in renal surgery, which may even necessitate removal of kidney. Hence the knowledge of vascular pattern of the kidney is indispensable for the Urosurgeon.
Although the renal vascular segments were first described by John Hunter long ago in 18th century, the present day concepts are largely due to work of Graves4 (1954). He gave the detailed account of primary pattern of renal vascular segments. He divided the renal parenchyma on the basis of arterial distribution into five segments _ Apical, Upper, Middle, Lower & Posterior. Each of them is supplied by its own segmental artery.
Ligation of segmental artery supplying the area of operation produces an almost bloodless operating field. Therefore it can be inferred that there is no collateral circulation between segments, & these segmental arteries are `end arteries'.
Since the knowledge of renal vasculature is of paramount importance during various renal surgeries, the present study was undertaken.
As most of the cadavers used in the present study are received from Maharashtra, this can be a regional study. It will be interesting to note whether incidence of these variations is different from other studies carried out in other parts of the world.
Material & Methods
The study was based upon 212 adult cadaveric kidneys. They were obtained from department of Anatomy and from department of Pathology (Autopsy section). It comprised of 124 male & 88 female kidney specimens. The specimens were collected as a `Kidney
block'. It consisted of both the kidneys with renal vessels, aorta and inferior vena cava.
Meticulous dissection of the kidneys and the renal pedicles was done. The origin and course of the renal artery was observed till it divided into segmental arteries. The variations in branching were noted.
The suspension of gelatin powder was prepared in lukewarm water. It was applied to the structure in the renal pedicle. It was allowed to dry for two hours and then each structure was painted with oil paint using the following color code. —
Arteries - Red
Veins - Blue
Pelvis and ureters - Green
The color photographs were taken which clearly demonstrated the various tructures in the renal pedicle.
Observations
Table No. 1 shows the sex wise distribution of the segmental branches from anterior division of the renal artery.
TABLE No. 1
Number of branches going to anterior aspect
NO. OF MALE FEMALE
BRANCHES RIGHT(%) LEFT(%) RIGHT LEFT(%)
1 00.00 00.00 00.00 00.00
2 01.61 03.22 0.4.54 04.54
3 12.90 12.90 09.09 06.81
4 69.35 72.58 72.72 77.27
5 14.51 11.29 11.36 06.81
6 01.61 00.00 02.27 04.54
Table No. 2 shows the sex wise distribution of the segmental branches from posterior division of the renal artery.
TABLE No. 2
Number of branches going to posterior aspect
NO. OF MALE FEMALE
BRANCHES RIGHT(%) LEFT(%) RIGHT LEFT(%)
1 58.04 62.90 65.90 68.18
2 24.19 22.58 20.45 18.18
3 17.74 14.51 13.63 13.63
The incidence of the standard pattern of segmental arteries is shown as a graph in an illustration below.
Illustration
Standard pattern of Segmental arteries
Discussion
Normally a renal artery gives rise to anterior and posterior divisions. These divisions then divide to form the segmental branches. These branches pass either to the anterior or to the posterior aspect of the kidney.
The segmental arteries going to the anterior aspect were commonly four in number (72.63%) in the present study, although variations from two to six branches were noted. The posterior aspect of kidney commonly showed a single segmental artery (63.19%), though variations up to three branches were observed. The number of these primary branches & their area of distribution suggests the presence of vascular segmentation in the kidney.
Standard pattern of segmental arteries : -
Commonly the renal artery gives rise to four anterior and one posterior segmental branch. F.T. Graves4 first described this in 1954. This is often referred as standard pattern of segmental arteries & is commonly followed.
Sykes6 in 1963 found that 83% of cases, the renal artery divided into anterior and posterior branches and finally giving rise to five segmental arteries. In the present study
the standard pattern segment arteries was found in 59.43% of specimens. The details are as follows:
Total 59.43%
Males (57.25%) Right 54.83%
Left 59.67%
Females (62.49%) Right 61.36%
Left 63.63%
It is evident from the figures that the presence of standard pattern of segmental arteries is more in Females & that too on the Left side. Therefore it can be concluded that the variations are more common in Males and on the Right side.
In 1966, Fine H. & Keen E.H.3 had introduced a concept of primary & secondary branching pattern. According to them, the renal artery was divided into three primary branches viz. Posterior, Lower & Upper. The secondary branches (Intermediate & Middle) were sufficiently constant, apart from suprahilar (Apical) artery, which could be primary or secondary in origin. But this pattern was not taken into account for the present study.
The study conclusively proved, the complex nature of renal vascular distribution and the necessity of the knowledge of renal vasculature to a surgeon operating on the kidney to have a bloodless field. The detailed information of the vasculature will reduce the chance of hemorrhage, due to accidental trauma. Thereby, he can avoid the unwanted postoperative morbidity.
The results of the present study are helpful for radiologists performing renal artery embolisation.
Also, for the upcoming renal transplants, the precise knowledge of the
vascular segments of the kidney and the 'end artery' nature of its blood supply is indispensable for the urosurgeon. It is very important for him to make an anastomosis with all the arteries of the donor kidney during transplantation. Otherwise, infarction of a segment can lead to serious postoperative complications.
References
1. Decker G.A.G., D.J.du Plessis: Lee Mc'Gregor's Synopsis of Surgical Anatomy. 12th edition, Indian Ed. - K.M. Varghese Co. Bombay. 1986: 289-300.
2. Goldstein A.E. Accidents in renal surgery. Surg. Gynec. And Obstet. 1937, 65:575.
3. Fine H., Keen E.H. The arteries of human kidney. J. Anat. 1966, 100 : 113-137.
4. Graves F.T. The anatomy of intrarenal arteries and its application to segmental resection of kidney. B.J. Surgery 1954, 42: 132-139.
5. Hollinshead W.H. Anatomy for Surgens, Vol. 2:2nd Edition, — Harper and Row, New York 1971: 527-530.
6. Sykes D. The arterial supply of the human kidney with special reference to accessory renal arteries. B.J. Surg. 1963, 50: 368-374.
7. Williams P.L., Bannister L.H., Berry M.M., Collins P., Dyson M., Dussek. J.E. Ferguson M.W.J. Gray's Anatomy, In: Urinary System.-38th edition, Churchill Livingstone, U.K. 1995: 1826.
Original Article
Immunogenicity and Bioefficacy Study of Purified Duck Embryo Vaccine (PDEV) manufactured by Cadila Healthcare Ltd. (VaxiRab), in Indian Cohort
Renu Singh * Sweta Kothari **
R. Mahajan @ R. Mittal#
S. Sapatnekar##
ABSTRACT
This study on Purified
Duck Embryo Vaccine (PDEV)/ VaxiRab of Cadila Healthcare Ltd., was a prerequisite
for approval of the vaccine from the office of the Drugs Controller General of India
(DCGI).
It was carried out with 21 volunteers and 32 post-exposure cases using VaxiRab Lot
No.: MA - 1425, in 2002. It involved vaccination as per the WHO schedules for pre- and
post-exposure cases. The volunteers/patients were bled on day 0, 14 and 35.
Anti-rabies antibodies were detected in sera by ELISA
and Mouse Neutralization Test (MNT). Mean antibody titre by MNT for VaxiRab were 5.33
IU/ ml on day 14 and 11.86 IU/ml on day 35 in volunteers; and 7.22 IU/ml and 12.23 IU/ml respectively in patients, indicating satisfactory immunogenicity of the vaccine, 10 to 23 times more than the minimum protective level of 0.5 IU/ml (WHO standard). No adverse reactions were observed in any of the recipients.
Key words: Rabies, PDEV, VaxiRab, immunogenicity, antibody
INTRODUCTION
According to the WHO estimates, 35,000 to 50,000 persons die of rabies encephalitis in the world and nearly 99% of them are from India (1, 2). Among the tools available to
* Research Fellow, Department of Virology, Haffkine Institute For Training, Research and Testing Parel, Mumbai -400 012 • Tel: +91-22-24160947/61/62 Fax: +91-22-24161787 • E-mail: renusingh283@rediffmail.com
** Research Fellow, Department of Virology, Haffkine Institute For Training, Research and Testing
Parel,
Mumbai -400 012 • Tel: +91-22-24160947/61/62 Fax: +91-22-24161787 • E-mail:
kotharisweta@yahoo.co.in
@ Research Fellow, Department of Virology, Haffkine Institute For Training, Research and Testing
Parel,
Mumbai -400 012 • Tel: +91-22-24160947/61/62 Fax: +91-22-24161787
# Medical Advisor & Head - Regulatory Affairs, Cadila Healthcare Limited, Sarkhej - Gandhinagar Highway Ahmedabad - 380052 Tel: +91-79-26868211 • Fax: +91-79-26862362
## Director, Haffkine Institute For Training, Research and Testing Parel, Mumbai -400 012
Tel: +91-22-24160947/61/62 Fax: +91-22-24161787
Corresponding author:
R. Deshmukh, Head, Department of Virology, Haffkine Institute For Training, Research and Testing
Parel,
Mumbai - 400 012 • Tel: +91-22-24160947/61/62 Fax: +91-22-24161787 •
control rabies, vaccines rank highest in effectiveness and economic feasibility (3). Some of the early 20th century antirabies vaccines worked very well, while other vaccines were either poorly antigenic or showed adverse reactions (4) Despite the availability of modern tissue culture vaccines viz. Human Diploid Cell Vaccine (HDCV), Purified Vero Cell Rabies Vaccine (PVRV), and Purified Chicken Embryo Cell Vaccine (PCECV), there still remains a great need for newer, effective and cheaper anti rabies vaccines in India (5).
The efficacy of any vaccine depends on the immunological response in humans involving primary and secondary lymphoid organs, the cells inhabiting them, various types of antibodies, cytokines, and the genes coding for B and T cell receptors. Hence the thorough understanding of immune induction, immunorecognition, immune effector mechanism, immune potency and immune evasion mechanism used by the infectious organism is needed Based on this basic immunological principal, Kenneth et al reported the decreased antibody response in persons from developing countries when they were given HDCV (6) Inspite of the vast data collected over the past decades on immunological processes, vaccine development remains to some extent a process of trial and error.
The Purified Duck Embryo antirabies Vaccine (PDEV) was indigenously produced by Cadila Healthcare Limited, Ahmedabad, India, under the brand name VaxiRab, by the
technology transfer from the Swiss Serum and Vaccine Institute. When VaxiRab was being planned to be introduced in the Indian market, the following study in the Indian cohort was mandatory for obtaining the marketing permission from the Office of the Drugs Controller General of India (DCGI).
MATERIALS
Due permission and clearance were obtained from the Animal Ethics Committee and the Institutional Ethical Committee were obtained before the commencement of the study. For the pre-exposure study, healthy adult volunteers were enrolled while patients with history of Grade I/II animal bites were included in the post-exposure study. The volunteers were explained the details of the study to their satisfaction and an informed written consent of the patients / relatives was obtained prior to their enrolment. Their inclusions and exclusions were based on the following criteria
Inclusion criteria:
Indian patients/volunteers above
18 years of age were included in the study. They had no history of animal bite(s) for
pre-exposure study, while only patients having grade I or II animal bites as per
WHO classification were included in the post-exposure study
Exclusion criteria:
Pregnant women or lactating mothers were excluded from the study. Any patient who had received any type of rabies vaccination
in the past, or had received any dose of rabies immunoglobulin (human/equine) within the previous three months was also excluded. Patients suffering from chronic illness, being treated with steroids, any other immuno-suppressants, concomitant anti-malarials, or known to be HIV positive were excluded. Patients planning for a surgery in the subsequent three months, or having a severe history of allergy were also excluded. Patients not likely to be available for follow up or having participated in another clinical trial in the previous 3 months were also excluded.
Volunteers:
For VaxiRab, 21 adult healthy volunteers of either sex were enrolled out of which 12 were males and 9 were females with a mean age of 19 years. Upon enrolment, previous medical history and vital signs were recorded. Inclusion and exclusion criteria mentioned in the protocol were meticulously followed.
Patients:
Thirty-two adult male patients with Grade II wounds were enrolled for study with VaxiRab, with a mean age of 26 years. Of these 32 post-exposure cases, 28 had been bitten by stray dogs, three by stray cats and the remaining one by a wild monkey. They were given wound care, anti-tetanus prophylaxis and antibiotics. Upon enrollment, previous medical history and vital signs were recorded. Inclusion and exclusion criteria mentioned in the protocol were meticulously followed. All the volunteers and patients were
monitored for a period of one year for their antirabies antibody titres.
