ijmrhs

International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 th Received: 26 Oct 2012 Revised: 19th Nov 2012 Accepted: 23rd Nov 2012 Original research article A QUESTIONNAIRE BASED EVALUATION OF TEACHING METHODS AMONGST MBBS STUDENTS Muneshwar JN1, *Mirza Shiraz Baig2, Zingade US3, Khan ST4 1 Associate Professor, 2Assistant Professor, 4Professor & Head, Department of Physiology, GMC, Aurangabad, Maharashtra. 3 Professor & Head, Department of Physiology, BJMC, Pune, Maharashtra. *Corresponding author e mail: shirazdoctor@yahoo.com ABSTRACT Background: The medical education and health care in India are facing serious challenges in content and competencies. Heightened focus on the quality of teaching in medical college has led to increased use of student surveys as a means of evaluating teaching. Objectives: A questionnaire based evaluation of 200 students (I MBBS & II MBBS) about teaching methods was conducted at a Govt Medical College & Hospital, Aurangabad (MS) with intake capacity of 150 students &established since 50 last years. Methods: 200 medical students of I MBBS & II MBBS voluntarily participated in the study. Based on teaching methods, an objective questionnaire paper was given to the participants to be solved in 1 hour. Results: As a teaching mode 59% of the students favored group discussion versus didactic lectures (14%). Almost 48% felt that those didactic lectures fail to create interest & motivation. Around 66% were aware of learning objectives. Conclusion: Strategies and futuristic plans need to be implemented so that medical education in India is innovative & creates motivation. Keywords: Teaching methods, Undergraduate students, Medical education INTRODUCTION The Government of India recognizes Health for all as a national goal and expects medical training to produce competent “Physicians of First Contact” towards meeting this goal. However, the medical education and health care in India are facing serious challenges in content and competencies1 With the growing awareness of the importance of teaching and learning in medical education and the need to move towards evidence-based teaching, it is important to re-examine the educational teaching methodology2. To take care of the huge Indian population India needs quality doctors and not just quantity. Heightened focus on the quality of teaching in medical college has led to increased use of student surveys as a means of evaluating teaching3. Good evaluation practices in medical training, at all levels, enhance both quality and accountability 19 Muneshwar J N et al., Int J Med Res Health Sci.2013;2(1):19-22 of medical education4.In recent a time there is a growing apathy of students towards attending lectures and clinics in medical colleges. Present study tried to evaluate the teaching methods & changing trends amongst first year and second year MBBS Students at Govt. Medical College, Aurangabad (MS). Aims and objective Primary To evaluate the teaching methods practiced in medical education in Ist MBBS & II nd MBBS medical students Secondary The strengths and shortcomings in teaching methods, areas of improvement in medical teaching: student’s scenario Study Design: A prospective observational study MATERIAL AND METHODS The study was approved by the Institutional Ethical Committee of Govt. Medical College, Aurangabad. Enrolled students were explained all the details of the study and objectives. The identity of the students was not allowed. 200 medical students of I MBBS & II MBBS voluntarily participated in the study. Based on teaching methods, an objective questionnaire paper was given to the participants to be answered in 1 hour. The questionnaire consisted of MCQs regarding: 1) Teaching methods 2) The audiovisual aids used in teaching. 3) 4) Evaluation Methods The environment related to studying RESULTS A) Teaching Methods: 66% were aware of the learning objectives, which is a welcome sign. 48% felt that didactic lectures fail to create interest & motivation in the subject. 59% of the students favored group discussion as a teaching mode over didactic lectures (14%). 87% pointed out that at the end of the lecture, the student becomes storehouse of book facts rather than being oriented. 83% were of the opinion that the current duration of the MBBS curriculum versus vast syllabus is a major hurdle in learning process. B) Audio Visual Aids: 90%Participants were in favor of using Audio visual aids for demonstrations with complimentary use of traditional chalk and blackboard methods. C) Evaluation Methods: 53%of the students feel that the current evaluation standards are not satisfactory considering the competitive examinations for future. They prefer introduction of more MCQs. D) Environment related to studies: 90%Students complained of average sound system quality in lecture halls, overcrowding in the demonstration sessions. 90% 80% Observat ion % 70% 60% 50% 40% 30% 20% 10% 0% Learning Object ives achieved Didat ic Lect ures acceptance Group Discussions required Change in Durat ion of M BBS Curriculum Required Teaching M ethods Fig: 1 Teaching Methods 20 Muneshwar J N et al., Int J Med Res Health Sci.2013;2(1):19-22 100% 90% Observat ion % 80% 70% 60% 50% 40% 30% 20% 10% 0% Audiovisual Aids Acceptance Evaluat ion M ethods Satisfact ory Teaching Environment change required Parameters Fig. 2: Other Parameters Studied DISCUSSION AND CONCLUSION The study is not judgemental. We are just trying to put forth the facts In front. It is not a complete picture. The information gained from evaluation can lead to changes in any aspect of teaching and evaluation methods. Curricular reforms to systematically address these issues and develop strategies to strengthen the medical education and health care system are needed at an institutional level & to be implemented at health universities who are involved in the curricular programmes. This will definitely help the Indian Medical Graduates match or better the international standards.4-6 Amongst the important suggestions received from the medical students were to decrease the generation gap between the student and the teachers by imparting Group activities in the form of seminars and symposiums. The teaching standard should be of competitive entrance examination level right from the basic sciences itself. A comprehensive initiative for complete assessment of teaching methods is urgently required at a state level involving Medical education technology units of all concerned universities for medical education. This will enable strategies and futuristic plans for proper and uniform implementations so that medical education Muneshwar J N et al., in India becomes innovative, competitive and is able to prepare undergraduates to perform in the changing scenario of medical science. REFERENCES 1. Vision2015-Medical council of India. Available at www.mciindia.org/tools/ announcement/MCI_booklet.pdf. Accessed on 14 Dec 2011. 2. Sybille K L. Evaluation of Teaching and Learning Strategies. Med Educ Online [serial online] 2001;6:4. 3. Harden R. AMEE Guide 21: curriculum mapping: a tool for transparent and authentic teaching and learning. Evaluating the outcomes of undergraduate medical education. Medical Education. 2003; 37: 580 – 81 4. Marton F, Saljo R. Qualitative differences in learning I-outcome and process. Brit J of Educ Psych. 1996;46:4-11 5. Second year student’s feedback on teaching methodologyy and evaluation methods in pharmacology. Nilesh Chavda, preeti yadav, mayor Chaudhari, kantharia. National Jour nal of Physiology, Phar macy and Phar macology 2011;1:23-31. 21 Int J Med Res Health Sci.2013;2(1):19-22 6. Learning Habits Evaluation of First M.B.B.S Students of Bhavnagar Medical College. Chinmay Shah, Shailesh Patel, Jasmin Diwan, Hemant Mehta. International Journal of Medical Science and Public Health. 201;’ 1(2):81-86 22 Muneshwar J N et al., Int J Med Res Health Sci.2013;2(1):19-22 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN:2319-5886 Received: 4thNov 2012 Revised: 3 rd Dec 2012 Accepted: 7 th Dec 2012 Original research article EVALUATION OF EFFICACY AND TOLERABILITY OF ACETAMINOPHEN (PARACETAMOL) AND MEFENAMIC ACID AS ANTIPYRETIC IN PEDIATRIC PATIENTS WITH FEBRILE ILLNESS: A COMPARATIVE STUDY. *Kunkulol Rahul R1, Sonawane Aishwarya2, Ashok Kumar Chavva3 1 Associate Professor, Department of Pharmacology, Secretary, Research Cell, PIMS-DU, Loni. UG, Rural Medical College, Loni.3Professor, Department of Pediatrics, Rural Medical College, Loni 2 *Corresponding author e mail: rahul4420@yahoo.com ABSTRACT Objectives: With the increase in reports of the failure of Paracetamol as antipyretic in pediatric patients and the increase in the use of Mefenamic acid, the study was undertaken to recommend best among the both antipyretics by comparing the efficacy and tolerability of both these drugs. Methods-It was a prospective, active treatment controlled study with follow up to 72 hours done over a period of 2 months after the Institutional Ethical committee approval. Total 124 pediatric patients with fever admitted to Pravara Rural Hospital, Loni having a body temperature >38.5 and fulfilling the inclusion and exclusion criteria were included. Patients included were categorized into two groups –group A and group B and administered Paracetamol and Mefenamic acid in the doses 15 mg/kg and 4 mg/kg body weight respectively. The parameters essential for comparing the efficacy and tolerability were observed and recorded. The collected data were subjected to ‘paired t test’ of significance and was analyzed statistically. Results-Both drugs significantly decreased body temperature in pediatric patients with fever. The antipyretic efficacy of Mefenamic acid was highly significant than Paracetamol (<0.05). No significant differences in adverse effects were noted in both the groups. Conclusion-Mefenamic acid was found to be more effective and equally tolerable than paracetamol as an antipyretic in pediatric patients with febrile illness and can be the best alternative to paracetamol. Keywords: Acetaminophen, Mefenamic acid, MTTES. INTRODUCTION Fever is one of the most important and common presenting symptom in pediatric clinics, outpatient departments and emergency. 