology. Deben Mahata Govt Medical College, Purulia.
4
Scientist E, ICMR-RMRCNE, Dibrugarh.
How to cite this article: Ranjita Santra, Nabanita Barua, Jayanta Dutta, Pramit Ghosh et al A Study on Adherence
of Anti-Glaucoma Medications in Adults – An Observational Hospital based Study. Volume 13 | Issue 4 |
Abstract
Introduction: Glaucoma is chronic progressive optic neuropathy which causes irreversible visual filed loss. Antiglaucoma
medication is the mainstay of treatment due to recent advances in the field. Due to increased life expectancy and availability
of newer investigation technology for early diagnosis of glaucoma, duration of treatment is long. Strict adherence is
required to prevent progression.
Aim: We aim to assess factors affecting adherence in a tertiary care setting.
Materials and Methods: 40 diagnosed cases of glaucoma, who were using on medication at least for 6 months, were
enrolled in the study after proper consent. All patients were asked about nature of drug intake based on standardized
questionnaire. Data were analysed using epi-info7 software.
Results: 40% study population were non adherent; it was comparable in males and females (p=.5). The factors like age,
sex, number of drugs didn’t show statistically significant association. Only parameter with significant association is
higher educational level (p=0.004).
Conclusion: Drug adherence is a complex process; various factors need to be considered before prescribing medication. In
case of chronic, progressive, blinding disease like glaucoma, educating patient about need to strict drug dosing, possible
side effects, cost-effectivity and regular follow up is required.
Keywords: drug adherence and compliance, antiglaucoma medication, predictors of adherence
Introduction lead to lead to complete visual loss, the constellation

Glaucoma is defined as a groups of multifactorial of features is diagnostic.1 It is estimated that over 60
ocular neurodegenerative disease, aetiology united million people are affected, 8.4 of these population
by a clinically characteristics optic neuropathy with are blind. The global incidence is projected to be 111.8
potentially progressive changes at optic nerve head, million by 2040.2 In India, it contributes to 0.6 million
thinning of neuro-retinal rim with enlargement of disability-adjusted life years (DALYs) or 1.96% of the
optic cup, corresponding pattern visual field defect, overall burden of diseases.3
may not be detected in perimetry in early stage; while Adherence has been defined as “the extent to
visual acuity may be spared initially, progression may which a person’s behaviour, taking medication,
Dr. Nabanita Barua
Assistant Professor, Department of Ophthalmology, Deben Mahata Govt Medical College, Purulia. West Bengal, India
609a, B block. Padmalaya Apartment. 70 South Sinthee Road. P.O: Ghughudanga. P.S: Sinthee. Kolkata -700030
Mobile no. 7890354791
following a diet, and/or executing lifestyle changes, 2. Patients with mental illness
corresponds with agreed recommendations from a All patients had been enquired about history,
health care provider.”4 Compliance is defined as “the detailed eye examination and their relevant findings
extent to which the patient’s behaviour matches the with structured interview. Informed consent will
prescriber’s recommendations”. 5 Magnitude of non- be obtained for those screened patients willing
compliance of AGM is high ranging from 20-75%. 6 to participate in this study. Ophthalmological
Average literacy rate of Purulia in 2011 were parameters to be studied are routine eye examination,
64.48% against the national average of 77.7%. There is visual acuity with illuminated Snellen’s chart,
no study done to assess adherence in this population applanation tonometry, direct ophthalmoscopy,
to our knowledge. Primary objective is to assess fundus examination, perimetry.
adherence pattern of AGM by interviewer’s method Only the diagnosed cases of glaucoma who were on
in glaucoma patients of district in literate population antiglaucoma medications for at least 6 months were
and secondary objective is to identify any correlation included in study. Treatment naïve patients or who
between factors and adherence. failed to show previous prescriptions were excluded
Materials and Methods from the study.
Study was conducted on all patients with primary Study Technique
and secondary glaucoma attending the department Adult patients with primary and secondary
of Ophthalmology at Deben Mahata Government glaucoma were enrolled in the study. Complete
Medical College, Purulia over the period of six ocular examination as per proforma and relevant
months. A total of 40 patients were included in the structured interview with the help of the following
study who underwent ocular examination with questionnaires will be done for every patient who will
primary investigations and structured interview. participate in this study:
The study was conducted after institutional ethics
committee (IEC) for review and approval. It was General Medication Adherence Scale
cross sectional observational, single centre, hospital-
based study. At the beginning of the study, a total of The scale has 11 questions with 4 possible answers.
40 consecutive adult patients of both the sexes, who It has three components. Component 1 is adherence
have been diagnosed with glaucoma and fulfilling the pattern based on the behaviour of patient (question
selection criteria will be recruited for this study. It is a 1-5). Component 2 measures adherence of patient
single day cross sectional study. based on their comorbidity and number of pills or
pill burden (question 6-9). Third component focuses
Inclusion Criteria or assesses adherence pattern depending on cost
1. Diagnosed and confirmed cases of Primary (question 10-11). Each item further carries individual
or Secondary Glaucoma in either or both the score ranging from 0 to 3. Answer option 1 (always),
eyes who have been prescribed anti-glaucoma 2(mostly), 3 (sometimes), 4 (never) is given score of 0,
medications for at minimum period of 6 1, 2,3 respectively. Maximum score is 33. Summation
months and attending Ophthalmology OPD of individual items will provide adherence score of
each patient. Cumulative adherence score is classified
2. Age limit: 21 to 65 years
as high (30-33), good (27-29), partial (17-26), low (11-
3. Voluntary participation 16) and poor (<10). This scoring methodology have
Exclusion Criteria been previously defined by Naqvi and colleagues.7,8
For statistical analysis we have grouped patients in
1. Prior surgical intervention
2 groups. Group 1 has patients with high and good
2. Patients with diagnosed demetia adherence (score >27), they are termed as adherent.
3. Patients who were seriously ill and unable to Group 2 is termed as non-adherent, has patients with
comprehend the study questionnaire (current partial, low and poor adherence (< 27).
acute complications of any disease) We have taken educational qualification,
1. Those who had a disturbance of consciousness number of drugs and classification of glaucoma
(Glasgow coma score lower than 15) and into consideration for each patient. Educational
cognitive impairment qualification of the patients was divided into 3
196
standards. Basic or primary (class1-5), intermediate larger population can show statistically significant
(class 5-8) or higher (Class 8 onwards). Number of result.
drugs 1 or more were noted.
In our study, 11 patients with basic education had
All the data were recorded and calculated using score of less than 27; 2 patients with intermediate
epi-info7 software. [ Epi Info™ 7.2.4.0; Division of education and 11 patients with higher education
Health Informatics & Surveillance (DHIS), Centre for had score of more 27 (image 2). This difference was
Surveillance, Epidemiology & Laboratory Services statistically significant. Comparing basic and others,
(CSELS) Centre for Disease Control & Prevention. p-value=0.004, while all those with basic education
USA]. For statistical significance of this study, p value had poor adherence, 56% among those with better
is <0.05. education had better adherence. Higher education
level of patients is critical for better adherence.
Results
We had total of 40 patients, 24 male and 16 female Discussion
patients. Group 1 or adherent group (good adherence Adherence is an active process, where appropriate
and more) had 24 patients; group 2/ non-adherent treatment is decided after a proper and detailed
group has 16 patients. The average adherence score of interaction with patient. The said patient is under
the study is 60%. (Table 1, image 1). no compulsion to accept that particular treatment,
thereby not to be held solely responsible for non-
Age of the patients ranged from 36 to 76years.
adherence.9
Average age was 56.8(+ 10.2) years and median
58years. 16 subjects were more than 60years old. Compliance, on the other hand, is a passive process,
it focusses on medication-taking behaviour. It may be
In our study, 11 out of 16 (31.2%) female patients
problematic for the patients as it narrates a process
were adherent whereas 13 out of 24 (45.8%) male
where autonomy of the patient is not considered.
patients were adherent. The difference was however,
This may hamper therapeutic benefits as it doesn’t
not statistically significant p=0.512 (>0.05) (Table 1).
take into account patient’s general awareness of the
We had classified into three subgroups; mild, disease, socio-demographic background, efficacy,
moderate and severe glaucoma depending on visual tolerability and adverse effects of medications, need
field loss (mean deviation or MD values) (table 2). to follow up, or lack of insight due to psychosocial
Mild glaucoma is a visual field defect corresponding abnormalities, abnormal mood states like depression,
to a mean deviation (MD) of −6 dB or better, moderate or personality traits etc.10
disease is a disease with MD between −6 and −12 dB,
In our study overall non-adherence is 40%. It is
and severe disease is a disease with MD of −12 dB
similar to study done is Southern India, where it was
or worse.21 For each patient, we determined POAG
53.6%.11. In other studies, non-adherence ranged from
severity for the worse eye (the more negative MD),
20 to 75 %, though the evaluation methods were not
the better eye (the more positive MD). We had 12
standardized. 6
patients with mild, 12 moderate and 16 with severe
glaucoma. Mean MD value of group 1/ adherent is In our study, male adherence was better 45.8%
-7.4 with mean age of 53.75 years. Mean MD value as compared to 31.2% in females, difference is not
of patients with adherence value of group 2/ non- statistically significant. It is comparable to study in
adherent is -9.4 with age of 58.8 years. Patients with Egypt where though females showed higher tendency
younger age and less severe disease seem to have for adherence, after multivariate analysis difference
better compliance. The difference is not significant, p was not significant. 11
values are .42 and .12 for MD and age respectively
In our study, patients with younger age and less
(>0.05) (Table 3).
severe disease seem to have better adherence, though
In our study, 22 patients were put on single drug, not statistically significant. Adherence in older
11 patients on two drugs and 7 patients on 3 drugs patients may be less due to lot of other factors such
(table 4). In this study there was no difference between as lack of family support or appointed care giver,
single and multiple drugs (p-vale=0.53, >0.05). It decreased vision, lack of dexterity, coordination,
appears that with multiple drugs adherence is poor comprehension, or memory.12 These factors are;
but it is not statistically significant. A study with however, this was not included in the questionnaire.

It appears that with multiple drugs adherence is Male 13(54.2%) 11(45.8%) 24

poor as compared to single drug. This agrees with
Total 24 16 40
previous studies.11,12 Though our study only showed
a tendency but it is not statistically significant. A p=0.512
study with larger population can show statistically (>0.05)
significant result.
Table 2: Classification of Glaucoma patients
In Our study, all patients with basic education
were non-adherent. 56% of patients with better Grand
education were adherent to medication. Difference MD value (worst eye) F M Total
of adherence on the basis of educational qualification MD >(-)6.00 5 7 12
were significant (p=0.004). Educated patients tend to
MD between (-) 6 to
be more information, knowledge about glaucoma,
thereby increasing more aware the disease and need to
(-)12 6 6 12
adhere to treatment regime. It is also found increasing MD <(-)12 5 11 16
knowledge and awareness about the disease increases Grand Total 16 24 40
adherence.11-13
Table 3: Distribution of disease by severity
Our findings also corroborated with Egypt of disease (degree of visual field defect) and
base study where gender, dose related problems, corresponding adherence score
medication side effects, and systemic comorbidity
Score groups Mean Max Score Age(Y)
did not have a significant association with adherence; MD MD
strong association is found with better education, Mean -9.41 -12.42 20 58.88
awareness about the disease.11,12
N 24 24 24 24
Conclusion <27
Std.
7.87 9.36 4.72 8.29
Group Deviation
Adherence to ocular hypotensive medications is
2/ non- Median -7.2 -9.85 20 58.50
a critical part of secondary prevention of visual adherent
impairment from glaucoma. Regardless of the Minimum -24.51 -27.77 11 45
definition, glaucoma patients attain the full benefits
Maximum -.32 -1.35 26 76
of AGM only when they use them every day.
Mean -7.49 -9.87 28.63 53.75
Although there are studies in the literature pertaining
to adherence and outcome of medical management N 16 16 16 16
of glaucoma in different geographical locations, >27, Std.
6.33 6.71 1.54 11.95
still there is paucity of results with subjects of low Group 1/
Deviation
economic status. Various factors such as age, sex, adherent Median -6.27 -9.18 28 55
severity of disease, number of pills, complexity of Minimum -24.73 -24.73 27 36
doses, cost effectiveness should be considered before
Maximum -.47 -1.16 32 73
prescribing the drugs. Patients should be made aware
of slow, progressive, blinding nature of the disease Mean -8.64 -11.4 23.45 56.82
and need for strict drug adherence and follow up. N 40 40 40 40
Active interaction with patients for reason for non- Std.
adherence, steps to improve it need to be discussed to 7.27 8.39 5.69 10.09
Total Deviation
reduce the ultimate disease burden. Median -6.48 -9.36 26 58
Table 1: Gender distribution of sample with Minimum -24.73 -27.77 11 36
adherence score
Maximum -.32 -1.16 32 76
Sex Score<27 Score >27 Total
p-value 0.42 0.35 0.12
Female 11(68.8%) 5(31.2%) 16

198
Table 4: Adherence score depending on number of the General Medication Adherence Scale in Pakistani
drugs used Patients With Rheumatoid Arthritis. Front Pharmacol.
2020 Jul 17;11:1039.
Number Score Score Total OR CI (lower-
of drugs <27 >27 upper) 9. Chakrabarti S. What’s in a name? Compliance,
1 12 10 22 1 Reference adherence and concordance in chronic psychiatric
disorders. World J Psychiatry. 2014 Jun 22;4(2):30-6.
2 6 5 11 1 0.23-4.27
3 6 1 7 0.2 0.02-1.95 10. Hughes CM. Medication non-adherence in the elderly:
how big is the problem? Drugs Aging. 2004; 21(12):793-
24(60) 16(40%) 40
811.
p-value = 0.53. between single drug and multiple drugs
p value= 0.2, when compared 2 drugs vs 3 drugs. 11. Teshome, D. F., Bekele, K. B., Habitu, Y. A., and
Gelagay, A. A. Medication adherence and its associated
Conflict of interest – None factors among hypertensive patients attending the
Debre Tabor General Hospital, northwest Ethiopia.
Source of Funding - Not required
Integr. Blood Press. Control 2017;10, 1–7.
13. Ethical clearance taken from institutional ethical 12. Jankowska-Polanska, B., Dudek, K., Szymanska-
committee Chabowska, A., and ´ Uchmanowicz, I. The influence
of frailty syndrome on medication adherence among
Reference
elderly patients with hypertension. Clin. Interv. Aging
1. Casson R, Chidlow G, Wood J, Crowston J, Goldberg 2016;11, 1781–1790.
I. Definition of glaucoma: clinical and experimental
concepts. Clin Exp Ophthalmol 2012;40:341–349. 13. Hou, Y., Zhang, D., Gu, J., Xue, F., Sun, Y., Wu, Q., et
al. The12.
association between self-perceptions of aging
Jankowska-Polanska, B., Dudek, K., Szymanska-Chabowska, A., and ´ Uchmanowicz, I.
The influence of frailty syndrome on medication adherence among elderly patients with
2. Tham Y-CC, Li X, Wong TY, Quigley HA, Aung T, and antihypertensive
hypertension. medication
Clin. Interv. Aging 2016;11, 1781–1790.adherence in older
13. Hou, Y., Zhang, D., Gu, J., Xue, F., Sun, Y., Wu, Q., et al. The association between self-
Ed F, Cheng CY. Global Prevalence of Glaucoma Chinese adults. Aging Clin.medication
perceptions of aging and antihypertensive Exp.adherenceRes.in older
2016:28, 1113–
Chinese adults. Aging Clin.
Exp. Res. 2016:28, 1113–1120
and Projections of Glaucoma Burden through 1120
2040. A Systematic Review and Meta-Analysis. Legends
Ophthalmology 2014;121:2081–2090. Legends

Image 1: Age and sex distribution of sample population
3. World Health Organization. Estimated DALYs by

Causes and Member States. Geneva: Department of
Measurement and Health Information. World Health
Organization; 2009.
4. Haynes RB. Determinants of compliance: The disease

and the mechanics of treatment. Baltimore, Johns
Hopkins University Press, 1979.
5. Ramesh PV, Parthasarathi S, John RK. An exploratory
study of compliance to anti-glaucoma medications
among literate primary glaucoma patients at an
urban tertiary eye care center in South India. Indian J
Ophthalmol. 2021 Jun;69(6):1418-1424. Image 1: Age and
Image 2: sex
Adherence score distribution of sample
with different levels of education
population
6. Cohen Castel O, Keinan-Boker L, Geyer O, Milman
U, Karkabi K Factors associated with adherence to
glaucoma pharmacotherapy in the primary care
setting. Fam Pract. 2014 Aug; 31(4):453-61
7. Naqvi AA, Hassali MA, Rizvi M, Zehra A, Iffat W,

Haseeb A, Jamshed S. Development and Validation
of a Novel General Medication Adherence Scale
(GMAS) for Chronic Illness Patients in Pakistan. Front
Pharmacol. 2018 Oct 9;9:1124.
8. Naqvi AA, Hassali MA, Rizvi M, Zehra A, Nisa ZU,

Islam MA, Iqbal MS, Farooqui M, Imam MT, Hossain
MA, Khan I, Iqbal MZ, Ali M, Haseeb A. Validation of Image 2: Adherence score with different levels of
education
Scoping Review on Brain Mapping Leadership and Talent Engagement
Rapeerat Thanyawatpornkul1, SupalakKhemthong2, Winai Chatthong3

1
Lecturer, Silpakorn University, Department of Mechanical Engineering, Faculty of Engineering and Industrial Technology,
6 RajamankhaNai Rd., Muang, Nakhon Pathom 73000, Thailand
2
Asst. Prof. Division of Occupational Therapy, Faculty of Physical Therapy, 999, Phuttamonthon 4 Rd., Nakhon Pathom 73170,
Mahidol University, Thailand
3
Lecturer, Faculty of Physical Therapy, Division of Occupational Therapy, Mahidol University, Salaya, Nakhon Pathom 73170 Thailand
How to cite this article: Rapeerat Thanyawatpornkul, SupalakKhemthong, Winai Chatthong et al Scoping Review
on Brain Mapping Leadership and Talent Engagement. Volume 13 | Issue 4 | October-December 2022
Abstract
Brain mapping performance (BMP) is an innovative assessment designed by psychosocial occupational therapists to create
talent engagement across lifespan. However, work readiness seems to be challenging assessment for anyone who has not
been accepted on why and how to develop their upskilling. This preliminary study aimed to examine the validity and
reliability of the BMP assessment. Six case studies were voluntarily participated as talented leaders of one corporate. Four
associations of soft skills were outcomes, i.e., creativity, flexibility, empathy, and leadership, in the consecutive assessment
of resting and voice-recording.This special formulation displays healthy brain performance, significantly associated in
between empathy and leadership (Sr = 0.880-0.943); creativity and flexibility (Sr = 0.886); eustress engagement and growth
mindset (Sr = 0.943); flexibility and positive thinking (Sr = 0.926). The BMP can individually explain how well of intrinsic
brain capacity for leadership talent. This is a transformative strategy to optimize human-centered performances.
Keywords: Human resources, Interdisciplinary, Deep learning, Leadership, Mirror neurons morality
Introduction and Development (L&D) leaders, three issues

The need for change is continued by looking at a must be determined: academic capability building,
descriptive score of the Southeast Asia employee technological tools integrated growth mindset and
engagement that resulted from 2014-2016 that 70% soft skills with powerful sustainability of empathetic
were not engaged and only 19% were engaged.1As listening.2
we have been facing the pandemic COVID-19 When we focus on optimizing sports performance
till now, deep experiential learning is the most under stressful situations, mental toughness is a
challengingskill for becoming a leadership talent major key to well-being. Successful performance
related new normal of the humanized learning is addressed underlying feedback mechanisms
organization. As seen by a few change makers per for the motivational role to optimize motor skill
each corporate, a unique non-standardized work learning. Prior to mental health assessment, the
enables talent engagement for moral purpose as well cognitive-behavioral rationale is to promote not only
as human-centered performance.1 This is congruent sports performance but also education, business,
with what human-centric autonomy brings stronger or health contexts. As known the Chinese concept
well-being at work by learning to be more flexible and of Jingjie, this spiritual thought aims to become
empathy in a big theme for 2022 Human Resources conscientious, selfless, responsible, and beloved
or HR transformation.2 Especially for Learning indealing with mental health challenges. In this
Winai Chatthong
Lecturer, Faculty of Physical Therapy, Division of Occupational Therapy, Mahidol University, Salaya,
Nakhon Pathom 73170 Thailand
200
new normal era, several fields of mental skills perform rather than hands-on instructions.15Vicarious
training havebeen movingthrough the 21st century learning can be derived from indirect sources such as
of effectivestrategies.3As seen, many workforce listening to your voices thinking with imagination.15
employees are impacted by accumulating stressful The vicarious learning process is represented in the
situations;their leaders could respond with openness, parietal regions (C3, C4, and Cz).15-17Also, the World
support, and compassion. However, soft skills are Health Organizationhas emphasized that the more
considered using the neuroscience approach4to learning from the meaningful activities, the more
understand personal and professional life in relation leadership engagement enables healthy aging or a
tobeing a better performer and wellness. Indeed, 21st- process of optimizing functional abilities.
century leadership is formulated into ninestyles.5
This concept will be promoted toward 2030,
Therefore, neuroscience may advocatefor a better strengthening an intrinsic capacity of the individual
integration of people from bigtalent to competencies autonomy to learn with freedom, dignity, integrity,
training of a resonant leadershipbased on the and independence and to maintain relationships in
personal needs as if they gain an optimal working environmental well-being.However, the BMP has
environment that fit their tangible andnon-tangible been preliminarily assessed in a group of executive
rewards circuit of the brain.4, 6Previous research managers in order to validate a cut-off scoring and
often used Electroencephalograph (EEG) to find to differentiate two consecutive sessions: resting
peak-performance training ranges of the cerebral and voice recording. This study hopes to gain a
functions.6, 7Specifically, those employees regain knowledge translation of healthy workplace-related
their adequate evidence-based brain performance intrinsic brain capacity assessment to be started at one
at the optimal strategy of self-conscious elaborated corporate social responsibility (CSR) in Thailand.
emotional intelligence, positive thinking, and
mindfulness through the organizational development Methods
process to expand their knowledge, qualifications,
Participants
and capacities.4
The total voluntary participants in this study were
Especially for the neuroscience approach, six case studies selected through purposive sampling.
multisensory cues in the human brain-behavior They all were executive managers working in the
teach us about other internal mental intentions and same company with non-identified confidentiality.
states of other person, allowing us to forecast a Brain All participants wore an Emotive EPOC helmet
Mapping Performance (BMP)7in a given setting of for the EEG measures while resting (thought) in a
MirrorNeurons Morality (MNM) which provides an comfortable seat with opened eyes and recording
internal experience of activities of another person’s
(action and time) for their three pitches of voice: high,
action observed as cognitive empathy.8-10 This
medium, and low on the same statement.
imitation permits us to infer the underlying desires,
emotions, and beliefs.11, 12 The MNM are located in A recording platform called the 4voices app
frontal regions (F3 and F7), temporal regions (T3), and was freely used for anyone who was interested in
parietal regions (C3, C4, and Cz).13, 14So that the MNM, improving self-positive thinking.The participants
through feeling, sensing, and empathizing with what would select one purposeful category in regard tothe
people perform rather than hands-on instructions, is thematic statement out of four: healthy, happiness,
called vicarious learning or intentional understanding worthy, and mindfulness.A criteria scoring was at
represented and activated in three brain locations; C3, 20% per one component of voice.
C4, and Cz.15
EEG Data Analysis
The element of empathy in the engagement index The EEG is a non-invasive recording technique
(EI) is cognitive or intentional understanding, that can measure electrical neural currents at the
represented in three mirror neuron brain locations the scalp level. The neural oscillations have different
frontal regions of two mirror neuron brain locations frequency bands including the EEG oscillations allow
(F3 and F7) and one mirror neuron brain location identification of the mu rhythm (8–13 Hz) with the
in the temporal region (T3)16which is connected a MNM.18, 19The raw data from F3, F7, T3, C3, C4, Cz
learning process, called vicarious learning, involves represented the location of the MNM.18, 20For this
feeling, sensing, and empathizing with what people experiment, the brain wave frequency of alpha, beta,
and theta wasselected and used for EIby applying and concurrent validity of 4voices app. Spearman’s
the EEG variable according to the international 10-20 correlation
enables (Sr)(100%
a growth mindset would bebased
full score) interpreted at 0.30-0.39
on previous trialsintegrated with three
method. moderate
theoretical relationship,
models.24-26 0.40-0.69 strong relationship,
and > 0.70 very strong relationship.27
The Quantitative Electroencephalogram (QEEG) Finally, all data has statistically been testedat the 95% confidence interval,i.e., normal
is used to create brain mapping using the EEG data Results
distribution with non-parametric K-S calculation, the median calculation for a cut-off score,
that associated with creativity, flexibility, empathy,
Normal
parallel-form distribution
reliabilityand predictive(n = 6,inpbetween
validity > 0.05) was
resting andfound in alland
voice recording
and leadership.1, 2Previous comparative case studiesin
variables
concurrent validity ofexcept the
4voices app. empathetic
Spearman’s thought
correlation (Sr) (p = 0.04).
would be interpreted at 0.30-0.39
the Psychosocial Occupational Therapy Clinic have
Median
moderate was0.40-0.69
relationship, computed in averaged
strong relationship, from
and > 0.70 very strong4 variables
relationship. 27
been validated in terms of the following calculations
(creativity, flexibility, empathy, and leadership)
in the total score of 100%, respectively: Creativity = Results
at 66.61 (thought) and 64.71 (action). Spearman’s
Theta*0.7, Alpha*0.5, Beta*0.5 (Fp2, F8, Fz, T4 /P4);
correlation
Normal distributionfound (n = 6, p very
> 0.05) strong
was found in relationship
all variables exceptbetween
the empathetic
Flexibility = Theta*0.7, Alpha, HBeta*0.7 (Fp1, Fp2,
positive
thought (p = 0.04). thinking
Median was computed(via in4Voices
averaged fromapp)
4 variables and flexible
(creativity, flexibility,
Fz, F4/T4); Empathy = Delta*0.7, Alpha, HBeta*0.7
thought (Sr = 0.926, p = 0.008). So that the
empathy, and leadership) at 66.61 (thought) and 64.71 (action). Spearman’s correlation found cut-off
(F7, F8, T5, T6/T4); Leadership = Theta, Alpha, Beta
veryscore of thebetween
strong relationship BMPpositiveandthinking
4Voices app
(via 4Voices app)to and distinguish
flexible thought (Sr =
(Fp1, Fp2, T3, T4/F4).
the intrinsic brain capacity assessment seemed to be
0.926, p = 0.008). So that the cut-off score of the BMP and 4Voices app to distinguish the
EIis calculated by using alpha, beta, and theta 60%,as shown in Figure 1.
intrinsic brain capacity assessment seemed to be 60%,as shown in Figure 1.
of brain wave activities: β/(α + θ) whichdirectly
related to human task engagement,relaxation, Positive Thinking 80.00
and information processing.21, 22According to the Leadership Action 80.21
EEG, variables were computed at the maximal EI

BMP & 4Voices app
Leadership Thought 79.17

Empathetic Action 54.58
of 6.0023converted into 100% so that an increase in Empathetic Thought 63.13
the EI index reflected an increase in the degree of Flexible Action 62.40
engagement.19The EI has provided a comprehensive Flexible Thought 65.42

Creative Action 61.67
understanding of ‘participants’behavior regarding Creative Thought 58.75
eustress and compassion engagement while resting 0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 90.00
A Cut-Off 60% MEDIAN
and recording the 4voices application. A summation
of eustress (C3, C4, Cz, F3, F7, T3) and compassion Figure 1 Median accounted for the BMP and 4Voices of positive thinking (n = 6)
Figure 1: Median accounted for the BMP and
(Fp1, Fp2, F7, F8, P3, T4,T5) engagement enables a
4Voices of positive thinking (n = 6)
growth mindset (100% full score) based on previous
trialsintegrated with three theoretical models.24-26 Interestingly, resting and voice recording
correlations indicatedfor parallel-form reliability
Finally, all data has statistically been testedat the 95% from 0.829 to 0.943 or very strong relationships (Table
confidence interval,i.e., normal distribution with non- 1). In regard topredictive validity, all variables were
parametric K-S calculation, the median calculation for significantly different (p = 0.028) using Wilcoxon
a cut-off score, parallel-form reliabilityand predictive signed-rank test except for a comparison of empathetic
validity in between resting and voice recording thought and action (p = 0.463).
Table 1: Comparison of mean & Standard Deviation (SD) in paired resting (thought) and 4Voices
recording (action)
Case No. Creative Creative Flexible Flexible Empathetic Empathetic Leadership Leadership
thought action thought action thought action thought action
Case A 63.96 62.50 65.83 65.63 70.21 58.13 89.58 85.42
Case B 60.63 59.38 67.92 56.67 66.46 51.04 77.08 75.00
Case C 54.58 66.67 61.46 67.92 58.54 59.17 75.00 85.42
Case D 53.54 30.21 55.63 31.25 59.79 30.42 72.92 35.42
Case E 56.88 60.83 65.00 59.17 54.17 50.21 81.25 66.67
Case F 63.13 63.75 72.92 72.71 68.54 63.96 89.98 85.42
Mean 58.78 57.22 64.79 58.89 62.95 52.15 80.97 72.22
SD 4.42 13.47 5.87 14.74 6.37 11.85 7.36 19.57
p-value 0.028 0.028 0.463 0.028

202
As seen in Table 2, only 11 out of 64 were selected nor compassion EI was correlated with any of the BMP
as very strong correlations among the BMP variables. variables. There was no significant difference between
Three outcomes were computed in order to understand eustress and compassion EI using Wilcoxon signed-
how mental health wellbeing will have been engaged, rank test (n = 6, p = 0.753). Moreover, concurrent
including eustress EI, compassion EI, and both validity of 4voices app and the BMP significantly
summation into a growth mindset. Regarding the showed very strong relationships: tone of voice and
median of participants, 11.18 for eustress EI; 11.47 for flexible thought (Sr = 0.828, p = 0.042); rhythmic
compassion EI; and 22.15 for growth mindset. Also, voice and empathetic thought & action (Sr = 0.828, p
there was a very strong correlation between eustress = 0.042); positive thinking and flexible thinking (Sr =
EI and growth mindset (Sr = 0.943). Neither eustress 0.926, p = 008).
Table 2: Very strong ‘Spearman’s correlation(Sr)oftheBMP at 95% confidential interval and non-
significant (NS)
BMP Creative Flexible Empathetic Leadership Creative Flexible Empathetic Leadership
thought thought thought thought action action action action
Creative 0.829 0.829 NS NS - NS NS NS
action
Flexible 0.886 NS NS NS NS - NS NS
action
Empathetic NS NS 0.943 0.943 NS NS - NS
Action
Leadership NS NS 0.880 0.941 NS NS 0.880 -
Action
Leadership NS NS 0.886 - NS NS 0.943 0.941
Thought
Discussion BMP resulted in one case that needs to be approached

The BMP has been successfully assessed in the case for mental skills training3since three components
studies positioning as executive managers similar of intrinsic brain capacity and four components of
to the previous classification as an important tool functional brain ability components were below
of occupational therapy.7Significant validation and 60%. In addition to determining cognitive strengths
reliability were demonstrated in two consecutive and weaknesses, the BMP reflects everyone to be
sessions: resting and voice recording. This study has connected by demonstrating a unique set of mental
interestingly gainedpractical solutions of healthy aptitudes concerning below- or above-average verbal
workplace-related intrinsic brain capacity assessment abilities linked into real-world functioning with
with acknowledgment to this CSR in Thailand. practical solutions, e.g., which types of memory to be
Similarly, this BMP used EEG cortical asymmetry for learnable part in hippocampal circuits, how emotion
understanding six brain locations of human empathy, regulation to be trainable part in prefrontal subcortical
which were F3, Fz, F4, C3, Cz, C4. To extend the networks.6, 7, 11, 28
findings, the six participants activatedthe MNM while This current study also gains a lesson learned
recording both EEG signals and 4voices app then only on how to L&D leaders which areagreed to three
one case could maintain empathetic action at the 60% issues of self-determination in academic capability
cut-off score. building14-17, technological tools integrated growth
Consequently, five cases could maintain 1-4 mindset1, 20, and soft skills2, however, those employees
components of intrinsic brain capacity (thought) who are executive managers supported to take
to 1-3 components of functional brain ability risks as well as challenges by thinking laterally
(action),especially for one case with accelerated or and creatively in various settings of social life and
talented BMP. This objective assessment enables human resources development upon an organized,
aninteresting evidence-based practice according to professional context. As an interdisciplinary field
the World Health Organization’s concept of healthy of research of BMP, utilization of neuro-techniques
aging and well-being environment.17However, the could support human resources management
towards a supportive action of personal life balance Funding details

and organizational well-being. From the results, no This work was supported by the Willskills Business
significant correlation was found in compassion EI Co., Ltd.
and any variable, meaning there was no situation to
express emotional empathy composed of compassion Declaration of Interest Statement
to respond to another person’s suffering.28However,
cognitive empathy refers to an individual’s ability The authors declare that the research was conducted
to recognize and comprehend others’emotions, as in the absence of any commercial or financial
shown in the correlation between eustress EI and relationships that could be construed as a potential
growth mindset. conflict of interest.
Interestingly, cognitive empathy is developed to Ethical Clearance

recognize the emotional states of others to process
their own emotions and behaviors28in which the BMP Ethical clearance is not required.
enables an explainable four soft skills processing References
associated with the MNM12, 18, 19resultingfrom thought
1. Ghani A, Kaliappen N, Jermsittiparsert K. Enhancing
(resting state) to action (4voices recording). Finally,
Malaysian SME employee work engagement: the
the new knowledgeable pathway of the MNM mediating role of job crafting in the presence of task
includes multiple relationships of flexible action and complexity, self-efficacy and autonomy. International
creative thought and action. Journal of Innovation, Creativity and Change.
2019;6(11):1-18.
Limitation and Recommendation
2. Moore JR, Maxey EC, Waite AM, Wendover JD.
Although optimization is essentially concerned
Inclusive organizations: developmental reciprocity
withboth motor and mental skills training, however,
through authentic leader-employee relationships.
the soft skills might have been unlocked by exploring Journal of Management Development. 2020.
in depths of our nervous system-related leadership
performance. Implementing the neuroscience 3. Bertollo M, Filho E, Terry PC. Advancements in Mental
assessment tools is innovatively expected to inspire Skills Training: Taylor & Francis; 2020.
all employees for a feeling of accomplishment at their 4. Petrou F, Rammata M. The emerging impact of
learning organizations.3Consequently, three common neuroscience in Human resource management and
factors might affect self-determination related in the public sector. SCIREA Journal of Management.
alignment of mind, brain, and working behavior that 2021.
fluctuating environmental exposure of either positive 5. Marques J. Business With a Conscience: A Research
or negative engagement,and a strong emotional Companion: Taylor & Francis; 2021.
situation linked cognitive distortion or individual
6. Bellone JA, Van Patten R. Becoming a
‘beliefs’bias.4A sample size of data collection will
Neuropsychologist: Advice and Guidance for Students
be further considered in order to reframe the BMP and Trainees: Springer International Publishing; 2021.
optimization according to new normal strategies of
human-centered performance and talent engagement 7. Chatthong W, Khemthong S, Wongsawat Y. Brain
by learning to be more creative, flexible, empathy, Mapping Performance as an Occupational Therapy
Assessment Aid in Attention Deficit Hyperactivity
and leadership1, 2, leading to logical and realistic
Disorder. Am J Occup Ther. 2020;74(2):7402205070p1-
sustainability1.
p7.
Conclusion 8. Chantika M, Kusumawati N. The Influence of
The BMP in the combination of resting and 4Voices Storytelling Approach towards Bandung Citizens’
recording highlights an important principle applied Empathy to Behaviour Intention on Waste Management
in what human-centric autonomy brings stronger Service. 2021.
well-being at work and in which the human resource 9. Chantika M, Kusumawati N, editors. SBM ITB
transformation could have made a collaborative Proceedings. The 6th International Conference on
assessment and accomplishment in conjunction with Management in Emerging Markets (ICMEM 2021);
interdisciplinary evolution of the L & Dleadership. 2021.

204
10. Thanyawatpornkul R. The role of mirror neuron 20. Kuijt A, Alimardani M, editors. Prediction of Human
morality in social awareness of waste management: Empathy based on EEG Cortical Asymmetry. 2020
a case study of empathetic variation. Thailand: Asian IEEE International Conference on Human-Machine
Institute of Technology; 2021. Systems (ICHMS); 2020 7-9 Sept. 2020.
11. Carlson R, Adkins C, Crockett M, Clark M. 21. Ray WJ, Cole HW. EEG activity during cognitive
Psychological selfishness2020. processing: influence of attentional factors. Int J
Psychophysiol. 1985;3(1):43-8.
12. Karimova E, Burkitbaev S, Katermin N. The Mirror
Neuron System and Social Contex 2020. 243-144 p. 22. Veigel B, Sterman MB. Topographic EEG Correlates of
Good and Poor Performance in a Signal Recognition
13. Nardi D. Neuroscience of Personality: Brain Savvy
Task. Proceedings of the Human Factors and
Insights for All Types of People: Radiance House; 2011.
Ergonomics Society Annual Meeting. 1993;37(1):147-
14. Oberman LM, Hubbard EM, McCleery JP, Altschuler 51.
EL, Ramachandran VS, Pineda JA. EEG evidence
23. Berka C, Levendowski DJ, Lumicao MN, Yau A,
for mirror neuron dysfunction in autism spectrum
Davis G, Zivkovic VT, et al. EEG correlates of task
disorders. Brain Res Cogn Brain Res. 2005;24(2):190-8.
engagement and mental workload in vigilance,
15. Paradiso E, Gazzola V, Keysers C. Neural mechanisms learning, and memory tasks. Aviat Space Environ
necessary for empathy-related phenomena across Med. 2007;78(5 Suppl):B231-44.
species. Current Opinion in Neurobiology. 2021;68:107-
24. Hasson G. Positive Thinking: Find Happiness and
15.
Achieve Your Goals Through the Power of Positive
16. Ohreen D. A Critical Review of Mirror Neurons in Thought: Wiley; 2017.
Business Ethics : They Don’t Reflect As Much As You
25. Hasson G. Emotional Intelligence: Managing Emotions
Think. Journal of Applied Ethics and Philosophy.
to Make a Positive Impact on Your Life and Career:
2021;12:8-18.
Wiley; 2019.
17. Ngai CSB, Einwiller S, Singh RG. An exploratory study
26. Hasson G. Mindfulness: Live in the Moment. Enjoy
on content and style as driving factors facilitating
Life to the Full: Rizzoli; 2019.
dialogic communication between corporations and
publics on social media in China. Public Relations 27. Dancey C, Dancey CP, Reidy J. Statistics Without
Review. 2020;46:101813. Maths for Psychology: Pearson Education Limited;
2020.
18. Kim JC, Lee HM. EEG-Based Evidence of Mirror
Neuron Activity from App-Mediated Stroke Patient 28. König A, Graf-Vlachy L, Bundy J, Little LM. A blessing
Observation. Medicina (Kaunas). 2021;57(9). and a curse: How CEOs’ trait empathy affects their
management of organizational crises. Academy of
19. Pope AT, Bogart EH, Bartolome DS. Biocybernetic
Management Review. 2020;45(1):130-53.
system evaluates indices of operator engagement in
automated task. Biol Psychol. 1995;40(1-2):187-95.

Study of Diabetic Peripheral Neuropathy in Adults of Telangana
Reyya Mohan Sundar1, Makandar U.K.2

1
Assistant Professor, Department of Physiology, TRR Institute of Medical Sciences and Hospital, Inole ,Patancheru (Mandal),
Sangareddy (District), Telangana state- 502319 , India
2
Professor, Department of Anatomy,TRR Institute of Medical Sciences and Hospital, Inole ,Patancheru (Mandal), Sangareddy (District),
Telangana state- 502319 , India
How to cite this article: Reyya Mohan Sundar, Makandar U.K. et al Study of Diabetic Peripheral Neuropathy in
Adults of Telangana. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Diabetic peripheral neuropathy (DPN) predisposes to foot ulceration and gangrene. It has been reported that
prevalence of DPN is lower in Indians relative to Caucasians. Studies among recent onset patients with type 2 diabetes
mellitus (Type2-M) are very few. We studied the prevalence and risk factors of DPN in patients with newly diagnosed
Type2DM.
Methods: We prospectively studied 80 consecutive patients over age 30 with a duration of diabetes ≤1 year. Every patient
underwent a clinical and biochemical evaluation and was screened for DPN using TCSS scale (Toronto clinical scoring
system) and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale.
Results: The cases had a mean age of 60.28 years and duration of symptoms of DM is <1year prior to presentation. The
overall prevalence of DPN was 12.5%. The prevalence of DPN showed an increasing trend with FBS (trend chi-square=
3.517, P = 0.0304). A logistic regression analysis showed that DPN was independently associated with Fasting Blood Sugar
(P = 0.0304), Body mass index (P= 0.0389), HbA1c (P = 0.0451), family history (P= 0.0426) and physical activity (P= 0.0219)
but not with age, sex and education.
Conclusions: Our study showed high prevalence of PN in recently diagnosed patients with Type2DM, which was
independently associated with age and duration of symptoms of diabetes prior to the diagnosis. FBS, HbA1c, BMI, were
found to be risk factors for prevalence of Diabetic Neuropathy.
Keywords: Diabetic Peripheral Neuropathy, Newly Diagnosed, Type 2 Diabetes Mellitus, Telengana
Introduction the risk of complications such as foot infections,

India has one of the highest prevalence of type 2 deformities, gangrene, and amputations.[7]In India,
diabetes mellitus (Type2DM) in the world (1). It is the adverse effects of peripheral neuropathy (PN)
estimated that by the year 2030 there are will be nearly are compounded by poor foot hygiene, improper
80 million Indians with Type2DM in the country (2) foot wear, and frequent bare foot walking. In such
(3)
. The disease constitutes a substantial burden for circumstances, complications of foot infections and
both the patient and health care system, mainly due gangrene are a common cause of hospital admissions
to macrovascular and microvascular complications.
(8)
.
[1],[2]
In contrast to patients in industrialized countries, Type2 DM is characterized by a long asymptomatic
Indians with Type2DM have an earlier age at onset of phase (ranging from 4 to 7 years) between the actual
the disease and fewer resources for achieving optimal onset of hyperglycemia and clinical diagnosis
metabolic control, potentially predisposing higher which may explain the relatively high prevalence
prevalence of complications (4). of microvascular complications in newly diagnosed
The prevalence of diabetic peripheral neuropathy patients with Type2 DM? The prevalence of DPN
(DPN) varies greatly in different studies, ranging at diagnosis of Type2DM ranges from 10% to 48%,
from 8% to 59% (5)(6). DPN significantly increases depending upon the population studied and method
used to evaluate neuropathy. In view of the poor
206
awareness and lack of regular screening programs, symptoms like pain, tingling, numbness,
the initial presentation to the physician is frequently weakness, ataxia, upper limb symptoms
delayed. This may predispose to an increased rate as symptom score, knee reflex and ankle
of microvascular complications at onset. Ethnic reflex as reflex score and pin prick,
differences in the prevalence of various diabetes- temperature, light touch, vibration sense,
related complications have also been documented (9). position sense as sensory score were
taken into account. Scoring was based
There is a paucity of reports on DPN in Indians.
on symptoms, reflexes, sensory tests.
In a study comparing European and south Asian
Depending upon the abnormalities, a
subjects with Type state 2DM in United Kingdom;
point of 0 or 1 was given. Score of 0-5=
the prevalence was lower in the latter. However,
no peripheral neuropathy; 6-8= mild
in surveys in Indian patients, the prevalence has
PN; 9-11= moderate PN; 12-19= severe.
ranged from 26% to 31%. In these studies, no controls
The TCSS have been previously been
were studied. Since PN is present in a significant
validated against electro-diagnostic
proportion of healthy individuals, especially among
studies.[10]
the elderly, this fact needs to be taken into account
before ascribing the PN to hyperglycemia. b. Leeds Assessment of Neuropathic
Symptoms and Signs (LANSS) pain scale
Its end-stage complications such as foot ulceration was used to assess the severity and pain
and amputation are associated with substantial health score of the subjects. This pain scale can
care costs, socioeconomic consequences including help to determine whether the nerves that
loss of work time and reduced quality of life.[11] are carrying the pain signals are working
Material and Methods normally or not. Scoring was given.
Total score (maximum 24) If score < 12,
80 (Eighty) Adult patients regularly visiting to
neuropathic mechanisms are unlikely to
TRR Institute of Medical Sciences and Hospital,
be contributing to the patient’s pain and
Inole, Patancheru (Mandal), Sangareddy (District),
If score ≥ 12, neuropathic mechanisms
Telangana state – 502319 were studied.
are likely to be contributing to the
Inclusion Criteria: included age ≥35 years, Patients patient’spain.
willing to co-operate, Patients detected with Type 2 Duration of study was from April 2020 to May 2022
DM recently (within 1 YEAR) and Patients with FBS-
> 120 mg/dl, HbA1c- > 6.5%. Patients diagnosed with Statistical Analysis: Continuous data have been
DM for more than 1 year, expressed as mean ± SD and 95% confidence interval
(CI) were determined for the variables. The Student’s
Exclusion Criteria: Patients with preexisting t-test was used for comparison of continuous
complication like Diabetic foot, Patients with Type variables if found to be normally distributed while
1 DM, Patients with Gestational Diabetes Mellitus, chi-square test was used to compare categorical
patients with acute illness or chronic diseases such variables. Variables associated with PN were
as leprosy, those with disability and patients taking tested using univariate logistic regression analysis.
medications known to impair nerve function were Variables shown to have a significant association
excluded from the study. by this analysis were tested by multivariate logistic
• Screening for peripheral neuropathy and case regression to determine the variables independently
definition of diabetic neuropathy associated with PN. A P value <0.05 was considered
a. Tests were performed in a random significant. Statistical analyses were performed using
sequence among different patients. the SPSS software package (version 15.0; SPSS Inc.,
Patients were screened for DPN using Chicago, IL, USA).
TCSS scale (Toronto clinical scoring
system). This scale was used to assess
for the presence of painful Peripheral
Neuropathy. In short, for TCSS,

Observation and Results: Discussion

Table No: 1 – Anthropometric Measurement details The patients newly detected with DM belonged to
age group above 30. HbA1c % of most of the patients
A- Age – 16 (40%) Males and 12 (30%) females
on recruitment was above 10%. FBS levels of most
were below 60 years and 24 (60%) males and
patients were less than 200 mg/dl. PLBS of most of the
28 (70%) females were 60 years.
patients was seen to be higher than 250 mg/dl. RBS of
B- H bA1c- 8 (20%) males and 14 (35 %) females most of the patients was seen to be above 180mg/dl.
had less than 10 % HbA1c value. 32 (80%)
We detected a high frequency of DPN in newly
males 26 and 26 (65%) females had more than
diagnosed patients with Type-2 DM. DPN was
10% Hba1c value.
independently associated with increasing age and
C- FBS (mg/dl) – 24 (60%) males and 22 (55%) duration of symptoms of diabetes prior to diagnosis.
females had less than 200 MG/dl FBS was In various Caucasian populations, the prevalence of
observed but in 16 (40%) males and 18 (45%) DPN in newly diagnosed Type-2 DM varies widely
females had more than 200 mg /dl FBS. from 10% to 48%. This may be due to different
P-value was 0.030, and chi-square value 3.517. methodologies employed for detection of neuropathy
D- PLBS (mg/dl) -16 (40%) males and 12 (30%) as well as variability inpatient ages and time lapsed
females had less than 250 mg/dl value. In 24 before diagnosis. However, ethnic differences in
(60%) males and 28 (70%) females more than DPN may also be relevant (12). Interestingly, it has
250 mg/dl PLBS value. been previously reported that both DPN and foot
ulcers are lower in Indians compared with European
E- RBS (mg/dl) – in 6 (15%) males , 10 (25%)
Caucasians.
females had less than 180 mg/dl RBS but in
34 (85%) males , and 30 (75%) females had In the current study, Prevalence of Diabetic
more than 180 mg/dl RBS in (mg/dl) values. Neuropathy is 30%. Two earlier studies in Indians
have reported on the prevalence of DPN in newly
Table No : 2 – Statistical analysis in Diabetic
Neuropathy Patients diagnosed TYPE- 2 DM of 19.5% and 29.0%. In the
latter study, the prevalence of DPN was measured by
A- Age- Complications were Observed in 9 NSS and NDS in 100 newly diagnosed TYPE-2 DM
Patients were between 40 - 60 years and (13)
. In a community-based study from Chennai, south
complications were also observed in 15 India, it was measured the prevalence of DPN using
patients above 60 years value was 0.4796 and VPT by biothesiometer. The prevalence in newly
Chi-square value was 0.003. diagnosed patients was 19.5% and 27.8% in those
B- Sex – In males 14 had complications in females with known diabetes (14). However, the frequency of
10 had complications the P-value was 0.1646, DPN in the subjects without diabetes was not studied.
Chi square value was 0.952. Prevalence of mild neuropathy was found to be
C- FBS (mg/dl) 10 complicated patients had 15%, moderate Neuropathy was found to be 8.75%
less than 200 FBS and 14 patients with and severe Neuropathy was found to be 6.25% based
complications had more than 200 FBS. on the TCSS and LANSS criteria. High FBS (>200mg/
dl), HbA1c (>10%), BMI (>30 kg/m2), were found to
D- HbA1c – Three Complicated patients had
be risk factors for prevalence of Diabetic Neuropathy
HbA1c ratio was between 6.5 – 10, 21 patients
(Table -1).
with complications had more than 10 HbA1c
P-value was 0.0451 ,Chi-square was 2.869. Since PN is found in a proportion of healthy
individuals, especially in the elderly, comparison
E- BMI ( Kg/M2 ) – in 5 patients with complications
with a matched control group is essential. We noted
and less than 30 BMI in 19 patients with
PN in 30% of age-and sex-matched control subjects,
complications had more than 30 BMI . P-value
which increased with advancing age. This fact should
was 0.0389 , Chi-square value was 3.111.
be taken into account when assessing PN in patients
F- Family History – Total 17 patients with with diabetes.
complications had family history P-value was
0.04 – 6, Chi- square value was 2.963. Monofilament sensation is a measure of protective
sensations in the foot and is strongly associated with
208
risk of foot ulceration (15). The prevalence of impaired examination is cost-effective means to prevent foot
monofilament sensation was 6%, considerably ulceration and infections in Indian patients with Type
lower than that of DPN. This low frequency may be 2 DM. The present study demands further Patho-
reflective of the fact that the10-g (5.07) monofilament physiological, Nutritional and genetic study because
testing is appropriate for the clinical assessment of exact pathogenesis of DPN is still unclear.
risk for foot ulceration (16), but not a sensitive means to
detect prevalence of neuropathy. In the latter case, a Limitation of study
monofilament of 1g or less may be more appropriate. Due to Tertiary location of Studied Centre and Small
number of patients and lack of latest Technologies,
Previous studies have identified several risk
We have limited findings and results
factors for DPN such as age, poor glycemic control,
increasing duration of diabetes, gender, height, body - The present research work is Approved
mass index, retinopathy, hypertension, smoking, and by Ethical committee of TRRIMS Inole,
alcohol consumption (17). In the current study, FBS, Patancheru ( Mandal ), Sangareddy (district),
HbA1c, BMI, family history and physical activity Telangana state – 502319.
were significant risk factors for Diabetic Peripheral - No Conflict of Interest
Neuropathy. The prevalence of DPN showed an
- No Funding
increasing trend with FBS (trend chi-square= 3.517,
P = 0.0304). A logistic regression analysis showed Table 1: Anthropometric Measurement Details
that DPN was in dependently associated with PARAMETER MALES FEMALES
Fasting Blood Sugar (P = 0.0304), Body mass index
(N =40) (N = 40)
(P= 0.0389), HbA1c (P = 0.0451), family history (P=
0.0426) and physical activity (P= 0.0219) (Table 2). AGE < 60 years 16 (40 %) 12 (30 %)
Since elderly patients have other risk factors for foot > 60 years 24 (60 %) 28 (70 %)
ulcerations, such as vision abnormalities and vascular HbA1C < 10 % 8 (20 %) 14 (35 %)
involvement, neuropathy screening assumes an even (%) > 10 % 32 (80 %) 26 (65 %)
greater importance in this age group.
FBS (mg/ < 200 mg/dl 24 (60 %) 22 (55 %)
The use of both qualitative and quantitative mode dl) > 200 mg/dl 16 (40 %) 18 (45 %)
of assessment of neuropathy was performed. It has a
few limitations; it was clinic based and may not reflect PLBS < 250 mg/dl 16 (40 %) 12 (30 %)
the actual prevalence of DPN in the community. We (mg/dl) > 250 mg/dl 24 (60 %) 28 (70%)
did not investigate metabolic causes of PN other than RBS (mg/ < 180 mg/dl 6 (15 %) 10 (25 %)
diabetes. dl) > 180 mg/dl 34 (85 %) 30 (75 %)
Summary and Conclusion HbA1c : Haemoglobin Adult Glycosylated
In summary, we detected a high prevalence of PN
FBS : Fasting Blood sugar
in recently diagnosed patients with Type 2 DM. The
neuropathy was independently associated with age PLBS : Post Lunch Blood sugar
and duration of symptoms of diabetes prior to the
RBS : Random blood sugar
diagnosis. Screening for DPN using simple clinical
Table 2: Statastical Values In Case of Diabetic Neuropathy

RISK FACTOR COMPLICATION P-VALUE CHI-SQUARE
YES NO VALUE
AGE (years) 40-60 9 19 0.4796 0.003
> 60 15 37
SEX MALE 14 26 0.1646 0.952
FEMALE 10 30
FBS < 200 10 36 0.0304 3.517
(mg/dl) > 200 14 20

RISK FACTOR COMPLICATION P-VALUE CHI-SQUARE

YES NO VALUE
HbA1c (%) 6.5 – 10 3 19 0.0451 2.869
> 10 21 37
BMI Kg/m2 ≤ 30 5 25 0.0389 3.111
> 30 19 31
FAMILY PRESENT 17 28 0.0426 2.963
HISTORY
References 10. Shaw JE, Hodge AM, de Courten M, Dowse GK,

1. Ramachandran A, Ramachandran S, Snehalatha C, Gareeboo H, Tuomilehto J, et al. Diabetic neuropathy
Augustine C, Murugesan N, Viswanathan V, et al. in Mauritius: Prevalence and risk factors. Diabetes Res
Increasing expenditure on health care incurred by Clin Pract, 1998; 42:131-9.
diabetic subjects in a developing country: A study
11. Deli G, Bosnyak E, Pusch G, Komoly S, Feher G.
from India. Diabetes Care, 2007; 30:252-6.
Diabetic Neuropathies: Diagnosis and Management.
2. ZargarAH,WaniAI,MasoodiSR,LawayBA,BashirMI. Neuroendocrinology, 2013; 98:267-80.
Mortalityindiabetesmellitus- data from a developing
12. Armstrong DG, Lavery LA, Harkless LB. Validation
region of the world. Diabetes Res Clin Pract, 1999; 43:
of a diabetic wound classification system. The
67-74.
contribution of depth, infection, and ischemia to risk
3. Wild S, Roglic G, Green A, Sicree R, King H. Global of amputation. Diabetes Care, 1998; 21:855-9
prevalence of diabetes: Estimates for the year 2000 and
13. Vijay V, Snehalatha C, Ramachandran A. Socio
projections for 2030. Diabetes Care., 2004; 27:1047-53.
cultural practices that may affect the development of
4. Boddula R, Yadav S, Bhatia V, Genitta G, Pandey D, the diabetic foot. IDF Bulletin, 1997; 42:10-2.
Kumar A, et al. High prevalence of type 2 diabetes
14. Harris MI, Klein R, Welborn TA, Knuiman MW.
mellitus in affluent urban Indians. Diabetes Res Clin
Onset of NIDDM occurs at least 4-7 yr before clinical
Pract, 2008; 81: e4-7
diagnosis. Diabetes Care, 1992; 15:815-9.
5. WHO expert consultation. Appropriate body-mass
15. Ratzmann KP, Raschke M, Gander I, Schimke E.
index for Asian populations and its implications
Prevalence of peripheral and autonomic neuropathy
for policy and intervention strategies. Lancet, 2004;
in newly diagnosed type II (noninsulin-dependent)
363:157-63.
diabetes. J Diabet Complications, 1991; 5:1-5.
6. Snehalatha C, Viswanathan V, Ramachandran A.
16. Weerasuriya N, Siribaddana S, Dissanayake A,
Cutoff values for normal anthropometric variables in
Subasinghe Z, Wariyapola D, Fernando DJ. Long-term
Asian Indian adults. Diabetes Care, 2003; 26:1380-4.
complications in newly diagnosed Sri Lankan patients
7. Young MJ, Boulton AJ, MacLeod AF, Williams DR, with type 2 diabetes mellitus. QJM, 1998; 91:439-43.
Sonksen PH. A multicentre study of the prevalence of
17. Spijkerman AM, Dekker JM, Nijpels G, Adriaanse
diabetic peripheral neuropathy in the United Kingdom
MC, Kostense PJ, Ruwaard D, et al. Microvascular
hospital clinic population. Diabetologia, 1993; 36: 150-
complications at time of diagnosis of type 2 diabetes
4.
are similar among
8. Partanen J, Niskanen L, Lehtinen J, Mervaala E,
Siitonen O, Uusitupa M. Natural history of peripheral
neuropathy in patients with non-insulin-dependent
diabetes mellitus. N Engl J Med., 1995; 333:89-94.
9. Dyck PJ, Kratz KM, Karnes JL, Litchy WJ, Klein R,

Pach JM, et al. The prevalence by staged severity of
various types of diabetic neuropathy, retinopathy,
and nephropathy in a population-based cohort: The
Rochester Diabetic Neuropathy Study. Neurology,
1993; 43: 817-4.

Original article Indian Journal of Public Health Research & Development
Study of Evaluation of Maternal Side Effects and Neonatal Outcome after

Treatment with Nifedipine at Tertiary Care Hospital
Ruchita Vajpai1, Swati Gagare2, Prashant Kharde3

1,2
Assistant Professor, Department of OBGY, DBVP Rural Medical College , Pravara Institute of Medical sciences (DU), Loni
3
Professor, Department of OBGY, DBVP Rural Medical College, Pravara Institute of Medical sciences (DU), Loni
How to cite this article: Ruchita Vajpai, Prashant Kharde et al Study of Evaluation of Maternal Side Effects and
Neonatal Outcome after Treatment with Nifedipine at Tertiary Care Hospital. Volume 13 | Issue 4 |
Abstract
Introduction: Compared to beta- agonists, nifedipine is associated with improvement in neonatal outcome. Nifedipine is
significantly more successful in prolonging pregnancy beyond 48 hours and effective in delaying upto 7 days.
Methodology: The present study was conducted in the department of obstetrics and gynaecology of Rural Medical
College , Loni, The present work comprises of 135 cases between 28 to 37 weeks of gestational age having premature
labour pains that were admitted in antenatal ward or labour room.
Results: Distribution of cases according to NICU admission of preterm baby. For observation total 9 cases were kept in
NICU, 3 cases were admitted in NICU for jaundice, at 1 was admitted for birth asphyxia.
Conclusion: This study on tocolytic effect of nifedipine in preterm labour shows, nifedipine has good tocolytic action on
arresting preterm labour with minimal side effects.
Keywords: Preterm labour, neonatal morbidity, nifedipine
Introduction compared with any other tocolytic agent (mainly

Compared to beta- agonists, nifedipine is associated beta-mimetic), calcium channel blockers (mainly
with improvement in neonatal outcome. Nifedipine nifedipine) reduce the risk of delivery within 7 days
is significantly more successful in prolonging of initiation of treatment and delivery before 34 weeks
pregnancy beyond 48 hours and effective in delaying of gestation with improvement in some clinically
upto 7 days. Recent studies have suggested that important neonatal outcomes such as respiratory
calcium channel blockers specifically nifedipine is distress syndrome, intraventricular heamorrhage,
considered relatively safe for use in pregnancy.1,2 necrotizing enterocolitis and neonatal jaundice. 4, 5 A
study on tocolysis and preterm labour showec that
Some authors have proposed that nifedipine, there appears to be a place for short-term tocolysis to
could be used as first line tocolyic agent. The most gain time so that corticosteroids can be administered
recent substantial update of the Conchrane review to enhance fetal lung maturation and reviewed the
regarding calcium channel blockers for acute effectiveness and complications of different tocolytic
tocolysis in preterm labour included 12 randomised agents. The rationale of this study is to demonstrate
control trials (10 using nifedipine) involving the efficacy and safety of nifedipine as a tocolytic
1029 patients.3 This review concluded that, when agent in preterm labour.6,7, 8
Swati Gagare
Assistant Professor,
Department of OBGY, DBVP Rural Medical College , Pravara Institute of Medical sciences (DU), Loni
Material and methods Table 2: Distribution of Cases as Per Preterm/Term

Delivery.
The present study was conducted in the department
of obstetrics and gynaecology of Rural Medical Frequency Percent
College, Loni, The present work comprises of 135 late preterm 17 12.6
cases between 28 to 37 weeks of gestational age
preterm 26 19.3
having premature labour pains that were admitted
in antenatal ward or labour room. The study was term 92 68.1
approved by the IEC . The sample size was estimated Total 135 100.0
with the help of expert using online sample size
estimation calculator. Table 3: Distribution of Cases As Per Apgar Score
Frequency Percent
Inclusion criteria:
APGAR 1 min
• Gestational age between 28weeks to 37 weeks
6 15 11.1
• Presence of regular uterine contractions 4 in
20 minutes or 8 in period of one hour 7 120 88.9
• Cervical dilatation > 1 cm Mean ± SD 6.88±0.31
• Primigravida as well as multigravida APGAR 5 min

• Exclusion criteria: 8 20 14.8
• Systemic diseases like diabetes mellitus, 9 115 85.2
cardiac disease, liver or renal disease, Mean ± SD 8.85±0.35
hypotension
The above table shows distribution of cases
• Obstetric complication like hypertensive
according to APGAR at 5 min and 10 minutes.
disorder of pregnancy, antepartum
haemorrhage, PROM Table 4: Distribution Of Cases As Per Nicu
Admission Of Newborn
• Multifetal gestation
• Foetal complications like chorioamnionitis, Frequency Percent
congenital malformations, IUGR, fetal birth asphyxia 1 0.7
distress, intrauterine death. Jaundice 3 2.2
Pregnant women presenting with preterm labour No 122 90.4
and those fulfilling inclusion and exclusion criteria Observation 9 6.6
will be admitted. A detailed history, complete physical Total 135 100.0
examination and routine investigations, obstetric The above table shows distribution of cases
ultrasound will be done for all patients. All women according to NICU admission of preterm baby.
will be screened for urinary tract infections/bacterial For observation total 9 cases were kept in NICU,
vaginosis with mid-stream clean catch urine sample 3 cases were admitted in NICU for jaundice, at 1 was
& a high vaginal swab respectively and antibiotic admitted for birth asphyxia.
treatment will be instituted.
Discussion
Results Babies born preterm have an increased risk of
Table 1: Distribution of Cases as Per Nicu morbidity , some are directly related to immaturity,
Admission of Newborn as with hyaline membrane disease due to lack of
Frequency Percent pulmonary surfactant, and retinopathy of prematurity
birth asphyxia 1 0.7 due to the excessive use of oxygen. Preterm birth
Jaundice 3 2.2 may also be a marker for other problems that
No 122 90.4 produce disease such as fetal infections and systemic
Observation 9 6.6 inflammation, which are associated with intracranial
Total 135 100.0 hemorrhage, cerebral palsy, cerebral white matter

212
damage, and chronic lung disease which include 3. Mari G, Kirshon B, Moise KJ, Lee W, Cotton DB.
bronchopulmonary dysplasia9. Doppler assessment of the fetal and uteroplacental
circulation during nifedipine therapy for preterm
In present study, side effects noted are distributed labor. Am J Obstet Gynecol 1989; 161:
as, 3 % had headache, 20.3% had hypotension and 18 %
4. Murray C, Haverkamp AD, Orleans M, Berga S, Pecht
had tachycardia, while 3% nausea, Similarly the study
D. Nifedipine for treatment of preterm labor: a historic
conducted by Gulati A10 depicted 4 % had headache,
prospective study. Am J Obstet Gynecoll992; 167: 52-
24 % had hypotension, 76 % had tachycardia, and 4%
56.
had nausea, and 4 % flushing.
5. Prevost RR, Pharm D, Sherif A, Whybrew DW, Sibai
In present study 17.8% of the cases had birth weight BM. Oral nifedipine: pharmacokinetics in pregnancy
between 1 kg to 2 kg, while 82.2 % had between 2 kg induced hypertension. Phannacotherapy 1992; 12: 174-
to 3 kg. 177.
Similarly in study conducted by Dhawle et el 151 6. Lawn E Joy et al. Global Report on preterm birth and
60.5 % had birth weight upto 2.5 kg. In our study, stillbirth (1of 7): definitions, description of the burden
0.7 % had birth asphyxia, 2.2 % had jaundice and and oppurtunities to improve data. BMC Pregnancy
6.6 % were admitted in NICU for observation. In and Childbirth 2010, 10 (suppl1):S1
study conducted by Dhawle et al 11 11. 6 % had birth 7. Tocolysis for women in preterm labor: Royal College of
asphyxia, 48.8 % had neonatal jaundice and 11.6 % Obstetrics and Gynecologists. Green –top Guidelines
were admitted in NICU care. No. 1b: February 2011.
In present study, 99.3 % vaginal delivery followed 8. Miller He, Hassanein K. Maternal factors in the
by 0.7% with LSCS, as obstetric complications in like incidence of low birth weight infants among black and
pre-eclampsia, heart disease, PROM are in exclusion white mothers. Pediatr Res 1978; 12; 1016.
criteria, which resulted in less number of cesarean 9. Aruna Kumar, Bharadwaj B, Pawar Namita.
section. In study conducted by Hangekar, mode of Glyceryltrinitrate patch in management of preterm
delivery only 2 cases (5.26%) underwent cesarean labour. J Obstet Gynecol India 2001:51(6):55-57.
section whereas rest delivered vaginally.12,13
10. Goffinet F. Primary predictors of preterm labour. Br J
Conclusion: This study on tocolytic effect of Obstet Gynecol 2005;112:48-50
nifedipine in preterm labour shows, nifedipine has 11. Yarlagadda S et al.Int J Reprod Contracept Obstet
good tocolytic action on arresting preterm labour Gynecol. 2018 Jun;7(6):2174-2179
with minimal side effects.
12. Smith GN, Walker MC, Mc Grath MJ. Randomised,
double-blind placebo controlled pilot study assessing
Ethical clearance:
Nitroglycerine as a tocolytic. Br J Obstet Gynecol. 1999;
For present study ethical clearance was obtained from 106:736-739.
our IEC , Pravara Institute of Medical Sciences (DU) 13. Dawle A et al. Int J Reprod Contracept Obstet Gynecol.
Loni . 2013 Mar;2 (1):61-66
Source of support: Nil
References
1. Lurie S, Fenakel K, Friedman A. Effect of nifedipine on
fetal heart rate in the treatment of severe pregnancy-
induced hypertension. Am JPerinatol 1990; 7: 285-286.
2. Visser W, Wallenburg HCS. A comparison between

the haemodynamic effects of oral nifedipine and IVI
dihydrazine in patients with severe pre-eclampsia. J
Hypertens 1995; 13: 791-795.