Enzyme linked Immuno Sorbent Assay (ELISA):
The ELISA-KIT (Platelia-Rage, BioRad) was used for detection of rabies virus antiglycoprotein antibody in the serum of all the vaccinees. The test is based on the principle of solid phase ELISA, prepared with the glycoprotein extracted from the inactivated and purified virus membrane, and an enzyme conjugate (protein A from Staph. aureus coupled with peroxidase enzyme)
Mice:
For the present study, Swiss albino mice, weighing 14 gms. were used. All the mice needed were procured from Haffkine Biopharma Corporation Ltd. (HBPCL), Mumbai and Mahavira Enterprises (Hyderabad) Both the organizations are Governments recognized animal breeders.
Vaccine:
Vaxirab Lot no: MA-1425 (Cadila Healthcare Ltd.), India, was the vaccine under investigation for the said study. The vaccine is free from myelin and myelin-like proteins due to absence of mechanical shear in their manufacturing process as the vaccine is prepared by the following method:
The Pitman Moore strain of the rabies virus is inoculated into the yolk sac of 7-day old duck eggs. After incubation for 14 days, the embryo are aseptically removed and decapitated. The heads are stored under
sterile conditions in liquid nitrogen. A batch of 40-60 heads is used for further processes to extract the antigen and subsequent centrifugation, removal of non-viral lipids using n-heptane, and final concentration, purification and elution of the viral particles. The virus is inactivated using b-propiolactone, and formulated to yield a dose of 107.5 MLD50/ml, generating an antibody titre of >2.5 I.U.per ml.
METHODS
Vaccination schedule:
The volunteers were vaccinated on day 0, day 7, and day 28 for the pre-exposure study, while the patients enrolled in the post-exposure study were vaccinated on day 0, day 3, day 7, day 14 and day 30.
Bleeding schedule for patients and volunteers:
All the subjects were bled on days 0 (before vaccination), and day 14 and day 35 post vaccination. The sera were separated using centrifugation. The sera samples were stored at -20°C till further use.
ELISA:
ELISA was carried out as per the pack-insert in the kit.
Mouse Neutralization Test (MNT):
The test was carried out as per WHO laboratory techniques. Titers were reported as the highest dilution in which complete neutralization was observed. For more critical
comparison of the end-point titers serial
2-fold dilution, 1:20, 1:40, 1:80, 1:160 and 1:320 were done and end-point between2-fold dilution were estimated by Reed- Muench method. Antirabies antibody titer
was expressed in International Units per ml (IU/ml) (7).
Challenge virus:
For each test, the rabies challenge virus (RV-CVS) standard was diluted in the range of 0.1, 0.01, and 0.001. For the above test 50 LD50 rabies challenge virus standard was used.
Standard antibody-sera:
The International Standard Reference Serum was obtained from Central Research Institute, Kasauli. The serum of titre >300IU/ml was titrated with each batch of test sera.
RESULTS AND DISCUSSION
Any new vaccine whenever introduced to a new cohort of genetically and ethnically different population may result in a different immunogenic response (1). Keeping this in mind, the pre- and post-exposure study for VaxiRab was carried to assess the immunogenicity in Indian population. In previous studies (8, 9) PDEV (Lyssavac N Berna) manufactured by Swiss Serum & Vaccine Institute, Berne, Switzerland has been reported as the most successful anti-rabies vaccine with good immunogenicity and bioefficacy and is accepted worldwide. In Western population, the response has' been excellent but it was the need of the time to
check it in Indian cohort, as the vaccine has now been proposed for the Indian market. Similarly, since PDEV \ (Vaxirab) has been manufactured indigenously by Cadila Healthcare Limited, Ahmedabad, India under a technology transfer agreement with Swiss Serum & Vaccine Institute, this vaccine needs to be assessed for immunogenicity and bioefficacy before it is marketed in the country. The study with Lyssavac N Berna was undertaken in 1998 by the same Department (14). To study the antibody assessment at earliest in study population both, in-vitro (ELISA) and in-vivo (MNT) tests were carried out for all the subjects.
Pre-exposure Cases:
No baseline antirabies antibody titre was detected on day O. The antibody titers by - ELISA were between the range of 0.8 IU/ml to 24.24 IU/ml with a mean value of 6.42 IU/ml on day 14 and 1.17 IU/ml to 22.19 IU/ml with a mean value of 10.0 IU/ml on day 35. The titers by MNT were 0.6 IU/ml to >20 IU/ml with a mean value of 5.0 IU/ml on day 14 and 1.66 IU/ml to >20 IU/ml with a mean value of 11.38 IU/ml on day 35.
Post-exposure Cases:
No baseline antirabies antibody titre was detected on day 0 in post-exposure cases, thus confirming their history of absence of exposure to previous similar vaccination. The antibody titers demonstrated by ELISA were 0.86 IU/ml to 24.27 IU/ml with a mean value of 7.89 IU/ml on day 14 and 3.18 IU/ml to 28.08 IU/ml with a mean of 11.85
IU/ml on day 35. For MNT, the values observed were between 1.0 IU/ml to 22.4 IU/ml with a mean of 7.22 IU/ml on day 14 and 4.6 IU/ml to 28.9 IU/ml with a mean of 12.23 IU/ml on day 35.
Based on ELISA test findings, it is apparent that all the patients had sero-converted within 14 days of administration of the vaccine. The MNT results further confirmed the immunogenicity of the vaccine in our population.
Unpublished data with the administration of Lyssavac N Berna from the same department showed similarity in antibody levels in both pre-exposure and post- exposure cases, as was obtained with VaxiRab. This testifies a satisfactory technology transfer adopted by Cadila HealthCare Ltd. Shaul J F, et al., have observed that the currently obsolete Duck Embryo Vaccine was less immunogenic in nature, and usually lead to the allergy to the avian antigen (10). Compared to this, VaxiRab is free from any kind of avian antigens. As compared to other tissue culture vaccines viz. neural tissue vaccines (Semple type) and HDCV, which are reported to cause allergic reactions (11, 12, 13), PDEV appears to be safer. In our series, one of the patients complained of dislocation of left shoulder in our study and was treated by an orthopedic surgeon with analgesics. The dislocation was natural and was unrelated to the vaccination. Barring this, no adverse drug reactions were reported or observed.
Rabies Vaccine was not included in this study.
ACKNOWLEDGEMENT
The authors are grateful to Cadila Healthcare Limited, India, for providing the vaccines used in the study. We are also thankful to Mrs. A. Gandhi, Senior Laboratory Technician at the Department Of Virology, Haffkine Institute, for her valuable support during the study.
REFERENCES
1. Dutta A. K. and Kawal
S.N, Rabies
and its prevention, J ofAPCRI, 1999;
1:5-13
2. WHO estimate: http://www.who.int/emc/diseases/zoo/ rabies.htm
3. Requirement of rabies vaccine for human use (amendment 1992). WHO Expert Committee on Biological Standardization. Forty-third report. Geneva. World Health Organization, 1994 (WHO technical report series, No. 840) Annex. 4.
4. Datta J.K, Adverse reactions to purified chick embryo cell rabies vaccine. Vaccine 1994; vol. 12, No. 15:- 1484.
5. Datta J.K, Rabies prevention; Cost to an Indian Labour, JAMA, 1996; 226-32.
6. Bernard Kenneth W., Daniel B. Fishbein et al. Pre- exposure rabies immunization with human diploid cell vaccine: decreased antibody responses in persons immunized in developing countries, Am. J. Trop. Med. Hyg., 1985, 34 (3), 633-647.
7. Fitzgerald E.A, "Potency Test for
antirabies serum and immunoglobulin." In: Meslin F.X, Kaplan M.M and Koprowski H, Editors. Laboratory techniques in Rabies, 4th edition. WHO Geneva, 1996:417-422.
8. Brigs D. T, Dreesen D. W., Morgan
P., Chin J. E., Seadle C. D., Cryz
L., Glueck R., Cryz S. J., Safety and immunogenicity of Lyssavac
Berna human diploid cell rabies vaccine in healthy adults. Vaccine 1996, vol.
14: 1361-1365.
9. Khawplod P., Glueck R., et ai, Immunogenicity of purified duck embryo vaccine (Lyssa vac-N) with use of the WHO- approved intradermal post exposure regimen. Clin. Info Dis. 1995, 20, (3), 646-651.
10. Shaul J F, et al. Duck embryo rabies
antirabies serum and immunoglobulin." In: Meslin F.X, Kaplan M.M and Koprowski H, Editors. Laboratory techniques in Rabies, 4th edition. WHO Geneva, 1996:417-422.
8. Brigs D. T, Dreesen D. W., Morgan
P., Chin J. E., Seadle C. D., Cryz
L., Glueck R., Cryz S. J., Safety and immunogenicity of Lyssavac
Berna human diploid cell rabies vaccine in healthy adults. Vaccine 1996, vol.
14: 1361-1365.
9. Khawplod P., Glueck R., et ai, Immunogenicity of purified
duck embryo vaccine (Lyssa vac-N) with use of the WHO-
approved intradermal post exposure regimen. Clin. Info Dis. 1995, 20, (3), 646-651.
10. Shaul J F, et al. Duck embryo rabies
vaccines. Anaphylactic reaction following initial reaction. J S C Med Assoc 1969, 65(10): 359-361.
11. Ahasan H A, Chowdhary M A, Azhar M A, Rafiqueuddin A K, Neuroparalytic complications after anti-rabies vaccine (inactivated nervous Tissue vaccine).
Trop Doct 1995, 25(2): 94.
12. Hemachudha T, et al., Neurologic complications of semple type rabies vaccine: clinical and immunological studies, Neurology 1987; 37: 550-556.
13. Systemic allergic reactions following immunization with human diploid cell rabies vaccine. Morbidity and Mortality weekly report 1984; 33: 185-187.
APPLICATION OF PAGE IN THE EPIDEMIOLOGICAL STUDY OF ROTAVIRUS INFECTIONS IN PEDIATRIC POPULATION
Kirtikar A A*
Kulkarni M V $
Deshmukh R A #
Abstract
Objectives: To determine the prevalence of rotavirus infection in pediatric cases of diarrhea, three methods for detection of rotaviruses, namely latex agglutination, polyacrylamide gel electrophoresis, and virus isolation in cell cultures were compared in the present study.
The study was carried out in Lokmanya Tilak Memorial Hospital, Sion, K.E.M.Hospital, Parel, and Kasturba Hospital for Infectious Diseases, Mumbai Central. Subjects for the study were pediatric patients under five years of age suffering from diarrhea and were admitted to one of the above hospitals. 225 subjects were included in the study. Of the 225 patients, 36 tested positive for rotavirus, giving
a rotavirus positivity of 16%. No atypical rotaviruses were observed. PAGE was found to be the most effective diagnostic method and is recommended for accurate diagnosis of rotavirus infection.
Surveillance to study the epidemiology of rotavirus infections should be carried out on a regular basis to ascertain the strains of rotavirus predominant in the community, which will aid in the development of a vaccine against rotavirus.
KEY WORDS: Rotavirus, pediatrics, diagnostic methods, agglutination, diarrhea It has long been recognized that diarrheal disease is a leading cause of morbidity and mortality, especially in developing countries and acute infectious gastroenteritis is one of the
* Junior Research Fellow, Department Of Virology, Haffkine Institute.
$ Head, Dept. of Pediatrics, Lokmanya Tilak Hospital, Sion.
# Head, Dept of Virology, Haffkine Institute, Parel.
Corresponding author:
Dr.(Mrs.)R.A.Deshmukh, Dept. Of Virology, Haffkine Institute, Parel, 400 012 • Tel. No. (022) 4160961/62 ext. 229
• Fax: (022) 4161787 • E-mail: rad21350@yahoo.com
commonest causes of childhood illness throughout the world and especially in developing countries, malnutrition being a major contributing factor. Another factor contributing to the unchecked spread of diarrhea is poor hygiene and sanitation. Coupled with ignorance and poverty, it makes the developing countries a virtual breeding ground for diarrheal diseases. Diarrheal diseases thus assume phenomenal proportions in developing countries and demand immediate action for their control. Within five years of its discovery in 1973, rotavirus was recognized as the most common cause of severe vomiting and diarrhea in infants and young children worldwide, accounting for approximately one third of cases of severe diarrhea requiring hospitalization (1,2,3). Rotavirus infects virtually all children by five years of age. Some of these infections are severe and many children are infected more than once, although severity of disease decreases with each infection (4).