1 Fever may be defined as a complex physiologic response to a disease, mediated by pyrogenic cytokines and Kunkulol Rahul et al., characterized by a rise in core temperature, generation of acute phase reactants and activation of immune systems2. Regulation of body temperature requires a delicate balance between production and loss of heat, the hypothalamus Int J M ed Res Healt h Sci.2013;2(1):23-29 23 regulates the set-point at which the body temperature is maintained. In fever this hypothalamus thermostat set point is elevated and body temperature increases over normal values. The normal range of body temperature is 36.5 º 37.5 º C.3 In most clinical situations, fever results from the presence of the substances called pyrogens. Various infections, toxins and other mediators induce production of pyrogens by host inflammatory cells such as macrophages, endothelial cells and lymphocytes. Best pyrogens are endotoxins (Lipopolysaccharides, LPS) produced by gram negative bacilli. Gram positive bacteria also produce pyrogens as their cell wall has peptidoglycan and Lipoteichoic acid. The endogenous pyrogens produced locally or systemically gain entrance in the circulation and produce fever.1,4. The major fever causing cytokines are various Interleukins (IL) IL-Iβ, IL-lα, 1L-6, TNF-α (Tumor necrosis factor) and INF-α (interferon). These pyrogenic cytokines directly stimulate the hypothalamus to produce PGE2 (prostaglandin I2) which then resets the temperature regulatory set point. IL-1 is an important pyrogen that on reaching the hypothalamus induces fever in 8-10 minutes time1.When the pyrogenic cytokines disappear from the circulation or inhibition of cyclooxygenase by the metabolites, the hypothalamus is again reset downward so now the heat dissipation mechanisms come into play causing vasodilation and sweating. It has been shown beyond doubt that increase in the temperature of the body puts the child under threat of convulsions, dehydration, metabolic acidosis and fever induced stroke. So Antipyresis is one of the most usual therapeutic interventions undertaken. 1 The most commonly used antipyretics are Nonsteroidal Anti Inflammatory Drugs (NSAIDS), which also have a considerable analgesic effect which promotes a general feeling of well-being. Antipyretic treatment is now routinely prescribed to febrile children, though variedly by most pediatricians. Antipyresis occurs with different classes of substance including Acetyl Salicylic Acid (ASA), Acetaminophen and the other nonsteroidal antiinflammatory agents represented by Indomethacin, Mefenamic acid, Ibuprofen and the latest Nimesulide. Some antipyretics are antiinflammatory. NSAIDs inhibit cyclooxygenase (COX) which catalyzes the conversion of arachidonic acid to prostaglandin E2. This reduction of prostaglandin E2 in the brain is believed to lower the hypothalamic set point.1, 4 Aspirin, once a preferred drug is no longer used in reducing fever as it has potential to cause Reye's syndrome. Acetaminophen, Mefenamic acid and Nimesulide are currently three preferred drugs for treating fevers in children. Acetaminophen (paracetamol) antipyretic is in use for a considerable time. As with ASA, the antipyretic effect of Paracetamol is believed to be caused by its ability to decrease prostaglandin synthesis in the brain. Since Paracetamol does not inhibit the synthesis of prostaglandins in the periphery, it does not possess any antiinflammatory action. Besides its beneficial effects PCM also has potential side effects and may cause severe hypersensitivity reactions1,4. Nimesulide is a non-steroidal anti-inflammatory drug with analgesic and antipyretic properties. Its efficacy has been compared with naproxen, ASA, paracetamol and Mefenamic acid but it is banned due to fulminant hepatitis. Mefenamic acid is a potent inhibitor of cyclooxygenase. It has a central as well as peripheral analgesic action. The drug is commonly used in patients with injuries, osteoarthritis, rheumatoid arthritis and dysmenorrhea. The pediatric suspension of Mefenamic acid is recommended 50mg/5ml or 25mg/kg body weight in divided doses.3-6 It is essential to establish a cause for a fever and then provide effective modern treatment. Judicious use of the antipyretics needs to be considered giving due respect to the body's response to the 24 Kunkulol Rahul et al., Int J M ed Res Healt h Sci.2013;2(1):23-29 infection in the form of fever. The decision to choose an antipyretic should be dictated by efficacy, safety, duration of action, effectiveness and cost. 1 PCM has always been a dependable antipyretic and has an additional advantage of being a cheaper drug and relatively safer antipyretic. There have been reports of failure of antipyretic drugs including paracetamol in controlling fever and trends of increase use of Mefenamic acid as antipyretic. Moreover there are no studies comparing efficacy and tolerability of Acetaminophen and Mefenamic acid. Hence it was thought prudent to evaluate both these drugs for better antipyretic efficacy in pediatric patients with febrile illness. Aims and objectives 1. To compare the efficacy of Acetaminophen (Paracetamol) And Mefenamic Acid in pediatric patients with fever. 2. To compare the tolerability and adverse effect of Acetaminophen (Paracetamol) And Mefenamic Acid in pediatric patients with fever 3. To recommend best antipyretic in pediatric patients. MATERIALS AND METHODS This was a prospective observational clinical study done in collaboration with the Department of Pediatrics, Pravara Rural Hospital, Loni. The Institutional ethical committee approval was obtained before the initiation of the study. Patients diagnosed by Department of Pediatrics with febrile illness were enrolled in the study according to the following inclusion and exclusion criteria. Written informed consent was taken from each patient. Inclusion criteria 1. Patients ready to give informed consent. 2. Hospitalized children having temperature > 99.6 º F 3. Patients 1-12 years. 4. Patients of either sex. 5. Patients of all types of febrile illness. Kunkulol Rahul et al., Exclusion criteria 1. Uncooperative patients. 2. Patients not following the protocol. 3. Patients above the age of 12 years. 4. Patients who were hypersensitive to drugs. 5. Patients having any inflammatory illness 6. Severely ill patients suffering from circulatory collapse, blood dyscrasias, cardiac or hepatic disease, G-6-PD deficiency or meningitis. 7. Children having collagen vascular diseases or malignancy as a primary or the underlying cause of fever and those receiving antimicrobials and/or corticosteroids within 24 hours preceding the study. Study conduct This was a prospective, observational, comparative study with follow- up till 72 hours. A total of 124 children having temperature > 99.6 º F admitted to the Pediatrics ward, Pravara Rural Hospital, Loni were included in the study. Enrolled patients were categorized into 2 groups depending on antipyretic treatment given by the pediatricians: Group A: Paracetamol treated at a dose of 15 mg/kg given as suspension 1, 10 Group B: Mefenamic acid 4 mg/kg given as a suspension. 8 Following parameters were recorded in each group for: 1. Efficacy evaluation7 Axillary temperature (measured with a mercury thermometer)  Before drug administration  Every 1 (H1), 4 (H4) and 6 (H6) h after the first dose.  Maximum temperature Withdrawal of the patient from the study    Body temperature increases above 104°F or decreased below 96.5 °C Occurrence any severe physical event Withdrawal of the consent of the parents/guardians. 2. Tolerability evaluation 25 Int J M ed Res Healt h Sci.2013;2(1):23-29 Modified Treatment Tolerability Evaluation Score (MTTES) 7,11: Vomiting, dislikeness for meals, daytime sleep and additional medication were assessed and scores were recorded from 0-3 (absent –severe): Score 0: Absent - Symptom is not present Score1: Mild - Symptom is present but is not annoying or troublesome Score 2: Moderate - Symptom is frequently troublesome but would not interfere with normal daily activity or sleep Score 3: Severe - Symptom is sufficiently troublesome to interfere with normal daily activity or sleep Symptoms for MTTES: Vomiting, Dislikeness for meals, Daytime sleeping, Additional medication The primary efficacy and tolerability end points were recorded as changes from the baseline values: Sample size: 62 patients were included in each group according to inclusion and exclusion criteria. (Total sample size: 124 pediatric patients with fever) Study period: 2 months starting from the date of approval of the study by the Institutional Ethical Committee Statistical analysis: The data will be collected, pooled, subjected to appropriate statistical analysis and conclusions were drawn RESULTS AND OBSERVATIONS Fig:1. The change in mean values of all parameters from baseline to 6 hours during treatment of patients included in group A (Paracetamol) By applying Student’s Paired ‘t’ test there is a 1 hour, 4 hours and 6 hours, 1 hour to 4 hours and highly significant decrease of body temperature in 6 hours, (i.e. p<0.01) and rest all other parameters treatment group A (Paracetamol) from baseline to remained constant at 4 and 6 hours Fig:2. Change in mean values of all parameters from baseline to 6 hours during treatment of group B (Mefenamic acid) Kunkulol Rahul et al., Int J M ed Res Healt h Sci.2013;2(1):23-29 26 By applying Student’s Paired ‘t’ test there is a highly significant decrease of body temperature in treatment group B (Mefenamic acid) from baseline to 1 hour, 4 hours and 6 hours, 1 hour to 4 hours and 6 hours, (i.e. p<0.01) and rest all other parameters remained constant at 4 and 6 hours Fig: 3. Comparison of average body temperature in group A and group B On comparison of average fall in body temperature in group A and group B after applying “Z” test of significance there was a highly significant difference in fall in temperature in Group B from baseline to 1 hour than Group A. Both the groups showed a highly significant fall in temperature from baseline to 6 hours. Table:1. Distribution of average percentage fall (decrease) from baseline to 6 hours for all parameters in Group A (Paracetamol) and Group B (Mefenamic acid) (n=62) Parameters Percentage (%) of fall (decrease) from baseline to 6 hours Body temperature (ºC) Pulse rate(per min) Systolic Blood Pressure (mm of Hg) Diastolic