Fungal Infections of Paranasal Sinuses: Sequelae to 2020 Pandemic
S. Pavani1, Syeda Touseef Banu2, Grace3, Jyothi Lakshmi4, P. Shashikala Reddy5

1
Associate professor, Department of Microbiology, Osmania medical college, Koti, Hyderabad
2
Final yr Pg, Department of Microbiology, Osmania medical college, Koti, hyderabad
3
Second yr Pg, Department of Microbiology, Osmania medical college, Koti, hyderabad
4
Professor, Department of Microbiology, Osmania medical college, Koti, hyderabad
5
Professor & Principal, Department of Microbiology, Osmania medical college, Koti, Hyderabad
How to cite this article: S. Pavani, Syeda Touseef Banu, Grace, Jyothi Lakshmi, P. Shashikala Reddy et al Fungal
Infections of Paranasal Sinuses: Sequelae to 2020 Pandemic. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: In recent decades, the prevalence of fungal sinus infection has increased. It’s plausible that this is related to
increased awareness, antibiotic usage, and the use of immunosuppressive drugs. Furthermore, much has been written on
the involvement of fungus as a causative organism.
Objectives: To identify fungal pathogens and correlate laboratory findings with clinical findings.
Materials and Methods: Patients with AIFR following recent COVID-19 infection were included. After performing
potassium hydroxide (KOH) wet mounts, post-operative material was collected and cultured on two tubes of Sabouraud
dextrose agar (SDA) and stored at 250 C and 370C for isolation and identification.
Results: Out of 329 diabetic individuals with AIFS following COVID-19 infection, 51% exhibited mucopurulent discharge
and 75.6 % had unilateral involvement. Only 57.4% of KOH mount samples were positive for fungal components, however
76.3% of SDA samples exhibited positive growth, with 62 % Mucorales, 8% Aspergillus, and 6 % Candida species.
Conclusion: Mucor mycosis can develop in COVID-19 patients, particularly those with diabetes, a high and imprudent
use of corticosteroids, and invasive ventilation. KOH test resulted in a preliminary diagnosis, whereas Culture remains
the gold standard for identification.
Keywords: Invasive fungal sinusitis, Mucor mycosis, COVID-19, Diabetes mellitus
Introduction known as Mucor mycosis infection, is caused due to

The severe acute respiratory syndrome coronavirus-2 decreased CD4+ and CD8+ lymphocytes associated
(SARS-CoV-2) induced coronavirus illness with uncontrolled diabetes, immunosuppression,
(COVID-19) was originally detected in Wuhan, acquired immunodeficiency syndrome (AIDS),
China. Until now, there has been no full research and underlying malignancies. Patients in critical
on COVID-19 sequelae.1 The COVID-19 pandemic care for influenza and respiratory virus infections,
has been associated with otorhinolaryngological particularly Covid-pneumonia, have been shown to
symptoms such as anosmia in the early stages to have a higher risk of acquiring invasive pulmonary
late-stage mucor mycosis presenting as invasive fungal infections, most likely due to their reduced
fungal sinusitis.2 The hyphal invasion and symptoms immunological competence.4
take around 4 weeks to appear and be detected. In recent decades, the prevalence of fungal sinus
Invasive fungal diseases are infections that can be infection has increased. This might be related
fatal in immunocompromised persons.3 They are also to antibiotic and immunosuppressant drug abuse.
Dr. Syeda Touseef banu, Final yr Pg, Osmania medical college, Koti, hyderabad
214
Furthermore, the involvement of fungus as a causative days. If colony growth happened within 5 days,
organism in chronic rhinosinusitis is well established.5 the morphology of the colony was observed. For
morphological identification, the fungal growth was
In moderate to severe cases with decompensated stained with Lactophenol cotton blue (LCB). Safety
pulmonary functions and the use of precautions were used throughout the collecting
immunosuppressive medicine for management and processing of materials. Gloves, N95, surgical
increase disease severity. Without early identification mask, plastic apron, and PPE Kit were provided to
and treatment, the condition may progress rapidly, operating employees. Before and after the procedure,
with reported fatality rates of 50 to 80 % due to intra- the work station was thoroughly disinfected with
orbital and cerebral complications.6 Despite prompt glutaraldehyde.
treatment, mortality rates were steadily rising due to
the disease’s rapid progression. Statistical Analysis: The SPSS 22 software was used
for statistical analysis. The outcomes was presented in
Materials and Methods the form of means and percentages.
Study Design: Prospective Cross sectional study
Observation and Results
Study Setting: Government ENT Hospital, Koti, Table 1: Distribution based on Gender and Side of
Hyderabad involvement
Study Duration: November 2021 to March 2022 Gender Frequency Percentage
Sample size: 329 patients Male 260 79%
Female 69 21%
Three-month research was undertaken on 329
individuals who had clinical signs of fungal infections Side of
after recovering from COVID 19 infection. involvement
Unilateral 251 76%
Inclusion Criteria Bilateral 78 24%
1. Patients with fungal sinusitis who have been Clinical
admitted to the hospital for treatment. features
2. Diabetes mellitus patients Mucopurulent
168 51%
discharge
3. Patients with suspected fungal sinusitis.
Nasal
106 32%
Obstruction
Exclusion Criteria
Facial puffiness 70 21%
1. Vaccinated against Covid-19.
Headache 65 20%
2. Patients who have had no present or previous Facial pain 52 16%
Covid-19 infection.
Polypoid
3. Patients who are not diabetic. 46 14%
disease
4. Patients unwilling to provide consent. Postnasal
33 10%
discharge
A comprehensive history was gathered from
individuals who had a clinical suspicion of paranasal 329 diabetic individuals with COVID-19 infection
sinus fungal infection. Material was collected in presented with AIFS (acute invasive fungal
sterile normal saline and sterile screw-capped and rhinosinusitis) — all of them had had COVID-19
leak-proof universal containers after surgery (small infection therapy during the previous 10 days. Males
or large surgical intervention). All samples were first predominated in the presenting pattern, with a mean
inspected microscopically using potassium hydroxide age of 49 years.
(KOH) wet mounts, then cultured on two tubes of
A total of 53.1% (175) of 329 diabetic individuals
Sabouraud dextrose agar (SDA) and maintained
with acute invasive fungal sinusitis got steroids,
at temperatures of 25°C and 37°C, respectively.
whereas 46.8% (154) did not. In our study, we
The culture slants were incubated for 48 hours and
observed that 38% (125) of individuals who got
then monitored for growth every day for up to 5
steroids required oxygen assistance, whereas 15%

(50) did not. The use of a ventilator was required by 10% KOH mount examination was negative for
3% of those on steroids (ten). Patients who did not get fungal elements in 140 (42.5%) samples of patients
steroids were administered oxygen assistance in 30.3
Table 4: culture and morphological identification
% (100), 16.4 % (54) did not require oxygen, and 0.6 by LPCB
% (2) were intubated. Mucopurulent discharge with
black particles (51 %), nasal obstruction (32 %), facial Culture and Number
puffiness (21 %), headache (20 %), facial discomfort (16 morphological of
Percentage
%), polypoid illness (14 %), and post nasal discharge identification by samples
LPCB (n=251)
(10 %) were the most prevalent symptoms. Black
staining and eschar development had occurred in Mucorales 156 62%
44% of the people. 75.6 % had unilateral involvement, Aspergillus Sp 20 8%
whereas 24% had bilateral involvement. Candida Sp 16 6%
Orbital complications occurred in 23 patients (7%), No growth 59 24%
the symptoms being, swelling of eye (3.34%), watering Out of 329 samples, 251 (76.3%) showed fungal
from eye (1.8%), ptosis (0.9%), pain in involved eye growth on SDA with LPCB showing 62% Mucorales,
(0.9%), orbital exenterating in 2 patients (0.6%) and 8% Aspergillus species, 6% Candida species.
blurring of vision in 1 patient. Palatal complication
observed in 8 patients (2.4%), the symptoms such as Table 5: Distribution based on various methods
used
tooth ache (1.2%), swelling on hard palate (0.6%) and
erosion of hard palate (0.3%). Methods Number of Percentage
samples
Table 2: Percentage of samples identified in 10%
KOH mount and fungal culture Both KOH and culture
140 42.5 %
positive
Samples Positive Negative
KOH positive and
identified with 49 14.9%
culture negative
method
KOH negative and
10% KOH 57.40% 42.50% 111 33.7%
culture positive
Fungal Culture 76.20% 23.70% Both KOH and culture
29 8.8%
In 10% KOH, 57.40% of the samples were positive negative
and with fungal culture 76.20% were positive. In 78 (23.7%) there was no fungal growth on SDA.
Table 3: Findings on KOH mount examination In this study, both KOH and Culture were positive in
140 patients (42.5%) while KOH negative and culture
KOH mount positive in 111 (33.7%), KOH positive and Culture
findings negative in 49 (14.9%) and both were negative in 29
Ribbon Shaped (8.8%).
hyphae; broad,
aseptate and
89 47.00% Discussion
hyaline Covid-19 infection, which is caused by the new
SARS-CoV-2, has been associated with broad array
Septate hyphae
with branching at 13 7.00% of symptoms, ranging from moderate cough to life-
acute angle threatening pneumonia.6 As we understand more
about this novel disease, a plethora of symptoms and
Budding yeast cells 7 4.00%
complications have been documented, and new ones
No fungal elements 80 42.50% are emerging and being reported almost every day.7
Mucor mycosis is a fungus infection of the Mucorales
In 189 samples (57.4%) of which 47% showed
family that affects diabetics with impaired immune
ribbon shaped hyaline, broad aseptate and hyaline;
systems. The most prevalent symptom is rhino orbital
7% septate hyphae with branching at acute angles; 4%
infection, which is a rare ailment.8 In 2019, few cases
showed budding yeast cells.
of Mucor mycosis were reported.9 The significant
increase in Mucor mycosis cases during COVID-19’s

216
second wave implies a strong correlation between References

COVID-19 and Mucor mycosis.10 1. Andersen KG, Rambaut A, Lipkin WI, Holmes EC,
Patients who require critical care due to Covid-19 Garry RF. The proximal origin of SARS-CoV-2. Nat
pneumonia have risk factors and underlying Med. 2020 Apr;26(4):450-452
conditions that make them susceptible to invasive 2. Tan BH, Chakrabarti A, Patel A, Clinicians’ challenges
fungal infections. A prominent predisposing in managing patients with invasive fungal diseases in
condition for acute invasive fungal rhinosinusitis is seven Asian countries: an Asia Fungal Working Group
uncontrolled diabetes mellitus, particularly diabetic (AFWG) survey. Int J Infect Dis. 2020; 95: 471-480
ketoacidosis. 3. Ferguson BJ Definitions of fungal rhinosinusitis
Song et al. studied the correlation between Covid-19 Otolaryngol Clin North Am 2000 33 227–35
and invasive fungal sinusitis, reporting that a high 4. Brunet K, Rammaert B. Mucormycosis treatment:
number of individuals who have been exposed to Recommendations, latest advances, and perspectives.
Covid-19 or have recovered from it are at an elevated J Mycol Med. 2020 Sep;30(3):101007.
risk of acquiring invasive fungal infections.11 5. Cornely OA, Alastruey-Izquierdo A, Arenz D, Chen
Uncontrolled diabetes and abuse of steroids are two SCA, Dannaoui E, Hochhegger B, Hoenigl M. et al.
of the most common causes of disease aggravation, Global guideline for the diagnosis and management
of mucormycosis: an initiative of the European
and both must be addressed. If infected, seek surgical
Confederation of Medical Mycology in cooperation
intervention and intravenous antifungal therapy as
with the Mycoses Study Group Education and Research
soon as possible, as post-coronavirus fungal infection Consortium. Lancet Infect Dis. 2019;19(12):e405–e421
can have a favorable prognosis and a less fulminant
disease course. 6. Sarkar S, Gokhale T, Choudhury SS, Deb AK. COVID-19
and orbital mucormycosis. Indian J Ophthalmol. 2021
Conclusion Apr;69(4):1002-1004.
Mucor mycosis can arise in COVID-19 patients, 7. Alekseyev K, Didenko L, Chaudhry B. Rhinocerebral
particularly those with diabetes, an increased and Mucormycosis and COVID-19 Pneumonia. J Med
imprudent use of corticosteroids, and invasive Cases. 2021 Mar;12(3):85-89.
ventilation. Mucor mycosis should be suspected 8. Reid G, Lynch JP 3rd, Fishbein MC, Clark NM.
in diabetic patients who have had COVID. KOH- Mucormycosis. Semin Respir Crit Care Med. 2020
examination resulted in a preliminary diagnosis and Feb;41(1):99-114
helped define surgical margins for an invasive fungal
9. Schell WA. Unusual fungal pathogens in fungal
infection. During the pandemic, early identification
rhinosinusitis. Otolaryngol Clin North Am. 2000
of fungal etiological agents using culture and LPCB Apr;33(2):367-73.
benefited in prompt Mucor mycosis treatment.
10. Prakash H, Chakrabarti A. Global Epidemiology of
Ethical Clearance: Ethical Clearance was obtained Mucormycosis. J Fungi (Basel). 2019 Mar 21;5(1):26.
from the institutional ethics committee prior to the
11. Song G, Liang G, Liu W. Fungal co-infections associated
commencement of the study.
with global COVID-19 pandemic: a clinical and
Conflict of Interest: Nil diagnostic perspective from China. Mycopathologia
2020;185:599–606

Study of the Future of those Recovered from COVID-19 from Treatment

centers in Guinea from March 2020 to January 2021
S. Sow,1, 2 F.B. Diakité,1 I. Diallo,1 C. T. Sidibe,1 A. B. Diallo3,

M. C. Tshikolasoni1, M.O. Balde1
1
Organisation Mondiale de la Santé, Bureau OMS Guinée, 2Faculté des Science et Technique de la santé, Chaire de santé publique,
Université Gamal Abdel Nasser de Conakry.
3
Organisation Mondiale de la Santé, Bureau de Dakar, 4Organisation Mondiale de la Santé, Bureau AFRO.
How to cite this article: S. Sow, F.B. Diakité, I. Diallo, C. T. Sidibe, A. B. Diallo, M. C. Tshikolasoni, M.O. Balde
et al Study of the Future of those Recovered from COVID-19 from Treatment centers in Guinea from March 2020
to January 2021. Volume 13 | Issue 4 | October-December 2022
Abstract
SARS-CoV-2 appeared in December 2019 in Wuhan, China. The Guinean Government has taken important measures
since the notification of the first case on March 12, 2020, in particular the follow-up of the recovered. The objective of this
study was to describe the health and socio-economic problems faced by those who recovered from COVID-19 in Guinea.
This was a descriptive cross-sectional study by simple random sampling in the five communes of Conakry and the regions
of Kindia, Labé, and Kankan. Up to 330 COVID-19 survivors responded to the survey, 99% of whom were from the urban
area. The male gender represented 70.3%, and the 19-38 age group was the most represented (61.82%). Pupils, students/
teachers, health personnel, and academics respectively represented 10.91%, 17.58%, and 62.73%. In this study, 70% were
married against 28.18% single, and 8.79% moved after leaving the CTEPI. There is a statically significant link between
stigma and job loss with a p-value of 0.002. Stigma was strongly associated with community residence, change in income,
and post Covid-19 stress (P <0.05). The cured people who live in the communes of Ratoma, Matam, and Matoto are more
in the process of being stigmatized than the others, with respectively 27.6%, 23.4%, and 19.1% (p = 0.001). These results
show the need to support COVID-19 survivors from health, psychological and socio-economic perspectives.
Keywords: Cured, COVID-19, Guinea, stigmatization, psychological, socio-economic perspectives.
Introduction The World Health Organization, due to the

The first cases of the new coronavirus responsible for emergency, has developed guidelines and enacted
the Covid-19 pandemic were notified in December measures for states to prevent the spread of the virus.
2019 in the city of Wuhan, China. Since then, Sras- Public health interventions have been introduced
cov-2 (new coronavirus) has continued to spread globally (5).
around the world and more than 200 countries are Countries that had invested in preparedness for
affected (1,2). Covid-19 has the usual manifestations past health emergencies such as Ebola virus disease
of a simple respiratory infection or pneumonia, with the adoption of a multisectoral community
including fever, cough, shortness of breath, difficulty approach (community engagement, infection
breathing, and in severe cases, severe acute respiratory prevention and control), would be able to limit the
syndrome, kidney failure see death (2). Constituting spread disease (6).
a serious threat to public health and safety, the WHO
After 6 months of response to the pandemic, several
declared on January 30, 2020, covid-19 as a public
countries are experiencing a marked slowdown in
health emergency of international concern. On March
the spread of COVID-19 and some of them are even
11, 2020 the WHO characterized COVID-19 as a
considering relaxing the containment rules decreed
pandemic (3,4).
for several weeks (7, 8).
218
As of July 22, 2020, the WHO reports 14,765,256 Methodology

confirmed cases worldwide with 612,054 (4.14%)
deaths and 8,656,734 recoveries, i.e. more than half. In
China, 86,226 people have been confirmed with 4,655
deaths, i.e. a lethality of 5.4% (9).
In Africa, lethality has remained generally low
since the start of the pandemic, 10,157 out of 623,851
confirmed cases as of July 22, 2020, i.e. 1.6% lethality.
South Africa and Egypt are the most affected with
381,798 and 89,078 cases respectively (1.4 and 5%
lethality) (10).
Guinea notified its first case of COVID 19 on March
12, 2020. Faced with this situation, the Guinean
government has taken important measures, in
particular the compulsory wearing of a mask, partial
confinement, the closure of borders, the state of health
emergency to contain the impact of the pandemic at
the health, social, economic and financial level (11). As
of July 19, 2020, Guinea has recorded 6,590 confirmed
cases with 40 hospital deaths (ANSS, Sitrep N°108
Covid-19, Guinea Ref).
According to the Guinean experience on the
experience of Ebola survivors, a number of problems
emerged that this group faced: Stigma, discrimination,
household dislocation (divorce, separation with
children), pressure to change home, job loss, isolation,
suicide among some.
In view of the experience of Ebola, the large
number of recoveries from COVID-19 and the need
to understand their current situation, the Ministry of
Health in collaboration with its partners is concerned
about the future of recoveries from COVID-19. 19. It
is within this framework that the present research
project entitled “Study of the future of those who
have recovered from COVID -19” is part of this
project. So, what would be the fate of those who have
recovered from COVID -19 in the administrative areas
of Conakry, Kankan, Labe and Kindia?
General objective: To describe the experience of
people recovered from COVID-19 in the 5 communes
of Conakry and the regions of Kankan, Labé, and
Kindia.
Specific objectives: To describe the community’s
attitude towards people who recovered from
COVID-19 and identify the health and socio-economic
problems they face.

Population: The people that recovered from the minimum sample size: ɳ = Z2 x Px (1-P) / d2 (Z = is
COVID-19 recorded in the areas used as the study the confidence level of the study, p = is the proportion
setting. Type and duration of study: this was a of cured in the population of confirmed Covid-19, d =
descriptive, quantitative and qualitative cross- is the margin of error of the study).
sectional study from January 29 to February 09, 2021,
With a confidence level of 95%, a margin of error α =
with a 2-day pre-survey phase.
5%, and the value of Z is equal to 1.96. The proportion
Inclusion criteria: Anyone recovered from of those cured in the 12,484 confirmed cases of
COVID-19 resides in the areas that served as the Covid-19 as of November 10, 2020 was estimated at
study setting. 87%, with 10,857 cured.
Exclusion criteria: children under 18 and people However, this estimate suffers from a bias, as more
with mental disorders were excluded. than 30% of confirmed cases had not been taken
care of at a Covid-19 treatment center, so their status
Variables: The study variables were socio-
remained unknown. For these reasons, we applied the
demographic characteristics (age, sex, residence,
principle of p = 50%. The sample size was estimated
occupation, marital status, and level of education),
to be 384 recovered.
medical history, knowledge of COVID-19, the attitude
of neighbors towards it, and the way of life of the To compensate for non-respondents, we adjusted
recovered person before and after his contamination. the size by 5%, or 403. The Randomizer software was
used to draw the numbers in the base of the cured
Data collection: Data collection was done using
according to the size of the sample. Excel and STATA
Kobo Collect administered directly to the cured by 20
were used. Comparisons were made using Pearson’s
investigators supported by six (6) supervisors.
Fischer and Chi-square tests (95% CI) and p <0.05 The
Sampling: We carried out random and simple study was approved by the ethics committee (N: 141/
sampling. We used the following formula to calculate CNERS/20).
Results
A total of 330 COVID-19 survivors responded to the survey or 85% of the expected sample size.
Table I : Factors associated with the stigma of COVID-19 survivors, March 2020-January 2021.
Stigma
Variables Total P-value
Yes No
Sex 0.500
• M 35 (74,5%) 197 (69,6%) 232
• F 12 (25,5%) 86 (30,4%) 98
Age (year) 0.325
• 19-29 18 (38,2) 85 (30%) 103
• 30-39 11 (23,4) 98 (34,6) 109
• 40-49 11 (23,4) 49 (17,3) 60
• 50 et plus 7 (14,8) 51 58
Marital status 0.164
• Married 28 (59,57%) 203 (71,73%) 231
• Single 18 (38,3%) 75 (26,5%) 93
• Divorced 1 (2,13%) 5 (1,77%) 6
Level of education 0.220
• Out of school / primary 2 (4,25%) 33 (11,67%) 35
• Secondary / vocational and 11 (23,4%) 77 (27,2%) 88
• University and more 34 173 207

220
Stigma
Variables Total P-value
Yes No
Occupation 0.333
• Pupil / Student / Teachers 7 29
• Personal health 8 50
• Workers 5 64
• Defense and security 4 20
• Other officials 23 120
Concerning this study, there is a predominance of The table shows that more than 90% of those
males as 232 are male against 98 females- discharged from the TC-IP did not change their
residence after discharge and only 7.83% of them lost
Among COVID-19 survivors’ occupations, 64 are
their jobs.
workers in different sectors, and 50 are health agents.
Concerning the returning to work after leaving the
Regarding the level of education, 23.4% were
TC-IP, 98.11% of those who had recovered returned to
limited to the secondary and professional level, and
work immediately after their recovery.
4% had never been to school.
Regarding sharing information about their covid-19
Table II: Distribution according to the
characteristics of those recovered from Covid-19 in status, 55.15% said they had shared their recovered
the region’s March 2020-January 2021. status with their colleagues and neighbors without
hesitation.
Variables Numbers Frequency
(%) Table III: Distribution of respondents according
to the perception and attitude of the COVID-19
Move entourage, March 2020-January 2021
Yes 29 8,79
Characteristics Number Percentage
No 301 91,21
Perception of family
Survivors with a job
N=310 No change; it was like
before COVID-19 88 26,67%
before
Yes 230 74,19 Good perception,
No 80 25,81 welcoming, friendly 191 57,88%
Survivors who lost their and pleasant
n=230 Bad perception,
jobs after Covid-19 14 4,24%
Yes 18 7,83 mistrust, stigma
Undetermined, the
No 212 92,17
whole family was
Return to work after 37 11,21%
n=212 positive, I live alone, no
illness one was informed
Yes 208 98,11 Attitude of the entourage
No 4 1,89 No change; it was like
109 33,03%
Survivors who agreed to before
share information about N=330 Good perception,
their status welcoming,
133 40,30%
sympathetic and
Yes 182 55 ,15
pleasant
No 148 44,85 Bad perception,
53 16,06%
Survivors showing signs mistrust, stigma
N=330
of stress Undetermined, the
Yes 27 8,18 whole family was
35 10,61%
No 303 91,82 positive, I live alone, no
one was informed

Regarding the attitude of the family towards those declining income. Almost half of the survivors, 148
whom COVID-19 has cured, 57.88% stated that they (45%) out of 330 recovered did not want their status
were well received on their arrival - on the other to be known to others.
hand, 4.24% said that they were badly received and
Among them, 62.73% were university students;
sometimes they were meme ignored by members of
70% of survivors were married against 28.18% were
their own family.
single; 99% of respondents lived in urban areas. Males
Table IV: Factors associated with the stigma of accounted for 70.3% of cases, and the 19-38 age group
COVID-19 survivors March 2020-January 2021 was the most represented at 61.82%. The average age
Variables Stigma Total P-value of participants was 37.5 years, with extremes of 19
Oui Non and 76 years.
Other districts 0.001 Among those who recovered from stress, 19% were
3 21 those who had lost their jobs. And those who had lost
Dixinn 21 their jobs were more stressed than the other survivors
(6,4%) (7,4%)
5 21 who did not lose their jobs. This relationship is
Kaloum 26 statistically significant P = 0.045. Although we
(10,6%) (7,4%)
11 19 only covered 330 people, this size is representative.
Matam 30 Among the 330 surveyed, 33% declared having
(23,4%) (6,7%)
9 102 been the victim of stigma. 21% lost their jobs; 4.2%
Matoto 111 experienced stigmatization from their families and
(19,1%) (36%)
13 107 friends. More than 16% are badly perceived when
Ratoma 120 they return to their respective communities. There is
(27,6%) (37,8%)
Other 6 13 a statically significant association between stigma and
19 job loss with a P = 0.002; 33% of respondents said they
districts (12,8%) (4,6%)
Income change 0.003 had not noticed a change in behavior towards them;
63.63% of these stigmatized people lost their jobs (P
14 40
Yes 54 = 0.007). Community residence, change in income,
(33,3%) (14,9%)
and COVID-19 post-stress are factors associated with
28 228
No 256 stigma (p = 0.003).
(66,7%) (85,1%)
Stress 0.000 The cured living in the communes of Ratoma,
15 12 Matam, and Matoto are more stigmatized than
Yes 27 the others, respectively 27.6%, 23.4%, and 19.1%
(31,9%) (4,2%)
32 271 (p = 0.001). There is not a statistically significant
No 303 relationship between gender, age, marital status,
(68,1%) (95,8%)
level of education, occupation, and the occurrence of
There were statically significant relationships
stigma among those recovered from COVID-19.
between the place of residence, variation in financial
earning, stresses, and stigma among Ebola recoveries Conclusion
(P≤0.05).
Our study shows that there is a need for psychological
Discussion and socio-economic support in addition to the medical
As soon as the first case of COVID-19 was notified follow-up the recovered from treatment centers. After
on March 12, 2020, the National Health Security their journey in the CTePi, the cured suffer from the
Agency activated its response plan. This plan did not stigma, stress, and loss of income.
take into account certain concerns, in particular those Ethical clearance : Taken from.AFRO Ethics
recovered from COVID-19. Review committee, September, 18th 2020 ( a copy will
This survey showed the need for support for be attached).
survivors on the health, psychological, social, and Source of funding : The study was carried out
economic levels. After experiencing the grim realities with funding from the WHO.
of CTePi, these healed people were still victims of
some issues such as stigma, stress, job loss, and Conflict of interest : There is not conflit interest .

222
References 7. O’Toole D. Comment des pays de l’OCDE ont réussi

à contrôler la COVID-19 dans les centres de soins de
1. Timeline: WHO’s COVID-19 response [Internet].
longue durée [Internet]. The Conversation. [cité 2 mai
[cité 2 mai 2022]. Disponible sur: https://www.who.
2022]. Disponible sur: http://theconversation.com/
int/emergencies/diseases/novel-coronavirus-2019/
comment-des-pays-de-locde-ont-reussi-a-controler-
interactive-timeline
la-covid-19-dans-les-centres-de-soins-de-longue-
2. Yuan Z, Xiao Y, Dai Z, Huang J, Zhang Z, Chen Y. duree-142595
Modelling the effects of Wuhan’s lockdown during
8. COVID-19 : tout sur la Pandémie du Coronavirus
COVID-19, China. Bull World Health Organ. 1 juill
| Radio-Canada.ca [Internet]. [cité 9 mai 2022].
2020;98(7):484‑94.
Disponible sur: https://ici.radio-canada.ca/
3. Tang D, Comish P, Kang R. The hallmarks of COVID-19 coronavirus-covid-19
disease. PLoS Pathog. mai 2020;16(5):e1008536.
9. WHO Coronavirus (COVID-19) Dashboard [Internet].
4. Mahajan P, Kaushal J. Epidemic Trend of COVID-19 [cité 9 mai 2022]. Disponible sur: https://covid19.who.
Transmission in India During Lockdown-1 Phase. J int
Community Health. 23 juin 2020;1‑10.
10. Suivez la propagation de la COVID-19 à travers
5. Radon K, Saathoff E, Pritsch M, Guggenbühl Noller le monde [Internet]. Le Devoir. [cité 9 mai 2022].
JM, Kroidl I, Olbrich L, et al. Protocol of a population- Disponible sur: https://www.ledevoir.com/
based prospective COVID-19 cohort study Munich, documents/special/20-03_covid19-carte-dynamique/
Germany (KoCo19). BMC Public Health. 26 août index.html
2020;20(1):1036.
11. B I H _ S o c i o e c o n o m i c - R e s p o n s e - P l a n _ 2 0 2 0 . p d f
6. WHO 2019 nCoV Emergency - Preparedness Long - [Internet]. [cité 2 mai 2022]. Disponible sur: https://
Term 2020.1 Eng | PDF | World Health Organization reliefweb.int/sites/reliefweb.int/files/resources/
| Emergency Management [Internet]. Scribd. [cité 2 BIH_Socioeconomic-Response-Plan_2020.pdf
mai 2022]. Disponible sur: https://www.scribd.com/
document/535137955/WHO-2019-nCoV-Emergency-
Preparedness-Long-term-2020-1-eng

Comparison of Causes of Infective and Non-Infective Epistaxis in the

Kolhan Belt Population of Jharkhand
Sanjay Kumar1, Bhimsen Hansda2, Rohit Kumar Jha3

1
Professor and Head, Department of ENT, MGM Medical College, Jamshedpur-831018
2,3
Assistant Professor, Department of ENT, MGM Medical College, Jamshedpur-831018
How to cite this article: Sanjay Kumar, Rohit Kumar Jha et al Comparison of Causes of Infective and Non-Infective
Epistaxis in the Kolhan Belt Population of Jharkhand. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Epistaxis is the commonest otolarangyngological emergency affecting 60 % of population in their life time
.If un-treated may affect hemodynamic status.
Method: 92 Epistaxic patients of different age groups were treated conservatively after routine blood examination and
serum electrolyte, Urea, S. Creatinine, Urine routine examination, Blood group, Coagulation profile, CT scan was done in
selected patients to rule out neoplasm of the nose, PNS and nasopharynx. Moreover chest-x-ray, ECG was performed for
fitness procedure required for general anaesthesia.
Results: In clinical manifestations of infective and non-infective epistaxis 32 (34.7%) were idiopathic, 19 (20.6%) were due
to trauma, 14 (15.2%) rhinitis, 15 (16.3%) HTN/Atherosclerosis, 2 (2.17%) due to tumours, 2 (2.17%) Iatrogenic, 3 (3.26%)
foreign bed, 2 (2.17%) blood dyscrasis, 1 (1.08%) congenital heart disease, 2 (2.17%) during pregnancy, 30 (32.1%) were
non-infective, 62 (67.3%) were infective epistaxic. Out of 92 patients 36 (39.1%) had non-infective bleeding sites and 56
(60.8%) had infective bleeding sites. Out of 6 (6.52%), 5 (5.43%) complications were observed in non-infective epistaxis.
Conclusion: Though epistaxis is idiopathic it is classified as local or systemic but it is difficult to classify. Hence 80-90%
were idiopathic (non-infective) Majority of the epistaxis were managed with conservative (non-surgical) treatment such
as nasal packing and local cauterization. It is safe and cost effective surgery will be the lost resort to cure epistaxis.
Keywords: Infective, Idiopathic, Rhinoscopy, nasal endoscopy, Abgel, Ribbon/gauze
Introduction Epistaxis is estimate to occur in 60% worldwide

Epistaxis or nasal bleeding is recognised as one of the during their life time and approximately 6% of those
most common otorhinolaryngological emergencies with nose bleeds seek medical treatment (1). The
globally and presents a challenge in tertiary care prevalence increases in children less than 10 years of
hospitals where facilities for caring these patients are age on then raises again after the age of 40 years (2).
limited. Epistaxis is a problem frequently encountered Generally males are affected more than females until
in general practice and may present as an emergency the age of 50 but after 50 no difference between sexes
as a chronic problem of recurrent bleeds or may be are reported (3).
a symptom of a generalised disorder. It affects the The aetiology of epistaxis can be broadly divided
hemodynamic status as well as psychological aspects in to local or systemic (infective or non-infective),
of the patients and family members causing anxiety. although even this distinction is difficult to male and
Bhimsen Hansda
Assistant Professor, Department of ENT, MGM Medical College, Jamshedpur-831018
224
the term “idiopathic epistaxis” is ultimately used in treatment was considered only when conservative
about 80 to 90% of the cases (4). Hence attempt is made method failed to control the epistaxis of the patients
to evaluate the causes of infective and non-infective. with bleeding disorders packed with absorbable
Epistaxis so that present study can be a guide line to gelatine sponge (Abgel). The rest of the patients
ENT surgeon who deals with Epistaxis in different received conventional anterior nasal packing with
age groups and both sexes. ribbon gauze posterior nasal packing was considered
in the case of re-bleed in a patient also had anterior
Material and Method nasal pack in site surgical methods were last resorts to
90 patients aged between 10 to 58 years regularly control bleeding in patients who had recurrent bleed
visiting to ENT department of MGM Medical College or whose bleeding could not be controlled with those
hospital Jamshedpur-831018 were studied. non-intentional methods.
Inclusive Criteria: All the patients presented the Duration of study was October-2021 to April-2022.
Epistaxis were selected for study.
Statistical analysis: Various studies of infective
Exclusion Criteria: Patients undergone recent and non-infective Epistoxis were done and classified
sinusoidal surgery, any bleeding diathesis or patients with percentage. The statistical analysis was carried
with earlier intervention on bleeding site were out in SPSS software. The ratio of the male and female
excluded from study. was 2:1.
Method: Every patient underwent routine Observation and Results
investigation such as CBC, Hb% level, platelet
Table-1: Study of causes of infective and Non-
count, RBS, Serum electrolyte, urea, creatinine, Urine
infective epistaxis – 32 (34.7%) were Idiopathic (Non-
routine, examination and blood grouping.
infective), 19 (20.6%) trauma, 14 (15.2%) Rhinitis
Coagulation profile such as prothrombin time (Inflammation), 15 (16.3%) HTN / atherosclerosis, 2
activated plasma thromboplastin time; bleeding (2.17%) Iatrogenic, 3 (3.26%) foreign body, 2 (2.7%)
and clotting time was ruled out. CT scan was done Blood dyscrasis, Glanzmanns thromboaesthetic
in selected cases to rule out neoplasm of the nose Haemophilia, 1 (1.08%) congenital heart disease, 2
and para-nasal sinuses and the naso-pharmnx. (2.17%) pregnancy.
Moreover chest-x-ray, ECG, and stereological test
Table-2: Comparative study of modalities in
was performed for the fitness procedure require
Epistaxis, out of 11 (11.9%), 5 (5.43%) were infective, 6
general anaesthesia, that is convention posterior nasal
(6.52%) were kept under observation, out of 37 (40.2%),
packing and surgical methods to control epistaxis.
24 (26.08%) of infective, 13 (14%) were non-infective
Intravenous line was established in all patients treated with light packing with gauzy antiseptic
with side bear canula. Initially the patients were antibiotic local haemostatic. Out of 15 (16.3%) patients
evaluated with anterior rhinoscopy to indentify 7 (7.60%0 infective, 8 (8.69%) non-infective treated
the site of bleeding. Patients who were brought with local trichlora aceticacid, Out of 13 (14.1%) 10
to emergency room with complaint of recurrent (10.8%) infective, 3 (3.26%) non-infective treated with
episodes of excessive bleeding, underwent nasal anterior nasal packing, 4 (4.34%) of infective were
endoscopic examination to search the site of bleeding treated with posterior nasal packing, 6 (6.25%) had
which might have located more posteriorly. endoscopic cuttery. Out of a 11 (11.9%) 6 (6.25%)
Treatment of patients with epistaxis included had infective and 5 (5.43%) non-infective combined
conservative or non-surgical treatment and surgical procedure, 30 (32.1%) patients were non-infective, 62
or interventional treatment. Non-surgical treatment 67.3%) were infected epistaxis patients.
included application of topical vasoconstriction such Table-3: Comparison of bleeding sites in both
as oxymetazoline and xylomyazoline nasal drop, infective and non-infective epistaxis out of 38 (41.3%)
chemical and electric cauterization of the bleeder and 24 (26.1%) infective, 14 (15.2%) had anterior septum,
anteri and posterior nasal packing, surgical methods out of 14 (15.2%) 9 (9.7%) infective, 5 (5.4%) non-
were endoscopic cauterization of the bleeder and SPA infective had posterior septal bleeding site. Out of 12
(spheno-palatine Artery) ligation. All the patients (13%), 7 (7.6%) infective, 5 (5.4%) non-infective had
were initially treated conservatively and surgical lateral wall (inferior turbinate) was bleeding site.

Out of 24 (26%), 13 (13.6%) infective, 11 (11.9%) non- infective espitaxis because in old age minor traumatic
infective had anterior floor was bleeding site. Out of 4 injury to nose result into server degree of epistaxis.
(4.3%), 1 (1.08%) infective, 3 (3.2%) non-infective had This epistaxis may be the diagnostic value of cerebro-
posterior floor was bleeding site, Out of 92, 36 (39.1%) vasular cardio vascular derangements. It is noted that
non-infective, 56 (60.8%) infective patients bleeding. epistaxis present in HTN patients is not controlled
by anti-HTN drugs hence there was recurrence of
Table-4: Comparison of frequency of complications
epistaxis in HTN patients (10) or the HTN patients with
in both infective and non-infective patient had
epistaxis might have essential hypertension. Under
hypovolmic shock, 3 (3.26%) non-infective had
such scenario it is difficult to classify the infective or
recurrent epistaxis, 1 (1.08%) non-infective had toxic
non-infective (Idiopathic) epistaxis.
shock, 1 (1.08%) non-infective had facial oedema. Out
of 6 (6.25%) 5 (5.43%) complications were observed in Managements epistaxis is well summarised by
non-infective patients. taking preventive measures including face mask with
shield gowns, hair coverage and double-gloving.
Discussion
The use of antimicrobial prophylaxis in the
In the present comparative study of infective and non-
presence of nasal packing for the treatment epistaxis
infective (idiopathic) Epistaxis. Clinical manifestations
remains controversial as it may lead to increased risk
were 32 (34.7%) were Idiopathic (non-infective), 19
for sinusitis and toxic shock syndrome. Blood soaked
(20.6%) were due to trauma, 14 (15.2%) were due to
pack and raw mucosal surface are good media for
rhinitis, 15 (16.3%) were due to Hyper tension / athero
bacterial multiplication resulting in infection including
sclerosis, 2 (2.17%) were due to tumours, 2 (2.17%)
sinusitis and some time toxic shock syndrome (11).
Iatrogenic, 3 (3.26%) were due to foreign body, 2
The mortality rates associated with epistaxis were
(2.17%) were due to blood dyscyasis haemophilia, 1
severe head injuries cardiac arrest associated tension
(1.08%) due to congenital heart anomalies, 2 (2.17%)
pnemothorax and nasopharyngeal cancer.
during pregnancy (Table-1). 30 (32.1%) Epistaxis
patients were non-infective (Idiopathic), 62 (67.3%) Summary and Conclusion
were due to infection (Table-2). Out of 92 (100%), 36
Present comparison of causes of between infective
(39.1%) epistaxis had non-infective bleeding and 56
and non-infective epistaxis, 32 (34%) of Idiopathic
(60.8%) had infective bleeding (Table-3). Out of six
(non-infective) epistaxis and remaining 60 (65.2%)
(6) frequency of complication patients 5 (5.41%) were
appears to be infective though the aetiology was not
non-infective (Idiopathic) (Table-4). These findings
clearly under stood. Majority of epistaxis is managed
are more or less in agreement with previous studies
with conservative methods and surgery remains to be
(5)(6)(7)
.
the last resort to treat epistaxis. The Present studies
Prevalence of epistaxis among the children aged demands further inventional study of embryological
between 3 and 6 years of age was observed. Few genetic, nutritional, patho-physiological studies
children were due to traumatic and few children because exact the factors and mechanism of epistaxis
using anticoagulants, some of the adults or children is still unclear.
had Diabetes mellitus Hypertension (8). Trauma being
Limitation of study - Due to tertiary location of
the major cause of epistaxis varied from minor injury
present institution, small number of patients and lack
such as digital trauma to varying degrees of nasal
of latest technologies we have limited results.
injury from road traffic injury, HTN (hypertension)
is the third commonest cause of epistaxis due to This research paper was approved by
poor blood pressure control. It is also reported that, Ethical committee of MGM Medical College
expistaxis is the one of the geriatric problem in older Jamshedpur-831018.
than 40 (forty) years of age (9). Hence it is confirmed No Conflict of interest
that, In old age there is lesser degree of immunity
leads to cardiovascular diseases like HTN / No Funding
Atherosclerosis, type-II DM could be the major cause Table 1: Clinical manifestation of Infective and
of epistaxis in old age above 40 years. Hence epistaxis Non-infective of Epistaxis
above 40 years can be classified or considered as

226
Causes of Epistaxis No. of Patients (92) Percentage (%)

Idiopathic (Non-infective) 32 34.7
Trauma 19 20.6
Rhinitis (Inflmmative) 14 15.2
HTN/Atherosclerosis 15 16.3
Tumours 2 2.17
Iatrogenic 2 2.17
Foreign Body 3 3.26
Blood Dyscrasis 2 2.17
(Dlanzmanns) Thromophilia Haemophilia
Congenital heart disease 1 1.08
Pregnancy 2 2.17
Table 2: Comparative study of Modalities in Epistaxis

Treatment Modalities Infective Non Infective Total
No. of % No. of % No. of patients
patients patients with percentage
Observation 5 5.43 6 6.52 11 (11.9%)
Light packing with gauzy antiseptic 24 26.08 13 14.1 37 (40.2%)
antibiotic / local haemostatic
Local trichlora acetic acid 7 7.60 8 8.69 15 (16.3%)
Anterior Nasal packing 10 10.8 3 3.26 13 (14.1%)
Posterior Nasal packing 4 4.34 -- -- 4 (4.34%)
Endoscopic cuttery 6 6.52 -- -- 6 (6.52%)
Combined procedure 6 6.52 5 5.43 11 (11.9%)
Surgical intervention 0 0 0 0 --
30 (32.1%) Epistaxis patients were non-infective, 62 (67.3%) patients were infected Epistaxis
Table 3: Comparison of bleeding sites in both infective and non-infective Epistaxis

Site of bleeding Infective Non-Infective Total number
of patients with
percentage
Septum
A. Anterior 24 26.1 14 15.2 38 (41.3%)
B. Posterior 9 9.7 5 5.4 14 (15.2%)
Lateral wall (Inferior turbinate / Middle 7 7.6 5 5.4 12 (13%)
turbinate / Middle Meatus
Floor
A. Anterior 13 13.6 11 11.9 24 (26%)
B. Posterior 1 1.08 3 3.2 4 (4.3%)
Out of 92 patients 36 (39.1%) had non-infective and 56 (60.8%) had infective bleeding
Table 4: Comparison of frequency of complications in both infective and non-infective

Epistaxis Infective Non-infective Total number and

Complications Epistaxis Epistaxis percentage (%)
6 (6.52%)
Hypovolmic shock 1 -- 1 (1.08%)
Recurrent Epistaxis -- 3 3 (3.26%)
Toxic Shock -- 1 1 (1.08%)
Facial oedema - 1 1 (1.08%)
Out of 6 (6.52%), 5 (5.43%) complications were observed in non-infective
References 6. Peter A, Kwabla AG – Incidence of epistaxis in a

tertiary hospital Ghana Natural Sci. Research 2012, 2
1. Varshey S, Saxena RK – Epistaxis a retrospective
(3); 30-33.
clinical study Indian J, Otolaranged head neck surg.
2005, 57 (2); 125-129. 7. Mgbor NC – Epistaxis in Enugu a 9 year review Nigi.
Journal otorhinolaryngol. 2004, 1 (1); 11-14.
2. Gilyma JM, Chalya PL – Etiological profile and
treatment outcome of epistaxis at a tertiary care 8. Petryson B – Epistaxis : A clinical study Indian J. of
hospital in Tanzania BMC Ear, Nose, throat disorders otolarangology 1974, 1-9.
2011, 11; 8-12.
9. Tseb KR, Mohamed Z – Pattern of Epistaxis in sokota
3. Nemer AK, Motassim AR – Evaluation of conservative Nigeria. A review of 72 cases Ann. Afr. Med. 2008, 7;
measures in the treatment of epistaxis Khartoum Med. 107-11.
J. 2008, 1 (11); 15-17.
10. Dauda A, Jaiswaly – Guidelines for the management of
4. Urvashi R, Raizada RM – Efficacy of conservative idiopathic epistaxis in adult’s how do you do? Clinical
treatment modalities used in epistaxis Ind. J. otolaragology 2008, 607-28.
Otolaryngol. Head Neck Surg. 2004, 56 (1); 21-23.
11. Pope LER, Hobbs CGL – Epistaxis an update on current
5. Akinpelu OV, Amusa YB – Retrospective analysis of management. Post-grade Med. J. 2005, 81; 309-314.
aetiology and management of Afr. J. Med. 2009, 28;
165-168.

Falls among Elderly in a Rural Community: Incidence and Determinants
Sanjay TV1, Ramu P2, Madhusudan M3, Nandhini RC4

Professor, Department of Community Medicine, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka
1
2
Assistant Professor, Department of Community Medicine, Al Ameen Medical College, Athani Road, Vijayapura Karnataka
3
Scientist ‘D’ (Medical), ICMR-National Centre for Disease Informatics and Research, Bengaluru, Karnataka
4
Assistant Professor, Department of Community Medicine, Dr B R Ambedkar Medical College and Hospital, Bengaluru, Karnataka
How to cite this article: Sanjay TV, Ramu P, Madhusudan M, Nandhini RC et al Falls among Elderly in a Rural
Community: Incidence and Determinants. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Falls are one of the emerging public health issues and a barrier for active aging. There is a scarcity of studies
on incidence of falls among elderly population which provide information on real burden from rural part of India. Hence,
the study was undertaken to find out the incidence of falls and determinants among elderly population.
Materials and Methods: A prospective cohort study was carried out by involving 260 elderlies in a primary health centre
area of Bengaluru by using simple random sampling technique over a period of one year. Data was collected regarding,
socio-personal characteristics, substance use, co-morbidities and self-perceived health status using interview method and
assessment of housing conditions was also undertaken. House visit was conducted to explain the purpose of the study
and to distribute falls dairy. Telephonic interview was undertaken to collect history of falls and related information once
in three months and at the end of one-year elderly were revisited to confirm the falls. All the data was analysed using Epi
info 7.2.2.1.
Results: The incidence of falls among elderly was 48.2%. The socio-personal characteristics such as age group ≥70 years
(p<0.001), low/medium standard of living index (SLI) (p=0.03), poor/average self-perceived health status (p=0.001),
provision of separate living room (p=0.0006) and location of bathroom and toilet outside the house (p=0.04) were
associated with falls.
Conclusion: The incidence of falls among elderly was more compared to previous studies and associated with advanced
age, poor income, poor self-perceived health status, living alone in separate room and location of bathroom and toilet
outside the house.
Keywords: Falls, Incidence, Elderly, Rural area, cohort study.
Introduction result from complex interplay of intrinsic causes such

Aging is a dynamic process which brings about as disorders of cardio-vascular, nervous and balance
morphological, functional and biochemical changes systems and extrinsic causes such as environmental
leading to an increase in the risk of falls among hazards which are potentially predictable and
elderly. Falls are one of the most serious emerging preventable.2
public health issues among elderly all around the Falls are responsible for injury-related
world. It is considered as a barrier for active aging and hospitalization, loss of independence, poor quality
identified as one of the important geriatric giants.1 of life and premature death. It has enormous socio-
Even though, falls are part of normal aging, economic impact in terms of increased hospital stay
majority of the falls are multifaceted in nature and and consumption of health care resources.3
Dr Ramu P, MD (Comm Med)
Assistant Professor, Department of Community Medicine
Al Ameen Medical College, Athani Road, Vijayapura, Karnataka-58610
It was documented that approximately one-third Sample size: The sample size was estimated to be
of elderly living in community and over two-third 233 considering ‘prevalence of falls among elderly’ as
of institutionalized elderly will fall at least once 18.6%, absolute precision of 5%. Assuming 10% non-
a year and also reported that about 4,24,000 fall- response it was revised to 260.12
related deaths occurred globally and around one-
Study population: A total of 884 ambulatory elderly
fifth of them (95,000 deaths) occurred in India. These
subjects (≥60 years) were enumerated in the PHC area
evidences confirm that falls among elderly in India is
by conducting house to house visit. Of which 570
a growing public health concern due to increase in the
subjects were identified based on inclusion criteria
population of elderly which is projected to reach 19
such as resident of the locality for at least six months,
per cent by the year 2050.4-7
ambulatory and willing to participate in the study.
Many prospective studies from developed countries Those with severe illness, cognitive impairment,
have shown that the incidence of falls for elderly speech and hearing difficulty were excluded. All the
living in the community varies between 29% to 40% subjects were line listed according to alphabetical
and this increases with age. Falls are responsible for order and finally, 260 subjects were selected by simple
19% of all emergency department visits and more random sampling technique using computerised
than 50% of injury-related hospitalisations among random number generator.
elderly people.8-9
Study tools: In the study, fall was defined
Recent reviews on falls among elderly in according to WHO as inadvertently coming to rest
India has shown that, there are many prevalence on the ground, floor or other lower level, excluding
studies displaying important information on the intentional change in position to rest in furniture,
epidemiological problem of falls and according to wall or other objects.13 Baseline data regarding socio
these studies burden of falls (prevalence) varies personal characteristics and substance use (currently
from 26% - 37%. The major drawback of prevalence using chewable and smokable tobacco, alcohol
study is the underestimation of real burden of falls and beverages) were collected. Co-morbidities
due to recall bias. This evidence is strengthened by were diagnosed based on clinical examination and
the fact that 13% to 32% of elderly had forgotten physician’s report. Self-rated health (SRH) status was
their previous falls. This sort of under-reporting assessed by asking the elderly subjects to rate their
is due to embarrassment and fear related to loss of present state of health as poor, average or good.
independence.10-11
Assessment of housing conditions included
There is limited information on burden of falls and following variables: overcrowding (<50 sq feet/
its determinants based on incidence studies carried person), adequate ventilation (total area covered
out on the elderly living in rural part of India where by doors and windows >2/5th of the total floor
majority of the elderly live. Such studies immensely space of the living room), adequate lighting (able
help policy makers and planners to design effective to read newspaper comfortably) in atleast 2/3rd
interventional strategies to improve the quality of life area of the living room, presence of unsafe furniture
of elderly in near future. Hence, present study was (haphazardly placed, projecting and broken), cooking
planned and undertaken with a primary objective on the floor, uneven stars, location of the bathroom,
to find out the incidence of falls and the secondary toilet and its flooring (uneven and slippery).14
objective to identify determinants of falls among Data collection: In the first house visit, purpose
elderly population. of the visit was explained and informed consent was
Materials and Methods taken from the elderly. By interview method, trained
investigator collected data using a pre-tested, semi-
This population based prospective cohort study was
structured questionnaire.
carried out in a primary health centre (PHC) area
having 21 villages with 13,901 population which Each elderly subject was followed up to one year
comes under rural field practice area of a medical for the incidence of falls. For better monitoring, every
college in Bengaluru from March 2017 to June 2018 elderly subject was instructed to record fall in a falls’
after obtaining approval from the Institutional ethics dairy given at the time of first visit. Every subject was
committee (KIMSIEC/D-10/2016). asked to record time of falls, cause, location, type of
injury, body part involved and treatment received

230
with the help of care giver. Along with this, follow-up were significantly more among subjects from low/
of each subject was undertaken once in three months middle SLI (50.2%) compared to subjects from high SLI
by telephonic interview and house visit was made in category (30.8%), P=0.03. Falls were significantly more
case of any fall. among subjects having poor/average self-perceived
health status (57%) compared to subjects with good
At the end of year, houses of 247 (11 subjects died
self-perceived health status (36.2%), P=0.001. There
and 2 subjects moved out of the study area) elderly
was no statistically significant association of falls with
subjects were re-visited to confirm the falls and its
sex (P=0.8), education (P=0.9), employment status
details by verifying falls dairies. At the end of the
(P=0.1), marital status (P=0.2), type of family (p=0.6),
study, every subject was given education on causes,
substance use (p=-0.4) and co-morbidity (p=0.09).
consequences and prevention of falls.
(Table – 3)
Statistical analysis: In this study, both descriptive
This study revealed incidence of falls significantly
(percentages, mean and standard deviation) and
more among subject living alone in separate room
inferential statistics such as chi-square test (to find out
(66.7%) compared to those sharing room with other
association of falls with socio-personal characteristics
family members (41.9%), P=0.0006. Similarly, falls
and housing conditions) were used. P-value of <0.05
were significantly more among subjects living in
was considered as statistically significant. All the data
house with bathroom and toilet placed outside (52.8%)
were entered and analysed using Epi info 7.2.2.1.
compared to bathroom and toilet placed inside the
Results: Out of 260 subjects, 115(42%) were males house (39.3%) P=0.04. There was no statistically
and 145(58%) females. The mean age of subjects significant association of falls with overcrowding
were 68.7 ± 7.5 years with a range of 60 to 98 years. (P=0.9), adequate ventilation and lighting (P=0.2,
136(52.3%) belonged to the age group of 60-69 years 0.3)), unsafe furniture (P=0.6), cooking on the floor
and, 124(47.7%) to >70 years age group. 132 (50.8%) (P=0.3), uneven steps in the entrance and stairs (P=0.7,
were literate, 128(49.2%) illiterate, 170(65.4%) were 0.6), slippery floor in the bathroom and toilet (P=0.2)
not working, 90(34.6%) working, 214(82.3%) were (Table – 4).
married, 46(17.7%) unmarried/widowed, 141(54.2%)
Table 1: Distribution of study subjects according to
were from joint family, 51(19.6%) from nuclear and characteristics of falls (n=143).
68(26.2%) from 3 generation family. 28(10.8%),
135(51.9%) and 97(37.3%) were respectively from Variable Category Total
high, medium and low socioeconomic class as per the 1 119(83.2)
No. of falls
Standard of Living Index. ≥1 24(16.8)
Intrinsic 48 (33.6)
Causes for Falls
Out of total 260 study subjects, 247 study subjects Environmental 95(66.4)
were included for the final analysis due to attrition. Indoor 93(65)
Location of falls
Totally, 119 elderly reported single fall in one year Outdoor 50(35)
(Incidence of falls was 48.2% (13.5 per 100 person- Day 46(32.2)
Time of Fall
years). Among them, 54 (45.4%) of the subjects were Night 97(67.8)
males and 65 (54.6%) were females. Elderly subjects Table 2: Distribution of study subjects according to
who had fallen more than once were 24 (9.7%) (recurrent characteristics of injury due to falls
falls). Totally there were 143 subjects (57.9%) who had Variable Category Total
reported falls. 95 (66.4%) of subjects had falls due to Injury after fall Yes 135(94.4)
environmental cause, 93(65%) of subjects experienced (n=143) No 8(5.6)
falls in the indoor settings and 97(67.8%) of them had Body parts Head and neck 97(48.7)
fall during night time (Table – 1). injured Trunk 93(46.7)
(n=199) * Upper limb 7(3.5)
Out of 143 falls, 135 (94.4%) of falls led to injury.
Lower limb 2 (1)
Most of the injuries were on the head and neck (48.7%) Type of Injury Contusion 98(72.6)
followed by trunk (46.7%). Contusion (72.6%) was the (n=135) # Abrasion 28(20.7)
major type of injury following falls (Table – 2). Laceration 3(2.2)
Incidence of falls were significantly more among Puncture wounds 2(1.5)
subjects aged ≥70 years (61.2%) compare to subjects Fractures 4(3)
in 60-69 years group (36.6%), P<0.001. Similarly, falls * Multiple parts; #subjects with injury

Table 3: Association between Socio-personal characteristics and falls (n=247)

CI
Variable Category Falls No Falls χ2 P-value
Lower Upper
60-69 48(36.6) 83 (63.4)
Age (years) 1.6 4.6 14.9 <0.001
≥70 71(61.2) 45(38.8)
Male 54(48.6) 57(51.4)
Sex 0.5 1.6 0.02 0.8
Female 65(47.8) 71(52.2)
Illiterate 58 (48.3) 62(51.7)
Education 0.6 1.7 0.002 0.9
Literate 61(48) 66(52)
Employment Working 35(41.7) 49(58.3)
0.8 2.2 2.1 0.1
Status Not Working 84(51.5) 79(48.5)
Married 95(46.3) 110(53.7)
Marital status 0.8 3.0 1.6 0.2
Others 24(57.1) 18(42.9)
Nuclear 22(44.9) 27(55.1)
Type of family 0.4 1.6 0.2 0.6
Non-Nuclear 97(49) 101 (51)
High 8(30.8) 18 (69.2)
SLI 1.0 5.4 3.5 0.03
Low/Middle 111(50.2) 110(49.8)
Yes 72(50.7) 70(49.3)
Substance use 0.7 2.1 0.8 0.4
No 47(44.8) 58(55.2)
Yes 58(54.2) 49 (45.8)
Co-morbidity 0.9 2.5 2.7 0.09
No 61(43.6) 79(56.4)
Self-perceived Good 38(36.2) 67(63.8)
1.4 3.9 11 0.001
Health status Poor/average 81(57) 61(43)
Table 4: Association between housing conditions and falls (n=247)
CI
Housing Conditions Falls No Falls χ2 P-Value
Lower Upper
Living alone in separate Yes 42(66.7) 21 (33.3)
1.5 5.1 11.6 0.0006
room No 77(41.9) 107(58.1)
Yes 53(48.6) 56(51.4)
Overcrowding 0.6 1.7 0.01 0.9
No 66(47.8) 72(52.3)
Yes 66(44.9) 81(55.1)
Adequate ventilation 0.4 1.2 1.5 0.2
No 53 (53) 47(47)
Yes 66(45.5) 79(54.5)
Adequate Lighting 0.4 1.2 0.9 0.3
No 53(52) 49(48)
Unsafe furniture (broken/ Yes 6(40) 9(60)
0.2 3.1 0.2 0.6
sharp edges) No 113(48.7) 119(51.3)
Yes 9(60) 6(40)
Cooking on the floor 0.5 4.8 1.0 0.3
No 110(47.4) 122(52.6)
Uneven stairs in the Yes 10(52.6) 9(47.4)
0.5 3.1 0.2 0.7
entrance No 109(47.8) 119(52.2)
Yes 4(57.1) 3(42.9)
Uneven stairs in the stairs 0.3 6.6 0.2 0.6
No 115(47.9) 125(52.1)
Location of Bathroom and Inside 33(39.3) 51(60.7)
0.3 0.9 4.0 0.04
toilet Out side 86(52.8) 77(47.2)
Slippery floor in bathroom Yes 39(47.3) 39(52.7)
0.8 2.4 1.8 0.2
and toilet No 80(45.1) 89(54.9)

232
Discussion the changing environment.21 Poor socio-economic

Falls is an important public health concern in status (poor/medium standard of living index) was
developing countries like India where a large associated with falls. The result is in agreement with
proportion of elderly live in rural areas. There has studies by Kuh D and Zhang L.22,4 The reason could
been limited research focusing on incidence of falls be due to the association of lower socio-economic
among elderly from India. This research studied status with poor health status and inadequate health
incidence, cause, location and time of falls, injury seeking behaviour which increases the risk of falls.
following falls and its determinants among elderly Falls were associated with poor self-perceived health
aged ≥ 60 years in a rural community. status. This is in line with studies by Singh DKA et
al and Zhang L.23,4 This could be due to presence of
The present study revealed that the incidence of falls physical, psychological and functional decline with
among elderly in the community was 48.2%. Similar poor self-perceived health status. Hence, advanced
incidence studies on falls by Sasidharan DK, Merom age, socio-economic status and self-perceived health
D et al and Palagyi A et al observed the incidence of staus can be used as risk factors for predicting falls
20.1%, 27% and 30.7% respectively.8,15,16 These findings among elderly population.
strengthen the evidence that the incidence of falls in
the present study is higher. This difference probably Assessment of housing environment showed that
could be due to variation in the socio-demographic falls were associated observations elderly living alone
background and divergent lifestyle of the study in separate room. Similar observations were made
population. by Bu F.24 This could be due to the fact that elderly
living in the separate room need to take care of
Most of the falls in this study occurred indoor themselves (self-care) which increases risk of falls. In
due to environmental cause and during night times. such cases, frequent monitoring of elderly is required.
Vikman I et al., have also reported similar findings.17 Falls were also associated with location of bath room
This probably could be due to spending more time more distance to be travelled and toilet outside the
in home environment because of functional decline house. This could be due to poor maintaince in terms
and reduced mobility. In such elderly, environmental of inadequate lighting, poor flooring and lack of
factors such as uneven or slippery floors, stairs, assistive devices like grab bar in bathroom and toilet
obstructed walkways due to poorly arranged located outside. This association needs to be probed
furniture and poor lighting increases the incidence in future studies.
of falls. Even though, majority of the causes for falls
are environmental in nature, it is difficult to rule out As a cohort study, it is limited by loss to follow-
influence of intrinsic factors due to ageing.18 up due to death and shifting of residence by elderly
and has many strengths such as use of falls diary and
Majority (94.4%) of the elderly had injuries close monitoring of elderly subjects with falls which
following fall and most of them were minor in nature. prevented loss of data.
Similarly, Chu LW observed that 75.2% of the fallers
had injuries.11 These facts show that falls in elderly Conclusions: Incidence of falls in this study was
invariably results in injury. Such injuries also cause more compared to previous studies. Advanced age,
fear of falling, loss of independence, functional low-income, poor self-perceived health status, living
decline and social isolation as age advances. This in a separate room and location of bathroom and toilet
study also documents that head and neck was the outside the house were associated with increased
most common site of injury. Such incidents increase incidence of falls. This study results reinforce the need
risk of hospitalization and demand high health care for similar prospective large representative sampled
cost. studies in near future to confirm the findings and to
generate needed information for the development of
Advanced age (≥70 years) was significantly long term, sustainable interventions in reducing falls
associated with falls. The result is consistent among elderly in rural parts of India.
with studies carried out elsewhere.17,19,20 Possible
explanations for increase in falls with age could Ethical clearance: Obtained from the from the
be due to setting of frailty leading to gradual Institutional Ethics Committee of Kempegowda
motor decline, decreased muscle strength affecting Institute of Medical Sciences, Bengaluru
motor activity and also decreased adaptability to (KIMSIEC/D-10/2016).

Source(s) of support/funding: Nil 14. Park K. Text Book of Preventive and Social Medicine.
Conflicts of Interest: Nil 23rd Edition. Jabalpur (India): Banarsidas Bhanot
Publishers; 2015.
References
15. Merom D, Mathieu E, Cerin E, Morton RL, Simpson
1. Lima MCSC, Diniz MLSBERS, Valença CNGAV. Falls
JM, Rissel C, Anstey KJ, Sherrington C, Lord SR,
in the Elderly: a Reflective Study. MOJ Gerontol Ger
Cumming RG. Social Dancing and Incidence of Falls in
2018;3(5):366-368.
Older Adults: A Cluster Randomised Controlled Trial.
2. Rajagopalan R, Litvan I, Jung TP. Fall Prediction and PLoS Med 2016;13(8): e1002112.
Prevention Systems: Recent Trends, Challenges, and
Future Research Directions. Sensors 2017;17:2509. 16. Palagyi A, McCluskey P, White A, Rogers K, Meuleners
L, Ng JQ, Morlet N, Keay L. While We Waited:
3. Vaishya R, Vaish A. Falls in Older Adults are Serious.
Incidence and Predictors of Falls in Older Adults with
Indian J Orthop 2020;54:69–74.
Cataract. Invest Ophthalmol Vis Sci. 2016;57:6003–
4. Zhang L, Ding Z, Qiu L, Li A. Falls and Risk Factors of 6010.
Falls for Urban and Rural Community-dwelling Older
17. Vikman I, Nordlund A, Näslund A, Nyberg L. Incidence
Adults in China. BMC Geriatrics 2019;19:379.
and Seasonality of Falls amongst Old People Receiving
5. Damián J, Barriuso RP, Gama EV, Cuesta JP. Factors Home Help Services in a Municipality in Northern
Associated with Falls among Older Adults Living in Sweden, International Journal of Circumpolar Health
Institutions. BMC Geriatrics 2013;13:6. 2011: 70(2): 195-204.
6. Joseph A, Kumar D, Bagavandas M. A Review of 18. Lee S. Falls Associated with Indoor and Outdoor
Epidemiology of Fall among Elderly in India. Indian J Environmental Hazards among Community Dwelling
Community Med 2019;44:166-8. Older Adults between Men and Women. BMC
7. Caring for our Elders: Early Responses. India Geriatrics 2021; 21:547.
Ageing Report – 2017. (https://india.unfpa.org/ 19. Bekibele CO, Gureje O. Fall Incidence in a Population of
sites/default/files/pub-pdf/India%20Ageing%20 Elderly Persons in Nigeria. Gerontology 2010;56:278–
Report%20-%202017%20%28Final%20Version%29. 283.
pdf). [Last accessed on 2022 Feb 14].
20. Gale CR, Westbury LD, Cooper C, Dennison EM. Risk
8. Sasidharan DK, Vijayakumar P, Raj M. Soman S, Factors for Incident Falls in Older Men and Women:
Antony L, Sudhakar A, Kabali C. Incidence and Risk the English Longitudinal Study of Ageing. BMC
factors for Falls among Community Dwelling Elderly Geriatrics 2018; 18:117.
Subjects on a 1-year Follow-up: a Prospective Cohort
Study from Ernakulam, Kerala, India. BMJ Open 21. Abreu HCA, Reiners AAO, Azevedo RCS, Silva AMC,
2020;10:e033691. Abreu DROM, Oliveira AD. Incidence and Predicting
Factors of Falls of Older Inpatients. Rev Saúde Pública
9. Zhao S, Cao Y, Lei Y, et al. Population Ageing and 2015;49:37.
Injurious Falls among One Million Elderly People who
Used Emergency Medical Services from 2010 to 2017 22. Kuh D, Bassey EJ, Butterworth S, Hardy R, Wadsworth
in Beijing, China: a Longitudinal Observational Study. MEJ. Grip Strength, Postural Control, and Functional
BMJ Open 2019;9:e028292. Leg Power in a Representative Cohort of British Men
and Women: Associations with Physical Activity,
10. Joseph A, Kumar D, Bagavandas M. A Review of
Health Status, and Socioeconomic Conditions. Journal
Epidemiology of Fall among Elderly in India. Indian J
of Gerontology 2005, 60A(2): 224–231.
Community Med 2019;44:166-8.
23. Singh DKA, Shahar S, Vanoh D, Kamaruzzaman SB,
11. Chu LW, Chi I, Chiu AYY. Incidence and Predictors of
Tan MP. Diabetes, Arthritis, Urinary Incontinence,
Falls in the Chinese Elderly. Ann Acad Med Singapore
Poor Self-rated Health, Higher Body Mass Index
2005;34:60-72.
and Lower Handgrip Strength are Associated with
12. Hafeez N. A Cross-sectional Study to Assess Falls among Community-dwelling Middle-Aged
Depression among Aged Population in a Rural and Alder Adults: Pooled Analyses from Two Cross-
Community [Dissertation]. Bangalore: Rajiv Gandhi sectional Malaysian Datasets. Geriatr Gerontol Int
University of Health Sciences, Karnataka; 2016. 2019;19(8):798-803.
13. WHO Global Report on Falls Prevention in Older 24. Bu F , Abell J , Zaninotto P, Fancourt D. A Longitudinal
Age. Geneva: World Health Organization;2007. Analysis of Loneliness, Social Isolation and Falls
http://www.who.int/ageing/publications/Falls_ amongst Older People in England. Scientific Reports
prevention7Mar ch.pdf. [accessed on 22.02.22 at 12:00 2020; 10: 20064.
PM].

Correlation of Automated cell counters RBC Histogram and

Peripheral smear in Anemias
Shabahat Hussain1, Mohammad Frayez2

1,2
Assistant Professor, Department of Pathology and Blood Bank, ASMC Shahjahanpur
How to cite this article: Shabahat Hussain, Mohammad Frayez et al Correlation of Automated cell counters RBC
Histogram and Peripheral smear in Anemias. Volume 13 | Issue 4 | October-December 2022
Abstract
Background and Aim: The RBC histogram visualizes particle size distribution that plays a critical role in the initial
screening and detection method for haematological disorders in current clinical settings. This present study was designed
to determine the relationship between Abbott cell dyn ruby- 5 part analyzer automated haematology analyzer histograms
and peripheral smear using the blood samples.
Material and Methods: A total of 500 samples sent for CBC and PS would be used for the present study for the duration of
5 months. The CBC samples received would be analyzed in the ABOTT cell dyn ruby instrument, and a peripheral smear
would be made from the same sample, using Leishman stain.
Results: Among all, 16% histograms were normal,31% had a left-shifted curve,40% showed broad-based curve, 03%
showed short peak, and Bimodal peaked histogram was demonstrated by 06% of total cases. In the present study, cases of
dimorphic anemia showed a normal range of MCV, MCH and MCHC. At the same time, RDW is increased due to the high
degree of anisocytosis and poikilocytosis, which was observed in the PBS. Cases of Macrocytic anemia show an increase
in MCV, MCH and RDW with normal MCHC.
Conclusion: Histogram plays an additional role with peripheral smear for diagnosing RBCs disorders. Haematology
analyzers were very useful and reliable for evaluation of abnormal peripheral smears. Histogram was correlated with
almost all peripherial smear interpretation in anemia cases.
Keywords: Histogram, Haematology Analyzer, Macrocytic anemia, Peripherial Smear
Introduction hematological abnormalities in modern clinical

The peripheral blood smear has been the main setups.
diagnostic aid in establishing the etiology of anemia. The RBC histogram visualizes particle size
Examining the blood films routinely has facilitated distribution that plays a critical role in the initial
interpretation of various hematological disorders. screening and detection method for haematological
Thirty to forty years ago, laboratory hematology was disorders in current clinical settings. With the
labor intensive and time consuming. Procedures were emergence of more powerful haematology analyzers
manual. Reagents were prepared in the laboratory with significant improvement and precision, the
from raw chemicals. Hemoglobin measurement manual peripheral smear examination steadily
was based on the cyanmethemoglobin method, declines. The number of the cells counted by the
which involved tedious procedure. The automated automated hematology analyzers is much more
hematology analyzer has replaced the traditional than the cells measured by manual peripheral smear
manual methods for hematological parameters examination, and computerized analyzers provide
as the initial screening and detection system for far better accuracy and with the usage of histograms.
Dr. Mohammad Frayez,
Department of Pathology and Blood Bank, ASMC Shahjahanpur
The RBC histogram, along with other CBC parameters This is a prospective cross-sectional study done
like RBC distribution width (RDW) and mean on all patients diagnosed with anaemia according to
corpuscular volume (MCV), has been discovered to WHO definition. The CBC samples received would
be aberrant in a variety of haematological illnesses be analyzed in the ABOTT cell dyn ruby instrument,
and may provide essential clues in the diagnosis and and a peripheral smear would be made from the same
treatment of significant red cell disorders.1-4 sample, using Leishman stain.
The curve of Red cell distribution is bell shaped and Results
peaks within 80 to 100 fl. For homogenous population
Out of the 500 samples, 192 samples were from Males,
of cells the curve was smaller, while for heterogenous
and 38 samples were from females. In the present
population the curve was wider. The curve was shifted
study, we found that the maximum number of cases
to right in megaloblastic anemia due to macrocytes;
were of Microcytic hypochromic anemia and showed
while in microcytic anemia it was shifted to left. If
various histograms. Among all, 16% histograms were
the patient had received treatment, Morphologically
normal,31% had a left-shifted curve,40% showed
two red cell population was seen, in which multiple
broad-based curve, 03% showed short peak, and
peaks can be observed and is referred to as Dimporhic
Bimodal peaked histogram was demonstrated by
anemia. In these conditions RDW was the better
06% of total cases. Correlation with Peripheral smear
indicator than MCV to assess anisocytosis. 5,6
findings: In our study, we observe that cases of
A histogram can assist laboratorians in 1) monitoring Microcytic hypochromic anemia with less than normal
the accuracy of the results provided by analyzers and range of Mean Corpuscular Volume (MCV) &Mean
2) examining the possible cause(s) of the erroneous Corpuscular (MCH) Hemoglobin with normal Mean
automated outcomes.3) establishing a tentative Corpuscular Hemoglobin Concentration (MCHC)
diagnosis 7 Certain situations, such as the presence and increased Red cell Distribution Width (RDW)
of fragmented red cells or red cell agglutination, may and this finding is correlated with anisopoikilocytosis
now theoretically Be seen on the red cell histogram, which was seen on the microscopic examination of
which could not previously be seen without a blood peripheral blood smear.
film study. A sequential histogram can also clearly
The cases of Normocytic Normochromic anemia
demonstrate the increasing emergence of a new
showed the standard limit of MCV, MCH and MCHC
erythrocyte population well ahead of other numerical
and occasional cases having mildly increased RDW.
indicators in patients with iron deficiency anaemia
In the present study, cases of dimorphic anemia
(IDA) or megaloblastic anaemia under treatment.8,9
showed a normal range of MCV, MCH and MCHC.
This present study was designed to determine the
At the same time, RDW is increased due to the high
relationship between Abbott cell dyn ruby- 5 part
degree of anisocytosis and poikilocytosis, which was
analyzer automated haematology analyzer histograms
observed in the PBS. Cases of Macrocytic anemia
and peripheral smear using the blood samples.
show an increase in MCV, MCH and RDW with
Objectives: 1) Interpretation of histograms in normal normal MCHC.
persons and patients with different types of anaemia.
Table 1: Age and gender distribution in the study
2) Comparison of automated histogram patterns with
morphological features noticed on peripheral smear Age 5-10 11-20 21-30 31-40 41-50 51-60 60
examination. group above
(years )
Material and Methods Male 13 9 56 38 43 23 10
A total of 500 samples sent for CBC and PS would female 9 19 158 82 21 14 6
be used for the present study for the duration of 5
Table 2: Case Distribution as per types of anemia
months.
Types of anemia No of cases Percentage (%)
Inclusion criteria: All patients who are diagnosed
as anaemic according to WHO definition Exclusion Normocytic 77 15.4
criteria 1) Patients who are less than five years of age. Microcytic 364 72.8
2) Inadequate quantity of blood sample for automated Macrocytic 21 4.2
analyzer (< 3ml). 3) Pre Analytical errors like clotted Dimorphic 38 7.6
sample.
236
Table 3: Distribution of RBC histogram in the in their reproductive years. Iron deficiency during
present study pregnancy is a significant problem in our nation.17,18 In
s. no. Type of histogram Percentage (%) macrocytic anaemia, a right shift with a broad-based
curve indicates a low Hb level and a macrocytic blood
1 Normal 16
image. The causes of macrocytosis range from benign
2 Left shift 31 to malignant, and determining the aetiology requires
3 Right shift 5 a comprehensive approach. Macrocytosis can strike
4 Broad base 40 at any age, though it is more common among the
5 Short peak 3 elderly.19-21
6 Bimodal peak 6 In our study majority of cases of macrocytic anemia
Discussion showed a right shift curve. Right shift curve correlated
well with increased MCV and MCH. The dimorphic
A single histogram graph can be equivalent to blood picture shows a bimodal curve, along with
1000 numbers. The effect of a vast collection of facts some cases leading to the left and right shifting of the
represented as a visual representation is significantly curve. There are wide reasons for dimorphic blood
greater than the impact of numbers alone. These picture, including nutritional anemia, recent blood
data can take numerous forms in haematology, one transfusion or therapy response to nutritional anemia
of which is the RBC histogram. The range, size, and sideroblastic anemia.
shape, and other conspicuous aspects of the red
cell morphology may all be seen by scanning the The majority of macrocytic anaemia cases in our
histogram visually.9 study had a right shift curve. Increased MCV and
MCH are associated well with the right shift curve.
Information about RBC parameters like RDW, The bimodal curve is visible in the dimorphic
MCH and MCV were obtained which helped in blood image, with some cases showing the left and
diagnosis and typing of anemia.3,4 Normal curve proper shifting of the curve. Nutritional anaemia,
was symmetrical bell shaped or showed Gaussian recent blood transfusion or therapeutic response to
distribution. Normal curve shows MCV range nutritional anaemia, and sideroblastic anaemia are
between 80-100 fl. 7,8. The analyzer can recognize only all possible causes of dimorphic blood images. To
those Red Blood cells 36fl to 360fl volume sizes as determine the specific cause, a complete examination
RBCs, and the range 24fl to 36 fl are not considered is required.22 These finding were correlated with
in the RBC count and not taken into consideration by study carried out by Sandhya14 and Chavda J.15 Our
the counter. The histogram begins above the baseline study was in concordance with the study conducted
(36fl) indicates the presence of small particles like by Constantino et al.16 in 2010. Using Fisher Exact test
microspherocytes, platelet clumps, normoblast, and comparing the two variables i.e peripheral blood
elliptocytes, malaria parasites, bacteria, etc. The RBC smear reports with histogram patterns the p values
count does not affect by WBCs count is increased by showed very high significant difference between
beyond 50000 cells / cumm.10-13 the two variables .This difference was largely due to
In the present study of 500 cases, the maximum dimorphic anemia cases which was in concordance
number of instances are having Microcytic anemia with Constantino et al.
followed by normocytic, Dimorphic and Macrocytic. Conclusion
Other studies like sandhya al14, BynaSyamSundara
Rao et al.15, Chavda J et al 16 were also found similar Histogram plays an additional role with peripheral
findings of anemia cases regarding Distribution. Our smear for diagnosing RBCs disorders. Haematology
survey of RBC histogram showed normal curve (16%), analyzers were very useful and reliable for evaluation
left shift (31%), right shift (5%), Broad base (40%), of abnormal peripheral smears. Histogram was
short peak (3%) and bimodal (6%) and these findings correlated with almost all peripherial smear
regarding RBC histogram were also correlated with interpretation in anemia cases. When the right
other studies. interpretation of the curve is paired with the
findings of blood count characteristics such as red
The most prevalent cause of microcytic RBC is iron cell distribution width and red cell indices, the RBC
deficiency anaemia, which affects mostly women Histogram becomes a useful diagnostic tool. Blood

indices and Hb values, as well as histograms, will help 12. Radadiya, Poonam, et al. Automated red blood
us. Histograms are a helpful tool for technologists cell analysis compared with routine red blood cell
since they may help them determine which instances morphology by smear review. NHL Journal of medical
require specialist peripheral smear testing. sciences 4. 1 (2015). [Crossref][PubMed] [Google
Scholar]
References 13. Gulati GL, Hyun BH. The automated CBC. A current
1. Bessman, J. David, P. Ridgway Gilmer Jr, and Frank H. perspective. Hematol Oncol Clin North Am. 1994
Gardner. Improved classification of anemias by MCV Aug;8(4):593-603 [Crossref][PubMed][Google Scholar]
and RDW. American journal of clinical pathology 80.3
14. Sandhya, I. and T. Muhasin. Study of RBC histogram
(1983): 322-326 [Crossref] [PubMed][Google Scholar]
in various anemias. Journal of Evolution of Medical
2. Williams, L. J. Cell histograms: New trends in data and Dental sciences 3.74 (2014): 15521- 15535 [Crossref]
interpretation and cell classification. Journal of medical [PubMed][Google Scholar]
technology 1. 3 (1984): 189-197 [Crossref] [PubMed]
15. Chavda, J. , P. Goswami, and A. Goswami. RBC
[Google Scholar]
histogram as diagnostic tool in anemias. IOSR Journal
3. Fossat C, David M, Harle JR, Sainty D, Horschowski N, of Dental and Medical Sciences 14.10 (2015): 19-22.
Verdot JJ, Mongin M. New parameters in erythrocyte
16. Constantino, Benie T. The red cell histogram and the
counting. Value of histograms. Arch Pathol Lab Med.
dimorphic red cell population. Laboratory Medicine
1987 Dec;111(12):1150-4 [Crossref][PubMed][Google
42. 5 (2011): 300-308. [Crossref] [PubMed][Google
Scholar]
Scholar]
4. Lawrence, A. , et al. “Red cell histograms in the
17. Constantino, Benie T. The red cell histogram and the
diagnosis of diseases. Hematology Beyond the
dimorphic red cell population. Laboratory Medicine
Microscope. New York, NY: Technicon Instruments
42. 5 (2011): 300-308. [Crossref] [PubMed][Google
(1984): 155-164.
Scholar]
5. Gulati GL, Hyun BH. The Automated CBC: A
18. Kakkar, Naveen, and Manisha Makkar. Red cell
Current Perspective. Hematol/Oncol Clin N Am.
cytograms generated by an ADVIA 120 automated
1994;8(4):593–603.
hematology analyzer: Characteristic patterns in
6. and Muhasin T P SI. Study of RBC Histogram in various common hematological conditions. Laboratory
anemias. J Evol Med Dent Sci. 2014;3(74):15521–34. Medicine 40. 9 (2009): 549-555.
7. Adewoyin AS, Nwogoh B. Peripheral blood film - A 19. Bessman JD. Red blood cell fragmentation. Improved
review. Ann Ib Postgrad Med. 2014;12:71–80. detection and identification of causes. Am J Clin Pathol.
1988 Sep;90(3):268-73. doi: 10.1093/ajcp/90.3.268
8. Kakkar, Naveen, and Manisha Makkar. Red cell
[Crossref][PubMed][Google Scholar]
cytograms generated by an ADVIA 120 automated
hematology analyzer: Characteristic patterns in 20. Kakkar N, Makkar M. Red cell cytograms generated
common hematological conditions. Laboratory by an ADVIA 120 automated hematology analyzer:
Medicine 40. 9 (2009): 549-555. [Crossref] [PubMed] Characteristic patterns in common hematological
[Google Scholar] conditions. Lab Med. 2009; 40:549- 555. [Crossref]
9. Benie T. Constantino, SH, I; ART, MLT(CSMLS); The
Red Cell Histogram and The Dimorphic Red Cell 21. Kaferle J, Strzoda CE. Evaluation of macrocytosis. Am
Population. LABMEDICINE. Volume 42 Number 5. Fam Physician. 2009 Feb 1;79(3):203-8.
May 2011.
22. Atul Shrivastava, Nilay Shah, Sunita Goyal and
10. Constantino, Benie T. The red cell histogram and the Cherry K Shah. RBC histogram: Utility in diagnosis of
dimorphic red cell population. Laboratory Medicine various anemia. International Journal of Clinical and
42. 5 (2011): 300-308. [Crossref] [PubMed][Google Diagnostic Pathology 2019; 2(1): 14-17.
Scholar]
11. Rao, Byna Syam Sundara, et al. RBC Histogram as

Supplementary Diagnostic Tool with Peripheral
Smear Examination in Evaluating Anaemia. Annals of
Pathology and Laboratory Medicine 4. 6 (2017): A668-
672. [Crossref][PubMed][Google Scholar]

Impact of COVID-19 Pandemic on Medical Education; Challenges for

Faculty and Medical and Paramedical Students in a Medical
College of South Kashmir.
Shaugfta Aara1, Mehak Mufti2, Shuaeb Bhat3, Mehbooba Rasool4, Meenakshi Sharma5
Assistant professor department of physiology GMC Anantnag, University of Kashmir
1,2
3
Assistant professor department of Pathology GMC Anantnag, University of Kashmir
4
Assistant professor department of Social and preventative Medicine GMC Anantnag , University of Kashmir
5
Assistant professor department of Physiology Kathua, University of Jammu
How to cite this article: Shaugfta Aara, Mehak Mufti, Shuaeb Bhat, Mehbooba Rasool, Meenakshi Sharma et al
mpact of COVID-19 Pandemic on Medical Education; Challenges for Faculty and Medical and Paramedical Students
in a Medical College of South Kashmir.
Abstract
Background: Coronavirus disease (COVID-19) is a highly contagious disease primarily involving the respiratory system.
On March 11, 2020, the World Health Organization proclaimed COVID-19 a pandemic. One of the important strategies
taken to prevent the spread of the disease has been social distancing around the world, Educational institutions have been
closed for the safety of both students and communities. Social distancing measures hamper the students’ learning process
as they are prevented from assembling in laboratories, lecture halls, or small-group rooms and engaging in person with
their peers and instructors. Although medical school is an adult schooling experience, the absence of interactive sessions
affects not only Medical education but all education curricula that require hands-on experience or internship. The most
significant response to the pandemic has been to shift teaching-learning and assessment online. Using standardized
patients and facilitators, schools have also attempted to shift clinical learning and teaching. Both professors and students
face obstacles when it comes to online teaching, learning, and assessment.
Materials and methods: This was a cross-sectional study conducted at Government Medical College Anantnag,
department of Physiology between October 2021 and December 2021 among 240 Medical, Paramedical students and
faculty members of GMC Anantnag. A questionnaire was distributed, by means of email to all the faculty members,
medical students, and paramedical students.
Results: The reported challenges to online education during the COVID-19 pandemic at this institution included issues
regarding in-person communication (19.5%), use of technology tools (12.5%), experience in online education (16.6%), time
management (29.1%), students’ evaluations of faculty (24.0%). In addition, we reported that 20% of participants did not
have fourth generation internet access. 45% had an unsatisfactory experience with the medical education program and
40% do not have availability of advanced technology.
Conclusion: COVID-19 has had an impact on many aspects of medical education as well as on medical students. The
degree of effect was especially influenced by the type of institution attended. When things return to normal, proper
planning and adequate rehabilitation will be needed to mitigate and possibly reverse the effects of COVID-19 on students’
health and welfare.
Keywords: COVID-19, medical education, online education, pandemic.
Corrosponding author:
Shaugfta Aara
Momin Abad Anantnag J & K, District Anantnag, 192101
Introduction Challenges for Student in shifting to online learning.