Rotaviruses affecting humans were once thought to be limited to one antigenic family termed Group A, whereas other antigenic groups (B-G) were thought to be strictly zoonotic. In 1982, however, an epidemic of Group B rotavirus affected millions of persons in China (including adults, children, and neonates) (5), and since then outbreaks have recurred, although affecting fewer persons.
Research to develop a safe and effective rotavirus vaccine began in the mid-1970s when investigators demonstrated that
previous infection with animal rotavirus strains protected laboratory animals from experimental infection with human rotaviruses. (6). However, the efficacy of these vaccines varied. Then exploiting the inherent property of rotaviruses to reassort their genome, multivalent vaccine candidates were developed. (7). On August 31st, 1998, a tetravalent rhesus-based rotavirus vaccine was licensed in the United States for vaccination of infants. (8).
Therefore, it becomes necessary to monitor the epidemiology of rotavirus infection in a population. This would not only enable us to foresee a possible epidemic of unusual rotavirus gastroenteritis but also to ascertain the prevalent strains with a view towards vaccine production.
Because the clinical features of rotavirus gastroenteritis are nonspecific, confirmation of rotavirus infection in children with gastroenteritis by laboratory testing of fecal specimens is necessary for reliable rotavirus surveillance (9). The most practical method taking into consideration accuracy and time required for the test is antigen detection by enzyme immunoassay. But this method is expensive. Another practical method that is also inexpensive is antigen detection by latex agglutination. This method, however, may compromise on accuracy. Other techniques including electron microscopy, reverse transcription-polymerase chain reaction, nucleic acid hybridization, polyacrylamide gel electrophoresis and culture are mainly used in research settings. Thus there is a lack of an appropriate diagnostic tool. A definitive viral
diagnosis can reduce indiscriminate use of antibiotics, eliminate necessity for other tests in search of causative agents and remove uncertainty, allowing the physician to make proper prognosis and remain alert to potential complications.
Taking all these points in consideration we undertook the present study.
Methodology
STUDY SUBJECTS
In this study, 225 patients and 25 control subjects were included.
The study subjects were admitted in the pediatric wards of Lokmanya Tilak Memorial Hospital, Sion, K.E.M.Hospital, Parel, and Kasturba Hospital for Infectious Diseases, Mumbai Central. All subjects were infants and children under 5 years of age.
SPECIMEN COLLECTION
PATIENTS
Stool samples were collected from children suffering from diarrhea and admitted in the pediatric wards of the hospitals. Children were excluded if they had an associated complicating illness. The samples were collected on the day of admittance.
CONTROLS
Control patients were children admitted to these hospitals with other illnesses and who showed no symptoms of gastroenteritis. Stools from these children were collected on any day after admittance to the hospitals.
The clinical features and personal history of all patients including controls was recorded. These include features like age, sex, family income, nature of current illness etc. The specimens were collected in sterile 15ml containers with wide mouths and screw caps. The specimens were labeled and stored at 4C until processed.
DETECTION OF ROTAVIRUS
Detection of rotavirus was done using three methods, namely, latex agglutination (LA), polyacrylamide gel electrophoresis (PAGE), and isolation of the virus in cell culture.
LATEX AGGLUTINATION
Commercially available latex agglutination kit for the detection of rotavirus manufactured by Sanofi Pasteur was used. The kit was stored at 2-8C as described. It is a rapid test based on latex agglutination, intended to detect rotavirus from feces in acute gastroenteritis.
The samples to be tested were kept at room temperature. The kit was also removed from the fridge to allow the reagents to reach room temperature. The stool specimens were mixed properly and the specimens were diluted 1:10 in rotalex buffer and mixed well with vortex mixer for 1min.
Two separate drops of about 25mml were taken on disposable slide (provided in the kit) with a micropipette. Contents of both latex reagent vials were well suspended before use by gently rolling the vials. One drop of rotalex reagent 1 was put on one of the sample drops with micropipette. Rotalex control suspension was added on to the other drop. Mixture was
carefully stirred by using fresh wooden stick for each drop. The drops were spread to cover the entire area of circle of test slide for interpretation of results. The slide was continuously tilted back and forth and observed against dark background for eventual development of precipitate. The detection of agglutination is done by the naked eye.
The result was considered to be negative if no agglutination was observed in the sample drop containing rotalex reagent within 2 mins. Result was considered to be positive if agglutination was detected in sample drop containing Rotalex reagent. Agglutination was either complete resulting in granules and a clear background, or partial when granules could be detected, but the background remained opaque. If the results were doubtful and the test could not be interpreted, the test was repeated. If agglutination was observed in the drop containing Rotalex control latex reagent, the particular specimen could not be studied by this method as instructed in the procedure with the kit. These samples were further tested by PAGE and cell culture.
POLYACRYLAMIDE GEL ELECTROPHO RESIS (PAGE)
The method followed for PAGE is a modification of the protocols standardized by AJ Herring et al (10)and SM Rodger et al (11). The modification was carried out by Krishnan T, Div. of Virology, National Institute for Cholera and Enteric Diseases, Calcutta.
The procedure for detection of rotaviruses by PAGE is separated into three
sections as follows:
A. Extraction of rotavirus dsRNA from fecal material.
B. Electrophoresis of dsRNA in polyacrylamide gels.
C. Silver-staining of dsRNA bands.
A. Extraction of rotavirus dsRNA from fecal samples
The stool samples were vortexed. In case of solid samples, a minimum amount of phosphate buffered saline (PBS) was added to the samples and the mixture was homogenized by vortexing. 0.5ml of the sample was added to 0.5ml of 0.1M sodium acetate buffer with 1% sodium dodecyl sulfate (SDS) in an eppendorf tube. To this mixture was added 0.5ml of phenol-chloroform mixture and vortexed. The tubes were then centrifuged at 10,000 rpm for 10 mins. The aqueous supernatant was collected in fresh eppendorf tubes and refrigerated until tested by PAGE.
B. Electrophoresis of rotavirus dsRNA in PAGE
Bio-Rad electrophoresis apparatus was used for PAGE and a discontinuous system of buffers was used. Separating gel mixture of 10% polyacrylamide was prepared and this solution was poured within glass plates with dimensions 14cm X 16cm. Spacers that were 0.75mm thick separated the glass plates. When the polyacrylamide was set, a 3% stacking gel solution was prepared. This solution was
poured over the separating gel till the glass sandwich was filled. A comb was placed onto the glass sandwich. When the gel was set, the comb was removed and the wells were washed with reservoir buffer. Approximately 30ml of the extracted supernatants were loaded in the wells. A current of 25mA was applied to each slab gel for 16hrs.
C. Silver staining
After the gel run was over, the spacers were removed from in between the glass plates. The stacking gel was removed and discarded. Also, the bottom left corner of each gel was cut off for orientation of the gel. The gel was gently lifted off the glass plate and placed in fixing solution in a glass tray. After rocking the tray for 30mins., the fixing solution was drained off and the silver stain was added. The tray was again rocked for 30mins., after which the stain was drained off. The gel was then rinsed with double distilled water to make sure that no traces of the silver stain were left behind. The developing solution was then added and the tray was rocked till the RNA bands were satisfactorily stained. To stop the reaction, the developing solution was drained off and the stopping solution was added. The bands were visualized against white light.
CELL CULTURE
The cell line used for the isolation of rotavirus was MA-104. This is an established cell line derived from the kidneys of embryonic rhesus monkeys. The cell line was supplied by The National Center for Cell Sciences, Pune.
Inoculation of flasks for cell culture:
The cells from the surface of the flask were dislodged by trypsin treatment. The medium from monolayer culture of cells in tissue culture flasks was aspirated. 1ml of trypsin solution was added and the flask was rocked 4-5 times quickly back and forth so that the trypsin coated the cells in the flask, and traces of medium and serum were diluted. The cells were not detached at this stage. The trypsin solution was aspirated. The flask was then kept at 37°C in an incubator for 2-5 mins. Cell detachment was checked by tapping the flask against the hand so that the small amount of fluid in the flask sheared the loosely attached cells off the surface. If no cells were detached, the flask was put back at 37°C for a few more minutes and the procedure was repeated until the cells were completely detached from the flask. The cells were then suspended in growth medium (MEM with 10% FCS) and triturated gently to disrupt cell clumps. The cell number was determined by counting the cells using a hemocytometer and viability staining was done with trypan blue. The cells were then diluted with growth medium to an approximate concentration of 2 X 104 to 4 X 105/ml. Aliquots of the cell suspension were then added to flasks containing growth medium. The cell suspension was rotated and evenly distributed on the surface of the culture flasks. The flasks were then incubated at 37°C until the formation of monolayers of cells. The growth medium was changed twice a week.
Isolation of the virus:
The isolation of rotavirus was done in tissue culture flasks and the protocol standardized by Kutsuzawa T et al was followed (12). The stool specimens that were positive for rotavirus by PAGE were used for virus inoculation.
The stool specimens were brought to room temperature. A 10% suspension in MEM of the specimens was then prepared. After centrifuging at 10,000rpm for 10mins., the clear supernatant fluids were collected. These supernatants were mixed with an equal amount of 20mg of trypsin per ml for 20 mins. at 37°C. This mixture was then diluted 1:20 with MEM before inoculation. Before these samples were inoculated, confluent MA104 cell monolayers were washed three times with MEM without serum. Excepting the controls, each well was inoculated with 0.1 ml of the diluted mixture. The plates were then incubated at 37°C for 60mins. The cultures were then washed three times with MEM without serum and fed with MEM without serum and containing 0.5mg of trypsin per ml. The plates were incubated at 37°C. Media were changed every other day. The plates were inspected everyday for the occurrence of cytopathic effects(CPE). When CPE was observed, the culture flasks were frozen, thawed, and then the culture lysates were centrifuged. The supernatants were collected and tested for the presence of rotavirus by PAGE. When no CPE was observed even after eleven days after inoculation, cultures were lysed by freeze-thawing and supernatents were obtained by centrifugation. These lysates were
trypsin treated as described above and inoculated into fresh MA104 cell cultures. This procedure was carried out till passage 6. All cell lysates were then tested by PAGE for rotavirus positivity regardless of the demonstration of CPE.
Results:
This study was carried out from March 1998 to January 2000. In this period, of the total 225 diarrhea samples collected, 36 samples were found to be positive for rotavirus by PAGE, giving rotavirus positivity of 16%.
Prevalence of rotavirus diarrhea cases:
Sex Total no. Percen- No. of Percen-
of diarrhea tage rotavirus tage
cases (n=225) diarrhea (n=36)
cases
225 36
Male 133 59.11 23 63.88
Female 92 40.88 13 36.11
It was found that all the detected rotaviruses belonged to group A. No atypical rotaviruses were observed.
Age-wise distribution of rotavirus diarrhea cases.
Age group Diarrhea Rotavirus Percentage
(months) cases diarrhea (n=36)
cases
<6 28 3 8.33
6-12 107 20 55.55
12-18 36 7 19.44
18-24 21 2 5.55
>24 33 4 11.11
Total no. of 225 36
patients
The age group of 6-12 months was found to be most susceptible to infection with
55.55% of the rotavirus cases occurring in this age group. Overall, the age group upto 24 months was more susceptible (88.88%) than the age group from 24 months to 5 years (11.11%).
Season-wise distribution of rotavirus diarrhea cases.
Seasons Total number Rotavirus Percentage
of cases cases (n=36)
Rainy (July-
October) 89 9 25
Winter
(November-
February) 74 17 47.22
Summer
(March-
June) 62 10 27.77
Total 225 36
Although rotavirus disease was recorded around the year, a slight seasonal variation was observed. 47.22% of the observed infections took place during the months of November to February.
Correlation of results by PAGE, latex agglutination, and in vitro isolation.