Blood Pressure (mm of Hg) Respiratory rate (per min) Group A (Paracetamol) 2.47% 13.48% 3.74% 1.32% Group B (Mefenamic acid) 3.23% 15.11% 3.94% 3.86% 15.17% 16.94% It is seen from the above table that the average fall efficient / consistent than drug paracetamol in (decrease) all parameters are significantly more in pediatric patients with fever. That is Mefenamic group B as compared to group A, thus it is acid shows better and faster recovery of fever in concluded that drug Mefenamic acid is more pediatric patients as compared to Paracetamol. Table:2. Total number of patients suffered with following adverse effect Group Vomiting Dislikeness meal Daytime sleeping Additional medication Paracetamol(n=50) 3 5 5 2 Mefenamic acid(n=50) 2 7 4 2 Significance P>0.05* P>0.05* P>0.05* P>0.05* * No significant difference between mean values of MTTES scores between Paracetamol and Mefenamic acid group. Kunkulol Rahul et al., Int J M ed Res Healt h Sci.2013;2(1):23-29 27 DISCUSSION The management of children with fever is based primarily on the elucidation and treatment of the underlying cause. The role of antipyretic therapy in such children is aimed at reducing the ever present risk of a febrile convulsion. A variety of pharmacological agents are available for Antipyresis. The so called superiority of one drug over the other is marginal and has no therapeutic significance.3, 12In our study both Paracetamol and Mefenamic acid proved to be effective antipyretic drugs. Antipyresis was achieved within 6 hours of administration of the dose. In Paracetamol group the baseline body temperature decreased since 101.81 º to 99.29 ºFat 6hours while in Mefenamic acid group from 102.12 º to 98.82 ºFat 6hours. Both the drugs are NSAIDs and act by inhibiting COX enzyme responsible for generating Prostaglandins (PGE2). Paracetamol has only central action with weak anti-inflammatory effect and so has been reported to be the best antipyretic drug. Mefenamic acid has central and peripheral action with antiinflammatory effect. The fall in temperature at 1 hr was more in Mefenamic acid group (102.12 oF to99.5 oF)compared with paracetamol group (101.81oF to 100.32oF).These results show that Mefenamic acid has better antipyresis at 1 hour than Mefenamic acid. A rough correlation has been established between the anti synthetase activities of many nonsteroidal anti-inflammatory drugs13 including Mefenamic acid in central nervous system. Our results are in accord with S. Keininen etal which also states Mefenamic acid to be more potent and powerful antipyretic drug.8. The children showed no adverse symptoms or signs in connection with the antipyretic therapy. There was no significant difference on Heart rate, BP and respiratory rate despite a slight fall in all above was noted. Mefenamic Acid shows highly significant decreases in the body temperature baseline to 6th hour as compared to Paracetamol in paediatric patients with fever (i.e. P<0.01.) This may be due to decline in the efficacy of Paracetamol which has been described as the best antipyretic. It is essential to establish a cause for a fever and then provide effective modern treatment. A persistent fever is a stimulus to both doctor and parents to maintain their vigilance. The use of the drugs should not become the refuge of the diagnostically destitute. Judicious use of the antipyretics needs to be considered giving due respect to the body's response to the infection in the form of fever9. PCM has always been a dependable antipyretic and has an additional advantage of being a cheaper medicine and relatively safer antipyretic. Other drugs like Mefenamic acid have marginally better antipyresis. 1 Study demands more detailed evaluation of the decline in paracetamol efficacy. CONCLUSION It is clear from this study that Mefenamic Acid is the best antipyretic as in-terms of their efficacy and tolerability in pediatric patients with fever and can be very helpful in treating febrile illness in pediatric age group more effectively. Mefenamic acid could be a suitable alternative as a "secondline" antipyretic agent, even in selected children. However, more clinical experience and information about side-effects are needed before they can be recommended for wider routine use. Our study results showed Mefenamic acid to be more efficacious than Paracetamol as antipyretic in the Paediatric age group but more extensive studies and clinical experience is required for its recommendation for wider use as antipyretic. 2. These extensive studies should address safety as well as efficacy issues and should be compared using all possible methods. 3. More extensive studies may yield a better antipyretic alternative to Paracetamol and will also discourage injudicious use of antipyretic drugs like Nimesulide which is banned but still used by some pediatricians. 4. Genetic studies to evaluate the decline in the 28 Kunkulol Rahul et al., Int J M ed Res Healt h Sci.2013;2(1):23-29 efficacy of paracetamol as antipyretic should be taken up. ACKNOWLEDGEMENT We acknowledge all the faculty members of the Department of Paediatrics for their help and cooperation for this study REFERENCES 1. Jagdish Chandra and Shishir Kumar Bhatnagarr. Antipyretics in Children. Indian J Pediatr. 2002; 69 (1) : 69-74 2. Avtar Let al. Antipyretic Effects of Nimesulide, Paracetamol and IbuprofenParacetamol. Indian Journal of Paediatrics. 2000; 67 (12): 865 3. Alexander KC et al. Fever in childhood. Canadian Family Physician.1992; 38: 1832-36 4. K. Rajeshwari. Antipyretic Therapy. Indian Pediatrics. 1997; 34 : 409-411 5. B S David. Fever panic. Sri Lanka Journal of Child Health, 2000; 29: 97 6. S Balasubramanian, A Sumanth. Mefenamic acid – Role as Antipyretic. Indian paediatrics. 2010; 47: 453 7. Autret E et al. Evaluation of Ibuprofen versus aspirin and paracetamol on efficacy and comfort in children with fever. Eur J Clin Pharmacol. 1997 ; 51: 367-371 8. S. Keininen et al. Oral Antipyretic Therapy: Evaluation of the N-Aryl-Anthranilic Acid Derivatives Mefenamic Acid, Tolfenamic Acid and Flufenamic Acid. Europ. J. Clin, Pharmacol. 1978; 13: 331-344 9. RP Khubchandani, KN Ghatikar, SS Keny, NG Usgaonkar. Choice of antipyretic in children. J. Assoc Physicians India.1995; 43 (9): 614-6 10. Keith R. Powell. Fever (ch.170). Nelson Textbook of Paediatrics: 16thedition.p738. 11. Bikas Medhi et al. Efficacy of fexofenadine in the Indian population suffering from allergic rhinitis and urticarial. JK Science. 2006; 8: 83 85. 12. John hunter. Study of antipyretic therapy in current use. Archives of Disease in Childhood.1973; 48: 313. -314 13. Praveen Kumar Goyal et al. Double blind randomized comparative evaluation of Nimesulide and Paracetamol as antipyretics. Indian paediatrics. 1998 ; 35: 24-26 29 Kunkulol Rahul et al., Int J M ed Res Healt h Sci.2013;2(1):23-29 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Received: 5th Nov 2012 Revised:30th Nov 2012 Copyright @2013 ISSN:2319-5886 Accepted: 7 th Dec 2012 Original research article DETECTION OF MALARIAL PARASITE BY BLOOD SMEAR EXAMINATION AND ANTIGEN DETECTION: A COMPARATIVE STUDY Erumalla Naveen1, Dimple Arora2, Vinod Agarwal3, Neelam sharma4, Anuradha B5, Vijay Durga S6 1 Lecturer, 3 Professor. Triveni Institute of Dental Sciences, Hospital & Research Centre, Bilaspur, Chhattisgarh. 2 Asst .Prof. Teerthankar Mahavir Medical College. Moradabad, UP. 4 Professor, 5 Associate Professor 6 Assistant Professor, department of microbiology, Mamata Medical College, Khammam, A.P * corresponding author email: erumalla@gmail.com ABSTRACT At present about 100 countries in the world are considered malarious, is thought to kill between 1.1 and 2.7 million people worldwide each year, of which about 1 million are children under the age of 5 years in these areas. Under ideal circumstances, the clinical suspicion of malaria would be confirmed by a laboratory test that is simple to perform, rapid, sensitive, specific and expensive. At the present time, no such test exists. The most common test for malaria diagnosis remains the microscopic examination of giemsa or the fields – stained blood smears. The test is based on the detection of Plasmodium falciparum specific histidine rich protein ii (hrp) and a pan malarial species specific enzyme aldolose, produced by the respective parasites and released into the blood and the test is based on immune chromatography, the test is highly sensitive. Method: In this study included 100 patients, 60% of patients had history suggestive of malaria, another 40% gave the history of irregular fever; For each patient peripheral blood sample was collected, thin and thick smear blood films were made immediately after blood collection, stained with Leishman stain and examined for malaria parasite by light microscopy. Results: The blood films results indicated that 40 (20%) patients were infected with malaria and the rest 171 (85.5%) were malaria negative. Among positive patients Plasmodium vivax was detected in 24 cases (60%) and Plasmodium falciparum in 10 cases (31%) and 6 cases mixed infection (PV + PF) (15%) correspondingly, the Para HIT Test results indicated that 29 (14.5%) of the patient sample were positive for malaria parasites and 171 (85.5) were malaria negative out 29 patients cases. Infection with Plasmodium vivax accounted for 17 (58.6%) while infection with Plasmodium falciparum accounted for 9 (25%) and 3 (1.3%) with mixed infection of Plasmodium vivax and Plasmodium falciparum. Keywords: Malaria, Blood smear, Para Hit test. INTRODUCTION Malaria is a parasitic infection of global importance and it remains to be one of the most significant cause of morbidity and mortality of humans, worldwide. The disease is a major health 30 Naveen et al., Int J M ed Res Healt h Sci. 2013;2(1):30-34 problem in the tropics and subtropics regions. Annually, approximately 500 million people in the world suffer from malaria and about 1 million deaths occur due to this infection. Current efforts to control malaria focus on reducing attributable morbidity and mortality by prompt diagnosis of suspected malarial infection with rapid and accurate diagnosis for effective therapeutic intervention. The protozoan parasite belongs to the genus Plasmodium. Four species of malaria parasite that are known to infect humans are Plasmodium