In December 2019, the Coronavirus Disease 2019 Students in online learning environments receive
(COVID-19) was first reported in Wuhan, Hubei less direct interaction and supervision than students
Province, China. It is characterized by pneumonia- in traditional classrooms. To stay motivated and
like symptoms. The virus spread exponentially, involved with the content, these kids will need to put
culminating in an outbreak throughout China and in more effort. There are specific standards for creating
the rest of world. Subsequently, on March 11, 2020, videos for online learning, such as minimizing video
World Health Organization declared it as a pandemic. duration, reducing cognitive load, and providing
As of October 2, 2020, there were more than 34.3 students with clear guidance and instruction5.
million confirmed cases. COVID-19 has caused Because the teacher’s supervision and guidance are
unprecedented disruption to the medical education limited in online learning environments, students
process and to healthcare systems1. Because of the should have well-developed self-regulated learning
virus’s high contagiousness it has been difficult to skills. There are issues with internet band width
continue with regular lectures, affecting the medical and a lack of a regular electrical source in several
education process, which is based on lectures and districts of South Kashmir. Many students do not
patient-centered education. The COVID-19 pandemic have access to a computer or laptop and have to rely
puts people at risk of developing life-threatening on their smartphones to access the internet. They had
conditions, presenting substantial challenges for to share devices with other family members because
medical education, as instructors must deliver lectures they work from home. During this time of crisis and
safely, while also ensuring the integrity and continuity uncertainty, both staff and students’ mental health
of the medical education process2. Our administration should be supported6.
developed a medical education curriculum that
Issues of assessment. Assessment of knowledge
provides students with learning opportunities on a
and especially of skills is particularly challenging
continual basis, while also avoiding delays due to the
in an online environment. Standard assessment
pandemic.
formats used in medical colleges, like: multiple choice
questions (MCQs), short answer questions (SAQs)
Online education and their challenges for faculty.
and objective structured clinical examination (OSCEs)
Online education and assessment are not without may need to be re-imagined.7
obstacles. Faculty face problems in transitioning from
Due to the concentration on COVID-19 patients,
face-to-face to online teaching. Not all professors are
these issues have resulted in limited patient
familiar with the technology that is utilized to provide
care, limiting the availability of bedside teaching
online sessions. Faculty members must put in a lot of
opportunities for medical students and training.
extra effort for transition to online learning, and they
The impact of the COVID-19 pandemic on medical
must deal with an uncertain and tough environment.
education and obstacles for teachers, medical
In an electronic learning environment, the teacher
students, and paramedical students are discussed in
has four major roles. These include instructional,
this study, with a particular focus on Government
managerial, societal, and technological issues³. In
Medical College, Anantnag (South Kashmir).
order for faculty members to be effective in these
jobs, they must undergo training. Faculty members Materials and Methods. We conducted a cross-
who work from home must balance additional family sectional study from December 2021 to January 2022
and social obligations. Not all faculty members, among medical, paramedical students (age group
particularly in south Kashmir, may have reliable 19-23 years) and faculty members(age group 30-55
internet connectivity at home. Due to work from home years) of GMC Anantnag. A total of 240 participants
and study from home rules, there may be a shortage were included in the study. A questionnaire was
of laptops, Personal computers, other information distributed, by means of email to all the faculty
technology equipment, and current resources may members, medical students and paramedical students.
have to be shared among family members. There A Google Form containing the study questionnaire
might not be enough physical space or a quiet setting was distributed among specific social media groups
in the house to record presentations and conduct comprising of medical students, and personal emails
synchronous conversations4. and messages were sent to them to ensure the

240
appropriate selection of study participants. A friendly 58 (24.16%) were faculty members and 182 (58.83%)
reminder was sent to potential respondents to ensure were Medical and Paramedical students.
the highest possible response rate. The questionnaire
Table 1: Urban Rural Comparison
was self-administered without intervention by
the authors or any specific person, and it did not Designation No. Of Urban Rural
contain any identifying data of the participants to and Age Participants Residents Residents
ensure confidentiality.The questionnaire covered Group
participants’ basic demographic data, such as their Faculty 58 38 20
gender, age, and their position in medical college. The (Age Group:
questionnaire also addressed their experience with 30-55 Years)
medical tele-education, including questions related
Students 182 47 135
to electronic device usage proficiency, type and (Medical and
quality of internet used, medical school educational Paramedical)
program status, availability of advanced technology,
, person communication ,student assessment, use of (Age Group:
19-23 Years)
technology tools, experience in online education and
time management . Total 240 85 155
Results. A total of 240 people took part in the Table 2: Male Female Comparison
research. The characteristics of the study respondents
Gender Number of Percentage
are depicted in Table 1 and Table 2
Participants
Characteristics Male 113 47.1%
Out of 240 participants, 113 (47.11%) were males and Female 127 52.8%
127 (52.89 %) were females.
Table 3: The reported challenges to online education during the COVID-19 pandemic at this institution
included issues regarding in-person communication (19.5%), use of technology tools (12.5%), experience in
online education (16.6%), time management (29.1%), students’ evaluations of faculty (24.0%),
Factors Faculty participants that Students participants that Total

associated with found it challenging found it challenging
online learning/
teaching Number Percentage Number Percentage Number Percentage
Communication 16 27.0% 31 17.22% 47 19.58%
Use of technology 10 17.2% 20 10.99% 30 12.50%

tools (access to
hardware and
software)
Time 23 40.23% 47 25.64% 70 29.17%
management
Overall 13 22.99% 27 14.65% 40 16.67%
experience with
online teaching/
learning
We reported that 20% of participants did not have fourth generation internet access. 45% had an unsatisfactory
experience with the medical education program and 40% do not have availability of advanced technology.

Table 4:Experience with Medical Teleducation Conclusion

Experience with Findings The COVID-19 epidemic has had an impact on and
medical teleducation will continue to have an impact on how knowledge
and skills are delivered at all levels of education.
Type and quality of 4G 192 (80%)
COVID-19 has caused a pause in medical education.
internet used
3G & Other 48 (20%) To address this issue, medical schools have begun
Impression of Medical Good 132 (55%) shifting to online lectures and introducing innovative
education program teaching methods that make use of technology to
Bad 108 (45%)
facilitate remote clerkships. Medical students are
Availability of Available 142 (60%) working on solutions to deal with the crisis as well.
advanced technology We need to establish a good online curriculum and
Unavailable 98 (40%)
effective evaluation tools in order to prepare for
Discussion. The purpose of this study was to assess the post-COVID era. We must build the necessary
the influence of the Covid 19 epidemic on medical infrastructure and allocate sufficient resources to
education and the issues that it presents for medical ensure its successful implementation. We also need
staff, medical students, and paramedical students at to teach students how to be socially responsible as
GMC Anantnag. The majority of medical students medical practitioners.
thought the Covid-19 outbreak had a detrimental
impact on their training, according to the conclusions Conflict of Interest:I declare that my article does
of this survey. Poor pedagogy has been linked to not have any potential or existing conflict of interest.
unfavourable learning experiences among medical
Author Declaration:
students in their first year8.
No conflict of interest. Informed consent was
The pandemic and subsequent prolonged periods obtained from participants.
of lockdown lead to a substantial reduction in the
volume of teaching received by medical students9. Ethical Clearance: Taken from Institutional Ethics
This had a greater impact on younger students in Committee, Government Medical College, Anantnag,
pre-clinical years, who rely heavily on pedagogical J&K.
methods compared to their older counterparts who References
rely on andragogy10. In our study it was found students
1. Adeleke victor faisku et al. Perception of Medical
who reported a reduction in conventional lectures
Students on the Effect of COVID-19 on Medical
and ward-based teaching were also significantly
Education in Nigeria. In International Journal of Medical
more likely report a negative impact on training. Students Aug 2021 ijms. 2021.914
Limited resources, poor infrastructure and technical
difficulties are significant barriers to virtual medical 2. WHO I Novel Coronavirus (2019-nCoV). Situation
report-1, 21 January 2020. [Internet] WHO World
training Waliany S et11 has found same results. The
Health Organization [Cited April 22, 2020] Available
reported challenges to online education during the
at:
COVID-19 pandemic at this institution included
issues regarding in-person communication (20.43%), 3. Sandhu P and de Wolf M. The impact of COVID-19
student assessment (30.43%), use of technology on the undergraduate medical curriculum. Medical
tools 13%), experience in online education (17.39.%), Education 2020; 25: 1764740.
time management (30.43%), students’ evaluations 4. Del Rio C, Malani PN. 2019 Novel coronavirus-
of faculty (21.47%), Furthermore, medical students important information for clinicians
reported high levels of computer and information
5. Torda AJ, Valen G, Perkovic V. The impact of COVID-19
technology proficiency. Most (80%) reported that they pandemic on medical education. The Medical Journal
had access to fourth generation internet services with of Australia, Preprint. 14 May 2020
an acceptable or good internet connection. while 20%
6. Abzwari S. Rethinking Assessment in Medical
experienced problem in medical education program
Education in the time of COVID19. MedEdPublish
and 80% of study participants do not have availability
2020; 9: 80.
of advanced technology. The same results have been
found by Ahmed Alsoufi12 et al and Jacob Hoofman13,
and Elizabeth Secoryet al14.

242
7. Barnett-Vanes A et. Impact of conflict on medical 10. Rose S. Medical student education in the time of
education: a cross-sectional survey of students COVID-19. JAMA. 2020;323(21):2131–2132.
and institutions in Iraq. BMJ Open 2016;6:e010460.
11. Singh K., Srivastav S., Bhardwaj A. Medical education
doi:10.1136/bmjopen-2015-010460
during the COVID-19 pandemic: a single institution
8. Tackle challenges of online classes due to COVID-19. experience. Indian Pediatr. 2020;57(7):678–679 11.
(2020). Accessed: May 9, 2020
9. Cecilio-Fernandes D, Parisi M, Santos T, Sandars J. The

COVID-19 pandemic and the challenge of using
technology for medical education in low and middle
income countries

Periodontics-Prosthodontics - An Interdisciplinary Approach
Shilpa Sharma1, Sameer Ahmed2, Mayur Kaushik3, Simran Mishra4

1
Postgraduate Student, Department of Periodontology, Subharti Dental College & Hospital, Meerut (250005)
2
Professor, Department of Periodontology, Subharti Dental College & Hospital, Meerut (250005)
3
Professor & Head, Department of Periodontology, Subharti Dental College & Hospital, Meerut (250005)
4
How to cite this article: Shilpa Sharma, Sameer Ahmed, Mayur Kaushik, Simran Mishra et al
Periodontics-Prosthodontics - An Interdisciplinary Approach. Volume 13 | Issue 4 | October-December 2022
Abstract
As the mean age of the population is increasing and the current therapeutic concerns is for teeth to be retained. It is
now quite common to encounter complex clinical situations like severe tooth-tissue loss, advanced periodontal disease
along with significant esthetic concerns. Dentists now a days, not just restore teeth to make them better for functioning,
but also cater an increased esthetic concern of the patients.Thus, many a times, patients who present with a complex
restoration also require an esthetic rehabilitation. Although periodontal factors do not usually have a direct effect on
the survival of fixed prosthesis however a harmony between prosthesis and periodontium remains critical, affecting the
longevity, esthetics and to prevent unsatisfactory treatment outcomes. The present article addresses and summarizes the
current knowledge of Prosthetic and Periodontic clinical procedures that play a role in any clinician’s attempt to create
biologically acceptable and aesthetically pleasing long-lasting restorations.
Keywords: Interdisciplinary dentistry, Esthetics, Biologic width, Implants, Crown lengthening, Restorative margin,
Gingival contour, Gingival Biotype, Soft-tissue augmentation.
Introduction interface.2 Periodontal therapy has developed beyond

Interdisciplinary dentistry can be described as the scope of the treatment of periodontal pathoses
mutual permeation of various specialities in dentistry and consists of the reconstructive procedures that
that goes hand in hand for the complete well-being enhance both function and esthetics which can be
of thepatient. Periodontology and Prosthodontics broadly categorised under:3
hold one of the powerful and close connections of 1. Anatomical Considerations.
all disciplines of modern dentistry where healthy 2. Biologic Considerations.
periodontium is vital for long term success of
restorations. On the other hand, defective prosthesis 3. Esthetic Considerations.
may lead to progression of periodontal disease.1 4. Peri-implant soft tissue Considerations.
A sound periodontium provides a firm foundation Anatomical Considerations
for an esthetic and functional prosthesis. Conversely, The relationships among the tooth-supporting soft
when restorations are designed to be self-cleansing and hard tissues, the junctional epithelium, the
and promote gingival health, the tissues present a connective tissue attachment, and the bone crest have
harmonious esthetic blend at the restorative-gingival been clarified in the landmark histological study by
Dr. Shilpa Sharma
Postgraduate Student, Department of Periodontology, Subharti Dental College & Hospital, Meerut (250005),
E-mail: [email protected],
Mob.: 8171619732
244
Gargiulo et al.4 The dimensions of dento-gingival crown height.7 The presence of sufficient sound tooth
complex called as “Biologic Width” is present around structure coronal to the bone crest is essential to satisfy
the natural teeth in a protective cuff- like barrier the placement of the restorative marginson sound
which has the tendency to self-restore and adapt tooth structure and preservation of biologic width
dynamically. (Figure 1) together with a healthy periodontium.8Furthermore,
crown lengthening procedures can be done
The suggested physiological function of the biologic
with:9(Figure 2)
width is that of a protective barrier for the subjacent
periodontal ligament and the supporting alveolar • Gingivectomy.
bone from the attack of a pathogenic biofilm present • An Apically Positioned Flap (APF) with
in the oral cavity. Hence, subgingival placement of osseous reduction.
crown margins mayaffect the homeostasis of the
• Forced eruption combined with surgery or
periodontal tissues.5
combined with fiberotomy.
Figure 1: Diagrammatic representation of Biologic
The additive methods correct gingival level and
contour by augmenting the gingival tissues. They
improve the esthetics by increasing the width of
attached gingiva with a primary aim of achieving an
even band of attached gingiva and maintaining root
coverage. These procedures should be completed
before the prosthodontic treatment using Free
gingival graft, Connective tissue graft, Coronally
positioned flap.10
Width
Violation of Biologic Width:It leads to difficult

impressioning and hygiene procedures and
unacceptable coronal contours of the restoration. The
reasons for the violation include an attempt to access
sound tooth structure, increased preparation length,
previous restorations, existing caries, resorption
defects, traumatic injury, iatrogenic insults, and
improper identification of sulcus depth.6 However,
treatment modalities to re-establish biological width Figure 2: A: Greater than 3mm soft tissue between
and modify the gingival contour can be classified bone and gingival margin, with adequate
under the Subtractive and Additive Methods. attached gingiva, allowing crown lengthening by
gingivectomy.
Subtractive methods are used more commonly
than additive methods as they are more predictable. B: Less than 3mm soft tissue between bone and
They re-establish a physiological biologic width by gingival margin, inadequate attached gingiva, flap
performing Crown Lengthening procedures. Crown procedure and osseous recontouring for crown
lengthening is a surgical procedure aimed at the lengthening.
removal of periodontal tissue to increase the clinical

Restorative margin placement: The effect of the crest. When the total dentogingival complex has a
location of an artificial crown margin on plaque length of less than 3mm, a high alveolar crest occurs
accumulation and gingival health were well and caution must be used. Margin location should
documented by Flores-de-Jacoby et al.11 According be at the level of the free gingival margin or no more
to the evaluation, interactions between dental than 0.5 mm apically, to avoid the risk of violating the
restorations and periodontal tissues, it was stated biological width.14
that restorative margin with a supragingival location
Margin placement must respect the attachment
was the most beneficial restoration type in terms of
apparatus and allow some degree of error during
periodontal health. In contrast, restorations with
the high-speed instrumentation. The clinical steps of
equigingival and subgingival margin terminations
tooth preparation consist of facilitation of the gingival
resulted in increased plaque accumulation.5
margin and placement of an extra-thin knitted
Despite better esthetics, subgingival restorations retraction cord that displaces the gingiva outward and
were also associated with greater periodontal apically.The preparation designs for full-coverage
inflammation in the sites with keratinized gingiva restorations can be classified into four distinct types.
less than 2 mm. With respect to periodontal health, (Figure 3)
the supragingival restoration is the most favourable
1. Feather-edge (vertical preparation)
design since it is easy to be cleaned.12
2. Chamfer (‘‘hybrid’’ preparation)
Richter & Ueno13 stated that marginal fit and finish
may be more significant to gingival health than its 3. Shoulder (horizontal preparation)
location. Ideally, the margin of a prosthetic restoration 4. Shoulder with bevel preparation
should be easily accessible for the facilitation
and fabrication of the provisional restoration and
impression taking. The most critical factor in margin
location seems to be the relationship to the supracrestal
fibre attachment. A margin placed apical to the base
of the periodontal pocket into the zone of biological
width, specifically, into connective tissue attachment,
violates important biological principles with adverse
consequences on long-term gingival health.
Therefore, the most important consideration for
intracrevicular restorative dentistry is locating the
Figure 3: Preparation designs.
base of the gingival sulcus or periodontal pocket.
The dentogingival complex comprises of three A. Feather-edge. B. Chamfer. C. Shoulder with
bevel. D. Shoulder.
components namely connective tissue fibrous
attachment, junctional epithelium,and gingival
Biologic considerations
sulcus.
The important biological parameters that decide
The histological sulcus depth ranges from 0.5 to 1 the success of Periodontic-Prosthetic treatment is
mm, whereas the clinical sulcus depth measures from dependent on the accumulation of plaque forming
1 to 4 mm in health. The biological width follows the bacteria upon the restorations and the resultant
osseous scallop. Therefore, the inappropriate use of a gingival inflammation. Also, marginal integrity of
more horizontal tooth preparation margin as opposed restoration and contour are another pivotal aspect.
to a scalloped margin on anterior teeth will often
violate the biological width in the interproximal area. Bacterial Plaque Accumulation: Patient
susceptibility to gingival inflammation is not based
Thus,it is important to know the total dentogingival solely on the mere quantity of dental plaque but also on
complex measurement when preparing a tooth. the virulence of the resident plaque microorganisms.
Assuming the normal 3 mm from the alveolar bone The bacterial biota of dental plaque is dynamic, and its
crest to the free gingival margin. The intracrevicular pathogenicity tends to change over time.6Adamczyk
margins might be located 0.5-1 mm apical to the free and Spiechowics17 evaluated plaque accumulation on
gingival margin or 2-2.5 mm coronal to the osseous crowns of various materials and inferred that rougher
246
material experiences a statistically greater incidence in the case of the thick-flat biotype and regrowth of
of plaque accumulation. gingival height after resective osseous surgery.20
Mechanical insults such as placing cords, copper Gingival Zenith:Harmony and symmetry are key
bands and retraction clamps create a wound that factors that need to be assessed when planning esthetic
may disrupt the junctional epithelium and connective restorations. The zenith point orientation is distal to
tissue attachment.The gingival health around the long axis of central incisors and cuspids and is
restorations can be managed by initial Periodontal coincident with the long axis of the lateral incisors.
therapy.18 As a general guideline, the height of the gingival
margins of central incisors and canines should be
Gingival level and Contour:It seem logical that the
at the same level. Correct orientation of the zenith
most predictable gingival response will occur when
and gingival height contour following therapeutic
the artificial crown portion mimics the original shape
manipulationhelps avoid gingival level disharmony
of the tooth as much as possible.The location of the
and aids in establishing correct tooth proportions.
proximal surfaces of adjacent teeth also seems to be
a critical factor in gingival health. With close root Importance of Attached Gingiva: Attached
proximity, even slight deviations from the original gingiva around teeth minimizes the risk of gingival
contour may compromise the complex relationship recession when preparing esthetic margins and to
of the interproximal gingival tissue. The initial tooth increase patient comfort when performing oral-
anatomy should be evaluated to determine the impact hygiene procedures. Lang & Loe21 claimed that
of treatment on esthetic, hygiene, and biomechanical gingival inflammation accompanied in cases in which
requirements. less than 2 mm of attached gingiva was present. It
was believed that the band of attached gingiva is
Esthetic Considerations important to dissipate the muscular pull forces and is
From an esthetic perspective, the intra-oral assessment capable of withstanding trauma from mastication and
involves evaluating the periodontal structures of the toothbrushing.
bone, gingiva, interdental papillae, the teeth,and the
Edentulous Area: It includes assessment of the
biologic space. To obtain a good esthetic outcome,
location, height, width, and contour of the residual
scrupulous attention to detail and an accurate
ridge. When a fixed dental prosthesis is planned,the
diagnosis should be established.
prosthesis components to be considered are the
Gingival Biotype: Clinically, assessing gingival pontic and the connectors because they influence
biotypes translates into observing gingival thickness. the esthetics, durability of the prosthesis and the
Accordingly, two biotypes can be identified: health of the soft tissue. Biologically, it has been
• A thick-flat type. proposed that pontics should exhibit pressure-free
contact on keratinized attached tissue,prevent food
• A thin-scalloped type. accumulation and facilitate plaque control.Regarding
Patients with thin biotype differ from patients with an ideal pontic design “Modified ridge lap” in the
a thick/average biotype as they present with a thinner posterior region and a “lap facing” in anterior region
labial plate and an alveolar crest position that is has been found ideal in maintaining Pontic-Ridge
located more apical in relation to the CEJ. Periodontal relationship.
biotype can be diagnosed by the ability to visualize
the periodontal probe through the gingival sulcus in Peri- implant soft tissue Considerations
thin biotype and the inability to visualize the probe in The development process of the tooth includes the
a thick biotype.19 It has been shown to affect soft tissue formation of a biologic connection between the living
esthetic outcomes around anterior implants. tissues. For a dental implant, this connection must
be created during the healing process after implant
Patients with a thin biotype have more interproximal
placement. The resulting attachment, although
and midfacial recession postimplant placement
similar in function, has biologic differences that must
than in patients with a thick biotype and they may
be comprehended to design surgical techniques and
require additional therapy such as hard and soft
biomaterials that will surround the implant with
tissue augmentation. Numerous research indicated
biologically functional and esthetic soft tissue.22
predictable results after root-coverage procedures
Soft tissue interface: The implant–soft-tissue bone
interface is like that of natural teeth.The epithelium a. The 3-mm space is needed on the
around the implants undergoes morphologic and prosthetic abutment for formation of
functional changes and the junctional epithelium is biologic width.
formed. This attachment is facilitated by the basal
b. An emergence profile of implant
lamina and the formation of hemidesmosomes which
restorations needs room for a smooth
prevents the apical movement of the epithelium.
transition from the circular implant
(Figure 4)
platform to triangular or square abutment
Figure 4: Soft tissue considerations around and crown.
Implants.
c. There should be space available for
restorative margin below marginal soft
tissue.
d. The possibility of peri-implant marginal
soft tissue recession increases as the
patient ages.
2. Buccolingually, the implant placement from
its outer aspect of platform is 1 mm palatal
from the anticipated facial margins of the
restoration.
3. The implant platform is located on same axis
Unlike tooth, the collagen fibres around implants with the gingival zenith and 3 mm lower than
do not insert into the titanium surface. Instead, they the free soft-tissue margin.23
form a cuff, making it less mechanical resistance than
natural teeth. Surfacecharacteristics of the implant Soft tissue augmentation around implants: Peri-
influence the orientation of the fibres, which are implant soft-tissue management can be regarded as
mostly parallel to the implant surface when thesurface a category of mucogingival procedures analogous
is smooth. Surface roughness allows connective tissue to reconstructive procedures around teeth including
to embed into the surface. When implants are loaded, Root coverage, Papilla reconstruction, Ridge
fibre orientation is more transverse hence the success augmentation and preservation. Prosthetic treatment
of implant is dependent on the establishment of a soft of uncorrected ridge defects with a fixed restoration
tissue barrier that can shelter the underlying osseous may lead to esthetic as well as functional complications
structure. such as open interdental spaces forming black
triangles, difficult pontic design causing inadequate
Keratinised attached mucosa: The stability of emergence profile, unesthetic gingival texture,
the mucosa provides better support to underlying whereas functional problems which may comprise
connective tissue, and junctional epithelium which food impaction.3 The augmentation procedures
creates a seal around the implant.The challenges to can be accomplished during extraction, before or
the soft tissue during the prosthodontic phase are during implant placement, or when the implant is
better absorbed by keratinized tissue and the esthetics uncovered, or even post restoration. Therefore, soft
of implant prosthesis also depends on the health and tissue augmentation techniques that provide better
stability of the peri implant tissue. esthetic outcomes includes:
Implant placement: Specific placement guidelines • Pedicle full- or split-thickness palatal flaps
have been developed to accomplish soft-tissue
stability around implants that are applicable when • Free gingival grafts
bone is sufficient and of good quality: • Soft tissue allografts
1. The apicocoronal placement of the dental • Combination Hard- and Soft-tissue Grafting
implant platform should be positioned 3 mm
below the facial marginal tissue. The 3-mm An appreciation of the relationship between
rule was created for the following reasons: periodontal health and restoration longevity remains
a key factor in ensuring a good function, form, and

248
esthetic of the dentition. Consequently, achieving a 7. Mukherji A, Rath SK. Full-mouth aesthetic
successful restorative outcome necessitates that the rehabilitation: A perio-prostho interdisciplinary
final restoration is planned and integrates well with approach. J Int Clin Dent Res Organ. 2015;7:155-160.
the surrounding periodontium. Thus, for obtaining 8. Assif D, Pilo R, Marshak B. Restoring teeth following
a good esthetic outcome clinician should establish crown lengthening procedures. J Prosthet Dent
a correct diagnosis and evaluate the prognosis to 1991;65:62–64.
carry out appropriate treatment plan that proceeds
9. Nowzari H. Aesthetic osseous surgery in the treatment
according to the biologic as well as clinical evidence.24 of periodontitis. Periodontol 2000 2001;27:8–28.
Conclusion 10. Camargo PM, Melnick PR, Kenney EB. The use of free
Predictability and success in esthetic dentistry are gingival grafts for aesthetic purposes. Periodontol
2000 2001;27:72–96.
largely dependent on the health and stability of the
periodontal tissues. Also, emphasis should be placed 11. Flores-de-Jacoby L, Ziafiropoulos GC, Ciancio S.
on the control of bacterial plaque, the marginal integrity The effect of crown margin location on plaque and
ofrestoration, its contourandlocation.6Although, periodontal health. Int J Periodontics Restorative Dent
patient cooperation is yet another aspect. Since it is 1989;9:197-205.
a multidisciplinary approach, multiple appointments 12. Hsu YT, Huang NC, Wang HL. Relationship between
and patient compliance are required to complete and periodontics and prosthodontics: The two-way street.
maintain the long-term success of treatment.25 J Prosthodont Implantol 2015;4:4–11.
Ethical clearance- Taken from Ethical committee of 13. Richter WA, Ueno H. Relationship of crown margin
Swami Vivekanand Subharti University. placement to gingival inflammation. J Prosthet Dent
1973;30:156–161.
Source of funding- Self.
14. Kois JC. The gingiva is red around my crown - a
Conflict of Interest - Nil. differential diagnosis. Dent Econ 1993;4:101-105.
References 15. Shillingburg Jr HT, Hobo S, Fisher DW. Preparation

design and margin distortion in porcelain-fused-to-
1. Tomar N, Bansal T, Bhandari M, Sharma A. The
metal restorations. J Prosthet Dent. 1973;29:276–284.
perio-esthetic-restorative approach for anterior
rehabilitation. J Indian Soc Periodontol 2013;17:535– 16. Rosner D. Function, placement, and reproduction of
538. bevels for gold castings. J Prosthet Dent 1963;13:1160–
1166.
2. Muddugangadhar BC, Siddhi T, Suchismita D.
Prostho-Perio-Restorative Interrelationship: A Major 17. Adamczyk E, Spiechowics E. Plaque accumulation on
Junction. J Adv Oral Res 2011;2:7–12. crowns made of various materials. Int J Prosthodont
1990;3:285-291.
3. Shett D, Dharmadhikari S, Shetty A, Bapat R. A
Case Report of Ridge Augmentation using Onlay 18. Sorensen JA, Doherty FM, Newman MG, Flemmig TF.
Interpositional Graft: An Approach to Improve Gingival enhancement in fixed prosthodontics. Part I:
Prosthetic Prognosis of a Deficit Ridge. Adv Hum Biol Clinical findings. J Prosthet Dent 1991;65:100–107.
2014;4:44–50.
19. Cook R, Lim K. Update on Perio-prosthodontics.
4. Gargiulo AW, Wentz FM, Orban B. Dimensions and Dental Clinics 2019;63:157-174.
relations of the dentogingival junction in humans. J
20. Pontoriero R, Carnevale G. Surgical crown lengthening
Periodontol 1961;32:261–267.
a 12-month clinical wound healing study. J Periodontol
5. Schmidt JC, Sahrmann P, Weiger R, Schmidlin PR, 2001;72:841–848.
Walter C. Biologic width dimensions–a systematic
21. Lang N, Loe H. The relationship between the width of
review. J Clin Periodontol 2013;40:493–504.
keratinized gingivae and gingival health. J Periodontol
6. Kois JC. The restorative-periodontal interface: 1972;43:623–627.
biological parameters. Periodontol 2000. 1996;11:29–
22. Jahan S, Kaushik M, Wadhawan A. Comparative
38.
Evaluation of Peri-implant Soft and Hard Tissue
with and without Application of Bisphosphonate

on Implant Surface and Osteotomy Site – A Clinico- 25. Bhat VS, Malli P. Periodontal Prosthesis-Review. J
radiographic, Cone-beam Computed Tomographic Health Allied Sci 2015;5:97–102.
Study. Contemp Clin Dent 2019;10:208–213.
23. Geurs NC, Vassilopoulos PJ, Reddy MS. Soft tissue

considerations in implant site development. Oral
Maxillofac Surg Clin 2010;22:387-405.
24. Lang NP. Periodontal considerations in prosthetic

dentistry. Periodontol 2000 1995;9:118-131.

Effectiveness of Planned Teaching Program on Knowledge Regarding

the Management of Hospital aquired Infections in Children.
Shivateerthayya Hiremath1, Prasad Patil2 , Madusudhan K.G3, Princely B Olickal4

1
Professor, Department of Medical-Surgical Nursing, V.M.P. College of Nursing & Medical Research Institute, Akluj,
Solapur, Maharashtra-413118, India.
2
Vice Principal , Department of Child Health Nursing, V.M.P. College of Nursing & Medical Research Institute,
Akluj, Solapur, Maharashtra-413118, India.
3
Assoicate Professor, Department of Community Health Nursing, MIT Nursing College, Aurangabad,Maharashtra-431001, India.
4
Assoicate Professor, Department of Child Health Nursing, MIT Nursing College, Aurangabad,Maharashtra-431001, India.
How to cite this article: Shivateerthayya Hiremath, Prasad Patil , Madusudhan K.G, Princely B Olickal et al
Effectiveness of Planned Teaching Program on Knowledge Regarding the Management of Hospital aquired Infections
in Children. Volume 13 | Issue 4 | October-December 2022
Abstract
In the present study, data were collected on knowledge regarding management of Hospital Aquierd infections in
children. The objective of the study is to identify the knowledge of B.Sc Nursing students regarding the management
of Hospital aquired infections in children and to determine the association between post-test knowledge scores with
selected demographic variables.The research method adopted for this study is the evaluative approach. The research
design adopted for this study was a pre-experimental design with one group pretest and post-test design. A simple
random technique was used to select the sample for the study. The sample consists of 60 B.Sc Nursing students of
Nursing institutions. The instrument used for the data collection is a structured questionnaire. Collected data were
analyzed by using descriptive and inferential statistics.The results of the study showed that the pretest overall knowledge
score regarding various aspects of management of Hospital Aquierd infections in children was a mean percentage of
46.86% and SD was 3.51. During the post–the test overall knowledge score was 80.53% and SD was 2.98.Hence the
difference between pretest and post-test over a knowledge score was 33.67. The results show that the difference between
the pretest and post-test knowledge scores for the management of Hospital Aquierd infections in children is statistically
significant and this difference is due to planned teaching program in the management of Hospital Aquierd infections in
children. The conclusion was drawn on the basis of the following findings of the study. This study shows that there was
a significant improvement in the knowledge of management of infections in children among B.Sc Nursing students as
evidenced and post-test knowledge scores.
Keywords: Asses, Knowledge, PTP, Hospital aquired infections
Introduction die as a result of their infections. Hospital-acquired

A hospital-acquired infection is usually one that infections usually are related to a procedure or
first appears three days after a patient is admitted treatment used to diagnose or treat the patient’s
to a hospital or other health care facility. Infections illness or injury. About 25% of these infections can
acquired in a hospital are also called Hospital be prevented by healthcare workers taking proper
aquired infections. About 5-10% of patients admitted precautions when caring for patients1.
to hospitals in the United States develop a Hospital Hospital-acquired infections can be caused
Aquierd infections. About 90,000 of these patients by bacteria, viruses, fungi, or parasites. These
Shivateerthayya Hiremath
Professor, Department of Medical-Surgical Nursing, V.M.P. College of Nursing & Medical Research Institute,
Akluj, Solapur, Maharashtra-413118, India.
microorganisms may already be present in the done in the hospital. The microorganisms come from
patient’s body or may come from the environment, contaminated equipment or the hands of health care
contaminated hospital equipment, health care workers. Some of these procedures are respiratory
workers, or other patients. Depending on the causal intubation, suctioning of material from the throat and
agents involved, an infection may start in any part mouth, and mechanical ventilation. The introduced
of the body. A localized infection is limited to a microorganisms quickly colonize the throat area. This
specific part of the body and has local symptoms. means that they grow and form a colony but do not
For example, if a surgical wound in the abdomen yet cause an infection. Once the throat is colonized, it
becomes infected, the area of the wound becomes red, is easy for a patient to inhale the microorganisms into
hot, and painful. A generalized infection is one that the lungs.Patients who cannot cough or gag very well
enters the bloodstream and causes general systemic are most likely to inhale colonized microorganisms
symptoms such as fever, chills, low blood pressure, into their lungs. Some respiratory procedures can
or mental confusion.Hospital-acquired infections may keep patients from gagging or coughing. Patients who
develop from surgical procedures, catheters placed in are sedated or who lose consciousness may also be
the urinary tract or blood vessels, or material from unable to cough or gag. The inhaled microorganisms
the nose or mouth that is inhaled into the lungs. The grow in the lungs and cause an infection that can lead
most common types of hospital-acquired infections to pneumonia5.
are urinary tract infections (U.T.I.s), pneumonia, and
WHO reported that every minute a mother dies
surgical wound infections2.
from complications in pregnancy and childbirthwhich
All hospitalized patients are susceptible to means 1400 mothers die every day. More than half a
contracting a Hospital Aquierd infections. Some million mothers die every year. The birth of a baby
patients are at greater risk than others young children, is a momentous occasion in a couple’s life. The aim
the elderly, and persons with compromised immune of modern MANAGEMENT of labor should be to
systems are more likely to get an infection. Other risk ensure optimum conditions for the mother and the
factors for getting a hospital-acquired infection are fetus during and after delivery as well as emotional
a long hospital stay, the use of indwelling catheters, satisfaction for all involved. The place of delivery
failure of healthcare workers to wash their hands, plays an important role in child survival and safe
and overuse of antibiotics3. Urinary tract infection motherhood. A child born withan unhygienic
(U.T.I.) is the most common type of hospital-acquired condition is more to get the infection. A properly
infection. Most hospital-acquired U.T.I.s happen assisted delivery with skilled personnel and following
after urinary catheterization. Catheterization is the aseptic precaution is highly advantageous to both
placement of a catheter through the urethra into the mother and fetus during delivery6. Health can neither
urinary bladder. This procedure is done to empty be demanded nor given, it can neither be bought
urine from the bladder, relieve pressure in the nor sold, but the circumstances and services that are
bladder, measure urine in the bladder, put medicine prerequisites to health can centrally be demanded
into the bladder, or for other medical reasons. The and received as right. A protective environment in the
healthy urinary bladder is sterile, which means it hospital unit is essential as a prerequisite, particularly
doesn’t have any bacteria or other microorganisms in when considering the services provided in the labor
it. There may be bacteria in or around the urethra, but room provision for a safe and protective environment
they usually cannot enter the bladder. A catheter can is a priority need7.
pick up bacteria from the urethra and allow them into
Healthcare-associated infections are defined as
the bladder, causing an infection to start4.
infections not present and without evidence of
Bacteria from the intestinal tract are the most incubation at the time of admission to a healthcare
common type to cause U.T.I.s. Patients with poorly setting. To better reflect the diverse healthcare settings
functioning immune systems or who are taking currently available to patients, the term healthcare-
antibiotics are also at risk for infection by a fungus associated infections replaced old ones such as
called Candida. Pneumonia is the second most Nosocomial, hospital-acquired, or hospital-onset
common type of hospital-acquired infection. Bacteria infections.Within hours after admission, a patient’s
and other microorganisms are easily brought into flora begins to acquire the surrounding bacterial
the throat by respiratory procedures commonly pool characteristics. Most infections that become

252
clinically evident after 48 hours of hospitalization are nursing personnel fails to adopt the infection control
considered hospital-acquired. Infections that occur technique, it maylead to septicemia and children’s
after the patient is discharged from the hospital can deaths. In order to prevent I.M.R., the nursing
be considered healthcare-associated if the organisms students (at the base level) should be knowledgeable
were acquired during the hospital stay8. in providing infection-free nursing care. The nurse
concerned with the care and management of infection
Need for the Study occurring through all the sources holds a responsible
Today’s Nursing students are tomorrow’s staff nurses involvement position. They have an important role in
who can contribute themselves more in the field of the management of infection in a pediatric hospital.
treatment. But today, this nursing curriculum doesn’t The nursing student has to be knowledgeable
give much importance to infection control measures. regarding preventive measures in controlling
Thus, students have less exposure to that field makes Hospital aquired infections12.
them vulnerable to knowledge. Educating these
Hospitals and other healthcare facilities have
students and creating awareness in help them to learn
developed extensive infection control programs to
more about the control of Nosocomialinfections in
prevent Hospital aquired infections. These programs
children, and they will be able to control the infection
focus on identifying high-risk procedures and other
in the pediatric hospital.In 2010 M.M.R. was reduced
possible sources of infection. High-risk procedures
to less than 100. The suggestion wasthree antenatal
such as urinary catheterization should be performed
check-ups, three postnatal check-ups, and clean, safe
only when necessary, and catheters should be left
delivery given by the national health and family
in for as little time as possible. Medical instruments
welfare department. Service to make motherhood
and equipment must be properly sterilized to ensure
safe includes care by skilled health personnel, aseptic
they are not contaminated. Frequent handwashing
delivery before, during, and after childbirth, health
by healthcare workers and visitors is necessary
education for women, their families, and decision-
to avoid passing infectious microorganisms to
makers; most maternal deaths and pregnancy
hospitalized patients. In 2003, the Joint Commission
complications can be prevented if efficient care is
on Accreditation of Healthcare Organizations
given during child care9.
(JCAHO) announced it would make the management
Surgical procedures increase a patient’s risk of of Hospital aquired infections a major goal in 2004
getting an infection in the hospital. Surgery directly and the coming years. JCAHO, the body that inspects
invades the patient’s body, giving bacteria a way into hospitals for quality and accredits them accordingly,
normally sterile parts of the body. An infection can issued an alert stating that hospital-acquired infections
be acquired from contaminated surgical equipment are seriously underreported13.
or from healthcare workers. Following surgery, the
The Study on the Efficacy of Hospital Aquierd
surgical wound can become infected. Other wounds
infections Control Project (SENIC) from 2005 showed
from trauma, burns, and ulcers may also become
Nosocomial rates could be reduced by 32% if infection
infected10.Many hospitalized patients need a steady
surveillance were coupled with appropriate infection
supply of medications or nutrients delivered to their
control programs. In 2005, Continued surveillance
bloodstream. An intravenous (IV) catheter is placed
and sound infection control programs led to
in a vein, and the medication or other substance is
decreased healthcare-associated infections and better
infused into the vein. Bacteria transmitted from the
prioritization of resources and efforts to improve
surroundings, contaminated equipment, or healthcare
medical care. Healthcare-associated infections are of
workers’ hands can invade the site where the catheter
important wide-ranging concern in the medical field.
is inserted. A local infection may develop in the skin
They can be localized or systemic, involve any body
around the catheter. The bacteria also can enter the
system, and be associated with medical devices or
blood through the vein and cause a generalized
blood product transfusions14.
infection. A localized infection causes swelling,
redness, and tenderness at the site of infection11. The investigator observed that many times nursing
students have adequate knowledge of aseptic
Nursing personnel working in the pediatric
techniques in a pediatric hospital. Hand washing,
ward should be knowledgeable and skillful in the
the single most measure in management and spread
management of Hospital Aquierd infections. If the
of infection from one person to another, is not being

done often. Another important area of concern is that B.Sc. Nnursing Students: It refers to those students
nursing students should be careful in doing the vaginal who are studying nursing course in selected Nursing
examination, conducting delivery, aseptic precaution institutions.
is very important to prevent the introduction of
infection to the mother. The recognition of ignorance
Variables
is the beginning of wisdom. To understand the degree Dependent variable: In this study knowledge of B.Sc.
of knowledge to help in future improvement thus, the Nursing students on management of Hospital aquired
investigator felt the need to take up the study such infections in children will be the dependent variable.
as it could assess the knowledge among B.Sc.Nursing Attribute variable: In this study Age, gender,
students in selected Nursing institutions. Religion, Type of family Occupation of the father
and sources of information on the management of
Hospital aquired infections in children are attribute
Objectives variables.
The main objectives of the present study are
mentioned here
Assumptions
• Students of B.Sc.Nursing may have
Objectives of the Study inadequate knowledge on management of
• To asses the pretest knowledge regarding the Hospital aquired infections in children.
management of Hospital aquired infections • B.Sc. Nursing students may utilize the
in children. planned teaching program on management
• To educate the students with a planned of Hospital aquired infections in children.
teaching program on the management of • A carefully prepared Planned Teaching
Hospital aquired infections in children Program may enhance the knowledge of B.Sc.
among B.Sc.Nursing students. Nursing students on management of Hospital
• To asses the effectiveness of a planned aquired infections in children.
teaching program on the management of
Hypothesis
Hospital Aquierd infections among B.Sc.
Nursing. students in terms of knowledge. H1: There will be significant difference in the pretest
and post knowledge score of B.Sc.Nursing students
• To determine the association between
regarding management of Hospital aquired infections
post-test knowledge scores with selected
in children.
demographic variables.
H2: There will be a significant association between
Operational Definitions
the post-test score with the selected demographic
Assessment: It is the organized, systematic, and variables.
continuous process of collecting data the regarding
management of Hospital aquired infections in Limitations
children. • The study is limited to only the selected
school of Nursing at Akluj.
Effectiveness: In this study, it refers to the extent
to which the planned teaching program on the • Students who are available at the time of data
management of Hospital aquired infections in collection.
children has achieved the desired effect in improving • The sample size is limited to 60 B.Sc.Nursing
the knowledge of B.Sc.Nursing students as evident students from selected Nursing institutions
from the gain in knowledge score. at Akluj.
Knowledge: It refers to the level of awareness Research Methodology
among selected subjects regarding the management
of Hospital aquired infections in children. Research Approach:
Hospital Aquierd Infections: An infection acquired The researcher found that the evaluative approach is
in the hospital by a patient who was admitted for a best suited and adopted for the present study.
reason other than that infection.

254
Research Design The tools were prepared on the basis of the

The present study’s pre-experimental one group objectives of the study.
pretest and post-test design was selected. Description of the Tool
Setting of the Study StructuredKnowledge Questionnaire
The study was conducted at the school of Nursing The structured knowledge questionnaire consists
setup. of two sections
Population Part - I
The population of the present study comprises This section includes a demographic background
selected Nursing institutions at Akluj. The accessible of the students i.e. Age, Gender, Permanent area of
populations are those available at the time of residence, Previous academic performance, Religion,
conducting the study. and Sources of information on infection control.
Sample Part -II
In the present study, 60 students of B.Sc.Nursing. This section is the second part of self-structured
studying in various instititons of Nursing, were questionnaire, which consists of the following
selected. headings
Sampling Technique: Section - A: Consists of questions assessing
The sampling technique adopted to select the study knowledge about management of Hospital aquired
samples was simple random technique. infections in children’s.
There are total 30 Multiple Choice Questions in
Sampling Criteria
section A, Item number 1-8 inquire general information
Inclusion Criteria on Hospital aquired infections in children, and 8-13
are related to measures used in the management of
• Students who are willing to participate in the Hospital aquired infections in children, 14-25 asepsis
study. and barrier techniques.
• Both male and female students are included.
There are total of 30 questions in section B, of which
• B.Sc.Nursing. students studying at the are positively stated
selected Nursing institutions at Akluj.
Scoring
Exclusion Criteria The 30 questions in section- A are Multiple-choice
• Students who are in internship. questions and for the correct option, the score is 1 and
other options 0.
• Students who are not available at the time of
the study. The 30 questions in Section- B are closed-ended
dichotomous questions.
Method of Data Collection
In positively stated items the score for Yes is 1 and
Data Collection Instruments. for No is 0. In negatively stated items the score for Yes
The present study is aimed at assessing the knowledge is 0 and for No is 1.
of students on the management of Hospital aquired Data Collection Procedure
infections in children. Thus, a structured knowledge
questionnaire to assess the knowledge was prepared Prior to data collection permission was obtained from
and used for data collection. the concerned authorities. Further, the investigator
obtained consent from the subjects. Confidentiality
Development of Tool was maintained during data collection.
A structured knowledge questionnaire was developed The data collection procedure was carried out for a
for assessing the knowledge on the management of period of six weeks. After obtaining permission from
Hospital aquired infections in children. the authorities of a Nursing institutions Akluj. The

data collection was carried . After obtaining formal belonged to some other religion.Family depicts that
permission from the school of Nursing and from the the majority of 3rd year G.N.M.students were 47%
participants, data were collected from 10 nursing from a joint family, 28% from a nuclear family, and
students selected by a simple random sampling the remaining 25% were from extendedfamily. Works
technique. depict that the majority of students’ fathers were,
28% were homemakers, 27% were private employers,
The investigator selected the Nursing students from
23% were self-employ,18% were daily wages, and the
VMP Nursing college at Akluj and administered the
remaining 3% hada government job.In the majority of
structured questionnaire to each of the B.Sc Nursing
3rd years, students gained knowledge 58% from their
students.
teachers/tutors, 35 % from mass media and 7% from
It took about 1 hour to collect the data. The health articles.
responses were recorded in the space provided in the
questionnaire itself followed by a structured teaching Section-II
programfor the samples.
Assessment of knowledge on management of
Results Hospital Aquierd infections in children
Analysis and interpretation of the information It shows that all 60, 53(88.3 %) had inadequate
collected through a structured questionnaire from knowledge, 7(11.7 %) had moderate knowledge
60 I year B.Sc.Nursing students of selected Nursing and adequate knowledge was zero. Table.1
institutions at Akluj. The present study was designed summarizes statistical outcomes of knowledge on
to assess the effectiveness of Planned teaching preventingHospital Aquierd infections in children
program on knowledge management of Hospital was 14.06 with SD 3.519 before S.T.P. The mean
aquired infections in children among collected data score percentage was computed, and it was 46.86%.
were coded, tabulated organized, analyzed, and The results found that the sampled subjects had
interpreted using descriptive and inferential statistics. inadequate knowledge regarding the management
of Hospital Aquierd infections in children.Thus from
Organizations of findings the statistical significance, it may be confirmed that
The data collected from the B.Sc.Nursing.students knowledge of the management of Hospital Aquierd
were organized, analyzed and presented under the infections in children increased after S.T.P.
following headings.
Tabel 1: shows the knowledge score after a planned
• Section I: Description of sample characteristics teaching program.
• Section II: Assessment of pre-existing Knowledge Mean S. D Mean ‘t’ Result
knowledge. % value
• Section III: Evaluating the effectiveness of Pretest 14.06 3.519 46.86% 20.215 HS
Planned teaching programme. Post -test 24.16 2.985 80.53% P<0.05
• Section IV: Association of Post-test knowledge Section-III

with selected demographic variables.
Evaluating the effectiveness of P.T.P. overall pretest
Section-I and post-test mean knowledge on preventing Hospital
Aquierd infections in children. Table. 2 shows the
Demographic Characteristics of the Samples pre and post-test knowledge of preventing Hospital
It depicts that the majority of 47% were between the Aquierd infections.
age group of 21-22yrs. Similarly, the remaining 26% Table 2: pre and post-test knowledge of
of students were between the age group of 23-24 management of Hospital Aquierd infections.
years, 18% of students were between the age group
Aspects Max. Respondent’s knowledge Paired
of 19-20yrs, and 8% were 24yrs and above.Gender
score ‘t-test
showsthat mostnursing students were female, 58%
Mean SD Mean (%)
and 42% were males.The majority of students, 53%
were Christian,23% students were Hindus,17% Pre-test 40 14.06 3.519 46.86% 20.215
were Muslims, and the remaining 7% of students Post-test 40 24.16 2.985 80.53%

256
The study shows that the pretest findings depict 6 Source of 6.25 Significant <0.05
that the pretest knowledge of preventing Hospital information
Aquierd infections in children, such as incidence and
cause aspect of management of Hospital Aquierd Health can neither be demanded nor given. It can
infections,the mean score is 28.63%.Pattern and route neither be bought nor sold, but the circumstances
of transmission of Hospital Aquierd infections mean and services that are prerequisites to health can
score is 28.33%, management of Hospital Aquierd centrally be demanded and received as right. A
infections in children mean score is 37.60%.The mean protective environment in the hospital unit is
combined score for preventing Hospital Aquierd essential, particularly when considering the services
infections in children is 33.05% and SD is 3.519. In provided in the pediatric wards. Providing a safe
post-test knowledge of preventing Hospital Aquierd and protective environment is a priority need. The
infections in children, such as incidence and cause, the present study was designed to assess the effectiveness
mean score is 52%. Pattern and route of transmission of structured teaching program knowledge regarding
of Hospital Aquierd infections mean score is 50.66%. preventingHospital aquired infections in children
Management of Hospital Aquierd infections in among B.Sc Nursing students of VMP college
children’s mean score is 82.65%.and combined of nursing at Akluj. The data findings have been
mean score of management of Hospital Aquierd organized and discussed based on the objectives and
infections in children meansthe score is 67.02%, and hypothesis.
SD is 2.985. Improvement of knowledge regarding The majority of students belong to the age group
the management of Hospital Aquierd infections in 21-22, i.e., 47% and 58% of students were female. 53 %
children, such as the general aspect of incidence and of students belonged to Christianity, and a maximum
cause mean score, is 23.37%. Pattern and route of of 47 % of them were from joint families. 28% of
transmission mean score is 23.33%. Management of the sample’s fathers were housemakers, and 58 5 of
Hospital Aquierd infections in children’s mean score the samples were getting the source of information
is 45.05%,the combined mean score of environmental regarding the management of Hospital aquired
hazards affecting the outcome of pregnancy mean infections from their teachers.The overall mean score
score is 33.97%, and SD is 6.50. Paired ‘t’ value of percentage of knowledge is 46.86%; the current study
management of Hospital Aquierd infections in investigator concludes that the selected student’s
children, combined paired‘t-test is 20.21. knowledge regarding the management of Hospital
Aquierd infections in children was inadequate.
Section-IV-Association of Post-test knowledge with The knowledge of students was influenced by the
selected demographic variables source of information. The calculated chi-square
Chi-square results of socio-demographic and post- value for association of knowledge with the source
test knowledge management of Hospital Aquierd of information was (Highly significant). The ability
infections in children among B.Sc Nursing students of students was also influenced by demographic
are shown in Table.3. variables such as a source of health information.
Table 3: Chi-square results for sample (n=60) In the majority of B.Sc Nursing , students have
inadequate knowledge about the incidence, causes,
Sl Characteristics Chi- Results P’ pattern of transmission and management of Hospital
no squareValue value
aquired infections in children.Education of students in
1 Age 2.891 Non- >0.05 these aspects is essential for the effective management
Significant
of Hospital aquired infections in children. It aims to
2 Gender 0.17 Non- <0.05 provide students with knowledge on identifying
Significant and avoiding trigger factors, maintaining asepsis
3 Religion 3.723 Non- >0.05 and regular use of barrier techniques to safeguard
significant children. Thus it may decrease the duration of
4 Type of family 1.835 Non- >0.05 hospital stay and provide comprehensive nursing
significant care.It was found that the majority of B.Sc Nursing
5 Father’s 2.860 Non- >0.05 students’ knowledge management of Hospital
occupation Significant aquired infections in children was inadequate.It
needs education in identifying and avoiding triggers,
sterilization and disinfection, and strict asepsis for 4. Coffin SE, Zaoutis TE. Infection control, hospital
proper preventive measures to be implemented in epidemiology, and patient safety. Infectious Disease
pediatric wards. The structured teaching program Clinics. 2005 Sep 1;19(3):647-65.
is beneficial to the nursing students in preventing 5. Barr CE, Schulman K, Iacuzio D, Bradley JS. Effect of
Hospital aquired infections.This reduces mortality oseltamivir on the risk of pneumonia and use of health
and morbidity associated with Hospital aquired care services in children with clinically diagnosed
infections. influenza. Current medical research and opinion. 2007
Mar 1;23(3):523-31.
Conclusions
6. Garg BS, Chhabra S, Zothanzami SM. Safe motherhood:
The structured teaching program’s efficiency in social, economic, and medical determinants of
preventing Hospital Aquierd infections in children maternal mortality. Women and Health Learning
has improved significantly among B.Sc Nuring Package, The Network: TUFH Women and Health
students. The pretest revealed that B.Sc Nuring Taskforce. Karachi: The Network. 2006 Sep;1132.
students understanding of Management of Hospital
7. Romoşan O, Bocşan IS. The existing profile of
Aquierd infections in children was lacking in all nosocomial infections in municipal hospitals of general
categories. It emphasizes the significance of regular surgery. Revista Medico-chirurgicala a Societatii de
in-service education sessions to keep students up to Medici si Naturalisti din Iasi. 2011 Oct 1;115(4):1231-6.
date on the latest developments in the management of
8. El Ayyat AA, Sayed HA, Abou Had AM. A KAP study
Hospital Aquierd infections in children.The post-test
among staff and student nurses about infection control
scores showed an improvement in knowledge after
in Theodor Bilharz Hospital. Journal of the Egyptian
P.T.P. was administered. Hence it was concluded that Society of Parasitology. 2000 Aug 1;30(2):511-22.
Planned teaching program was an effective strategy
for improving the knowledge of the B.Sc Nuring 9. Wheeler DS, Giaccone MJ, Hutchinson N, Haygood
M, Bondurant P, Demmel K, Kotagal UR, Connelly
students.
B, Corcoran MS, Line K, Rich K. A hospital-wide
Acknowledgment quality-improvement collaborative to reduce catheter-
associated bloodstream infections. Pediatrics. 2011
The authors would like to express their gratitude to
Oct;128(4):e995-1007.
the Institutions of Nursing at Akluj for their help in
conducting this study and the study participants for 10. Nichols RL. Preventing surgical site infections: a
their whole hearted support. surgeon’s perspective. Emerging infectious diseases.
2001 Mar;7(2):220.
Ethical clearance: Taken from institutional ethical
11. Askarian M, Honarvar B, Tabatabaee HR, Assadian O.
committee.
Knowledge, practice and attitude towards standard
Funding isolation precautions in Iranian medical students.
Journal of Hospital Infection. 2004 Dec 1;58(4):292-6.
None
12. Klevens RM, Edwards JR, Richards Jr CL, Horan TC,
Conflicts of Interest Gaynes RP, Pollock DA, Cardo DM. Estimating health
None care-associated infections and deaths in US hospitals,
2002. Public health reports. 2007 Mar;122(2):160-6.
References 13. Nseir S, Grailles G, Soury-Lavergne A, Minacori F,
1. Park K. Preventive and social medicine. Jabalpur. Alves I, Durocher A. Accuracy of American Thoracic
Society/Infectious Diseases Society of America
2. Bitsori M, Maraki S, Koukouraki S, Galanakis E.
criteria in predicting infection or colonization with
Pseudomonas aeruginosa urinary tract infection in
multidrug-resistant bacteria at intensive-care unit
children: risk factors and outcomes. The Journal of
admission. Clinical microbiology and infection. 2010
urology. 2012 Jan;187(1):260-4.
Jul 1;16(7):902-8.
3. Ducel G, Fabry J, Nicolle L. Prevention of hospital
14. Sydnor ER, Perl TM. Hospital epidemiology and
acquired infections: a practical guide. Prevention
infection control in acute-care settings. Clinical
of hospital acquired infections: a practical guide..
microbiology reviews. 2011 Jan;24(1):141-73.
2002(Ed. 2).

Give space between C and reactive Protein as an early Predictor of

acute Pancreatitis: An Observational Study
Shivendra Dhakhda1, Virendrakumar Dhakhada2

Assistant Professor, Department of Surgery, Shantabaa Medical College & General Hospital Amreli, Gujarat
1
2
Assistant Professor, Department of Medicine, Shantabaa Medical College & General Hospital Amreli, Gujarat
How to cite this article: Shivendra Dhakhda, Virendrakumar Dhakhada et al Creactive Protein as an early Predictor
of acute Pancreatitis: An Observational Study. Volume 13 | Issue 4 | October-December 2022
Abstract
Background and Aim: In the early risk stratification of acute pancreatitis, C-reactive protein (CRP) is being used
extensively worldwide. There are few studies that show that CRP is useful in predicting pancreatic necrosis which is a
determinant of severe pancreatitis. Aim of the present study was to assess the role of CRP as a prognostic indicator in
acute pancreatitis.
Material and Methods: A total of 128 patients that were diagnosed to have acute pancreatitis were included in the study.
Data collected from the patient’s record (file/EMR) and organised in an Excel sheet that contained basic demographic
data (age and gender), cause, APACHE score, length of hospital/intensive care unit (ICU) stay and the CRP level. Blood
samples for CRP and biochemical markers for the APACHE II score were routinely drawn and processed on admission.
Results: The patients were divided into two groups, those with mild pancreatitis and those with severe acute pancreatitis.
Men were predominating in the study group where they contributed to 85.9% of the study population. Mean age of
presentation of acute pancreatitis was 37.7 years. Amylase and lipase were taken for the diagnosis of acute pancreatitis;
amylase and lipase were elevated significantly in 104 and 108 patients respectively. Twenty eight patients had an elevated
CRP > 150 in BISAP positive patients. There was significant association of CRP and BISAP.
Conclusion: Acute pancreatitis is a life-threatening disease with a wide spectrum of clinical symptoms. The job of
diagnostic markers as prognostic pointers has been a disappointment. However, CRP as a prognostic marker has shown
promising results in earlier studies.
Keywords: Amylase, Acute pancreatitis, C reactive protein, Pancreatic Necrosis
Introduction AP has many different etiologies, and overall

Acute pancreatitis, the sudden inflammatory process mortality is 5% to 10%. Most cases (80% to 90%) are
of the pancreas is a common disease that has a variable mild or self-limited and have a good prognosis. The
clinical course, and its severity is often difficult to remaining 10% to 20% of cases warrant monitoring
predict.[1]Although this condition does resolve in in intensive care units due to pancreatic necrosis
some cases without any medical intervention and or distant organ damage. Severe AP cases usually
patients can make full recovery within a relatively require surgical intervention, and overall mortality
short period, there are others who end up developing can be up to 40%.3, 4
severe complications that could be fatal. Acute Acute Pancreatitis is a disease of unpredictable
pancreatitis (AP) is an inflammatory condition which outcome; early intervention can prevent the
may be mild or severe; in severe cases, pancreatic development of acute severe pancreatitis which
enzymes can cause damage to the gland itself.1, 2 develops in 20 to 30% of patients with Acute
Dr. Virendrakumar Dhakhada
Assistant Professor,
Department of Medicine, Shantabaa Medical College & General Hospital Amreli, Gujarat
Pancreatitis.5 The progression of the disease and the demographic data (age and gender), cause, APACHE
development of complications are mainly due to score, length of hospital/intensive care unit (ICU)
the release of proinflammatory cytokines leading to stay and the CRP level. Blood samples for CRP
third space volume loss. C –reactive protein ( CRP) and biochemical markers for the APACHE II score
being an acute phase reactant is elevated in the were routinely drawn and processed on admission.
ensuing inflammation of the pancreas , this elevation Collected data analysed to assess the possible
when above 150 mg/L has been noted to be a statistical significance of the variables and to present
predictive marker of the development of acute severe the data accordingly. Their CRP levels were sent on
pancreatitis.6 second day of admission and CT scan done after 72
hours of admission.
In the early risk stratification of acute pancreatitis,
C-reactive protein (CRP) is beingused extensively All the data collected in proforma were entered in
worldwide.7 There are few studies that show that Microsoft excel sheet and SPSS software version 21
CRP is useful in predicting pancreatic necrosis which was used for statistical calculations. Chi-square test
is a determinant of severe pancreatitis. There not with Fischers exact was used to calculate p value and
many studies reported from our country using CRP find the significant association between CRP and
to differentiate between MAP and SAP which is the different variables. Serial C reactive proteins levels
need of the hour for better use of our limited resources were analyzed at 72 hours. Computed tomography
as it is a simple and an efficacious way to triage acute with oral and IV contrast agents was done at 72 hours
pancreatitis patients. Considering its peak at only 48- after admission and CT severity Index with CT grade
72 hours, so cannot be used to access severity in the and necrosis grade was ascertained.
therapeutic window of pancreatitis (first 72 hours).8
CRP is also elevated in conditions like coronary heart Results
disease, insulin resistance, diabetes, dental disorders, A total of 128 patients of acute pancreatitis were
smoking, overweight, obesity, Alzheimer’s disease, studied. The patients were divided into two groups,
rheumatoid arthritis and cancer.9 Hence the aim of those with mild pancreatitis and those with severe
the present study was to assess the role of CRP as a acute pancreatitis. Both moderately severe acute
prognostic indicator in acute pancreatitis. pancreatitis and severe acute pancreatitis were
considered as severe acute pancreatitis. Young and
Materials & Methods middle age persons were the predominant population
The present study is the observational study that of the study i.e., < 50 years constituted > 80% of the
was done in the medical college and the associated study population. Men were predominating in the
hospital. A total of 128 patients that were diagnosed study group where they contributed to 85.9% of the
to have acute pancreatitis were included in the study. study population. Mean age of presentation of acute
Variables (age, sex), were recorded along with local pancreatitis was 37.7 years.
complication and systemic complication. The ethical
In the present study, Pain was the predominant
committee was informed about the study, and the
presenting complaint seen in 98% of the study
ethical clearance certificate was obtained prior to the
population, while the least common presenting
start of the study.
complaint or associated symptom was upper
The inclusion criteria and exclusion criteria were gastrointestinal bleed which was seen only in one
as follows: the patients with more than age of 18 individual. Extra pancreatic manifestations were seen
years and those who satisfy the Atlanta classification in a frequency of 1.8% to 19.4%.
for diagnosis of acute pancreatitis were included in
Amylase and lipase were taken for the diagnosis of
the study. Patients who had any of the following
acute pancreatitis; amylase and lipase were elevated
were excluded from the study: Age < 18 years,
significantly in 104 and 108 patients respectively.
already diagnose with chronic pancreatitis, severe
Patients who did not have significantly elevated
acute pancreatitis on admission, Pregnant women,
amylase and lipase levels were diagnosed by means
Hematologic diseases, Connective tissue disorders,
of abdominal pain and CT findings.
Collagen vascular diseases.
All individuals underwent CT Abdomen. Eighty
Data collected from the patient’s record (file/EMR)
two patients had a normal study or had mild
and organised in an Excel sheet that contained basic

260
pancreatic or peri pancreatic inflammation. Forty In our country where resources are limited, the
six patients had pancreatic or peripancreatic fluid simplest and the most economical of the scores or
collection with or without accompanying necrosis of markers are the ones which would have a great impact
the gland. Severity on CT was classified into 3 groups, on the society in the prediction of severity in AP
Group 1: Normal CT or mild enlargement of the gland Epidemiology.12 In the study population of 110 were
,Group 2 :presence of pancreatic or peri pancreatic male contributing to 86.5% of the study population.
fluid collection and Group 3-presence of necrosis. This is higher than studies from the Mediterranean
by Stimac et al13 and the study of Roberts14 from UK
Twenty eight patients had an elevated CRP > 150
who showed only a slight male predominance of 53%
in BISAP positive patients. There was significant
and 50.7% respectively. The probable reason could be
association of CRP and BISAP with p value of 0.0001.
that gall stone disease is not as common as it is in the
Table 1: Distribution of CRP in the patients west, the predominant cause of AP in this study being
alcohol which is more abused by men than women
C reactive protein Number of patients
and are young comparatively in our country.
< 150 82
> 150 46 Symptoms Abdominal pain (96.9%) and vomiting
(59.4%) were the predominant complaints seen in
Table 2: Symptoms on presentation the study population. This is similar to the study by
Symptoms Present Absent Milheiro et al15 who stated the predominant symptom
in AP as abdominal pain in 100% followed by
Pain 124 4
vomiting in 69.2%. A symptom association of extra-
Vomiting 76 52 pancreatic manifestations to the occurrence of SAP
Abdominal 22 106 was done, which showed that the presence of extra
distention pancreatic manifestations in acute pancreatitis had a
Fever 22 106 high probability to be associated with SAP.
Jaundice 14 114 In this study there was a significant association
Oliguria 10 118 with jaundice, fever, dyspnea and oliguria which is
Dyspnoea 10 118 similar to the study by Abbasi and Jacobs et al.7 Thus
this study further emphasizes the well known fact of
Table 3: Analysis CRP with CT in Predicting
Severe Acute pancreatitis the need of aggressive fluid management in AP thus
preventing volume depletion, which may lead on to
CRP Severity Chi P the development and progression of SAP.
basedon CT square value
C - reactive protein A CRP of > 150 mg /L was taken
1 2 &3 to predict acute severe pancreatitis, 46 (35.9%) patients
< 150 66 16 15.21 .0001 of the 128 study population had an elevated CRP at 48
> 150 16 30 hours of admission. 30 of the 46 patients who had a
significant elevation of CRP had CT features of SAP (P
Discussion = 0.0002), while 24 of the 46 patients with significant
Acute pancreatitis is undoubtedly a disease in which elevation of CRP had Necrotising pancreatitis on CT
the progression can be greatly altered by early (P = 0.0004). Thus drawing on a conclusion that CRP
intervention. Numerous scores and single prognostic had a significant association in predicting severity
markers have been suggested to predict the severity of pancreatitis, which is in accordance to studies by
of pancreatitis on admission or after a couple of days, Alfonso and Cardoso who took a CRP value of 200
this by itself suggests none of the available scores or mg /L and 170 mg/L respectively in predicting SAP
markers are the gold standard to predict the severity and necrotising pancreatitis. This study achieves the
of the disease.10, 11 In this study CRP and pancreatitis same association with a CRP cut off of 150mg/L as
predicting scores BISAP were analyzed to predict suggested by recent studies by Wilson. Thus this study
the severity of pancreatitis. Scores which had many confirms that a CRP of >150mg/L is as diagnostic as
markers may have had an increased sensitivity but higher levels in predicting SAP.
simpler and easily available scores and markers were
The Positive predictive value of CRP in predicting
taken.
SAP was 65.2% while it had a negative predictive
value of 80.5%.This is similar to previous studies 6. Tenner S: Initial management of acute pancreatitis:
which have stated a at 48 hours CRP had a sensitivity critical issues during the first 72 hours. Official journal
ranging from 65% to 100% and a positive predictive of the American College of Gastroenterology| ACG
value of 37% to 77%. 82 patients of the study 2004, 99:2489-94.
population had mild pancreatitis, while 46 patients 7. D Vinish B: Role of C-Reactive Protein in Predicting
had SAP as determined by CT, which is taken as Acute Severe Pancreatitis. Kilpauk Medical College,
standard to predict the severity of pancreatitis. Chennai, 2014.
Incidence of SAP is similar to study by Svetlana. The 8. Kasapis C, Thompson PD: The effects of physical
reason could be that in our population there is a delay activity on serum C-reactive protein and inflammatory
in presentation to the hospital as the patients seek markers: a systematic review. Journal of the american
over the counter medications or complementary and College of Cardiology 2005, 45:1563-9.
alternative forms of medicine for the most common
9. Pischon N, Heng N, Bernimoulin J-P, Kleber B-M,
symptom of abdominal pain or it could be that of a
Willich S, Pischon T: Obesity, inflammation, and
referral bias. periodontal disease. Journal of dental research 2007,
86:400-9.
Conclusion
Acute pancreatitis is a life-threatening disease 10. Balthazar EJ: Acute pancreatitis: assessment of severity
with clinical and CT evaluation. Radiology 2002,
with a wide spectrum of clinical symptoms. The
223:603-13.
job of diagnostic markers (pancreatic enzymes like
amylase and lipase) as prognostic pointers has been 11. Triester SL, Kowdley KV: Prognostic factors in acute
a disappointment. However, CRP as a prognostic pancreatitis. Journal of clinical gastroenterology 2002,
marker has shown promising results in earlier 34:167.
studies. CRP levels can give a prior insight about the 12. Sabat A, Budimir A, Nashev D, Sá-Leão R, Van Dijl
undergoing inflammatory process. J, Laurent F, Grundmann H, Friedrich A, Markers
ESGoE: Overview of molecular typing methods for
Ethical Approval is taking from institutional ethical outbreak detection and epidemiological surveillance.
committee Eurosurveillance 2013, 18:20380.
Sources of funding: Nil. 13. Stimac D, Mikolasevic I, Krznaric-Zrnic I, Radic M,

Milic S: Epidemiology of acute pancreatitis in the
Conflict of interest: None declared. North Adriatic Region of Croatia during the last ten
years. Gastroenterology Research and Practice 2013,
References
2013.
1. Hollender LF: Controversies in acute pancreatitis:
Springer Science & Business Media, 2012. 14. Roberts S, Akbari A, Thorne K, Atkinson M, Evans P:
The incidence of acute pancreatitis: impact of social
2. Zerem E: Treatment of severe acute pancreatitis and deprivation, alcohol consumption, seasonal and
its complications. World Journal of Gastroenterology: demographic factors. Alimentary pharmacology &
WJG 2014, 20:13879. therapeutics 2013, 38:539-48.
3. Boumitri C, Brown E, Kahaleh M: Necrotizing 15. Milheiro A, Medeiros A, e Sousa FC: Acute pancreatitis.
pancreatitis: current management and therapies. An analysis of 91 consecutive cases (1988-1991) with a
Clinical endoscopy 2017, 50:357-65. brief review of the literature. Acta medica portuguesa
4. Yigit Y, Selçok K: Can C-reactive Protein Increase the 1995, 8:269-77.
Efficiency of the Bedside Index of Severity in Acute
Pancreatitis Scoring System? Cureus 2019, 11.
5. Fan S-T, Lai E, Mok F, Lo C-M, Zheng S-S, Wong J: Early

treatment of acute biliary pancreatitis by endoscopic
papillotomy. New England Journal of Medicine 1993,
328:228-32.