Samples Latex PAGE Cell culture
agglutination positive positive
positive
Patients 33 36 19
Controls Nil Nil nil
Rotavirus was detected in 36 samples
by PAGE, in 33 samples by latex agglutination, and in 19 samples by isolation in cell culture. Latex agglutination gave 4 false positive results and 7 false negative results as compared to the results given by PAGE. Considering PAGE as the standard test for detection of rotaviruses, latex agglutination showed a sensitivity of 87.87%. No rotavirus was detected by any of the methods in control subjects.
Discussion:
In the present study, the study subjects are pediatric patients admitted to three municipal hospitals in Mumbai. Though all these hospitals are in central Mumbai, they serve patients from all over the city. Our findings reflect incidence of rotavirus infections all over the city since municipal hospitals cater to lower and middle class society in Mumbai. The patients admitted to these hospitals all belong to the lower socio economic strata of society, with low literacy levels, no source of potable water, and poor hygiene and sanitary conditions. Hence it can be said that these factors aid in the spread of rotavirus disease. The factors that could be used to study the role of the virus in causing diarrhea in children under 5 years of age, and those that are taken into consideration in this study are the age and sex of the affected children and the seasonality of the virus.
In our study, the age group of 6 - 12 months was maximally represented with 55.55% of the rotavirus diarrhea cases occurring in this group. A maximum of cases might have occurred in this group as it is at this age that maternal antibody has just been lost and virus can cause disease. However, the rate
primarily in the American's. In the tropics, the seasonality of such infections is less distinct and within 10 degrees latitude of the equator, some locations exhibited no trend. A recent study carried out in Bangladesh has found no seasonal variation15.
In our study we have found the rate of proportion of rotavirus to be 16.0% by PAGE method. Since all the detected rotaviruses belonged to group A, we can safely assume that rotavirus infection in Mumbai as of yet is by the conventional strain. However, the absence of any atypical rotaviruses should not stop us from carrying out routine surveillance in order to keep a check on the strains of rotavirus circulating in the community.
We have considered PAGE to be the standard one because its sensitivity is more than 90% and its specificity is 100%16. Compared to this method, LA gave a sensitivity of 87.87% and specificity of 97.88%. LA can therefore be used as a bedside method for preliminary testing of stools for rotavirus. However, results from this test need to be confirmed by another method. Also, viruses belonging to groups B and C go undetected by this method of diagnosis.
Another method of diagnosis that we have tested is isolation of the virus in cell culture. The sensitivity of this method was calculated to be 52.77%. The specificity of this method could not be checked as only samples that were positive for rotavirus by PAGE were tested by this method. This method, besides being time consuming, has proved to be cumbersome as after every passage of the
virus in cells, PAGE had to be used to confirm the presence or absence of the virus as CPE is not always visible and hence is not very useful as a diagnostic tool. It is more suited to a research setting.
PAGE has been used to detect rotaviruses in many studies and PAGE of rotavirus can provide information on variation in rotavirus strain prevalent in the community. Also, in developing countries like India, where the cost of diagnostic kits like EIAs is prohibitive, PAGE becomes a handy tool in the hands of laboratory technicians. Besides being extremely sensitive and specific, it is also inexpensive with no requirement for fancy reagents.
If PAGE will be carried out as a matter of routine by representative hospitals in a city, the descriptive epidemiology of locally prevalent strains will be available to clinicians on a fortnightly or monthly basis. Such practice will yield laboratory surveillance of viral strains that will discriminate between bovine and human strains. Its potential is obvious when rotaviral vaccines will be needed to be manufactures on the basis of locally prevalent strains.
Key Message
A surveillance of this type if done as a matter of routine by representative hospitals in a city, can keep a check on the simultaneous co-circulation of multiple strains in the community, which may lead to extensive genomic variation in rotavirus strains. This information would be vital when rotaviral vaccines will be needed to be manufactured on the basis of locally prevalent strains.
References:
1. Kapikian AZ, Cline WL, Mebus CA,
et al.
New complement-fixation test for the human reovirus-like agent of
infantile gastroenteritis. Nebraska calf diarrhea virus used as antigen.
Lancet 1975;1:1056-1061.
2. Kapikian AZ, Cline WL, Kim HW, et al.
Antigenic relationships among five reovirus-like (RVL) agents by complement fixation (CF) and development of new substitute CF antigens for the human RVL agent of infantile gastroenteritis.
Proc Soc Exp Biol Med 1976;152:535-539.
3. Yolken RH, Kim HW, Clem T, et al.
Enzyme-linked immunosorbent assay (ELISA) for detection of human reovirus-like agent of infantile gastroenteritis.
Lancet 1977;2:263-267.
4. Mata L, Simhon A, Urrutia JJ, Kronmal RA, Fernandez R, Garcia B. Epidemiology of rotaviruses in a cohort of 45 Guatemalan Mayan Indian children observed from birth to the age of three years.
J Infect Dis 1983;148:452-461.
5. Hung T, Chen G, Wang C, et al.
Waterborne outbreak of rotavirus diarrhea in adults in China caused by a novel rotavirus.
Lancet 1984;i:1139-1142.
6. Wyatt RG, Mebus CA, Yolken RH, et al. Rotaviral immunity in gnotobiotic calves:
heterologous resistance to human virus induced by bovine virus.
Science 1979;203:548-550.
7. Midthun K, Greenberg HB, Hoshino Y, Kapikian AZ, Wyatt RG, Chanock RM.
Reassortant rotaviruses as potential live rotavirus vaccine candidates.
J Virol 1985;53:949-954.
8. CDC.
Rotavirus vaccine for the prevention of rotavirus gastroenteritis among children - recommendations of the Advisory Committee on Immunization Practices.
MMWR 1999;48 (no.RR-2).
9. Kapikian AZ, Chanock RM.
Rotaviruses.
In: Fields BN, Knipe DM, Howley PM, et al, eds. Fields Virology. 3rd ed. Philadelphia: Lippincott-Raven, 1996:1657-1708.
10. Herring AJ, Inglis NF, Ojeh OK, Snodgrass DR, Menzies JD.
Rapid diagnosis of rotavirus infection by direct detection of viral nucleic acid in silver-stained polyacrylamide gels.
J Clin Microbiol 1982;16:473-477
11. Rodger SM, Holmes IH.
Comparison of the genomes of simian, bovine, and human rotaviruses by gel electrophoresis and detection of genomic variation among bovine isolates.
J Virol 1979;30:839-846
12. Kutsuzawa T, Konno T, Suzuki H, Kapikian AZ, Ebina T, Ishida N.
Isolation of human rotavirus subgroups 1 and 2 in cell culture.
J Clin Microbiol 1982;16(4):727-730
13. Chakravarti A, Kumar S, Mittal SK,
Broor S.
Clinical and epidemiological features of acute gastroenteritis caused by
human rotavirus subgroups.
J Diarrh Dis Res 1992;10(1):21-24.
14. Cook SM, Glass RI, LeBaron CW, Ho MS.
Global seasonality of rotavirus infections.
Bull WHO 1990;68:171-177.
15. Desikan P, Daniel JD, Kamalarathnam CN, Mathar MM.
Molecular epidemiology of nosocomial rotavirus infection.
J Diarrh Dis Res 1996;14(1):12-15.
16. Allen JR, Gouvea V, Moe C, Monroe SS.
Viral agents of gastroenteritis: public health importance and outbreak management.
MMWR 1990;39(RR-5):1-25.
Acknowledgements
We thank Dr.B.G.Khadse, ex-Director, Haffkine Institute, for making available excellent facilities to carry out the research.
We also thank Dr.(Mrs.)M.V.Kulkarni, Head, Dept. of Pediatrics, Lokmanya Tilak Memorial Hospital, Sion, Dr.(Mrs.)J.Kamat, Head, Dept. of K.E.M.Hospital, Parel, and Dr. Aigle, Medical Superintendent, Kasturba Hospital for Infectious Diseases, Mumbai Central.
EFFECTS OF RELAXATION TECHNIQUE ON SYMPATHETIC ACTIVITY IN PATIENTS OF MILD TO MODERATE HYPERTENSION
Dr. M.M. Jain, M.D.,*
Dr. V. Y. Deshpande, M.D.,**
Dr. Alka Deshpande, M.D.***
Dr. S. P. Gite, Ph.D.$
V.S. Keskar#
Abstract
Aim of the study
The aim of the study was to assess effects of Relaxation Technique (RT) on sympathetic activity in mild to moderate uncomplicated hypertensive patients.
Methodology
A prospective open label clinical study was undertaken. It was an ICMR sponsored short term undergraduate research projet. The project was approved by institutional Ethical Review Committee Subject for the study included mild to moderate, uncomplicated hypertensive patients who were attending medical OPD at JJ Hospital. After meeting inclusion criteria, each patient blood pressure pulse and respiratory rate was recorded. Patients were asked to practice mental and physical relaxation in the morning
as well as in the evening for about 20 minutes every day for two weeks. BP, pulse and respiratory rate was assessed every week for two weeks. The effect of relaxation was assessed by changes in BP, pulse and respiration before and after the intervention. Also, all the patients wre broadly divided in to sub-groups by direct questioning on their food habits and spirituality to evaluate effects of relaxation on such personal characteristics.
Results
There is significant decrease in diastolic BP and respiratory rate in all the patients. However, no significant change in systolic BP and pulse was observed. Among sub group of patients, spirituality and vegetarian food habits had significant reduction in diastolic BP, pulse and respiration while no significant difference was observed in non-vegetarian and no spirituality group.
* Associate profesor of Pharmacology.
** Professor of Pharmacology.
*** Professor of Medicine.
$ Statistician, Department of PSM
# Undergraduate student
At Grant Medical College & Sir J. J. Group of Hospitals, MUMBAI.
Reprint Request :
Dr. M. M. Jain, Associate Professor of Phermacology, Grant Medical College, Mumbai - 400 008.
e-mail : mangal_m_jain@hotmail.com
Conclusion
Physical mental relaxation might help in reducing sympathetic tone in some of the hypertensive patients within a short period of two weeks. This approach may be useful in management of some cases of hypertension.
INTRODUCTION
Indian Council of Medical Research encourage short term research project for undergraduate students to train them in research methodology under the guidance of their seniors1. It is desired that the research project so selected need to be simple, clinically relevant and ethically acceptable.
In recent years, hypertension has become one of the major cardiovascular disorders associated with increased morbidity and morality. According to one estimates as much as 5% of the urban population is suffering from various grades of hypertension with an estimated 10% below 35 years of age. Although, hypertension is due to multiple etiological factors ranging from neuropsychiatry and endocrine abnormalities to receptors and vascular defects2,3, sympathetic over activity seems to be a common denominator in most of the patients4. Sympathetic Nervous System is highly sensitive to acute stress known as Acute Phase Response characterized by rise in blood pressure, tachycardia, tachypnoea, hyperglycemia, sweating, restlessness, and anxiety5. Chronic stress may increase sympathetic tone and set it at higher level6. Thus it can be postulated that hypertension, in some patients, is the consequence of chronic physical or mental stress which is amenable to those measures that provide physical and mental relief7. Incidentally, ancient techniques such as transcendental meditation, yoga,asked to visit Medical OPD at weekly interval for 3 weeks. At the end of one week, baseline measurements for BP, Pulse & RR were made. Subsequently, patients were given a lecture cum demonstration on Relaxation Technique at Clinical Pharmacology Unit of the department. In addition, they also received a written hand out in their own mother tongue
pranayam and simple procedures to restore mental peace have shown beneficial effects in patients with hypertension8, Ischemic Heart Disease9,10, Hypercholesterolemia".
In the present study, we have tried to evaluate effects of Relaxation Technique (RT) on sympathetic activity in mild to moderate hypertensive patients using BP, Pulse and Respiratory Rate (RR) as parameters. We also evaluated effects of RT among subgroups of patients based on their food habits and spiritually Subgroups were formed by direct questioning and consisted of either Veg-Non veg or Spiritual-No spiritual groups.
MATERIAL AND METHODS
The study was carried out at Medical (OPD) of JJ Hospital. The protocol was approved by Institutional Ethics Review Committee.