falciparum, Plasmodium vivax, and Plasmodium ovale and Plasmodium malariae. Plasmodium falciparum accounts for the majority of infections that term out to be lethal. While the three other species cause a less severe form of malaria. The infection is characterized by intermittent fever with chills and anemia1-3. At present about 100 countries in the world are considered malaria, about half of which are in subSaharan Africa. Although this number is considerably less than it was in the mid 1950s, more than 2.4 billion of the world’s population is still at risk. Malaria is thought to kill between 1.1 and 2.7 million people worldwide each year, of which about 1 million are children under the age of 5 years in this areas2-5. In many developing- world settings, a presumptive diagnosis of malaria is based upon the presence of fever alone. While statistically justifiable in sole regions, such an approach inevitably leads to the overuse of antimalarial drugs. Under ideal circumstances, the clinical suspicion of Malaria would be confirmed by a laboratory test that is simple to perform, rapid, sensitive, specific and expensive. At the present time, no such test exists. The most common test for malaria diagnosis remain the microscopic examination of Giemsa or Fields – Stained blood smears. However, the examination of blood films requires technical expertise and the availability of a good – quality microscope. The microscope is also time- consuming and has limited sensitivity when parasitemia is low3-5. Besides these majorities of Malaria cases occur in rural areas where there is a little or no access to reference laboratories and in many areas microscopy is not available. Keeping all these in a study was done to compare microscopic examination of blood films with newly develop Immuno Chromatography dipstic Test. The test is based on the detection of Plasmodium Falciparum specific Histidine Rich protein II (HRP II) and a Pan Malarial Species specific enzyme Aldolose, produced by the respective parasites and released into the blood and the test is based on Immuno Chromatography. The test is highly sensitive and specific for the diagnosis of Plasmodium Falciparum, Plasmodium Vivax, Plasmodium Ovale and Plasmodium Malarial Infection. MATERIALS AND METHODS After approval of the Institutional Ethics Committee and inform consent form the patient in this study included 100 patients attending Mamata General Hospital 60% of patients had history suggestive of malaria i.e., rigor, chill, rise of high temperature with profuse sweating. Another 40% gave the history of irregular fever; Patients that have been treated for malaria in the previous four weeks were excluded from this study. For each patient peripheral blood sample was collected into a sterile tube containing potassium EDTA. Thin and thick smear blood films were made immediately after blood collection, stained with Leishman stain and examined for malaria parasite by light microscopy. According to standard practice a thin blood smear was examined for 15 minutes and for a thick blood film 200 fields were visualized. All the blood sample was tested with Para HIT total dipstick test according to manufacturers instruction and results were compared to those obtained from examination of thin and thick blood smears. The test is based on the detection ofPlasmodiumm falciparum specieshistidinee rick protein II (HRP 31 Naveen et al., Int J M ed Res Healt h Sci. 2013;2(1):30-34 II) and a pan malarial species specific enzyme Aldolase, produced by the respective parasites and released into the blood. RESULTS Positive: Appearance of three magenta red colored bands, one each in the anti falciparum antibody region, anti malarial antibody region and control region indicates that the sample is reactive for Plasmodium falciparum and mixed infection with another malarial species. (Plasmodium vivax is most commonly encountered in India). Negative: Appearance of only one magenta red colored band in the control region indicates that the sample is non-reactive for Plasmodium species. Error: No band observed in control or test region indicates improper test procedure or deterioration of reagents. Repeat the test using a fresh test strip. The magenta red coloured test bands indicate reactive result representing the binding of antigen antibody complex to a monoclonal antibody that has been pre-immobilized on the test strip. In nonreactive sample no magenta red coloured band is seen in test region. A reactive procedural control band is also built into validate the results as well as proper test performance. Blood Smear Para HIT 22 P. vivax 11 3 24 13 3 P. falciparum Both Pf+pv 164 160 Negative Fig.1: Examined Blood smear report & Para hit report Table:1. Comparision of blood smear examination and antigen detection Parameters Positive Blood Smear % Positive Para HIT % PF 10 (25%) 9 (31%) PV 24 (60%) 17 (58.6%) Mixed 6 (15%) 3 (10.3%) Total 40 (20%) 29 (14.5%) A total of 200 blood samples was tested from the month of March 2007 to December 2007 for malaria parasites by the Para HIT method and the results were compared to those obtained from examination of thin and thick smear blood films. The blood films results indicated that 40 (20%) patients were infected with malaria and the rest 171 (85.5%) were malaria negative. Among positive patients Plasmodium vivax was detected in 24 cases (60%) and Plasmodium falciparum in 10 cases (31%) and 6 cases mixed infection (PV + PF) (15%) correspondingly, the Para HIT Test 32 Naveen et al., Int J M ed Res Healt h Sci. 2013;2(1):30-34 results indicated that 29 (14.5%) of the patient sample were positive for malaria parasites and 171 (85.5) were malaria negative out 29 patients cases. Infection with Plasmodium vivax accounted for 17 (58.6%) while infection with Plasmodium falciparum accounted for 9 (25%) and 3 (1.3%) with mixed infection of Plasmodium vivax and Plasmodium falciparum. The blood film examination identified 7 Plasmodium vivax positive samples that were not detected by the Para HIT Test and 1 Plasmodium falciparum case identified by blood film examination and not detected by the para HIT test. However there was 100% agreement between blood film results and Para HIT results for the other 29 cases. DISCUSSION The resurgence of malaria has renewed interest in developing not only preventive measures, but also rapid diagnostic techniques. A multitude of factors has contributed to the reemergence of malaria, including (i) Insecticide resistance in the Anopheles Mosquito. (ii) Social instability resulting in movements of unexposed non immune individuals in areas where malaria is endemic, and (iii)The failure to develop an effective malaria vaccine. Compounding the problems of malaria’s geographical expansion and of increasing morbidity and mortality are the emergence and rapid spread of antimalarial drug resistance. Which necessitate the use of more expensive and sometimes toxic antimalarial drugs and longer treatment courses? In addition, the cyclic recurrence of malaria epidemics has a tremendous impact on the health infrastructure in developing countries and adversely affects local economics, since infected individuals are often too debilitated to work. One of the most pronounced problems in controlling the morbidity and mortality caused by malaria is limited access to effective diagnosis and treatment in areas where malaria is endemic. Clinical diagnosis of infection with the malaria parasite requires microscopic observation of parasites on a Giemsa – stained blood smear. Microscopic examination of blood smears requires highly skilled people to perform or interpret results. Several methods have been developed to supplement and replace the conventional microscopic method. The most promising new malaria diagnostics are the serological Antigen detection tests. Para HIT is one amongst them. We employed this test and compared it with a conventional smear examination for diagnosis of Plasmodium falciparum and Plasmodium vivax infection6-8. The antigen detection test identified (14%) as malaria positive while the blood film identified (20) to be malaria positive. Some malaria infections detected by blood film were not detected by the Para HIT test. This may be explained by the fact that increased awareness of malaria among the general public has led to a rampant misuse of antimalarial drugs in inadequate doses empirically for any fever. Since Para HIT detects PLDH which is produced only by living parasites, the blood samples judged negative by Para HIT may have been dead parasites and not yet cleared from the host. Two cases of Plasmodium vivax detected by blood film were not detected by Para HIT. This may be due to insufficient enzyme production which occurs during early malarial infection or the patient blood samples contained parasites at concentrations below the Para HIT tests detection level eight blood samples in which Para HIT detected Plasmodium falciparum band were found to be negative in the blood smear examination. This may be explained by the fact that Plasmodium falciparum can sometimes sequester and may not be present in circulating blood. 9,10 This test has the added advantage that it can detect all fouPlasmodiumum species and can be used to follow the efficiency of drug therapy since it detects on enzyme produced only by living 33 Naveen et al., Int J M ed Res Healt h Sci. 2013;2(1):30-34 parasites. Although it has got a number of advantages one needs to keep in mind the cost of the test which may not be affordable by many. The high cost of the test may prevent its regular and routine we in many of the laboratories. However, it was a valuable adjunct at the time of emergency for rapid diagnosis, although microscopy remains the mainstay for the diagnosis of malaria for routine use in countries like India. REFERENCES 1. Momar Ndao, Etienne B, Evelyne K, Theresa WG, Dick MacLean , Brian J W. Comparison of Blood Smear, Antigen Detection, and Nested-PCR Methods for Screening Refugees from Regions Where Malaria Is Endemic after a Malaria Outbreak in Quebec, Canada. J Clin Microbiol. 2004; 42 (6): 2694–2700. 2. Manjunath PS, Preeti BM, Basavaraj VP. Comparative Study of Peripheral Blood Smear, QBC and Antigen Detection in Malaria Diagnosis. Journal of Clinical and Diagnostic Research. 2011;5 (5): 967-9. 