Association of Academic Performance and load with Depression, Anxiety

and Stress among School going Students (9th-12th class) of District Amritsar:
A Cross Sectional Study.
Simran Kaur1, Sanjeev Mahajan2, Manohar Lal Sharma3, Preeti Padda4,

Shyam Sundar Deepti5
1
Junior Resident, 2Professor and Head, 3Professor, 4Associate Professor,
5
Professor, Department of Community Medicine, Government Medical College, Amritsar, Punjab
How to cite this article: Simran Kaur, Sanjeev Mahajan, Manohar Lal Sharma, Preeti Padda, Shyam Sundar Deepti
et al Association of Academic Performance and load with Depression, Anxiety and stress among School going
Students (9th-12th class) of District Amritsar: A Cross Sectional Study. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Adolescence is a ripe stage where the onset of many psychiatric illnesses increases sharply. Identification of
factors making adolescent population vulnerable to disturbed mental health is of high public health importance.
Materials and methods: A cross sectional study was conducted among students of 9th -12th class of government and
private schools of urban and rural areas of Amritsar. Sample size was calculated using formula N > 4pq/ d2. Data was
collected during the period of one year. Pre tested, semi structured questionnaire and DASS -21 scale were used. Chi
squared tests were applied and statistical analysis was conducted using Epi-Info. P value <0.05 was considered to be
statistically significant.
Results: The prevalence of Stress, Anxiety and Depression was found to be 53%, 58% and 54% respectively having
significant associations with academic performance, excessive homework, performance satisfaction among self & parents
and comparison by parents.
Conclusion: Stress, anxiety and depression were associated with factors like academic performance, academic load,
performance satisfaction by self and parents and other parental factors. There is need to provide a healthy and supportive
school as well as home environment to reduce the risk of stress, anxiety and depression among adolescents.
Keywords – Stress, anxiety, depression, academic performance, academic satisfaction, parental satisfaction.
Introduction evolving understanding of the world can overwhelm

Worldwide there are 1.2 billion adolescents, an adolescent outside his/her coping capacity. Such
which is approximately 1 in every 6 persons1. 21% circumstances increase the risk of mental disorders
of Indian population comprises of adolescents in adolescents most commonly mood disorders like
i.e about 243 million, making India the country stress, anxiety and depression.
harboring highest number of adolescents in the According to World Health Organization (WHO) 1
world. Although adolescence is the period of life in 13 globally suffer from anxiety2. It is estimated that
filled with most vitality, specific needs regarding 3.6% of 10-14 year-olds and 4.6% of 15-19 year olds
changes in mental and physical growth along with experience an anxiety disorder3. Stress and anxiety
Dr. Sanjeev Mahajan
e-mail: [email protected]
Dr. Simran Kaur
can make a person vulnerable to depression which in the final sample size for the study was decided to
adolescents is a real, distinct clinical entity. Increasing be 480. However, 444 students participated in the
academic pressure; unrealistic parental & social study due to the prevailing COVID-19 pandemic and
expectations; unstable home environment; emotional, lockdowns.
sexual or physical abuse; bullying; loss of a closed
one; chronic illness in self & family are some of the Data collection tool
important factors that can upset the mental health of Data collection tools consisted of a pre-tested semi
an adolescent. Various studies done in India report structured questionnaire developed to collect the
prevalence of stress among school students ranging desired information on the socio-demographic profile
from 40%-50%4,5,6. Whereas anxiety is reported to be and contributory factors towards Stress, Anxiety and
17-59%5,7,8. Indian studies conducted on adolescents Depression and a standardized Depression Anxiety
report prevalence of depression to be 40% – 54%5,9. and Stress Scale -21 used for assessment of presence
of Depression, Anxiety and Stress. DASS -2 1 consists
Evolution from childhood to adulthood exposes
of 3 subscales and each of the three DASS-21 subscales
an adolescent to changing academic environment
contains 7 items. Scores for depression, anxiety and
from the playful junior schools to more serious senior
stress are calculated by summing the subscale items
grades. Students with high stress levels in academia
individual scores which were marked on a likert scale
are seen to exhibit signs of depression, anxiety, phobia,
of 0-314.
school refusals, increased irritability, and complaints
and reduced interest in schoolwork10. In a Delhi based Methodology
study all the three (depression, anxiety and stress) After required ethical committee’s and District
were found to be higher among students having Education Officer’s approvals, 4 schools as per the
lesser academic performance11. Pushed by the parents selection criteria were randomly selected. Consents of
to ‘be the best’, some students cannot cope with the Principals of selected schools were taken and students
demands anymore and emotionally collapse. This in equal representations from each class were selected
can result in deep rooted nervous disorders. Keeping using simple random sampling. Written informed
such factors in mind, this cross sectional study was consents were obtained from the parents/guardians
conducted to find the prevalence of stress, anxiety of the selected students along with written assent
and depression and it’s association with academic from students themselves. Data was collected over the
pressure & load among the students of 9th-12th class of period of 1 year using self-administered, pre-tested,
district Amritsar. semi structured questionnaire and DASS -21 scale.
Circulation of google forms was done among the
Materials and Methods students through whatsapp groups during COVID-19
Study population – students studying in 9th-12th lockdown and personal visits were conducted once
class of government and private schools consisted restrictions were lifted. Visits to the schools were
the study population. Those who gave their written conducted in such a manner so that school’s routine
assent were included in the study whereas those who schedule was not disturbed. Students of only one
did not and those who were already suffering from a class were studied during a visit and next visit
mental disorder were excluded from the study. was planned as per the convenience of the school’s
Principal. Students were sensitized regarding stress,
Study period – 1 year (1 st April 2020 – 31st March
anxiety and depression and instructions related to
2021)
filing-up the forms were also discussed. After fully
Sample size and sampling technique - Sample size ensuring the students regarding the confidentiality
was calculated using the prevalence rate of stress of their responses performas were distributed to be
among students, found to be 47% in a similar study filled. The performas were collected after an average
conducted at Chandigarh in the year of 201412. Formula period of 45 minutes.
N > 4pq/ d2 was used, where p= prevalence of the
Statistical Analysis
problem, q = (1-p) and d = absolute error/precision
(taken as 5% for the current study)13. Assuming Prevalence of depression, anxiety and stress were
power of the study to be 80% and α to be 5% required calculated by dividing the number of students having
sample size was calculated to be 399 using the above score above the respective cut offs of DASS-21 by total
formula. Taking the non - response ratio to be 20%, students and was compared across various groups.

264
Mean scores of all the subscales were calculated along 12% (55) and 14% (62) scored above 90% and <60% in
with standard deviation of the same. Responses of last exam, respectively. Scores of rest of the students
each student were compiled using Microsoft excel and (74%) ranged between 61%-90%. Failure in exam was
later imported into Epi-Info for the statistical analysis. faced by 15% (69) of the study participants. 66% (291)
The distribution of various variables was represented of the study participants were satisfied with their
through frequencies and proportions whereas, for own academic performance and teachers of 60% (265)
continuous variables mean ± standard deviations study participants were satisfied with their academic
were calculated. Association of various contributing performance. It was observed that parents of 55%
factors with three subscales was established by using (245) students were not usually satisfied with their
Chi-square test where p-value of less than 0.05 (on both academic performance, whereas, that of 53% (236) of
sides) was considered to be statistically significant. If study participants compared them with others. Out of
any of the expected cell value of <5 was found then all the study participants, 16% (71) felt nervous while
Fisher’s exact test was used. Those who were found conveying their results to parents.
to have stress, anxiety and depression were advised Figure 1: Distribution of depression, anxiety and
to seek counseling and appropriate treatment. stress in study participants (N = 444)
Figure 1: Distribution of depression, anxiety and stress in study participants (N = 444)
Results
Chart Title
205 (46%) students studied in government schools
300
whereas 239 (54%) were from private schools. 250
Minimum participation was from 12th standard 200

Axis Title
because of ongoing board examinations at the time 150

100
of the study. As far as age was concerned majority 50
of the students, 218(49%) were of 16-17 years of age 0
Depression (239:
followed by 138 (31%) of those in the age group of
Stress (233: 53%) Anxiety (257:58%)
54%)
Extremely severe 10 65 34
13-15 years and only 20% (93) were above 18 years Severe 24 40 27
of age. A total of 227 (51%) students were male and Moderate

Mild
73
126
95
57
108
70
217 (49%) students were female. More than half (253:
57%) of the students belonged to Sikh religion, while Based onresponses
Based on the the responses to DASS-21,
to DASS-21, stress, stress,
anxiety and depression anxiety
related symptoms
264 (60%) were of general caste. Out of the total 444 andweredepression related
found to be present among, symptoms
53%, 58% and 54%were found to
study participants. be
Moderate
study participants, students participating from rural depression (46%) and anxiety (40%) were most common whereas mild symptoms
present among, 53%, 58% and 54% study participants.
related to stress were the commonest (54%). A significant proportion of study
areas were 245 (55%) whereas those from urban areas Moderate depression (46%) and anxiety (40%) were
participants having anxiety and depression had severe symptomology (27% and 14%
were 199 (45%). most common whereas mild symptoms related to
respectively).
stress were the commonest (54%). A significant
The prevalence of Stress was 53% (233/444) in
proportion of study participants having anxiety and
study participants with majority of them (126; 54%)
depression had severe symptomology (27% and 14%
having mild stress, anxiety was found to be in 257
respectively).
(58%) students with majority (95; 40%) having
moderate anxiety and 239 (54%) study participants Table 1: Association of academic load with
had depression with high prevalence (108; 46%) of depression, anxiety and stress among study
moderate depression. participants (N = 444)
166 (38%) students thought homework to be Variable Depression Anxiety Stress

excessive but majority, (294; 66%) completed their (n=239) (n=257) (n=233)
assignments on time. Among the study participants, Excessive homework
56% (247) felt nervous when new assignments were Yes (166) 87(53) 84(51) 82(49)
given. Assistance for doing homework was required
by 69% (305) of the study participants out of which half No (278) 152(55) 173(62) 151(54)
(50%) took tuition classes for completing homework χ 2
0.21; df=1 5.7; df=1; 1.00; df=1;
while 20% and 14% took assistance from friends and (p value) (0.6) (0.01)* (0.3)
siblings for doing the same. Minimum (23; 7%) used Completion of assignments
internet as an assistant to complete their homework.
As far as academic performance was concerned,

Variable Depression Anxiety Stress with depression, anxiety and stress among study
participants (N = 444)
(n=239) (n=257) (n=233)
On time 146(50) 164(58) 143(49) Variable Depression Anxiety Stress
(n=239) (n=257) (n=233)
(n=294)
Performance grade in last exam
Not on 93(62) 93(62) 90(60)
>80% 68(44) 76 (50) 70 (46)
time
(n=150) (n=153)
60-80% 132 (58) 143 (62) 131 (57)
χ2 6.08; df=1; 1.57; 5.14; df=1;
df=1; (n=229)
(p value) (0.01)* (0.02)*
(0.2) <60% 39 (63) 38 (61) 32 (52)
Nervousness at new assignments (n=62)
Yes 30 (67) 27(60) 27(60) χ2 8.8; df-1; 6.4; df-1; 4.8; df-1;
(n=45) (p value) (0.01)* (0.03)* (0.08)
No 209 (52) 230(58) 206(52) Satisfied with own academic performance
(n=399) yes 146(50) 157(54) 135(46)
χ2 3.32; df=1; 0.09; 1.13; df=1; (n=291)

df=1; no 93(61) 100(65) 98(64)
(p value) (0.06) (0.2)
(0.7) (n=153)
Need for assistance with homework χ2 4.54; df=1; 5.35; df=1; 12.54;
df=1;
Yes 162(53) 182(60) 162(53) (p value) (0.03)* (0.02)*
(0.0003)*
(n=305)
Teacher satisfaction with grades
No 77(55) 75(54) 71(51) yes 133(50) 150(57) 130(49)
(n=139) (n=265)
χ 2
0.19; df=1; 1.2; df=1; 0.15; df=1; no 106(59) 107(60) 103(58)
(p value) (0.6) (0.2) (0.6) (n=179)
• All figures in parenthesis are percentages χ2 3.50; df=1; 0.44; df=1; 3.08; df=1;
• *= p < 0.05 is considered to be significant (p value) (0.06) (0.50) (0.07)
Depression (62%) and stress (60%) were significantly Parental satisfaction with grades
higher among those who did not complete their Usually 90 (45) 110 (55) 93 (47)
assignments on time when compared to those who
(n=199)
completed their assignments on time (depression-50%
Unusually 149 (61) 147 (60) 140 (57)
and stress-49%)
(n=245)
Similarly depression (67%), anxiety (60%) and χ2 10.73; df=1; 1.00; df=1; 4.77; df=1;
stress (60%) were relatively higher among those who
(p value) (0.001)* (0.3) (0.02)*
felt nervous when they were given new assignments.
Comparison with others by parents
Depression (53%) was lower, whereas anxiety
No 88(42) 102(49) 90(43)
(60%) and stress (53%) were higher among those
who needed assistance with homework without (n=208)
statistically significant differences. Yes 151(64) 155(66) 143(61)
Table 2: Association of academic performance (n=236)

266
Variable Depression Anxiety Stress adequate adjustment to the opposite sex along with
(n=239) (n=257) (n=233) conflicting beliefs with parents; academic, parental
and social pressure; quality of friends, etc. all
χ2 21.8; df=1; 13.3; df=1; 14.03;
contribute towards the disruption of mental harmony
df=1;
(p value) (0.000)* (0.00)* that result into tremendous stress, anxiety and
(0.00)* depression among this population. Lagging behind
Feeling of nervousness while telling in academics can result in self and parental academic
results to parents dissatisfaction that causes worry and stress among
Unusually 193(52) 205(55) 192(51) students. Constant academic inferiority complex
and incapacity to achieve goals set by self, parents
(n=373)
and teachers may result in stress and anxiety due to
Usually 46(65) 52(73) 41(58) which student feels incapacitated to complete work
(n=71) on time, thus piling up of more work which results in
χ2 4.08; df=1; 8.17; df=1; 0.94; df=1; overburdening of a student.
(p value) (0.04)* (0.004)* (0.3) Various studies have also found low academic
performance to be the cause of stress, anxiety and
• All figures in parenthesis are percentages depression11,16. In our study too, students who had
• *= p < 0.05 is considered to be significant lower grades in exams were found to have high
levels of anxiety (61%) and depression (63%). Large
Depression increased with decreasing percentage
number of students (70%) who did not attend tuition
in exam (44% in those who scored >80% to 63%
classes were found to be significantly depressed in
among those who scored <60%) and this difference
the present study. Being overburdened by academic
was found to be statistically significant. Levels of
load, especially in board classes and not getting
depression (61%), anxiety (65%) and stress (64%)
proper help to handle it may be the cause of such
were found to be significantly higher among those
finding. This finding was opposite to a study where
who were not satisfied with their own performance,
strong association of stress, anxiety and depression
but teacher satisfaction with grades did not have
was observed in students taking tuitions11.
significant associations. Depression (61%) and stress
(57%) was higher among those whose parents were Negative effects of stress at home linger and affect
not satisfied with their and this difference was student’s academic performance at school17. Present
statistically significant. Depression (64%) anxiety research showed high prevalence rates of stress
(66%) and stress (61%) were significantly higher (57%), anxiety (60%) and depression (61%) among
among those students whose parents compared them students whose parents were not satisfied with their
with others. Those who felt nervous while telling grades. Similar significant results were seen among
their results to parents had significantly higher levels those students whose parents compared them with
of depression (65%) and anxiety (73%). others. It has been noted in other studies as well that
students whose parents pressurize them to study
Discussion have significantly higher depression and stress18.
Prevalence of anxiety was reported be highest
Conclusion
(58%) in the present study, which was followed by
depression (54%) and stress (53%). Similar results Present study highlights the prevalence of stress,
have been noticed in different parts of country where anxiety and depression among students of 9th -12th
the prevalence of stress, anxiety and depression classes studying in government and private schools of
ranged from 19%-49%; 24%-81% and 21%-65%4,5,15. rural and urban Amritsar. It also identifies important
In our study, 27% of the anxious, 14% of depressed positive and negative risk factors associated with
and 4% of stressed were graded to be suffering from adolescent depression. The results of this study
extremes of these conditions. are cautious reminder of the extreme pressure the
adolescent face in this particular age. The study
Adolescent population already suffers from the
reflects the importance of student friendly curriculum,
stage of rapid physical and mental maturation that can
positive parenting and psychological counseling
give rise to intense psychological and physical change.
availability at school.
The desire to be needed by others, independence,

Conflict of interest – the author declares that there District, Kerala, India. International Journal of Health
is no conflict of interest Sciences. 2016;6(8):225-8.
Source of funding – study was funded by the 9. MOHFW, GoI. National Mental Health Survey of India;
author herself 2016. 2016 [cited on Dec 24] Available from:http://
www.indianmhs.nimhans.ac.in /Docs/Summary.pdf
Ethical clearance – clearance granted from
10. Reddy JK, Menon K, Thattil A. Understanding
Institutional Ethics Committee (IEC), Government
Academic Stress among Adolescents. Artha Journal of
Medical College, Amritsar
Social Sciences. 2017;16(1):39–52
References 11. Wani M. Stress Anxiety and Depression Among
1. Sivagurunathan C, Umadevi R, Rama R, Science and Arts Students. International Journal of
Gopalakrishnan S. Adolescent health: present status Educational Psychology. 2016;5:48–52.
and its related programmes in India. Are we in the 12. Tomb M., Hunter L. Prevention of Anxiety in Children
right direction? Journal of Clinical and Diagnostic and Adolescents in a School Setting: The Role of
Research. 2015 Mar;9(3):LE01-6. doi: 10.7860/ School-Based Practitioners. Children & Schools,
JCDR/2015/11199.5649. PMCID: PMC4413087. 2004:26(2):87–101. https://doi.org/10.1093/cs/26.2.87
2. World Health Organization. Depression and other 13. George B. Sample Size Estimation and Power
common mental disorders: global health estimates. Calculation - A Guide to Biomedical Researchers.
World Health Organization. 2017 [cited on Nov Pulmon journal of Academy of Pulmonary and Critical Care
1]. Available from: https://apps.who.int/iris/ Medicine. 2013;15:25–34.
handle/10665/254610.
14. Lovibond, S H, and Peter F. Lovibond. Manual for
3. World Health Organizatiion. Adolescent mental the Depression Anxiety Stress Scales. Sydney, N.S.W:
health [Internet]; 2021 [cited 2021 Nov 1]. Available Psychology Foundation of Australia, 1995.
from: https://www.who.int/news-room/factsheets/
detail/adolescent-mental-health 15. Kumar KS, Akoijam BS. Depression, anxiety and
stress among higher secondary school students of
4. Sandal RK, Goel NK, Sharma MK, Bakshi RK, Singh Imphal, Manipur. Indian Journal of Community Medicine
N, Kumar D. Prevalence of Depression, Anxiety and .2017;42:94-6.
Stress among school going adolescent in Chandigarh.
Journal of Family Medicine and Primary Care. 2017; 6(2): 16. Bhasin SK, Sharma R, Saini NK. Depression, anxiety
405– 410. doi: 10.4103/2249-4863.219988 PMCID: and stress among adolescent students belonging to
PMC5749094 affluent families: a school-based study. Indian Journal
of Pediatrics. 2010; 77(2):161–5.
5. Shaikh BM, Doke PP, Gothankar JS. Depression,
anxiety, stress, and stressors among rural adolescents 17. Warner, J. Teen Stress at Home Lingers in School,
studying in Pune and a rural block of Nanded district WebMD Health News, Reviewed by Louise
of Maharashtra, India. Indian Journal of Public Health. Chang, MD. [Internet] May 15. [Cited 2021 Dec 28].
2018;62(4):311-314. doi: 10.4103/ijph.IJPH_174_17. Available from: https://www.webmd.com/balance/
PMID: 30539897. stressmanagement/news/20080514/teen-stress-at-
home-lingers-in-school
6. Baksannylla Khongwir, et.al. “Depression,
Anxiety and Stress among High School students in 18. Lander L, Howsare J, Byrne M. The Impact of
Manipur.”IOSR Journal of Dental and Medical Sciences Substance Use Disorders on Families and Children:
(IOSR-JDMS);2020;19(1): 28-3 From Theory to Practice. Social Work in Public Health.
2013;28(0):194–205.
7. Deb S, Chatterjee P, Walsh K. Anxiety among high
school students in India : comparisons across gender,
school type, social strata, and perceptions of quality
time with parents. Australian Journal of Educational and
Developmental Psychology. 2010;10(1):1831.
8. Nair BK, Elizabeth KE. Prevalence of Stress, Anxiety

and Its Correlates among Adolescents in Kannur

Emotional and Behavioural issues in children during early Phases of school

opening after Covid 19 Pandemic in Eastern India
Somsubhra Chattopadhyay1, Sharmistha Debnath2, Rumi Gayen3, Subhendu Dattta4

1
Associate Professor, Department of Psychiatry,College of Medicine and Sagore Dutta Hospital
2
Associate Professor, Department of Oncopatholoogy, Medical College, Kolkata
3
Assistant Professor, Department of Biochemistry, College of Medicine and Sagore Dutta Hospital
4
Assistant Professor, Department of Psychiatry, Medical College, Kolkata
How to cite this article: Somsubhra Chattopadhyay, Sharmistha Debnath, Rumi Gayen, Subhendu Dattta4 et al
Emotional and Behavioural issues in children during early Phases of school opening after Covid 19 Pandemic
in Eastern India. Volume 13 | Issue 4 | October-December 2022
Abstract
Introduction: The Covid 19 pandemic was first officially noted in China in late 2019. After that, the virus spread globally.
At that time it was a new virus and we did know nothing about the virus. So lock down or home confinement was the only
option to control the spread of the virus (1). During that time children suffered the most as they were confined at home (2).
During this period they showed various behavioural problems and when restrictions were withdrawn they still showed
some behavioural issues.
Methodology: We conducted a cross-sectional study using an English questionnaire. The questionnaire was validated
by five independent psychiatrists who were finally excluded from the study. Responses from the parents of randomly
selected 76 children were recorded. We included the children aged between 3 to 12 years and who previously used to go
to school.
Results: 40.8 % of children were of 6 to 10 years of age and the male and females were almost equal in number in our
study (M: F = 40:36). Maximum children are from urban residences (about 59.2%) and the nuclear family (56.6%) followed
by joint families (38.2%) and single-parent families (5.3%). In most of the cases ( 61.8%) father is the only earning member
followed by both parents working (34.2%) and in only 3.9% of cases, the mother is the only earning member of the family.
About 76.3% of parents observed behavioural issues in their children. The problems were mostly observed in 6 to 10 yrs
of age. Males showed the problem most often than females ( M:F = 33:25). Children from urban areas showed behavioural
problems more often.
Discussion: Most of the parents reported that their children were having different sorts of problems during this period(3).
The families of small children aged 6 to 10 yrs of age were facing various problems more often. The children of this age
group showed problems more often as they were isolated at home. Previously they were in the discipline of school and
society. Due to the sudden release of pressure, all routine activities got disturbed.
Keywords: Covid 19, Temper tantrum, restlessness, inattention
Introduction March 2020 (5). India’s first novel coronavirus disease

Severe acute respiratory distress syndrome, caused was reported in January 2020 in Kerala (6). Within
by a new strain of coronavirus(COVID 19) was first about 50 days India had reported 360 cases. As it was
officially reported in Wuhan, China in late 2019 (4). a new virus and also there was no known effective
Since then it has spread in alarming speed all over treatment it was the primary concern to break the
the world. WHO declared it a global pandemic in chain of virus transmission by confining the people
Dr Subhendu Datta
Assistant Professor, Department of Psychiatry, Medical College , Kolkata
E-Mail: [email protected]
at home (7). On March 25 nationwide lockdown was 61.8%) father is the only earning member followed
imposed by India Government (8). by both parents working (34.2%) and in only 3.9% of
cases, the mother is the only earning member of the
Since the day of lockdown, the children are
family.
confined at home. Before lockdown children could go
for a face to face interaction with their peers, teachers, Table 1: Basic Socio-Demographic data of study
and relatives. They could go outside for playing or participants
for some extracurricular activities. But from the very Frequency Percent
beginning of lockdown children were confined at
Age 11-15 23 30.3
home. All the learning and communications became
restricted to digital platforms (9)(10). Children often 3-5 22 28.9
show emotional and behavioural problems during 6-10 31 40.8
this period of lockdown.(11) Sex M 40 52.6
In this background, we studied a few children to F 36 47.4
record the degree of changes in this tough time of Residence Metro 22 28.9
home confinement. Rural 9 11.8
Materials and Method Urban 45 59.2
We conducted a cross-sectional study using an Family type Joint 29 38.2
English questionnaire. India was under unlock period Nuclear 43 56.6
during the study. The questionnaire was validated Single 4 5.3
by five independent psychiatrists who were finally Parent
excluded from the study. Before the start of the study, Occupation Both 26 34.2
we did a pilot study. The final questionnaire consists of Parents Working
of 51 items. The questionnaire was divided into three
Father 47 61.8
groups, Socio-demographic data (age, sex, religion,
Working
residence, family type, occupation of parents),
behavioural changes in children ( inattention, sleep Mother 3 3.9
pattern, change of eating habits, depression, anxiety, Working
engagement in mobile, television and internet game, We tried to assess the change of behaviour in
nail-biting, thumb sucking) and parents perception of children during this tough time. They were detached
prolonged home confinement. from school, friends and social activities for the last
Responses from the parents of randomly selected 2 yrs. About 76.3% of parents observed behavioural
76 children were recorded. We included the children issues in their children. And the problems are mostly
aged between 3 to 12 years and who previously used to observed in 6 to 10 yrs of age. Males showed the
go to school. The children having previous psychiatric problem most often than females ( M: F = 33:25).
problems had been excluded from the study. Before Children from urban areas showed behavioural
participating in the study written or verbal consent problems more often than in rural areas and metro
was obtained from the parents. After receiving the cities. Children are having problems whose father
consent details of the study were explained. We is the only earning member of the family and where
assured every parent about the confidentiality of both parents were working.
responses. The sample consisted of all the residential Table 2: Changes in behaviour as per different
areas including rural, urban, and metro areas. socio-demographic parameters
Result (N=76) Change of Behaviour

No Yes
40.8 % of children were of 6 to 10 years of age and
(n=18) ; (n=58)
the male and females were almost equal in number
23.7% 76.3%
in our study (M: F = 40:36). Maximum children are
Age (yrs) 11-15 5 18
from urban residences (about 59.2%) and the nuclear
family (56.6%) followed by joint families (38.2%) and 3-5 8 14
single-parent families (5.3%). In most of the cases ( 6-10 5 26

270
(N=76) Change of Behaviour Frequency Percent

No Yes Easy Often 41 53.9
(n=18) ; (n=58) distraction Rare 8 10.5
23.7% 76.3% Sometimes 27 35.5
Sex M 7 33
Sleep more Often 26 34.2
F 11 25
Rare 25 32.9
Residence Metro 6 16
Sometimes 25 32.9
Rural 1 8
Sleep less Often 19 25.0
Urban 11 34
Rare 37 48.7
Family type Joint 5 24
Sometimes 20 26.3
Nuclear 12 31
Increased Often 54 71.1
Single 1 3 mobile use Rare 6 7.9
parent Sometimes 16 21.1
Occupation Both 6 20
Fearful Often 4 5.3
of Parents working
Father 12 35 Rare 39 51.3
working Sometimes 33 43.4
Mother 0 3 Anxious Often 41 53.9
Working
Rare 18 23.7
The following table shows different behavioural Sometimes 17 22.4
problems and their frequencies.51.3% of children
Aggressive Often 19 25.0
demand attention from their family members.
Rare 24 31.6
55.3% of children became restless and 46.1% became
inattentive in family settings. 53.9% of children got Sometimes 33 43.4
distracted easily. Sleep pattern was more or less Disobedience Often 29 38.2
normal. A significant number of children (71.1%) Rare 18 23.7
increased their mobile use behaviour. 53.9% of Sometimes 29 38.2
children became anxious in different circumstances.
Telling lie Often 15 19.7
64.5% of children showed temper tantrums and
38.2% of children argued with their family members Rare 26 34.2
in various contexts. Watching television and mobile Sometimes 35 46.1
gaming increased more than before. 68.4% of children Temper Often 49 64.5
increased television watching and 59.2% of children tantrum Rare 9 11.8
increased playing mobile games. Sometimes 18 23.7
Table 3: Frequencies of different behavioural Argues a lot Often 29 38.2
issues
Rare 22 28.9
Frequency Percent Sometimes 25 32.9
Demands Often 39 51.3 Nail biting Often 6 7.9
attention Rare 6 7.9 Rare 50 65.8
Sometimes 31 40.8 Sometimes 20 26.3
Restlessness Often 42 55.3 Increased TV Often 52 68.4
Rare 11 14.5 watching Rare 5 6.6
Inattention Often 35 46.1 Increased Often 45 59.2
Rare 11 14.5 mobile Rare 11 14.5
gaming

Table 4: behavioural issues in different age groups, sex, family type, working status of parents
11-15 Age (yrs) Sex Family type Working status of parents
3-5 6-10 F M Joint Nuclear Single Both Father Mother
parent Working Working Working
Inattention Often 9 9 17 15 20 16 17 2 13 21 1
Rare 4 3 4 6 5 2 9 0 4 7 0
Sometimes 10 10 10 15 15 11 17 2 9 19 2
Temper Often 14 14 21 21 28 20 26 3 17 29 3
tantrum Rare 3 2 4 5 8 3 6 0 4 5 0
Sometimes 6 6 6 10 4 6 11 1 5 13 0
Increased Often 16 16 22 28 26 21 31 2 17 36 1
mobile use Rare 2 2 2 1 5 2 4 0 2 4 0
Sometimes 5 4 7 7 9 6 8 2 7 7 2
Increased Often 14 16 22 19 33 17 31 4 14 35 3
TV watching Rare 2 1 2 2 3 4 1 0 2 3 0
Sometimes 7 5 7 15 4 8 11 0 10 9 0
The table above shows different behavioural Increased watching of TV Total

problems in different age groups. Mainly 6 to 10 yrs
old children became inattentive mostly. All the other Often Rare Sometimes
behavioural problems like temper tantrums increased Mobile use increased
mobile use and increased watching of television were Often 35 4 10 49
observed mostly in the 6 to 10 yrs age group.
Rare 4 2 3 9
Inattention, temper tantrum and increased
Sometimes 15 0 3 18
television watching were seen most often in males.
But females were using mobiles more often than Total 54 6 16 76
males. The above cross-tabulations shows behavioural
All the behavioural problems of inattention, issues (temper tantrum ) in children who used Mobile
temper tantrums, increased mobile use and increased phones and watch television more often. Temper
television watching are seen mostly in nuclear tantrums increased in children who spend more time
families. using the screen.
Surprisingly the problems are most often seen Discussion

where the father was working than both parents were We got 76 responses from different regions like
working. Inattention, temper tantrums, and increased metro cities, and urban and rural areas. During
mobile and television use are seen in families where the pandemic, children were confined at home
the father is the only working member. and when the pandemic related restrictions were
Table 5: Behavioural issues and watching withdrawn, little kids continues to show maladjusted
Television and mobile use behaviour. In our study, 76.3% of parents reported
some behavioural and emotional problems in their
Increased watching of TV Total
children. Previous studies conducted during the early
Often Rare Sometimes phases of lockdown show various kinds of emotional
Often 38 3 8 49 and behavioural issues in children. (12)
Temper Rare 1 1 7 9 In our study, we collected the data when strict

tantrum Sometimes 13 1 4 18
restrictions were withdrawn. The kids started to go
outside, but their emotional issues persisted which is
Total 52 5 19 76 most notable at 6 to 10 yrs of age. Our study matches

272
with a study done on Chinese children which shows discipline all routine activities got disturbed. They
significant behavioural issues in a reopened school spent most of their time watching television and
group. (13) different activities on mobile phones.
In our study children from rural areas were affected Most behavioural issues occurred in nuclear families
less often. It is assumed that housing conditions where children got less chance to play with the family
during the isolation phases have a definite impact members who also got emotionally disturbed by the
on children’s mental health. When the children have uncertainty of future, health and economy. The small
more access to spend time in nature, they are more kids with pent up emotional stress often behaved in a
healthy both physically and mentally. It is supported way that was not acceptable to their families.
by one previous study which was conducted during
A significant number of children (53.9%) became
the early phases of quarantine in three different
anxious in various family and social circumstances.
European countries (14).In rural areas people were
During the pandemic, children spent most of their
more reluctant to maintain restrictions. So the children
time with their families. They did not have a chance
could go outside and could mix and play with their
to socialize or attend the social gathering which
friends.
ultimately provoked anxiety in the environment
In our study, we noticed children showed which is not very familiar to them.
behavioural problems in attention, restlessness, easy
distraction, sleep disturbances, fearfulness, anxiety,
aggression, disobedience, temper tantrum, nail-biting Source of Funding: Nil
and increased television and mobile phone use. The Ethical Clearance: Informed consent was
previous studies also showed similar findings in obtained from each participant. Only willing parents
behavioural issues (15). During the isolation phases participated in the study. They were assured to keep
when kids were detached from their friends, relatives the information confidential. Respondents were asked
found the only way of pleasure is watching TV or that they have full right to withdraw from the study if
mobile phone use. In some families, domestic violence they feel embarrassed to answer any question. Ethical
increased during the isolation phases which changed clearance was not obtained for the study.
the children’s behaviour (16).
References
Temper tantrums increased in children who
watched mobile and television more often and in 1. Atalan A. Is the lockdown important to prevent
nuclear families. Few previous studies also show the COVID-19 pandemic? Effects on psychology,
environment and economy-perspective. Annals of
similar findings where there was a positive correlation
Medicine and Surgery. 2020 Aug 1;56:38–42.
between screen time and behavioural and emotional
symptoms (17) . During the time of home confinement, 2. Spinelli M, Lionetti F, Pastore M, Fasolo M. Parents’
children had less chance to ventilate emotions. Their Stress and Children’s Psychological Problems in
pent up emotions were channelized into unacceptable Families Facing the COVID-19 Outbreak in Italy.
emotional expressions. Frontiers in Psychology. 2020 Jul 3;11.
3. Singh S, Roy D, Sinha K, Parveen S, Sharma G, Joshi G.

Conclusion Impact of COVID-19 and lockdown on mental health
We studied behavioural problems during the early of children and adolescents: A narrative review with
phases of school opening after about 2 yrs of home recommendations. Vol. 293, Psychiatry Research.
confinement during Covid 19 pandemic. Most of Elsevier Ireland Ltd; 2020.
the parents reported that their children were having 4. Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe
different sorts of behavioural problems during this acute respiratory syndrome coronavirus 2 (SARS-
period. The families of small children aged 6 to 10 yrs CoV-2) and coronavirus disease-2019 (COVID-19):
of age were facing various problems more often than The epidemic and the challenges. Vol. 55, International
children younger and older than this age group. The Journal of Antimicrobial Agents. Elsevier B.V.; 2020.
children of this age group showed problems more 5. Cucinotta D, Vanelli M. WHO declares COVID-19
often as they were being isolated at home when they a pandemic. Vol. 91, Acta Biomedica. Mattioli 1885;
started to socialize and were in the discipline of school 2020. p. 157–60.
and society. Due to the sudden release of pressure of

6. Andrews MA, Areekal B, Rajesh K, Krishnan J, 13. Wang L, Zhang Y, Chen L, Wang J, Jia F, Li F, et al.
Suryakala R, Krishnan B, et al. First confirmed case of Psychosocial and behavioral problems of children and
COVID-19 infection in India: A case report. Vol. 151, adolescents in the early stage of reopening schools
Indian Journal of Medical Research. Wolters Kluwer after the COVID-19 pandemic: a national cross-
Medknow Publications; 2020. p. 490–2. sectional study in China. Translational Psychiatry.
2021 Jun 1;11(1).
7. Kharroubi S, Saleh F. Are Lockdown Measures
Effective Against COVID-19? Frontiers in Public 14. Francisco R, Pedro M, Delvecchio E, Espada JP, Morales
Health. 2020 Oct 22;8. A, Mazzeschi C, et al. Psychological Symptoms and
Behavioral Changes in Children and Adolescents
8. Ray D, Subramanian S. India’s lockdown: an interim
During the Early Phase of COVID-19 Quarantine in
report. Indian Economic Review. 2020 Nov 1;55:31–79.
Three European Countries. Frontiers in Psychiatry.
9. Pokhrel S, Chhetri R. A Literature Review on Impact 2020 Dec 3;11.
of COVID-19 Pandemic on Teaching and Learning.
15. Takahashi F, Honda H. Prevalence of clinical-level
Higher Education for the Future. 2021 Jan 1;8(1):133–
emotional/behavioral problems in schoolchildren
41.
during the coronavirus disease 2019 pandemic in
10. Pandya A, Lodha P. Social Connectedness, Excessive Japan: A prospective cohort study. JCPP Advances.
Screen Time During COVID-19 and Mental Health: 2021 Apr;1(1).
A Review of Current Evidence. Frontiers in Human
16. Bradbury-Jones C, Isham L. The pandemic paradox:
Dynamics. 2021 Jul 22;3.
The consequences of COVID-19 on domestic violence.
11. Morgül E, Kallitsoglou A, Essau CA. Psychological Vol. 29, Journal of Clinical Nursing. Blackwell
effects of the COVID-19 lockdown on children and Publishing Ltd; 2020. p. 2047–9.
families in the UK. Revista de Psicologia Clinica con
17. Li X, Vanderloo LM, Keown-Stoneman CDG, Cost KT,
Ninos y Adolescentes. 2020 Sep 1;7(3):42–8.
Charach A, Maguire JL, et al. Screen Use and Mental
12. Jiao WY, Wang LN, Liu J, Fang SF, Jiao FY, Pettoello- Health Symptoms in Canadian Children and Youth
Mantovani M, et al. Behavioral and Emotional during the COVID-19 Pandemic. JAMA Network
Disorders in Children during the COVID-19 Epidemic. Open. 2021 Dec 28;4(12).
Vol. 221, Journal of Pediatrics. Mosby Inc.; 2020. p. 264-
266.e1.

Seroprevalence of Hepatitis C Virus in Blood Donors of

Kathua District (J & K)
Sonia Gupta1, Vidhu Mahajan2, Meenakshi Gupta3

1
Lecturer, Department of Blood Transfusion Medicine, GMC Kathua
2,3
Assistant Professor, Department of Pathology, GMC Kathua
How to cite this article: Sonia Gupta, Vidhu Mahajan, Meenakshi Gupta et al Seroprevalence of Hepatitis C Virus
in Blood Donors of Kathua District (J & K). Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Hepatitis C is a transfusion transmitted infection and leads to Chronic liver disease and cirrhosis in about 10
to 20 percent of infected individuals. Aim: To find out the seroprevalence of HCV in Blood donors of Kathua district and
also see the trend of the HCV infection. Methods: Retrospective analysis of the number of HCV seroreactive donors over a
period of 6 years was done from the records. Results: In the present study, the seroprevalence of HCV in blood donors was
0.7% (n=57) and the number of HCV seroreactive donors has increased gradually from 3 in 2016 to 27 in 2021. Maximum
(73.68%) HCV seroreactive donors were in the age group of 18-30 years. Conclusion: The seroprevalence of HCV infection
is increasing that too in the young population so for provision of safe blood, focus should be laid on the prevention of
HCV infection at the community level.
Keywords: Blood Donor,Transfusion Transmitted Infection, Hepatitis, Seroprevalence
Introduction It is estimated that worldwide about 58 million

Blood is a life saving resource but at the cost of risk people have chronic hepatitis C virus infection and he
of acquiring Transfusion Transmitted Infections via incidence of HCV is 1.5 million per year. According to
Blood Transfusion. Hepatitis C is one of the infections WHO factsheet 2019 , approximately 290 000 people
that can be transmitted via blood transfusion and died from hepatitis C, the most common cause being
primarily affects the liver leading to chronic liver cirrhosis and hepatocellular carcinoma .[2]
disease and cirrhosis in about 10 to 20 per cent of Our institute is a newly established Medical College
those infected and can also lead to hepatocellular and therefore the present study was conducted to
carcinoma (HCC). The worldwide seroprevalence find out the seroprevalence of HCV in blood donors
of HCV varies from 0.4 to 19.2 per cent in blood of Kathua district as no such previous data was
donors and therefore the risk of transmission of HCV available from this area.
infection from donors who are in the window period
is quite significant. In India, every blood unit is tested Materials and Methods
for HIV, HBV, HCV, malaria and syphilis. The main This is a retrospective observational study conducted
route of HCV transmission is blood-to-blood contact in Blood Centre, GMC Kathua (J&K) over a period
via intravenous drug abuse, unsterilized medical of 6 years from April 2016 to March 2022 to find out
devices, needlestick injuries in healthcare, and Blood the seroprevalence of Hepatitis C infection in blood
Transfusions. In addition, vertical transmission from donors of this region and also to see its changing
mother to child can occur during birth [1] trend over the years.
Dr Meenakshi sharma
Assistant Professor, Dept. of Physiology, GMC Kathua
All the Blood Donors were screened according Punjab & New Delhi respectively but higher than the
to the standard Blood Donor Questionnaire and retrospective studies done in Jammu region i.e Sidhu
blood was collected from those found fit. About et.al. with HCV seroprevalence of 0.2% and 0.17%
5 ml of blood sample was collected in test tubes in replacement and voluntary donors respectively[6]
at the end of donation and screened for the five & Arora et. al. reported a seroprevalance rate of
mandatory markers i.e HIV, HBV, HCV, malaria 0.075%[7].This difference in seroprevalence rate could
and syphilis. HCV screening was done by Enzyme be due to different sociodemographic variables, lack of
Linked Immunosorbent Assay (ELISA) method using awareness about blood safety & high risk behaviour.
ErbaLisa HCV Gen 3 kits.
Among studies done in New Delhi,Makroo et.al.
Results reported seroreactivity for anti HCVas 0.39%[1]
Pahuja et.al. as 0.66%[5] , Jain et.al.as 1.57%[8]. Kaur
Out of the total 8192 blood donors, 8127 were males
et.al.showed high HCV seropositivity of 2.44% in
(99.21%) and 65(0.8.%) were females. 57 blood donors
punjab[9] & Arora et.al. 1.0% in Haryana[10].Other
were found reactive for HCV. In the present study,
studies have shown variable results, Khaneta et.al.
the seroprevalence of HCV in blood donors was 0.7%
HCV 1.04% in Mumbai[11], Kumar et.al.0.28% in
and the number of HCV seroreactive donors has
Wardha,Maharashtra[12], Karmakar et.al. 0.59% in
increased gradually from 3 in 2016 to 27 in 2021 (Table
Kolkata[13]& Dowerah et.al. 0.1%North East[3]
1)Maximum(73.68%) HCV seroreactive donors were
in the age group of 18-30 years (Table 2). There was a increasing trend in HCV seroprevalence
over a period of 6 years which is consistent with
Table I. Number of HCV seroreactive donors
studies by Kumar et. al[12], Saini et. al[14], Ram et.
Year Total Number HCV al[15],Patel et. al[16].
number of HCV seroreactive
In the present study,73.68% seroreactive donors
of donors seroreactive donors(%)
tested donors were in the age group of 18-30 years as also reported
by Makroo et.al.[1]. In another study conducted by
2016 956 3 0.31
Karmakar et.al al[13] more than two-third seropositive
2017 1008 1 0.1 (69.36%) were in the age group of 21-40 years of age.
2018 993 3 0.3
The rising seroprevalence that too in the young
2019 1194 10 0.84 population is a matter of concern for Blood Centres
2020 1771 13 0.73 as it shrinks the donor pool. India is a developing
2021 2270 27 1.19 country and unlike the western countries, is far away
Total 8192 57 0.7 from the universal implementation of NAT testing in
all Blood Centres of the country, so for minimizing
Table II. Age distribution of Seroreactive HCV donors the chances of HCV transmission from donors
Age (yr) Total number (%) of HCV who may be in the window period ,we still have to
of donors seroreactive donors depend on vigilant History taking and identification
18-30 42 73.68 of blood donors with high risk behavior. Thus we
should put emphasis on the need of a trained and
31-40 13 22.8
efficient Counselor in every Blood Centre. Healthcare
41-50 1 1.75
authorities should also focus more on the prevention
51-60 1 1.75 of the disease by creating awareness as there is no
Discussion vaccine available till date and it is an ailment with
high chronicity and thus increased morbidity and
Maximum donors in our study were males 8127
mortality in our population.
(99.2%).All HCV seroreactive donors were also males
which is comparable with studies of Dowerah et. al[3] Conclusion
where male donors showed greater seropositivity The seroprevalence of HCV infection is increasing
than female donors. that too in the young population so for provision of
safe blood, focus should be laid on the prevention of
In our study, HCV seroprevalence of 0.7% was
HCV infection at the community level.
found in blood donors which is comparable to study
done in Kaur et.al.(0.77%)[4] & Pahuja et.al. (0.66%)[5] in

276
Ethical Clearance 9. Kaur A , Maharishi RN, Jindal N, Kukar N, Arora H,

Syal N. Seroprevalence of Hepatitis C Virus Antibodies
Taken from Institutional Ethical Committee(IEC),
among Blood Donors of North India: A Prospective
GMC Kathua Study. Annals of International Medical and Dental
Conflict of Interest: NIL Research.2021Jul-Aug;7(4):01-12
Funding: SELF 10. Arora D , Arora B, Khetarpal A .Seroprevalence of

HIV, HBV, HCV and syphilis in blood donors in
References Southern Haryana. Indian J pathol Microbiol Apr-Jun
2010;53(2):308-9.
1. Makroo RN, Walia RS, Chowdhry M, Bhatia A ,
Hegde V & Rosamma NL. Seroprevalence of anti-HCV 11. P Khaneta , Khan AF, Khan AS. The seroprevalence
antibodies among blood donors of north India. Indian of HIV, hepatitis B, hepatitis C and venereal disease
J Med Res 138, July 2013, pp 125-128 research laboratory test seropositivity in blood
donors: a 5-year retrospective comparative study at
2. WHO FACTSHEET 27 July 2021
tertiary care hospital in Mumbai, Maharashtra, India.
3. Dowerah S, Sharma A,Thapa GSeroprevalence of International Journal of Research in Medical Sciences
Hepatitis B and C among blood donors attending a 2017;5(6).
State of the Art Model Blood Bank of North East India
12. Kumar A, Sharma S, Ingole N, Gangane N. Rising
.Scholars Journal of Applied Medical Sciences (SJAMS)
trends of HCV infection over a period of 4 years among
Sch. J. App. Med. Sci., 2017; 5(8D):3264-3267
blood donors in central India: A retrospective study.
4. Kaur K , Locham R, Aulakh SK , Bassi R, Pannu JS. International Journal of Medicine and Public Health
Seroprevalence of human immunodeficiency virus, 2013Oct-Dec;3(4): 240-243
hepatitis B and hepatitis C among blood donors at a
13. Karmakar PR, Shrivastava P,Ray TG.Seroprevalence
tertiary care hospital in North India. International
of Transfusion Transmissible Infections Among Blood
Journal of Basic & Clinical Pharmacology Int J Basic
Donors at the Blood Bank of a Medical College of
Clin Pharmacol. 2020 Nov;9(11):1671-1674
Kolkata. Indian Journal of Public Health.2014Jan-
5. Pahuja S, SharmaM, Baitha B and Jain M. Prevalence Mar;58(1):61-64
and Trends of Markers of Hepatitis C Virus, Hepatitis
14. Saini PA, Chakrabarti PR and Gupta Priyanka.
B Virus and Human Immunodeficiency Virus in Delhi
Hepatitis C Virus:Unnoticed and on the rise in Blood
Blood Donors: A Hospital Based Study. Jpn. J. Infect.
Donor Screening ?A 5 year Cross sectional study on
Dis.2007; 60: 389-391
Seroprevalence in Voluntary Blood Donors from
6. S Meena, K Urvershi, K Raman, Raina TR. Central India. Journal of Global Infectious Diseases J
Seroprevalence of human immunodeficiency virus, Glob Infect Dis.2017Apr-Jun;9(2):51-55
hepatitis B virus and hepatitis C virus in blood donors
15. Ram J, Nigam N,Singh A,Khan L.Increasing
of Jammu Province: A tertiary care centre experience.
seroprevalence of Hepatitis C Virus among Blood
Asian J Transfus Sci.2013 Jul-Dec; 7(2): 162–163.
Donors- A 3 year study in north India.Journal of Evidence
7. Arora S, Sharma M. Seroprevalence of HIV, HBV, Based Medicine and Healthcare2021;8(07):379-383.
HCV, Syphilis and Malaria among blood donors in a
16. Patel S, Popat C, Mazumdar V,Shah M, Shringarpure K,
tertiary care hospital of Jammu. J. med. sci. clin. res.
Mehta KG,Gandhi A.Seroprevalence of HIV, HBV,HCV
2018Oct.;06(10):1257-1260.
and syphilis in blood donors at a tertiary hospital
8. Jain A, Rana SS, Chakravarty P, Gupta RK, Murthy (Blood Bank) in Vadodara.International Journal of
NS, Nath MC, Gururaja S, Chaturvedi N, Verma U and Medical Science and Public Health2013;2(3)747-750.
Kar P. The Prevalence of Hepatitis C Virus Antibodies
among the Voluntary Blood Donors of New Delhi,
India. European Journal of Epidemiology 2003;18(7)
695-697

Predicting and Identifying Postpartum Blues may be the key to

implementing Preventive Approaches in Perinatal Mental Health:
Findings from a Prospective, follow up Study in India
Sreyoshi Ghosh1, Sripathy Bhat2

1
Assistant Professor, Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru
2
Professor, Department of Psychiatry, Kasturba Medical College, Manipal
How to cite this article: Sreyoshi Ghosh, Sripathy Bhat et al Predicting and Identifying Postpartum Blues may
be the key to implementing Preventive Approaches in Perinatal Mental Health: Findings from a Prospective,
follow up Study in India. Volume 13 | Issue 4 | October-December 2022
Abstract
Objective: The present study aimed to estimate the prevalence of post-partum blues and investigate the correlates of
the disorder. An additional objective was to study the correlation of blues with subsequent development of psychiatric
disorders.
Methods: A prospective study design was adopted and a total of 73 women were included. Those who developed
maternity blues were compared with those who hadn’t on multiple socio-demographic, obstetric, psychiatric and psycho-
social variables.
Results: The prevalence of post-partum blues was estimated to be 28.8 %. Of the women with blues 14.2% went on to
develop post-partum depression whereas none of the women who had not experienced blues developed depression. It
was found that there was a significant correlation between post-partum blues and the following variables in decreasing
order of significance: poor marital quality, pre-menstrual dysphoric disorder, past history of psychiatric illness, higher
scores on stressful life events in the past one year, fear of labour and upcoming events, perinatal complications to the
mother, unplanned pregnancy and family history of psychiatric illness.
Conclusions: The study highlights the importance of post-partum blues as these women are at higher risk of developing
post-partum depression. Psycho-social variables that can contribute to the development of blues such as stressful events
experienced during pregnancy and poor marital quality should be assessed and interventions planned accordingly to
reduce the impact of these on women.
Keywords: maternity blues, post-partum, maternal mental health
Introduction predicted blues.3 As many as 20 % of women with

Post-partum blues refers to the tearfulness, irritability, blues go on to develop post-partum depression.4. In
hypochondriasis, sleeplessness, impairment of India, to the best of our knowledge there has been
concentration, headache that occurs in the 10 days or only one previous study 5 that has investigated
so postpartum. A peak in symptoms occurs around the phenomenon of blues and there is a paucity of
the fourth to fifth day after delivery, coinciding with literature on this topic worldwide. This study was
maximal hormonal changes. A recent systematic therefore planned to further understand maternity
review and meta-analysis estimated the prevalence blues so that vulnerable women can be identified
of blues as 39.6 % in 5667 women.1. Predictors of early and pre-emptive measures taken so that the
postpartum blues from existing literature are a downstream path to post-partum depression and its
previous history of post-partum depression and devastating consequences can be potentially averted.
lower education level whereas normal delivery Materials and Methods
has been found to be protective.2. A study from
This was a prospective, follow up study and 73
Japan found that availability of social support and
women who delivered a healthy baby at Haji
living with parents following delivery negatively
278
Abdullah Municipal Maternity and Child Health Procedure

Centre, Udupi were included. Informed consent was The first assessment was carried out in the third
taken from the participants. The study was approved trimester after admission for safe confinement. Scales
by the Ethics Committee of Kasturba Medical College, that were administered at this time were the General
Manipal. information proforma, GHQ-5, Marital Quality Scale,
The Lubben Social Network scale, Presumptive Life
Instruments used
Events Scale. All women who scored 2 or above on
1) General Health Questionnaire- 5 6 GHQ-5 were then interviewed using MINI-PLUS
This is a 5 item self-rated questionnaire widely and those with syndromal psychiatric disorders were
used as a screening tool for mental disorders. The excluded at this point. For those women who did not
cut-off score of 1 produced optimum indices of have any psychiatric illness following interview with
validity. MINI-PLUS, Blues Questionnaire was administered
on the 5th day following delivery. A follow-up
2) Blues Questionnaire7
assessment was carried out at 6 weeks using GHQ-
It is a self-rated 28 items self-rated questionnaire 5 and MINI-PLUS to look for development of
valid for detecting and measuring specific brief post-partum psychiatric disorders with the main
psychological disturbances occurring in a few focus being identifying women with post-partum
days after childbirth. For the calculation of the depression and anxiety.
cut-off point for severe maternity blues the
authors suggest that the mean peak score of all Statistics
women should be used. The highest score on any The participants were divided into two groups for
of the days of observation is considered the peak statistical analysis. The first group comprised of
score for each woman. women with post-partum blues and the second
3) The Marital Quality Scale8 group without post-partum blues. Data was analyzed
descriptively to determine the basic characteristics
It is a multidimensional measure of marital
of the sample like age, parity, type of delivery.
quality that gives global and specific scores. It is
Independent t-test was used to compare the groups
a 50 item self-report standardized scale. Higher
on continuous variables for data that was normative
scores are indicative of poorer quality of married
like social network scale, marital quality scale. For
life.
comparing the groups in case of life events score,
4) The Lubben Social Network Scale 9 Mann Whitney U test was used as the data was non-
It is a self-report 10 item scale to assess the level of normative. The Chi-square test was used to know
social support available to a person. The minimum if there was a significant association between the
score is 0 and maximum is 50, with higher scores two groups on categorical variables such as socio-
indicating greater level of social support. demographic details, obstetric history, past and
family history.
5) Presumptive Stressful Life Events Scale
(PSLES)10 Results and Discussion
The PSLES comprises 51 life events relevant to A total of 73 women completed both the baseline
the Indian setting which is standardized for 2 assessment and the Blues Questionnaire. As suggested
frames: past 1 year and lifetime. The scores can be by the authors, the mean peak blues score of all the
calculated according to two formats- number of women was calculated which was 4.3, hence the cut-
life events and weighted stress scores. off for diagnosing maternity blues was taken as 5. A
total of 21 women (28.8 %) were found to have blues.
6) MINI PLUS- International Neuro-Psychiatric
A 6 week follow up was carried out and a total of 70
Interview. 11
women were interviewed. Four women were lost to
The MINI Plus is a short structured diagnostic follow-up at this point.
interview. A total of 19 psychiatric disorders are
included. The instrument has a good inter rater Prevalence of Post-Partum Blues
and retest reliability.

Prevalence of post-partum blues was found to be The mean age of the sample was 25.8 years (S.D
28.8 %. In most prior studies the prevalence quoted 8.1). Majority of the women (78.08%) belonged to an
is between 40-60% 12, 13 with the lowest prevalence extended family setup. When the socio-demographic
rates of 15.3% being reported for Asian countries like variables were compared between women with blues
Japan. 14 The present study also has a relatively low and those without, no significant difference was
prevalence rate compared to Western authors and found between the two groups.
is more proximal to the rates reported in Japan. A
similar socio-cultural milieu in both countries where Obstetric Variables:
women return to their maternal home for delivery Obstetrics variables pertaining to mother as predictors
and have extensive social support in view of living in of blues
large joint families 14 may be the reason for this. Table-1
Socio-Demographic Details:
Variable Group Postpartum Postpartum Total Chi p

blues present blues absent square χ2
n(%) n(%)
Planned Yes 15(20.5%) 49(67.1%) 64(87.6%)

7.196 .007**
pregnancy No 6(8.2%) 3(4.1%) 9(12.3%)
Antenatal Hypertension 2(2.7%) 4(5.4%) 6(8.2%)
complications Diabetes 0(0%) 3(4.1%) 3(4.1%)
1.342 .719
Others 2(2.7%) 4(5.4%) 6(8.2%)
None 17(23.2%) 41(56.1%) 58(79.4%)
Delivery Type Normal 11(15.06%) 29(39.7%) 40(54.7%)
.069 .792
Caesarian 10(13.6%) 23(31.5%) 33(45.2%)
Perinatal Post-partum
1(1.4%) 0(0%) 1(1.4%)
Complications hemorrhage
3(4.1%) 0(0%) 3(4.1%) 10.479 .005**
Infection
17(23.2%) 52(71.2%) 69(94.5%)
None
Primi 13(17.8%) 36(49.3%) 49(67.12%)
Parity Second 8(10.9%) 15(20.5%) 23(31.5%) .930 .628
Third 0(0%) 1(1.4%) 1(1.4%)
Fear of labor Yes 16(21.9%) 20(27.3%) 36(49.3%)
and upcoming 8.519 .004**
events No 5(6.8%) 32(43.8%) 37(50.6%)
**p<0.01
The present study found that unplanned pregnancy (p=0.007**), fear of upcoming events in late pregnancy
(p=0.004**), perinatal complications in the mother about their thoughts and emotions regarding the
(p=0.005**) significantly predicted the development upcoming delivery and clarifying any doubts they
of post-partum blues. This would indicate that it is may have may go a long way towards allaying their
necessary to ask expecting mothers about whether the anxiety which in turn may prevent the development
pregnancy was planned or not, and address any anxiety of blues.
related to the same to reduce their vulnerability.
Table 2: Obstetrics variables pertaining to child as
Similarly, towards the end of pregnancy, sensitizing predictors of blues
obstetricians about the importance of asking mothers

280
Variable Group Postpartum Postpartum Total Chi p

blues present blues absent square χ2
n(%) n(%)
Gender of the male 8(10.9%) 25(34.2%) 33(45.2%)
child .602 .438
female 13(17.8%) 27(36.9%) 40(54.7%)
Gender as yes 18(24.6%) 46(63%) 64(87.6%)
expected .104 .747
no 3(4.1%) 6(8.2%) 9(12.3%)
Postnatal yes 5(6.8%) 4(5.4%) 9(12.3%)
3.595 .058
Complications no 16(21.9%) 48(65.7%) 64(87.6%)
In our study the gender of the newborn, parity, Nigeria by Adewuya 15 where the birth of a female
gender of the child contrary to expectation and type child had been shown to contribute significantly
of delivery was not found to have any significant towards development of blues. Such a finding may
association with the development of blues. reflect increasing levels of awareness and a gradual
shift of the mindset at least in parts of our country
The finding that the gender of the newborn was
from a conservative, patriarchal outlook to one that is
not found to predict the subsequent development
more gender-neutral.
of blues is in contrast to another study from West
Table 3: Past and family history as predictors of blues
Variable Group Postpartum blues Postpartum blues Total Chi p
present n(%) absent n(%) square χ2
Past History
of Mental yes 6(8.2%) 2(2.7%) 8(10.9%) 9.372 .002**
Illness
no 15(20.5%) 50(68.4%) 65(89.04%)
Family history
of mental yes 4(5.4%) 1(1.3%) 5(6.8%) 6.876 .0098**
illness
no 17(23.3%) 51(69.8%) 68(93.1%)
Pre-menstrual
dysphoric yes 7(9.5%) 2(2.7%) 9(12.3%)
12.033 .001***
disorder no 14(19.1%) 50(68.4%) 64(87.6%)
(PMDD)
**p<0.01
***p≤0.001
In our study, amongst those women with a past depression” or a previous postnatal depressive
history of mental illness, a greater proportion went on episode. O’Hara et al. 17found that women with blues
to develop blues and this association was significant. were more likely to report depressive symptoms
(p= 0.002**) Although history of several types of during pregnancy. This points to the importance of
mental illnesses were enquired into, all the women enquiring into the past history of psychiatric disorders
with blues having significant past psychiatric history especially depression during antenatal visits.
reported having experienced depression. Previous
We also found that past history of pre-menstrual
studies have also found a link between past history
dysphoric disorder significantly predicted the
of depression and blues. Stein 16 reported that the
development of post-partum blues. (p=0.001***).
most severe symptoms in the first postpartum week
Earlier studies have also consistently reported the
occurred in women with a history of “neurotic

link between PMDD and post-partum blues 18,19,20. their support is during the post-partum period can
There is a massive reduction in levels of circulating go a long way to improving a mother’s psychological
estrogen following delivery that may mimic the sort well-being which will have a positive impact on their
of estrogen fall that occurs during the pre-menstrual infant’s health and development as well.
phase. This would explain why women who have
Table 6: Stressful life events as a predictor of blues
experienced depressive symptoms during the latter
may also develop maternity blues after having a baby. Variable Postpartum Mean Mann Z, p value
blues Rank Whitney
A majority of those with family history of mental U
illness in a first degree relative went on to experience
Stressful yes 47.62 323.000 Z= -2.905,
blues and this relationship was significant. (p=0.009**). life p=.004**
This finding has been replicated in previous studies. events no 32.71
17,18
**p<0.01
Table 4: Social support as a predictor of blues Women who developed blues had higher weighted
Variable Postpartum Mean SD t df p scores (47.62) on stressful life events in the past one
blues year compared to those who did not develop blues
Social yes 26.83 6.91 1.56 30 .128 (32.71) and this difference was significant. (p=0.004**).
Support Financial difficulties were the most common stressor
no 30.25 5.36
reported. This echoes the findings of O’Hara et al.
There was a difference in the mean scores on 17
who found that women who had more severe blues
Lubben’s Social Network Scale in women with blues were more likely to have experienced negative life-
(Mean 26.8, SD 6.91) and those without (Mean 30.25, events during pregnancy than those who did not.
SD 5.37) with higher scores indicating higher level of Economic insecurity specifically has been found to be
social support in women who did not develop blues. related to the development of blues in a recent study
However, this association was not significant. from Greece. 22
Table 5: Marital quality as a predictor of blues Outcome of Post-Partum Blues

Variable Postpartum Mean SD t df p In our study it was found that 21 women developed
blues blues out of a total of 73 and of these, 3 women went
Marital Yes 90.23 24.93 3.73 31 .001*** to develop major depression that was diagnosed at
quality 6 weeks post-delivery. None of the women who had
No 66.05 12.14
not experienced blues developed depression later
***p≤0.001
on. Thus, in our sample 14.2 % of women with blues
On the Marital Quality Scale, a significant difference went on to develop depression. Previous studies have
(p=0.001***) was seen in the mean scores of women in reported that approximately 20% of women suffering
the group with post-partum blues and those without. from maternity blues are diagnosed as having major
When the mean scores were compared across the depression in the first year following delivery. 17 The
groups, the women with blues had higher scores (Mean fact that our figure is slightly less can be explained by
90.23, SD 24.93) than those without blues (Mean 66.05, the fact that in our study the follow-up was limited to
SD 12.14) indicating poorer quality of marital life. One 6 weeks’ post-partum. A longer duration of follow-up
previous study has found an association of reported may have been ideal to look for any such association.
discontent with the quality of the marital relationship
and development of blues. 21 An Indian study 5 had Conclusions
also found that poor marital relationship was found In conclusion, our study was a prospective follow-up
to significantly predict blues. Therefore, given that study that estimated the prevalence of post-partum
marital quality has been found to consistently predict blues to be 28.8 %. Of the women with blues 14.2%
blues, it is important to enquire about the health of went on to develop post-partum depression whereas
the marital relationship when a woman is pregnant. none of the women who had not experienced blues
This can even be gauged informally by observing how developed depression. The study highlights the
involved the lady’s partner is during antenatal visits. importance of early post-partum mood changes or
Emphasizing to expecting fathers how importance post-partum blues and the need to identify these

282
women as they are at higher risk of developing post- 8. Shah, A. Clinical validity of marital quality scale.
partum depression. Some of the variables identified Nimhans Journal. 1995; 13(1), 23-31
as risk factors such as history of pre-menstrual 9. Lubben JE. Assessing social networks among elderly
dysphoric disorder and past history of mental illness populations. Family and Community Health. 1988. 11(3),
should be carefully enquired into during routine 42-52.
antenatal assessments. Psycho-social variables that
10. Singh, G., Kaur, D., & Kaur, H. Presumptive stressful
can contribute to the development of blues such
life events scale (PSLES)—a new stressful life events
as stressful events experienced during pregnancy scale for use in India. Indian Journal of Psychiatry. 1984;
and poor marital quality should also be assessed 26(2), 107–114.
and interventions planned accordingly to reduce
11. Sheehan, DV., Lecrubier, Y., Sheehan, KH., Amorim,
the impact of these on the women. It is hoped that
P., Janavs, J., Weiller, E., Dunbar, GC. The Mini-
more studies of this kind will further expand on this
International Neuropsychiatric Interview (M.I.N.I.):
important area and aid in formulating comprehensive
the development and validation of a structured
management plans for women’s mental health in diagnostic psychiatric interview for DSM-IV and ICD-
pregnancy and the puerperium. 10. J Clin Psychiatry. 1998; 59 Suppl 20, 22-23.
Source of funding - This was a non-funded project 12. Gonidakis, F., Rabavilas, A. D., Varsou , E.,
Kreatsas, G., & Christodoulou, G. N. Maternity blues
Conflict of Interest – Nil
in Athens, Greece: A study during the first 3 days after
References delivery. Journal of Affective Disorders. 2007; 99, 107-115.
1. Rezaie-Keikhaie K, Arbabshastan ME, Rafiemanesh 13. Hau, F., & Levy, V. The maternity blues and Hong-
H, Amirshahi M, Ostadkelayeh SM, Arbabisarjou. Kong Chinese women: an exploratory study. Journal of
A Systematic Review and Meta-Analysis of the Affective Disorders. 2003; 75, 197–203.
Prevalence of the Maternity Blues in the Postpartum
14. Murata, A., Nadaoka, T., Morioka, Y., & Oiji, A.
Period. J Obstet Gynecol Neonatal Nurs. 2020; 49(2):127-
Prevalence and background factors of maternity
136.
blues. Gynecologic & Obstetric Investigation. 1998; 46,
2. Gerli S, Fraternale F, Lucarini E, Chiaraluce S, 99-104.
Tortorella A, Bini V, Giardina I, Moretti P, Favilli A.
15. Adewuya, A. O. The maternity blues in Western
Obstetric and psychosocial risk factors associated with
Nigerian women: prevalence and risk factors. American
maternity blues. J Matern Fetal Neonatal Med. 2021
Journal of Obstetrics & Gynecology. 2005; 193(4), 1522-
Apr;34(8),1227-1232.
1525.
3. Takahashi Y, Tamakoshi K. Factors associated with
16. Stein, G. S. The pattern of mental change and body
early postpartum maternity blues and depression
weight change in the first post-partum week. Journal of
tendency among Japanese mothers with full-term
Psychosomatic Research. 1980; 24(3-4), 165–171.
healthy infants. Nagoya J Med Sci. 2014 Feb;76(1-2):129-
38. 17. O’Hara, M. W., Schlechte, J. A., Lewis, D. A., &
Wright, E. J. Prospective study of postpartum blues.
4. Paykel, ES., Emms, EM., Fletcher, J., Rassaby, ES. Life
Biologic and psychosocial factors. Archives of General
events and social support in puerperal depression. Br J
Psychiatry. 1991; 48(9), 801-806.
Psychiatry. 1980;136,339-46.
18. Hapgood , C. C., Elkind, G. S., & Wright , J. J. Maternity
5. Manjunath, N. G., Venkatesh, G., & Rajanna. Postpartum
blues: phenomena and relationship to later post-
blue is common in socially and economically insecure
partum depression. The Australian and New Zealand
mothers. Indian Journal of Community Medicine. 2011;
journal of psychiatry. 1988; 22(3), 299-306.
36(3), 231–233.
19. Condon, J. T., & Watson, T. L. The maternity blues:
6. Shamasunder ,C., Sriram,TG., Murali Raj, SG.,
Exploration of a psychological hypothesis. Acta
Shanmugham, V. Validity of a short 5-item version
Psychiatrica Scandinavica. 1987;76(2),164–171.
of the general health questionnaire (g.h.q). Indian J
Psychiatry. 1986;28(3), 217-9. 20. Kennerley, H., & Gath, D. Maternity blues III:
associations with obstetric, psychological and
7. Kennerley, H., & Gath, D. Maternity blues I: detection
psychiatric factors. British Journal of Psychiatry.
and measurement by questionnaire. British Journal of
1989;155, 367–373.
Psychiatry. 1989; 155, 356–362.

21. Ehlert, U., Patalla, U., Kirschbaum, C., Piedmont, E., & 22. Ntaouti E, Gonidakis F, Nikaina E, Varelas D, Creatsas
Hellhammer, D. H. Postpartum blues: Salivary cortisol G, Chrousos G, Siahanidou T. Maternity blues: risk
and psychological factors. Journal of Psychosomatic factors in Greek population and validity of the Greek
Research. 1990; 34(3), 319–325. version of Kennerley and Gath’s blues questionnaire.
J Matern Fetal Neonatal Med. 2020 Jul; 33(13), 2253-
2262.

Forecasting Multivariate time-series data using LSTM Neural Network

in Mysore district, Karnataka
Stavelin Abhinandithe K1, Madhu B2, Somanathan Balasubramanian3,

Sridhar Ramachandran4
1
Assistant Professor, Division of Medical Statistics, School of Life Sciences, 2Professor, Department of Community Medicine, JSS Medical College
3
Former Director Research, JSS AHER, Mysore, Karnataka, India, 4HOD, MCA, Ramakrishna Mission Vidyalaya, Coimbatore, India
How to cite this article: Stavelin Abhinandithe K, Madhu B, Somanathan Balasubramanian, Sridhar Ramachandran
et al Forecasting Multivariate time-series data using LSTM Neural Network in Mysore district, Karnataka.
Abstract
Advanced and precise forecasting of infectious diseases plays a critical role in planning and providing resources effectively.
Time series forecasting for non-linear issues are accessible using deep learning techniques. The association between
climatic parameters and dengue occurrences was investigated in this work, and a forecasting model was constructed
using a deep learning approach called long short-term memory (LSTM). Univariate and multivariate LSTM time series
forecast models were developed using meteorological and dengue incidence data from January 2006 to December 2019.
For univariate data, the Pycharm/Google Colab platform was implemented, as the deep learning framework Keras,
which is one of the models in the machine learning library based on Tensorflow. The Pandas Python package with built-
in support for time series data was used for multivariate data. The final model was chosen using the mae loss and the
Adam optimizer. Once the model had been fixed, predictions were made using the model. The research showed that
the meteorological factors such as maximum temperature at lag 3, minimum temperature at lag 3, maximum vapour
pressure (lag 0,1 and 2), minimum vapour pressure at lag 1, and vapour pressure daily mean at lag 0,1,4 are all significant
predictors of dengue along with RMSE value of 1.121 . The results indicated that LSTM network has higher prediction
accuracy than any other traditional forecasting methods. Timely management of seasonal diseases such as dengue along
with meteorological parameters can predict epidemics in the future.
Keywords: Dengue, LSTM, Prediction, Meteorological variables, RMSE
Introduction such that every individual across the globe is at risk

Infectious diseases which are caused by agents, .International Organization for Migration (IOM)
(1)
most probably microorganism impairs human further reports that improved global health can be
health. Infectious diseases occurring either naturally achieved through evidence from the studies that
or purposefully instigated biological threats bear advise on how to reduce the burden of disease and
intensifying risk to trigger disease, disability, and disability due to infectious diseases in low-middle-
death. Infectious diseases are a worldwide threat income or developing countries, thus eliminating
that transcends political and geographic boundaries the emerging threats of infectious diseases on global
health. Dengue is one of such infectious diseases
Stavelin Abhinandithe K,
Assistant Professor, Division of Medical Statistics, Division of Medical statistics, School of Life sciences, JSSAHER, Mysuru-570015.
Contact No: 8095726333
which is increasing and has doubled over the last LSTM Architecture
years. It is more prone in tropical and subtropical RNN is one of the powerful techniques for deep neural
countries (2). For understanding its transmission to network that plays a significant role in processing
humans by a microbe, studying climate change and long-term dependent time-series data. Hochreiter and
its effects to the disease is necessary. Temperature, Schmidhuber (1970) proposed the problem of gradient
rainfall, humidity, vapour pressure, sunshine are the descent for long-term dependence is handled utilizing
significant meteorological factors for the spread of the the LSTM neural network model (7). LSTM can encode
disease. Knowing the relationship between variation and decode time series data; hence memory units can
in these climatic factors and dengue incidences helps be used in place of hidden layer neurons in RNNs to
to predict the disease outbreak accurately. Machine actualize previous knowledge from memory. One or
learning along with deep learning techniques are more memory cells, as well as three door controllers,
used as the powerful predictive techniques to know are found in each memory unit.
the influence of climatic factors on dengue incidences
(3)
. LSTM have chain like structure. The cell state,
which is a kind of conveyor belt that runs straight
Fang et al., (2020) studied the relationship between down the entire chain, is a key structure of LSTM.
meteorological elements and air quality by using The ability of LSTM to add or subtract information
LSTM neural networks for Beijing data. In his studies, from the cell state is controlled by a structure known
he observes that the LSTM models predicts better as as gates. Gates are the one which allows information
the model with better accuracy and robustness and through .These gates are made up of a sigmoid neural
thus he concludes that LSTM models can be used net layer and a point wise multiplication operation
as prediction methods(4). Chathurangi et al., (2021) sigmoid(7). layer’s outputs are integers between 0 and
describes the machine learning models such as LSTM 1, indicating how much of each component should
to analyse dengue incidences along with weather and be processed. A value of zero indicates that ‘nothing
population density to predict and forecast the dengue should be allowed through;’ whereas a value of one
incidences (5). In his study, he observes and predicts indicates that ‘everything should be allowed through
the incidence of dengue with a good precision level. (8)
. As a result, the LSTM contains three gates to protect
The recent advances in deep learning have helped and control the state of the cell.
the healthcare industry. Various applications have
been implemented and commercialized which The Fundamental building of RNN and LSTM are
incorporated AI-driven component that assists alike that it has a chain structure. LSTM is not based
doctors and healthcare providers in achieving on single network-layer and four modules interact
accurate diagnosis (6). with each other.
In this study, we have applied LSTM models LSTM Time Series Network
taking into account the univariate and multivariate In sequence to sequence learning, RNN models
time series infectious data along with meteorological are specialists at mapping an input sequence to an
parameters. LSTM are distinct type of RNN capable of output sequence. The length of the input and output
handling long-term dependences. Machine learning does not have to be the same. Two RNNs, such as
is increasingly being utilized for linear and non-linear LSTMs, are used as a sequence to sequence model.
time series models to improve predictions. RNN, one These are encoders and decoders, respectively (9). The
of the machine learning models, works with time encoder’s job is to convert a given input sequence into
series to construct network structures, making it more a context vector, which is a fixed length vector. To
adaptable in time series data analysis. The LSTM forecast the output sequence, the decoder is given the
model is one of the RNN variations that address context vector as input and the final encoder state as
the problem of RNN gradient disappearance and a starting decoder state. Speech recognition, language
explosion, allowing damaged neural networks to be translation, time series forecasting, and other
utilized for long-term time series forecasting. LSTM applications use this form of sequence to sequence
models have turned into a vital model for forecasting learning.
time-series and are suitable for situations involving
sequences with autocorrelation.