A formal request was made to all the
doctors working in medical OPD to refer cases of mild
to moderate uncomplicated hypertension which is defined as Systolic BP between 130 to 180
mm of Hg and Diastolic BP between 90 to 110 mm of Hg. All patients were taking
antihypertensive drugs at least for one month and asked
to continue same treatment during entire period of the study. All patients participated in the
study have approval from their physician and also
gave informed written consent.
After screening and verification of eligibility criteria (Figure-1), patients were
asked to give details about their food habits and spiritual practices by asking direct
questions. Their BP, Pulse & RR were recorded after
they were made to sit quitely for 10 minutes. BP
was measured in supine position in right upper arm using same instrument by same
investigator taking muffling sound (Vth Korotkoffs
sound) as point for Diastolic BP. The patients were describing details of RT. The patients
were advised to practice relaxation technique for
20 minutes every day in the morning and evening. At the end of the second week the patients
were called for compliance reports about
relaxation practice. On third visit, i.e. at the end of
third week, the compliance report was reassessed. BP, pulse and respiration was recorded. (Figure
Fig. 1.: Selection criteria for the patients
Age - < 30 - 80> years
SBP - <130 - 180> mm of Hg
DBP - <090 - 110> mm of Hg
INCLUSION Informed written content
permission from the
treating physician 1 month on
SCREENING antihypertension treatment.
Hypertension related complications
EXCLUSION Associated Diseases.
Fig. 2: Study Protocol
WEEKS 1 2 3
DAYS 0 7 14 21
ACTIVITY
Screening, Baseline Compliance Compliance Detailed Measurements, Report, BP Report, BP History, Lecture Cum Pulse, Resp. Pulse, Resp. BP, Pulse, Demo and Resp. written instructions
2)
Data Analysis :-
The difference in treatment outcome i.e. BP, pulse, respiration before and after relaxation intervention was assessed using students paired 't'' test. Significance was set at a value of p <0.05. The difference in treatment outcome for BP, pulse and respiration was also
measured in subgroups of patients based on food habits and spirituality Students paired "t" test was used to know the difference.
RESULTS:
Over a period of one month, 64 patients suffering from mild to moderate hypertension were referred to us by the doctors working in medical OPD. On screening, 14 patients were excluded from the study for not meeting inclusion criteria (3-extremes of age, 7-irregular
a period of 5 days without any complaint of pain and thereafter continued relaxation technique as per protocol. These patients were included for statistical calculations.
Table - 1 shows demographic characteristics of the patients. As this was add-on, open label study, there is some variation in age. SBP, DBP among sub group of patients. However, the difference is not significant statistically.
Following Relaxation Technique, there was significant reduction in DBP & RR in all the patients. There was no significant reduction in SBP or Puls. (Table -
Table-1 Demographic characteristics of patients and sub-groups (mean+SD)
Sub group of Patients
Characteristics All Patients Spiritual No-spiritual Vegetarian Non-Veg
(n=31) (n=19) (n=12) (n=16) (n=15)
Age 51.4+12.9 55.1+13.8 45.5+8.6 47.3+12.4 55.9+12.0
Sex (males) 22 12 10 10 12
SBP 154.5+14.7 152.0+16.1 158.5+12.1 151.4+14.4 157.8+14.2
DBP 98.2+5.4 100.2+4.9 95.0+4.8 96.6+4.5 93.5+8.7
Pulse 76.9+9.0 77.7+9.4 76.2+7.3 80.0+8.2 74.2+9.4
RR 16.7+2.54 16.5+2.61 16.9+2.57 16.7+2.86 16.6+2.29
Table 2 Difference in Systolic BP, Diastolic BP, Pulse and RR between baseline and after two weeks of Relaxation Practice in all patients and sub-groups. (mean+SD).
Sub group of Patients
All Patients Spiritual No-spiritual Vegetarian Non-Veg
(n=31) (n=19) (n=12) (n=16) (n=15)
SBP -4.0+4.2 -5.4+3.6 -2.8+3.8 -4.4+3.2 -4.3+4.9
DBP -3.0+4.7* -6.1+3.1* 2.2+1.7 -4.3+5.6* -1.7+3.8
Pulse -3.2+6.9 -5.2+7.0 0.1+5.9 -6.6+5.7 0.1+6.8
RR -1.6+2.3* -2.4+2.0* -0.2+2.5 -1.9+2.4* -1.5+2.6
*P<0.05
Among subgroup of patients, RT has caused significant reduction in DBP. Pulse & RR in spiritual group while no difference is found in no-spiritual group. Significant difference is also found in DBP, Pulse & RR between baseline and post relaxation measurements in patients having vegetarian food habits. No significant difference in these parameters is found among patients having non-vegetarian food habits. None of the groups showed significant difference in SBP. (Table - 2)
DISCUSSION
The hypothesis that stress is important in the pathogenesis of hypertension is strengthened by the finding that Relaxation practices have significantly reduced blood pressure in mild to moderate hypertensive patients. Although, relaxation response has long latent period before any measurable change is evident, the present study has demonstrated significant changes in Diastolic BP, Pulse & Respiratory rate in two weeks of anti stress intervention in patients on anti hypertensive medication. The diastolic decrease reflects reduction in peripheral resistance consequent to decrease in sympathetic tone. The decrease is not associated with reflex increase in pulse as seen with anti hypertensive drug treatment12. On the contrary, there is decrease in pulse along with decrease in diastolic pressure. This is desirable as relaxation practice seems to normalize basic defects without causing activation of compensatory mechanisms which is the essence of RT. However, there is no significant difference in systolic BP. This may be partly due to very short period of relaxation intervention. Also, some reports indicate different response
to anti stress maneuver13., 14 in hypertensive patients. In the present study, we found greater reduction in diastolic BP, Pulse & RR among patients with spirituality and/or non-vegetarian food intake. It appears that spiritual life in hypertensive patients enables them to accept the concept of anti stress approach in treatment of hypertension. Perhaps as corollary of this, they were able to gain much rest and relaxation. In the present study, we have not attempted any reduction in dose of the antihypertensive drugs but it is advisable to decrease the dose in those patients who respond favourably to RT. It is found to be safe, effective, simple and acceptable additional therapy for patients with mild to moderate hypertension.
ACKNOWLEDGEMENT
The authors gratefully acknowledge kind help from Dr. S. H. Gaikwad, Dr. P. P. Rao,
Dr. Sanas, Dr. Jayram, Dr. Patel and
entire clinical staff of the Department of
Medicine. We are also thankful to Dr. Swati Lad and
Dr. Anirudh Chillar for their assistance and all
those patients who participated in the study.
REFERENCES
1. Letter from Sr. Deputy Director General, Indian Council of Medical Research, New Delhi - 110029.
2. Dzau V.J., Sasamura H.,: Heterogeneity of angiotensin synthetic pathways and receptor subtyres. Physiological and Pharmacological implications.
J. Hypertension II (suppl.3), 1993
513-518.
3. Julio A.P.: Role of endothelium derived nitric oxide in abnormal endothelium
dependent vascular relaxation of patients with essential hypertension. Circulation. 1993, 87, 5 : 1468.
4. Froberg J. Karlsonc L..., Lidbert L. : Physiological and Biochemical stress reactions induced by psychological stimuli. In Society—Stress & Disease. 1971 Editor-L. Levi Vol. I.P. 280, Oxford University Press NY.
5. Johnson E.O., Kamilaris T.C., Chrousus G.P. et al.: Mechanism of stress: A dynamic over view of hormonal and behavioral homoestasis. Neurosci.
_ Biobehav. Rev. 1992, 16 : 115-130.
6. Cryer P.E.: Physiology and Pathophysiology of human
sympatho-adrenaline-neuroendocrine system. N.
_ Engl. J. Med. 1980, 303 : 436-444.
7. Schnall P.I., Pieperc S.J. etc al.: The relationship between job strain
work place, diastolic blood pressure and left ventricular mass index. JAMA.
1990, 263, 1929-35.
8. Datey K.K., Deshmukh S.N., Dalvi C.P. et al.: Shavasan - A yogic exercise in management of hypertension. Angiology 1969, 20 : 325-333.
9. Omish D. M., Scherwitz L.W., Doody R.S. etc.: Effects of stress management training and dietary changes in treating Ischaemic Heart Disease. JAMA, 1983, 249 : 54-59.
10. Omish D.M. et al.: Can lifestyle changes reverse coronary heart disease? Lancet, 1990, 336 : 129-133.
11. Patel C.H.: Reduction of serum cholesterol and BP in hypertensive patients by behavioral modifications, J.R. Coll. Gen Pract. 1976, 26 : 211-215.
12. Lake C.R., Zigler M.G., Coleman M.D. etc al. : Hydrochlorthiazide induced sympathetic hyperactivity in hypertensive patients. Clin. Pharmacol. Ther. 1979, 26, 428-432.
13. Jacob R.G., Shapiro A.P., Reeves R.A. etc al.: Relaxation therapy for hypertension: Comparision of effects with concomitant Placebo, Diuretics and P-blockers. Arch. Med. 1986, 146 : 2335-2340.
14. Eisenberg D.M. Belbanco T.L. et al.: Cognitive and behavioral techniques for HT: Are they effective? Ann. Intern. Med. 1993, 118 : 964-972.
SOME EPIDEMIOLOGICAL FACTORS RELATED TO POISONING CASES
*Dr. Bhatkule P. R. **Dr. Ku. Wahab S. N.
***Dr. Pathak A. A.
Abstract
10.3% cases were found to be of poisoning out of total MLCs admitted. 66.3% were male while 33.7% female in 2:1 ratio. Rural, Urban cases were more or less equal with no significant difference. Majority of patients were engaged in laborious work.
Average monthly admissions were 69 per month. During the 3 and 4th quarter of year i.e. July to Dec. more number of cases were admitted in hospital and this difference was found to statistically significant. Most common chemical agent responsible for poisoning were organophosphorous compounds i.e. for 33.3% and alcohol intoxication for 13.4% cases.
Vomitting was the most common (77.65%) presenting symptom. Mean duration
of stay in hospital was found to be 5 days and 6 hrs.
More than 70% cases have been cured and discharged but 12.3% cases could not be saved.
INTRODUCTION
Acute poisoning is a common medical emergency all over the world. According to World Health Organization (WHO) 3 million acute poisoning cases with 2,20,000 deaths occur annually.
It's incidence is steadily rising and now atleast 10% of all adult emergency admission to hospitals are suffering from poisoning in Britain. Accidental poisoning in the home is also very common, especially in young children2.
In developing countries like India
* Associate Professor of PSM
** Professor of PSM
* Dean.
Department of Preventive & Social Medicine, Shri V. N. Govt. Medical College, Yavatmal.
agrochemicals are the commonest agents responsible for poisoning. Organophosphorus poisoning is the most common poisoning in India, followed by Aluminium phosphide.
Area served by Shri V. N. Govt. Medical College & Hospital is a rural and tribal area. A large number of cases of poisoning are coming to the hospital from the peripheral area. This study has been undertaken to know some epidemiological factors and type of chemical poison consumed by the victims involved.
Though poisoning is an universal phenomenon, knowing the pattern in a particular area will help for rapid clinical diagnosis and subsequent treatment. It will also help for adequate teaching in educational institutes to make the treatment facilities easily available and for health education along with prevention.
With these views this study was taken in medical college, Yavatmal.
MATERIAL & METHOD
The study was conducted at Shri V. N. Govt. Medical College & Hospital Yavatmal which one is a teaching and speciality hospital.
A separate medical record section is available in this college & hospital. An information about various variables such as patients age, sex, address, occupation, mode of poisoning, nature of poison, duration of hospital stay, type of treatment received, outcome after treatment etc. was obtained from the case tickets of all admitted poisoning cases. The record was traced about all those cases
who were admitted and an information was collected in a designed proforma from Medical Record Section for January 2001 to July 2003.
Deaths due to poisoning cases were cross checked from death registers maintain in medical record section of this college.
The analysis of this record was done with the help of intens under guidance of investigators during the period of Aug. to October 2003.
OBSERVATIONS & DISCUSSION
In this study, total 20727 medico legal cases had been reported in Shri V. N. Govt. Medical College & Hospital Yavatmal during the period of January 2003 and July 2003. Out of these 2144 (10.3%) cases were found to be of poisoning cases (which exclude the snake bite cases).