3. Cooke AH, Chiodini PL, Doherty T, Moody AH, Ries J, Pinder M. Comparison of a parasite lactate dehydrogenase-based immune chromatographic antigen detection assay (OptiMAL) with microscopy for the detection of malaria parasites in human blood samples. Am J Trop Med Hyg. 1999; 60(2):173-6. 4. DK Mendiratta , Bhutada K, Narang R, Narang P. Evaluation of different methods for diagnosis of P. Falciparum malaria. Indian Journal of Medical Microbiology, (2006) 24 (1):49-51 5. Parija SC, Dhodapkar R, Subashini Elangovan, DR Chaya. A comparative study of blood smear, QBC and antigen detection for diagnosis of malaria. 2009; 52(2):200-2 6. Bhat Sandhya K, Sastry S, Nagaraj ER, Sharadadevi Mannur, Sastry AS. Laboratory diagnosis of malaria by conventional peripheral blood smears examined with Quantitative Buffy Coat (QBC) and Rapid Diagnostic Tests (RDT) - A comparative study. International Journal of Collaborative Research on Internal Medicine & Public Health. 2012; 4(10): 1746-55 7. Hovette P, Aubron C, Perrier-Gros-Claude JD, Schieman R, N'Dir MC, Camara P. Value of Quantitative Buffy Coat (QBC) in borreliasis-malaria co-infection] Med Trop (Mars). 2001; 61(2):196-7. 8. Carol JP, John FL, Winslow IK, Jose AQ, Rina Kaminsky, Marianna KB, Arba LA. Evaluation of the OptiMAL Test for Rapid Diagnosis of Plasmodium vivax and Plasmodium falciparum Malaria. Journal of Clinical Microbiology. 1998; 36 (1) 203–6 9. Beatriz EF, Iveth J González, Fanny de Carvajal, Gloria I Palma, Nancy G Saravia Mem Inst Oswaldo Cruz, Rio de Janeiro, Performance of OptiMAL in the Diagnosis of Plasmodium vivax and Plasmodium falciparum Infections in a Malaria Referral Center in Colombia.2012; 97 (5) 731-35 10. Kakkilaya BS. Rapid Diagnosis of Malaria. Lab Medicine. 2003;8(34):602-08 34 Naveen et al., Int J M ed Res Healt h Sci. 2013;2(1):30-34 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN:2319-5886 Received: 15 th Nov 2012 Revised: 13th Dec 2012 Accepted: 19th Dec 2012 Original research article A COMPARATIVE STUDY AMONG THE THREE WHEELER AUTOMOBILE DRIVERS ON PULMONARY FUNCTION TESTS IN ADULT MALES OF GULBARGA CITY *Afshan Afroz1, Salgar Veeresh B2, Sugoor Manjushree3, Swati I Amrutha 1 Department of Physiology, KIMS, Amlapuram, 2Dept of Gen. Medicine, KBNIMS, Gulbarga, 3Dept of Biochemistry, KBNIMS, Gulbarga, 4Department of Com. Medicine, KBNIMS, Gulbarga. *Corresponding author email: drafrozafshan@gmail.com ABSTRACT Background: Development of our country has led to rapid urbanization and there is increasing use of automobiles that is aggravating environmental pollution. Occupational exposure to automobile exhaust and industrial smokes has been shown to affect functioning of different systems of the body. The present study was taken up to assess the Pulmonary Function Tests (PFT) in auto rickshaw drivers of Gulbarga city. Methods: Fifty non –smoker male auto drivers in the age group of 20–50 years for more than 5 years of auto driving experience formed the study group. Age and sex matched individuals not exposed to auto rickshaw driving [administrative staff] formed the control group. Pulmonary function parameters FVC, FEV1, FEV1%, PEFR, PIFR, FEF25-75, FEF50 and MVV were assessed using a computerized Spiro meter during their working hours and were statistically analyzed. Results: There was a highly significant decrease in FVC and FEV1 in the study group compared to control group. The decrease in FEV1%, PIFR, FEF25-75 and FEF50 were statistically significant but the decrease in PEFR and MVV were statistically nonsignificant. Conclusion: Our findings point towards the adverse effects of vehicle exhaust on lung functions, mainly on lower airways with restrictive pattern of disease. Keywords: Automobiles, Auto drivers, Pulmonary function tests. INTRODUCTION The development of our country has brought many changes that include increased industrialization, improved transportation facilities, jobs in various fields. Modern lifestyles have certain adverse effects on our surroundings. Rapid urbanization led to increased use of automobiles that is aggravating environmental pollution. Experimental studies indicate that airborne contaminants lead to injury to the airways and lung parenchyma in subjects who are exposed to it (1,2). Occupational exposure to automobile exhaust and industrial smokes has been shown to affect functioning of different systems of the body. Numerous epidemiological studies have documented decrements in pulmonary function and various other health 35 Afshan Afroz et al., Int J M ed Res Health Sci. 2013;2(1):35-39 problems associated with long term air pollution exposure(3-7) .Health effects of occupational exposure to petroleum vapors and air pollution from vehicular sources is relatively unexplored among auto rickshaw drivers. There is limited published data regarding the pulmonary function test abnormalities in auto-rickshaw drivers. Hence we undertook this study. To meet the present day requirement, there is an increase automobile use and because of the predominant role of gasoline [petrol] as a motor vehicle fuel, the effects of gasoline engine emissions are potentially even greater problems. In the persons exposed to these pollutants, pulmonary function tests are used as screening tests to determine their effects8 .Therefore, the present study is taken up to evaluate the changes in Pulmonary Function Tests (PFTs) like Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), FEV1/FVC ratio, Peak Expiratory Flow Rate (PEFR), Peak Inspiratory Flow Rate (PIFR), Forced Expiratory Flow in 2575% of vital capacity( FEF25-75), Forced Expiratory Flow at 50% of vital capacity (FEF50 ) and Maximum Voluntary Ventilation (MVV) of auto rickshaw drivers in Gulbarga city. MATERIALS AND METHODS The present study was conducted in Salgar hospital in Gulbarga city. Gulbarga is located in the north Karnataka region of South India. Ethical clearance was taken from the Institutional Ethical Committee and each subject gave the consent. The study group consisted of 50 males in the age group of 20–50 year, who was driving auto rickshaw for 8 hours per day for more than 5 years in Gulbarga city. The control group consisted of 50 males of the same age group from administrative post, who were not exposed to auto rickshaw driving. The subjects in the study group and the control group had certain inclusion and exclusion criteria. Inclusion criteria Male subjects of age between 20-50 years and subjects with no history of allergic disorders, respiratory disorders like asthma, or any systemic disease, no history of smoking, chewing tobacco and intake of alcohol. Exclusion criteria Subjects with age less than 20 years and more than 50 years of age, alcoholics, persons with systemic diseases, smokers who had chest wall deformities, neuromuscular disease, severe obesity, previous thoracic surgery and females were excluded from the study. Age, height, and weight were recorded. All the Pulmonary functions were tested during day time using computerized Spirometer [MEDSPIROR]. The subjects were familiarized with the instrument. All the tests were carried out at the same time of the day, between 10-11 AM. All the subjects were in sitting position and wearing nose clips9. The subjects were asked to breathe forcefully following deep inspiration into the mouthpiece attached to the pneumatachometer. 3 readings of maximal Inspiratory and expiratory efforts were recorded and the best reading was taken for statistical analysis. Statistical methods used in our study was a student’s unpaired t test using SPSS-16. The P< 0.05 was considered statistically significant and P< 0.001 was considered highly statistically significant. RESULTS Table:1. Comparison of mean values of the age, height and weight of the subjects and the controls Parameters Study group Control group 36.4±7.40 34.8±3.76 Age [years] 170.40 ± 3.39 174.60 ± 4.15 Height [cm] 72.60 ± 7.56 74.40 ± 8.24 Weight [kg] The subjects and controls did not differ significantly on above parameters. 36 Afshan Afroz et al., Int J M ed Res Healt h Sci. 2013;2(1):35-39 Table: 2. Comparison of lung volumes and capacities between study and control groups Parameter Study group (n=50) Control group (n=50) p-value 2.77±0.41 3.33±0.50 FVC (L) 2.67±0.46 3.11±0.33 FEV1 (L) 88.25±13.34 90.31±10.12 FEV1% 110.80±18.63 130.16±26.89 MVV (L/min) *P value<0.05 is statistically Significant, **P value<0.001 is highly statistically Significant 0.001** 0.001** 0.050* 0.059 In table-2 there was highly statistically significant decrease in FVC, and FEV1 in the study group when compared to the control group. There was a statistically significant decrease in FEV1. In addition, there was a decrease in MVV but it was not statistically significant. Table: 3. Comparison of flow rates among study and control groups Parameter PEFR (L/min) PIFR (L/min) FEF25-75 (L/min) FEF50 (L/min) Study group (n=50) Mean ±SD 5.47±1.40 2.21±0.67 3.60±1.33 4.16±1.22 Control group (n=50) Mean ±SD 7.05±1.59 3.61±1.10 4.85±1.11 5.17±1.32 P value 0.15 0.04* 0.04* 0.05* *P value<0.05 is statistically Significant, **P value<0.001 is highly statistically Significant Table 3 indicates the flow rates among both the groups. The decrease in PEFR was statistically not significant whereas the decrease in PIFR, FEF25-75 and FEF50 was statistically significant with p ≤0.05. DISCUSSION Occupational health has been gaining importance for the fact that long term exposure to vehicle exhaust, petrol and dust can lead to a permanent morbidity. The acute health risks involved are minimal, provided that the precautionary methods are used in accordance with appropriate health and safety practices. Highly statistically significant decrease in FVC and FEV1 was observed in auto drivers when compared to their controls, and their ratio (FEV1%) was significant between the two groups. This finding indicates the restrictive pattern of pulmonary involvement in the study group. Auto rickshaw drivers are at risk of dust inhalation, petrol vapor inhalation and also inhalation of automobile exhaust for a longer period of time that is at least 8 hours per day for more than one year and they have more chances of chronic involvement of lungs as indicated by the results in the present study. The benzene content of petrol has typically been in