286
Univariate LSTM (uncombined meteorological

variables)
The Environment pycharm/Google colab platform,
the deep learning framework are used in Keras which
is one of the models in machine learning library
based on Tensorflow, Keras are considered to be one
of the high-level neural networks which are edited
Figure 1: Multivariate
Figure 1: Multivariate Multistep
Multistep forecasting time series data forecasting time to
using stacked LSTM sequence
sequence auto encoder in tensorflow/Keras by python. In this scenario, 80% of the data was
series data using stacked LSTM sequence to
employed as a training set, with the remaining 20%
sequence auto encoder
Need for applying LSTM in tensorflow/Keras
meteorological parameters) to predict and
forecast infectious diseases. being used as a testing set.
LSTM can automatically handle long
Need for applying LSTM
and short term dependencies and it can be Objectives
used when there is a presence of Multivariate LSTM (combined meteorological
LSTM can automatically handle long and short
multivariate time series data. In our study The objective of LSTM is to capture
we have used LSTM models for temporal dependency in data and preserves variables)
term dependencies and it can be used when there
uncombined (Without meteorological back propagated error through time and
parameters) and combined (With layers. It is also used to compute new states
is a presence of multivariate time series data. In our For multivariate data the Pandas library in Python
in the memory cell given old ones.
study we have used LSTM models for uncombined with built-in support for time series data is used.
Data and Methodology prediction: training period (12*5), testing
(Without meteorological parameters) period (12*2), andand combined
span period (12*1).
Pandas represented the time series datasets as a
Data
(With meteorological parameters) to predict and Data Normalization series. The read csv() method is the most important
Data of monthly incidence of infectious
forecast infectious diseases. Machine learning algorithms such as function in Pandas for loading CSV data. We have
diseases (dengue) were used from the year Tensorflow and Keras needs the data to be
2006-2019. We have used natural logarithm normalized. Here we have used
run the algorithm in google colab platform. We have
Objectives
for all the diseases. Since some of the minmaxscaler to normalize the data considered combined exogenous variables along with
observations are zero which means no case
The objective of LSTM is to capture temporal
of the infectious diseases are added by 5 and infectious disease data and performed spearman’s
taken natural logarithm (ln). Therefore we Univariate LSTM (uncombined
dependency in data and preserves
have considered logarithm for the dengue back propagated correlation analysis.
meteorological variables)
error through time and layers.
incidences. It is also used to
The Environment pycharm/Google The infectious illnesses dataset must first be
Data Preprocessing
compute new states in the colab memory
platform, thecell given
deep learning old
framework
prepared for the LSTM. The input variables must
To fit the data we employed a three- are used in Keras which is one of the models
ones.
layer stacked LSTM. The LSTM model is in machine learning library based on be normalized and the dataset must be viewed as
separated into three periods for training and Tensorflow, Keras are considered to be one
Data and Methodology a problem of supervised learning. The supervised
learning task was posed to forecast infectious
Data diseases based on the previous time step’s climatic
circumstances. The series to supervised () function
Data of monthly incidence of infectious diseases
was used to modify the dataset. To create a model
(dengue) were used from the year 2006-2019. We have
for LSTM on multivariate input data, we divided the
used natural logarithm for all the diseases. Since some
prepared dataset into train and test sets. The input and
of the observations are zero which means no case
output variables were then extracted from the training
of the infectious diseases are added by 5 and taken
and validation sets. Finally, the inputs (X) are molded
natural logarithm (ln). Therefore we have considered
into the [samples, time steps, features] 3D structure
logarithm for the dengue incidences.
that LSTMs expect. The LSTM has 50 neurons in the
Data Preprocessing first hidden layer and 1 neuron in the output layer for
anticipating infectious diseases. The input form will
To fit the data we employed a three-layer stacked
be a single time step with eight attributes. The Mean
LSTM. The LSTM model is separated into three
Absolute Error (MAE) loss function and the Adam
periods for training and prediction: training period
optimizer are used.
(12*5), testing period (12*2), and span period (12*1).
The model will be suitable for 50 training epochs
Data Normalization with a batch size of 72. Keras resets the internal state
Machine learning algorithms such as Tensorflow and of the LSTM at the conclusion of each batch. Finally,
Keras needs the data to be normalized. Here we have the fit() function’s validation data parameter is set to
used minmaxscaler to normalize the data the training and test loss during training. At the end
of the run, both the training and test losses are shown.
After the model has been fitted, the prediction for the
complete test dataset is derived, and the forecast is

Figure 2: Fitted and forecasted values of the dengue for the year 2008-2019
Visualization was done through ggplot2 and cowplot by Keras Stateful

Sampling Plans and Results Prediction with LSTM backtested Predictions.
Data is split into train set and test set The Figure 3 shows the data splits into
data in 80% and 20% ratio. slice 1 and 2.
mixed with the test dataset and the scaling is inverted.
An error score for the model was produced using
forecasts and actual values in their original scale, i.e.,
the Root Mean Squared Error (RMSE), which provides
error in the same units as the variable is calculated.
Cross correlation
It was performed to identify the significant lagged
meteorological parameters for the incidences of
infectious diseases. Figure 3: testing
Figure 3: Back Back testing
strategy shows forstrategy shows
the year 2008-2014 as slice 1for the
and for year
the year 2012-2018 as
slice 2
2008-2014 as slice 1 and for the year 2012-2018 as
Software’s used slice 2
R, Python, keras and tensor flow programming From the Figure 3, Slice 1 shows the predicted value
language are used to build LSTM model and stepwise for 2014 by using 2008-2012 data and Slice 2 shows the
LSTM package was adopted. In this R is used for predicted values for 2018 by using 2012-2016.
univariate LSTM with keras and Tensorflow, whereas
Python is used for multivariate LSTM with keras and The Autocorrelation plot was obtained for
Tensorflow. Data set of dengue cases
Results Algorithm of deep learning estimates accurately
predicted dengue cases. The backtested Keras Stateful
Univariate LSTM models for dengue cases LSTM Model plot was constructed.
To predict incidence of dengue, we used LSTM model Table 1: RMSE value based on different slices of
which was developed by using Keras, connects Tensor data Fromofthedengue cases.
Figure 3, Slice 1 shows the 2012 data and Slice 2 shows the predicted
Flow in R backend. Using the rsample package’s predicted value for 2014 by using 2008- values for 2018 by using 2012-2016.
Sl. No Slice No RMSE Data
rolling forecast origin resampling it performs Time The Autocorrelation plot was obtained for
Data set of dengue cases
Series Cross Validation with Back Testing. The trend 1 1 1.2 2010-2015
value and forecasted value of dengue for the year Algorithm2 of deep learning2 estimates 1.3 Keras Stateful
backtested 2011-2019
LSTM Model plot
accurately predicted dengue cases. The was constructed.
2008-2019 using keras LSTM deep learning is shown
Using the rsample package's rolling forecast trend value and forecasted value of dengue The RMSE (or another equivalent statistic) average
in the
origin Figure
resampling 2. Time Series
it performs for the year 2008-2019 using keras LSTM
Cross Validation with Back Testing. The deep learning is shown in the Figure 2.
and standard deviation are a helpful approach to
Figure 2: Fitted and forecasted values of the dengue compare the performance of different models. The
results obtained by using LSTM model are presented
Table 1: RMSE value based on different slices of data of dengue cases.
in Table 1 .We 1
observe
Sl. No
that the mean
Slice No
1
RMSE
1.2
of the Data
above slices
2010-2015
of dengue cases 2 is 1.25 2 and its1.3standard deviation is

2011-2019
0.05.
The RMSE (or another equivalent mean of the above slices of dengue cases is
statistic) average and standard deviation are 1.25 and its standard deviation is 0.05.
From the Figure 4, we observeFrom
a helpful approach to compare the the the trend value
Figure 4, we observeand
the trend
forecasted value for dengue cases using
value and forecastedKeras
performance of different models. The results value for LSTM
dengue cases
using Keras LSTM deep learning.
obtained by using LSTM model are
Figure 2: Fitted and forecasted values of the dengue for the year 2008-2019 deep learning.
presented in Table 1 .We observe that the
for the year 2008-2019
Visualization was done through

Visualization was done through ggplot2 and Sampling
cowplot by Keras Plans
Stateful
Sampling Plans and Results Prediction with LSTM backtested Predictions.
and Results Prediction with ggplot2 and cowplot by
Keras
Data isStateful LSTM
split into train backtested
set and test set Predictions.
The Figure 3 shows the data splits into
data in 80% and 20% ratio. slice 1 and 2.
Data is split into train set and test set data in 80%
and 20% ratio.
The Figure 3 shows the data splits into slice 1 and 2.
Figure
Figure 4:4: Trend
Trend value andvalue
forecasted and
value forforecasted
dengue cases using value for
Keras LSTM deep learning
dengue cases using Keras LSTM deep learning
Figure 3: Back testing strategy shows for the year 2008-2014 as slice 1 and for the year 2012-2018 as
slice 2 IJPHRD / Volume 13 Issue 4 / October-December 2022
288
We also observed that the Observed and Predicted more when added with exogenous meteorological
incidences of dengue that is R2 value is exactly equal variables. Further based on Univariate LSTM, we
to 1 indicating that all the values are falling on the observed that R2 value is exactly equal to one for
regression line indicating that the fitted model is best dengue incidences indicating that the predicted
suited for the observed data. values fit the observed data exactly and RMSE value
for univariate data was 1.25 and for multivariate
Multivariate LSTM models for dengue cases LSTM was 1.121.Our results indicated that compared
to univariate LSTM, multivariate LSTM that is when
To construct multivariate LSTM, we have taken
meteorological variables are added, improves the
logarithm (ln) dengue data which is taken as
accuracy of LSTM. The R square value for univariate
dependent variable or targeted variables. Exogenous
LSTM was equal to one for dengue.
variables i.e., meteorological variables are considered
to be independent variables or features in machine LSTM models require significantly less time to
learning language. There are 144 observations in the train in terms of accuracy and computational, and
dengue cases. The whole dataset was split into training once trained, constant prediction can be estimated.
and tested data. Correlated exogenous variables Therefore LSTM models are suitable for predicting
are considered along with dengue cases which the monthly incidence of dengue in Mysuru district,
are entered as columns. Meteorological variables Karnataka.
maximum temperature at lag 3, minimum temp_3,
Ethical clearance - Taken from JSSMC/
maximum vapour pressure (lag 0,1 and 2), minimum
IEC/2308/19NCT/2019-20 dated on 3/9/2019 from
vapour pressure at lag 1 and vapour pressure daily
JSS Medical College. IE Committee.
mean at lag 0,1,4 are significant predictors for dengue.
These series are then converted to supervise learning. Source of funding- No funding has been received.
Depending on the amount of the data, automatically
Conflict of Interest - Nil
training and testing data will be considered. Here
number of observations is equal to number of hours References
multiplied by number of features. The next step is to 1. De Cock KM, Simone PM, Davison V, Slutsker L. The
reshape the input to a 3D format that is samples, time new global health. Emerging infectious diseases. 2013
steps and features. In order to design the network, Aug; 19(8):1192-7.
epoch will be set 50. Final model will be selected based
2. Miranda JJ, Kinra S, Casas JP, Davey Smith G, Ebrahim
on mae loss and adam optimizer. Once the model is
S. Non-communicable diseases in low-and middle-
fixed, prediction will be done based on the model. income countries: context, determinants and health
RMSE value 1.121 was obtained for the dengue. policy. Tropical Medicine & International Health. 2008
Oct;13(10):1225-34.
Discussion and Conclusion
In the current study, a univariate and multivariate 3. Fang H, Zhang L. Analysis and Prediction of Air
Quality based on LSTM Neural Network——Take
LSTM was considered for dengue incidences. The
Beijing Temple of Heaven as an Example. InJournal of
developed model estimates by using existing data of
Physics: Conference Series 2020 Sep 1 (Vol. 1637, No. 1,
a given month, the number of cases can be estimated p. 012126). IOP Publishing.
with minimal error. Our study has considered the
dengue incidence along with 19 meteorological factors 4. Edussuriya C, Deegalla S, Gawarammana I. An
to know the impact of climatic change on infectious accurate mathematical model predicting number of
dengue cases in tropics. PLoS Neglected Tropical
diseases. We have used machine learning algorithm
Diseases. 2021 Nov 8;15(11):e0009756.
i.e., Long Short-Term Memory (LSTM) for the
infectious diseases for combined with meteorological 5. Said AB, Erradi A, Aly HA, Mohamed A. Predicting
parameters (multivariate) and uncombined COVID-19 cases using bidirectional LSTM on
(univariate) data. Based on the results compared with multivariate time series. Environmental Science and
RMSE value for both univariate and multivariate Pollution Research. 2021 Oct;28(40):56043-52.
LSTM models, RMSE value for multivariate LSTM 6. Hochreiter S, Schmidhuber J. Long short-term memory.
is less, indicating that the prediction of accuracy is Neural computation. 1997 Nov 15;9(8):1735-80.

7. Khodabakhsh A, Ari I, Bakır M, Alagoz SM. 9. Shah SR, Chadha GS, Schwung A, Ding SX. A Sequence-
Forecasting multivariate time-series data using LSTM to-Sequence Approach for Remaining Useful Lifetime
and mini-batches. InThe 7th International Conference Estimation Using Attention-augmented Bidirectional
on Contemporary Issues in Data Science 2019 Mar 6 LSTM. Intelligent Systems with Applications. 2021 Jul
(pp. 121-129). Springer, Cham. 1;10:200049.
8. Wan R, Mei S, Wang J, Liu M, Yang F. Multivariate

temporal convolutional network: A deep neural
networks approach for multivariate time series
forecasting. Electronics. 2019 Aug;8(8):876.

Evaluation of Vitek2 and Colistin broth disk elution test in comparison with Micro broth dilution for
Susceptibility testing of Colistin among Carbapenem Resistant Enterobacterales.
Sujatha S R1, Deepashree Rajasekhar2, Satyasai. Badveti3,

Krishna Karthik Manthravadi4
Senior resident, Department of Microbiology, JSS Medical college, JSSAHER, Mysore, Karnataka
1
2
Assistant Professor, Department of Microbiology, JSS Medical college, JSSAHER, Mysore, Karnataka
3,4
Tutor & Research Scholar, Department of Microbiology, JSS Medical college, JSSAHER, Mysore, Karnataka
How to cite this article: Sujatha S R, Deepashree Rajasekhar, Satyasai.Badveti, Krishna Karthik Manthravadi et al
Evaluation of Vitek2 and Colistin broth disk elution test in comparison with Micro broth dilution for Susceptibility
testing of Colistin among Carbapenem Resistant Enterobacterales. Volume 13 | Issue 4 | October-December 2022
Abstract
Colistin is the last expedient for treating the infections caused by Carbapenem resistant Enterobacter ales (CRE).
Expanding usage of colistin as led to development of Colistin resistance. This urges for a need of reliable and accurate
testing method that can be adopted as routine for susceptibility testing of Colistin. The innate cationic property of
colistin molecules is associated with complexities. Hence evaluation of testing method is needed for detection of colistin
resistance. Present study is done to evaluate the results yielding from Vitek2 and CBDE in comparison with rBMD. About
200 CRE isolated from clinical specimens were tested, results of Vitek2, CBDE was compared with rBMD. In comparison
with BMD Categorical agreement (CA) of Vitec 2 was 83% with major error of 17% .CA of CBDE was 99% with 1% of very
major error. Since the resistance to colistin is increasing accurate reporting of Colistin MIC by a validated method becomes
important. So, we would recommend CBDE for routine testing of Colistin susceptibility.
Keywords: Carbapenem resistant Enterobacterales, Colistin broth disk elution, rBMD- reference broth microdilution,
Categorical Agreement.
Introduction crucial that clinical microbiology laboratories should

Emergence of MDR (Multidrug resistant) be able to appropriately identify organisms which
microorganisms especially Carbapenem resistant are resistant to colistin, so that such kind of drugs
Enterobacterales (CRE) are alarmingly being reported are cautiously used for treatment [3,4]. This further
worldwide. Because of the restricted treatment signifies the need of requirement of a standardised
choice, it’s been challenging to treat the infections antimicrobial susceptibility test (AST) for colistin,
caused by these CRE organisms. Polymyxins (colistin that helps for both patient-care and for surveillance
or Polymyxin B and Polymyxin E) antimicrobials purposes. Presently Broth Micro dilution (BMD) is
remain the last resource for treating the infections the only standard reference method for colistin AST
caused by these Carbapenem resistant gram- according to CLSI [5] CLSI is also evaluated other
negative bacteria (1). Acquired resistance to these alternative MIC based methods such as colistin
polymyxins was reported less in the past but in the broth disk elution test (CBDE) & colistin agar test
present situation because of its expanding usage both (CAT) as accurate as reference BMD [4]. Although
clinically and non -clinically resistance to colistin is BMD is a reference method it is difficult to be done
more frequently being reported [2]. Hence it becomes on routine basis because of its laborious nature. In
Dr. Deepashree Rajasekhar
Assistant Professor, Department of Microbiology, JSS Medical college, Mysore-Karnataka, India
Phone: 9916815822
most of the laboratories, MIC of colistin is determined method (CBDE and vitek-2 ) is same as the reference
and reported by Vitek-2 automated antibiotic standard method (BMD), the test method is said to be
susceptibility test (AST) system, even though it is categorically agreed with that of the reference method,
not an approved method by CLSI [5]. In view of this if not it is categorically disagreed. Again Categorical
present study was taken up to evaluate the results of disagreement is classified into Very Major, Major
Vitek-2, CBDE in comparison with rBMD so that we and Minor errors. If the test method shows sensitive
can analyse if we can continue reporting Colistin MIC category and the reference method is resistant, it is
from Vitek-2 AST or adapt new test like CDBE. very major error. If the test method shows resistant
category and the reference method is sensitive, it
Materials and Methods is major error. If the test method is intermediate
A cross sectional analytical study was conducted in category and the reference method is either sensitive
department of Microbiology, JSS medical college or resistant category, it is said to be Minor error. As
and hospital, about 200 clinical isolates yielded from EUCAST does not give any intermediate breakpoint
routine clinical specimens , such as blood, endotracheal for colistin, Minor errors is not applicable for colistin .
aspirate, sputum, sterile fluids (bile, ascitic fluid, CSF)
and exudate specimens which were Enterobacterales Results
& Carbapenem resistant were included in the study Among 200 clinical isolates the most common
. Other organisms from the Enterobacterales which organism isolated was Klebsiella pneumoniae (112),
are intrinsically resistant to colistin such as Proteus, followed by Escherichia coli 71 and Enterobacter
Serratia, Morganella and Providencia were excluded, cloacae 13 (Table 2). Colistin MIC distribution of 200
also clinical isolates from stool samples & clinical clinical isolates by reference BMD method. 23 isolates
isolates isolated from same patient were also excluded showed resistance and organism that exhibited
from the study. The study involved the specimens that highest resistance was by Klebsiella pneumoniae (Table
were collected from the samples that were routinely 30). 92 isolates showed MIC value of ≤1 by both CBDE
received in Microbiology laboratory for evaluation & & MBD, 11 isolates showed MIC of 2 in both CBDE
since no intervention was needed informed consent and reference BMD, 21 isolates showed MIC of ≥4 in
was not taken , by application of statistical tool 200 both CBDE & reference BMD , 2 isolates showed MIC
clinical isolates which were resistant to Carbapenem of 2 in CBDE & 4 MIC value in reference BMD which
were subjected to broth micro dilution (BMD), accounts for very major error . Categorical agreement
colistin broth disk elution and vitek-2 AST system of CBDE with respect to reference BMD was 99%
. Results were noted and analyzed. Reference in- (Table 4) 135 isolates yielded MIC of ≤1 in vitek-2 &
house BMD was performed according to standard reference BMD , 23 isolates showed MIC of ≥ 4 in both
operating protocol issued by National Programme Vitek 2 and reference BMD , 13 isolates showed MIC
on Antimicrobial Resistance Containment National of 4 in Vitek-2 and 1 in reference BMD, 12 isolates
Centre for Disease Control, India, August 2020 , yielded MIC value of 8 in Vitek 2 and 2 in reference
Cation adjusted Mueller-Hinton broth (90922) was BMD, 9 isolates showed MIC of 16 in Vitek 2 and 2 in
used for performing CBDE , discs were procured from reference BMD, in total 34 isolates were resistant in
Oxoid™ & test was performed according to CLSI 2020, test method that is Vitek -2 and sensitive in reference
M100 document using appropriate control strains. BMD which indicates major error. 83% of categorical
Thermo Scientific company and colistin sulphate salt agreement in comparison of test method that is Vitek
(C4461) was procured from Sigma Aldrich company. 2 with reference method that is BMD.
If susceptibility result of the isolate done by the test
Tables & Figures
Table 1: Colistin interpretative breakpoints according to the Clinical and Laboratory Standards Institute
(CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines- 2021 was
used for interpretation of the results.
Organism/groups CLSI 2021 EUCAST 2021
S I R S R ATU
Enterobacterales - ≤2 ≥4 ≤2 >2 -
Pseudomonas aeruginosa - ≤2 ≥4 ≤2 >2 4

292
Organism/groups CLSI 2021 EUCAST 2021

Pseudomonas spp - - - ≤2 >2 4
Acinetobacter baumannii complex - ≤2 ≥4 ≤2 >2 -
Acinetobacter spp - - - ≤2 >2 -
Non-Enterobacterales* - - - - - -
*Other non-fermenting Gram-negative bacilli except Pseudomonas aeruginosa, Acinetobacter baumannii,
Stenotrophomonas maltophilia and Burkholderia cepacia
ATU- area of technical uncertainty; S- Susceptible; I- intermediate; R-resistant
Table 2: Distribution of carbapenem resistant Enterobacterale isolates
Organism Number of isolates
tested
Klebsiella pneumoniae 112
Escherichia coli 71
Enterobacter cloacae 13
Citrobacter species 04
Table 3: Colistin MIC distribution for 200 isolates with reference BMD method is shown in [Table-3]
Organism No. of isolates MIC range (μg/mL)
tested 0.125 0.25 0.5 1 2 4 8 16
Klebsiella pneumoniae 112 20 10 30 16 18 8 4 6
Escherichia coli 71 20 21 22 3 2 3 0 0
Enterobacter cloacae 13 2 3 4 1 1 2 0 0
Citrobacter species 04 1 1 2 0 0 0 0 0
Table 4: Colistin MIC distribution of CBDE with reference to MBD method
MIC of MBD
MIC 0.125 0.25 0.5 1 2 4 8 16
range
MIC of
CBDE (μg/mL)
≤1 23 18 30 11 10 0 0 0
2 20 17 28 9 11 2* 0 0
≥4 0 0 0 0 0 11 4 6
*Indicated very major error
Table 5: Colistin MIC distribution of Vitek-2 with reference to MBD method
MIC range (μg/mL) 0.125 0.25 0.5 1 2 4 8 16
≤0.5 20 16 30 3 0 0 0 0
1 18 19 25 4 0 0 0 0
2 5 0 3 0 0 0 0 0
4 0 0 0 13* 0 8 3 0
8 0 0 0 0 12* 5 1 4
16 0 0 0 0 9* 0 0 2

* Indicates major error pneumoniae in 2012 [14]. CBDE was performed the
results were compared with reference BMD. Based
Discussion on EUCAST 2021 guidelines Categorial agreement
There is re-emergence of usage of polymyxin drugs was analysed. Essential agreement was not analysed
over the past as last agent for treatment of infections as CBDE was performed only in 3 dilutions whereas
caused by multi drug resistant gram-negative rods. BMD was performed in 8 dilutions. As shown in
Although polymixins being considered as last option (Table 4). 2 of the isolates showed MIC of 2 in CBDE &
of treatment it should be used carefully since even MIC value of 4 in reference BMD which is very major
in optimal doses they are highly nephrotoxic and error, categorical agreement of CBDE with reference
neurotoxic , hence knowing the MIC of infecting BMD was 99%. In a study conducted by Simner PJ,
organism is of clinical importance so that accurate et al; which was a 2-site evaluation of CBDE method
report is communicated to the treating physician conducted in 2019, in this study in both the evaluation
centre CBDE had 100% categorical agreement in
which ensures that such kind of drugs are discreetly
comparison with reference BMD method (14). Similar
used [6]. CLSI and EUCAST [7,8 ] in the year 2017
findings were observed by Humphries RM et al, (2019)
together recommended rBMD as the reference test for
in which they reported 97.9% categorial agreement
Colistin testing. But it has its own limitations since the
compared to the reference MIC and reported 9 VME
procedure is tedious and also difficult to use as routine
(3.2%). Dalmolin TV et al., conducted a study in two
test for detection of colistin resistance in resource different research centres in Brazil, in his study he
limited settings , so there is a need of an alternative reported 91.18% of CA and 4.95% of VME with CBDE
method which is more amicable to be performed on compared to reference method (15).
routine basis . Many laboratories are reporting colistin
MIC by using Vitek-2 system which is not an approved As mentioned in (Table 5) 13 isolates with MIC
method by CLSI . Apart from rBMD CLSI is also value of 4 obtained by Vitek-2 showed MIC value of 1
recommended CBDE and CAT as alternative method in reference BMD, 12 isolates that yielded MIC of 8 in
for colistin MIC reporting , present study focuses on Vitek 2 showed MIC of 2 in reference BMD, 9 isolates
evaluation of results of colistin MIC with VITEK -2 with MIC of 16 resulted from Vitek 2 showed MIC
system & CBDE in comparison with rBMD to evaluate value of 2 in reference BMD, 34 isolates totally were
which is the better method that can be adopted on resistant in test method that is Vitek -2 and sensitive
routine basis for testing the colistin susceptibility. in reference BMD .Categorical agreement between
Reference micro broth dilution (MBD) was performed Vitek-2 (Test method ) in comparison with reference
on 200 Carbapenem resistant Enterobacterales which method(BMD) was 83% with 17% of major error and
were isolated from clinical specimens among which no very major error , many studies have been done
11.5 % were resistant to colistin . Various other for evaluation of Vitek-2 automated method for
studies also showed similar kind of resistant pattern, testing of colistin susceptibility. In a study conducted
Klebsiella pneumoniae showed the highest resistance by Ka Lip Chew et al Similar categorical agreement
to colistin among other Enterobacterales which was was seen between Vitek -2 and BMD, which was <
around 9% similarly In the year 2019 Walia k et al 90 % with very major error of 36% & no major error
also reported around 8 % of colistin resistance in
(17)
. In a study conducted by Jerome R. Lo-Ten-Foe et
K. pneumoniae causing hospital-acquired infections al vitek-2 had high level of categorical agreement in
12.6% of klebsiella species isolated from urinary tract comparison with BMD, and he concluded that Vitek
infection were colistin resistant in study conducted -2 is a reliable alternative tool for detection of colistin
by Jain S. et al., (2018) [10]. 20.4 % of colistin resistance susceptibility and he specified that it’s a good tool for
were reported in 2020 by Sarumathi D et al., [11]. detection of colistin susceptibility only in isolates that
High resistance to colistin was noted in many other do not exhibit hetero resistance (18).
studies conducted by authors like L. Bardet et al., in N. Pfennig Werth et al in his study Vitek 2 had
2019 reported 63.4% of colistin resistance among gram 90.5% of categorical agreement with BMD and 31% of
negative rods [13]. Qadi M, et al., (2021) has reported very major error with no detection of false resistance
41% of Enterobacterales that were resistant to colistin (19)
. Another study done by Salima Qamar et al the
[12]
. Capone A, et al. reported around 36.1% of colistin categorical agreement between Vitek 2 and BMD was
resistance that were carbapenem resistant klebsiella 100% (20).

294
In our current study done for evaluation of 4. Romney M. Humphries,a,b Daniel A. Green,c Audrey
alternative method for routine colistin testing Vitek N. Schuetz,d,e Yehudit Bergman,f Shawna Lewis,f
2 showed 83% of categorical agreement 17% of major Rebecca Yee,f Stephania Stump,g Mabel Lopez,c Nenad
error was detected in our study that is resistant in test Macesic,g Anne-Catrin Uhlemann,g Peggy Kohner,d
Nicolynn Cole,d Patricia J. Simnerf Multicenter
method (Vitec 2) and sensitive in reference method
Evaluation of Colistin Broth Disk Elution and Colistin
(MBD) which indicates the detection of false resistance
Agar Test: a Report from the Clinical and Laboratory
to colistin. And to be noted that there was no very
Standards Institute Journal of Clinical Microbiology
major error detected by Vitec 2compared to BMD in November 2019 Volume 57 Issue 11 e01269-19
our study. Whereas CBDE had very good categorical
agreement of 99% with only 1 % of very major error 5. Joseph D. Lutgring,a,b Anny Kim,a Davina Campbell,a
Maria Karlsson,a Allison C. Brown,a Eileen M. Burdc
and no major error compared to rBMD.
Evaluation of the MicroScan Colistin Well and Gradient
Conclusion Diffusion Strips for Colistin Susceptibility Testing in
Enterobacteriaceae Journal of Clinical Microbiology
As per our study Vitec 2 detected more of false
May 2019 Volume 57 Issue 5 e01866-18
resistance to colistin but no false susceptibility was
seen. Parallelly CBDE yielded good categorical 6. Humphries RM, Green DA, Schuetz AN, Bergman
agreement with only 1% of false susceptibility. Hence Y, Lewis S, Yee R, Stump S, Lopez M, Macesic N,
Uhlemann AC, Kohner P. Multicenter evaluation
Vitek2 can be used routinely for testing of Colistin
of colistin broth disk elution and colistin agar test: a
susceptibility but if colistin resistance is yielded by
report from the Clinical and Laboratory Standards
Vitek 2 then that isolate needs to be retested by one
Institute. Journal of clinical microbiology. 2019 Sep
more method. CBDE can be used as alternative to 11;57(11):e01269-19.
vitek2 so that the isolate susceptibility will be double
confirmed and false resistance will not be reported. 7. Clinical and Laboratory Standards Institute. 2018.
Performance standards for antimicrobial susceptibility
This further avoids the unnecessary usage of other
testing; 28th informational supplement. Clinical and
antibiotics like Fosfomycin,Tigecycline & other drugs
Laboratory Standards Institute, Wayne, PA.
that are used for treating colistin resistant infections.
8. EUCAST. 2017. Breakpoint tables for interpretation of
Source of Funding: Nil
MICs and zone diameters, version 8.1. http://www.
Ethical Clearance: Institutional Ethics committee eucast.org/fileadmin/src/media/PDFs/ EUCAST
approval was obtained from JSS Medical college, files/Breakpoint tables/v_8.1_Breakpoint_Tables.pdf.
Mysore. Accessed 6 December 2018.
Conflict Of Interest: No potential conflict of 9. Clinical and Laboratory Standards Institute. 2020.
interest relevant to this article reported Performance standards for antimicrobial susceptibility
testing; 29th informational supplement; CLSI M.100.
References
Clinical and Laboratory Standards Institute, Wayne,
1. zÁvila, Julia Kranich, Gabriel Ibrahim Borba Carneiro PA
d, Lavinia Nery Villa Stangler Arend c, Guilherme
Nardi Becker c, Karin Obladen Ferreira c, Daiana de 10. Jain S. Emergence of colistin resistance among gram
Lima-Morales a, Afonso Luís Barth a,b,*,1, Marcelo negative bacteria in urinary tract infections from super
Pillonetto Elution methods to evaluate colistin specialty hospital of North India. International Journal
susceptibility of Gram-negative rods Diagnostic of Infectious Diseases. 2018 Aug 1;73:133.
Microbiology and Infectious Disease 96 (2020) 114910 11. Sarumathi D, Rajashekar D, Sastry AS. Comparison
2. Walia, K., J. Madhumathi, B. Veeraraghavan, et al., of Antimicrobial Susceptibility Testing Methods
Establishing Antimicrobial Resistance Surveillance for Colistin against Carbapenem Resistant
& Research Network in India: Journey so far. Indian Enterobacteriaceae in a Tertiary Care Hospital of
Journal of Medical Research, 2019. 149(2): p. 164-179. Southern India. Journal of Clinical & Diagnostic
Research. 2020 Jul 1;14
3. Michael J. Satlina The Search for a Practical Method
for Colistin Susceptibility Testing: Have We Found 12. Qadi M, Alhato S, Khayyat R, Elmanama AA. Colistin
It by Going Back to the Future? Journal of Clinical Resistance among Enterobacteriaceae Isolated from
Microbiology February 2019 Volume 57 Issue 2 e01608- Clinical Samples in Gaza Strip. Canadian Journal of
18 Infectious Diseases and Medical Microbiology. 2021
Apr 20;2021.

13. L. Bardet, L. Okdah, S. Le Page, S. A. Baron, and J.- 18. Lo-Ten-Foe JR, de Smet AM, Diederen BM, Kluytmans
M. Rolain, “Comparative evaluation of the UMIC JA, van Keulen PH. Comparative evaluation of the
Colistine kit to assess MIC of colistin of gram-negative VITEK 2, disk diffusion, Etest, broth microdilution,
rods,” BMC Microbiology, vol. 19, no. 1, p. 60, 2019. and agar dilution susceptibility testing methods for
colistin in clinical isolates, including heteroresistant
14. Capone A, Giannella M, Fortini D, Giordano A,
Enterobacter cloacae and Acinetobacter baumannii
Meledandri M, Ballardini M, Venditti M, Bordi E,
strains. Antimicrobial agents and chemotherapy. 2007
Capozzi D, Balice MP, Tarasi A. High rate of colistin
Oct;51(10):3726-30.
resistance among patients with carbapenem-resistant
Klebsiella pneumoniae infection accounts for an excess 19. Pfennigwerth N, Kaminski A, Korte-Berwanger M,
of mortality. Clinical Microbiology and Infection. 2013 Pfeifer Y, Simon M, Werner G, Jantsch J, Marlinghaus L,
Jan 1;19(1):E23-30. Gatermann SG. Evaluation of six commercial products
for colistin susceptibility testing in Enterobacterales.
15. Simner PJ, Bergman Y, Trejo M, Roberts AA, Marayan
Clinical Microbiology and Infection. 2019 Nov
R, Tekle T, Campeau S, Kazmi AQ, Bell DT, Lewis S,
1;25(11):1385-9.
Tamma PD. Two-site evaluation of the colistin broth
disk elution test to determine colistin in vitro activity 20. Qamar S, Shaheen N, Shakoor S, Farooqi J, Jabeen
against Gram-negative bacilli. Journal of clinical K, Hasan R. Frequency of colistin and fosfomycin
microbiology. 2019 Jan 30;57(2):e01163-18 resistance in carbapenem-resistant Enterobacteriaceae
from a tertiary care hospital in Karachi. Infection and
16. Dalmolin TV, Mazzetti A, Ávila H, Kranich J, Carneiro
drug resistance. 2017;10:231.
GI, Arend LN, Becker GN, Ferreira KO, de Lima-
Morales D, Barth AL, Pillonetto M. Elution methods to
evaluate colistin susceptibility of Gram-negative rods.
Diagnostic microbiology and infectious disease. 2020
Jan 1;96(1):114910.
17. Chew KL, La MV, Lin RT, Teo JW. Colistin and
polymyxin B susceptibility testing for carbapenem-
resistant and mcr-positive Enterobacteriaceae:
comparison of Sensititre, MicroScan, Vitek 2, and
Etest with broth microdilution. Journal of clinical
microbiology. 2017 Sep;55(9):2609-16.

Periodontal Ligament: Health, Disease and Regeneration
Surbhi Yadav1, Shivi Khattri2, Mayur Kaushik3, Soumya Sharma4

1
2
Professor, Department of Periodontology, Subharti Dental College & Hospital, Meerut (250005)
3
Professor & Head, Department of Periodontology, Subharti Dental College & Hospital, Meerut (250005)
4
How to cite this article: Surbhi Yadav, Shivi Khattri, Mayur Kaushik, Soumya Sharma et al Periodontal
Ligament: Health, Disease and Regeneration. Volume 13 | Issue 4 | October-December 2022
Abstract
Understanding of the structure and metabolism of connective tissue components in recent years has increased drastically.
The support and attachment of the tooth in the bones of the jaw is provided by a complex comprising of four connective
tissues and is known as the Periodontium. It is attached to the dentine of the root by the cementum and to the bones of
the jaw via the alveolar bone. Two of the connective tissues are mineralized and comprise of cementum and alveolar
bone, while the other two are essentially fibrous in nature and are represented by the periodontal ligament (PDL) and the
gingiva. This review article summarizes the current knowledge of the periodontium and will discuss the most important
vital structure in detail that is Periodontal ligament.
Keywords: Periodontal ligament, Regeneration, Disease.
Introduction of the tooth. It is diminished around tooth that are not

The periodontium is a dynamic structure that is served in function and in unerupted teeth but it is increased
throughout life by a unique vascular arrangement, a in cases of hyperfunction and excessive occlusal
lymphatic system and a highly specialized network stresses.3
of nervous elements. The periodontium is defined Cells of the PDL
simply as “the tissues investing and supporting the
A healthy, functioning periodontal ligament consist
teeth”. Thus, the periodontium is composed of the
of numerous cell types, which involves: Connective
following tissues: (Fig-1) alveolar bone, root cementum,
tissue cells; Bone forming cells; Epithelial rest
periodontal ligament and gingiva.1
cells and Immune system cells.4 These cells have
The unique properties of the periodontal ligament specialized properties. They all act together to sense
endow this tissue with functional attributes that are applied physical forces and respond to them by
not replicated by other tissue. Other names include maintaining PDL width and preserving cell viability.
periodontal membrane, alveolo-dental ligament, They are also capable of synthesizing and releasing
desmodont, pericementum, dental periosteum and bioactive molecules, for instance cytokines, growth
gomphosis.2 Width of periodontal ligament ranges factors and cell adhesion molecules.5
from 0.15mm to 0.38mm. Its shape is like an hourglass
apicocoronally, corresponding to the rotation point of Connective tissue cells
the tooth. The thickness of the periodontal ligament Connective tissue cells include fibroblasts,
seems to be maintained by the functional movement cementoblasts and osteoblasts. Fibroblasts are the
Surbhi Yadav
Postgraduate Student, Department of Periodontology, Subharti Dental College & Hospital, Meerut (250005),
E-mail: [email protected],
Mob.: 9999266790*
main component cell type in the PDL. In rodents, towards cementum was found to be more mature than
they make up 35% of the volume space of the that towards bone. This also indicates that remodelling
ligament, approximately 20% in sheep and 25-30% is faster on the bone side of PDL. This might also be
in humans. The fibroblasts are interconnected by gap attributed to the fact that alveolar bone undergoes
junctions and adherence-type junctions. Fibroblasts continuous remodelling whereas cementum on the
are responsible for forming and remodeling the PDL other hand, doesn’t undergo remodelling under
fibers. Periodontal fibroblasts are responsible for normal conditions.11
the overall production and turnover of most of the
extracellular matrix.The fibroblasts are the major Development of PDL fibers
resident cells which inhabit the periodontal tissues In the pre-occlusional stage, developing transseptal
and the ability of the fibroblast to proliferate, migrate, fibers extend over the alveolar crest in an oblique–
elongate, adhere, immobilize itself and commence apical direction toward the cementoenamel junction
matrix synthesis is critical for cell function, wound of the nonerupted adjacent tooth.However, when
healing and tissue integrity.6 the adjacent tooth has erupted, the mechanical field
around the erupting tooth changes.4 This results in a
Bone forming cells: Osteoblasts and re-orientation of the transseptal fibers in a superior–
osteoclasts oblique direction toward the erupted tooth. When
Osteoblasts are bone-forming cells located along the the tooth reaches the first occlusal contact, PDL fiber
alveolar bone surface, which differentiate locally organization is more advanced.
from mesenchymal cells when needed. They are
only prominent when there is active bone formation.
Bone is constantly being turned over. Therefore, the
osteoblasts will form new bone in that area of alveolar
bone being remodelled.7 Osteoclasts originate from
monocytes within the blood vascular system and are
found in areas where bone and cementum are being
resorbed.
Epithelial cell rests of Malassez

The PDL also contains characteristic epithelial
islands, known as epithelial cell rests of Malassez,
which may in fact be a “chicken-wire” network of
cells throughout the ligament. The origin of these cell
At this stage, the dentogingival and transseptal
rests is thought to be the result of the breakdown of
fibers are well developed. In the cervical third of the
Hertwig’s epithelial root sheath during embryological
root, closely spaced fibers emerge from the cementum
root formation.8The fact that the epithelial cells are
in an oblique, downward direction toward the
in connective tissue is a unique characteristic. They
alveolar bone. Near the bone these fibers join with
may maintain normal PDL width and do not prevent
more widely spaced Sharpey’s fibers. When in full
ankylosis and root resorption.9
function, all principal fiber groups in the ligament
Immune cells: Defense cells are present. As a result of dental loading, overall, the
fiber bundles thicken and form a network.12 (FIG.2)
Defense cells in the periodontal ligament include
neutrophils, macrophages, mast cells, lymphocytes, Periodontal ligament fibers
and eosinophils. Macrophages are derived from
The most important elements of the periodontal
blood monocytes and make up approximately 4% of
ligament are the principal fibers, which are
the PDL population.1
collagenous and arranged in bundles and which
Maintenance of periodontal function follow a wavy course when viewed in longitudinal
The integrity of PDL tissue is maintained by the section. The terminal portions of the principal fibers
extremely high turnover of collagen. This is because that are inserted into cementum and bone are termed
PDL collagen has half-life of only few days.10 Collagen Sharpey’s fibers.13 Sharpey’s fibers are extensions

298
of the principal fibers of the ligament into the tooth lymph vessels and nerves traversing the periodontal
cementum and bone. Once they insert themselves ligament space at the root apex.
into the alveolus wall or the cementum, they calcify
The interradicular fibers fan out from the cementum
and become associated with non-collagenous proteins
to the tooth in the furcation areas of multirooted
in cementum and bone. Sharpey’s fibres are coupled
teeth. Their function is believed to be resisting tooth
with high levels of osteopontin and bone sialoprotein.
tipping, torquing and luxation. Three types of elastic
This could give useful physical properties to the hard
fibers exist: elastin, oxytalan and elaunin. Only
and soft tissue interface.14
oxytalan fibers are found in the human PDL, but
The ligament collagen bundle fibre composition is the gingival ligament also has fibers bundles which
primarily interstitial collagens I and III, which then may be linked to elaunin fibers. Oxytalan fibres were
arrange as banded fibrils. Collagen V is also involved described initially by Fullmer. They are pure bundles
with these fibrils and is located in the interstitial of microfibrils, which resemble pre-elastic fibres and
spaces between the bundles or within the centre of run in a vertical direction from the surface of the
the fibrils. Other minor collagens involved in the cementum, which forms a meshwork that covers the
fibrous meshwork of the PDL are collagens IV, V, VI tooth root.17
and XII, which are important to maintain the normal
architectural structure of the PDL.15 The principal Blood and nerve supply of PDL
fibers of the periodontal ligament are arranged in six For a fibrous connective tissue, the PDL has an
groups that develop sequentially in the developing unusually rich nerve and blood supply. In addition
root, which are as follows: transseptal; alveolar crest; to the usual autonomic nerves associated with the
horizontal; oblique; apical; interradicular fibers. vasculature, the sensory nerves show endings of the
Transseptal fibers extend interproximally over Ruffini type that play an important role in the reflex
the alveolar bone crest and are embedded in the control of mastication. It also releases neuropeptides
cementum of adjacent teeth. They are reconstructed such as substance P, vasoactive intestinal peptide and
even after destruction of the alveolar bone that results calcitonin gene-related peptide.1
from periodontal disease. Fibers also run from the The major blood vessels of the PDL lie between
cementum over the alveolar crest and to the fibrous the principal fiber bundles, close to the wall of
layer of the periosteum that covers the alveolar bone. the alveolus. The majority of vessels appear to be
The alveolar crest fibers prevent the extrusion of the postcapillary venules.4
tooth and resist lateral tooth movements, helps in
securing teeth in their sockets.16 The incision of these Functions of Periodontal Ligament
fibers during periodontal surgery does not increase The functions of the PDL are categorized as:
tooth mobility unless significant attachment loss has
occurred. 1. Physical: Provision of a soft-tissue “casing” to
protect the vessels and nerves from injury by
The horizontal fibers are found immediately apical
mechanical forces. Transmission of occlusal
to the alveolar crest fiber group. The fiber bundles
forces to the bone.
of this group pass from their cemental attachment
directly across the periodontal ligament space to 2. Formative and remodeling: Cells of the PDL
become inserted in the alveolar process as Sharpey’s participate in the formation and resorption
fibers. Oblique fibers constitute the largest group in of cementum and bone, which occur during
the periodontal ligament, extend from the cementum physiologic tooth movement, during the
in a coronal direction obliquely to the bone. Oblique accommodation of the periodontium to
fibers bear the brunt of vertical masticatory stresses occlusal forces, and during the repair of
and transform such stresses into tension on the injuries.
alveolar bone.1 The apical fibers radiate in a rather 3. Nutritional and Sensory: The PDL supplies
irregular manner from the cementum to the bone at nutrients to the cementum, bone, and
the apical region of the socket. They do not occur on gingiva by way of the blood vessels, and
incompletely formed roots. The apical fiber bundles it also provides lymphatic drainage. The
resist the forces of luxation, may prevent tooth tipping PDL is abundantly supplied with sensory
and probably also protect the delicate blood and

nerve fibers that are capable of transmitting Regeneration of periodontal tissues is one of the
tactile, pressure, and pain sensations via the most important goals for the treatment of periodontal
trigeminal pathways.16 disease. Periodontal regeneration requires the
coordinated formation of new alveolar bone,
Periodontal ligament in disease cementum and functional PDL.19
The PDL can be destroyed because of the following
PDL regeneration can be expected under the
causes:
following conditions:
A. Abnormal occlusal forces
1. PDL regeneration during tooth movement
B. Periodontal diseases
2. PDL around implants
C. Periodontal component of systemic diseases
3. After the treatment of periodontal diseases
A. Abnormal occlusal forces Regeneration of tooth and periodontal ligament
tissue is of great interest in dental research as well
he PDL has a cushioning effect on forces applied
T
as in clinical practice. PDL regeneration can be done
to teeth as means to accommodate forces exerted
through stem cells and guided tissue regeneration.20
on the crown. Due to the elastic nature of the
Successful periodontal regeneration relies on the re-
periodontal ligament, all teeth with normal bone
formation of an epithelial seal, deposition of new
support present with physiologic mobility in all
acellular extrinsic fiber cementum and insertion of
directions. Whenever occlusal forces exceed the
functionally oriented connective tissue fibers into
adaptive capacity of the tissues, tissue injury results
the root surface, and restoration of alveolar bone
and tissue responses occur in three stages.
height.21 Therefore, the major factor believed to
a) Injury; prevent periodontal regeneration after conventional
b) Repair; therapeutic approaches is the migration of epithelial
cells into the defect area at a faster rate than that of
c) Adaptive remodeling of the periodontium.18 mesenchymal cells, which leads to the formation of a
long junctional epithelium and the prevention of the
B. Periodontal diseases formation of a new attachment apparatus over the
eriodontal diseases are mainly characterized by
P previously diseased root surface.
affecting the composition and integrity of all the The goal of regenerative procedures is to prevent
structures involved in the periodontium resulting apical migration of gingival epithelial and connective
in the destruction of the connective tissue, the loss tissue cells and to provide maintenance of a wound
of attachment and finally the resorption of alveolar space into which a selective population of cells (hence
bone. If periodontitis is left untreated, it will guided tissue regeneration [GTR]) is allowed to
eventually result in loss of tooth and unfortunately migrate, favoring the formation of a new periodontal
conventional therapies are only palliative. Once the attachment. Derived from the classic studies of
periodontium is disrupted, restoration of its normal Nyman, Lindhe, Karring, and Gottlow,21 this
structure and function is very difficult.9 method is based on the assumption that periodontal
ligament and perivascular cells have the potential for
C.Periodontal component of systemic diseases regeneration of the attachment apparatus of the tooth.
eriodontium can also be affected by systemic
P The biologic basis of GTR is based on the assumption
diseases such as Down Syndrome, Papillon- that the placement of physical barriers prevents apical
Lefevre syndrome, Ehler Danlos Syndrome, migration of the epithelium and gingival connective
Hypophosphotasia. tissue cells of the flap and provides a secluded space
PDL in Regeneration for the inward migration of periodontal ligament
cells (PDL) and mesenchymal cells on the exposed
Regeneration is defined as the reproduction or
root surface, which in turn promote periodontal
reconstitution of a lost or injured part of the body
regeneration.22Types of barrier membranes used can
in such a way that the architecture and function of
be non-resorbable or resorbable membranes.
the lost or injured tissues are completely restored.

300
PDL tissue engineering presents several specific 3. Pitaru S, McCulloch CA, Narayanan SA. Cellular
challenges. First, the very narrow PDL space, which origins and differentiation control mechanisms during
spans approximately 150-400 μm from alveolar bone periodontal development and wound healing. J
Periodontal Res 1994;29:81-94.
4. Mcculloch CA, Lekic P, Mckee MD. Role of physical

forces in regulating the form and function of the
periodontal ligament. Periodontol 2000 2000;24:56-72.
5. Pierce GF, Mustoe TA, Lingelbach J, Masakowski

VR, Griffin GL, Senior RM, et al. Platelet-derived
growth factor and transforming growth factor-beta
enhance tissue repair activities by unique mechanisms.
J Cell Biol 1989;109:429-440.
6. Beertsen W, Everts V. Junctions between fibroblasts

in mouse periodontal ligament.J Periodontal Res
1980;15:655-668.
7. Caetano-Lopes J, Canhao H, Fonseca JE. Osteoblasts

to tooth, limits the possibilities of placing off-the shelf
and bone formation. Acta Reumatol Port 2007;32:103-
constructs. The second challenge is engineering of
110.
a soft tissue between two mineralized surfaces and
specifically anchoring it to them. PDL engineering 8. Hughes FJ. Periodontium and periodontal disease.
constructs needs to be able to functionally cope InStem cell biology and tissue engineering in dental
with high forces and should contain a self-repair sciences. Academic Press 2015;20:433-444.
mechanism to maintain their integrity, as damage 9. Rincon JC, Xiao Y, Young WG, Bartold PM. Production
resulting of osteopontin by cultured porcine epithelial cell rests
of Malassez. J Periodont Res 2005;40:417-426.
Conclusion
10. Sodek J. A comparison of the rates of synthesis and
The PDL is a highly organized tissue between two turnover of collagen and non-collagen proteins in adult
mineralized surfaces, which is capable of coping with rat periodontal tissues and skin using a microassay.
extremely high forces. The complex arrangement of Arch Oral Bio 1997;22:655-665.
this tissue makes PDL tissue engineering an enormous
11. Sodek J, McKee MD. Molecular and cellular biology
challenge. So, the current researches still target on the
of alveolar bone. Periodontol 2000 2000;24:99-126.
regeneration of the PDL by novel methods.
12. Berkovitz BK. The structure of the periodontal
Ethical clearance- Taken from Ethical committee of ligament: an update. Eur J Orthod 1990;12:51-76.
Swami Vivekanand Subharti University.
13. Kraw AG, Enlow DH. Continuous attachment of the
Source of funding- Self. periodontal membrane. Am j anat 1967;120:133-147.
Conflict of Interest - Nil. 14. Beertsen W, McCulloch CA, Sodek J. The periodontal
ligament: a unique, multifunctional connective tissue.
References Periodontol 2000 1997;13:20-40.
1. Newman MG, Takei H, Klokkevold PR, Carranza FA.
15. Romanos G, Schröter-Kermani C, Hinz N,
Newman and Carranza’s Clinical periodontology.13th
Bernimoulin JP. Immunohistochemical distribution of
ed. Philadelphia (US): Elsevier Health Sciences; 2018:29-
the collagen types IV, V, VI and glycoprotein laminin
31.
in the healthy rat, marmoset and human gingivae.
2. Menicanin D, Mrozik KM, Wada N, Marino V, Shi S, Matrix 1991;11:125-132.
Bartold PM, et al. Periodontal-ligament-derived stem
16. Gillespie BR, Chasens AI, Brownstein CN, Alfano
cells exhibit the capacity for long-term survival, self-
MC. The relationship between the mobility of human
renewal, and regeneration of multiple tissue types in
teeth and their supracrestal fiber support. J Periodontol
vivo. Stem Cells Dev 2014;23:1001-1011.
1979;50:120-124.

17. De Jong T, Bakker AD, Everts V, Smit TH. The 20. Weissman IL. Stem cells: units of development, units of
intricate anatomy of the periodontal ligament and its regeneration, and units in evolution. Cell 2000;100:157-
development: Lessons for periodontal regeneration. J 168.
Periodont Res 2017;52:965-974.
21. Gottlow J, Nyman S, Lindhe J, Karring T, Wennström
18. Biancu S, Ericsson I, Lindhe J. Periodontal ligament J. New attachment formation in the human
tissue reactions to trauma and gingival inflammation: periodontium by guided tissue regeneration Case
An experimental study in the beagle dog. J Clin reports. J Clin Periodontol 1986;13:604-616.
Periodontol 1995;22:772-779.
22. Nyman S, Gottlow J, Karring T, Lindhe J. The
19. Hammarström L, Heijl L, Gestrelius S. Periodontal regenerative potential of the periodontal ligament: An
regeneration in. J Clin Periodontol 1997;24:669-677. experimental study in the monkey. J Clin Periodontol
1982;9:257-265.

Application of Lean Methodology in Radiology Department of a

Multispecialty Hospital.
Susmit Jain1, Mahima Jha2

1
Associate Professor, IIHMR University, Jaipur, Rajasthan, India,
2
Healthcare Manager, Alumni, MBA Hospital & Health Management, IIHMR University, Jaipur.
How to cite this article: Susmit Jain, Mahima Jha (P.T.) et al Application of Lean Methodology in Radiology
Department of a Multispecialty Hospital. Volume 13 | Issue 4 | October-December 2022
Abstract:
Hospital Administrators are continually looking for ways to reduce the cost and expenditure related to healthcare services.
The radiology department is one of the key areas for reducing the expenditures of the hospital. The radiology department
is an important revenue-generating department, but it also houses one of the costliest technologies to maintain and repair.
The study was carried out in a Multispecialty Hospital in India. The objective of the study was to reduce identify wastes
or “muda” as in lean methodology of Toyota Production System and to study the cost of materials consumed in the
radiology department without compromising the quality of services. The study design was descriptive & cross-sectional,
and data of cost analysis was obtained from the Hospital Information System. The period of the study was over a three-
month period between March - June 2021. Data of Radiology Information System (R.I.S) (medical imaging software) was
also used. The cost related to radiology was determined for the consumables. The sampling technique was purposive.
Data was analysed using Minitab and MS Excel. Value Stream Map was created, and 8 types of wastes (lean tool) were
identified in the study. The wastes or “muda” occurred during transportation which occurred during shifting of patients
and material transportation, inventory, motion, too many clicks for uploading images, waiting for procedures, waiting
for reports, re-do and unnecessary tests, excess radiation doses, reporting errors, and insufficient training to staff. In the
MRI procedure, Value Stream Map was made, the takt time of 24 min, but the cycle time was 100 min and waiting of 120
minutes, which resulted in the lead time of 220 minutes. Pareto analysis of the consumables was done for 28 products,
the products were classified under ABC categories. Radiographic Film-14 x 17 inch & Contrast Omnipaque consumed
73.3 % of the consumption value, they were classified under A category products, 3 products viz Contrast Omniscan,
Radiographic Film-11x14inch, Radiographic Film-8 X10inch were categorized under B category which consumed
additional 21.05 % of the expenditure, the remaining 20 products were classified under C category, which consumed only
5.68 % of the monetary consumption value.
Category A materials are the most expensive and hence require strict control. From the data analysis, it was observed that
stringent control on consumption, monthly consumption analysis, and commitment of the staff members could be the
contributory factors for the reduction in expenditure. The maximum scope for cost reduction in the radiology department
was in the MRI Studies.
Some of the strategies for cost reduction could be digitalization of services, use of IT in MRI studies CDs could be provided,
linking the RIS with mobile application. The reports could be made assessable online which would reduce paper records.
is another money-saving tactic. The purchase department must be informed of the consumption pattern on a weekly or
monthly basis, particularly for costly products like contrast (Omnipaque and Omniscan).
Keywords: Radiology, Lean, Toyota Production System, Muda, Consumables, Value Stream Map, Pareto Chart.
Introduction (MRI) etc. to diagnose and treat diseases. It is an

Radiology is the medical discipline that uses important revenue-generating department, but
medical imaging to diagnose and treat diseases it also houses one of the costliest technologies to
within the bodies of animals, including humans. It maintain and repair. For example, cost of an MRI
is involved with medical imaging techniques such Machine for GE Systems 1.5 Tesla ranges from 80
as X-ray, Ultrasound sonography (USG), Computed Lakhs to 8.5 crores, the CT Scan machine ranges from
tomography (CT), Magnetic Resonance Imaging 80 lakhs to 3.8 crore and X Rays machine ranges from
1.5 lakhs to 75 lakhs. As the department is important value stream map (VSM), identifying & eliminating
revenue generating area in a hospital, it is key area wastes, and continual improvement of the processes
for reducing the expenditure of the hospital. Hence, for improving quality. These tool and techniques
hospital administrators are continually looking for are aimed to optimize time, improve productivity,
ways to reduce the cost and expenditure related to while improving quality of products and services3.
radiology services1. In Lean approach there are 7 type of wastes or muda
as referred in Toyota Production System which
The need for containing and controlling the imaging
are Transportation, Inventory, Motion, Waiting,
cost requires an understanding of procedures and
Overproduction, Overprocessing, Defects. These
quantify the cost of the imaging services. Radiology
wastes were defined by Taiichi Ohno, father of
department uses consumables for procedures like X
the TPS. Some practitioners include 8th waste as
Ray, CT, MRI & USG and may include X-ray film for
Skills or unutilized talent. They make the acronym
producing radiographic image and generally consists
TIMWOODS.
of emulsion of silver bromide (AgBr), Contrast or
dyes like Omnipaque™ (iohexol) by GE Healthcare, First application of lean principles in healthcare
which contains iodine and add contrast to body parts, was in 2001 in Virgina Mason Medical Centre, in
and is taken before imaging tests (such as CT scans), Seattle, Washington, when they applied Toyota
Contrast Omniscan™ which is a Gadolinium based Production System (TPS) to the healthcare context.
contrast agent used in MRI examination generally They implemented Virginia Mason Production
for tumours and abnormalities in brain and spine, System (VMPS) to identify and eliminate “muda” or
electroencephalogram (EEG) conducive paste used for waste to improve productivity and efficiency4.
brain disorders, and helps in reducing skin impedance
Value stream mapping in hospitals maps all
while using EEG electrodes, intravenous cannula or
the operational processes related to patient flow,
IV cannula which is a tube inserted into the body for
material supplies, information related to the journey
delivery of fluids into the body, Syringe-plain with
of patients, etc. and acts as a visual tool of the health
needle, 3 way Stop cock for infusion of two fluids,
care service delivery. Takt time is calculated which
Mannitol 20% Infusion which is a medicine with
signifies the time in which a service needs to be
high osmotic pressure and increases water retention,
completed keeping in mind the demand and total
Examination gloves, Ultrasound Gel which reduces
available service time. Current-state and future State
the air between the skin and the probe or transducer,
Value Stream Map are drawn5.
Surgical paper tape, General stationery, personal
protective equipment (PPE) face shield for infection Lean techniques could be applied to reduce costs
control2, sodium chloride solution (intravenous) and improve quality in radiology department. The
normal saline (NS), Surgical drape which is OT linen basic tools included “kaizen” which means continuous
used to isolate surgical site from other areas of patient improvement, VSM(value stream mapping) of the
body and reduce surgical site infection (SSI), Scalp department, applying 5 S’s which include Sort, Set in
vein set for drawing blood or for intravenous (I.V.) order, Shine, Standardise and Sustain, and other lean
therapy into a vein, N95 respirator & surgical masks, productive improvement techniques6,7,8.
Syringe-plain with needle, Xylocaine 2% Jelly which With this backdrop the current study was
contains Lidocaine used for local anesthetics, Baccirub undertaken to apply lean concepts and explore
Plus which is Antimicrobial Alcohol Hand Rub, etc. avenues for cost containment and to identify the
The diverse nature of value and cost of radiology wastes (non-value adding steps) in the radiology
consumables gives rise to a complex set of dynamics, department for resource utilization.
with various items to be purchased, consumed, and
in turn influence the cost of the images which is the Materials and Methods
primary product. The research was undertaken with the objective
Lean manufacturing concepts were established to identify wastes using lean approach, and to
in Toyota corporation in Japan in 1970s and 1980s, conduct a cost analysis of the material consumption
hence are also called as Toyota Production Systems. in the radiology department. It was carried in a
The principles of lean include identifying all steps Multispecialty tertiary care hospital based in Jaipur,
that add value to the product or service through India.

304
The study design is descriptive & cross-sectional, of the department. Both the inventory costs and
and data of cost analysis was obtained from the increase in the stock levels act as a burden to the
Hospital Information System. The period of the hospital’s financial performance. The inventory is
study was over a three-month period between under the control of the purchase department of
March - June 2021. Data of Radiology Information the hospital. The strict control of the inventory is
System (R.I.S) (medical imaging software) was also always kept. Excess inventory or low inventory
used. The cost related to radiology was determined are both responsible for the rise in expenditure by
for the consumables for three weeks. The sampling the department.
technique was purposive. Data was analysed using
3. Motion: It was identified as too many clicks for
Minitab & MS Excel. 8 type of wastes (TIMWOODS)
loading and uploading the images in the PACS9.
were identified for the radiology department, current
and future state Value Stream Maps were developed, 4. Waiting: Waiting was observed as waiting
and Pareto analysis of the material consumed in for the procedure i.e. the time between the
the radiology department was done using Minitab patient arrived at the counter to the time of
software. the procedure, waiting in report generation i.e.
time between examination/procedure and the
Results & Discussion report finalization by the radiologist, and waiting
Waste (TIMWOODS) analysis of Radiology for receiving the materials from the store.
Department9,10,11
5. Over-processing/non-value-adding processing:
In Lean Six Sigma, the type of wastes may include This type of waste occurs when more steps are
transportation (i.e. unnecessary movement of people, added to the procedure than required or doing
products and information), inventory, movement, more work or producing the service which is
waiting, over-production, overprocessing, defective required. The over-processing in the department
products or services and underutilized skills & occurred due to unnecessary tests performed.
inadequate training. They may be memorized with
The re-dos are done for CT, MRI, and X-ray which
the acronym as “timwoods”.
all adds to the over processing and increases the
The concept was analyzed in the radiology cost of the department.
department and all types of wastes were identified12.
6. Overproduction: This type of waste occurs when
1. Transportation: The transportation type of waste products and services are delivered before they
took place while shifting the patients from wards/ were required. The radiation dose in excess can
ICU to the radiology department. It also occurs be an example of overproduction.
while shifting the patient back to the respective
7. Defects: Defects occur when the products are not
ward or ICU. Transportation of patients took a
deemed fit for use. They add unnecessary costs to
great deal of time and it requires communication
the operations of the department without adding
on the part of technicians as well as nursing
any value. Reporting errors are the defects in the
staff in the wards. The subsequent delay in the
radiology department. The reporting error can
transportation and the time between the billing
occur before the report is dispatched or after the
and procedure adds to the waiting time of the
report is dispatched.
patient. The waiting time increases in the case
of delays in transportation. The transportation 8. Staff:
delay also occurs when the portable machines The 8th waste is the waste of unutilized human
are shifted from the department during a bedside resources. This happens when the staff is not
procedure. Furthermore, transportation can lead involved in the management processes such
to the wear and tear of the machine leading to an as planning, organizing, controlling, and
increase in the cost of maintenance. The shutdown innovating. The staff should also be included
time of the machine during maintenance can also in the overall process and quality improvement
adds to the cost. and should be encouraged to come up with
2. Inventory: Inventory contributes to the material ideas by the management. Another type of
expenditure and consumption both add to the cost waste is because of insufficient training. Due to

COVID-19 restrictions, training sessions were not Current State MRI Value Stream Map
conducted for the staff during the study period.
When the machine is idle or underutilization of
the machine takes place in the department, the
human resources also remain unutilized. The
staff should be motivated, encouraged to give
proper feedback, and challenged to come up with
new ideas at work.
The wastes have been depicted in Fig.1 below.
Fig. 2: Value Stream Map (Current State) - MRI
The total no. of procedures in the study month

were 400 and timings was 9.00am-5.30pm, daily 6
days / week, which gave the takt time of 24 min. The
cycle time was observed at 83 min and Lead time of
220 min.
In the future state map, lean time was reduced to 83
min, as shown in Fig. 3.
Future State Value Stream Map for MRI

procedure
Fig. 1 8: wastes of the Radiology Department
Value Stream Maps of the Radiology

procedures13,14
The workflow of radiology department for
Outpatient (OPD) was recorded which included
request for examination, registration at the billing
counter, and included collecting history of diseases
such as hypertension, diabetes, and cardiac health
conditions, allergies to the contrast, surgeries, metallic
implants, etc. A consent form was filled for the MRI Fig. 3: Value Stream Map (Future State) - MRI
scan. When the process of registration is completed,
the patient was directed to wait for his/her turn. The Cost Control of consumables15
patient was called for the examination and the patient Radiology department consumables for the procedures
was prepared for the examination. The technician (X Ray, CT, MRI & USG) was studied for three months.
explains the procedure to the patient in brief. The The consumables included Radiographic films (14x
images for the examination are uploaded in PACS. 17Inch, 11x14inch, 8 x10inch), contrast (Omnipaque
From PACS, the radiologist could view images and & Omniscan), Baccirub plus, Surgical face mask, EEG
the process of reporting of images starts. The images paste, IV cannula, Syringe-plain with needle, Stop
are read, reports are finalized, and then uploaded in cock-3 way, Mannitol-Infusion-20%, Examination
the RIS. The RIS is integrated with the HIS and the gloves, Ultrasound gel, Surgical paper tape, General
reports can be printed and dispatched afterwards. stationery, PPE-visor shield, Contrast media Syringe,
The reports are then collected by the patient at the Sodium chloride(NS), Douche set complete, Surgical
designated time. drape-plain sheet, IV cannula, Syringe-plain with
As there was maximum waiting in the MRI needle, Infant feeding tube, Scalp vein infusion set,
procedure, current and future state Value Stream Respiratory protection mask N95, Syringe-plain with
Map (Lean TOOL) of MRI were created for the same needle, Lidocaine-jelly-2% etc.
(Figure 2, Figure 3) using Minitab software.

306
The material consumption consists of 28 items It was observed that consumables Radiographic
indented for the radiology department during film-14x 17inch, Contrast Omnipaque, Contrast
the study period i.e. from March to May 2021. To Omniscan were consuming 87.5% of the monetary
understand the products which were consuming value. Hence it was suggested to utilize the film size
maximum consumption value, Pareto Chart was 14 x 17 inches in X-ray by dividing it into 4 portions,
developed which is shown in the Figure 4 below. which may help in cost reduction. The contrast
used were of 2 types – Omnipaque & Omniscan
and consumption was dependent on investigations
ordered by the physicians. It was advised to use the
contrast judiciously, avoiding any wastage. It was
also advised that have tighter inventory control of the
above material and supplies (Radiographic film-14x
17inch, Contrast Omnipaque, Contrast Omniscan). As
cost reduction practices of the radiology department
is holistic approach, the radiologists, technicians, and
administration must work as a team for achieving the
goals.
Some of the strategies for cost reduction could be
Fig. 4: Pareto Chart for consumables in Radiology digitalization of services, use of IT in MRI studies
Dept. CDs could be provided, linking the RIS with mobile
application. The reports could be made assessable
The total consumption expenditure is 598598.282
online which would reduce paper records. is another
(approx. value). In the data analysis, the consumption
money-saving tactic. The purchase department must
of 28 consumables were studied (three months).
be informed of the consumption pattern on a weekly
Radiographic Film-14 x 17 inch & Contrast Omnipaque
or monthly basis, particularly for costly products like
consumed 73.3 % of the consumption value, hence
contrast (Omnipaque and Omniscan).
they were classified under A category products,
3 products viz Contrast Omniscan, Radiographic Ethical clearance : Due considerations of
Film-11x14inch, Radiographic Film-8 X10inch were confidentiality and privacy of information has been
categorized under B category which consumed undertaken in this study.
additional 21.05 % of the expenditure, the remaining
Source of funding : Self.
20 products were classified under C category, which
consumed only 5.68 % of the monetary consumption Conflict of Interest : Nil
value.
References
Conclusion 1. Rubin GD. Costing in radiology and health care:
The wastes or “muda” occurred during transportation rationale, relativity, rudiments, and realities.
Radiology. 2017 Feb;282(2):333-47. Available from:
which occurred during shifting of patients and
https://doi.org/10.1148/radiol.2016160749
material transportation, inventory, motion, too many
clicks for uploading images, waiting for procedures, 2. Kadom N, Itri JN, Trofimova A, Otero HJ & Horny
waiting for reports, re-do and unnecessary tests, excess M. Cost-effectiveness Analysis: An overview of
radiation doses, reporting errors, and insufficient Key Concepts, Recommendations, Controversies,
training to staff16. and Pitfalls. Academic Radiology, 26(4), 534-541;
2019. Available from: https://doi.org/10.1016/j.
In the MRI procedure, Value Stream Map was acra.2018.10.014
made, the takt time of 24 min, but the cycle time was
3. Roberge R. J. (2016). Face shields for infection control:
100 min and waiting of 120 minutes, which resulted in A review. Journal of occupational and environmental
the lead time of 220 minutes. Since waiting is waste, hygiene, 13(4), 235–242. https://doi.org/10.1080/1545
so it needs to be reduced as shown in the future state 9624.2015.1095302
value stream map.