Table No. 1. Age & Sex wise distribution
Age groups Sex Total Percen-
(Yrs) tage
Male Female
0 to 12 102 53 155 7.22
13 to 18 156 80 236 11.00
119 to 25 326 168 494 23.04
26 to 35 483 245 728 34.00
36 to 50 298 152 450 21.00
50 + 56 25 81 3.74
Total 1421 723 2144 100
(66.3) (33.7) (100)
It was observed that out of 2144 patient of poisoning 66.3% were male and 33.7% wee female. The male: female ratio was 2:1 showing
male preponderance. It was also observed that maximum 57% patient were in your age groups i.e. 19 to 35 yrs and male & female shows the same ratio.
Similar finding were reported by Multani et al (1991) and Singh et al (1997). This may be because this age group is more involved in all types of strains-domestic, educational and unemployment. Males have easy accessibility to agrochemicals due to more involvement in agricultural work. Males are also exposed to greater stress and strain.
Table No. 2 Rural and Urban Distribution
Area No. of cases Percentage
Rural 1157 54
Urban 987 46
Total 2144 100
Patients coming from rural areas seems to be more than urban areas apparently. But statistically not significant.
Table No. 3 Occupation wise distribution of cases
Occupation No. of cases Percentage
group
Agriculturist 118 5.5%
Labourers 1864 86.94%
Others 162 7.56%
Total 2144 100%
It was observed that majority of cases i.e. 86.96% were from labourer group. It may be more due to easy accessibility to agrochemicals because of their occupation.
Table No. 4 Time distribution of cases
Total admission in 2 yrs and 7 months were 2144. Hence average monthly admission were found to be 69 per month.
Year Total cases Monthly average
2001 759 63
2002 979 82
2003 upto July 406 68
Total 2144 69
Table No. 4 (a) Time distribution of cases.
Years 2001 Year 2002 Total
Month No. of % No. of % No. of %
cases cases cases
January
to March 196 25 197 20.1 393 22.6
April to
June 124 16.3 232 23.7 356 20.48
July to
Sept 228 30 252 25.8 481 27.67
Oct to
Dec 211 27.7 297 30.3 508 29.22
Total 759 100 979 100 1738 100
Table 4 (a) shows the percentage of distribution of poisoning cases according to year and quarters of the year 2001-2002. It was observed that 759 and 979 cases were admitted in 2001 ande 2002 resp. If quarter wise distribution of the cases is observed, it is found that 22.6% cases were in 1st quarter of the year, 20.48% in 2nd quarter, while 27.67% and 29.22% in 3rd and 4th quarter of the year. So this distribution do not seems to be uniform. More cases were admitted in 2nd half of the years i.e. 27.67% and 29.22% than 1st half of the year. After application of X2 test, the difference in distribution of cases was found to
be statistically significant (p<0.05). This may be due to the more exposure of the labour to insecticides as spraying operations are commonly caried out during this period of the year in agriculture.
Table No. 5 Names of the poison abused.
Name of Poisons No. of cases Percentage
Organophosphrous 714 33.30
Other insecticides 287 13.40
Alcohol intoxication 279 13.40
Zinc Phosphide (Rat Killer) 236 11.00
Drug intoxication 154 7.18
Vegetable source 125 5.84
Phenyl 52 2.42
Kerosine 51 2.40
Food poisoning 50 2.33
Unknown 196 9.14
Total 2144 100
Most of common agents responsible for the poisoning were the organophosphrous compounds (33.30%) followed by other insecticides and alcohol intoxication 13.40% and 13.0% resp. 236 patients (11%) misused the rodenticide (Zinc phosphide) for self poisoning. In this study, from records it could not be revealed that what was the type of poison used by 196 (9.14) patients ?
Similar findings were reported by investigation like Basu et al (1999) and Multani et al (1991). Easy availability of highly toxic substance like organophosphrous compound has pushed up the incidence of poisoning.
Increasing incidence of poisoning (either suicidal or accidental) make it necessay to take some measures so as to reduce the
same.
Table No. 6 Predominant symptoms at the time of presentation of the cases in hospital.
Symptoms No. of cases Percentage
Vomiting 1665 77.65
Unconciousness 309 14.41
Breathlessness 15 0.69
Pain In abdomen 103 4.80
Convulsions 52 2.42
Total 2144 100
Vomitting and unconciousness were found to be prominent feathers in most of the cases i.e. 92% cases. Beside pain in abdomen, convulsions & breathlessness were found.
Table No. 7 Duration of stay in hospital
Stay in days No. of cases Percentage
1 to 5 1473 68.72
5 and more 671 31.28
Total 2144 100
Mean duration of stay was found to be 5 days 6 hrs. Majority of cases (68.72%) stayed in hospital for 1 to 5 days. While 31.28% patients had to stay for more than 5 days for the recovery.
Table No. 8 Out come of the admitted cases
Outcome No. of cases Percentage
Cured 1510 70.42
DAMA 304 14.20
RETERAL 66 3.07
DEATHS 264 12.31
TOTAL 2144 100
It was observed that majority of cases (70.42) were cured and discharged, while — 14.2% — were discharged against medical advice.
66 patients (3.07%) were referred to super speciality hospitals for their further management. But 12.31% cases could not be saved in spite of all medical efforts. It mean mortality amongst the poisoning cases was found to be 12.31% in this study. The overall mortality rate in study of Multani et al (1991) was 25.5% and S. Singh et al was 17.3%. So in comparison mortality in V. N. Govt. Medical College Yavatmal is found to be less.
Surprisingly it was observed that 225 (97.2%) deaths were occurred within 48 hrs of admission.
It may be due to patients reaching late in hospital after consummation of the poisons substance, may be the medicine or anti dose of choice might not have been made available or correct diagnosis about type of the poisoning might have not been established.
Hence it is suggested that due care about the possible reason to establish the diagnosis must be taken by the attending Physician, so as to prevent the high mortality within 48 hrs of admissions.
CONCLUSION
In Shri V. N. Govt. Medical College, Yavatmal a rural Medical College from Vidharbha Region, most of the poisoning cases
were referred form Primary Health Centers, Rural Hospitals, and belonged to laborer group of low Socio-economics status.
Common poisoning in this region noted were O.P. Poisoning resulting to fatal outcome. Plant poisons and household articles causing poisoning though not fatal, but require attention mainly from prevention aspects. The age group mostly affected was between 19 to 35 years of age with male preponderance. Mortality rate among the admitted cases was 12.3%.
REFERENCES
1 Davidson's principles and practice of Medicine EIBS Publication, Eleventh Ed. 1974 : 947-51.
2 Dr. Zinc Dr. Mohanty-Pattern of acute poisoning at IGMC Nagpur.
3. Dr. O.P. Murty - Acute poisoning in India AIMS, Delhi.
4. Dr. Multani B.S., Gupta M.M., Kazol H. L., Chopra B.K. (1991) - Specturm of acute poisoning in adults JAPI
Vol. 47 : (11).
5 Surjit Singh, Weig et al (1997) - Changing pattern of acute poisoning.
6 Basu. D, Bhadari B, Kunda A. K., Sarkar N. (1999) Profile of acute poisoning in a teaching hospital. Calcutta JAPI,
Vol. 47 (1).
7 Vaidya Y. V. , Keoliya A, Pathak A.A. (2003) - A study of trends of
poisoning in the cases reported to Shri V. N.
Govt. Medical College, Yavatmal, ICMR, Project by Medical Student.
DRUG DELIVERY SYSTEMS IN ASTHMA
Dr. Vijay Thawani**
Mrs. K. J. Gharpure#
Dr. Sonali Kalikar*
Continuing quality respiration is Vital input for optimal performance of life system - and any problem with the respiratory functions is distressful. In asthma there is recurrent, reversible airway obstruction, resulting in wheeze, cough and difficulty in breathing. In most of the patients the disease exists in chronic state, necessitating medical intervention on continuing maintenance level. The number of patients suffering from asthma being sizeable, need has been always felt to improve upon the medicine delivery in these patients. The respiratory route of administration has been rightfully exploited in this disease for the cherished advantages of ease and comfort of self-administration, improving compliance, directly delivering the medicine to the affected system, improVing bioavailability, decreasing
the dose, reducing the systemic adverse reactions, increasing the therapeutic index and saving the cost of therapy. With such potential advantages, it is natural that there is increased thrust in R&D in this area. It is unfortunate that the medical graduates hardly know how to handle these newer drug delivery devices. It has been realized that even the respiratory care practitioners have deficient information in selection and correct application of these devices.
Breathing in the medicines
Nasal route has been used since the time when humans started enjoying the psychedelic effects of snuffing intoxicants. In Indian traditional medicine; fumes have been inhaled since antiquity for treatment of
** M.D. Associate Professor
# B Pharma Pharmacist
* MD, Lecturer
All from Department of Pharmacology, Govt. Medical College, Nagpur - 440 003.
* Corresponding Author
Dr. Vijay Thawani
14-A, Jeevan Jyoti, Clarke Town, Nagpur - 400 004.
Tel. : 0712-2522977 • vijaythawani@rediffmail.com
Beclomethasone dipropionate PMDI delivers 50 mcg /puff and is used in the dose of 2 puffs 3-4 times / day without any systemic adverse effects. Doses upto 1.5 mg per day in adults does not suppress hypothalomo-pitutary axis. Triamcinolone acetonide and fluticasone propionate are also used by inhalation. Budesonide has higher ratio of topical to systemic activity and is more potent than beclomethasone. It can be administered in total daily dose upto 3200 mcg in two divided doses. Disodium cromogiycate is the mast cell stabilizer used by inhalation - for its anti-inflammatory effect and no tolerance is seen with this even with long-term use.
The advantages of metered dose inhalation
Among the various advantages is speedy delivery of accurate dose, in needed particle size. After administration by this route the onset of action of the drug is rapid. This route circumvents first pass hepatic metabolism and minimizes adverse effects. It needs lower dosage to produce therapeutic effect and makes dose titration possible to cater to individual needs. It does not suffer from the erratic kinetics as seen with oral or parental administration and is safer in children and pregnant women. The physical or chemical incompatibility due to concurrent drug administration is not there. The packaging is tamper proof, easy / ready to use and there is no risk of contamination. Effects due to exposure to air or moisture are avoided. Overuse as seen with topical creams, lotions is not there. The spray can be used as foam and even to deliver semisolids. The cooling
effect of liquefied gas propellent used in aerosols is desirable. The PMDI are much better than atomizers and nebulizers, which are bulky and require cleaning after each use. Efficacy of inhaled drug in 1-2 puffs twice daily has been found to increase patient compliance tremendously.
The problem areas with metered inhalation
Metered dose inhalers are generally considered complicated devices. A patient usually requires 10-15 manoeuvres. The patients feel disappointed, frustrated and dejected due to failure to perform the psychomotor skill correctly as lot of coordinated activities are required for use with inspiration. This problem is more with children, aged and seriously ill patients. Inappropriate administration of the repeated doses of potent sympathomimetics can induce lethal cardiac arrhythmias. The actuator design varies from company to company, needing fresh adaptation to the new product. Chlorinated fluoro carbons (CFC) used as propellents themselves cause allergic problems. Spacer devices with larger tubes are inconvenient because of their size, high cost and difficulty to clean. Particles larger than 10 um are primarily deposited in mouth and oropharynx and particles smaller than
0.5 um are inhaled right upto the alveoli and subsequently exhaled without being deposited in the lungs. So far no aerosol system in clinical use can produce the particles of uniform size in the desired size range. Inadequate dose delivery is the cause of apparent "resistance". Topical steroid use by this route can lead to
Candida albicans infection of mouth and throat. It may interfere with growth of lung and other organs in young children. Hoarseness of voice, sore throat and dysphonia are also seen. There may be flare-up of allergic rhinitis and nasal polyps on stoppage of the treatment. And to top the problem, it is valueless in acute attacks. Higher inhaled dose of corticosteroids (>1500 mcg /day) has been found to increase the risk of skin bruising, cataract, decrease bone density and suppression of hypothalamo-pitutary axis. What is in practice in developed economies but is missing in India
In developed economies many pharmaceutical companies provide placebo inhalers to the patients for practice. It is rational to train the potential users with a dummy rather than active drug. The patients are imparted instructions about how to use the device through videotapes. One-to-one demo of the device has been found to be most successful. A breath-activated inhaler developed by 3 M Pharmaceuticals was found to increase its efficient use from 50 to 91 % when accompanied by written as well as verbal instructions. Recommendation
The actuator (pressure releasing valve) design should be internationally standardized and uniformly applied to all inhalers so that the patients are not put to inconvenience due to variation. This will improve the competence of the usage of the device. The CFC propellents should be replaced with compressed gases like air, Nitrogen, Nitric oxide. Even though the new, environment friendly hydrofluroalkane (HFA) MDI have been introduced in developed
economies, the developing ones are still to catch up. The generic metered dose aerosol inhalers should be made available, as the branded ones are not within the reach of the poor in the developing economies. Currently there are many devices that are off patent and these can be freely manufactured. Companies marketing the inhalers should arrange to provide on-line simulated training for the correct use. Bioequivalence studies should be performed to scientifically validate the recommended advantages of these devices.