the range 1–5% may be an exacerbating factor for the lung function abnormalities observed as the study groups were nonsmokers. Smoking as an independent variable was found to affect FEV1 significantly and smoking has shown to accelerate the decline in lung function in a time dependent manner10. As the auto drivers are most of the time on busy roads and exposed to automobile exhaust and other air pollutants. Automobile exhaust is a complex mixture of different gases like Sulphur dioxide (SO2), Carbon dioxide, Carbon monoxide (CO), Nitrogen dioxide (NO2) and particulate matter. Some studies have demonstrated that exposure to particulate matter combined with exposure to an 37 Afshan Afroz et al., Int J M ed Res Healt h Sci. 2013;2(1):35-39 irritant gas such as NO2 results in greater damage to the lung than when exposed to either substance individually11.In combination with particulate pollutants, SO2 and NO2 have a greater chance to reach the deeper parts of the lungs. The gaseous pollutants may also alter the properties and concentration of surfactant and contribute to the early closure of small airways. Much of the terminal bronchioles may be compromised before other pulmonary function tests such as FEV1 are affected12. Few histopathological studies have provided evidence that the small airways are the site of damage in people living in areas of high air pollution13. The particles generated from diesel exhaust are extremely small and are present in the nuclei or accumulation modes with a diameter of 0.02 ηm and 0.2 ηm respectively. These small sized particles, by virtue of their greater surface area to mass ratio, can carry a much larger fraction of toxic compounds, such as hydrocarbons and metals on their surface. Importantly they can remain airborne for long periods of time and get deposited in greater numbers and deeper into the lungs than larger sized particles. Hence chronic exposure to them can lead to chronic inflammation of respiratory tract and lung parenchyma. These would contribute to the substantial decrease in lung functions in the form of a restrictive pattern as indicated in the present study. Rajkumar studied the effect of air pollution on the respiratory system of the auto rickshaw drivers in Delhi. The study found that (19%) drivers showed normal Pulmonary Function Test (PFT). (80%) showed mild and moderate to severe obstruction, of which (48%) were nonsmokers and (52%) were smokers and the result concludes that auto rickshaw drivers have a high respiratory morbidity due to exposure to pollution.14 In a study, reduced mechanical properties of breathing were attributed to exposure to benzene in the vapors of petrol15. Bijendra Kumar et al examined the pulmonary function test in three wheeler diesel taxi drivers in Bikaner city. They found restrictive impairment in 87% of the study group, of which 50% were smokers and 37% were non-smokers, mixed pattern (both restrictive and early obstructive impairment) was found in only 13% of the study group, of which 7% were smokers and 5% non-smoker. So they concluded that when all the five parameters (FVC, FEV1, FEV1/FVC, FEF 25–75% and PEFR) were taken together they were indicative of mixed pattern (obstructive and restrictive) lung impairments 16. Chattopadhyay et al conducted a study on garage workers, drivers and conductors of Kolkata city to assess the pulmonary function status of these workers and found that FEV1, FEV1% and flow rates, FEF 02-121, FEF25%-75% values showed a gradual decrement as age and duration of exposure increased17. CONCLUSION From the present study it was concluded that respiratory functions of the auto rickshaw drivers who are continuously exposed to emissions from vehicles, petrol vapor and dust were significantly reduced as compared to respiratory functions of age, weight and height matched control groups. To prevent the respiratory dysfunction among auto drivers, medical observation and periodic checkups for pulmonary function tests should be performed. Control strategies should be adopted to reduce the vapor concentration in the air, like vapor adsorbents and to reduce the benzene concentration in the ambient air. Personal protective equipment must be worn by auto rickshaw drivers. Imparting health education to auto rickshaw drivers will prevent respiratory morbidity. Further long term perspective studies on auto rickshaw drivers will help in getting a comprehensive picture of long term effects. ACKNOWLEDGEMENT This research paper is made possible by the support from the participants of our study. We dedicate our acknowledgment of gratitude towards Mr.Shaik.Meera and Dr. Rashmi.C.G as 38 Afshan Afroz et al., Int J M ed Res Healt h Sci. 2013;2(1):35-39 they kindly read our paper and offered valuable detailed advices on grammar, organization, and theme of the paper. Finally, we sincerely thank almighty, family and friends, who provided financial support and timely advice. REFERENCES 1. Lewis TR, Moorman WJ, Yang YY, Stara JF. Long term exposure to auto exhaust and other pollutant mixture. Arch Env Health 1974; 21:102–06 2. Chhabra SK. Air pollution and health. Indian J Chest Dis Allied Sci 2002; 44: 9–11. 3. Mayank Singhal et al “pulmonary functions in petrol pump workers: A preliminary study” IJPP; 2007; 51 (3)244-248. 4. Gamble J, Jones W, Minshall S. Epidemiological- Environmental study of Diesel Bus Garage workers: Acute effects of NO2 and respirable particulate on the respiratory system. Environ Research 1987; 42: 201–214. 5. Nakai S, Maeda K, Crest JST. Respiratory health associated with exposure to automobile exhaust. III. Results of a cross sectional study in 1987, and repeated pulmonary function tests from 1987 to 1990. Arch Environ Health 1999; 54: 26–32. 6. Chabra SK, Chabra P, Rajpal S, Gupta RK. Ambient air pollution and chronic respiratory morbidity in Delhi. Arch Environ Health 2001; 56: 58–63. 7. Ware JH, Spengler JD, Neas LM, Samet JM, Wagner GR, Coultas D et al. Respiratory and irritant health effects of ambient volatile organic compounds. The Kanawa county health study. Am J Epidemiol 1993; 137: 1287–1301. 8. Kamat SR et al. Prospective 3 year study of health morbidity in relation to air pollution in Bombay India; Methodology and early results up to 2 years. Lung India, 2, 1984, 120. Afshan Afroz et al., 9. Standardisation of spirometry 1994 Update. American Thoracic Society. Am J Respir Crit Car Med 1995; 152 (3) :1107–36. 10. Chawla A, Lavania AK. Air pollution and fuel vapour induced changes in lung functions: Are fuel handlers safe? IJPP 2008; 52 (3) :255–61. 11. Boren HG. Pathophysiology of air pollutants. Environ Res 1967; 1:178. 12. Cotes JE. Lung function assessment and application in medicine. 5th ed. Oxford Blackwell Scientific Publications, 1993. p122. 13. Souza MB, Saldiva PHN, Pope CA, Capelozzi VL. Respiratory changes due to long term exposures to urban levels of air pollution. Chest 1998; 113:1312–18. 14. Rajkumar. Effect of air pollution on respiratory system of auto rickshaw drivers in Delhi. Indian Journal of Occupational and Environmental Medicine. 1999 Oct-Dec.; 3 (4) :171-73. 15. Kesavachandran C, Mathur N, Anand M, Dhawan A. Lung function abnormalities among petrol pump workers of Lucknow, North India. Current Science 2006; 90:1177– 78. 16. Binawara BK, Gahlot S, Kamlesh Chandra Mathur, Ashok kakwar, Reshu Gupta, Rajnee. Pulmonary function tests in three wheeler diesel taxi drivers in Bikaner city. Pak J Physiol 2010; 6 (1):28-31. 17. Chattopadhyay BP, Alam J, Roychowdhury A. Pulmonary function abnormalities associated with exposure to automobile exhaust in a diesel bus garage and roads. Lung India, 2003, 181 (5), 291-302. 18. Madhuri BA,ChandrashekharM, Ambareesha Kondam. A study on pulmonary function test in petrol pump workers in Kanchipuram Population. IJBMR. 2012;3(2):1712-14 Int J M ed Res Healt h Sci. 2013;2(1):35-39 39 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN:2319-5886 Received: 1st Dec 2012 Revised: 15th Dec 2012 Accepted: 20th Dec 2012 Original research article AN ETHNOBOTANICAL SURVEY OF MEDICINAL PLANTS USED BY TRADITIONAL HEALERS OF THADVAI, WARANGAL DISTRICT, ANDHRA PRADESH, INDIA. Soma Manjula , *Estari Mamidala Infectious Diseases & Metabolic Disorders Research Lab, Department of Zoology, Kakatiya University, Warangal, Andhra Pradesh, India *Correspondence author email : estari08@gmail.com ABSTRACT Since ancient times, plants have been used as medicine, foods, Agrochemicals and pharmaceuticals by large number of tribes, rural and urban people. India has more than 300 tribal communities. The tribal region of Andhra Pradesh has not received proper attention of ethnomedicinal researchers. Therefore, a survey of ethnomedicinal plants used by Koya tribes of Medaram and Narlapura villages which are on the south of the Godavari River, Thadvai Mandal, Warangal District; Andhra Pradesh, India was undertaken. The information on plants was collected by interviewing the local tribal traditional practitioners. The present study revealed that the plants which are used in traditional systems are mostly collected from the wild resources. A total of 36 plant species (belonging to 24 families) of ethno botanical interest upon inquiries from these tribal informants’ between the age of 35-78 were reported. They have been using these parts in the form of paste, powder, decoction, juice, infusion and also in crude form, with other additives like honey, curd, and urine and cow milk to get relief from different ailments like diabetes, inflammations, wounds, skin diseases, headache, indigestion, urinary infections, fever, snake bites, cough, and dental problems. This study therefore concludes, it is necessary that suitability requirements are needed in order to protect the traditional knowledge in a particular area with reference to medicinal plant utilization. The plants need to be evaluated through phytochemical investigation to discover potentiality as drugs. Keywords: Ethnomedicine, Koyas, Warangal INTRODUCTION Traditional medical practices are an important part of the primary health care system is the developing World.1 The ethno botanical survey can bring out many different clues for the Development of drugs to treat human diseases. Now-a-days, a trend in the study of medicinal plants and their use in traditional medicine has been drawing the attention of different medical practitioners throughout the world. People have become health cautious; the phototherapy is more safe and effective in curing 40 Manjula et al., Int J M ed Res Healt h Sci.2013;2(1):40-46 ailments without any side effects. 