4. Čiarnienė R, Vienažindienė M. LEAN 11. Lawal AK, Rotter T, Kinsman L, Sari N, Harrison
MANUFACTURING: THEORY AND PRACTICE. L, Jeffery C, Kutz M, Khan MF, Flynn R. Lean
Econ Manag [Internet]. 2012 Apr 24;17(2):726–32. management in health care: definition, concepts,
Available from: https://ecoman.ktu.lt/index.php/ methodology and effects reported (systematic review
Ekv/article/view/2205 protocol). Systematic reviews. 2014 Dec;3(1):1-6.
https://doi.org/10.1186/2046-4053-3-103
5. Nelson-Peterson DL, Leppa CJ. Creating an
environment for caring using lean principles of 12. Camgoz-Akdağ H, Beldek T, Konyalıoğlu AK. Process
the Virginia Mason production system. J Nurs improvement in a radiology department with value
Adm [Internet]. 2007 Jun 37(6):287–94. Available stream mapping and its linkage to industry 4.0. Prod
from: https://journals.lww.com/jonajournal/ Manuf Res—An Open Access Journal. 2018;6(1):416-
Fulltext/2007/06000/Creating_an_Environment_for_ 32.
Caring_Using_Lean.7.aspx
13. de Bucourt M, Busse R, Güttler F, Wintzer C,
6. Cohen RI. Lean Methodology in Health Care. Collettini F, Kloeters C, Hamm B, Teichgräber
Chest. 2018 Dec;154(6):1448-1454. doi: 10.1016/j. UK. Lean manufacturing and Toyota Production
chest.2018.06.005. Epub 2018 Jul 10. PMID: 29909284. System terminology applied to the procurement of
vascular stents in interventional radiology. Insights
7. Kruskal JB, Reedy A, Pascal L, Rosen MP, Boiselle
into imaging. 2011 Aug;2(4):415-23. https://doi.
PM. Quality initiatives: lean approach to improving
org/10.1007/s13244-011-0097-0
performance and efficiency in a radiology department.
Radiographics. 2012 Mar;32(2):573-87. 14. Karstoft J, Tarp L. Is Lean Management implementable
in a department of radiology? Insights into Imaging
8. Cohen R. Lean Methodology in Health Care. CHEST:
2011 23 [Internet]. 2011 Mar 22 [cited 2022 May
2018. 154(6):1448-1454. Available from: https://doi.
10];2(3):267–73. Available from: https://link.springer.
org/10.1016/j.chest.2018.06.005
com/articles/10.1007/s13244-010-0044-5
9. Marin-Garcia JA, Vidal-Carreras PI, Garcia-Sabater
15. Amaratunga T, Dobranowski J. Systematic Review
JJ. The role of value stream mapping in healthcare
of the Application of Lean and Six Sigma Quality
services: A scoping review. International journal
Improvement Methodologies in Radiology. J Am Coll
of environmental research and public health.
Radiol. 2016 Sep 1;13(9):1088-1095.e7.
2021 Jan;18(3):951. Available from: https://doi.
org/10.3390/ijerph18030951 16. Gupta S, Jain SK. A literature review
of lean manufacturing. http://dx.doi.
10. Moodley I, Moodley S. A comparative cost analysis
org/101080/175096532013825074 [Internet]. 2013
of picture archiving and communications systems
8(4):241–9. Available from: https://www.tandfonline.
(PACS) versus conventional radiology in the private
com/doi/abs/10.1080/17509653.2013.825074
sector. SA Journal of Radiology. 2015 Jan 1;19(1):1-
7. Available from: https://hdl.handle.net/10520/
EJC168602

Comparative evaluation of MIC of Vancomycin among methicillin resistant

Staphylococcus aureus (MRSA) isolates in tertiary care hospital
Swarupa Rani1, Tejashree.A2, Ranjitha Shankare Gowda3, Krishna Karthik M.V.S 4,

Eeshita Dhar5 , B. Satya Sai6
M.Sc Post graduate, Dept of Microbiology, JSSMC, JSSAHER, Mysore, 2Prof & HOD, Dept of Microbiology, JSSMC, JSSAHER, Mysore
1
3
Assistant Professor, Dept of Microbiology, JSSMC, JSSAHER, Mysore, 4Tutor, Dept of Microbiology, JSSMC, JSSAHER, Mysore
5
PhD Research Scholar, Dept of Microbiology, JSSMC, JSSAHER, Mysore, 6Tutor, Dept of Microbiology, JSSMC, JSSAHER, Mysore
How to cite this article: Swarupa Rani, Tejashree.A, Ranjitha Shankare Gowda, Krishna Karthik M.V.S , Eeshita Dhar,
B. Satya Sai et al Comparative evaluation of MIC of Vancomycin among methicillin resistant Staphylococcus aureus
(MRSA) isolates in tertiary care hospital. Volume 13 | Issue 4 | October-December 2022
Abstract
Vancomycin, a glycopeptide antibiotic with in-vitro activity against all staphylococci and clinical response to methicillin
resistant staphylococcus aureus (MRSA) infection, became the backbone of treatment due to MRSA’s universal
resistance to the antimicrobial agents belonging to beta-lactams and There are no other viable options. In patients with
staphylococcal infections, this study demonstrated a significant conflict of minimum inhibitory concentrations (MICs) of
vancomycin for MRSA strains between an automated system, Vitek 2, and the method. test E-strip. In the Microbiology
laboratory of JSS hospital which is a tertiary care center situated in Mysuru, 90 isolates were acquired from various
clinical samples to analyse Vancomycin MIC. Out of 90 isolates, 2.2% MRSA isolates showed highest vancomycin MIC
2μg/ml by Vitek-2 method, where no isolates showed MIC up-to 2μg/ml by E-strip method. But the higher vancomycin
MIC 1μg/ml was observed in 82.2% by vancomycin E-strip method compared to 37.7% by Vitek-2 method. Lowest MIC
0.5μg/ml showed by Vitek-2 method in 58.8% compared to 4.4% by E-strip method. The study concludes that all S. aureus
isolates were resistant to methicillin by both Vitek-2 system and cefoxitin disc diffusion method and also identified as
VSSA (vancomycin susceptible Staphylococcus aureus) by Vitek-2 and E-test method. Higher vancomycin MIC ≥1μg/ml
in 93.3% may be due to using of vancomycin improperly and infrequently in MRSA infection with lowest MIC value.
Therefore, this method can also be used as routine laboratory practice or as alternative method where Vitek 2 system or
other methods are not available.
Keywords: Staphylococcus aureus, MIC (minimum inhibitory concentration), MRSA (methicillin resistant Staphylococcus
aureus), VSSA (Vancomycin susceptible Staphylococcus aureus).
Introduction mentioned in 1960s) appeared in the previous decade

Staphylococcus aureus normally found as normal as a cause infection linked to healthcare accountable
flora in human beings. For more than a centrury, for mortal diseases as well as serious life-threatening
S. aureus has been identified as a major source of pneumonia, osteomyelitis, severe sepsis, necrotizing
human diseases. It has been associated with various fasciitis, endocarditis, and toxicoses such as toxic
infections which cover minor skin infections and shock syndrome. [1]
osteomyelitis to urinary tract infection and severe In 1960, MRSA emerged and spread throughout
bloodstream infection. MRSA strains, also known as the world after the implementation of methicillin
multidrug-resistant Staphylococcus aureus (earlier it is for the treatment of S. aureus diseases that produce
Badveti. Satya sai
Tutor, Dept of Microbiology, JSSMC, JSSAHER, Mysor
Email ID: [email protected]
penicillinase. S. aureus strains which are resistant to like pus, blood, endotracheal swabs, blood and
antibiotics, specially to methicillin, are uniformly other body fluids received in the laboratory. All the
adapted to hospitals and external territory, developed isolates were subjected to standard procedure for
as a universal pathogen of communal health concern. identification. MRSA was detected by modified Kirby-
[2]
Bauer disc diffusion method. Isolate suspension of 0.5
McFarland turbidity was applied on Muller-Hinton
MRSA strains are mainly mediated by mecA
agar followed by application of Cefoxitin disc (30μg)
gene, and resistant to other higher β-lactam group
incubated at 37°C for 18-24 hours. Zone of inhibition
of antibiotics including cephalosporins. To treat
around Cefoxitin disc <21mm were considered as
MRSA infection other antibiotics also used such as,
methicillin resistant.
Cotrimoxazole, aminoglycosides, erythromycin,
clindamycin etc. The glycopeptide antibiotic, For detection of vancomycin MIC by E-test method,
Vancomycin was once thought to be the best option isolates were inoculated on Mueller Hinton agar
for treatment. Apart from vancomycin, other efficient (MHA) media. Vancomycin E-strip (paper strip from
medications such as linezolid and teicoplanin are Hi-media) impregnated with vancomycin drug,
extensively utilised.[3] comprises of predefined antibiotic gradient was
placed on the MHA plate and incubated for overnight
Vancomycin has been used in clinical practice
at 35°C to determine the MIC, in μg/ml (Figure 1).
for more than 50 years and is remain the gold
standard for treating MRSA infections. [4] In MRSA
infection with lowest MIC value, indiscriminate and
sporadic administration of vancomycin has led in
the establishment of isolates with higher vancomycin
MIC values. Only VISA (Vancomycin intermediate
S. aureus) strains were known in the early 1920s,
however S. aureus strains with higher vancomycin
MIC are now appearing in India. [3] Vancomycin acts
especially by suppressing the cell-wall synthesis.
It functions against gram positive cell walls by Figure 1: Quality control of Staphylococcus aureus
preventing N-acetyle glucosamine from being
incorporated into the peptidoglycan matrix. [5] The
isolate was designated as VISA because of slightly
higher vancomycin MIC, in the range of 4-8μg/ml. [4]
Recently, vancomycin-resistant S. aureus
(VRSA) has been discovered. This larger MIC of
vancomycin in VRSA is associated with mutations
due to excessive peptidoglycan accumulation and
cell wall thickening. The vancomycin MIC test is the
gold standard for determining whether a strain is
susceptible, intermediate, or resistant to vancomycin.
Figure 2: vancomycin E-strip test result of MIC 1μg/
[3] According to CLSI criteria, S. aureus is sensitive ml.
to vancomycin if its MIC is ≤2µg/ml, resistant strains
have MIC ≥16µg/ml while VISA strain has MIC of The test organisms were suspended in sterile
4-8µg/ml. [6] physiological saline to 0.5 McFarland standards for
the Vitek2 method to obtain the vancomycin MIC
Materials and Method
values. The bacterial suspension was auto-filled into
The study was performed in the Department of an antimicrobial susceptibility test card, which was
Microbiology at a tertiary care hospital, Mysuru, in then inserted into the the Vitek 2 system incubator
a duration of 1 year. A complete 90 MRSA clinical reader and results are expressed as MIC values in
isolates were obtained from various clinical samples micrograms / ml.

310
Results patient. MRSA infections that do not respond to

A total of 90 MRSA strains were collected from various standard treatment may require a combination of
clinical specimens. Pus was the predominant sample medicines, such as vancomycin and one or more
81(90%) followed by 2(2.2%) were blood samples, additional antibiotics. When choosing an antibiotic to
5(5.5%) from Ear swabs and ET (2.2%) samples. treat a serious infection, the MIC is the key predictor.
(Chart 1) Many investigations in recent years have found a link
between vancomycin therapy failure and MIC values
100 of 1.5 or 2µg/ml which are within the range of clinical
90
80 a laboratory standards institutes (CLSI).[6]
70 r
60 In the current study maximum numbers of MRSA
50 No. of
40 Samples in were isolated from pus sample 80(90%) followed by
d
30
i
Percentage 2(2.2%) from blood, 5(5.5%) from Ear swabs, and ET
20
10
a (2.2%) samples. Similar findings has been reported by
0
PUS BLOOD EAR SWAB ET SWAB Dimple Raina et al., where 78% of isolates from the pus
sample.[7] The frequency of isolating maximum rate of
Chart 1: Bar diagram showing the various clinical
MRSA from pus also reported by Tiwari et al.(68%) in
isolates.
Varanasi, Mallick SK and Basak et al., in Maharashtra
All the MRSA isolates were sensitive (<4 μg/ml) by (51.8%), which were resistant to penicillin and
vancomycin E-strip method and Vitek-2 method also. sensitive to vancomycin and linezolid.[8], [9] Rao B. N
(Table 1) et al., in Andhra Pradesh (64%) and Dar JA et al. in
Aligarh reported highest (n151;35.5%) percentage of
Table 1: Comparison of vancomycin MIC values by MRSA found in pus specimens followed by sputum
E-test with Vitek-2 system.
and throat swabs.[10], [11]
Vancomycin No. of isolates No. of
The incidence of MRSA strains in clinical samples
MIC values by isolates
varies in each area of India. This variance could be
by E-strip
(μg/ml) Vitek-2 method related to the selective use of antibiotics to battle the
Method (n=)
(n=) infection, or it could be related to MRSA screening of
0.5 54 (60%) 4 (4.4%) patients and health care personnel.[3]
1 34 (37.7%) 74 (82.2%) Vancomycin MICs of MRSA strains were
1.5 0 12 (13.3%) determined using the Estrip test and the Vitek 2
2 2 (2.2%) 0 method (MIC measured in µg/ml) in this study. Using
≥ 4 to 16 0 0 both approaches, all MRSA strains were determined
to be susceptible to vancomycin (MIC ≤ 2 µg/ml).
Highest vancomycin MIC determined was 2μg/ml In our review, the MIC of vancomycin by the Estrip
by Vitek-2 method for 2.2% MRSA isolates, where no test was in the range of 0.5-2 μg/ml, similar to and
isolates showed MIC upto 2μg/ml by E-strip method. correlating with the studies of Anitha T. K et al. (2019),
Higher vancomycin MIC 1μg/ml was observed in Himani et al. the (2018) and Eeshita (2016) are very
82.2% by vancomycin E-strip method compared to good. In their studies, the MIC range of vancomycin
37.7% by Vitek-2 method. Vancomycin MIC 1.5μg/ was 0.52 g/ml. [2],[12],[3]
ml was observed in 13.3% by E-strip test method but
no isolate had an MIC at this level by Vitek2 method. The present study with lowest MIC 0.5μg/ml
Lowest MIC 0.5μg/ml showed by Vitek-2 method in showed by Vitek-2 method in 58.8% compared to
60% compared to 4.4% by E-strip method. 4.4% by E-strip method followed by 11(12.6%) of the
isolates showed the MIC range of 1.5µg/ml by E-strip
Discussion test, which is comparable to the study of Brandon J.
MRSA is becoming a global problem, producing a et al, where 35 isolates with an MIC of 0.5µg/ml via
wide spectrum of infection compared to methicillin- vitek 2 while only 1 isolate (1.3%) having an MIC at
sensitive S. aureus (MSSA). Antibiotic choice usually this level according to E-test. Further, 50 isolates with
begins with trimethoprim- sulfamethoxazole or, mics of 1.5µg/ml via E-test method, where no isolates
doxycycline or minocycline for the sulfa allergic with MIC at this level by vitek 2 system in the study

of Brandon j. et al., which is similar to the present Source of Funding: Nil

study.[13] In the study of Daiana C. S. Rodrigues et al,
Ethical Clearance: Institutional Ethics committee
vancomycin MIC with 0.5µg/ml showed by 42 MRSA
approval was obtained from JSS Medical college,
isolates out of 51 via vitek 2, where E-test detected
Mysore.
only 1 isolate with MIC at 0.5µg/ml. Moreover, in
their study, 18% MRSA with vancomycin MIC 1μg/ Conflict of Interest: No potential conflict of interest
ml by E-strip method and 27% by Vitek-2 method, relevant to this article reported
which is comparable to our study with higher
References
vancomycin MIC 1μg/ml observed in 82.2% isolates
by vancomycin E-strip method compared to 37.7% by 1. Eyob Yohaness Garoy, Yacob Berhane Gebreab,
Vitek-2 method.[14] Oliver Okoth Achila, Daniel Goitom Tekeste, Robel
Kesete, Robel Ghirmay, Ruta Kiflay, Thomas Tesfu.
In current study, highest vancomycin MIC was Methicillin-resistant Staphylococcus aureus (MRSA):
2μg/ml by Vitek-2 method for 2.2% where no isolates prevalence and antimicrobial sensitivity pattern among
showed MIC upto 2μg/ml by E-strip method which patients-A multicentre study in asmara, Eritrea. Can
can be compare to the study of behara et al., where J Infect Dis Med Microbiol. 2019 Feb 6;2019:8321834.
all the MRSA strains with MIC lower than 2μg/ml doi: 10.1155/2019/8321834.
by E-test method including those isolates having 2. Anitha T.K., Morubagal Raghavendra Rao, Ranjitha
vancomycin MIC ≥2μg/ml by Vitek 2 method.[15] Shankaregowda, Rashmi P. Mahale, Sowmya G.S. and
Vidyavathi B. Chitharagi, Evaluation of Vancomycin
To summarize the findings of present investigation,
Minimum Inhibitory Concentration in the clinical
which illustrate that there was substantial conflict isolates of Methicillin Resistant Staphylococcus aureus
amongst vancomycin MICs when correlating (MRSA), J Pure Appl Microbiol., 2019; 13(3): 1797-1801.
E-test results to Vitek 2 results, but all isolates were https://doi.org/10.22207/JPAM.13.3.56.
vancomycin sensitive by both the methods. According
3. Eeshita Dhar, Sakshita Agnihotri, B. G. Unni
to earlier studies, E-test frequently reports MICs
Comparison of Vancomycin MIC against methicillin
higher than 1µg/ml, even among isolates with MICs
resistant Staphylococcus aureus and methicilin sensitive
as low as 0.5µg/ml by Vitek2 system. It is very rare Staphylococcus aureus isolated at a tertiary care centre in
getting vancomycin MIC at ≥2µg/ml by Vitek while Jaipur, India. December 2016: Vol.-6, Issue- 1, P. 76-82.
no isolates having MIC at this level with E-strip test
method. 4. Maureen U. Okwu,1, Mitsan Olley,2 Augustine O.
Akpoka,1 and Osazee E. Izevbuwa. Methicillin-
Conclusion resistant Staphylococcus aureus (MRSA) and anti-MRSA
activities of extracts of some medicinal plants: A brief
In this study we conclude that in the determination
review. AIMS Microbiol. 2019 Apr 15;5(2):117-137. doi:
of vancomycin MIC by Vitek-2 method and E-test 10.3934/microbiol.2019.2.117.
method, all the MRSA isolates were confirmed as
VSSA by both methods. The performance of E-test 5. Enu Ju Choo, Henry F. Chambers. Treatment of
is cheaper, and easiest to determine the vancomycin Methicillin Resistant Staphylococcus aureus Bacteremia.
Infect Chemother. 2016 Dec;48(4):267-273. doi:
MIC when compare to other methods. This method
10.3947/ic.2016.48.4.267.
can also be used as routine laboratory practice or as
alternative method where Vitek 2 system or other 6. Wayne, PA: Clinical and Laboratory Standards
methods are not available. Higher vancomycin MIC Institute(CLSI). Performance Standards for
may be the result of inappropriate and infrequent Antimicrobial Susceptibility Testing. 30th ed. CLSI
use of vancomycin in MSSA infection or in MRSA Supplement M100. 2020.
infection with lowest vancomycin MIC values. 7. Raina D, Sakeena, Chandola I, Roy R. Detection of
Vancomycin is still remained the corner stone of vancomycin susceptibility among methicillin resistant
treating MRSA infection. MRSA isolates with higher Staphylococcus aureus in a tertiary care hospital. Panacea
MIC values (even
in the susceptible range) appeared J Med Sci. 2020;10(3):245-249.
more frequently, leading to vancomycin treatment 8. Tiwari HR, Sapkota D, Sen MR. High prevalence of
failure. The higher vancomycin MICs in isolates of multidrug-resistant MRSA in a tertiary care hospital of
MRSA have become a matter of concern, and further northern India. Infection and Drug Resistance. 2008:1
studies will help detect significant MRSA infections. 57–61.

312
9. Mallick SK and Basak S. MRSA- too many hurdles to 13. Brandon J. Bloomgren and Brad R. Laible. Etest versus
overcome: a study from Central India. Tropical Doctor. Vitek 2 vancomycin minimum inhibitory concentration
2010; 40: 108–110. testing methods for methicillin-resistant staphylococcus
aureus: an antimicrobial stewardship initiative to
10. Dar JA, Thoker MA, Khan JA, Ali A, Khan MA, Rizwan
evaluate the degree of discordance among methods
M, et al. Molecular epidemiology of clinical and carrier
at a rural tertiary hospital. Journal of Pharmacy Practice
strains of methicillin resistant Staphylococcus aureus
2013 26: 415.
(MRSA) in the hospital settings of north India. Ann
Clin Microbiol Antimicrob. 2006; 5:22. 14. Daiana C. S. Rodrigues, Ana Paula P. Costa, Paulo
Roberto V. Santos, Elizabeth A. Marques, Jose
11. Rao BN, Srinivas B. A prospective study of Methicillin
F. Nogueira Neto, Robson S. Leao. Comparative
resistant staphylococcus aureus (MRSA) in a teaching
evaluation of the phoenixr, vitekr 2, e-testr and
hospital of rural setup. Journal of Pharmaceutical and
microdilution test for vancomycin susceptibility testing
Scientific Innovation. 2012; 1(2): 37-40.
in staphylococcus aureus isolated from bloodstream
12. Himani, Vinay Kumar Srivastava. Prevalence of infection. BJHBS, Rio de Janeiro, 2021;20(1):11-18.
methicillin resistance & comparison of vancomycin
15. Behera B, Mathur P. Erroneous reporting of
minimum inhibitory concentration by e test & vitek 2
vancomycin susceptibility for staphylococcus spp. by
in staphylococcus aureus isolates. International Journal
Vitek software version 2.01. Jpn. J. Infect. Dis.2009; 62:
of Research & Review (www.ijrrjournal.com). 2018
298-9.
September. Vol.5; Issue: 9; 2454-2237.

Original article Indian Journal of Public Health Research & Development
Study of Perinatal Outcome in Oligohydraminos in third Trimester of

Pregnancy in Tertiary Care Hospital
1
Swati Gagare, 2Ruchita Vaijpai, 3Keerthana Meka
1,2,3
Assistant Professor, Junior Resident, Department of OBGY, DBVP Rural Medical College, Pravara Institute of
Medical sciences (DU) Loni
How to cite this article: Swati Gagare, Ruchita Vaijpai , Keerthana Meka et al Study of Perinatal Outcome in
Oligohydraminos in third Trimester of Pregnancy in Tertiary Care Hospital. Volume 13 | Issue 4 |
Abstract
Introduction: Oligohydraminos, often due to impaired placental function, has been associated with an increased risk of
caeserean delivery for fetal distress, low Apgar score, post maturity and high perinatal morbidity and mortality.
Material and methodology: The prospective Longitudinal study was carried out over the period of two years in the
Department of Obstetrics and Gynaecology of Rural Medical College, Loni. 170 pregnant women in 3 trimester of
pregnancy, presenting clinically as oligohydramnios with AFI less than 5cm and intact membranes; were included in the
study. All cases were evaluated on indoor basis.
Results: In the present study, Eight babies were admitted in NICU for further management, five babies gestational age
>37 weeks and associated with asymmetrical IUGR they were kept in NICU for birth asphyxia (apgar<7 at birth) and
birth weight was <2kg. all were delivered by caesarean section
Conclusion: All cases of Oligohydramnios rise suspicion about perinatal outcome. Unessessary Intervation in the form of
Induction of Labour can result into increased operated intervention.
Keywords: Oligohydramnios , maternal outcome , Neonatal care , Oligohydraminos
Introduction OPD basis as fetal parts can be felt more easily and
Oligohydraminos, often due to impaired placental prominently. As many cases are associated with
function, has been associated with an increased risk intrauterine growth restriction, the fundal height is
of caeserean delivery for fetal distress, low Apgar less than the corresponding weeks of amenorrhea.4
score, post maturity and high perinatal morbidity and Intrapatum assessment of amniotic fluid index has
mortality. 1, 2Thus, it is not entirely clear weather the been considered as the ideal admission test because,
adverse perinatal outcome merely reflect the sequels regardless of the causes of oligohydramnios, an
of other associated high risk conditions or if reduced amniotic fluid index of ≤ 5cm in early labour has been
amniotic fluid volume itself contributes to the found to be associated with poor perinatal outcome.
adverse outcome.3 Casey and coworkers 1 reported an chronic oligohydramnios is associated with poor
incidence of oligohydramnios as 2.3% in their study prognosis. The squeals of chronic oligohydramnios
of more than 6400 pregnancies, at Parkland Hospital. are, Fetal Demise, Pulmonary Hypoplasia, Fetal
Oligohydramnios can be diagnosed clinically on Demormities and Skeletal Deformities. Facial and
Dr Ruchita Vaijpai
Assistant Professor
Department of OBGY, DBVP Rural Medical College, Pravara Institute of Medical sciences (DU) Loni
314
skeletal deformities are due to the restriction of fetal Results

movement with oligohydramnios. Oligohydramnios Table 1: Significant Correlations with Apgar
adversely affect fetal lung development, resulting Score
in pulmonary hypoplasia that typically leads to
death from severe pulmonary insufficiency. The Compared To Rho Interpretation
proposed study was carried out at tertiary care centre, (P Value)
where many high risk cases are referred for expert Birth Wt 0.346 There is positive
management.5,6,7 Before the advent of obstetric USG, (<0.001) correlation with birth
reduced liquor volume was suspected on clinical weight & APGAR
grounds. With wide spread use of USG in obstetrics score
more and more cases of oligohydramnios are detected, Congenital -0.203 There is negative
before complications arise. Anomaly (0.008) correlation between
APGAR score and
Material and methods Rds -0.173 presence of RDS or
The prospective Longitudinal study was carried (0.02) congenital anomalies
out over the period of two years in the Department Table 2: Significant Correlations with
of Obstetrics and Gynaecology of Rural Medical Oligohydramnios
College, Loni. 170 pregnant women in 3 trimester of
pregnancy, presenting clinically as oligohydramnios Compared To Rho Interpretation
with AFI less than 5cm and intact membranes; were (P Value)
included in the study. All cases were evaluated on Post Date 0.356 Oligohydromnios
indoor basis. is positively
0.001
Depending upon the clinical presentation, necessary correlated with
Iugr 0.231 presence of post
investigations were performed. Investigations
were done to confirm the diagnosis, to find out the 0.002 date, IUGR,
cause of oligohydramnios, to know the severity of Pih 0.279 PIH & other
oligohydramnios and to assess the maternal and fetal complications.
0.002
wellbeing. Considering the increased maternal and
fetal risk, associated with continuation of pregnancy; Other 0.220
induction or augmentation of labour was done at Complications
0.004
appropriate time in maternal and fetal interest.
Table 3: Significant Correlations with Iugr
Decision regarding mode of delivery (vaginal/
abdominal) was individualized, depending on clinical Compared To Rho Interpretation
findings, associated high risk factors and severity of (P Value)
oligohydramnios. Cases which were kept for vaginal Gestational Age -0.333 Iugr Is Negatively
delivery were closely monitored by using continuous Correlated With
0.001
electronic fetal monitor, for evidence of fetal heart Gestational Age,
rate abnormalities. Usg Wt -0.418 Afi, Weight On Usg,
0.001 Apgar Score And
The epidemiological information will be recorded Positively Correlated
in a structured proforma. Information regarding Risk Afi -0.164
With Presence Of
factors will be noted in proforma. 0.03 Rds.
Information on maternal and perinatal outcome Apgar -0.411
will be collected from the individual case sheet of the 0.001
woman or from the registers maintained in the labour Rds 0.279
room of the Pravara Rural Hospital.
0.001
Data collected on important variables will be
analyzed by using appropriate statistical test.

Table 4: Other Significant Correlations by vaginaly delivery. Maternal high risk factors
associated with these cases were Anhydramnios
Compared To Rho Interpretation
(n=1), prematurity(n=1), intrauterine growth
(P Value) restriction (n=5),pregnancy induced hypertension (1)
Age : Parity 0.353 Positive correlation Considering the amniotic fluid index, it was 5cm in 1
case, 4cm in 1case, 2cm in five and anhydramnios in one
(p<0.001)
cases.5 cases delivered by caesarean section for IUGR
AFI: Vaginal 0.436 Higher AFI has with severe oligohydramnios one for anhydramnios
Delivery (p<0.001) better chance of and one for PIH with severe oligohydramnios, one
vaginal delivery delivered by vaginally. three babies was low birth
AFI: APGAR 0.227 Higher the AFI weight and five babies. premature with intrauterine
better the APGAR growth restriction, No Induction of labour was
(0.004)
score done. One baby was 1.2 kg with Apgar score of 7
at 5 minute with meconium aspiration. Baby was
LSCS: Live Birth 0.211 Positive correlation
admitted to NICU for further management Baby
(0.04) was given intravenous antibiotics and put on O2 by
Anomaly : 0.308 Positive correlation hood, after 3 days baby discharged with mother in
Anhydramnios healthy condition. In one baby anhydramnios was
(p<0.001)
observed and baby admitted to NICU for meconium
Vaginal Delivery: -0.207 Those undergoing aspiration syndrome with apgar 7 at 5 min baby
Apgar At 5 (P<0.007) vaginal delivery observed for 24 hours and shifted to mother side in
Mins are likely to have healthy condition. Two intrauterine death due to
lower APGAR at 5 anhydramnios and post date with 2cm AFI, baby was
mins as compared macerated with peeling of skin.
to LSCS
Conclusion
Discussion
All cases of Oligohydramnios rise suspicion about
Perinatal mortality is markedly increased in patients perinatal outcome. Unessessary Intervation in the
with oligohydramnios. The lack of amniotic fluid form of Induction of Labour can result into increased
allows compression of fetal abdomen, which limits the operated intervention.
movement of the diaphragm. In addition to chest wall
fixation, decreased liquor amnii leads to pulmonary Ethical clearance
hypoplasia . 7 For present study ethical clearance was obtained from
our IEC , Pravara Institute of Medical Sciences (DU)
Chamberlain and co-workers8 calculated the gross
Loni .
and corrected perinatal mortality rate in patients with
decreased qualitative amniotic fluid volume and Source of support: Nil
found it to be 188/1000 and 109/1000 respectively
Severe oligohydramnios, in which the largest vertical
pocket of amniotic fluid measured less than 1 cm, References
was associated with gross perinatal mortality rate of 1. Casey Brian M. Donald D McIntire : Pregnancy
133/1000 in a population of high risk referral cases in outcomes after antepartum diagnosis of
a study done by Bastide et al 8 oligohydramnios at or beyond 34 weeks gestation. Am
In the present study, Eight babies were admitted in J Obstet Gynecol, April 2000, 182(4): 909-912.
NICU for further management, five babies gestational 2. Brace RA Physiology of amniotic fluid regulation. Clin
age >37 weeks and associated with asymmetrical Obstet Gynecol, 1997; 40:280-289.
IUGR they were kept in NICU for birth asphyxia 3. Klipatric SJ, Safford KL, Pomeroy T et al: Maternal
(apgar<7 at birth) and birth weight was <2kg. all hydration increases amniotic fluid index. Obstet
were delivered by caesarean section. 9 Gynecol, 1991: 78,1098 to 1102.
Two cases for meconeum aspiration and one for
birth asphyxia. among eight cases only one delivered

316
4. Harding R Development of respiratory system. 7. Seeds AF: Current concepts of amniotic fluid dynamics.
Textbook of fetal physiology, Oxford 1994; 140-167. Clin Obstet Gynecologist 1997, 40(2):280-289.
5. Brace RA, Wlodek ME : Swallowing of lung fluid 8. Brace RA, Wolf EF: Normal Amniotic fluid volume
and amniotic fluid ovine fetus under normoxic and changes throughout pregnancy. Am J Obstet Gynecol,
hypoxic conditions. Am J Obstet Gynecologist 1994; 1989, 161.382-388.
171:1764-1770.
9. D.C. Dutta : Textbook of Obstetrics, 6 edition 2004:37.
6. Gilbert WM, Brace RA Amniotic fluid volume and
normal flow to and from amniotic cavity. Seminar
Perinatal 1993, 17:150.

Probiotics Efficacy and Safety as add-on Therapy to Metformin in

Type 2 Diabetes Mellitus
Valishetti Manoj Kumar1, Zoha Ahmed2, Syed Atiq Ur Rahman3

1
PG MD Pharmacology, Osmania Medical College, Hyderabad., 2MBBS, Deccan College of Medical Sciences, Hyderabad.,
3
Professor & Head, Department of Pharmacology, Government Medical College, Mahabubnagar.
How to cite this article: Valishetti Manoj Kumar, Zoha Ahmed et al Probiotics Efficacy and Safety as
add-on Therapy to Metformin in Type 2 Diabetes Mellitus. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Insulin secretion is decreased, and peripheral insulin sensitivity is diminished, resulting in type 2 diabetes
mellitus. Diet, oral antihyperglycemic medications, and insulin are all modalities for treatment.
Objective: The goal of this study was to compare the efficacy of probiotics as an add-on treatment to metformin in
patients with Type 2 Diabetes Mellitus.
Methods: The study participants were randomly allocated to one of two groups, Group A or Group B, using a computer-
generated randomization chart, with each group consisting of 75 patients. Group A - For 12 weeks, patients in this group
were administered Tab. Metformin 500 mg twice daily with meals. Group B - For 12 weeks, patients in this group were
administered Tab. Metformin 500 mg twice daily with meals and Cap. Probiotics 1 capsule twice daily with meals. At the
culmination of the second, fourth, eighth, and twelfth weeks, all patients were evaluated. Fasting and postprandial blood
glucose levels were measured at each visit. The HbA1c test was performed at the end of the 12th week.
Results: The male predominance was seen with males 57% and females 43% in the group A and the male : female ratio
was 1.34:1. In Group B males were 55% and females were 45%. The male: female ratio was 1.20 : 1. The mean HbA1C
slightly reduced since the start till the end of the study. A total of 37% of the patients experienced minor self-limiting side
effects in group A as compared to 6.66% of Group – B.
Conclusion: In treatment for type 2 diabetes mellitus, probiotics as an add-on therapy with metformin was observed
to lower fasting blood glucose, postprandial blood glucose, and HbA1c levels when compared to metformin alone. In
terms of effectiveness, probiotics have shown no substantial significant outcomes in combination therapy. However, the
probiotics study group had fewer reported gastrointestinal adverse effects associated with metformin treatment.
Keywords: Hyperglycaemia, Metformin, Probiotics, T2DM
Introduction of which are micro and macrovascular complications,

Diabetes mellitus (DM) is a chronic metabolic which increase the risk of cardiovascular disease by
condition marked by persistent hyperglycaemia. It 2- to 4-fold.2
could be due to a lack of insulin secretion, resistance Diabetes is typically categorised into three
to insulin’s peripheral actions, or both.1 Chronic categories based on aetiology and clinical
hyperglycaemia, when combined with other presentation: type 1(T1DM), type 2(T2DM), and
metabolic irregularities, can impair numerous organ gestational diabetes (GDM). Other, less prevalent
systems, resulting in chronic, progressive, and life- kinds of diabetes include monogenic and secondary
threatening health consequences, the most common diabetes.
Dr. Syed Atiq Ur Rahman
Professor & Head, Department of Pharmacology, Government Medical College, Mahabubnagar.
318
T2DM is the most common type of diabetes, Inclusion Criteria:

accounting for about 90% of all cases. Insulin • All patients diagnosed with T2DM
resistance is defined as a decreased insulin response
in T2DM patients. Because insulin is ineffective in this Exclusion Criteria
situation, more insulin must be produced to maintain
• Pregnant women
glucose homeostasis. Insulin production, on the other
hand, decreases over time, leading to T2DM. • Type 1 Diabetes mellitus
T2DM is most usually prevalent in those over the • Other anti-diabetic drugs
age of 45.3 Despite this, it is becoming more common • Unwilling to give informed consent
in children, adolescents, and younger adults as a
A comprehensive medical and drug history was
consequence of rising obesity and physical inactivity.
obtained, followed by a thorough clinical examination
Regardless of the fact that many drugs have been and laboratory tests that included fasting and
developed to maintain glycaemic control and regulate postprandial blood glucose, HbA1C, and basic blood
blood glucose levels, whether through increased tests.
insulin production and utilisation, suppressed glucose
The study participants were randomly allocated
production and absorption, blocking urine glucose re-
to one of two groups, Group A or Group B, using a
absorption and increasing glucose excretion in urine,
computer-generated randomization chart, with each
or a combination of these, these drugs may cause a
group consisting of 75 patients.
variety of side effects. Sulphonylureas, for example,
have a risk of causing kidney failure.4 Group A (Control group) - For 12 weeks, patients
in this group were administered Tab. Metformin 500
Metformin is an oral biguanide that reduces
mg twice daily with meals.
gastrointestinal glucose absorption and hepatic
glucose production while enhancing peripheral Group B (Study group) - For 12 weeks, patients in
insulin sensitivity. It also has a significant impact on this group were administered Tab. Metformin 500 mg
lipid profiles in the blood.5 twice daily with meals and Cap. Probiotics 1 capsule
twice daily with meals.
Probiotics modulation of the gut microbiota may
be useful in the prevention and control of diabetes, At the culmination of the second, fourth, eighth, and
according to clinical data.6 Probiotics are living twelfth weeks, all patients were evaluated. Fasting
microorganisms that provide a health benefit to and postprandial blood glucose levels were measured
the host when given in adequate amounts. These at each visit. The HbA1c test was performed at the
microorganisms are physiologically present in a end of the 12th week. Throughout the trial, adverse
healthy human body, and they may also be received events were also monitored.
in the form of over-the-counter dietary supplements. The decrease in fasting blood glucose, postprandial
Probiotics, particularly lactobacillus species, have blood glucose, and HbA1c at the conclusion of 12
been reported to be effective in the treatment of type weeks was used to determine effectiveness.
2 diabetes in recent years.7,8
The safety assessment was based on spontaneously
Materials and Methods reported adverse events and changes in laboratory
Type of study: Randomized Prospective observational results following the study.
study. Statistical Analysis: The data was statistically
Study setting: Department of Pharmacology, evaluated using SPSS 22 software. The data was
Osmania Medical College, Koti, Hyderabad. analysed using the mean standard deviation method.
The student independent t test was used to compare
Study Duration: May 2019 to January 2020
quantitative data between the two groups, while the
Sample size: 150 Patients diagnosed with T2DM Chi square test was utilised to compare qualitative
data.
Study drugs: Oral drugs were administered
• Tab. Metformin 500 mg
• Cap. Probiotics

Observation and Results Group – A : The Mean PPB reduced from baseline
A total of 150 patients were allocated in two groups 227.29 + 8.39 to 179.71 + 6.49 at the end of week 12.
with 75 patients each. Group – B : The Mean PPB reduced from baseline
The male predominance was seen with males 57% 224.49 + 9.21 to 175.01 + 10.15 at the end of week 12.
and females 43% in the group A and the male : female At the end of the 12-week study, there was no
ratio was 1.34:1. In Group B males were 55% and statistically significant difference in Post prandial
females were 45%. The male: female ratio was 1.20 : 1. blood glucose decrease between the group A and
In group A the majority of the patients belonged to group B.
the age group of 51 to 60 yrs with 54.66% followed by Table 3: Distribution based on Haematological
40 to 50 yrs in 44% of the cases and the least belonged parameters
to the age group of >60 yrs in 1.33% of the cases. The
End of 12th
mean age was 51.06 + 5.42 yrs. Baseline
Parameter Group week
In group B the majority of the patients belonged to Mean + SD Mean + SD
the age group of 51 to 60 yrs with 49.33% followed by Group - A 11.55 + 1.34 11.67 + 1.33
Haemo-
40 to 50 yrs in 48% of the cases and the least belonged
globin Group - B 11.65 + 1.55 11.46 + 1.35
to the age group of >60 yrs in 2.66% of the cases. The
mean age was 50.90 + 6.24 yrs. 8260.59 + 8338.59 +
Group - A
Total 1931.84 1812.70
Table 1: Distribution based on FBS Count 9013.79 + 8896.95 +
Group - B
Fasting Control Study 2946.75 2892.95
p-
blood Group - A 21.63 + 6.09 21.65 + 5.75
Mean + SD Mean + SD value Urea
glucose
Group - B 20.40 + 5.35 19.77 + 5.19
Baseline 133.89 + 3.49 133.41 + 4.39 0.976
S. Creati- Group - A 0.62 + 0.21 0.62 + 0.21
Week 2 124.91 + 3.19 122.91 + 4.19 0.898 nine Group - B 0.69 + 0.16 0.65 + 0.16
Week 4 112.31 + 5.12 113.11 + 5.29 0.957
165.50 + 162.65 +
Week 8 103.91 + 5.39 103.61 + 6.49 0.983 Total Group - A
21.91 20.74
Week 12 94.81 + 5.59 93.31 + 5.31 0.912 Choleste-
161.52 + 159.29 +
rol Group - B
Group – A : The Mean FBS reduced from baseline 22.03 22.09
133.89 + 3.49 to 94.81 + 5.59 at the end of week 12. Group - A 45.85 + 4.86 44.83 + 4.40
HDL
Group – B : The Mean FBS reduced from baseline Group - B 44.95 + 3.75 44.48 + 3.95
133.41 + 4.39 to 93.31 + 5.31 at the end of week 12. 99.81 + 98.71 +
Group - A
24.65 24.67
At the end of the 12-week study, there was no LDL
112.13 + 111.85 +
statistically significant difference in fasting blood Group - B
15.55 15.51
glucose decrease between the group A and group B.
161.89 + 160.49 +
Table 2: Distribution based on PPB Group - A
25.55 24.59
TGL
Post Control Study 174.64 + 173.45 +
Group - B
prandial 12.33 12.75
p-value
blood Mean + SD Mean + SD Total Bi- Group - A 0.51 + 0.19 0.46 + 0.20
glucose lirubin Group - B 0.40 + 0.16 0.34 + 0 .15
Baseline 227.29 + 8.39 224.49 + 9.21 0.895
Group - A 22.81 + 5.65 22.26 + 5.15
Week 2 216.39 + 8.69 210.19 + 7.81 0.764 SGOT
Week 4 200.49 + 8.09 198.39 + 7.29 0.916 Group - B 22.10 + 4.65 21.90 + 4.15
Week 8 188.21 + 5.91 187.51 + 7.81 0.971 Group - A 22.85 + 5.95 22.88 + 5.35
SGPT
175.01 + Group - B 24.95 + 4.79 24.64 + 4.15
Week 12 179.71 + 6.49 0.802
10.15

320
End of 12th Around 37% of the patients experienced minor self-

Baseline limiting side effects in group A as compared to 6.66%
Parameter Group week
of Group – B.
Mean + SD Mean + SD
136.25 + 136.08 + Discussion
Group - A
4.25 3.95 Probiotics have been shown to be beneficial in
Na
139.55 + 138.26 + disorders such as infective diarrhoea, chronic
Group - B
4.29 4.35 inflammatory bowel disease, lactose intolerance, and
Group - A 3.99 + 0.35 3.95 + 0.35 allergies, and their potential in diabetes has been
K studied. It has been demonstrated that there is a
Group - B 4.25 + 0.45 4.15 + 0.45
correlation between pathogenic microorganisms and
In both groups A and B, there were no substantial persistent low-grade inflammation. The processes
variations between baseline and end-of-study values. through which inflammation causes insulin resistance
HbA1C: are also well documented. Clinical research have
demonstrated that using probiotics to restore normal
The mean HbA1C slightly reduced since the gut flora has resulted in improvements in glycaemic
inception from 6.77 till the end of the study, 6.41in indices.
Group A
The most commonly administered probiotics in
The mean HbA1C slightly reduced since the these studies were Lactobacillus and Bifidobacterium
inception from 6.71 till the end of the study, 6.39 in species.9,10 Because each bacterium has a unique
Group B. method of action, using numerous species is preferred
Table 4: Distribution based on Adverse effects until trials identify a single strain. When probiotics
were utilised for a modest to considerable length of
Adverse effects Group A Group B time, the effectiveness increased (around 12 weeks).
Abdominal However, in several experiments, probiotics had no
5(6.66%) 3(4%)
discomfort effect on glycemic indices, yielding contradictory
Flatulence 3(4%) 2(2.66%) results. This might be due to subtherapeutic dosages
Diarrhoea 9(12%) 0(0%) or a short research duration. The mean FBS, PPB,
Nausea 5(6.66%) 0(0%) HbA1c levels were considerably lower in both
Indigestion 3(4%) 0(0%) the groups. However, there was no statistically
Metallic taste 3(4%) 0(0%) significant difference in HbA1c decrease between the
Total 28(37.33%) 5(6.66%) two groups.
Study Probiotics used Participant age Duration Outcome
Mazloom et L. acidophilus, 25 – 65yrs 6 weeks Non-significant declining trend in the
al11 L. bulgaricus, level of TG. MDA. and IL-6 and insulin
L. bifidum, resistance
L. casei
Ejtahed et al12 Yogurt containing L. 30 – 60 yrs 6 weeks Improved fasting blood glucose and
acidophilus LaS, B. lactis antioxidant status
Bb12
Moroti et al13 L. acidophilus, 50 – 60 yrs 30 days Significant increase in HDL and a
B. bifidum, significant decrease of glycaemia
fructooligosaccharides
Andreasen L. acidophilu 55 – 62 yrs 4 weeks Preserved insulin sensitivity, but did not
et al14 affect the systemic inflammatory response
Asemi et al15 L. sporogenes and inulin as 35-70 yrs 6 weeks Significant effects on serum insulin, hs-CRP,
prebiotic 35-70 uric acid, and plasma total GSH levels
Tonucci et L. acidophilus La-S, B. 35 – 60 yrs 6 weeks Improved glycaemic control, decrease
al16 animalis subsp lactis BB-12 in inflammatory cytokines (TNF-a and
resistin) and increase in acetic acid
Firouzi et al17 Lactobacillus and 30-70 yrs 12 weeks Modest improvement in HbAlc and fasting
Bifklobacterium insulin
The haematological parameters were unaltered by 5. Isolauri E: Probiotics: from anecdotes to clinical
probiotics. In contrast to metformin monotherapy, the demonstration. J Allergy Clin Immunol 2001, 108.
study group was depicted to have less side effects. 6. Sanders ME: Probiotics: considerations for human
The study group had less reported gastrointestinal health. Nutr Rev 2003, 61:91-99.
adverse effects related with metformin medication,
7. Burcelin R, Serino M, Chabo C, Blasco- Baque V, Amar
which was statistically significant. In both groups,
J: Gut microbiota and diabetes: from pathogenesis to
there were no severe side effects.
therapeutic perspective. Acta Diabetol 2011, 48:257-
Despite limited research, the use of probiotics 273.
as add-on therapy is recommended, owing to the 8. Gomes et al.Gut Microbiota, Probiotics and Diabetes.
significant preclinical and clinical evidence in treating Nutrition Journal 2014 13:60 pg no 2.
diabetes, as well as their favourable tolerability
9. Voreades, Diet and the development of the human
profile. Further studies should determine the best
intestinal microbiome. Front Microbiol. 2014;5:494
strain, therapeutic dosage, and study period for the
optimum outcome. 10. Salvetti S, Rapid determination of vitamin B2
secretion by bacteria growing on solid media. J Appl
Conclusion Microbiol. 2003;95(6):1255-60.
In treatment for type 2 diabetes mellitus, probiotics as 11. Mazloom Z, Effect of probiotics on lipid profile,
an add-on therapy with metformin was observed to glycemic control, insulin action, oxidative stress, and
lower HbA1c, fasting blood glucose and postprandial inflammatory markers in patients with type 2 diabetes:
blood glucose levels when compared to metformin a clinical trial. Iran J Med Sci. 2013;38(1):38-43.
alone. In terms of effectiveness, probiotics have shown 12. Ejtahed HS, Probiotic yogurt improves antioxidant
no substantial significant outcomes in combination status in type 2 diabetic patients. Nutrition.
therapy. However, the probiotics study group had 2012;28(5):539-43.
fewer reported gastrointestinal adverse effects
13. Moroti C, Effect of the consumption of a new symbiotic
associated with metformin treatment.
shake on glycemia and cholesterol levels in elderly
Ethical Clearance: The ethical clearance was people with type 2 diabetes mellitus. Lipids Health
obtained from the Osmania medical college and Dis. 2012;11:29.
hospital institutional ethics committee prior to the 14. Andreasen AS, Effects of lactobacillus acidophilus
commencement of the study NCFM on insulin sensitivity and the systemic
inflammatory response in human subjects. Br J Nutr.
2010;104(12):183-8.
15. Asemi Z, Effects of synbiotic food consumption on
References metabolic status of diabetic patients: A double-blind
randomized cross-over controlled clinical trial. Clin
1. Alvin C.Powers. Diabetes Mellitus ,Harrisons
Nutr. 2014;33(2):198-203.
principles of internal medicine. 18thedition , pg 2968.
16. Tonucci LB, Clinical application of probiotics in type
2. Shaw JE, Sicree RA, Zimmet PZ. Global estimates of
2 diabetes mellitus: A randomized, double-blind,
the prevalence of Diabetes Res Clin Prac . diabetes for
placebo-controlled study. Clin Nutr. 2017;36(1):85-92.
2010 and 2030. 2010;87:4-14.
17. Firouzi S, Effect of multi-strain probiotics (multi-strain
3. Stephen J. McPhee, Maxine A. Papadakis, Ralph
microbial cell preparation) on glycemic control and
Gonzales, Roni Zeiger. Diabetes Mellitus and
other diabetes-related outcomes in people with type
Hypoglycaemia Current Medical Diagnosis &
2 diabetes: A randomized controlled trial. Eur J Nutr.
Treatment 2010 . 49 th edition pg 1192
2017;56(4):1535-50.
4. Aline Corado Gomes, Allain Amador Bueno, Rávila
Graziany Machado de Souza1 et all. Nutrition Journal
2014, 13:60 doi:10.1186/1475-2891- 13-6.

A Cross- Sectional Study of Prevalence of Substance Use and Its Associated

Factors Among Late Adolescents in Gadag city.
Vasundara Gayakwad1, Rekha Sonavane2, Bhagyalaxmi Sidenur3, Roopadevi V4

1
Assistant Professor, Department of Community Medicine, GadagInstitute of Medical Sciences, Gadag.
2
Professor & HOD, Department of Community Medicine, , Gadag Institute of Medical Sciences, Gadag.
3
Assistant Professor, Department of Community Medicine, Basaveshwara Medical College, Chitradurga.
4
Assistant Professor, Department of Community Medicine, Gadag Institute of Medical Sciences, Gadag.
How to cite this article: Vasundara Gayakwad1, Rekha Sonavane2, Bhagyalaxmi Sidenur3, Roopadevi V4
et al A Cross- Sectional Study of Prevalence of Substance Use and Its Associated Factors Among Late
Adolescents in Gadag city. Volume 13 | Issue 4 | October-December 2022
Abstract
Background: Substance use is a growing public health problem in India especially among adolescents. It has serious
effects on overall wellbeing. The onset of substance abuse most often stems in adolescents and hence it is important to
know the prevalence of substance use to take preventive steps to protect their health.
Objective: To determine theprevalence of substance use and its associated factors among college going late adolescents
of Gadag city. 2. To assess the attitude of adolescents regarding substance use.
Materials and Methods: This cross-sectional study was conducted among college going late adolescents ofGadag city
from Jan 1st 2018 to March 31st 2018 in 250 subjects from randomly selected 3 colleges of Gadag district. Data wascollected
by using predesigned semi-structured questionnaire.
Results: Overall prevalence of Substance use was 35.2%. Most commonly used substance was alcohol (27.8%). Mean
age of initiation of substance use was 16.6 + 0.7 years. Gender, parents education and addicted member in the family to
substances were statistically significant associated factors. Among substance users, 60% have positive attitude regarding
substance use.
Conclusion- Prevalence of substance use was high and hence health education and other interventions to prevent
substance use has to be undertaken.
Keywords: Adolescent, substance use, tobacco, alcohol
Introduction behaviour among adolescents is substance use like

Adolescence is a transition from childhood to smoking cigarettes, alcohol consumption and illicit
adulthood. This is a period of intensive biological drugs use5.
and sexual growth, emotional and psychosocial In developing countries like India, by the time
maturation. In this period they want to identify they reach adolescence, the young people are already
themselves, to experiment, to try out certain exposed to various stresses such as competition in
behaviours, because of curiosity, desire to imitate the fields of education and employment likewise,
someone or self-assertion1–4. In this period adolescents alongside changing roles in the family and society,
are prone to risky behaviour. The most common risky new-found responsibilities, and a changing identity,
physically, mentally, and emotionally.6
Dr. Roopadevi V
Assistant professor, Dept of Community Medicine, Gadag Institute of Medical Sciences, Gadag, Karnataka, India
Mob: 08951127808
According to a prevalence study, 13.1% of the Results

people involved in substance abuse in India are below In our study overall prevalence of substance use was
20 years of age7. A clinic-based survey revealed that 35.2%.Most commonly used substance was alcohol
63.6% of the substance users seeking treatment were (20.4%) followed by cigarettes (4.4%) and tobacco
introduced to drugs at a young age when they were Statistical data analysis was done by using Microsoft Excel, Open Epi software. Percentages,
(2.4%) and least was nicotine use (1.2%).6.8% of the
15 years or younger 8. Pearson’s Chi-square test or Fisher’s exact test were used wherever applicable. For all the statistical
adolescents were multiple substance users (Figure
tests, “P” < 0.05 was considered statistically significant.
Early initiation of drug use is often associated with 1). Among the prevalence of individual types of
poor prognosis and lifelong pattern of disturbed substance
Results used, alcohol (27.8%) was found to be the
behaviour. Drugs can have long-lasting effects most Inconsumed one followed by cigarettes (11.6%)
our study overall prevalence of substance use was 35.2%.Most commonly used substance
on the developing brain and may interfere with and tobacco (2.8%) and nicotine use (1.2%). Majority
was alcohol (20.4%) followed by cigarettes (4.4%) and tobacco (2.4%) and least was nicotine use
positive family and peer relationships and school of(1.2%).6.8%
the alcohol users consumed beer followed by
of the adolescents were multiple substance users (Figure 1). Among the prevalence of
performance.9, 10. So it is important to know the brandy. Among cigarettes filtered ones, tobacco in the
individual types of substance used, alcohol (27.8%) was found to be the most consumed one followed
substance use and attitude towards it among late form

by cigarettes (11.6%) and tobacco (2.8%) and nicotinein
of chewing and nicotine use the
(1.2%).form
Majority of
of thegum
alcohol was
users
adolescents to bring some intervention in action. In used

consumedmost commonly.
beer followed by brandy. Among cigarettes filtered ones, tobacco in the form of chewing
our study we are seeking information on attitude and nicotine in the form of gum was used most commonly.
Majority of the times, substance use was done
towards substance use and their practices as well as occasionally
Majority of the like
times, mainly
substance use wasduring party
done occasionally like celebrations
mainly during party
factors associated for the same at Gadag city. among
celebrations39.8%
among 39.8% ofof the
thestudystudy subjects
subjects followed followed
by once a week byin Figure
(22.7%) as shown once
Objectives a 2.week (22.7%)
Mean age of asuseshown
starting substance was 16.6 + 0.7inyears.Figure 2. Mean age of
starting substance
Fig 1: Distribution usebywas
of Study Subjects 16.6
Proportion + 0.7useyears.
of Substance
1. To determine the prevalence of substance
use and its associated factors among college 64.8%
going late adolescents.

2. To know the attitudeof adolescents regarding
substance use. 20.4%
4.4% 2.4% 6.8%

1.2%
Methodology ALCOHOL CIGARETTE TOBACCO NICOTINE MULTIPLE NON USERS
This is a cross sectional study conducted from

January to April 2018 among students aged 17-19 Fig 1: Distribution of Study Subjects by Proportion
years of randomly selected 3 colleges of medical, of Substance use
technical and ayurvedic college at Gadag city.Based Fig 2: Distribution of Study Subjects by Frequency of Substance use
on the study done in an urban area in Gujarat12, 35(39.8%)

required sample size was calculated in Open Epi
20(22.7%)
version 2 software taking, absolute allowable error 13(14.8%) 13(14.8%)
(d) = 5% , p=18.86% which was 237 and a total of 7(7.9%)
250 subjects data was collected. . The study was

conducted after getting ethical clearance from the ONCE A DAY MORE THAN
ONCE A DAY
ONCE A WEEK SEVERAL TIMES
A WEEK
OCCASSIONALY
college.All the students aged 17-19 years who gave

consent for study were included and those who were
not present during 3 consecutive visits of the survey Fig 2: InDistribution of Study Subjects by Frequency
our study we have collected information among medical, technical and ayurvedic college
ofstudents.
Substance use
Substance use was found to be more among those study subjects who were 19 years old
were excluded from the study.After taking informed (35.4%), male gender (49.1%) and studying in medical college (50.5%). Majority of the students
consent, data was collected using Predesigned, In our
belonged study
to Hindu religionwe have
(35.4%). collected
According information
to socio-economic status, substance useamong
was high
pre-tested, semi-structured questionnaire through medical, technical
among study subjects and1(39%)
belonging toclass ayurvedic
followed by class college
3 (37%).Most of students.
the substance
interview technique.The questionnaire included Substance usesubjects
users among the study was found
belonged to nuclearto be(37.4%)
family more among
and family those
size with less than 4
questions on socio demographic information, attitude study
members subjects
(38%) followed by who werein the
4 to 7 members 19family
years(35.5%).old
It was (35.4%), male
found that in majority of
and practices about substance use. gender (49.1%) and studying in medical college
substance users i.e. 68% had addicted person to substances in the family.Majority of the substance
Statistical data analysis was done by using Microsoft (50.5%).

users parents Majority
education that isof theeducation
Father’s students (66.7%) and belonged to (62.5%)was
mother’s education Hindu
Excel, Open Epi software. Percentages, Pearson’s Chi- religion (35.4%). According
primary school education.Statistically significant association wastofoundsocio-economic
between substance use and
square test or Fisher’s exact test were used wherever status, substance use was high among study subjects
gender, student’s educational course,parent’s educational status, and addicted person in the family.
applicable. For all the statistical tests, “P” < 0.05 was belonging toclass 1(39%) followed by class 3 (37%).
95.2% students received information on substance use mainly from media followed by friends and
considered statistically significant. Most

family.
of the substance users among the study subjects
Among substance users, 28.3% students had sleep disturbance, 25% had decrease in
IJPHRD / Volume 13 Issue 4 / October-December

efficiency of work and 27.3% 2022
had disputes under the influence of substance use. 86% of the students
complained of having either physiological or psychological side effects. In physiological side effects
drymouth, miosis, constipation, diarrhea and mydriasis were reported respectively and psychological
324
belonged to nuclear family (37.4%) and family size Discussion

with less than 4 members (38%) followed by 4 to 7 In our study overall prevalence of all types of
members in the family (35.5%). It was found that in substance use was high (35.2%) and similar results
majority of substance users i.e. 68% had addicted were reported in the study conducted by Prashant
person to substances in the family.Majority of the et al.11and Tanusri et al.17 but multiple substance use
substance users parents education that is Father’s reported was higher in Prashant et al11,studycompared
education (66.7%) and mother’s education (62.5%) to our study. In other studies conducted at Gujarat
was primary school education.Statistically significant 12
and Uttar Pradesh 13 showed less prevalence
association was found between substance use compared to our studyand more prevalencethan our
and gender, student’s educational course,parent’s study was reported at Bangalore14 and Delhi15.
educational status, and addicted person in the family.
95.2% students received information on substance use We found the most commonly used substances
mainly from media followed by friends and family. were alcohol and tobacco in their various forms and in
other studies frequency of tobacco consumption was
Among substance users, 28.3% students had more compared to alcohol 11-15. In studies conducted by
sleep disturbance, 25% had decrease in efficiency of Tanusri et al,17and Lisa et al,16 Guthka was consumed
work and 27.3% had disputes under the influence by majority of the adolescents. Multiple substance use
of substance use. 86% of the students complained was reported high in other studies compared to our
of having either physiological or psychological study 5, 11. This might be due to their easy availability.
side effects. In physiological side effects drymouth,
miosis, constipation, diarrhea and mydriasis were Mean age of initiation of substance use was similar
reported respectively and psychological side effects to our study in a study done by Lisa et al16 but in
like aggressiveness, euphoria, anxiety followed by other studies it was less 11,13-15,17. In a study by Jain et
hallucination and memory loss were reported after al18 found curiosity as a reason for starting substance
starting
reported after substance use.According
starting substance use.According to attitude of the to attitude
subjects for substance of the
use, 60 % of use in 68% of the cases and in our study also we found
subjects for substance
the substance usersdid use,use60
not feel guilty for substance %3). of the substance
(Figure the same result15. But in other studies peer pressure
usersdid not feel guilty for substance use (Figure 3). was found to be the reason for initiating substance
Fig 3: Distribution of Study Subjects According to Attitude for Substance Use
use 11,14,15. This difference may be due to the different
FEEL GUILTY ABOUT THE USE OF SUBSTANCE
study setting and different social environment.
YES NO
our study we have considered late adolescents

40% age group as highest prevalence is noted among
60%
this population. We found a decreasing trend in
the initiation of substance with the increasing age
similar to the study conducted by Stockings et al8.
Fig 3: present
In the Distribution
study,majority ofofthe Study Subjects
students initiated substance According to for
use for the first time
The initiation of substance use at a young age is a
Attitude
curiosity(50%)for Substance
followed Usedispute (19.3%) and joy seeking (18.2%) as shown
by family or relationship
matter of concern as earlier the age at which student
in Table 1.
In the present study,majority of the students initiated experiment with the first substance, the higher are the
substance useof Study
Table 1: Distribution forSubjects
the byfirst
reasons time foruse curiosity(50%)
for substance rates of addiction and the greater the risk of suffering
followed from health problems in adulthood19.
REASON FORby THE family or relationship dispute (19.3%)
USE OF SUBSTANCE
and joy seeking
FOR THE 1ST TIME
(18.2%) as shown N(=88)in Table 1.%
In our study we found statistically significant
Table 1: Distribution of Study Subjects by reasons
Curiosity 44 50 association with substance use and gender and similar
for substance
Memory Improvement use 4 4.5 results were reported by Tanusri et al17. In other
studies education of the study subjects were found
Reason
Joy Seeking for the Use of 16 18.2
N(=88) % to be significantly associated with substance use11, 15,
Substance forthe
Family/Relationship Disputes 1 Time
St
17 19.3
17
. Studies conducted among different professional
Curiosity
Others 7 44 8 50 education are rare and in our study it was found to be
Memory Improvement 4 4.5 statistically significant.
Joy Seeking
Discussion: 16 18.2
Parent’s educational status was an influencing
Family/Relationship factor for substance use in other study byPrashant et
17use was high (35.2%)
In our study overall prevalence of all types of substance 19.3and similar
Disputes 11 17
results were reported in the study conducted by Prashant et al. and Tanusri et al. but multiple al11, and similar result was found in our study and it
Others
substance use reported was higher in Prashant et al 11 7 to our study. In 8other studies
,studycompared was noticed that as the parental educational status
increased the frequency of substance use decreased References

among adolescents. In our study we have found that 1. Rakiý D, Petroviý đ. Health of Children and
students who were using substances were reported Adolescents - A Handbook for health monitoring and
to have more frequency of an addicted person to improving the health of children and adolescents.
substances in the family compared to nonusers of Novi Sad: Rakiý D; 2006.
substances and it was found statistically significant,
2. Backoviý D, Maksimoviý M, Stevanoviý D.
whereasin other studies parental and peers and Psychosocial risk factors and substance abuse in
siblings substance use were reported to be associating adolescents. Vojnosanit Pregl 2007; 64(5): 331–6.
factors 11,17.
3. Bratberg GH, Nilsen TI, Holmen TL, Vatten LJ.
Many community based studies on prevalence Perceived pubertal timing, pubertal status and the
of substance use have been conducted in India prevalence of alcohol drinking and cigarette smoking
but studies among late adolescents of professional in early and late adolescence: a population based study
courses are very rare. The attitudes towards quitting of 8950 Norwegian boys and girls. ActaPaediatr 2007;
the substances could not be assessed which was 96(2): 292î5.
an important limitation of the study. Subjects’ 4. Stojadinoviý A. Protective and risk factors for
expenditure on substances and whether subjects live engagement of adolescents in risky behaviors:
with their parent’s information were also limitations. smoking, drinking and drugs use [dissertation]. Novi
Interventional studies of health education and Sad: Faculty of Medicine, University of Novi Sad; 2004.
counselling impact on substance users and qualitative 5. Rakic D, Rakic B, Milosevic Z, Nedeljkovic I. The
studies on substance use are the important future prevalence of substance use among adolescents and
research areas. its correlation with social and demographic factors.
Vojnosanitetskipregled. 2014;71(5):467-473.
Conclusion and recommendations
6. Agarwal, M, Nischal A, Agarwal A, Verma J,
The prevalence of substance use was high among our
Dhanasekaran S. Substance abuse in children and
study population. Most commonly used substance
adolescents in India: Review article. J Indian Assoc
was alcohol. Majority of them have positive outlook Child Adolesc Mental Health 2013;9:6279.
about substance use. Curiosity for initiation of
substances and party occasions are the reasons for 7. Child Protection and Child Rights. Vulnerable
substance use. Initiation of substance use for first time Children Affected by Substance Abuse. Childline 1098;
2008. Available from: http://www.childlineindia.org.
was found in late adolescent period. Sex, student’s
in/childrenaffectedbysubstanceabuse.htm.
educational courses, parental educational status and
presence of any addicted person in the familywere 8. Stockings E, Hall WD, Lynskey M, Morley KI, Reavley
potential associating factors. N, Strang J, et al. Prevention, early intervention, harm
reduction, and treatment of substance use in young
Educating parents will help in decreasing people. Lancet Psychiatry 2016; 3:28096.
substance use among adolescents as well as use of
9. Tripathi BM, Lal R. Substance abuse in children and
media for prevention can be used. Health education
adolescents. Indian J Pediatr 1999;66:56975.
and counselling activities have to be undertaken to
bring about such changes in their lifestyle.Present 10. Mehta M, Sagar R. Prevalence of substance use among
day programmeslike nashamuktiabhiyan have to be male adolescents in an urban slum. J Indian Assoc
strengthened through peer education and health care Child AdolescMent Health 2015;10:4768.
facilities should be made easily accessible to these 11. Kokiwar P, Jogdand G. Prevalence of substance use
vulnerable groups. among male adolescents in an urban slum area of
Karimnagar district, Andhra Pradesh. Indian Journal
Source/s of funding: Self
of Public Health. 2011;55(1):42.
Conflict of interest: None 12. Dadawani RS, Thomas T. Prevalence of substance
abuse: a community based study. Int J Community
Med Public health 2016;3:647-50

326
13. Sardana S, Narain R, Gupta S. Prevalence and risk 17. Bardhan T, Saikia A, Baruah R. Factors influencing
factors associated with substance use in children: substance use among adolescent slum dwellers of
A questionnaire-based survey in two cities of Guwahati City, Assam. Journal of Mahatma Gandhi
Uttar Pradesh, India. Indian Journal of Psychiatry. Institute of Medical Sciences. 2018;23(1):25.
2020;62(5):517.
18. Jain V, Pradhan SK, Vibha. Socio-Demographic Profile
14. Benegal V, Seshadri S, Karott M. Drug Abuse among of 15 – 24 years old male narcotic substance users in
Street Children in Bangalore. A Project in Calibration a resettlement colony of Delhi. Indian J Public Health
between NIMHANS, Bangalore andthe Bangalore 2009;53:44-7.
Forum of Street Children, Monograph Funded by
19. Centers for Disease Control and Prevention. HIV
CRY; 1998
Surveillance Report; 2011. p. 23. Available from:
15. Daniel LT, Krishnan G, Gupta S. A study to assess the https://www.cdc.gov/hiv/pdf/statistics_2011_
prevalence and pattern of substance use among male HIV_Surveillance_Report _vol_23.pdf.
adolescents in suburban area of Delhi. Indian J Soc
Psychiatry 2017;33:208-12
16. Lisa S, Himanshu PA, Om PP. Substance abuse among

adolescents in urban slums of Sambalpur. Indian J
Community Med 2008;33:265-7

Original Article: Indian Journal of Public Health Research & Development
Study of trimester wise effect of hypothyroidism in pregnancy and

its maternofetal outcome
Vidya Gaikwad1, Pankaj Salvi2, Nandini. R3

1
Professor and head of unit, Department of Obstetrics and gynaecology, Dr. D.Y. Patil medical College hospital and
research centre, Pimpri pune-411018
2
Associate professor, Department of Obstetrics and gynaecology, Dr D.Y.Patil medical College hospital and
research centre, Pimpri pune-411018
3
Resident, Department of Obstetrics and gynaecology, Dr.D.Y.Patil medical College hospital and research centre Pimpri pune-411018
How to cite this article: Vidya Gaikwad, Pankaj Salvi, Nandini. R et al Study of trimester wise effect of hypothyroidism
in pregnancy and its maternofetal outcome. Volume 13 | Issue 4 | October-December 2022
Abstract
Introduction: Pregnancy is associated with a number of physiological and hormonal changes that result in significant
but reversible alterations in thyroid function tests (TFTs). Production of thyroid hormones and iodine requirement each
increases by approximately 50% during pregnancy.
Methodology: All the patients coming to OPD for regular antenatal visits, after obtaining the gestational age and informed
consent were randomly selected for the study. The patients fulfilled all the inclusion criteria. A detailed history was
taken regarding, The symptoms, and signs of thyroid disorders, menstrual history, obstetric history, past medical history,
family history and personal history.
Results : In our study , while we analysed , trimester wise effect of hypothyroidism in pregnancy and it’s meterno-fetal
outcome , we found , mothers who were detected with thyroid disorder in first trimester were more with pregnancy
associated complications (45% ) as compared to second trimester (21%) and third trimester ( only 3%)
Conclusion: From this study , we conclude that maternal hypothyroidism is associated with a variety of neonatal and
pregnancy related adverse events like abortion,fetal growth restrictions, Oligohydramnios, gestational hypertension
preterm delivery,operative delivery.
Keywords: maternofetal complications, third trimester , hormonal changes , pregnancy
Introduction mediated by oestrogens and reduced clearance of

Pregnancy is associated with a number of physiological thyroxine-binding globulin which results in increased
and hormonal changes that result in significant levels of total T4 and T3 2 . However, many factors
but reversible alterations in thyroid function tests such as ethnicity, age, manufacturer’s methodology,
(TFTs). Production of thyroid hormones and iodine iodine status of the reference population and
requirement each increases by approximately 50% calculation method may affect the establishment of
during pregnancy.1 The various other changes in TFT reference intervals for TFTs. Since reference range for
during pregnancy include - increase in serum free hypothyroidism needs to be gestational age specific,
thyroxine (FT4), reciprocal decrease in thyrotropin there is need to establish trimester-specific thyroid
(TSH) due to the thyrotropic activity of human levels for its effects on maternal and fetal outcome.In
chorionic gonadotrophin during the first trimester. India, limited data is available over trimester-specific
1
There is increased sialyation of thyroid hormone, thyroid hormones level during pregnancy. 3, 4, 5 With
this objective present work was planned to study of
Dr. Nandini. R
Resident, Department of Obstetrics and gynaecology, Dr.D.Y.Patil medical College hospital and
research centre Pimpri pune-411018
328
trimester wise effect of hypothyroidism in pregnancy All the information collected is kept confidential
and its materno fetal outcome. and will be used only for research purposes. Ethical
clearance was obtained from the Institutional Ethics
Methodology Committee.
This was a longitudinal study with sample size -
Total 114 hypothyroid pregnant females selected for Results
the study. Sample size was determined by taking In present study mean age of patients was 25.56 years,
prevalence as 2%, at 95% CI and acceptable errors while maximum patients - 97 patients (85%) were in
of 5%,using WINPEP1 Software Material required - range of 20 – 30 years of age. 11 patients (10%) were
blood sample and syringe 5cc . above 30 years of age while only 6 patients (5%) were
below 20 years of age.
The main source of data for the study is patients
from DY PATIL MEDICAL COLLEGE, All pregnant In the present study maximum patients were
women coming for routine antenatal checkups. primigravida; minimum were fourth gravida. 64
patients of 114 were primigravida, 38 patients were
Patient selection 2nd gravida, 10 patients were 3rd gravida, and 2
patients were 4th gravida in our study.
Inclusion Criteria
In our present study 89 patients (78%) had no
● Singleton Pregnancy
history of previous abortion, while 25 patients (22%)
● Primigravida/Multigravida have history of previous abortion.
● Know case of hypothyroidism on treatment Among them 22 patients(19%) had previous 1
● Cases with Recurrent pregnancy loss abortion, 2 patients (2%) had previous 2 abortions,
1 patient(1%) had 3 abortions prior to the present
Exclusion Criteria pregnancy.
● known case of hyperthyroidism In this study 111 patients(97%) had singleton

pregnancy while 3 patients (3%) had twin gestation.
● Patients with thyroid tumors
The study shows that hypothyroidism was
All the patients coming to OPD for regular antenatal detected by screening during the present pregnancy
visits, after obtaining the gestational age and informed in 35 patients (30.7%); and in 79 patients (69.3%)
consent were randomly selected for the study. The it was detected prior to present pregnancy. In our
patients fulfilled all the inclusion criteria. study 10 patients (29%) had hypothyroid detected
A detailed history was taken regarding, The in first trimester,16 patients (46%) during second
symptoms, and signs of thyroid disorders, menstrual trimester,and 9 patients (25%) during third trimester
history, obstetric history, past medical history, family in present pregnancy.
history and personal history. In our study we found 87 patients (76%) with
A thorough general physical examination followed overt hypothyroidism and 27 patients (24%) with
by examination of Cardiovascular system(CVS), Subclinical hypothyroidism
Respiratory system(RS), Central nervous Table 1: Table showing distribution of patients
system(CNS), Per abdomen and local thyroid gland according to the complications of pregnancy
examined and findings noted.
Pregnancy Number Percentage
Patients are sent for TSH,FT3 and FT4 levels and complications of patients
haematological parameters to be checked. Patients Cholestasis of pregnancy 1 1
with deranged thyroid function tests are followed up
FGR & Oligohydramnios 13 11
and assessed for maternal and fetal outcome
GDM 2 2
Ultrasonography is done to monitor fetal growth
Oligohydramnios 13 11
and development in second and third trimester.
Oligohydramnios & PIH 2 2
At the end, the trimester wise obstetrics outcome
PIH 5 4
and perinatal outcome of the pregnancy noted.

Pregnancy Number Percentage In the study we saw prolonged labour in 10 (9%)

complications of patients patients; Postpartum hemorrhage in 7 (6%) patients;
and 97 (85%)patients had no complications during
Thrombocytopenia of labour.
pregnancy & PIH 1 1
Table 3: Fetal outcome - distribution of patients
No complications 77 68
114 100 Fetal outcome Number of Percentage
patients
The present study shows that 13 (11%) pregnant
Low birth weight 17 15
hypothyroid women were having Fetal growth
restriction and Oligohydramnios; 13 (11%) pregnant Normal 97 85
hypothyroid women had Oligohydramnios; and 2 (2%) 114 100
pregnant hypothyroid women has Oligohydramnios
85% (n=17)of babies born to hypothyroid mothers
and gestational hypertension; 5 (4%) pregnant
has normal weight and 15% (n=97)of babies had low
hypothyroid women had gestational hypertension
birth weight .
; 2 (2%) pregnant hypothyroid women had GDM; 1
(1%) pregnant hypothyroid women had cholestasis of Kalpana Mahadik et al [89] reported, 31.6% had
pregnancy and 1 (1%) pregnant hypothyroid women LBW babies, and the association between LBW and
had Thrombocytopenia of pregnancy; while 77 (68%) hypothyroidism was significant (p = 0.001).
pregnant hypothyroid women had no associated Table 4: Neonatal hypothyroidism - distribution of
complications. babies
Table 2: Labour complications - distribution of Neonatal Number of Percentage
patients hyothyroid babies
Labour Number of Percentage YES 2 2
complications patients
NO 112 98
Prolonged labour 10 9
114 100
PPH 7 6
Nil 97 85 Neonatal hypothyroidism was detected in 2 babies
born to hypothyroid mothers, and was not detected
114 100
in 112 babies.
Table 5: Trimester wise effect of hypothyroidism in pregnancy and it’s Materno-Fetal outcome.
Gestational week - Pregnancy associated labour complications Low birth NICU admission
Thyroid detected complications (%) (%) weight (%)
First trimester 45 22 30 35
( N=10)
Second Trimster 21 15 22 24
(N=16)
Third trimester 3 2 4 6
(N=9)
In our study , while we analysed , trimester wise Discussion

effect of hypothyroidism in pregnancy and it’s In the present study a total of 114 hypothyroid
meterno-fetal outcome , we found , mothers who were pregnant females were recruited and followed up
detected with thyroid disorder in first trimester were throughout the pregnancy till delivery. The aim was
found more with pregnancy associated complications to study the trimester wise effect of hypothyroidism
(45%) as compared to second trimester (21%) and in pregnancy and it’s meterno fetal outcome.
third trimester ( only 3%) .