The desired patient information in package inserts There are no laws existing in India about what all information should be included in the package inserts. The package inserts are in such fine print that these require magnifying glass to read. The style and contents of these make no sense to commonsense and hence generally is nonsense. The companies boisterously hoist that the information is for registered medical practitioner or a laboratory. It is most unfortunate that the product users - the patients continue to be deprived of vital information and they use the medicinal products without any drug information.
It is desired that package inserts of new devices must contain detailed information about the correct use of the device. Instructions about shaking the container thoroughly before use, holding the mouthpiece of inhaler 4 cm away from the open mouth or use of spacer device should be there. Directives about breathing out slowly and completely, discharging the inhaler
while taking a slow deep breath of 5-6 seconds and then holding the breath in full inspiration for 10 secs should be explained in steps along with diagrammatic representations. All patients being prescribed an inhaler must be taught how to synchronize the actuation of the inhaler With inspiration in order to maximize the drug delivery to lungs, even though this problem has been reduced as a result of use of spacers. Dose must be prescribed as number of puffs, number of times per day.
What is coming up
Aerosols are being tried for other diseases also. Three corporations are reportedly active in developing the system for administration of inhaled insulin. A variable dose valve for use with nasal insulin is under development. Industry is fast to pick up the new technology for consumer goods, which provides quantum sale. The aerosol is already used for many non-medical products, the latest one being shoe polish spray.
Different barrier systems for drug delivery, alternative propellents, and user-friendly actuator designs are being tested. Their success will pave the way for effective utilization in asthmatic patients.
References
1. Bennett PN, Brown MJ. Respiratory System. In: Clinical Pharmacology. 9th edition 2003:549-564. Churchill Livingstone. An imprint of Elsevier Science.
2. Bradley J, Liechtenstein LM. Drugs used in the treatment of Asthma. In: Goodman & Gilman's The Pharmacological Basis of Therapeutics. Editors Hardman JG, Limbird LG, Goodman GA. 10th International edition; 733-754. McGraw Hill, Medical Publishing Division.
3. Rang HP, Dale MM, Ritter JM, Moore PK. The Respiratory System. In: Pharmacology. 5th edition 2003:340-351. Churchill Livingstone. An imprint of Elsevier Science.
4. Pharmacotherapy of Bronchial Asthma & Rhinitis. In: Pharmacology & Pharmacotherapeutics. Editors Satoskar RS, Bhandarkar SP, Ainapure SS.18th edition; 346-361. Popular Prakashan, Mumbai.
5. Sciarra JJ. Aerosols. In: Remington: The Science & Practice of Pharmacy. EdItor Gennaro AR. 19th edItion 1995 : 1676-1692. Mack -Publishing Company, Easton, Pennsylvania.
PROGRESSIVE SYSTEMIC SCLEROSIS
Mane Satish*
Handargule Sunita**
Dhule Sunita#
Introduction
Progressive Systemic Sclerosis is a known clinical entity of unknown etiology. It is a diffuse connective tissue disease of autoimmune origin. Commonly occurs in female at the age 30 to 50 years.2
It is a disease characterised by changes in skin, blood vessel, skeletal muscles and internal organs like lung and kidney. It affects ling paranchyma hence have adverse effect on Respiratory System.2
The present study was undertaken to evaluate the effect of disease on Pulmonary Function tests.
Case Report
A 38 year old nonsmoker, nonhypertensive presented with dyspnea. His complaints of shortness of breath began 5 years prior to evaluation and had gradually worsned.
Dyspnea exacerbates after exercise. Cardiac examination is normal, remainder of physical examination is also within a normal limit. There is no history of Silica dust exposure, no history suggestive of same disease in family.
Along with Dyspnea patient is having Raynaud's phenomenon causing severe pain, which aggravate on exposure to cold. Respiratory System examination reveals increased respiratory rate and unequal expansion of the chest. On auscultation diminished respiratory sounds and crepts are observed.
Patient has received Glucocorticoid, antibiotic and pain killer for 5 years but there is no significant improvement in respiratory function. Raynauds phenomenon is worsening day by day.
Hematological investigation shows anemia, increase in total leucocyte count. eosinophilia and E.S.R. is elevated.
* Lect. in Physiology
** Associate Professor in Physiology
# Lect. in Physiology
Observations
Pulmonary Function in Systemic Sclerosis
Test Predicted Actual % Predicted
FVC (L) 3.32 1.34 40
FEV1 (L) 2.75 1.17 42
FEV1/FVC 82.83 87.31 105
Abbrevation - FVC - Forced vital Capacity
FEV1 - Forced Vital Capacity in 1 st. Second.
Discussion
Progressive systemic Sclerosis is disease of unknown etiology2 also called as crest syndrome. It is said that it is autoimmune disorder caused by antibody against own connective tissue of skin, blood vessel, Skeletal muscles and internal organ like lung and
kidney.2
In Respiratory System it
affects Parenchyma of lung tissue which is
responsible for fibrosis and leads to decrease in total
lung capacity for external respiration hence there might be mismatching of ventilation
and perfusion of gases. This might be the major cause of dyspnea in patient suffering
from systemic sclerosis.
The results of Pulmonary function (Spirogram) shows restrictive pattern. As
there is extensive fibrosis of lung tissue resulting
in to decrease lung elastance and compliance. Muscle weakness might have
decreased effective contraction of respiratory muscles
and hence there is decrease in forced vital capacity.
Summary
Progressive systemic sclerosis affects lung and shows restrictive patterm of Pulmonary function tests due to decrease in lung elastance and compliance.
There is no effective treatment for it hence more research needs to be conducted in this area to understand etiopathogensis and for effective line of treatment.
References
1) Cotes J. E. Lung function assessment and application in medicine. III Edi. Black well scientific publication:1975 : 18-20 : 59-58, 326-329 and 464.
2) Johnson D.A., Drane W.E. : Curran
J; Cattau E.L. Jr. Ciarleglio C; Khan A; Cotelingam J; Benjamin S.B.-Pulmonary Disease in Progressive systemic sclerosis ARCH. INTERN MED 1989 ; 149/3 589-593.
3) Reddy D.V.S. and Sastry P.B. Studies
in Vital Capacity: Ind. Jr. Med. Res:
32:237, 1944.
4) Slomim N.B. and Hamilton L.H.-Respiratory Physiology, IV th edt; 1981, C.V. Mosby company P.T. 1981, 220-223, 228.
PRIMARY CARCINOMA OF FALLOPIAN TUBE - A RARE CASE
Dr. Jadhav B. J.
MD* (Obstetrics & Gynecology)
Dr. Kurdukar D. V. MD** (Obstetrics & Gynecology)
ABSTRACT:
Primary carcinoma of the fallopian is a rare malignancy, represents less than 2% of all gynecological malignancies. Postmenopausal women with infertility and low parity are at risk. The clinical presentation varied from postmenopausal bleeding or serosanguinous vaginal discharge and pelvic mass. This case, 54 years old obese woman had complaints of P.V. bleeding and there was no adnexal mass felt on bimanual examination. But pelvic USG showed left TO mass. Laparotomy was performed which revealed primary carcinoma of left fallopian tube. Therefore, staging laparotomy with TAH with BSO was performed. Histopathology showed papillary adenocarcinoma with no secondaries in omentum and peritoneal biopsies. (FFIGO Stage I)
She could not offer postoperative chemotherapy but she is under follow up since then and is asymptomatic for features of recurrence.
Key words : Gynecological Malignancies, Fallopian tube.
Introduction:
Primary carcinoma of fallopian tube
is a rare gynecological tumor, represents 0.18% to 1.6% of all gynecological malignancies1,2,4. The first case of primary carcinoma of the fallopian tube was presented by Renaud at Manchester Pathological Society meeting in 1847, but the first authentic description was given by Orthmann (1888)2. Since then about 1500 or so cases have been reported in the world literature3.
We report a rare case of primary carcinoma of fallopian tube.
* Lecturer, Dept. of Obstetrics and Gynecology, S. R. T. R. Medical College, Ambajogai.
** Asso. Professor, Dept. of Obstetrics and Gynecology, V.M. Medical College, Solapur.
Address for Correspondence:-
Dr. Jadhav B. J.
4-Sindhudurga, Medical College Campus, Ambajogai, Dist-Beed PIN-431517
Ph - (02446) 249847 • Office : Fax : (02446) 247132
Case history:
A 50 years old postmenopausal nulligravida came from rural area to Gynaec OPD on Jan. 2001, with the chief complaint of P. V. bleeding since one year. She was obese and except pallor there were no other findings on general and systemic examination.
Per speculum examination showed watery-blood stained discharge through the OS. There was no growth either on cervix or vagina.
On bimanual examination, the uterus could be felt with difficulty without any adnexal mass.
Pelvic ultrasound showed TO mass? Malignancy in left adnexa with collection in the endometrial cavity and endometrial thickness was found to be 4 mm.
On D&C scanty endometrium was obtained and histopathology was inconclusive. X-ray chest was normal. Results of hematological and biochemical investigations were within normal limit.
Laparotomy was performed for TO mass and on opening of abdomen there was found to be left sided hematosalpinx (approx 5 x 4 cm in size) with completely sealed fimbrial end and ovaries were atrophic. Findings were suggestive of primary fallopian tube carcinoma. Therefore, staging laparotomy with TAH with BSO was performed. Cut sections of the mass showed intraluminal mass of about 4 % 3 cm size.
Histopathology showed papillary adenocarcinoma of the left fallopian tube and no malignant deposits were found in omentum and peritoneal biopsies. Peritoneal washings were also negative for malignant cells. The right fallopian tube and ovary, endometrium and the endocervix showed normal histology and no malignant deposits (FIGO stage I).
She was advised postoperative chemotherapy, but she could not afford it. She is under follow up and asymptomatic for features of recurrence.
Discussion:
Little is known about the etiology or epidemiology of this malignancy. The old age (median age 54 years), infertility, low parity and history of PID are few reported risk factors1-6. The clinical presentation varied from postmenopausal bleeding or serosanguinous vaginal discharge, pelvi-abdominal pain, pelvic mass and abdominal mass. But 3% to 14% of patients may be asymptomatic1,4,5.
The classical triad of symptoms-vaginal discharge that is profuse, recurrent and amber to red in color, pain and adnexal mass, so called hydrops tubae profluens was occasionally observed2-4.
Because of nonspecific symptoms and vague physical findings in few patients, preoperative diagnosis may not be made1,2,4. But occasionally the diagnosis will be incidental, made by pathologists and
not recognized at the time of laparotomy1. Therefore, high index of suspicion is essential. Additionally, the elevated CA 125 levels may help to suspect the disease.
In this case no adnexal mass was felt and D&C was inconclusive. USG findings were suggestive of an adnexal mass. The true state of affairs could be revealed only after laparotomy and it was s/o fallopian tube malignancy with no obvious involvement of omentum. Survival highly depends upon the stage of disease. The postoperative platinum based chemotherapy regimens may lead to prolonged disease free interval.
In 1951, Stanley Way wrote that 'the paucity of reports of primary carcinoma of the fallopian tube demand that every case be reported in detail'3. even today this plea continues to be true.
Fig. 1 : "Primary Carcinoma of the fallopian tube"
References
1. Gary L. Eddy, Larry J. Copeland, David M. Gershenson et al. Fallopain tube carcinoma. Obstet Gynecol 1984; 64:546-52.
2. K. S. Raju, G. H. Barker, Eve Wiltshaw. Primary carcinoma of the fallopian tube (Report of 22 cases). Br J Obstet Gynaecol 1981; 88: 1124-29.