2 Ethnic groups of various regions of the world are the real custodians of nature’s wealth and experts in herbal medicine.3 The traditional indigenous knowledge transferred orally for centuries is fast disappearing because of the technological developments and changing culture of ethnic groups.2 It is for this reason the study of ethnomedicine and its restoration have been taking place. In many countries of Africa, Asia and Latin America people depend on traditional knowledge and medicinal plants to meet some of their primary health care needs. For instance in Africa up to 80% of the population use traditional medicine for primary health care.4 Likewise, many Ethiopian communities are dependent on local plant resources for medicine. Moreover, the people in ethnic tribes are averse to change the mode of their life and traditions. But this traditional medical knowledge is slowly diminishing, so it is to be procured and preserved in various forms for future generations. Thus, this study aimed to ascertain the detailed information on the use of plants and their therapeutic medical practices popular among Koya tribes of Thadvai Mandal, Warangal district, Andhra Pradesh. MATERIALS AND METHODS Study Area Warangal is a city and a municipal corporation in Warangal district in the Indian state of Andhra Pradesh. Warangal is located 148 kilometers northeast of the state capital of Hyderabad and is the administrative headquarter Hyderabad, Warangal District. Warangal is located at 18.0°N 79.58°E. It has an average elevation of 302 meters (990 feet). As of 2011 India census5, Warangal had a population of 759,594. Males constitute 51% of the population and females 49%. Warangal has an average literacy rate of 84.16%, higher than the national average of 74.04%: male literacy is 91.54%, and female literacy is 76.79%. Fig:1. Study area location Ethno botanical Survey The ethnomedicinal information was collected from knowledgeable local aged people, herdsmen and local healers of Medaram and Narlapur villages of Warangal district, Andhra Pradesh aged between 35-78 years. The information on ethnomedicine was collected during August 2011 Manjula et al., to September 2012 through interviews and discussions. The collected information includes useful plant species with local names, parts of the plant used for curing different diseases. The plant specimens collected with the help of the inhabitants of surveyed villages. The scientific Int J M ed Res Healt h Sci.2013;2(1):40-46 41 names of plant species their families were identified with the help of a senior taxonomist of Department of Botany, Kakatiya University, Warangal. The data collected from different sources of ethnic community consists of 36 plant species whose different parts are used for curing different diseases. RESULTS AND DISCUSSION The present study includes 36 numbers of plant species of Angiosperms belonging to 24 families are reported. The alphabetical order of scientific name of the plants, their families local names, diseases, parts used, mode of administration with duration and doses are furnished with table-1. The information provided in the table is collected from local healers through interviews and discussions. They have good knowledge about the use of plants for curing various ailments and also believe in supernatural powers which are also a part of their healing methods. The diagnosis of different pathologies is the first step in phyto cure treatment which can be known by one's nose, ear, hands, and eyes and is interesting. Table. 1: List of medicinal plant used by Koyas of Thadvai Mandal, Warangal District, Andhra Pradesh, India. S.No Botanical & family name Common Part used & Mode to use Medicinal uses Name Andrographis Parculata Nelavemu Leaf crush or Powder with Control Diabetes 1 (Acanthaceae) honey mixture Acassia auriculata Thangedu All parts in same quantity Diabetics and Urinary 2 (Caesapinaceae) and add the water or puss honey. Tinospora Cordifalia Thippa Teega. Creepers and Leafs Diabetics 3 (Menispermaceae). Dry powder or 1 teaspoon Juice Emblica aphicinalis, Usiri Powder of dry fruit is Diabetics 4 (Euphorbiaceac) mixed with turmeric powder along with thangedu leafs Mymosa Peudica, Athipathi. Leaf powder with water Blood purification, 5 (Mimosoidae) nose bleeding, and jaundice. Respiratory diseases, heart disease. Removing water from the body Eugeniajambolana Neredu Seed, Dried and powered Diabetes 6 (myrtaceae or mixed with and taken myrluscuceius) before meals Aclupta alba (asteraceae, Guntagalagara Leaves, Dried under shade Grey hair 7 . and finally powered this is boiled with oil and applies to white hair for about 40 days Partheniunhisteroporouse Nagkesaralu. Flower, Powered and Hyper urination 8 (asteraceae) mixed with buttermilk. Aerva lenata Pindi kura. Whole plant Boiled with Kidney pains or 9 (Amaranthaceae) water. kidney stones 42 Manjula et al., Int J M ed Res Healt h Sci.2013;2(1):40-46 10 Tectonegrandis (Verbenaceae) Teaku Flower, Flower is grinded with water and made into paste now this paste is layered below the stomach 11 Dolichas biflorous (Fabaceae) Blackuluvalu Seed, Soak in water and Piles can be controlled grind into a paste and place on the anus 12 Bombox ceiba (Bombacaceae) Phyllonthus niruri (Euphorbiaceae) Parteinsonia ariculata (Caesalpinacea) Casiafistula, (Caesalpinaceae), Hardwictia binata, (Caeselpinacaae) Odinaoodier (Anacardiaceae) Litseasebifera (Lauraceae) Holoptaliaintegricelia (Urgicaceae) Burugu chekka Nela usiri 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Bark, Grind the bark and mixed with water Creepers are grinded and mixed with water Giluku Cekka. Roots, Grinded form Raala kaya. Fruit Direct intake Narepa Bark, Directly layer on the leg or hand fracture Dhumpudu Bark, Directly applied on wounds Narre mamedi Bark, Juice of bark Is mixed with water Namelinara Bark, Fresh juice of the bark is mixed with curd and taken Leucasaspera Thumikuru, Root, Mix the grind roots and peppers and then mix (Lamiaceae) with boiling water and take through orally Menordica Kakara chettu, Leaf and unripe. (cucurbitaceae) The leaf extract is poured into nostril Sphaeranthus indicus Linn Bodasaram Leaf. The leaves are grinded with pepper and a (Asteraceae) dose of spoon extract is orally Soymida febrifuga A. Juss. Somi Bark. The bark soaked ( Meliaceae) water Solanum xanthocarpus Nelamulaka Root. The aqueous extract Schard. & Wendl of the root with a dose of 1 ( Solanaceae) spoon per day is orally Barinka, Pakki Latex, Streblus asper Lour The latex in ( Moraceae) combination with turmeric applied on head Bryophyllum Ranapala Leaves. Grind the leaf and (Crusulaceae) applied to wounds Cyperus rotandus Garika Leafs Applied to the (Cyperaceae) wounds Urine flow will be cleared Body heat regulations Jaundice Regulation of Body temperature Fids legs scrams Pains can be controlled The wound will be healed quickly. Diabetes Abdominal pain asthmatic problem Migraine Sexual stimulation. Body pains and Diabetic Diarrhea. fever and cough, cold Cold relief Wounds healing Wounds healing 43 Manjula et al., Int J M ed Res Healt h Sci.2013;2(1):40-46 28 29 30 31 32 33 34 35 36 Datura metal (Solanaceae) Madhuca indica (Convolvunaceae) Riccinus communis (Euphorbiaceae) Strichnus nuxvimoca (Loganiaceae) Lowsina (Lytrhoceae) Centella aciatica (Mackinlayaceae) Plumbago zeylancia (Plambaginaceae) Nona squmosa (Annonaceae) Ocimumtenuifloram (Lamiaceae) Nalla Ummetta Ippa Leaf and Bark Skin allergy Flower and seeds Blood purification Amudam leafs Control body pains Vishamushti Bark and fruit juice. Leprosy Gorinta Saraswthi Leaves Jaundice Leaves. leaf is grinded & Improve mixed with honey Memory power Root, bark and leaves Relief body pain Chitramala Seetapalam Leaves. Grained the leaf and applied to the tumor Leaves. Juice of leaves Tulasi The tribal healer’s preparations are either based on single plant part or combination of several plant species parts. The mode of ethnomedicine usage for different diseases is in various forms, such as aqueous extract, paste and oil. In addition, milk, ginger, pepper, oil, turmeric and jiggery etc. are used as ingredients in the administration of ethnomedicine. The ethnic tribe (Koya) of these villages is healthy and not suffering from common problems like depression, blood pressure and diabetes which are common in urban people. List Root, 14% Tumours can controlled Cold and cough be of medicinal plant used by Koyas of Thadvai Mandal, Warangal District, Andhra Pradesh, India. Conversely, the same ethnic tribe occupying different vegetation habitats is to be studied ethno botanically.6 Among 36 plants belongs to 24 Families, 31% of leaves, 21% Bark, 14% roots, 12 % Flowers, 12% Seeds and 5% Fruits are used for various diseases. The most widely sought after plant parts in the preparation of remedies in the study area are the leaves (31%) and stem bark (21%) (Figure 2). Creaper, 5% Leaf, 31% Seed, 12% Bark, 21% Flower, 12% Fruit, 5% Fig: 2. Parts using from the Different Plants 44 Manjula et al., Int J M ed Res Healt h Sci.2013;2(1):40-46 These plant species are used for the treatment and prevention of many ailments and diseases grouped under 10 ailment categories (Figure 3). The main ailments in the study area were cold, cough, wound healing, urinary disorders, body pains, stomach pain, jaundice, diarrhea, kidney diseases, neural and other diseases. The largest number of medicinal plant species are available for the treatment of skin diseases, body pains and stomachache. Half of the remedies for the above ailments are taken orally, followed by external application. Generally, fresh part of the plant is used for the preparation of medicine. To improve the acceptability of certain oral remedies, additives are frequently used. Most of the reported preparations in the area are drawn from a single plant; combinations are used in twelve cases. In other parts of the country, the use of mixtures of plant species in treating a particular ailment is fairly common.7,8 Fig: 