330
In our study , while we analysed , trimester wise In our study , while we analysed , trimester wise
effect of hypothyroidism in pregnancy and it’s effect of hypothyroidism in pregnancy and it’s
meterno-fetal outcome , we found , mothers who were meterno-fetal outcome , we found , mothers who
detected with thyroid disorder in first trimester were were detected with thyroid disorder in first trimester
found more with pregnancy associated complications were more with pregnancy associated complications
(45% ) as compared to second trimester (21%) and (45% ) as compared to second trimester (21%) and
third trimester ( only 3%) . third trimester ( only 3%) .
Similar pattern was observed in labour Similar pattern was observed in labour
complications , where in first trimester was seen complications , where patients with hypothyroid
maximum (22%) , while in second trimester ( 15%) , since first trimester (22%) had labour complications
while in third trimester only 2% . ,in hypothyroid since 2nd trimester (15%) had labour
complications, hypothyroid since third trimester,
When we studied Fetal outcome in hypothyroid
only 2% had complicated labour.
mothers,babies born with low birth weight , in first
trimester , it was seen in 30% , in second trimester With low birth weight , in first trimester , it was
it was 4% , no low birth weight babies were born to seen in 30% , second trimester was 4% , while no low
mothers detected with hypothyroid in third trimester. birth weight babies in third trimester group. 8,9
NICU admission required in babies with maternal NICU admission was required by 35% babies born
hypothyroid since first trimester was found in 35% , to hypothyroid mothers since first trimester,while in
in the second trimester was reported in 24% , while in second trimester , it was reported in 24% , while in
third trimester , it was reported only in 6% . third trimester , it was reported only in 6% . In our
study, 33% delivery was Vaginal delivery, while 55%
Maraka S et al reported, thyroid harmone treatment
were reported as LSCS with 12% reported abortion.
was associated with decreased risk of pregnancy loss
While correlation of type of delivery & association of
among women with Subclinical hypothyroidism,
hypothyroid disease, we found higher number of LSCS
however, the increased risk of other pregnancy
and abortion were reported in clinically diagnosed
related adverse outcome calls for additional studies
cases rather than sub clinical cases. While correlation
evaluating safety of thyroid harmone treatment in
of type of delivery & association of hypothyroid
this patient population.6
disease, we found higher number of preterm delivery
In our study, 17(15%) babies were found with were reported in clinically diagnosed cases rather
low birth weight, 2(2%) babies were found with than sub clinical cases.
neonatal hypothyroid, 44(39%) babies required NICU
Maraca et al reported, thyroid harmone treatment
admission, Neonatal Hyperbilirubinemia was seen in
was associated with decreased risk of pregnancy loss
38(33%) babies.
among women with Subclinical hypothyroidism,
Kalpana Mahadik et al observed, 31.6% had however, the increased risk of other pregnancy
LBW babies, and the association between LBW related adverse outcome calls for additional studies
and hypothyroidism was significant (p = 0.001). evaluating safety of thyroid harmone treatment
NICU admission 42.1% was significantly associated in this patient population. 10 Thyroid disorders are
with hypothyroidism (p = 0.000). Risk of delivery common in women of childbearing age, and are the
of LBW babies is 6.3 times higher in women with most common endocrine disorders after diabetes
hypothyroidism (95% CI = 2.03–19.5) than in women in these years. The prevalence of thyroid disease in
with euthyroidism. Risk of NICU admission were pregnancy and its maternal and child complications
0.14 times (95% CI = 0.048–0.39) higher in babies born in pregnant women varies widely in different regions
to women with hypothyroidism compared to those depending on many factors. To date, there are very
born to women with euthyroidism. 7 few studies of thyroid function and pregnancy
in India associated with maternofetal effect.11
Fisher DA et al observed that neonatal or fetal
Complications of hypothyroidism during pregnancy,
hypothyroidism secondary to transplacental
in mother and fetus are well established. For these
transfer of maternal auto-antibodies is very rare,1 in
reasons, it is important to use appropriate strategies to
180,000 neonates or ~2% of babies with congenital
identify women at risk of these side effects and to use
hypothyroidism. 8

diagnostic tools for early detection and start effective 5. Iskaros J, Packard M, Evans I, Sinha A, Harriman P,
treatment. Thus this study aims to determine the Ekins R. Thyroid hormone receptor gene expression in
prevalence of thyroid disease during pregnancy and first trimester human fetal brain. J Clinical Endocrine
its effects on maternal and child health care in India. Metab 2000;85:2620-23.
Although targeted testing is often made, the latest 6. Maraka S, Mwangi R, McCoy RG, Yao X,
evidence seems to suggest that universal testing may Sangaralingham LR, Singh Ospina NM, O’Keeffe DT,
be a better option.So, routine tests, early confirmation De Ycaza AE, Rodriguez-Gutierrez R, Coddington CC
of diagnosis and immediate treatment along with 3rd, Stan MN, Brito JP, Montori VM. Thyroid hormone
regular postnatal follow-up, is necessary to ensure treatment among pregnant women with subclinical
positive outcomes for both mother and baby. 12 hypothyroidism: US national assessment. BMJ. 2017
Jan 25;356:i6865.
Conclusion 7. Mahadik K, Choudhary P, Roy PK. Study of thyroid
From this study, we conclude that maternal function in pregnancy, its feto-maternal outcome;
hypothyroidism is associated with a variety of a prospective observational study. BMC Pregnancy
neonatal and pregnancy related adverse events like Childbirth. 2020;20(1):769. Published 2020 Dec 10.
abortion,fetal growth restrictions, Oligohydramnios, doi:10.1186/s12884-020-03448-z
gestational hypertension preterm delivery,operative 8. Fisher DA. Fetal thyroid function: Diagnosis and
delivery. management of fetal thyroid disorders. Clin Obstet
Gynecol 1997;40:16-31.
Conflict of interest: Authors has no any conflict of
interest. 9. Maraka S, Mwangi R, McCoy RG, Yao X,
Sangaralingham LR, Singh Ospina NM, O’Keeffe DT,
Source of Funding: This study was not supported De Ycaza AE, Rodriguez-Gutierrez R, Coddington CC
by any source of funding. 3rd, Stan MN, Brito JP, Montori VM. Thyroid hormone
Ethical Clearance: We obtained Institutional Ethics treatment among pregnant women with subclinical
hypothyroidism: US national assessment. BMJ. 2017
Clearance from our IEC, DYPMC.
Jan 25;356:i6865. doi: 10.1136/bmj.i6865.
References 10. Sheehan PM, Nankervis A, Araujo Júnior E, et al:
1. Lazarus JH, Bestwick JP, Channon S, et al. Maternal thyroid disease and preterm birth: systematic
Antenatal thyroid screening and childhood review and meta-analysis. J Clin Endocrinol Metab.
cognitive function. The New England Journal of 2015;100(11):4325
Medicine. 2012;366(6):493–501.
11. American College of Obstetricians and Gynecologists:
2. Saraladevi R,Nirmala Kumari T,Sheeren B Usha Rani Thyroid disease in pregnancy. Practice Bulletin No.
V. Prevealence of thyroid disorder in pregnancy and 148, April 2015, Reaffirmed 2017.
pregnancy out come. IAIM, 2016; 3(3):1-11.
12. Stagnaro-Green A, Abalovich M, Alexander E, et
3. Abalovick M, Amino N, Barbour LA, Management al. Guidelines of the American Thyroid Association
of thyroid dysfunction during pregnancy and for the diagnosis and management of thyroid
postpartum. An endocrine society practice guideline. disease during pregnancy and postpartum. Thyroid.
J Clin Endocrinol Metab 2007;92:S1-S7. 2011;21(10):1081–125.
4. M. T. Sahu, V. Das, S. Mittal, A. Agarwal, and M. Sahu,
“Overt and subclinical thyroid dysfunction among
Indian pregnant women and its effect on maternal
and fetal outcome,” Archives of Gynecology and
Obstetrics.2010;281(2):215-20.

Surgical and Oncological Outcomes of Extremity soft Tissue Sarcoma

following en bloc Resection of the Neurovascular Bundle
Haitham Fekry Othman¹, Reham Saied Oreaba¹, Marawan Yousry²,

Assem Ahmed Elbrashy¹
¹Lecturer of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt,
²Lecturer of vascular surgery, faculty of medicine, Cairo University, Cairo, Egypt,
How to cite this article: Haitham Fekry Othman, Reham Saied Oreaba, Marawan Yousry, Assem Ahmed Elbrashy
et al Surgical and Oncological Outcomes of Extremity soft Tissue Sarcoma following en bloc Resection of the
Neurovascular Bundle. Volume 13 | Issue 4 | October-December 2022
Abstract
Purpose: Vascular involvement is a major limitation in attaining limb salvage with negative margins for managing soft
tissue sarcomas (STS). The study evaluated surgical and oncological outcomes of vascular resection and reconstruction
during the management of extremities STS.
Methods: The study involved 60 patients with STS treated with limb-sparing surgery divided into two groups;
the Reconstruction Group (n=30) needed vascular reconstruction (VR) due to vascular involvement, and the Non-
reconstruction Group (n=30) did not require vascular resection. All patients were followed up for at least one year to
compare surgical and oncological outcomes.
Results: Vascular reconstruction involved a major artery and vein (n=16), a major artery alone (n=13), or a major vein
alone (n=1). Most patients (n = 22) had VR with a saphenous vein graft. An artificial Gore-Tex graft was used in the other
cases. A primary vascular repair was possible for the femoral artery in 3 more patients. Major wound complications, DVT,
and persistent severe edema were more frequent in the Reconstruction Group (p = 0.004 0.015, and 0.001, respectively).
Amputation was eventually required in 17% of the reconstruction group and a single patient in the non-reconstruction
group. The overall survival (OS) at 18 months was apparently higher in the Reconstruction group (85.9%) than the
non-reconstruction group (64.7%, p = 0.063). On multivariate analysis, age at diagnosis and surgical margin were the
independent factors affecting OS. The functional outcome of both groups was similar (p= 0.676).
Conclusion: En-bloc resection of major vascular structures with the tumor and reconstruction has proven to be a feasible
option in limb-salvage surgery. Vascular resection en bloc with limb sarcoma in locally advanced disease increases the
safety of the surgical margins and gives comparable life expectancy and RFS to limb sarcoma patients with early disease
who were treated with resection without vascular involvement. However, it keeps the advantage of having preserved
functioning limb.
Keywords: soft tissue sarcoma, vascular resection, negative margin
Introduction Traditionally, STSs of the extremities were treated

Soft tissue sarcomas (STSs) can arise anywhere in the with amputation, especially for tumors close to the
body, but extremities are the most common primary vascular bundle2. In nearly all patients, surgery is
sites accounting for 60% of the cases1. the primary local therapy. The therapeutic goals in
treating extremity STS are survival and prevention
Haitham Fekry Othman
Department of Surgical Oncology, National Cancer Institute, Cairo, Egypt
66 Elmanyal ST, Elpasha SQ, floor 6, 33
Tel.: +201005890222
of local recurrence with minimal morbidity and femoral (n = 14), superficial femoral (n = 8), popliteal
maintaining function3. Limb salvage surgery was (n = 4), axillary (n = 2) and brachial (n =1). Most
proved feasible with adequate free margins in most patients (n = 22) had vascular reconstruction with
patients with STS of the limbs4 with better functional a saphenous vein graft for both the artery and vein
outcomes5. However, vascular 2involvement is a (n = 9) or the artery alone (n = 9). In four cases, the
major limitation in attaining limb salvage with artery was reconstructed with an artificial Gore-Tex
negative margins. Therefore, vascular resection and graft, and the vein was replaced with a saphenous
reconstruction became a critical element of surgical vein graft. The artery alone was replaced with a Gore-
removal of STSs infiltrating or enclosing a major Tex graft in another four patients. A primary vascular
vessel 6. repair was possible for the femoral artery in 3 more
patients. At the same time, associated femoral veins
Few studies are available in the literature reporting
were ligated without reconstruction. Also, another
the outcome of limb salvage surgery with vessel
patient had the femoral vein resected only without
reconstruction in cases of STS. This study aimed to
reconstruction, and these patients developed DVT
evaluate the surgical and oncological outcomes of
and severe edema, which resolved with therapeutic
vascular resection and reconstruction during the
anticoagulation. In addition to the vascular resections,
management of extremities STS.
four patients required resection of major motor nerves
Patients and Methods (Table 1).
A prospectively collected database of 60 patients Table 1 shows a comparison of surgical and
treated at National Cancer Institute, Cairo oncological outcomes in the two groups. Persistent
University for a primary or locally recurrent STS of severe or very severe postoperative limb edema was
the extremity. All patients were treated with limb- more frequent in the Reconstruction group (p = 0.001).
sparing surgery and were divided into two groups.
Table 1: Treatment outcomes in the two studied
The first group, Reconstruction Group (n=30), needed groups
vascular reconstruction due to vascular involvement.
Vessel resection was necessary to obtain adequate Reconstruction Non- p
Group reconstruction value
oncological surgical margins. The Non-reconstruction
(n = 30) Group
Group (n=30) did not require vascular. All patients
(n = 30)
were followed up for at least one year or to the time
Margin 0.115
of death.
R0 > 1 cm 18 (60.0%) 10 (33.3%)
Comparison for Surgical and Oncological Outcome 8 (26.7%) 14 (46.7%)
R0 < 1 cm
The two groups were compared regarding R1 4 (13.3%) 6 (20.0%)
demographic criteria, tumor characteristics, treatment Muscle transfer 13 (43.3%) 5 (16.7%) 0.024
modalities, surgical outcome, and oncological Motor nerve 4 (13.3%) 0 (0.0%) 0.112
outcome. resection
The functional outcome of surgery was evaluated Deep Vein 11 (36.7%) 3 (10.0%) 0.015
Thrombosis
by the Toronto Extremity Salvage Score (TESS)7.
Significant 26 (86.7%) 6 (20.0%) <
Results edema 0.001
Wound 20 (66.7%) 9 (30.0%) 0.004
The tumor size was larger in the Reconstruction complications
Group but not statistically significant (p=0.055). Most Hospital stay 0.067
tumors were histologically graded 2 or 3. Malignant (days)
fibrous histiocytoma and synovial sarcoma were the ≤7 14 (46.7%) 21 (70.0%)
most common histological diagnoses. <7 16 (53.3%) 9 (30.0%)
In the Reconstruction Group, 16 patients had both Data are presented as number (%)
a major artery and vein resected together en bloc with The limb salvage rate of the Reconstruction Group
the tumor, 13 had a major artery removed, and one was 83%, as five patients ultimately underwent
required excision of only a major vein with the tumor. amputation. All of them received preoperative
Vessels resected and reconstructed were the common radiation. Two patients experienced severe wound
334
infection despite initial local flap coverage in the distal Prognostic n No. OS p-
thigh. This led to osteomyelitis and compromised factor Died at 18 value
function of the GSV grafts for arterial replacement and m
required an above-knee amputation. Two patients (%)
experienced a rupture of the iliofemoral vascular RTH Postoperative 42 6 88.4 0.006
repair after repeated wound complications. The last Preoperative 15 7 52.5
patient had a compartment syndrome developed
Margin R0 > 1 cm 28 1 96.4 0.006
peri-operatively, likely because the saphenous R0 < 1 cm 22 7 79.5
vein graft used for reconstruction was too small in
R1 10 5 33.8
diameter compared with the size of the autogenous
Muscle flap Yes 18 5 60.9 0.202
common femoral vein, thus essentially creating a
relative outflow obstruction and, finally, breakdown No 42 8 86.0
of the vascular anastomoses that necessitated a Limb Fate Limp salvage 54 11 82.8 0.475
hip disarticulation. A single patient in the Non- Amputation 6 2 50.0
reconstruction group needed amputation due to local OS: Overall survival, MFH: malignant fibrous
recurrence fixed to the bone. histiocytoma, RTH: Radiotherapy
Survival and effect of different prognostic Table 3: Multivariate analysis of factors affecting
factors overall survival
The median follow-up period was 17 months (range: B p- HR 95%CI
2-28 months). The overall survival (OS) at 18 months value
was higher in the Reconstruction group (85.9%) Age 1.293 0.026 3.65 1.16-11.41
than the Non-reconstruction group (64.7%), but the Margin 0.018
difference was not statistically significant (p = 0.063). Margin 2.473 0.021 11.86 1.45-97.20
On multivariate analysis, age at diagnosis and surgical (R0 < vs. R0 > 1 cm)
margin were the independent factors affecting overall Margin 3.156 0.005 23.47 2.62-210.34
survival (Table 3). (R0 < vs. R1)
B: regression coefficient, HR: Hazard ratio, CI:
Table 2: Factors affecting overall survival of the
whole studied group (n=60) Confidence Interval
Figure 1: Overall survival of Reconstruction and
Prognostic n No. OS p-
Non-reconstruction groups
factor Died at 18 value
m
(%)
Treatment Reconstruction 30 3 85.9 0.063
type No 30 10 64.7
Reconstruction
Age (years) > 50 23 8 63.2 0.056
≤ 50 37 5 90.0
Sex Female 27 6 74.3 0.878
Male 33 7 78.9
Size (cm) ≤ 10 27 3 91.7 0.017
> 10 33 10 67.8
Location Thigh 28 5 83.1 0.572
Others 32 8 77.3
Pathological MFH 22 8 71.0 0.120
type
The RFS of the two groups were slightly different
Synovial 16 2 81.8
but without statistical significance (p = 0.155). Large
Other 22 3 87.8
tumor size, advanced grade, previous unplanned
Grade Grade 1-2 29 3 88.2 0.026
surgery, preoperative radiotherapy, positive surgical
Grade 3-4 31 10 70.4
Previous Yes 16 5 64.2 0.190
margin, and muscle flaps were associated with worse
unplanned No 44 8 84.5 RFS (Table 4). Multivariate analysis was invalid due
excision to the small number of events in some subgroups.

Table 4: Factors affecting recurrence-free survival of the whole studied group (n=60)
Prognostic factor n No. Recurrences RFS at 18 m (%) p-value
Treatment type Reconstruction 30 5 83.0 0.155
No Reconstruction 30 10 71.0
Age (years) > 50 23 7 73.8 0.445
≤ 50 37 8 79.0
Sex Female 27 7 78.8 0.795
Male 33 8 75.4
Size (cm) ≤ 10 27 4 87.7 0.045
> 10 33 11 67.8
Location Thigh 28 6 78.7 0.454
Others 32 9 75.8
Pathological type MFH 22 5 79.2 0.856
Synovial 16 5 78.8
Other 22 5 73.6
Grade Grade 1-2 29 3 87.8 0.005
Grade 3-4 31 12 67.0
Previous unplanned Yes 16 9 43.9 < 0.001
excision No 44 6 89.5
RTH Postoperative 42 6 86.5 < 0.001
Preoperative 15 9 45.7
Margin R0 > 1 cm 28 1 95.0 < 0.001
R0 < 1 cm 22 4 95.2
R1 10 10 0.0
Muscle flap Yes 18 8 52.5 0.010
No 42 7 86.7
Limb Fate Limp salvage 54 12 79.6 0.202
Amputation 6 3 53.3
RFS: Recurrence-free survival, MFH: malignant fibrous histiocytoma, RTH: Radiotherapy
The functional outcome of both groups was similar. Discussion:

The median postoperative TESS score range was 65 The treatment goals of extremities STSs are
(range: 35-100) in the Reconstruction Group compared long-term survival, avoiding recurrence, and
to 59 (range: 40-100) in the Non-reconstruction Group maintaining function. Thus, limb-sparing surgery
(p= 0.676). plus radiotherapy is the optimal choice. Invasion of
large vascular structures creates a major challenge
in managing these cases to assure safe excision with
adequate surgical margins while maintaining a
sufficient vascular supply of the limb. In this study,
the amputation rate was higher in patients requiring
vascular resection and reconstruction. This higher
risk of amputation was associated with a significantly
higher rate of wound complications. Two-thirds of the
reconstruction group had major wound complications
compared to 30% of the control group. Furthermore,
resection of major vessels leads to loss of collateral
vessels and interruption of lymphatic vessels. This
causes further impairment of wound perfusion and
Figure 2: Recurrence-free survival of increases postoperative edema 8. Meta-analysis has
Reconstruction and Non-reconstruction groups shown that wound complication rates varied from
336
17.6% to 48%9. In one series, wound complications reconstruction in 13 patients with a saphenous
were recorded in 43.3%. It was more common in cases vein graft. Many reports support this approach
of vascular reconstruction (34.5% vs 15.3%; p = 0.05) of attempting venous reconstruction in all cases,
10
. especially when the collateral flow is unclear 23,24. The
rate of postoperative edema may correlate with the
Deep venous thrombosis was significantly more
degree of disruption of venous collaterals at the time
common in the reconstruction group (p=0.015). This
of resection25.
complication may be another factor contributing to
the higher rate of amputation. It has been shown that An important limitation of this study is that it is
patients undergoing vascular surgery are at a higher not a typical comparative one as randomization is not
risk of developing perioperative DVT11. Patients possible. The patients in the non-reconstruction group
with STSs may be at increased risk of DVT due to did not require any type of vascular manipulation.
malignancy and poor functional independence. 12 However, we supposed that a comparative group is
a better way to show the impact of vascular resection
It is crucial to note that all five patients who
and reconstruction on outcome of treatment of STSs.
fated to have an amputation received preoperative
In conclusion, limb-salvage surgery of extremities
radiotherapy. Major wound complications were
STSs is an effective treatment option achieving
a common precipitating factor in four cases. It is
negative margins in most cases. Vascular resection
believed that radio- and chemotherapy may inhibit
and reconstruction were associated with more
wound healing by preventing collagen synthesis13. It is
postoperative wound complications, DVT, and severe
known that previous radiotherapy in flap procedures
limb edema. Also, amputation was more frequent
may affect vascular availability14. Preoperative
after vascular reconstruction. Overall survival was
radiotherapy is often associated with higher rates of
better after reconstruction but with no statistically
wound complications when surgery is done after the
significant difference.
standard dose of 50 Gy15. In a multicenter randomized
trial, major wound complications were recorded Ethical clearance: taken from the NCI, Egypt ethical
in 35% of patients treated with preoperative RT16. committee
This risk is increased in lower extremities sarcomas
Source of funding: self-funding
adjacent to major neurovascular structures17.
Conflict of interest: nil
Yet, the current study has shown a relative
survival advantage in the vascular reconstruction References
group. Thus, we believe that limb-salvage surgery 1. von Mehren M, Randall RL, Benjamin RS, et al. Soft
followed by reconstruction of the vascular defect Tissue Sarcoma, Version 2.2014. Journal of the National
is the best alternative in cases involving vascular Comprehensive Cancer Network. 2014;12(4):473-483.
structures. The guidelines of this type of surgery doi:10.6004/jnccn.2014.0053
need to be standardized. In a trial for guiding surgical
2. Hoefkens F, Dehandschutter C, Somville J, Meijnders
management of STSs, Schwarzbach et al. 18 suggested P, van Gestel D. Soft tissue sarcoma of the extremities:
their classification of vascular involvement pattern. pending questions on surgery and radiotherapy.
They proposed arterial and venous reconstruction Radiation Oncology. 2016;11(1):136. doi:10.1186/
in type I involving both major arteries and veins if s13014-016-0668-9
collateral venous drainage was impaired. Arterial
3. Brownstein JM, DeLaney TF. Malignant Soft-
reconstruction will be enough with adequate venous
Tissue Sarcomas. Hematology/Oncology Clinics of
drainage. In the current study, 16 patients were North America. 2020;34(1):161-175. doi:10.1016/j.
classified as Type I, while 13 were Type II. hoc.2019.08.022
It was found that venous resection without 4. Deo SVS, Manjunath NML, Shukla NK. A Review
reconstruction leads to limb edema and of Controversies in the Management of Soft Tissue
discoloration19,20. However, venous reconstruction Sarcomas. Indian Journal of Surgery. 2012;74(3):228-
did not reduce limb edema in other studies 21,22. 233. doi:10.1007/s12262-012-0587-4
In the current series, we have performed venous

5. Ramu EM, Houdek MT, Isaac CE, Dickie CI, Ferguson 15. Curtis KK, Ashman JB, Beauchamp CP, et al.
PC, Wunder JS. Management of soft-tissue sarcomas; Neoadjuvant chemoradiation compared to
treatment strategies, staging, and outcomes. SICOT J. neoadjuvant radiation alone and surgery alone for
2017;3:20. doi:10.1051/sicotj/2017010 Stage II and III soft tissue sarcoma of the extremities.
Radiation Oncology. 2011;6(1):91. doi:10.1186/1748-
6. Kumar S, Manjunath NML, Manoj Gowda S, Kumar N,
717X-6-91
Bharati S, Deo SVS. Limb Preservation Using Vascular
Reconstruction in Patients with Large Extremity Soft 16. O’Sullivan B, Davis AM, Turcotte R, et al. Preoperative
Tissue Sarcomas: Results of Multi-Modality Therapy. versus postoperative radiotherapy in soft-tissue
Indian Journal of Surgery. 2020;82(6):1088-1093. sarcoma of the limbs: a randomised trial. The
doi:10.1007/s12262-020-02161-7 Lancet. 2002;359(9325):2235-2241. doi:10.1016/S0140-
6736(02)09292-9
7. Davis AM, Devlin M, Griffin AM, Wunder JS, Bell RS.
Functional outcome in amputation versus limb sparing 17. Wang D, Zhang Q, Eisenberg BL, et al. Significant
of patients with lower extremity sarcoma: A matched Reduction of Late Toxicities in Patients With Extremity
case-control study. Archives of Physical Medicine and Sarcoma Treated With Image-Guided Radiation
Rehabilitation. 1999;80(6):615-618. doi:10.1016/S0003- Therapy to a Reduced Target Volume: Results of
9993(99)90161-2 Radiation Therapy Oncology Group RTOG-0630 Trial.
Journal of Clinical Oncology. 2015;33(20):2231-2238.
8. Ghert MA, Davis AM, Griffin AM, et al. The Surgical
doi:10.1200/JCO.2014.58.5828
and Functional Outcome of Limb-Salvage Surgery
With Vascular Reconstruction for Soft Tissue Sarcoma 18. Schwarzbach MHM, Hormann Y, Hinz U, et al. Results
of the Extremity. Annals of Surgical Oncology. of limb-sparing surgery with vascular replacement for
2005;12(12):1102-1110. doi:10.1245/ASO.2005.06.036 soft tissue sarcoma in the lower extremity. Journal
of Vascular Surgery. 2005;42(1):88-97. doi:10.1016/j.
9. Slump J, Bastiaannet E, Halka A, et al. Risk factors for
jvs.2005.03.017
postoperative wound complications after extremity
soft tissue sarcoma resection: A systematic review and 19. Matsushita M, Kuzuya A, Mano N, et al. Sequelae
meta-analyses. Journal of Plastic, Reconstructive & after limb-sparing surgery with major vascular
Aesthetic Surgery. 2019;72(9):1449-1464. doi:10.1016/j. resection for tumor of the lower extremity. Journal
bjps.2019.05.041 of Vascular Surgery. 2001;33(4):694-699. doi:10.1067/
mva.2001.112799
10. Perrault DP, Lee GK, Yu RP, et al. Risk Factors for Wound
Complications After Soft Tissue Sarcoma Resection. 20. Nishinari K, Wolosker N, Yazbek G, Zerati AE,
Annals of Plastic Surgery. 2021;86(3S):S336-S341. Nishimoto IN. Venous reconstructions in lower limbs
doi:10.1097/SAP.0000000000002592 associated with resection of malignancies. Journal of
Vascular Surgery. 2006;44(5):1046-1050. doi:10.1016/j.
11. Aziz F, Patel M, Ortenzi G, Reed AB. Incidence of
jvs.2006.07.033
Postoperative Deep Venous Thrombosis Is Higher
among Cardiac and Vascular Surgery Patients as 21. Adelani MA, Holt GE, Dittus RS, Passman MA,
Compared with General Surgery Patients. Annals of Schwartz HS. Revascularization after segmental
Vascular Surgery. 2015;29(4):661-669. doi:10.1016/j. resection of lower extremity soft tissue sarcomas.
avsg.2014.11.025 Journal of Surgical Oncology. 2007;95(6):455-460.
doi:10.1002/jso.20679
12. Abdol Razak N, Jones G, Bhandari M, Berndt M,
Metharom P. Cancer-Associated Thrombosis: An 22. Tsukushi S, Nishida Y, Sugiura H, Nakashima H,
Overview of Mechanisms, Risk Factors, and Treatment. Ishiguro N. Results of limb-salvage surgery with
Cancers (Basel). 2018;10(10):380. doi:10.3390/ vascular reconstruction for soft tissue sarcoma in the
cancers10100380 lower extremity: Comparison between only arterial
and arterovenous reconstruction. Journal of Surgical
13. Dantzer D, Ferguson P, Hill RP, et al. Effect of radiation
Oncology. 2008;97(3):216-220. doi:10.1002/jso.20945
and cell implantation on wound healing in a rat model.
Journal of Surgical Oncology. 2003;83(3):185-190. 23. Emori M, Hamada K, Omori S, et al. Surgery With
doi:10.1002/jso.10242 Vascular Reconstruction for Soft-Tissue Sarcomas
in the Inguinal Region: Oncologic and Functional
14. Talbot SG, Athanasian EA, Cordeiro PG, Mehrara BJ.
Outcomes. Annals of Vascular Surgery. 2012;26(5):693-
Soft tissue reconstruction following tumor resection
699. doi:10.1016/j.avsg.2011.12.003
in the hand. Hand Clinics. 2004;20(2):181-202.
doi:10.1016/j.hcl.2004.03.006

338
24. Umezawa H, Sakuraba M, Miyamoto S, Nagamatsu 25. McGoldrick NP, Butler JS, Lavelle M, Sheehan S,
S, Kayano S, Taji M. Analysis of immediate vascular Dudeney S, O’Toole GC. Resection and reconstruction
reconstruction for lower-limb salvage in patients with of pelvic and extremity soft tissue sarcomas with
lower-limb bone and soft-tissue sarcoma. Journal major vascular involvement: Current concepts. World
of Plastic, Reconstructive & Aesthetic Surgery. Journal of Orthopedics. 2016;7(5):293. doi:10.5312/
2013;66(5):608-616. doi:10.1016/j.bjps.2013.01.001 wjo.v7.i5.293

Fertility Preservation in Young Breast Cancer Patients: a Concept Analysis
Hyeon gyeong Yoon1, Joomin Lee2

1
Assistant Professor in Department of Nursing Eulji University, Seongnam campus, Korea
2
Postgraduate, Psychology Department, Sogang University, Seoul, Korea
How to cite this article: Hyeon gyeong Yoon1, Joomin Lee2 et al Fertility Preservation in Young Breast Cancer
Patients: a Concept Analysis. Volume 13 | Issue 4 | October-December 2022
Abstract
The purpose of this study was to clarify and analyze the concept of fertility preservation in young breast cancer patients.
As the reproductive age of women increases and the number of young cancer patients increases, there is an uncertain
situation in which young cancer patients diagnosed with breast cancer may lose fertility in the course of cancer treatment.
Fertility preservation is a widely used concept It is necessary to clarify the meaning and concept of fertility preservation
in young breast cancer patients in order to reduce confusion in the selection of cancer treatment and fertility preservation.
For this study the process of Walker & Avant’s analysis was used. Eleven studies from electronic data bases met criteria
for selection. Fertility preservation can be defined by the following attributes 1)basic human desire 2)voluntary choice
according to the individual’s point of view 3)change of perception through consultation. The antecedents of fertility
preservation consisted of: 1)Appropriateness of providing information 2)differences in individual values 3)socio-
environmental factors. The consequences occurring as a result of fertility preservation were: 1)improvement distress and
2)enhancement of quality of life. Results of this analysis provides a theoretical framework for oncology medical staff to
better understand fertility preservation in young breast cancer patients, to improve quality of life.
Keywords: fertility preservation, breast neoplasm, concept analysis, young adult
Introduction preserving fertility. Although medical staff focuses

A woman’s view of fertility changes throughout her on cancer treatment itself when diagnosing cancer,
life. Changes in a woman’s body along with time the completely revised American Society of Clinical
leading to menarche, pregnancy, and menopause Oncology guideline5 emphasized that a sufficient
are most pronounced. However, when a woman explanation of fertility should be provided to the
is diagnosed with infertility or has an unwanted patients before starting any treatment. According
pregnancy, it is considered distressing. The number to the ranking of cancer incidence among women
of unmarried young cancer patients is increasing according to age group in Korea published by the
because of the increase in women’s reproductive Ministry of Health and Welfare in 20186, breast
age and advances in medical technology, which cancer had the second-highest incidence rate of
in turn is also leading to a higher cancer survival 5.1% after thyroid cancer, among 15–34-year-old
rate. Naturally, preservation of fertility after cancer patients, whereas its incidence rate in 35–66-year-old
treatments is emerging as an important issue for patients was 77.6%6. An important characteristic of
young female cancer patients 1-4. In 2006, the American breast cancer in Korea is that it increases at a high
Society of Clinical Oncology presented a guideline rate of 6.1% every year. The total number of breast
stating that patients receiving cancer treatment for cancer patients per 100,000 female population is
the first time should receive sufficient explanations continuously increasing; in 2000, it was 26.3; in 2012,
about the possibility of infertility and methods of it was 76.8; and in 2017, it was 103.07. In Western
Hyeon gyeong Yoon
Department of Nursing Eulji University, Seong-nam campus, Korea
340
countries, the proportion of premenopausal women preservation in young breast cancer patients who are
with breast cancer is very low, and the incidence in an uncertain situation where they can lose their
increases with age. The figure is more than twice fertility during cancer treatment. This study was
as high as in Korea 6,7. With improvement in cancer also conducted to reduce the confusion in choosing
treatment, in particular, the 5-year survival rate for cancer treatment and to preserve fertility and to help
breast cancer improved to 93.3%, which is higher determine fertility preservation. Therefore, based on
than that of other female cancers, i.e., 75.2% for gastric the conceptual analysis framework of Walker and
cancer and 80.5% for cervical cancer7. Given the Avant13 this study will unify the concepts through a
characteristics of Korean breast cancer, which occurs systematic conceptual analysis of fertility in young
frequently in young women under the age of 40 and breast cancer patients and provide a clear theoretical
has a high incidence and survival rate, it is necessary basis. The purpose of this study is to clarify the
to minimize the side effects that occur in the course of conceptual attributes of fertility preservation in young
cancer treatment and to improve the quality of life by breast cancer patients and to prepare a theoretical
preserving and recovering body functions7. basis. This study used the conceptual analysis
procedure of Walker and Avant.
Chemotherapy is an important cancer treatment,
and high-dose chemotherapy causes ovarian Materials and Method
dysfunction, with a risk of about 92%, regardless of
age3. Young female cancer survivors are anxious and 1. design
stressed about the possibility of infertility, hoping to be This study was conducted using the previous study
able to become parents after treatment4,5. Preservation and literature search method. The conceptual analysis
of fertility is very important because the number of of “preserving fertility in young breast cancer
young cancer patients who are of childbearing age is patients” was carried out according to the conceptual
increasing, and preservation of fertility is one of the analysis procedure of Walker and Avant13. The
most important parts of life after cancer treatment8. detailed process is as follows:
In a study of young breast cancer survivors under 40
years of age, 12% considered fertility preservation as • First, select a concept.
a factor in determining treatment, and it was reported • Second, establish the purpose of conceptual
that after diagnosis, about 53% attempted pregnancy9. analysis.
Women diagnosed with cancer, on the other hand, • Third, check the scope of use of the concept.
may be preoccupied with survival and be unaware
of the potential future fertility impairment10. When • Fourth, determine the properties of the
chemotherapy and hormone therapy are started, a concept.
woman’s fertility may decrease, and she may not have • Fifth, present model examples.
the opportunity to give birth in the future. Therefore, • Sixth, present additional examples.
sufficient discussion about the fertility of young
• Seventh, identify the antecedent factors and
women should be made before starting treatment2,4.
results.
According to a study on female cancer patients of
childbearing age if they received professional advice • Eighth, determine the definition of empirical
from a medical team about their fertility before reference.
treatment, they had less regret and a higher quality of
life, even if their fertility was decreased11. However, 2. Subjects
in a telephone interview study of young African- The scope of the literature review for this study is
American breast cancer survivors under the age of 45 limited to dictionary definitions of “breast cancer” and
years, 45% of respondents said they wanted to have “preservation of fertility,” theories related to fertility,
children at the time of breast cancer diagnosis, but and previous studies. For literature searches in Korea,
50% of them were not informed about their fertility journals and dissertations retrieved from the Korea
at all12. Education and Research Information Service (www.
The purpose of this study is to accurately recognize riss4u.net) were used for analysis, and for overseas
the meaning of fertility for breast cancer patients by literature, papers retrieved from PubMed, CINAHL,
clearly defining the meaning and concept of fertility and PsycInfo were used for analysis. The study

period considered was the last 15 years, i.e., from meanings and attributes of concepts. The data table
January 1, 2006, to June 30, 2021, and the keywords was independently prepared by two researchers,
were “young breast cancer or breast neoplasm” and and after discussion and agreement, the reliability
“fertility preservation.” There were 4 cases in RISS, and validity of the study were secured by selecting
684 cases in PubMed, 94 cases in CINAHL, and 62 and analyzing data and extracting the meaning and
cases in PsycInfo. Results, excluding 130 publications, attributes of concepts. This process was repeated
that were duplicated out of a total of 844 searched three times until the two researchers reached a full
materials, publications that were evaluated to be consensus. The purpose of preparing the prepared
completely irrelevant to the purpose of the research datasheet is not to reach a final judgment, but to
according to certain criteria, and 679 publications that conduct a comprehensive review in the process of
were written in languages other than Korean and first reviewing the literature. After that, the decisive
English, or 35 whose original text was not accessible, attributes of the concept were identified; model cases,
were confirmed. Among them, the full texts of 19 additional cases, antecedent factors, and results were
documents, excluding 16 documents that did not meet derived; and theoretical definitions were derived by
the criteria, were examined by checking the abstract, organizing them.
and a total of 8 documents that did not meet the
criteria were excluded; thus, a total of 11 documents Results
were used for the final analysis (Figure 1). Literature
1. Scope of use of fertility preservation in young
that met the following criteria was excluded from the
breast cancer patients
study.
1) Dictionary definition
• Documents related to fertility in male and
gynecological cancer patients, and data on Merriam-Webster’s dictionary defines fertility
the experience of medical staff in preserving as “the ability to produce young,” “the Dictionary,
fertility rather than patients “fertility means productiveness, meaning the number
of births distinct from the capability to bear, and
• Data on drug treatment regimens and fecundity means “capability to bear children”17.
treatment guidelines for the preservation of
In other words, fertility is a concept that includes
fertility in breast cancer patients.
fecundity, where the idea of the number of progeny
• In the process of reading the entire text, is included, whereas fecundity means the quality of
some materials are judged to be of too low reproduction without the concept of number, and it
relevance to the research topic. was confirmed that fertility is a larger concept than a
fecundity.
After reviewing the literature related to the
preservation of fertility in young breast cancer
2) Scope of use of the concept
patients, in order to understand and appreciate the
various uses of the concept of fertility, in addition (1) Use of concepts in other academic fields
to studies dealing with fertility, Korean and English Demographers used the term fertility to indicate
dictionaries, life sciences, neuroscience, psychology, the pregnancy power, meaning the number of
public health, and sociology research literature was children born in a country, and they used this term
additionally reviewed. In addition, literature dealing “fertility” to estimate demographic change with
with theories related to the concept of fertility was the number of children born18. In psychology and
searched and utilized by referring to references from research, fertility is also used as a concept of the
previous studies. ability to reproduce many offspring. Fertility refers
to a woman’s health status, such as age, waist and
3. Data Collection and Analysis Methods hip ratio, and body fat distribution when a man
The researcher confirmed how the concept of fertility chooses a mate, which was considered an indicator of
preservation in young breast cancer patients was fertility19. In medicine, fertility is the ability to become
used within the selected literature. After that, each pregnant, and in the case of young cancer patients,
data table was created, and systematic and reliable many medical treatments are being studied to
conceptual analysis was made possible by extracting preserve fertility before and during cancer treatment.
and describing the types of documents and the In the case of young female cancer patients, ovarian

342
function deteriorates because of treatment such as pregnancies and whether fertility treatment may
chemotherapy, and once the ovarian function has affect cancer treatment and negatively affect medical
degenerated, it cannot be restored. In the case of the prognosis25. The level of concern about fertility
aforementioned patient group, fertility is likely to depends on three factors: the environment, personal
decrease significantly during the cancer treatment values, and expectations. Fertility is of paramount
process, so research on fertility preservation methods importance and a high priority for patients who have
is ongoing20. The method of preserving fertility in tried to conceive, are young, or have no children4,26.
female cancer patients currently being applied in Young patients who consider survival to be the most
clinical practice varies depending on marital status. important priority accept the possibility of infertility
Married women use the embryo cryopreservation and choose to receive cancer treatment immediately26.
method, which involves fertilizing and freezing the In a qualitative study of unmarried breast cancer
sperm and oocytes of their spouses. For unmarried patients, the preservation of fertility is an important
women, the oocyte freeze-preservation method is issue, but at the same time, uncertainty about fertility,
used. Since both require a superovulation induction due to the influence of chemotherapy, etc., acts as a
process for oocyte collection, cryopreservation of major stress factor. In addition, it was very difficult
ovarian tissue is used to separate and preserve to consult with the medical staff regarding fertility
ovarian tissue when emergency chemotherapy is preservation because patients considered it a very
needed, such as in the case of leukemia3,8. sensitive and complex issue 27. In addition, compared
to men, women’s fertility-preserving treatment is
(2) Use of concepts in nursing literature
more complex and difficult to find practical solutions,
A woman’s fertility depends on changes in her so it is difficult for female cancer patients to consult
life and environment, and it may be something with medical staff first28. They answered that they
she wants, but it is also used as a negative concept felt lonely and alienated when having conversations
that she does not want and has to21. For example, with family members and medical staff on the topic of
regardless of the stage of mental maturity, with the fertility due to the difficulty of the topic29. Therefore,
onset of menstruation, a woman’s body is ready it is very important for the medical staff to sufficiently
for childbirth, but a woman must keep herself from discuss with the patient before treatment about the
becoming pregnant until menopause outside of family preservation of fertility and to provide accurate
planning22. For this reason, “fertility” can be used as information on the method of preserving fertility as it
an opposing concept depending on the situation, such reduces the psychological distress of cancer patients
as women who are not planning to become pregnant 8,24,25
. In particular, in nursing, more holistic care can
should be careful not to become pregnant during be provided by sharing opinions and explaining
intercourse, even though they can become pregnant21. experiences about uncertainty regarding fertility after
treatment, fears, and concerns about fertility after
Biologically, the desire to be a parent is an important
treatment27. For effective counseling, medical staff
part of cancer survivors’ lives and affects their lifelong
also need to receive conversational education such as
health and quality of life 23. Fertility is an important
how to communicate with the patients29.
area of interest for young female cancer patients24.The
preservation of fertility serves as a hope for cancer For young female cancer patients, being able to
patients, and it causes major distress when fertility have children after treatment has many meanings.
is lost1,10,24. However, young female cancer patients Preservation of fertility has the greatest impact on
have to make decisions about fertility preservation improving the quality of life of patients. It makes
and adjuvant chemotherapy as soon as they are them feel “healed”; looks at the future positively;
diagnosed. The patients not only do not have enough becomes a link to reconnect with colleagues, friends,
time to consider fertility preservation, but they may and family; and becomes a stimulant to recover their
be overwhelmed by the cancer diagnosis itself and health2,27.
not consider the therapeutic effect on fertility after
2.List of tentative criteria and attributes of fertility
breast cancer treatment4,25,26. Particularly, in the case
preservation in young female cancer patients
of unmarried breast cancer patients, fear of hair loss,
chemotherapy, and shameful feelings about breast As a result of examining a wide range of literature
surgery can cause anxiety. Patients are also concerned in which the concept of fertility preservation in young
about whether cancer treatment will affect future female cancer patients is used, the following tentative

list of criteria and attributes were identified. This counseling can be differentiated. Therefore, the
process is the core of conceptual analysis and is a properties of fertility preservation in young female
process of identifying the properties of concepts that cancer patients confirmed in this study are as follows
appear repeatedly in the literature13. (Table 1).
(1) Parenthood is a basic human desire (③,⑥).
1) List of provisional standards
(2) Voluntary choice according to individual’s point
① Preservation of fertility can be downplayed
of view (①,⑧).
as the burden of cancer diagnosis itself 25
(3) Negative psychological changes due to

② Treatment to preserve fertility can have a
uncertainty (②④⑦).
negative effect on cancer survival 2,30
(4) Change of perception through consultation with

③ The desire to become a parent affects the
medical experts (⑤).
quality of life throughout life 1
3. Model examples of concepts

④ Uncertainty increases fear and distress24,27.
A model case is an example in which all the
⑤ Timely and sufficient counseling from
important properties of a concept are included13.
medical staff reduces distress8,24,25
K, a 32-year-old woman who was married last
⑥ Being able to become a parent serves as hope4
year and does not yet have children, accidentally
⑦ Uncertain situations make you feel lonely29 touched a hard lump on her left chest while taking a
shower. She came to the hospital and was diagnosed
⑧ The choice of fertility varies according to
with stage 2 breast cancer after an ultrasound and
society, culture, environment, and individual
biopsy. K was so sad that she thought she was going
values4,23,26,30
to die right away when the doctor told her that she
2) Defining attributes needed surgery and chemotherapy right away and
As a result of reviewing the literature on the could not believe that she had this disease. The doctor
fertility of young female cancer patients, we find that explained that after the operation, she had to undergo
fertility is a basic human desire and can be voluntarily chemotherapy for 6 months and antihormonal drugs
selected according to an individual’s point of view. It for 5 years. She was also told that if she received this
was confirmed that the perception of fertility through treatment, her ovaries could delegate degenerate and
lead to infertility. K was
Table 1. Antecedent, Attributes and Consequences of Fertility Preservation in Literature Review
First Author Research Antecedent Attributes Consequences

(year) design
Bártolo Descriptive Partner disclosure of fertility Desire to have a Improve
A. (2021) study status biological child psychosocial
Outcome (distress↓)
Camp-Sorrell Review counseling (future pregnancy is) Impact long term
D. (2009) Viable option health and quality
of life
Carneiro, Review Advances in breast cancer Individualized option Supportive
MM (2018) treatment Consultation with care
a reproductive specialist
Corney, Qualitative Various information by Option of ART Improve quality of
R. (2014) study healthcare professional Emotional and life
practical support
Gorman J.R. Qualitative Timely information Life circumstances Improve quality of
(2011) study and timing In relation care
to diagnosis varied

344
First Author Research Antecedent Attributes Consequences

(year) design
Goossens J. Qualitative Feeling of Difficulties in improve
(2015) study loneliness communicating quality of
potential fertility oncofertility
loss care
Hampe M. E. Review counseling fertility preservation Improve
(2020) is not a priority quality of life
Penrose R.B. Review enduring distress and feeling Lack of information Improve
(2013) uncertainty Cancer treatement distress
Peate M. Review distress Possibility of losing
(2009) their fertility after
cancer treatement
Rosen(2009) Review Timely Desire for biological Improve
information parenthood distress
Desperate to be told that she could not have 4. Development of additional cases
children and thought that not being a mother would 1) Similar cases
be equivalent to giving up on being a woman (a
basic human desire). Doctors introduced that she Similar cases are cases in which most of the
had embryo cryopreservation methods if she wanted attributes of the concept of interest are included,
to have children, as K and her husband are a young but not all of them. This example demonstrates why
couple without children. The doctor said breast it cannot be a model case and helps clarify what is
cancer treatment is delayed by about 2 months considered a concept and what is not, helping to
because the procedure requires an egg collection clarify actual concepts and confirm their properties13.
process. The doctor also warned that superovulation A 37-year-old Y, who was diagnosed with breast
injections administered for oocyte collection could cancer, asked her doctor if she could have children
make breast cancer worse and advised her to discuss after 6 rounds of chemotherapy after surgery. Then,
with her family whether to start breast cancer the doctor said that she has to take
treatment or choose a fertility-preserving method. K’s
husband thought that she should receive treatment tamoxifen for 5 years from now and could not
as soon as possible and become healthy rather than become pregnant during the drug treatment period
h the possibility of having a child. However, K felt and that there is a very high probability that she will
that life without children would be too frightening not be able to have children because she is currently
and meaningless, so she wanted to receive fertility- amenorrhetic. Y, who thought that she would be able
preserving treatment (a voluntary choice based on to have a child after chemotherapy (parenting is a basic
her personal point of view). K was worried about human wish), claimed that she had not heard enough
whether to choose between chemotherapy and from the medical staff before starting treatment. She
preservation of fertility (psychological changes due to said that her choice would have been different if
uncertainty). After hearing detailed explanations of someone had informed me about it (voluntary choice
fertility preservation methods and experiences from based on a personal point of view). She expressed that
other patients from a breast cancer nurse, she gained it was difficult and hopeless to accept the fact that
confidence that breast cancer can be cured sufficiently she could not have a family and that she could not
even after embryo cryopreservation (recognition have children, even though cancer could be treated
change according to the role of medical staff). This (negative psychological changes due to uncertainty).
childless young breast cancer patient’s case includes This similar case is a case in which the attribute of
all four attributes of fertility. change of perception according to the role of medical
staff is not included.

2) Related cases age of 24. However, L was diagnosed with stage

2 breast cancer at the age of 33 and heard the news
A related case is an example of a concept related
that a Hollywood actor with a BRCA gene mutation,
to the concept being analyzed, but a case that gives
similar to her case, had undergone oophorectomy and
a different idea when closely examined. It is similar
mastectomy to prevent breast cancer. She also said
to the concept under analysis, and in a sense, is
that she would undergo ovarian resection in advance.
connected to it26.
In this case, among the attributes of preserving
L, a 28-year-old unmarried woman, visited the
fertility, the patient’s behavior is determined by
hospital with a lump on her chest and was diagnosed
information obtained through an Internet search,
with stage 3 breast cancer. She had a large cancer
rather than by consultation with medical staff and
and was told that she could get the surgery after
voluntary selection according to an individual’s
she received prior chemotherapy. The doctor said
point of view. A case in which a patient decides to
that ovarian dysfunction may occur as a side effect
undergo oophorectomy to prevent the recurrence
of chemotherapy prior to chemotherapy and may
of breast cancer rather than feeling anxious about
lead to infertility. In the words of the medical staff,
preserving fertility during cancer treatment is a case
L said that she did not want to become pregnant and
of not thinking about preserving fertility. In this case,
that if she wanted a child, she could adopt it later
“parenting is a basic human desire,” “voluntary
(voluntary choice according to the individual’s point
choice according to an individual’s point of view,”
of view). It is more important for her to be healed
“negative psychological change due to uncertainty,”
quickly and become healthy than for a child. She was
and “attributes of cognitive change according to the
always worried about getting pregnant while having
role of medical staff” are not included.
intercourse with her boyfriend, but now she does not
have to worry about having an unwanted pregnancy
5. C
onfirmation of antecedent factors and results of
in the future.
the concept
In this case, among the properties of fertility
Antecedents are events or ancillary conditions
preservation, “parenting is a basic human desire,”
that occur before the occurrence of a concept. After
“negative psychological change due to uncertainty,”
conceptual analysis, checking the antecedent factors
and “recognition change according to the role of
and results helps to reflect the social situation in
medical staff” factors could not be found. In this case,
which the concept is commonly used and refine its
fertility is negative, meaning that it is uncomfortable
attributes. Antecedents are things that must happen
when having sex with a boyfriend, and parenting is
before a concept occurs, and consequences are events
also possible through adoption, one’s choice without
or ancillary conditions that occur after they occur13.
the attribute of basic human desire. The attribute for
fertility preservation includes only the voluntary 1) Antecedent factors
choice attribute according to an individual’s point of
The first antecedent factor for fertility preservation
view.
in young breast cancer patients identified through
3) Opposite case the literature is the adequacy of providing sufficient
A counter-example is an example of “what the information on fertility preservation.
concept is not.” This example helps with the concept Young breast cancer patients often do not receive
because it is easier to say what a concept is not than accurate information about fertility preservation.
what it is13. The reasons are as follows: failing to consider the
L, 30, unmarried, has a family history of being possibility of future fertility preservation because of
diagnosed with breast cancer by both her maternal the pressure to be diagnosed with breast cancer, lack
grandmother and mother. When she was 24, her of time to discuss fertility preservation, and the belief
mother was diagnosed with breast cancer. At this that delaying breast cancer treatment negatively
time, she also received a BRCA genetic test, and both affects cancer treatment. As a result, it can be stated
BRCA I and II were positive. L has been thoroughly that the provision of information on fertility by
self-examination and regular check-ups and has medical staff with professional knowledge is a major
accumulated knowledge through an Internet search driving factor8,24,25. The second antecedent factor is
for breast cancer diagnosis and prevention since the the preservation of fertility and parenting, which

346
is a factor determined by differences in individual 6. Empirical reference

values. The desire to have children was found to be As the last stage of conceptual analysis, it refers to
influenced by the frequency of partner-supportive the classification or category of actual phenomena to
conversations among married people 1,25.In the case of explain the occurrence of a certain concept9. It was
unmarried breast cancer patients, there is a dilemma found that the important attributes and empirical
in making a choice due to the fear of being rejected criteria of fertility in young female cancer patients
by their spouse in the future and the anxiety that if were the same. They were found as follows:
they choose fertility-preserving treatment, the time to
receive breast cancer treatment will be delayed27. In (1) basic human desire,
the case of young breast cancer patients, the choice
Discussion
of breast cancer treatment or fertility-preserving
treatment when diagnosing breast cancer differs Treatments for cancer diagnosis include surgery,
according to individual priorities2,31. The third chemotherapy, and radiation therapy, which cause
antecedent factor is a socioenvironmental factor. ovarian dysfunction and lower fertility in women.
According to this factor, there are social and cultural Recently, as the childbearing age of women for
differences in fertility decisions4 Family or spouse’s the first child is gradually increasing and also
support, which can be seen as one of the social and the proportion of young female cancer patients is
environmental factors, is an important essential factor increasing, it is an important issue to preserve the
when planning on fertility preservation, so it can be fertility of young women diagnosed with cancer 3. In
said to be a prerequisite for fertility preservation26. In particular, it is difficult to recover ovarian function,
addition, since financial resources are required for the which has been degraded once due to treatment, and
treatment to preserve fertility, financial status can also it is uncertain whether or not to preserve fertility
be said to be a prerequisite for fertility preservation8. after treatment. Therefore, this study confirmed the
meaning and concept of fertility in young female
The three antecedent factors for fertility preservation cancer patients who may lose fertility due to cancer
in young breast cancer patients are as follows: treatment. Therefore, for young women who are
1. adequacy of provision of information on fertility single or do not have children, it is very important to
preservation 8,24,25 provide and understand sufficient information about
preserving fertility before cancer treatment,4,8,26. As
2. differences in individual values26,29 shown in previous studies, fertility is a basic human
3. socioenvironmental factors 8,9,27 desire for young breast cancer patients. However,
it is uncertain whether fertility can be preserved
2) Confirmation of consequences
due to cancer treatment, such as chemotherapy and
The decision on whether to preserve fertility in antiestrogen therapy7. Therefore, cancer treatment
young breast cancer patients is determined by complex has been shown to increase fear and distress in young
and diverse individual factors32. A (2)voluntary choice breast cancer patients. However, when the medical
according to the individual’s point of view, staff gave sufficient explanations and discussions
about fertility preservation to the patients before
(3) psychological changes due to uncertainty, and
treatment, the psychological distress of cancer
(4) changes in perception according to the role of patients was low9. When selecting the treatment after
medical staff navigator role is needed that integrates fully knowing about the uncertainty of fertility, it was
the role of a counselor to heal various psychological found that even if the patient lost fertility, the feeling
emotions such as anxiety, fear, and sadness, as well of regret was low and the quality of life was high. In
as providing medical information on fertility through particular, the choice of fertility may vary according
sufficient information and communication with to an individual’s point of view. If the medical staff’s
medical staff before breast cancer treatment. This can professional counseling and discussion on fertility
increase the satisfaction of breast cancer treatment, preservation were done well before treatment,
lower the distress, and ultimately improve the quality the psychological impact on patients would be
of life(Figure2). relatively low even if they lost fertility. Therefore,
pre-consultation with professional medical staff on
: Improving the quality of life2,27,29
fertility is very important.

Therefore, this study aims to reduce confusion References

that may occur in uncertain situations after breast 1. Bártolo A, Santos IM, Guimarães R, Reis S, Monteiro
cancer diagnosis through conceptual analysis and S. Attentional Bias Toward Reproduction-Related
understanding of fertility preservation in young breast Stimuli and Fertility Concerns Among Breast Cancer
cancer patients. The application of interventions for Survivors. Behavioral Medicine. 2021:1-16.
fertility preservation, such as the development and
2. Hampe ME, Rhoton-Vlasak AS. Fertility preservation
application of professional counseling programs for in breast cancer with case-based examples for
fertility preservation, is thought to ultimately improve guidance. Journal of assisted reproduction and genetics.
the quality of life of young breast cancer patients. 2020;37(3):717-729
However, this study has limitations in generalizing 3. Lee JR, Kim SH. Fertility preservation in female cancer
the results of studies, such as the results were survivors. Korean Journal of Obstetrics and Gynecology.
obtained by selecting only Korean and English 2008;51(8):820-834.
literature, which were used by viewing the title and 4. Sobota A, Ozakinci G. Determinants of fertility issues
abstract. The concept analysis method of Walker and experienced by young women diagnosed with breast
Avant13 used in this study has limitations in analyzing or gynaecological cancer–a quantitative, cross-cultural
concepts appropriate for the nursing phenomenon; study. BMC cancer. 2018;18(1):1-14.
thus, various concept analysis methods that combine
5. Loren AW, Mangu PB, Beck LN, et al. Fertility
the theoretical and field steps are needed. Therefore,
preservation for patients with cancer: American
it is thought that repeated research on the concept of Society of Clinical Oncology clinical practice guideline
“preserving fertility” is necessary to identify various update. Journal of clinical oncology. 2013;31(19):2500.
influencing factors that were not confirmed in this
study. 6. National Cancer Information Center. National cancer
information Web site. http://www.cancer.go.kr/cms/
Conclusion statics/. Accessed June 28, 2021.
This study is a conceptual analysis study using 7. Korean breast cancer society. 2020 Breast cancer facts &
Walker and Avant’s method. figures. Seoul: Authors; 2020.
As a result of the analysis, 1) young female cancer 8. Kelvin JF, Kroon L, Ogle SK. Fertility preservation for
patients’ fertility is a basic human desire, 2) they patients with cancer. Clinical journal of oncology nursing.
experience psychological changes due to uncertainty 2012;16(2).
about fertility before treatment, 3) they can choose to 9. Gorman JR, Malcarne VL, Roesch SC, Madlensky L,
preserve fertility according to the individual’s point Pierce JP. Depressive symptoms among young breast
of view, and 4) it was found that there is a property cancer survivors: the importance of reproductive
that can change the perception of whether to preserve concerns. Breast cancer research and treatment.
fertility depending on the role of the medical staff. 2010;123(2):477-485.
From the above research results, the following 10. Shear A. Fertility preservation: an option for
women with cancer?. Clinical Journal of Oncology
conclusions were drawn. First, research related to the
Nursing.2010;14(2):240-242.
development of an intervention program for sufficient
education and counseling on the preservation of 11. Letourneau JM, Ebbel EE, Katz PP, et al. Pretreatment
fertility in young female cancer patients in actual fertility counseling and fertility preservation improve
clinical practice is necessary. Second, it suggests quality of life in reproductive age women with cancer.
conducting a follow-up study to confirm the patient’s Cancer. 2012;118(6):1710-1717.
quality of life results after the application of an 12. Lewis PE, Sheng M, Rhodes MM, Jackson KE, Schover
educational intervention program on the preservation LR. Psychosocial concerns of young African American
of fertility in nursing practice. breast cancer survivors. Journal of Psychosocial Oncology.
2012;30(2):168-184.
Ethical Clearance : An ethical clearance is not
required for this study 13. Walker LO, Avant KC. Strategies for theory construction
in nursing. 4th ed. NJ: Pearson; 2011: p157-179.
Source of Funding: Self source
14. Marriam W. Merriam -webster’s advanced learner’s
Conflict of interest: No conflict of interest english dictionary. Springfield Mass: Merriam-Webster;
2008.
348
15. National academy of the Korean language. The Korean 26. Gorman JR, Usita P, Madlensky L, Pierce JP. Young
standard dictionary. Seoul: Doosan donga;1999. breast cancer survivors: their perspectives on
treatment decisions and fertility concerns. Cancer
16. Geobank. The dictionary of physical geography. Paju:
nursing. 2011;34(1):32.
Hanul; 2004.
27. Corney R, Puthussery S, Swinglehurst J. The stressors
17. Oxford English Dictionary. Web
and vulnerabilities of young single childless women
site. https://www.oed.com/view/
with breast cancer: a qualitative study. European
Entry/69506?redirectedFrom=fertility#eid. Accessed
Journal of Oncology Nursing. 2014;18(1):17-22.
August 11, 2021.
28. Olsson C, Berglund A-L, Larsson M, Athlin E. Patient’s
18. Chung SY. The causes of low-fertility in Korea:
sexuality–A neglected area of cancer nursing? European
discussion, issues and a geographical approach. The
Journal of Oncology Nursing. 2012;16(4):426-431.
Geographical Journal of Korea.2013;47(2):129-141.
29. Joline Goossens MSc RM. Communication difficulties
19. Kang P, Sul S, Choi I. Gender differences in thin-
and the experience of loneliness in patients with cancer
slice judgement during the opposite-sex impression
dealing with fertility issues: a qualitative study. In:
formation. Korean Journal of Social and Personality
Oncology Nursing Forum. Vol 42. Oncology Nursing
Psychology.2011;25(3):61-76.
Society; 2015:34.
20. Gracia CR, Sammel MD, Freeman E, et al. Impact
30. Peate M, Meiser B, Hickey M, Friedlander M. The
of cancer therapies on ovarian reserve. Fertility and
fertility-related concerns, needs and preferences of
sterility. 2012;97(1):134-140.
younger women with breast cancer: a systematic
21. Keogh LA. Women’s contraceptive decision-making: review. Breast cancer research and treatment.
Juggling the needs of the sexual body and the fertile 2009;116(2):215-223.
body. Women & health. 2006;42(4):83-103.
31. Carneiro MM, Cota AM, Amaral MC, , et al.
22. Rodriguez D. Female Fertility: A Conceptual and Motherhood after breast cancer: can we balance
Dimensional Analysis. 2013;58(2):7 fertility preservation and cancer treatment? A narrative
review of the literature. JBRA assisted reproduction.
23. Camp-Sorrell D. Cancer and its treatment effect on
2018;22(3):244.
young breast cancer survivors. In: Seminars in Oncology
Nursing. Vol 25. Elsevier; 2009:251-258. 32. Catherine Klein, M.B.A. Addressing Fertility Concerns
for Young Women with Breast Cancer. Journal of
24. Penrose R, Beatty L, Mattiske J, Koczwara B. The
Oncology Navigation & Survivorship.
Psychosocial Impact of Cancer-Related Infertility on
Women. Clinical journal of oncology nursing. 2013;17(2).
25. Rosen A, Rodriguez-Wallberg KA, Rosenzweig L.

Psychosocial distress in young cancer survivors.
In: Seminars in Oncology Nursing. Vol 25. Elsevier;
2009:268-277.