3. F. Lawton, C. Less, C. Kelleher. In : Progress in obstetrics and Gynaecology, Vol. 12, John Studd ed. (Churchill Livingstone) 1996; 393-402.
4. E. H. McMurrary, A. J. Jacobs, C. A. Perez et al. Carcinoma of fallopian tube. (Management and site of failure). Cancer 1986; 58: 2070-75.
5. W. A. Peters III, W. A. Andersen, M. P. Hopkins et al. Prognostic features of carcinoma of the fallopian tube. Obstet Gynecol 1988; 71: 757-62.
6. A. P. Davies, Andrew Fish, R. Woolas et al. Raised serum CA 125 preceding the diagnosis of carcinoma of fallopian tube: two case reports. Br J Obstet Gynecol 1991; 98:602-03.
be directed must be indicated. Submission of e -mail address is encouraged.
Title
Title of the article should be short and yet sufficiently informative so as to be useful in indexing and information retrieval.
Abstract
The abstracts should be brief (about 200 words) and structured (for special and original articles) to contain purpose/ background, material and methods, results and conclusions of the paper. It should only highlight the principal findings and conclusions so that it can be used by abstracting services without modification. Conclusions and recommendations not found in the text of the article should not be inserted in the Abstract.
Key Words
Upto five key words may be given, which will be helpful for indexing purposes.
Introduction
Introduction should be brief and state precisely the scope of the paper. Review of the literature should be restricted to reasons for undertaking the present study and provide only the most essential background.
Material & Methods
The nomenclature, the source of material and equipment used, with the manufacturer's details in parenthesis, should be clearly mentioned, the procedures adopted should be explicitly stated to enable other workers to reproduce the results, if necessary. New methods may be described in sufficient detail and indicating their limitations. Established methods can be just mentioned with authentic reference and significant deviations, if any, given with reasons for adopting them. When reporting experiments on human subjects, it should be indicated whether the procedures followed were incoordinate with the ethical standards on human experimentation (as per the guidelines laid down by the Central Ethical Committee of the Indian Council of Medical Research).
When reporting experiments on animals, procedures adopted for the care and use of laboratory animals need to be mentioned. The drugs and chemicals used should be precisely identified, including generic name(s), dosage(s) and route(s) of administration.
The statistical analysis done and statistical significance of the findings when appropriate should be mentioned. Unless absolutely necessary for a clear
Scope
`Milestone' a quarterly journal entertains original communications on all aspects of biomedical research contributing to the advancement of knowledge in Medical sciences. The scope of the Journal allows publication of papers on medical education at undergraduate and postgraduate levels in either medical or paramedical courses; innovations in techniques; epidemiologic investigations and interdisciplinary work in human diseases. Readers are encouraged to write comments on papers published in the Journal in the form of letter to the Editor. Short communications containing significant findings will be given priority. Those who wish to contribute review articles may write to the Editor expressing their intention. It is issued quarterly in January, April, July and October every calendar year. All papers are subjected to peer review by Editorial Board and experts in the field before acceptance for publication. All papers are accepted subject to editorial changes.
Submission of Manuscripts
Manuscripts should be submitted with the undertaking that they are not under consideration elsewhere and have not been reported earlier partly/totally. It is necessary that all the authors give an undertaking (in the format given at the end) indicating their consent to be co-authors in the sequence indicated on the title page. Typescripts in triplicate should be sent to the EDITOR, Milestone, DMER, St. Georges Compound, Near CST, Mumbai: 400001.
Preparation of Manuscripts
Authors are advised to consult a recent issue of the Journal to get familiar with the format adopted in respect to various elements of a paper. Manuscripts should be presented in as concise form as possible, typewritten in double space on one side of good quality bond paper (21.0 x 29.7 cm ). Pages should be numbered consecutively and the contents arranged in the following order: Title, Name(s), of the author(s) with highest academic qualification of each author, abbreviated title, manuscripts are to be submitted. Department(s) and Institution(s), Abstract, Key words, Introduction, Material & Methods, Results, Discussion, Acknowledgment, References. Abstract, Tables and legends for figures should be typed on separate sheet and not in continuation of the main text. Three copies of the manuscript are to be submitted. Due to the high cost of postage, it may not be possible for the Editor to return the original manuscripts to the authors if not accepted for publication.
The name and mailing address of the author to whom requests of reprints or correspondence should
understanding of the article, detailed description of statistical treatment may be avoided. Articles based heavily on statistical considerations, however, need to give details particularly when new or uncommon methods are employed, others need to give only authentic references.
Results
Only such data that are essential for understanding the discussion and main conclusions emerging from the study should be included. The data should be arranged in unified and coherent sequence so that the report develops clearly and logically. Data presented in tables and figures should not be repeated in the text. Only important observations need to be emphasized or summarised. The same data should not be presented both in tabular and graphic forms. Interpretation of the data should be taken up only under the Discussion and not under Results.
Discussion
Long, rambling and involved discussion should be scrupulously avoided. The discussion should deal with the interpretation of results without repeating what already was presented under Results. It should relate new finding to the known ones and include logical deductions.
The conclusions can be linked with the goals of the study but unqualified statements and conclusions not completely supported by the data should be avoided. Claiming of priority on work that is ongoing should also be avoided. A hypothesis should, if warranted, clearly be labelled as such; recommendations may be included as part of the Discussion, only when considered absolutely necessary and received.
Case report
For description of uncommon infections. It should be divided into introduction, case history and discussion with not more than 10 references as possible. Illustrations and tables when included should be limited to one each. It should have an abstract (unstructured) limited to 100 words and key words limited to 3 words.
Brief Communications
Recommended for brief observations that do not warrant a full length paper. It may be divided into sections as for the full paper. It must not exceed 1000 words. References must be as few as possible and not more than 13. Illustrations and tables when included should be limited to one each. It should have an abstract and
(unstructured) limited to 100 words and key words limited to 3 words.
Correspondence
Addressed to the editor, corres- pondence can
be related to previously published articles or for
presentation of preliminary results. It should be limited in length
to 250 words. And should be continuous without
headings. It may include 2-3 paragraphs, not more than
5 references and no tables and figures.
Acknowledgment
Acknowledgments should be brief and made for specific scientific and technical assistance only and nor for providing routine departmental facilities and encouragement or for help in the preparation of the manuscripts (including typing or secretarial assistance).
References
References will not be checked in the Editorial office. Responsibility for their accuracy and completeness lies with the author. The total number of references should normally be restricted to a maximum of 20 for an original research article, 10 for a case report, 13 for a brief communication and 5 for correspondence. References to literature cited in the text should be numbered consecutively and placed at the end of the manuscripts in the text they should be indicated above the line (superscript). As far as possible mentioning names of authors (s) under reference should be avoided in text.
Journals
The titles of the journals should be abbreviated according to the style used by the Index Medicus. The January issue of the Index Medicus may be consulted. In citing reference to research papers, names and initials of all the authors should be given, followed by: the title of the article, journal (italics), year (in circular brackets), volume number (bold), and first page and last page of the reference.
e.g. Chande C, Thakar YS, Pande S, Dhanvijay AG and Saoji AM. Productions of anti-light chain antisera. Indian J Med Microbial (1996) 14: 145-149.
If a paper has been accepted for publication, the name and initials of all the authors and the journal should be given followed by the words "in press" within circular brackets. Parikh M and Singh N. Rapid diagnosis of neonatal bacteraemia Indian J Med Microbiol (1995) (in Press).
Books
When the book has only authors and no editor(s).1) S.C. Parija A text book of Medical Parasitology: 1 st ed. (All India Publishers and Distributors, Madras) 1996.-30-34.
2) Hamerton John L. Human cytogenetics. (New York Academic Press) 1971, Vol. 1112-18.
When the reference is to author(s) who has contributed a chapter in a book edited by someone else. Samadel Joseph E. In: Viral and rickettsial infections of man, 3rd ed. Thomas M. Rivers and Frank L. Horsfall Jr. Eds (J.B. Lippincott Co., Philadelphia) 1959: 400.
Proceedings of symposia/conferences
Published proceedings of conferences/ symposia should be treated as books.
Vijayaraghavan R. Inter-laboratory evaluation of VDRL Test. In: Proceedings of WHO Workshop on Quality control in Clinical Microbiology. R. Sambasiva Rao(ed) (Department of Microbiology, JIPMER, Pondicherry) 1990: 63
Monographs/reports
The name of the book should appear first followed by the other details.
WHO Environmental health criteria: carbon disulphide (World Health Organisation, Geneva) (1979): 1 O.Satyavati GV, Raina MV and Sharma M. (Eds) Medicinal plants of India (Indian council of Medical Research, New Delhi) 1976, vol I: 332.
Thesis (doctorate)
Satynarayana K. some Biochemical studies on the tenotomized gastronemius muscles of frog, Rana hexadactyla (Lesson) Ph. D. Thesis, Sri Venkateswara University, Tirupati,1976.
Unpublished data/personal communications
Unpublished abstracts and abstracts reference. personal communications should be indicated in the text itself and not numbered as (I) (Swami KS, unpublished work); (II) (Swami KS, personal communication): (III) (National Institute of Nutrition unpublished data).
On Line Journals
Friecman SA, Preeclampsia: A review of the role of prostaglandins obstet Gynaecol (serial online). January 1988: 71-22-B7 Available from BRS Information Technologies, Melean VA, Accessed December 15,1990.
Illustrations:
Three sets of Illustrations (one set original and 2 copies) should be submitted, numbered consecutively in Arabic numerals. Line drawings should be made on good quality tracing paper or Bristol board. Letters, numbers and symbols should be clear in the figures and of sufficient size, so that when reduced, they could be accommodated in single column (8.5 cm) or double (17.0 x 21.0 cm ) column sizes. All the illustrations must be protected by thick card board packing against damages during transit. Photomicrographs should have internal scale markers regarding details of magnification to facilitate reduction in size. Symbols, arrows and letter used in the photomicrographs should contrast with the background.
All published material should be acknowledged and copyright material should be submitted along with the written permission of copyright holder. Colour illustrations will be accepted only at the author's expense.
Electronic manuscript
Upon acceptance for publication or at the time of revision when a manuscript is likely to be accepted for publication, the corresponding author will be requested to send an electronic file on floppy, in addition to the original manuscript. Disks that are IBM PC compatible (non macintosh) will be accepted. Floppy disks should be 3.5 inch, double sided and high density. Text and tables files should be in MS word for windows. The disk should be labelled with the manuscript number title of
the article, author's name, the file name and software used including version. The disk must contain exactly the same material as the revised manuscript including the tables, Legends and graphs. Graphs and diagrams must be sent in graphic format, preferably MS EXCEL, MS Power Point and Adobe Photoshop. Do not send graphs and diagrams in freehand. The disk should be sent in proper packaging to avoid damage and corruption of the information during transit.
Tables
Tables should be typed separately and numbered consecutively with Arabic numerals (1,2,3, etc.,). They should bear brief title and column headings should also be short. Units of measurement should be abbreviated and placed below the headings. Statistical measurement variations such as SO and SE should be identified. Also table should not be submitted as photographs. Any other queries may be clarified from the Editor.
Undertaking
We, the undersigned, give an undertaking to the following effect with regard to our article entitled "………..………" submitted for publication in the milestone Journal of Medical Research Council of Maharashtra.
1. The article mentioned above has not been published or submitted to or accepted for publication in any form, in any other journal.
2. We also vouchsafe that the authorship of this article will not be contested by anyone whose by anyone whose name(s) is/are not listed by us here.
3. We also agree to the authorship of this article in the following sequence:-
Authors Names (in sequence) Signature of Authors with date
Important
1. All the authors are required to sign independently in this form in the sequence. 2. Each author should have generated at least part of the intellectual content of the paper.
3. Each author should be able to defend publicly in the scientific community, that intellectual content of the paper for which he/she can take responsibility.
4. No addition/deletion or any change in the sequence of the authorship will be permi- ssible at a later stage, without valid reasons/ permission of the Editor.
5. If the authorship is contested at any stage, the article will not be processed for publication till the issue is resolved.