A Study to assess the prevalence of Respiratory Morbidity among Petrol

Filling Station Employees in New Delhi, India
Indumathy V1, Gandhimathi. M 2, Kishore. J3

1
Ph.D Scholar, Rani Meyyammai College of Nursing, Annamalai University, Chidambaram, Tamil Nadu
2
Professor & Guide, Rani Meyyamai College of Nursing, Annamalai University, Chidambaram, Tamil Nadu
3
Professor cum Director & Co-guide, Head of the Department, Community Medicine,
Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi
How to cite this article: Indumathy V, Gandhimathi. M, Kishore. J et al A Study to assess the prevalence of
Respiratory Morbidity among Petrol Filling Station Employees in New Delhi, India. Volume 13 | Issue 4 |
Abstract
Good quality natural environment provides basic needs, in terms of clean air and water, fertile land for food production,
and energy and material inputs for production. Human health and well-being are intimately linked to the state of the
environment. Though several types of environments exist, it is the physical environment which plays an important bearing
on health. Occupational environment plays a major role on the health of those exposed to pollutants. The objectives of
the study were to:(1) assess the prevalence of respiratory morbidity among petrol filling station employees (2) determine
the association between respiratory morbidity among employees with selected demographic and occupational variables.
The study was conducted among 40 petrol filling station employees at New Delhi. The study revealed significant
association between phlegm with locality (p<0.05), breathlessness with age in years (p<0.001), chest illness with age
in years, employment status, exposure to type of pollutant and number of working days per week (p<0.05). The study
found adverse effects of workplace exposures on respiratory health and development of respiratory morbidity symptoms
among petrol filling station employees.
Keywords: Respiratory morbidity, Prevalence, Petrol filling station employee
Introduction as with the present trends half the world’s population

Health is not something that one possesses as a is living in urban settlements. It is estimated that the
commodity, but connotes rather a way of functioning problem is most acute in developing countries, where
within one’s environment (work, recreation and millions suffer and die from respiratory diseases
living). The work environment constitutes an caused by indoor or outdoor pollution. Hence health
important part of man’s total environment, so health of urban population deserves urgent attention4,5
to a large extent is affected by work conditions. Occupational environment plays a major role
Though several types of environments exist, it is on the health of those exposed to pollutants. The
the physical environment which plays an important health hazards get more severe when the duration
bearing on health10. of exposure increases. This fact is more important in
Environmental pollution is a growing problem to case of traffic cops or enforcers, petrol filling station
mankind. The problem is pertinent in the urban context workers, taxi drivers etc.
Indumathy V
Ph. D Scholar, Rani Meyyammai College of Nursing, Annamalai university, Chidambaram, Tamil Nadu
Phone: +919868993988;
350
Rapid urbanization, increasing use of automobiles of lung, constriction of the bronchioles, severe airway
and industrial activities give rise to urban air pollution obstruction, pulmonary oedema and hypoxemia,
dominated by oxides of Sulphur (Sox), nitrogen while NO2 (Nitrogen Dioxide) impairs the immune
(NOx), carbon (Cox), volatile organic compounds defense mechanism of lungs.
(VOCs) and suspended particulate matter (SPM)
Human lung functionality is evaluated by
in all cities of the world8,9. In urban areas certain
pulmonary function testing (PFT) and the main
occupations like petrol filling station workers, vehicle
type of PFT is spirometry. Spirometry is performed
repairing and servicing are associated with exposure
by spirometer; This device employs non-invasive
to fumes, vapors, gases, exhausts, dusts and SPM.
diagnostic techniques for testing and screening of
Vehicular pollution is an important contributor to air
lung functions. These are relatively cheaper and can
pollution in Delhi.
be performed within minutes. As lung diseases like
According to the Department of Transport, bronchitis, emphysema and asthma are prevailing and
Government of National Capital Territory of Delhi common, spirometry has become an indispensable
(2019), total vehicle count estimated at more than 3.4 technique in epidemiology, clinical and occupational
million, reaching higher at a growth rate of 7% per settings as well as in industrial Medicine6
annum. Air pollution in urban area has health effects
Hence the early recognition of respiratory illness
on the public as well as on workers specially those
and preventive measures of susceptible employees
working in traffic congested environment, where they
with respiratory morbidity need to adapt health
are regularly exposed such job-related exposures9.
promoting behavior in the work place before the
Vehicular exhaust is the worst type of exhaust as it is
chronic impairment develops will prove to be
emitted at the ground near the breathing level, and it
beneficial.
gives maximum human exposure1. Respiratory health
problems like reduction in pulmonary functions due Aim and Objectives
to such working exposures are relatively unexplored The present study is aimed to assess the occupational
area of research2. exposure and respiratory morbidity among petrol
Respiratory disorders range from deterioration of filling station employees in selected Petrol filling
pulmonary function, dryness of the throat, coughing, stations at New Delhi. The objectives of the study
tightness in the chest, wheezing and breathlessness to were to: (1) assess the prevalence of respiratory
chronic bronchitis. Workers who are regularly exposed morbidity among petrol filling station employees (2)
to fuels, gasoline oils, solvents report 30-40% incidence determine the association between respiratory illness
of pulmonary health related problems3. Exposure to among employees with selected demographic and
petroleum products among certain occupations for occupational variables.
a long time significantly affects respiratory system
Methods and Materials
and the symptoms such as breathless ness, chronic
cough and wheezing can be observed. Moreover, if A total of 40 petrol filling station employees were
the exposure concentration is higher there is a chance selected from petrol filling stations at New Delhi.
of marked systemic pulmonary inflammatory occur8. The study was conducted during November 2020.
Purposive sampling technique was used to select
The inhaled air contains pollutants that adversely the subjects. After getting approval from Vardhman
affect the respiratory health of the workers. The fuel Mahavir Medical College Institutional Ethical
exhausts release the particles which are extremely committee, researcher enrolled the subject after
fine having large surface area and can transport high getting their informed consent and data were collected
rate of toxic compounds including hydrocarbons from the samples. Demographic data, Occupational
on their surface. These fine particles are capable of data, Health history and Medical Council Research
longer retention and have a probability to deposit in Questionnaire (MRCQ; developed by Medical
greater number and deep into the lungs8. COx (Oxides Research Council, The United Kingdom,1986) were
of carbon) and SOx (oxides of Sulphur) can cause
administered to assess their respiratory morbidity.
multitude adverse effects on a respiratory system
The reliability of the tool was assessed by test re-test
like tissue hypoxia, reversible decrease in functions
method and it was found to be feasible (r= 0.90)

Discussion and Results S. Variables Sub variables Frequency Percentage

No
7. Average 8 hours 32 80
working hours
12 hours 8 20
per day
8. Toral hours of 48 hours 32 80
exposure per
60 hours 8 20
week
Table 1. shows the Occupational Variables of Petrol

Filling Station employees. About 58% of them were
temporary employees and highest, 47% were skilled
workers. The type of pollutant exposure shows that
Figure 1: Demographic Variables of employees of 32% had exposure to smoke, dust and chemicals
petrol filling stations whereas, 30% had exposure to only smoke, 28% had
dust exposure, and 10% had chemical exposure.
Figure 1. show the Demographic data of Petrol Highest, 40% of employees had more than 2 years
Filling Station Employees. About 30% of employee of exposure. Regarding type of work majority, 74%
belonged to the age group of 26 to 35 years and least, were service station attendants and least (8%) were
20% belonged to >45 years of age group. Majority managers. Highest percentage (88%) of employees
were males (90%) and 45% had higher secondary works more than 5 days per week. Similarly, highest
education. Majority were married (90%) and 44% were (80%) of employees work 8 hours per day and 48
from nuclear family. Regarding monthly income, the hours per week.
majority 68% of employees earned between Rs. 5001-
Table 2: Association between respiratory morbidity
10000, 52% of employees hailed from rural area, and with selected Demographic and Occupational
more than half (58%) of the employees lived in pucca Variables N=40
house.
S Variables Respiratory Chi- p-
Table 1: Frequency and Percentage Distribution of No Morbidity square df value
Occupational Variables among Employees of Petrol (x2)
Filling Stations. N=40 value
S. Variables Sub variables Frequency Percentage 1 Demographic Breathlessness
No Variable 0.005***
No Yes
1. Employment Permanent 17 42 Age in years 12.973 3 S
status 09 00
Temporary 23 58 18-25
12 00
2. Occupational Unskilled 11 28 26-35
11 00
category Semi-skilled 10 25 36-45
05 03
Above 45
Skilled 19 47
2 Demographic Phlegm
3. Type of Smoke 12 30
pollutant Variable No Yes 0.032*
Dust 11 28 Locality 6.889 2 S
Exposure
Chemicals 4 10 Rural 19 02
Urban 09 03
All the above 13 32
Semi Urban 03 04
4. Duration of <1 year 12 30
Exposure 1-2 years 12 30 3 Occupational Chest illness
Variable No Yes 4.097 1 0.043*
>2 years 16 40
Employment S
5. Type of work Managerial 3 8 09 08
status
Clerical 7 18 Permanent 19 04
Attendant 30 74 Temporary
6. Number of <5 days 5 12
working days
5 -7 days 32 88
per week

352
S Variables Respiratory Chi- p- Conclusion

No Morbidity square df value The research study highlighted adverse effects of
(x2) workplace exposures on respiratory health and
value impairment of the pulmonary functions among
4 Occupational Chest illness petrol filling station employees. From the present
Variable
No Yes
study, it is concluded that the exposed workers are
Exposure highly vulnerable for developing respiratory health
to type of 05 07 11.459 3 0.009**
symptoms and the highest reported symptoms were
pollutant 11 00 S
chest tightness.
Smoke 04 00
Dust 08 05 The studied petrol filling station employees are
Chemicals found to be vulnerable occupational groups due to
All of the above deficiency of resources, unsafe working conditions,
5 Occupational Chest illness lack of education on lung health and lack of regular
Variable No Yes 5.986 2 0.050* monitoring and inspections, unaware of use of
Number of S personal protective equipment to safe guard them.
03 02
Working Days Interventional plans like education awareness, use of
25 10
<5 days personal protective equipment need to be advocated
5-7 days
for the workers.
S – Significant ***Significant at
p<0.001 level Ethical Clearance:
**Significant at p<0.01 level *Significant Ethical clearance was obtained from Institutional
at p<0.05level Ethical Committee of Vardhman Mahavir Medical
Table 2. (Serial No. 1 &2) revealed that there was a College and Safdarjung Hospital on 7th of February
significant association between respiratory morbidity 2020.
with selected Demographic and Occupational
variable. There was a significant association of Source of Funding:
breathlessness with age (in years) of the employees at No fund was received from any source to conduct this
p<0.001 and phlegm with the demographic variable study.
locality (urban locality) at p<0.05 level. There was
Conflict of Interest: Nil.
no significant association with gender, educational
status, monthly income, marital status, housing type References
and type of family with respiratory morbidities such
1. Ahmad I, Balkhyour A, Tarek Abokhashabah M. Work
as cough, wheezing and chest illness. place safety Health conditions and facilities in small
Table 2 (Serial No. 3, 4 & 5) shows that only chest industries. Journal of safety studies. 2017; 3 (1), ISSN
illness had a significant association with occupational 2377-3219
variables like employment status at p<0.05 level, 2. Aparajita, Neeraj K Panwar, Sharma R.S. A study
exposure to type of pollutant at p<0.01 level, and on the Lung Function test in Petrol-pump workers.
number of working days per week at the level of Journal of Physiology. 2011; 5: 5; 1046-1050. DOI:
p<0.05 level. There was no significant association https://doi.org/10.7860/JCDR/2011/.1520
found between other occupational variable such as 3. Brousseau,L.M, Ramirez-Andreotta, I.L., &
occupational category, total hours of exposure, type of Maximillain, J.Environmental Impacts on Human
work, working hours and source of health information. Health and Well-Being. Environmental and Pollution
The study found adverse effects of workplace Science. 2018; 3: 477-499
exposure on respiratory health and development
4. Brosseau, L. M., Bejan, A., Parker, D. L., Skan, M., Xi,
of respiratory morbidity like breathlessness, chest M. Workplace safety and health programs, practices,
illness and phlegm were predominant among petrol and conditions in auto collision repair businesses.
filling station employees. Journal of occupational and environmental hygiene.
2014; 11: 354-365. https://doi.org/10.1080/15459624.
2013.866714

5. Department of Delhi Transport Corporation. Report 8. Rosa Faner, Nuria Gonzalez, Tamaria et al. Systemeic
of Government National Capital Territory of Delhi inflammatory response to smoking in COPD, PLOS
Website. 2019 ONE.2014; 9: 5, e97491: 1-12
6. Harbison, Stephen Casey. Evaluation of Pulmonary 9. Rachna Agarwal, Gririja Jayaraman, Sneh Anand and P
Risks Associated with Selected Occupations, USF Marimuthu. Assessing respiratory morbidity through
Tampa Graduate Theses and Dissertations. 2013; pollution status and meteorological conditions for
Https://digitalcommons.usf.edu/etd/4687 Delhi. Journal of environmental sciences. 2006; 114(1-
3);489-503; doi: 10.1007/s10661-006-4935-3
7. MRC. Questionnaire on Respiratory Symptoms.
Medical research Council. 1976; Retrieved from:http:// 10. Rajkumar. Air pollution and Respiratory Health.
www.thoracic.org/statements/resources/ archive/ Journal of Advanced Pedicatrics and Child Health
rrdquacer.pdf, accessed on March 15th 2016.Google (JAPCH). 2020; 3: 032 -037
Scholar

Perceptions and Barriers to Deceased Organ Donation in Armenia:

A Qualitative Research
Nare Ghazaryan1, Miqayel Adamyan2, Samvel Grigoryan3, Tatevik Hovakimyan4

1
MD, Researcher, Nork-Marash Medical Center, Armenia, Yerevan
2
MD, Researcher, Tutor, Head of Nork-Marash Medical Center, Armenia, Yerevan
3
Reseracher, American University of Armenia, School of Public Health
4
MD, MPH, MSc, Nork-Marash Medical Center, Armenia, Yerevan
How to cite this article: Miqayel Adamyan, Samvel Grigoryan, Tatevik Hovakimyan et al Perceptions and Barriers to
Deceased Organ Donation in Armenia: A Qualitative Research. Volume 13 | Issue 4 | October-December 2022
Abstract
Background and aim: Transplantation is the treatment of choice for end-stage organ failure. The worldwide shortage
of organs focuses the attention of scientific community and policymakers on it. Despite having a favourable legislative
framework Armenia still do not perform transplantation from deceased donors. Aim of this study is to understand
perceptions and barriers of deceased organ donation in Armenia.
Methods: This qualitative study utilizes semi-structured, in-depth interviews to produce rich descriptions of healthy
adult individuals and main stakeholders about the perceived drivers and barriers to deceased organ donation and
transplantation in Armenia. Participants included healthcare providers, policymaker, priest and healthy adult individuals
of other occupation. Content analysis with deductive approach was utilized.
Results: 11 in-depth interviews were performed. The main concepts around which the themes evolved were knowledge,
attitudes, interaction with health system, family, cultural, religious and socioeconomic factors. Several factors emerged
during the interviews: lack of knowledge, medical distrust, role of the donor’s family as a buffer and misinterpretation of
religious stance are examples.
Conclusion: Lack of knowledge regarding the brain death and deep mistrust to healthcare system were identified as the
major barriers to acceptance of donation after death. It is recommended to conduct a comprehensive educational and
awareness raising campaign both for public and providers.
Keywords: Organ transplantation. Brain death. Medical mistrust
Introduction Azerbaijan. It is highly monoethnic country (98.1%

First successful kidney transplantation was performed are Armenians according to 2011 census) with more
in 1954 in Boston (1). The barrier of genetic compatibility than 94% being Christian. Armenia’s transplantation
fell after introduction of immunosuppression (1). law was enacted in 2002.
Success of immunosuppressive therapies resulted Presumed consent is the legislative default for
in significant increase in the number of transplanted deceased organ donation in the country. Armenia’s
solid organs (2). overall transplantation rate of solid organs is 3.79
Armenia is a lower-middle income country in per million. Before 2019 only kidneys from living
Caucasus, between Iran, Georgia, Turkey and donors were transplanted. In 2019, the first two adult
Nare Ghazaryan MD
Researcher, Nork-Marash Medical Center, Armenia, Yerevan
Armenak Armenakyan St. 13, 0047 Yerevan, Armenia
Tel.: 00374-94-92-42-49
and pediatric liver transplantations were performed primary author. The study population consisted of
from living donors (3). No deceased organ donations the following groups:
have been performed in Armenia till now. The need • Healthy adult individuals – these were young
for organs is significant given the high prevalence of people aged from 25-40,
end-stage organ diseases in the country.
• Healthcare providers with potential to be
It is imperative to understand community involved with the process of donation and
perceptions to organ donation and transplantation transplantation- cardiovascular surgeon,
in the country and suggest policy implications for renal transplant surgeon, liver transplant
further improvement. surgeon, intensivist.
Methods • Former Minister of Health of the Republic of
Armenia,
This qualitative study produces rich descriptions of
healthy adult individuals and key informants about • Psychiatrist,
perceived barriers and drivers to deceased organ • Priest.
donation and transplantation in Armenia.
All the interviews were recorded with permission
The study conceptual framework was adopted of participants. One of participants refused the
and slightly modified from the Irving’s 2009 study. recording, so the primary investigator took the
It demonstrates the balance of attitudes to deceased permission to take notes on her answers. The
organ donation and transplantation process in the recordings were transcribed verbatim in Armenian
form of a scale, which is balancing the drivers and the same day. The participation in the study was
barriers between main concepts regarding the topic (4). anonymous for ethical reasons, so each participant
Concepts were knowledge, attitudes, interaction with was given an ID in the process of transcription. Audio
health system, body integrity, family/relational ties, recordings were performed using an iOS device with
cultural aspects, religious beliefs and socioeconomic a fully encrypted hard drive and transcribed the same
factors. day. No personal details were collected as name,
Semi-structured in-depth interviews were workplace, phone numbers or addresses. Only the
conducted among healthy adult individuals and author had access to data and performed the process
key informants. They allowed to understand deep of audio recording and transcription herself to avoid
feelings, knowledge and attitudes of all groups. dissemination of sensitive material.
The data were collected using individual, Demographic data were analysed with help of
semi-structured in-depth interviews with study Microsoft Excel Spreadsheet. A conventional theory-
participants. Demographic parameters as age, gender driven content analysis with deductive approach
and occupation were also collected. has been applied to analyse the transcribed data (6).
Data obtained were coded using meaningful words,
The semi-structured interview guide consisted of phrases and sentences, which combined into major
10 open-ended questions, which were administered themes and categories (7). The process of analysis
to participants after obtaining a preliminary written was done manually in original Armenian language
consent. The questions were constantly discussed until to avoid any changes in content and meaning of
repetition was observed. Almost all interviews were the phrases and misinterpretation of information
recorded with permission of participants. Interviews (8)
. The pre-determined themes were taken from the
were continued until the data reached saturation. At literature. The main themes around which the coding
the end of the interview, all the participants were of data was performed were: 1) Religious; 2) Cultural;
asked for specific recommendations to improve the 3) Family; 4) Body Integrity; 5) Interaction with health
situation. The study interview guide was adopted system; 6) Knowledge; 7) Socioeconomic; 8) Attitudes.
and modified/ suited for Armenian participants from The choice of deductive approach is justified by the
a South Korean study (5). fact, that there is a significant amount of qualitative
A purposive sampling method was the method of research focused on the topic of organ donation and
choice to reach interviewees. All study participants transplantation. Triangulation of data analysis results
were recruited using individual connections of between healthy individuals, healthcare providers

356
and policymaker significantly increases the credibility everything meaningless. It would be better, if we
of the study results (9). In addition, to strengthen the could organize this using our own resources and
trustworthiness of the study, participant validation would not leave people helpless or force them to
method (member check on spot) was used: the leave the country.” (Psychiatrist, 40)
interviewer rephrased the information received from
participant and returned to them to be sure that they 2. Attitudes
reflected the meanings of their ideas clearly (10). Overall attitude to organ donation was very positive.
Results All the respondents agreed with the fact that if the
brain is dead, there is no need to keep the remaining
Overall, 10 in-depth interviews were conducted with
organs. There were minor precautions again about
11 separate participants. The mean age of participants
validity of brain death. One of the respondents (non-
was 47y, ranging from 25 to 72. Eight of them were
healthcare provider) had philosophical concerns
male participants. Mean duration of in-depth
about increasing number of people living on earth.
interviews was 18 min, ranging from 7 to 37min. All
The other concern raised was the potential for
the responders had a graduate degree of education.
commercialization.
There were eight predefined themes chosen for the
“I have a very positive opinion about organ
study.
donation and transplantation. For me it is a very
healthy and humanistic attitude. The only concern is
1. Knowledge
declaration of death after brain death”. (journalist, 40)
Knowledge about brain death
3. Interaction with health system
All the non-healthcare professional respondents
did not know the definition of brain death. It was Medical mistrust
commonly misinterpreted as inability to think or
The answers concerning the mistrust to doctors and
absence of consciousness, a vegetative state, when
overall healthcare system were highly repetitive, this
all other organs work properly and brain does not.
was the most frequently mentioned barrier perceived
They also had psychological difficulty to interpret
by all participants. The culture of mistrust seemed to
brain death as death of whole organism. Healthcare
be enrooted deeply in the relationship of patients and
providers and policymaker had different opinions –
providers. It related to different aspects of donation
those, who were involved in living organ donation
and transplantation processes: people did not trust
and transplantation processes formerly, had proper
the system’s capability to perform it with normal
understanding of what is brain death and its
quality, availability of infrastructure was of concern,
irreversible nature. Those who were not involved in
fear of organ trafficking and development of black
the process of organ donation and transplantation,
market, validity of brain death and possibility of
could also misinterpret it as a “vegetative” state,
intentional and unintentional euthanasia were major
without knowing the exact diagnostic methods of
concerns. At the same time, they also recognized that
irreversible brain death.
this issue of trust and mistrust is something irrational,
“Brain death is, when the brain stops, does not which could require major reforms in the system or
think. I don’t know if other organs can work. It’s only a role model (like a good, competent minister
really interesting, isn’t it?” (sports NGO worker, 27) of health), who could lead the change management
process. There were also answers from health
Understanding the need
providers, stating that the medicine in our country is
Majority of respondents agreed on the fact that the pretty developed and physicians’ potential is not of
demand of organs for transplantation is crucial and concern.
that it is not possible to close the gap with only living
“You know, the question is comprehensive: we
organ donations.
need an exclusive trust in physicians, that they did
“I know a person, who escaped to Belgium for everything to save the patient’s life, but failed” (renal
getting a liver transplant, lived in a ghetto for months transplant surgeon, 69)
and eventually became sick with AIDS, which made

4. Body integrity donation or giving to their neighbor, their proponents

Thoughts about distortion of body integrity did argued that the official apostolic church will be against
not come out frequently. Only two of respondents the organ donation because the body should keep its
had that concern, not for themselves, but for others. wholeness to be ready for the second advent of Christ:
General opinion was that it is not a major problem. this view was not shared by the priest-interviewee.
“Maybe they [the relatives] think, that it is better “If it is possible to save one’s life with donation,
to decay under the ground, than to be helpful to then why not doing it? I think of it as a manifestation
someone? I know that frequently people give money of Christian compassion and sacrifice” (Priest, 53)
to “correct” the face [of the deceased] before burial.
We have such stupid things” (Food manager, 29) 8. Socioeconomic factors
Among frequently mentioned factors were adequate
5. Family/relational ties financial compensation to providers and need for
All respondents agreed that the family of the donor financial resources to accomplish the establishment
plays a crucial role in our society and it is imperative of service. It was mentioned that high-income people
to take their permission before proceeding with organ would be more prone to discuss the donation of their
procurement. Majority of healthcare providers agreed organs after death. Improvement of education system
that with proper and timely preparedness (i.e. that the and advocacy of humanitarian principles were other
family knows the wishes of the deceased person well drivers of the process.
ahead of the tragic event) and adequate trust to health “Those are hard questions, we know definitely,
providers they would agree to donate the organs. that everything to be done should be compensated
“Many things depend on the impression of family: properly” (former minister of health, 72)
If they feel that everything is done for their patient, he Discussion
was treated conscientiously, they will not be against”
Our study results demonstrated that there are several
(Intensivist, 63)
barriers to development of system for deceased organ
donation and transplantation in Armenia. Among
6. Cultural
them, the deep mistrust to the health system and
Majority of respondents agreed on the fact that we providers was the most prominent. It was mainly
need to develop as a society to understand not only the explained with the previous distrustful experience
importance of our personal ego, but to look at facts as with the system and questioning the doctors’ ability
a society, as a whole. Lack of teamworking ability and to diagnose the brain death adequately.
residential perspective were frequently mentioned
as barriers which was explained by the fact that if In our study we did not observed concerns
people need to think about day-to-day survival, there regarding treating the body of the donor with respect
is no time to consider donation and help to society, and dignity, or using the organs for experiments
which is a remote and less tangible target. The other
(11)
, but there were major concerns about unequal
cultural barrier noted was the importance of opinion distribution or even “sales” of donated organs.
of neighborhood, which frequently could be negative The best solution in this situation would be “to
toward donation and transplantation. make donation happen for those who want it”, or at
“Opinion of the neighbors is very important. One least we believe, that they do. The respect for person
of the recipients telling that the villagers constantly is the legal and ethical basis of basic law almost
blamed her for taking the organ of her daughter” everywhere, including in Armenia.
(Liver transplant surgeon, 50) Another barrier which was frequently mentioned
was the lack of knowledge about the “dead donor
7. Religious beliefs rule” and its frequent misinterpretation. Even some
Common opinion was that the role of the church healthcare providers could not differentiate between
will be tremendous to foster or prevent the process of the end-stage coma and brain death.
organ donation. Some of the respondents who were The good news is that majority recognize the
standing closer to church favored the idea of altruistic need for establishing the system for deceased

358
organ donation and transplantation and with good in Armenia. To our best knowledge, this is the first
educational effort it would be possible to improve the study exploring the perceptions and barriers of
situation (12) (13). deceased organ donation and transplantation in
Armenia. Its findings point out on the potential
General attitude to organ donation and
facilitators and barriers for establishing the service in
transplantation idea was really favourable in our
our country.
research, everyone agreed that it is humanistic and
kind, the best motivator being the human altruism as Funding: This research received no external
mentioned elsewhere in the literature (14). funding.
Role of the donor’s family as a surrogate decision Conflicts of Interest: The authors declare no
maker was perceived as highly important in our conflict of interest.
study, which could affect the donation rates in both
Ethical clearance : Taken from Nork-Marash
positive and negative meanings.
Medical Center ethical review board.
Armenian Apostolic Church views do not reject
the idea of organ donation, but is overall favour of it, References
provided that everything was done to save the life of 1. Linden PK. History of solid organ transplantation and
the donor. organ donation. Crit Care Clin. 2009;25(1):165–84.
Based on our findings, several recommendations 2. Leppke S, Leighton T, Zaun D, Chen S-C, Skeans
M, Israni AK, et al. Scientific Registry of Transplant
can be made:
Recipients: collecting, analyzing, and reporting data
1. As a first step it is recommended to conduct on transplantation in the United States. Transplant
a comprehensive quantitative research with a Rev. 2013;27(2):50–6.
country-representative sample to understand 3. Voskanyan M, Nazaryan H, Babloyan S, Geyikyan
the acceptance rates for deceased organ P, Arakelyan S, Kyurkchyan K, et al. MP787
donation in Armenia; FIFTEEN YEARS OF LIVING DONOR KIDNEY
TRANSPLANTATION PROGRAMME IN ARMENIA.
2. Comprehensive program educating and
Nephrol Dial Transplant. 2017;32(suppl_3):iii723–4.
raising awareness of general public about
the need of organ donation, including social 4. Irving MJ, Tong A, Jan S, Cass A, Rose J, Chadban S,
advertising with help of well-known actors et al. Factors that influence the decision to be an organ
and role models; donor: a systematic review of the qualitative literature.
Nephrol Dial Transplant. 2011;27(6):2526–33.
3. Special education and training of healthcare
5. Kim JR, Elliott D, Hyde C. The influence of sociocultural
providers who will be involved in transplant
factors on organ donation and transplantation in
services;
Korea: findings from key informant interviews. J
4. Inclusion of all transplantation procedures in Transcult Nurs. 2004;15(2):147–54.
Basic Benefit Package offered for people with 6. Hsieh H-F, Shannon SE. Three approaches to qualitative
disabilities; content analysis. Qual Health Res. 2005;15(9):1277–88.
5. Adequate compensation mechanisms for 7. Given LM. The Sage encyclopedia of qualitative
specialists to avoid the presence of informal research methods. Sage publications; 2008.
payment to providers;
8. Van Nes F, Abma T, Jonsson H, Deeg D. Language
6. Finally, governmental support and leadership differences in qualitative research: is meaning lost in
are imperative for developing this initiative translation? Eur J Ageing. 2010;7(4):313–6.
and build the necessary trust to it. 9. Carter N, Bryant-Lukosius D, DiCenso A, Blythe J,
Neville AJ. The use of triangulation in qualitative
Limitations and strengths
research. In: Oncology nursing forum. 2014.
The major limitation of our research is its external
10. Birt L, Scott S, Cavers D, Campbell C, Walter F.
generalizability, as a major limitation of all qualitative
Member checking: a tool to enhance trustworthiness
studies. Our intention was to understand the deep or merely a nod to validation? Qual Health Res.
feelings, values and attitudes towards organ donation 2016;26(13):1802–11.

11. Morgan SE, Harrison TR, Afifi WA, Long SD, 13. Mathur M, Taylor S, Tiras K, Wilson M, Abd-Allah S.
Stephenson MT. In their own words: the reasons why Pediatric critical care nurses’ perceptions, knowledge,
people will (not) sign an organ donor card. Health and attitudes regarding organ donation after cardiac
Commun. 2008;23(1):23–33. death. Pediatr Crit Care Med. 2008;9(3):261–9.
12. DuBois JM, Waterman AD, Iltis A, Anderson J. Is rapid 14. Newton JD. How does the general public view
organ recovery a good idea? An exploratory study of posthumous organ donation? A meta-synthesis
the public’s knowledge and attitudes. Am J Transplant. of the qualitative literature. BMC Public Health.
2009;9(10):2392–9. 2011;11(1):791.

Conservative Management of Acute Appendicitis in a Tertiary Care Center
Ramesh Chhaganbhai Badhiya1, R. M. Jitia2, Haresh B. Vala3

1,2,3
Assistant Professor, Department of Surgery, Shantabaa Medical College & General Hospital Amreli, Gujarat
How to cite this article: Ramesh Chhaganbhai Badhiya, R. M. Jitia, Haresh B. Vala et al Conservative Management
of Acute Appendicitis in a Tertiary Care Centre. Volume 13 | Issue 4 | October-December 2022
Abstract
Background and Aim: Appendectomy is the most favored treatment of appendicitis in most of the cases. Considered safe
and routine surgery few patients develop complications of surgery like recurrent pain, obstruction, wound complications
and rarely fistula and death. Present study was done with an aim to study the outcome of conservative treatment in acute
appendicitis using antibiotic therapy.
Material and Methods: The present study was a prospective study conducted at the medical institute and associated
hospital for a period of 2 years. All the patients attending our emergency department with pain in the lower abdomen
were assessed clinically for signs of acute appendicitis. Injection ceftriaxone and injection metronidazole was given for
48-72 hours. Patients who responded for i.v. antibiotics were switched to tablet ciprofloxacin and tablet metronidazole for
7 days and followed for 6 months.
Results: In this present study, 200 patients were included. 168 patients had migratory abdominal pain in the present
study. Anorexia was seen in 180 patients and absent in 20 patients. 174 patients had nausea and vomiting. Tenderness in
the right inguinal fossa was seen in all the patients. Rebound tenderness was seen in 68 patients and absent in 132 patients.
Conclusion: The overall success rate of conservative treatment according to the present study was 82%. However, there
were 12% failures and 6% recurrences in the present study. The success rate of conservative treatment in patients with
MAS 4-6 is more than the patients with MAS 7-9 according to the present study.
Keywords: Acute appendicitis, Anorexia, Lower Abdomen, Tenderness
Introduction of appendicitis: simple appendicitis with no tendency

Acute appendicitis is one of the commonest causes to progress, and complex appendicitis.6,7
of acute abdomen with life time risk of 7-8%. In the pre-antibiotic era, acute appendicitis
Appendectomy is the most favored treatment progressed from uncomplicated to complicated
of appendicitis in most of the cases.1 Even after appendicitis, so it prompted the surgeon McBurney
clinoradiological diagnosis 10 percent of cases to implement appendectomy for all the cases of
after appendectomy appendix is found normal.1-3 acute appendicitis. But appendectomy has its own
Considered safe and routine surgery few patients complications, morbidity and mortality. In the
develop complications of surgery like recurrent pain, antibiotic era surgeons gave a trial of conservative
obstruction, wound complications and rarely fistula treatment for acute appendicitis. The nonoperative
and death.4,5 Based on epidemiologic, radiologic, conservative management of uncomplicated
and pathologic studies, several authors no longer acute diverticulitis and salpingitis has been well
consider appendicitis as an invariably irreversible established but the non-operative management of
progressive disease.6-10 Rather, they envisage 2 types acute appendicitis is yet to be explored. Most authors
Dr. Ramesh Chhaganbhai Badhiya
Shantabaa Medical College & General Hospital Amreli, Gujarat
conclude that antibiotic treatment alone is less effective findings were documented. MAS was calculated and
than an appendectomy and therefore promote documented. Patients were advised nil by mouth for
appendectomy.11-15 However, the methodologic 24 hours and administered intravenous antibiotics
quality of the included studies was low to moderate, ceftriaxone every 12 hours and metronidazole every
there was considerable statistical heterogeneity, and 8 hours with dose depending on age of the patient for
these inferences continue to be questioned.14,15 In 48-72 hours. Paracetamol infusion was given every 8
addition, potential longterm disadvantages of surgery hours to relieve the pain of the patient. The clinical
in children have not been evaluated adequately. assessment was done every 12 hours. Patients who
responded for i.v. antibiotics were switched over to
Recent studies showed majority of patients with
oral antibiotics- tablet ciprofloxacin 500 mg with tablet
acute, uncomplicated appendicitis can be treated
metronidazole 400 mg thrice a day for a total of 7
safely with an antibiotics-first strategy. Antibiotics
days. In those patients, whose clinical condition were
which are more effective is used in the treatment
deteriorating or not improving, open or laparoscopic
of acute appendicitis. Antibiotic therapy is not a
appendectomy was performed. The patients were
complete substitute for surgery in the management
followed at 10 days and every month for a period of
of acute appendicitis. In this regard, we aimed to
6 months. The disease recurrence would be managed
study the outcome of conservative treatment in acute
either conservatively or surgically depending on the
appendicitis using antibiotic therapy.
clinical presentation and upon patient preference.
Material and Methods After completion of treatment and follow up for
6 months period, the patients were grouped into
The present study was a prospective study conducted
successful/failure of conservative treatment. Failure
at the medical institute and associated hospital for
of conservative treatment again divided into treatment
a period of 2 years. Institutional Ethics committee
failure and recurrence. Treatment failure was clinical
approval was taken before start of this study.
deterioration or lack of clinical improvement in
Inclusion criteria: Radiologically diagnosed acute admitted patients treated conservatively. Recurrence
appendicitis cases with age>10 years attending within was defined as onset of appendicitis in a follow up
2 days of symptom onset with Modified Alvarado patient successfully treated initially with conservative
score (MAS) more than or equal to 4. treatment.
Patients having guarding, rigidity, perforation, Statistical analysis
abscess, lump on clinical examination and radiological
The recorded data was compiled and entered in a
reports were excluded from study.
spreadsheet computer program (Microsoft Excel
All the patients attending our emergency 2007) and then exported to data editor page of SPSS
department with pain in the lower abdomen were version 15 (SPSS Inc., Chicago, Illinois, USA). For all
assessed clinically for signs of acute appendicitis. tests, confidence level and level of significance were
Ultrasound examination was done to diagnose set at 95% and 5% respectively.
acute appendicitis and to exclude other differential
diagnosis and complications of acute appendicitis. All Results
the patients who were diagnosed as acute appendicitis In this present study, 200 patients were included. The
radiologically without any other complications were minimum and maximum age in the present study
enrolled into the study considering the inclusion was 17 and 72 years. The mean age in this study was
and exclusion criteria. The patients were counseled 35.10. 88 males and 112 females were included in this
for conservative treatment of acute appendicitis, study. 168 patients had migratory abdominal pain in
explaining all the pros and cons of the treatment. The the present study. Anorexia was seen in 180 patients
patients who were willing to undergo conservative and absent in 20 patients. 174 patients had nausea and
management were included in this study after taking vomiting. Tenderness in the right inguinal fossa was
written informed consent. All the demographic date seen in all the patients. Rebound tenderness was seen
like age, sex, occupation, contact details and address in 68 patients and absent in 132 patients. 188 patients
were recorded from the patient. Detailed history was in this study had leucocytosis and 90 patients had
taken and abdomen was examined thoroughly and fever (Table 1).
signs of acute appendicitis were noted. The ultrasound

362
CT scan was performed in 18 cases and ultrasound Overall post appendectomy complication rates are
was done in 182 cases for diagnosis of acute around 10-19% for appendicitis without perforation
appendicitis. MAS was in between 4-6 in 56 patients and can reach up to 30% with perforation.6,7 So if
and was 7-9 in 144 patients with an average of 7.29. appendectomy treated successfully with antibiotics,
24 patients had complicated acute appendicitis and morbidity and mortality can be avoided.
176 had uncomplicated acute appendicitis. Acute
Advantages of conservative management over
appendicitis was resolved in 48 hours in 62 patients
surgical management include: i) Antibiotics offer an
and in 114 cases it resolved in 72 hours. Conservative
alternate source of treatment for acute appendicitis
treatment failed in 24 cases in this study. In those
when access to surgical areas are not easily available.
24 cases, 12 cases who had appendicular mass was
ii) Antibiotic treatment offers a low cost treatment for
treated with i.v. antibiotics for 5 days, 8 cases who
acute appendicitis patients. Hansson et al, reported
had perforation was operated and in 4 cases who had
25-50% reduction in the cost of hospital expenses
abscess, extraperitoneal drainage was performed. 176
among conservatively treated patients than patients
cases were followed for a period of 6 months and 12
treated surgically. 5 iii) Conservative treatments with
cases recurred over a period of 6 months (Table 3).
antibiotics avoid the anaesthesia risks of surgery
Table 1: Distribution of clinicopathological factors and also eliminate the morbidity and mortality
in the present study associated with surgery. iv) In remote areas where the
Clinicopathological Number Percentage diagnostic facilities are lacking acute abdominal pain
factors (%) might be misdiagnosed as acute appendicitis leading
to negative appendectomies. In such scenarios
Migratory abdominal 168 84
pain conservative treatment avoids unnecessary removal
of appendix. According to a study by Sebastiano,
Anorexia 180 90
neuroproliferation is involved in the pathophysiology
Nausea and vomiting 174 87 of acute abdominal pain even in the absence of
Tenderness 200 100 inflammation of appendix. There is an increase in the
Fever 90 45 neurotransmitters like substance P and vasoactive
Leucocytosis 188 94 intestinal polypeptide in such cases of neuro immune
appendicitis.16 This neuroimmune appendix might
Table 2: Outcome of conservative treatment in the be the aetiology of acute abdominal pain in negative
present study
appendicitis.
Conservative Number Percentage (%)
In the present study, the mean age of presentation
treatment outcome
was 35.10±9.45. According to Gedam et al, the mean
Successful 164 82 age in their study was 30.45±9.71 years.17 The majority
Failure 24 12 of patients were seen in the age group of 21-30 years
Recurrence 12 6 which was consistent with the study of Rajasekhar et
al and Lohar et al.18,19 There was female predominance
Table 3: Outcome of conservative treatment with
different MAS in this study with male to female ratio 1:1.32 which
was compared to a study by Gedam et al, which was
Conservative Modified Alvarado score 1:1.09.17
treatment 4-6 7-9
Abdominal pain was seen in 84% of patients which
Successful 56 120 was contrary to the study conducted by Ekka et al,
Failure 0 24 which was seen in 100% of patients.20 Anorexia was
Total 56 144 seen in 90% of patients in the present study, whereas
anorexia was seen in 61% of patients in a study by
Discussion Berry et al.21 87% of patients had nausea/vomiting
Worldwide the standard of care for appendicitis is in this present study, which was similar to a study
appendectomy and considered simple and routine by Kodliwadmath. 45% of patients had fever in
surgery.1 However the mortality rate of operation this study, but Reddy et al reported fever in 76% of
ranges from 0.07 to 0.7 and from 0.5 to 2.4% in patients in their study. 16 94% of patients in this study
patients without and with perforation respectively. had leukocytosis, but Ekka et al reported leukocytosis

in 66.4% of patients in their study.20 Tenderness in References

right inguinal fossa was seen in all 100% of patients 1. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The
and rebound tenderness was seen in 68 patients. An epidemiology of appendicitis and appendectomy in
eastern Indian study reported tenderness in right US. Am J Epidemiol., 1990; 132: 910-23.
inguinal fossa in 89.6% and rebound tenderness in
2. Raja AS, Wright C, Sodickson AD, Zane RD, Schiff
72.8% of patients.20
GD, Hanson R, Baeyens PF, Khorasani R. Negative
In the present study, ultrasound was performed in appendectomy rate in era of CT: An 18-year
91% of cases. CT scan was performed in the remaining perspective: Radiology, 2010; 256(2): 460-5.
9% of cases in this study as ultrasound can’t able 3. Colson M Skinner, Dunnington G. High negative
to detect the features of acute appendicitis. In the appendectomy rates are no longer acceptable. Am J
present study, 28% of patients had MAS in between Surg., 1997; 174: 723-7.
4-6 and 72% had in between 7-9. The conservative
4. Franz MG, Norman J, Fabri PJ. Increased morbidity
treatment was successful in all the patients with MAS of appendicitis with advancing age. Am Surg., 1995;
of 4-6. According to the results of the present study, 61(1): 40-4.
majority of patients recovered in 72 hours, so at least
72 hours should be awaited to detect the response 5. Mason RJ. Surgery for appendicitis: is it necessary.
Surg infect (Larchmt), 2008; 9: 481-8.
for conservative treatment. In the present study,
conservative treatment failed in 12% of patients. In a 6. Livingstone EH, Woodward WA, Sarosi GA,
study done by Mumtaz et al, 11.1% of patients had et al. Disconnect between the incidence of non-
failure of conservative treatment which was similar perforated and perforated appendicitis: implications
to our present study.21 In a study done by Gedam et for pathophysiology and management. Ann Surg
al the success rate was 74.65%, and failure rate was 2007;245:886-92.
14.08% which was similar to the present study.17 In the 7. Andersson RE. The natural history and traditional
present study the recurrence rate among successfully management of appendicitis revisited: spontaneous
treated acute appendicitis cases was 6%. In a study resolution and predominance of prehospital
done by Gedam et al, the recurrence rate was 13.11% perforations imply that a correct diagnosis is more
which was higher than our present study.17 According than an early diagnosis. World J Surg 2007;31:86-92.
to a study by Malik, the recurrence rate was 10% 8. Narsule CK, Kahle EJ, Kim DS, et al. Effect of delay
which was slightly higher than our present study.23 in presentation on rate of perforation in children with
appendicitis. Am J Emerg Med 2011;29:890-3.
Conclusion
9. Carr NJ. The pathology of acute appendicitis. Ann
The overall success rate of conservative treatment Diagn Pathol 2000;4:46-58.
according to the present study was 82%. However,
there were 12% failures and 6% recurrences in the 10. Cobben LP, de Van Otterloo AM, Puylaert JB.
present study. The success rate of conservative Spontaneously resolving appendicitis etc. Radiology
2000;215:349-52.
treatment in patients with MAS 4-6 is more than the
patients with MAS 7-9 according to the present study. 11. Varadhan KK, Neal KR, Lobo DN. Safety and efficacy
Uncomplicated acute appendicitis can be managed of antibiotics compared with appendicectomy for
by conservative treatment provided they were strictly treatment of uncomplicated acute appendicitis:
followed every month for at least 6 months period to meta analysis of randomised controlled trials. BMJ
detect recurrences. 2012;344:e2156.
12. Wilms IMHA, de Hoog DENM, de Visser DC, Janzing

HMJ. Appendectomy versus antibiotic treatment for
ethical committee and written Informed
acute appendicitis (review). Cochrane Database Syst
Consent was taken from all the participants. Rev 2011:CD008359.
Source of funding: Nil 13. Mason RJ, Moazzez A, Sohn H, Katkhouda N. Meta-
analysis of randomized trials comparing antibiotic
Conflict of Interest: None declared therapy with appendectomy for acute uncomplicated
(no abscess or phlegmon) appendicitis. Surg Infect
(Larchmt) 2012;13:74-84.

364
14. Ansaloni L, Catena F, Coccolini F, Ercolani G, Gazzotti 19. Asger Calcuttawala M, Nirhale D, Athavale V,
F, Pasqualini E, et al. Surgery versus conservative Malhotra M, Priyadarshi N, Lohar H. Epidemiological
antibiotic treatment in acute appendicitis: a systematic aspects of appendicitis in a rural setup. Med J Dr DY
review and meta-analysis of randomized controlled Patil Univ. 2014;7(6):753.
trials. Dig Surg 2011;28:210-21.
20. Ekka NMP. A Clinicopathological study of acute
15. Liu K, Fogg L. Use of antibiotics alone for treatment of appendicitis in eastern India. Int J Med Dent Sci.
uncomplicated acute appendicitis: a systematic review 2016;5(2):1145.
and meta-analysis. Surgery 2011;150:673-83.
21. Berry J, Malt RA. Appendicitis near its centenary. Ann
16. Di Sebastiano P, Fink T, Di Mola FF, Weihe E, Innocenti Surg. 1984;200(5):567-75.
P, Friess H, et al. Neuroimmune appendicitis. Lancet.
22. Alnaser MK, Hassan QA, Hindosh LN. Effectiveness
1999;354(9177):461-6.
of conservative management of uncomplicated acute
17. Gedam BS, Gujela A, Bansod PY, Akhtar M. Study appendicitis: A single hospital based prospective
of conservative treatment in uncomplicated acute study. Int J Surg Open. 2018;10:1-4.
appendicitis. Int Surg J. 2017;4(4):1409.
23. Malik AA, Bari SU. Conservative management of acute
18. Jade R, Muddebihal UM. Modified Alvarado Score and appendicitis. J Gastrointest Surg. 2009;13(5):966-70.
its application in the diagnosis of acute appendicitis.
Int J Contemp Med Res. 2016;3(5):2454-7379.

Original Research Article Indian Journal of Public Health Research & Development
A cross-sectional study on Quality of life and stress

among nursing students in Central Karnataka.
Rashmi. B.M.1 , Sindhu. B.M.2*, Abhinandan.S.Kumbar3
1
Associate Professor, Department of Community Medicine, Basaveshwara Medical College & Hospital, S.J.M Campus,
N.H.4(48) Bypass road, Chitradurga-577502. Karnataka, India
2
Assistant Professor, Department of Community Medicine, Basaveshwara Medical College & Hospital, S.J.M Campus,
N.H.4(48) Bypass road, Chitradurga-577502. Karnataka, India
3Associate Professor,Department of Respiratory Medicine,Basaveshwara Medical College & Hospital,S.J.M Campus,N.H.4(48)
Bypass Road,Chitradurga-577502.Karnataka, India
How to cite this article: rashmi. B.M., Sindhu. B.M., Abhinandan. S.Kumbar. et al A cross-sectional study on Quality
of life and stress among nursing students in Central Karnataka. Volume 13 | Issue 4 | October-December 2022
Abstract
Introduction: Various studies have shown higher levels of stress and lower quality of life (QoL) among healthcare
students compared to others. This study was done to assess the quality of life and perceived stress levels among nursing
students and correlation between them. The symptoms in case of stress and coping strategy for stress were also studied.
Methodology: All students studying in a nursing college in Central Karnataka were interviewed. WHO Qualtiy of Life-
Bref (WHOQOL-BREF) scale and Perceived Stress scale (PSS-10) were used to assess the Quality of life and perceived
stress levels respectively.
Results: 175 students participated. Psychological domain and environment domain scores (55.6 and 53.8 respectively)
were lower. Significant negative correlation was observed between all the domains of Quality of life and Stress scores.
Majority (81.7%) of nursing students were under moderate stress.
Conclusion: Efforts should be made to improve the Quality of life of nursing students. Effect of various better coping
methods for stress should be researched and taught to them.
Keywords: Quality of Life, Stress, Coping strategy, nursing students.
Introduction studies have found higher stress levels among

WHO defines Quality of Life as “an individual’s students, and still more among students in healthcare
perception of their position in life in the context of field. Various socio-demographic, college related
the culture and value systems in which they live and factors are associated with stress.3-10 There are lesser
in relation to their goals, expectations, standards number of studies in this area in India. Hence, the
and concerns”. Many physical, psychological, social, present study was done to assess the quality of life
demographic, environmental factors affect quality of and perceived stress levels among nursing students
life.1 and correlation between them, to find out various
symptoms experienced in case of stress and coping
Psychological stress, as defined by Lazarus and strategies used by students in case of stress. This can
Folkman (1984) is “a particular relationship between help administrators, college managements to address
the person and the environment that is appraised by the factors to improve quality of life and decrease
the person as taxing or exceeding his or her resources stress levels among nursing students.
and endangering his or her well-being”.2 Various
Corresponding author
Dr. Sindhu B.M.
Assistant Professor, Department of Community Medicine, Basaveshwara Medical College & Hospital, S.J.M Campus, N.H.4(48) Bypass
Road, Chitradurga-577502. Karnataka, India
366
Methodology respondents, a majority (96.6%) belonged to age-

After obtaining institutional ethics committee group of 18-22 years, 77.1% were females, 68% were
clearance, this study was conducted among nursing from rural area, 87.4% were pursuing B.Sc. Nursing
students studying in SJM Institute of Nursing course whereas 12.6% were studying General Nursing
Sciences, Chitradurga, Karnataka from August to and Midwifery (GNM). A higher percentage of 76.6%
September 2022. Permission from the head of the were currently residing in hostel accommodations,
institution was taken. Universal sampling was done. 16% resided at their homes and 7.4% students opted
The purpose of the study was explained and a pre- for other accommodations such as paying guest
designed self-administered questionnaire was sent to facilities or sharing flats with friends. (Table 1).
all the students via google forms. The responses from 149 respondents (85.1%) reported that they were
all those students who consented to participate in the currently ill. 49% reported their overall quality of
study and returned fully filled questionnaire forms life as ‘good’. Followed by ‘neither poor nor good’,
were considered for analysis. ‘poor’, ‘very good’, ‘very poor’ (29%, 11%, 6% and
WHO Quality of Life Bref (WHOQOL-BREF) scale 5% respectively). 61% reported ‘satisfied’ for self-
was used to assess the Quality of life and Perceived reported satisfaction with one’s health. Followed by
Stress Scale -10 (PSS-10) scale was used to assess ‘neither satisfied nor dissatisfied’, ‘dissatisfied’, ‘very
perceived stress levels. WHOQOL‑BREF is a 26‑item satisfied’ (19%, 10%, 7% respectively). Least was for
survey with respect to experiences in past 2 weeks. It ‘very dissatisfied’ (3%).
evaluates quality of life (QOL) in 4 domains: Physical Mean of social relationship domain of WHOQOL-
health, psychological health, social relationships, and BREF was maximum (71.9±20, median = 75). This
environment. It has single item questions for Overall was followed by that of physical domain (65.5±14.7,
QOL and satisfaction with health as well. It is a likert- median = 63), psychological domain (55.6±16.8,
scale ranging from 1 (very poor) to 5 (very good). median = 56), environment domain scores (53.8±15.4,
This survey has been used in diverse populations median = 56). PSS scores ranged from 7 to 29, with
wherein good reliability with Cronbach’s α of 0.68– a mean of 18.6 (SD = 4.3, median = 19). (Figure 1).
0.82 is shown. Final scores can be transformed into Most of the students (81.7%) were under moderate
0-100 measured in a positive direction. Higher scores stress. 12% and 6.3% were under low and high stress
Figure 1: The description of Domain Scores of WHOQOL-BREF Scale and Perceived Stress
indicate better quality of life. respectively.
Levels as per PSS-10 Scale.
PSS-10 is a survey with 10 questions. It is self-

reported measure of amount of stress with respect
to experiences in the past 1 month. Questions have
responses in a likert-scale ranging from 1 (never) to 5 Q3=75
Q3=75
Median=75
(always). Responses to questions 4,5,7,8 are reversed Q3=69 Q1=47
and overall total is calculated which ranges between 0 Median=63 Q3=63
Median=56
Q1=56 Median=56
to 40. Low stress is 0-13. And 14-26, 20-40 are moderate

Q1=47
stress and high stress respectively. Q1=44
Data was entered in Microsoft excel and analysed

using SPSS V 20. Qualitative variables are presented Q3=21
Median=19
as frequencies and percentages. Quantitative variables

Q1=16
are presented as mean, SD, median and mode.

Statistical tests like t-test, ANOVA, Mann- Whitney
test, Kruskal Wallis test were used for statistical
analysis. P value less than 0.05 was considered as Figure 1: The description of Domain Scores of
statistically significant. WHOQOL-BREF Scale and Perceived Stress Levels
as per PSS-10 Scale.
Results
A total of 175 nursing students participated in
the present study. It was found that, among the

Table 1: Quality of Life domains and PSS scores with respect to various socio-demographic variables
Socio- Frequency WHOQOL-BREF domains PSS Score
demographic n (%) Physical Psychological Social Environment
variables domain Relationships domain
Domain
domain
Mean ± SD Mean ± SD
Mean ± SD
(Median) Mean ± SD (Median)
(Median)
(Median)
Sex
Male 40 (22.9%) 69.8±14.7 60.3±17.7 78.7±17.9 57.9±13.8 18.1±4.0
(69) (56) (75) (56) (19)
Female 135 (77.1%) 64.2 ±14.5 54.3 ± 16.3 69.9±20.2 52.6±15.7 18.7±4.4
(63) (56) (75) (56) (19)
Mann- 2209.5, 2235.5, 2032, 2253, 2526
Whitney U,
p>0.05 p>0.05 p<0.05 p>0.05 p>0.05
p-value
Academic Year of studies
1st year 69 (39.4%) 65.7±12.4 56.5±13.8 74.5±17.8 54.6±12.2 18.2±3.6
(63) (56) (75) (56) (19)
2 year
nd
49 (28.0%) 64.0±16.9 55.1±19.7 65.9±26.4 51.7±17.1 19.9±4.8
(69) (56) (75) (56) (20)
3 year
rd
31 (17.7%) 66.7±17.1 55.9±18.2 72.9±12.9 54.6±17.3 18.2±5.1
(69) (56) (75) (56) (19)
4 year
th
26 (14.9%) 66.2±12.9 54.0±17.0 75.1±17.2 54.6±17.8 17.6±3.6
(63) (56) (75) (56) (17)
Kruskal 0.346, df:3 0.262, df:3 3.495, df:3 0.594, df:3 F (3,174) =
Wallis H, 2.209 ,
p<0.05 p>0.05 p>0.05 p>0.05
df, p-value p > 0.05
Present accommodation
Home 28 (16.0%) 68.8±15.0 54.6±16.2 72.9±16.9 55.9±15.7 16.5±4.5
(63) (56) (75) (56) (16)
Hostel 134 (76.6%) 63.7±14.2 54.9±17 70.5±20.9 52.7±15.6 19.2±4.3
(63) (56) (75) (56) (19)
Others 13 (7.4%) 76.5 + 13.1 64.4+ 13.9 84.7 + 12.2 60.2 + 11.4 17.0±2.6
(75) (56) (75) (56) (16)
Kruskal 8.876, df:2 2.845, df:2, 6.580, df:2, 2.751, df:3 9.892, df:2,
Wallis H,
p<0.05 p>0.05 p<0.05 p>0.05 p<0.05
df, p-value
Significant negative correlation was seen between all the domains of quality of life and the PSS scores (r
= -0.38, -0.34, -0.35, -0.3 between PSS scores and physical domain, psychological domain, social relationship
domain, environment domain scores respectively).

Fig 2: Symptoms experienced during stress
368
Indecisiveness 1.1
Agitation 4.6
GIFig 2:
upset Symptoms
6.3 experienced during stress
environmental domain scores (67.81 ± 17.39) and
Abnormal behavior Indecisiveness
like nail biting 1.1 12.6 psychological health domain scores (64.37 ± 14.27)
Appetite change
Agitation 4.6 15.4 were found to be higher than those from our study.6
Forgetfulness
GI upset 20
Social relationship domain scores were significantly
6.3
Abnormal behavior likeAvoidance

nail biting 12.6 22.3
Worrying
Appetite change 15.4 23.4
different with respect to sex. Malibary H et al reported
Low confidence
Forgetfulness 20 28 no significant difference between sex and various
Sleep disturbance
Avoidance 22.3 49.1 domains of Quality of Life.6 In the study on medical
Worrying
Headache 23.4 57.1 students in China by Zhang Y et al, males had
Low confidence 0 10 20 2830 40 50 60
significant higher scores than females in the physical
Sleep disturbance 49.1
Headache 57.1
and psychological health domains.8 They reported
0 10 20 30 40 50 60
significantly higher scores for females for social
relationships domain. Blebil A et al found significant
Fig 3: Coping strategy practiced for managing stress association between sex and QoL in their study on
pharmacy students in Malaysia.9
Consumption of tobacco/alcohol 2
Fig 3: Coping strategy practiced for managing stress We found no significant difference between
Reading/Diary writing 9
domains of Qol and urban or rural place of origin.
Zhang Y et al found significantly higher scores for
Consumption of tobacco/alcohol 2
Practice of Meditation/Yoga/Breathing Exercises 17
Reading/Diary writing 9 psychological health and social relationships domains

Mobiles/TV/Gadget usage 20
Practice of Meditation/Yoga/Breathing Exercises 17

in urban students compared to rural ones.8
Praying to God/ Discussing with family and friends, 22
Mobiles/TV/Gadget usage 20 We found no significant difference with QoL with

Listening to music 30
respect to year of studies. Malibary H et al, Moritz
Praying to God/ Discussing with family and friends, 22
Resting. Sleeping 37.7 AR et al reported similarly.6,10 Blebil A et al reported
Listening to music
0 5 10 15 20 25
30
30 35 40
otherwise.9 Zhang Y et al found significant difference
Resting. Sleeping
PERCENTAGE
37.7
for psychological health and social relationships
domains scores with respect to year of studies.8
Discussion
0 5 10 15 20 25 30 35 40
PERCENTAGE
We found significant difference with physical
The present study was done to assess the quality health, social relationships domains of QoL and
of life, stress levels among students studying in a place of staying/accommodation. Blebil A et al found
nursing college in Central Karnataka. The symptoms otherwise.9
in case of stress and coping strategy for stress were
also studied. In our study, PSS-10 total scores range was 7 – 29.
Whereas, 0-35 was found in the study on University
In our study, only 6% respondents reported overall students in Saudi Arabia by Anwer S et al.11 Mean PSS-10
QoL as ‘very good’. Whereas in the study on medical total score was 18.58±4.32. Manzar MD et al (University
students in Saudi Arabia by Malibary H et al, it was students in Ethiopia) and Opoku-Acheampong A et
33.6%.6 Only 7% respondents reported satisfaction al (pharmacy students, Ghana) reported similarly
with health as ‘very satisfied’. Malibary H et al, (18.07±4.72 and 18.06±6.21).12-13Slightly lower average
reported it as 23.7%.6 (16.28±5.93) was seen in study by Anwer S et al.11
Average for WHOQOL-BREF scores for physical Slightly higher means were seen in studies by Lippke
health domain, psychological health domain, social S et al (international students studying at a German
relationships domain, environment domain were University), Henning MA et al (pre-medical and
65.45±14.67, 55.63±16.77, 71.91±20.03, 53.78±15.43 health science students in New Zealand) and Gupta K
respectively. Alkatheri AM et al reported lower et al (college students in India) (19.89±6.90, 20.24±7.33,
scores for physical (57.1) and social relationship 20.43±6.30 respectively).14-16
domains (58.3) and higher scores for psychological Majority of students (81.7%) had moderate stress,
(58.3) and environment domains (62.5) in their followed by low (12%) and high stress (6.3%). Gajula
study on students studying in a Health Sciences M et al, in their study on adolescent school students in
University in Saudi Arabia.7 Malibary H et al reported India, reported higher proportion of students in high
lower scores for social relationship domain (55.67 ± stress (24.44%).17
23.95) and physical domain (46.94 ± 14.24). Whereas

We found no significant difference with respect 4. Henning K, Ey S, Shaw D. Perfectionism, the imposter
to stress and sex of students. Gupta K et al reported phenomenon and psychological adjustment in
similarly.16 Whereas, Karaca A et al, in their study medical, dental, nursing and pharmacy students.
on nursing students in Turkey, reported otherwise.18 Med Educ. 1998 Sep;32(5):456-64. doi: 10.1046/j.1365-
2923.1998.00234.x.
We found no significant difference with respect to
stress and year of studies. Karaca et al and Opoku- 5. Marshall LL, Allison A, Nykamp D, Lanke S. Perceived
Acheampong A et al reported similarly.18, 13 stress and quality of life among doctor of pharmacy
students. Am J Pharm Educ. 2008 Dec 15;72(6):137. doi:
Significant negative correlation was seen between 10.5688/aj7206137.
physical health domain, psychological health
domain, social relationships domain, environment 6. Malibary H, Zagzoog MM, Banjari MA, Bamashmous
RO, Omer AR. Quality of Life (QoL) among medical
domain scores with PSS scores (-0.382, -0.337, -0.354,
students in Saudi Arabia: a study using the WHOQOL-
-0.3 respectively). Alkatheri AM et al also reported
BREF instrument. BMC Med Educ. 2019 Sep 9;19(1):344.
similarly.7
doi: 10.1186/s12909-019-1775-8.
Conclusion 7. Alkatheri AM, Bustami RT, Albekairy AM, Alanizi
Physical health, Psychological health and environment AM, Alnafesah R, Almodaimegh H et al. Quality
domains scores (65.4, 55.6 and 53.8 respectively) were of Life and Stress Level Among Health Professions
Students. Health Prof Educ [Internet]. 2020 [cited
lower. Efforts should be made to improve them.
2022 Aug 23]; 6(2): 201-10. Available from: https://
Majority (81.7%) of nursing students were under www.sciencedirect.com/science/article/pii/
moderate stress. Effect of various better coping S245230111930094X
methods should be researched and taught to them to 8. Zhang Y, Qu B, Lun S, Wang D, Guo Y, Liu J. Quality
handle stress. of life of medical students in China: a study using the
WHOQOL-BREF. PLoS One. 2012;7(11):e49714. doi:
Limitations of the study
10.1371/journal.pone.0049714.
Being a single-centre study, the present study results
9. Blebil A, Dujaili J, Mohammed AH, Cheong CM, Hoo
cannot be generalised to the students of all the health
Y. The effect of stress and depression on quality of life of
care courses. Regional or national level multi-centric
pharmacy students in Malaysia. Pharmacy Education.
studies have to be done to know quality of life, stress, 2021 Aug 9;21(1):323-3. Available from: https://
coping methods in case of stress among students of pharmacyeducation.fip.org/pharmacyeducation/
various health care courses’ students. article/view/1228/1148
Ethical Clearance: Ethical Clearance was 10. Moritz AR, Marques Pereira E, Pereira de Borba K,
obtained from the institutional ethics committee Clapis MJ, Gryczak Gevert V, de Fátima Mantovani M.
of Basaveshwara Medical College and Hospital, Quality of life of undergraduate nursing students at a
Chitradurga, prior to the commencement of the study. Brazilian public university. Invest Educ Enferm. 2016
Oct;34(3):564-572. doi: 10.17533/udea.iee.v34n3a16.
Source of funding: Self
11. Anwer S, Manzar MD, Alghadir AH, Salahuddin
Conflict of interest: Nil M, Abdul Hameed U. Psychometric Analysis of the
Perceived Stress Scale Among Healthy University
References Students. Neuropsychiatr Dis Treat. 2020 Oct
1. WHOQOL: Measuring Quality of Life [Internet] [cited 19;16:2389-2396. doi: 10.2147/NDT.S268582.
24 Aug 2022]. Available from: https://www.who.int/
12. Manzar MD, Salahuddin M, Alghadir A, Anwer
tools/whoqol
S, Peter S, Bahammam AS, Pandi-Perumal SR.
2. Lazarus R, Folkman S. Stress, appraisal and coping. Psychometric properties of the Generalized Anxiety
New York: Springer Publishing; 1984. Disorder-7 Scale in Ethiopian university students. Bull
Menninger Clin. 2021 Fall;85(4):405-427. doi: 10.1521/
3. Dutta AP, Pyles MA, Miederhoff PA. Stress in health
bumc.2021.85.4.405.
professions students: myth or reality? A review of the
existing literature. J Natl Black Nurses Assoc. 2005 13. Opoku-Acheampong A, Kretchy IA, Acheampong F,
Jul;16(1):63-8. Afrane BA, Ashong S, Tamakloe B et al. Perceived stress

370
and quality of life of pharmacy students in University 16. Gupta K, Kiran NC. Empathy and Perceived
of Ghana. BMC Res Notes. 2017 Mar 2;10(1):115. doi: Stress among College Students. Int Indian Psychol.
10.1186/s13104-017-2439-6. 2021;9(2):220-31. doi: 10.25215/0902.027
14. Lippke S, Schalk TM, Kühnen U, Shang B. Pace of life 17. Gajula M, Bant D, Bathija GV. Perceived Stress among
and perceived stress in international students. Psych J. Adolescent School Students in Hubli: A Cross-Sectional
2021 Jun;10(3):425-36. doi: 10.1002/pchj.426. Study. Natl J Community Med 2021;12(7):169-74. doi:
10.5455/njcm.20210625054326
15. Henning MA, Krägeloh CU, Booth R, Hill EM, Chen J.
Webster C. An exploratory study of the relationships 18. Karaca A, Yildiirim N, Ankarali H, Acikgoz F, Akkus D.
among physical health, competitiveness, stress, Nursing Students’ Perceived Levels of Clinical Stress,
motivation, and grade attainment: Pre-medical and Stress Responses and Coping Behaviors. J Psychiatr
health science students. Asia Pac Scholar. 2018; 3(3): Nurs. 2017;8(1):32-39. doi: 10.14744/phd.2017.22590
5-16. doi: https://doi.org/10.29060/TAPS.2018-3-3/
OA1054

Original Article Indian Journal of Public Health Research & Development
Sleep quality and predictors of sleep disturbances among adult patients

admitted in a selected hospital, Mangaluru.
Amala Sibichan1, Albeena Binu2, Aleena Anil3, Alphonsa Mathew4, Amitha K Joy5
1,2,3,4,5,6
III year UG students, Father Muller College of Nursing
How to cite this article: Amala Sibichan, Albeena Binu, Aleena Anil, Alphonsa Mathew, Amitha K Joy et al Sleep
quality and predictors of sleep disturbances among adult patients admitted in a selected hospital, Mangaluru.
Abstract
Sleep has an important role in maintaining health. Being active and energetic inversely related to the quality of sleep. We
can say that sleep is an important parameter to measure health and vitality. Sleep disturbance is common among patients
admitted in the hospital. A new place, new people, pain and various amounts of discomfort, fear, hospital routines and
many more parameters can disturb the sleep of those patients admitted in the hospital. The patients admitted in the
general wards get almost no choice to postpone their bedside procedures to their preferred time. Somewhere over the
line, we need to realize the predictors of sleep disturbance in the hospital environment and take measures to tackle those
factors. We need to look at those situations at the patient’s point of view and implement changes in our routines. Though
nurses write sleep status of each patient at night, their assessment on sleep quality is not measured with any standard
tools. This study would help to implement such strategies to take specific actions on those factors which cause sleep
deprivation.
Objective of the study: The aim of this study is to assess the quality of sleep and to identify the predictors of sleep
disturbance among hospitalized patients.
Methods and materials:A descriptive survey designwas used for this study. The sample consists of 60 adult patients
admitted in the medical wards of a selected medical hospital. The subjects were selected by using purposive sampling
technique.The tool has been prepared by the investigators keeping in mind those concepts presented by the U.S.National
sleep foundation on the quality of sleep. The data were obtained by sleep quality index and using a five- point rating scale
to assess the predictors of sleep disturbances.
Results: Out of total patients 48.3% of them had fair sleep during hospitalization and 30% of them had poor sleep and
only 21.7% of them had good sleep. Most of the sleep distracters (78.3%) found to be at low level, 20% of the sleep
distracters were present in moderate level and 1% in high level. Conclusion: The present study shows that many patients
do have sleep deprivation due to a wide variety of factors. This shows that health personnel need to be extra conscious
and cautious in planning the activities for their patients and minimize distractions.
Keywords: Sleep quality, sleep pattern, sleep predictors, sleep distracters, Patients, Adults and Hospital.
Introduction personal feelings and comfort. Sleep is considered

Every patient admitted in the ward expects to have as an important parameter to gain vitality; yet, most
a comfortable stay and a speedy recovery. It’s a of the patients get disturbed by the hospital routines
common practice in the hospital to focus more on and get less sleep. Commencement of routine nursing
disease entity and pay a less attention to patient’s care starts at 5 am with the expectation of completing
Dr Devina E Rodrigues
Professor
Father Muller College of Nursing
Mangalore: 575002
[email protected]
9945516899
372
before the change of shift. Those wards having 40 -50 Exclusion Criteria for Sampling
patients obviously made to wake up early and it can
• Patients with hypertension and Diabetes
cause sleep disturbance among patients.Somewhere
Mellitus or any endocrine disorders
over the line, we need to realize the predictors of
sleep disturbance in the hospital environment and • Admitted in the private rooms
take measures to tackle those factors. We need to look • Those who are hospitalized for less than 2
at those situations at the patient’s point of view and days
implement changes in our routines.
• Those who are with sedatives
Materials & Methods
• Unconscious and disoriented patients
The data were collected from 60 adult patients
admitted in the general wards. Ethical consent was • Those who are not able to read Kannada
taken from the institutional ethics committee before ,Malayalam or in English
the data collection. The investigator explained the Statistics: SPSS 23 Version was used for analysis
purpose of the study to the subjects by using a detail
Subject participation information sheet. Informed Results
consent was obtained from the participants.The tool
was formulated by the investigator by using various Assessment of sleep quality of adult patients
literatures had 09 items on baseline variables, the The study results revealed that 48.3% of the subjects
Part B was on sleep quality which had 6 items with had fair sleep during hospitalization &30% of them
maximum scores of 15. The tool II was on predictors of had poor sleep and only 21.7% of them had good
sleep disturbances was a 5 point rating scale, this tool sleep.
had three parts. The first component was related to
Table 1: Mean, SD, Mean% and SEM scores
physical environment which had 4 items .The second
regarding sleep quality (N=60)
component was with 05 items ( patient related ) and
the third component ( Hospital facilities ) was with Variable Mean/ Mean% SEM 95 %CI
13 items .The entire tool was with 22 items with a SD
possible maximum scores of 110. The tool regarding Lower Upper
quality of sleep was tested for internal consistency Overall 11.77± 78.47 .27 11.24 12.30
using Chronbach’s Alpha and it was found to be.65. sleep 2.07
The predictors of sleep distracters was tested for quality
homogeneity using Chronbach’s Alpha and it was
found to be r =.60 Area I , r =.65 ,Area II, r =.82 .Both From the table 2, it can be interpreted that overall
the tools found to be reliable. sleep quality was fair among hospitalized patients.
Out of total subjects 57 of them had mean quality
Study design: Descriptive design sleep index scores of 11.24 to 12.30.
Selection & Description of participants: The data was
collected from the patients from three general wards. Assessment of Predictors of sleep distracters.
The data was collected at bedside. The information Table 2: Frequency and percentage distribution
sheet was given for the participants to read, after that of predictors of sleep disturbances among adult
only consent was obtained. No patients were forced patients. N =60
to participate and they were assured saying non
Variables f %
participation will not cause any changes or differences
in due health care. Overall predictors of sleep:
High level of sleep distracters 1 1.7
Criteria for the sample selection: Moderate level of sleep 12 20.0
Inclusion criteria: destructors
• Those patients between age group of 20-40 Low level of sleep distracters 47 78.3
years of age Physical aspects:
• Admitted in the general wards with medical High level of physical sleep 3 5.0
distracters
conditions only
Variables f % more than the study conducted in USA4. The study

conducted by Kusleikaiteet al showed that 66.7%
Moderate level of physical 26 43.0
of ESRD (End Stage Renal Failure) patients on HD
sleep distracters
(Hemodialysis) had poor sleep quality5. That means
Low level of physical sleep 31 52.0
two times more than our study results. Kusleikaite
distracters
says that sleep duration less than 6 hours /night
Patient related factors: can cause negative health outcomes5. The study
High level of patient related 2 3.3 conducted in a Chinese general hospitalreported poor
sleep distracters sleep quality (45·6%) during hospitalization and a
Moderate level of patient 21 35.0 reduction in sleep quality after hospitalization (57·4%)
related sleep distracters 6
. The study by Magdy in Egypt among critically ill
Low level of patient related 37 61.7 patients demonstrated 48% of the patients admitted to
sleep distracters the RICU (Reparatory Intensive CARE Unit) had poor
Hospital facilities related: sleep quality7. The study conducted by MarnJoon
High level of hospital related 0 0 Park discerns 86% of the hospitalized patients having
sleep distracters disturbed sleep 8. The study conducted by Pawar
in Maharashtra also supports the study, the author
Moderate level of hospital 7 11.7
related sleep distracters of the study has revealed 47.3% of the subjects had
insomnia, 26.3% had hypersomnia 9.
Low level of hospital related 53 88.3
sleep distracters
Factors causing sleep disturbances:
The above statistical table indicates 20% of the sleep
The overall most of the sleep distracters were found
distracters were present in moderate level and 1% in
to be at a low level (78.3%), 20% in moderate level
high level .From this it can be interpreted that most of
and found 1.7% in high level. Overall Mean % 46.59
the sleep distracters (78.3%) found to be at low level.
indicates distracters were at low level.
Around 43% of the physical factors were causing
moderate sleep destruction and 35% of the subjects Hospital related factors: Shoe sound said by 5% of the
‘personal factors were causing sleep destruction. subjects causing most of the time sleep disturbances
and 11.5% said, sometimes sound generated by the
Discussion: Sleep duration: The current study
shoes disturbed their sleep in the hospital. Regarding
indicates the Mean sleep duration of the subjects
bright hospital light, causing disturbances most of the
before the hospitalization7.53±1.38/24hrs and during
time was revealed by 18.4% of the subjects and 28.3%
hospitalization is 6.72±1.68. This indicates there was
agree upon causing sleep disturbance sometimes by
a reduction of at least 1 hour of sleep/day. The study
the presence of bright lights. Snoring: 21.7% of the
conducted by Jean reported the proportion of people
subjects said that snoring heard from the adjacent bed
reporting mid-range sleep (6.5 to 8.5hrs/24hrs)2. Mai
causing sleep disturbances whereas, 10% said always
study result found that highly statistically significant
their sleep disturbed by an adjacent patient’s snoring
correlation between the quality of sleep pattern before
habit .Loud talk: They were 38.3% of the subjects
and after hospitalization whereas (p=0.000)3. From
revealing loud talk by the health personnel disturbing
this it can be said that the above studies are on pace
their sleep and same factor is causing always sleep
with the current study results.
disturbance among 8.4% of the subjects. Around 22%
Sleep quality: From the present study it is said that poor bedding causing poor sleep .
discerning that 48.3% of them had fair sleep during
The study conducted by Chinese has shown the
hospitalization and 30% of them had poor sleep. From
using of toilets at night and sound generated from
the table it also can be stated that only 21.7% of them
the nurse’s shoes are one of the causes for sleep
had a good sleep.
distraction at night6. A study conducted by Hilde
The study conducted in the USA among chronically ill point out (70.4%) having been awakened by external
patients, out of total subjects 16.3% had severe sleep causes, out of which, (35.8%) concerned hospital
problems, 16.8% had moderate and 12.5% had mild staff10. The study conducted by Magdy highlights
sleep problems4. The current study, the proportion Noise (7.60±1.40) was the main sleep disruptive
of the subjects with poor sleep found to be two times factor; hospital staff conversations (7.77±1.38) and

374
medical staff pagers and phones (7.42±1.53) were 2) Wheel chair generating sounds, machine
the maximum noises7. Frequent use of light is alarms, bright lights, shoe sounds can be
the second influential factor for sleep disruption eliminated by sensitizing the people those
(6.82±1.31), followed by nursing interventions and engaged in such activities
blood sampling7. MarnJoon study results on noise in
Ethical clearance: The ethical clearance was obtained
ICU’S revealed the mean equivalent continuous noise
from the Institutional Ethics Committee (Ethical
level for 24 hours was 63.5 decibel A (DBA), which
Number: FMEC/CCM/36/19 dated 11-3-2019)
was far higher than 30 DBA recommended by the
World Health Organization for hospital wardrooms. Source of funding: Rajiv Gandhi University of Health
The most common sleep disturbed patient-perceived Sciences, Bangalore.
sources of noise were noise caused by other patients’,
Conflicts of Interest: None
caregivers and visitors (23.6%), followed by noise,
caused by other patients such as snoring or groaning, References
toilet flushing, medication/food trolleys and phone 1. Palesh OG, Roscoe JA, Mustian KM, et al. Prevalence,
or TV sound, medical staff, and medical equipment’s. demographics, and psychological.Associations of
sleep disruption in patients with cancer: University
Age and sleep quality: The subjects between 25-30
of Rochester Cancer Center-Community Clinical
years of age had better sleep than those subjects above
Oncology Program. J ClinOncol 2010; 28(2): 292–8.
30 years (23.07 and 20.06 respectively). These findings
further obvious in the worst sleep category too, the 2. Jean A. “Socio- economic positions and sleep quality
older adult in large proportion had bad sleep against among UK adults .J Epidemiol Community health.
those who below the age of 30.9 35.3% and 23.07% Mar 2006; 60(3): 267-269.
respectively). 3. Mai EM. Factors associated with sleep pattern
Disturbance among patients in critical care units. Mar
The study conducted by Jean had indicated that
2015; 4(2); 54.
as age advances the sleep reduction is obvious, the
subjects admitted of 25-35 years had less sleep to that 4. Michael M, San K, John E, Ware. Sleep problems,
of subjects under 25 years of age2. Cengic also said health-related quality utilization among the chronically
that the younger patients undergoing hemodialysis ill. Quality of life research. 2001; 10(1): 331-345.
had better sleep than the older adults11. 5. Kusleikaite N, Bumblyte IA, Razukeviciene L,
Sedlickaite D, Rinkūnas K. [Sleep disorders and
Strengths of the study quality of life in patients on hemodialysis]. [Article in
1) The study has helped to know the intensity Lithuanian] Medicina (Kaunas). 2005;41Suppl 1:69-74.
and type of factors causing Sleep disturbance
6. Zhang Lie, Yuan Q,WuQiuli,KwauksS,LiaoX,Wong
among patients admitted in the hospital C.Sleep quality and sleep disturbing factors of
2) It has helped the organization to sensitize inpatients in a Chinese general hospital. JCN .Sept
the hospital staff on factors contributing 2009;18(17):2521-29.
sleep disturbances and bring change in their 7. Magdy DM,Metwally A, MakhloufHA.Study
behaviors that can cause sleep disturbances. of sleep quality among patients admitted to the
Limitations: The study was limited to one time data respiratory intensive care unit.Egypt J Broncho (Serial
Online) 2019 (cited 2019 Jul 8);13:114-9.Available
collection and three wards of the hospital only.
from:http://www.ejbronchology.eg.net/text.
Implication of the study asp?2019/13/1/114/252188.
A present study is a foundation to undertake an 8. Park MJ, Yoo JH, Cho BW, Kim KT, Jeong WC, Ha
exploratory study on clients experience during the M. Noise in hospital rooms and sleep disturbance in
hospital stay. hospitalized medical patients. Environ Health Toxicol.
2014;29:e2014006. Published 2014 Aug 18. doi:10.5620/
Suggestions: eht.2014.29.e2014006
1) Hospital facilities concern issues causing 9. Pawar AJ. Study of Sleep Disorders in Patients
sleep disturbances can be thought about and Attending Psychiatry OPD at Tertiary Care Centre
could be eliminated from its root. of MaharashtraInternational Journal of Contemporary
Medicine- January-June 2019, Vol.7, No. 1. PG 71-75.

10. Heidi D,Orla H., Francesea R ,Marie LH, Nina A, 12. Verster J, Van De Loo A, Moline M, Roth T ,The effects
Isabella H. Sleep quality in non complaining elderly of middle-of-the-night administration of hypnotic
subjects. JSTOR Dec 2006; 64(4): 369-376(accessed 29- drugs on next-morning on-road driving performance.
1-2019). Sleep Medicine.2015; 16 : Available from:http://dx.doi.
org/10.1016/j.sleep.2015.02.111
11. Cengić B, Resić H, Spasovski G, Avdić E, Alajbegović A.
Quality of sleep in patients undergoing hemodialysis. 13. National sleep foundation.”How much sleep do we
IntUrolNephrol. 2012;44:557-67. really need?”home page. Sleep foundation.org

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Volume 13 Number 4 October-December 2022

INTERNATIONAL EDITORIAL ADVISORY BOARD NATIONAL EDITORIAL ADVISORY BOARD

1. Healthcare Service Provision Seen through Villager’s Lenses ..................................................................1

IJPHRD / Volume 13 Issue 4 / October-December 2022

11. Comparative Assessment of two behavioural risk factors

12. Assessment of Appropriateness of Doing CT Scan for Investigating Headache

13. Management of Tympanic Membrane Perforation with Cartilage Tympanoplasty in

14. Lilliputian Hallucination-An Exceptional Psychiatric Symptom.................................................................... 74

15. Effect of Vaginal pH on Efficacy of Prostaglandin Gel for Labour Induction............................................... 80

16. Ophthalmic Manifestations in Blood Dyscrasias - An Observational Study................................................. 85

17. A Comparative Study of Hernioplasty With Suction Drain and

18. A Study of Enhanced View Total Extraperitoneal Laparoscopic

20. Attitude of Healthcare workers towards Disaster Management

21. Study of Complications and Outcomes of Phacoemulsification

22. Perspective approach to Nutritional anemia among Medical students

23. Clinical Profile of Unilateral Disc Edema: A Cross-sectional Study............................................................... 122

24. A Study of Effectiveness of Videolaryngoscopy and Conventional

IJPHRD / Volume 13 Issue 4 / October-December 2022

25. Comparative Analysis to Assess Pregnancy Related Issues

26. Diabetic Retinopathy and Typical Retinitis Pigmentosa.................................................................................. 137

27. A Study on the Spectrum of Thyroid Abnormalities in Liver Disease

28. Functional Outcome of Rotating Platform Versus Fixed Platform of

29. Socio-Demographic Determinants of Non-Communicable

30. Hemiarthroplasty in Unstable Intertrochanteric Fractures in Elderly:

31. A Study of Clinical Profile of Patients with Traumatic Cataract..................................................................... 161

34. Evaluation of Pradhan Mantri Jan Arogya Yojana (PM-JAY) Utilization

35. Comparative Analysis of Optical Coherence Tomographic Study of

37. A Study on Adherence of Anti-Glaucoma Medications in Adults –

IJPHRD / Volume 13 Issue 4 / October-December 2022

39. Study of Diabetic Peripheral Neuropathy in Adults of Telangana................................................................. 205

41. Fungal Infections of Paranasal Sinuses: Sequelae to 2020 Pandemic.............................................................. 213

42. Study of the Future of those Recovered from COVID-19 from

43. Comparison of Causes of Infective and Non-Infective Epistaxis in

45. Correlation of Automated cell counters RBC Histogram and

46. Impact of COVID-19 Pandemic on Medical Education; Challenges for

47. Periodontics-Prosthodontics - An Interdisciplinary Approach....................................................................... 243

48. Effectiveness of Planned Teaching Program on Knowledge Regarding

49. Creactive Protein as an early Predictor of acute Pancreatitis:

50. Association of Academic Performance and load with Depression,

51. Emotional and Behavioural issues in children during early

IJPHRD / Volume 13 Issue 4 / October-December 2022

52. Seroprevalence of Hepatitis C Virus in Blood Donors of

53. Predicting and Identifying Postpartum Blues may be the key to

54. Forecasting Multivariate time-series data using LSTM Neural Network

56. Periodontal Ligament: Health, Disease and Regeneration .............................................................................. 296

57. Application of Lean Methodology in Radiology Department of

58. Comparative evaluation of MIC of Vancomycin among methicillin

59. Study of Perinatal Outcome in Oligohydraminos in third Trimester

60. Probiotics Efficacy and Safety as add-on Therapy to Metformin in

61. A Cross- Sectional Study of Prevalence of Substance Use and

62. Study of trimester wise effect of hypothyroidism in pregnancy and

63. Surgical and Oncological Outcomes of Extremity soft Tissue Sarcoma

IJPHRD / Volume 13 Issue 4 / October-December 2022

65. A Study to assess the prevalence of Respiratory Morbidity among

66. Perceptions and Barriers to Deceased Organ Donation in Armenia:

67. Conservative Management of Acute Appendicitis in a Tertiary Care Centre............................................... 360

68. A cross-sectional study on Quality of life and stress among nursing

IJPHRD / Volume 13 Issue 4 / October-December 2022