3. The different elements of study area grouped under different ailment categories The present study revealed that the local traditional healers of Khammam district, Andhra Pradesh are rich in ethnomedicinal knowledge and the majority of people rely on plant based remedies for common health problems like headache, body ache, constipation, indigestion, cold, fever, diarrhea, dysentery, wounds, skin diseases, urinary troubles, etc. The survey also revealed that all the traditional healers have strong faith on ethno-medicines although they were less conscious about the documentation and preservation of ethno medicinal folklore and medicinal plants. The group discussion and personal interviews show that youngsters of the Koya tribal community are less aware about the use of ethnomedicines; our findings are similar to reports from India [9]. On the other hand, traditional healers who are the main repository of ethno medicinal knowledge claim extreme secrecy over their ethnomedicinal knowledge. The traditional healers have strong believe that if they disclose the secrecy about the medicinal properties of particular plant all the medicinal potentialities of the plant will be lost and the remedy will not work properly. The study concluded that the local and tribal people of the Warangal district have very good knowledge on the use of medicinal plants. But such knowledge of medicinal plants is restricted to a few persons in rural area. Therefore it is necessary that suitability requirements are needed in order to protect the traditional knowledge in a particular area with reference to medicinal plant utilization and it was found that traditional ethno- 45 Manjula et al., Int J M ed Res Healt h Sci.2013;2(1):40-46 medicine still persists among the tribal’s in Thadvai Mandal, Warangal district. ACKNOWLEDGEMENTS The authors acknowledge the kindness and cooperation of the informants and local administrators in the study area, and the support of the Department of Botany, Kakatiya University, and Warangal for identification of the plant species. My thanks also to tribal people in study area. 8. Jain. SK. Dictionary of Indian Folk medicine and Ethnobotany. Deep Publications, Paschim Vihar, New Delhi. 1991. 9. Uniyal SK, Sharma S, Jamwal P. Folk Medicinal Practices in Kangra District of Himachal Pradesh, Western Himalaya. Human Ecol. 2011;39:479-488. REFERENCES 1. Sheldon JW., Balick MJ and Laird SA. Medicinal Plants: Can utilization and Conservation co-exist. New York Botanical Garden Press Department, New York, 1997; 104. 2. Ganesan S, Suresh N and Kesavan L. Ethnomedicinal Survey of Lower Palani Hills of Tamilnadu, I.J. Trad. Knowledge, 2004;3 (3): 299-304. 3. Burmol KS and Naidu TS. National seminar on “Tribal medicinal System and its Contemporary Relevance. Forest flora of Hyderabad state. 2007. 4. Samy RP, Ignacimuthu S, Raja DP. Preliminary screening of ethnomedicinal plants from India. J Ethnopharmacol. 1999;66:235240. 5. Census of India. Household Schedule - Side Government of India. 2011. 6. Ravisankar T, Henry AN. Ethnobotany of Adilabad district Andhra Pradesh, India.Ethnob.1992; 4:45-52. 7. Ayyanar, M; Ignacimuthu, S. Traditional Knowledge of Kani tribals in Kouthalai of Tirunelveli hills, Tamil Nadu, India. J. Ethnophar. 2005;102:246–255. 46 Manjula et al., Int J M ed Res Healt h Sci.2013;2(1):40-46 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 Received: 1st Dec 2012 Revised: 20th Dec 2012 Accepted: 23rd Dec 2012 Original research article BENEFICIAL EFFECT OF LOW DOSE AMLODIPINE VS NIFEDIPINE ON SERUM CHOLESTEROL PROFILE OF RABBITS RECEIVING STANDARD DIET. *Bavane DS, Rajesh CS, Gurudatta Moharir, Bharatha Ambadasu Department of Pharmacology, Shri. B. M. Patil Medical College & Research Centre, BLDE University Bijapur- Karnataka *Corresponding author e-mail: ajaybawane02@gmail.com ABSTRACT Objective: To investigate the effect of low dose amlodipine v/s nifedipine on serum cholesterol profile of rabbits receiving standard diet. Methods: Fourty Newzealand rabbits were selected for the study. Their cholesterol profile was estimated at the beginning of the study. Rabbits were grouped into 4 groups receiving standard diet (control group), standard diet + vehicle propylene glycol, standard diet + nifedipine dissolved in propylene glycol and standard diet + amlodipine dissolved in propylene glycol. Along with standard diet they were treated with respective drugs for ten weeks. At the end of ten weeks serum cholesterol profile was estimated. Results: The cholesterol profile was estimated at the beginning and at the end of ten weeks. Total cholesterol in the amlodipine group decreased from 97±4.06 mg/dl to 90±4.2 mg/dl and HDL-Cholesterol increased from 32.01±4.40 mg/dl to 37±4.60 mg/dl after 10 week treatment but these changes were not significant. LDL cholesterol decreased significantly in rabbits with low dose of amlodipine from 55.42±3.32 mg/dl to 32.40±3.22 mg/dl and. In the nifedipine group there was a slight increase in total cholesterol from 102.49±5.16 mg/dl to 106±5.39 mg/dl, HDL cholesterol from 34.10±2.80 to 35.16±2.82 mg/dl and LDL cholesterol also increased from 56.20±2.20 mg/dl to 59.00±2.20 mg/dl after 10 week treatment. Conclusion: The study shows amlodipine produces favorable alterations in serum cholesterol profile. Key words: Cholesterol profile, Standard diet, Amlodipine, Nifedipine INTRODUCTION Hyperlipidaemia and hypertension are often two co-existing risk factors for coronary artery disease. Among different cholesterol high serum levels of total cholesterol and low density lipoprotein cholesterol favours coronary artery disease. A report by the National cholesterol education program11 has focused attention on the necessity for managing lipid disorders. Serum cholesterol plays a central role in the atherosclerotic process, in particular, abnormal levels of total cholesterol 47 Bavane DS et al., Int J M ed Res Health Sci.2013;2(1):47-51 and low – density lipoprotein cholesterol. High density lipoprotein particles function in the opposite way from low density lipoprotein, they act as a scavenger of free cholesterol and enhance the rate of clearance of cholesterol from the arteries.3 It has been reported in a large number of animal and human experimental studies that various classes of antihypertensive agents have either adverse or significant, effect on plasma lipid & lipoprotein levels.1,4,5 Beta-blockers without partial intrinsic sympathomimetic activity increase serum triglycerides and tend to lower high-density lipoprotein cholesterol.9 Recently there has been an epidemical increase in hypertensive cases resulting in coronary artery disease and abnormal lipid profile. Therefore we planned in this study to see whether amlodipine versus nifedipine to test if this drug having antihypertensive effect in human, has any effect on serum cholesterol profile of rabbits fed on standard diet. MATERIALS AND METHOD Fourty healthy male Newzealand rabbits weighing between 2-3 Kg was selected and placed under ideal conditions. Animals were maintained on the routine standard feed and acclimatized for seven days prior to start of the experiment. Nifedipine (Pfizer Ltd): A solution of 5 mg/40ml in propylene glycol prepared and administered orally in a dose of 2ml/kg i.e. 0.25 mg/kg orally. Amlodipine (Pfizer Ltd): A solution of 2.5mg/40 ml in propylene glycol prepared and administered orally in a dose of 2ml/kg i.e. 0.125 mg/kg orally. Estimations of serum total cholesterol and serum high and low density lipoprotein cholesterol were done at the beginning of the study and after 10 weeks of administration of the study drugs. Study design The rabbits were divided into four groups containing 10 rabbits each. The groups were treated as follows: Group I Standard diet (control group) Group II Standard diet+ vehicle propylene glycol 2ml/kg/day Group III Standard diet +Nifedipine (0.25mg/kg/day) Group IV Standard diet +Amlodipine 0.125mg/kg/day orally A routine diet containing bread, milk and vegetable on an average of 100gm/rabbit was given to the rabbits during the study period with water given ad-libitum. The animals were treated in this manner for 10 weeks. For analysis of cholesterol profile i.e. total cholesterol, HDL-cholesterol and LDL-cholesterol 1ml blood samples were collected from the marginal ear vein of rabbit after an overnight fast at the beginning before starting the drug administration and then after ten weeks of the drug administration. Readings were taken on a photo colorimeter. The data were analyzed using students paired ‘t’ test for the same group and students unpaired t test for between the groups. Table: 1. Cholesterol profile in the rabbits baseline values (Pretreatment) Sr. No Group 1. 2. 3. 4. Group I Group II Group III Group IV Total Cholesterol (mg/dl) HDL-cholesterol (mg/dl) LDL-cholesterol (mg/dl) 95.00± 1.28 97.00± 1.28 102.49± 5.16 97.00± 4.06 32.16± 2.08 34.01± 3.20 34.10± 2.80 32.01± 4.40 56.55±3.72 54.20± 5.20 56.20± 2.20 55.42± 3.32* 48 Bavane DS et al., Int J M ed Res Healt h Sci.2013;2(1):47-51 Table: 2. Cholesterol profile in rabbits after 10 weeks of drug administration Sr. Group Total Cholesterol (mg/dl) HDL-cholesterol (mg/dl) LDL-cholesterol (mg/dl) No 1. Group I 2. Group II 3. Group III 99.00± 1.28 100.00± 1.28 106.00± 5.19 31.02± 2.08 34.00± 3.20 35.16± 2.82 53.12± 3.72 55.00± 5.20 59.00± 2.20 4. Group IV 90.00± 4.06 37.00± 460. 32.40± 3.32* The data were analyzed by paired ‘t’ test (p<0.001)*LDL-C is decreased significantly in group 4 treated with amlodipine as compared to group 3 treated with nifedipine , control group1; 2 & pretreatment groups1, 2, 3 & 4. RESULTS The group 1 and 2 did not exhibit any significant alteration in serum cholesterol profile. There was a slight decrease in serum total cholesterol in the group-4 treated with amlodipine than non treated group 1, 2 & 4. But the mean serum total and LDL-C levels of the group 4 treated with amlodiine, rabbits were significantly reduced when compared to group 3 at tenth weeks.Thus amlodipine significantly prevented the rise of LDL-C(p<o.oo1). There was a considerable rise in HDL-C in group 4 rabbits receiving amlodipine. The mean serum levels of HDL-C of group 3 & 4 rabbits receiving nifedipine & amlodipine respectively increased marginally after 10 weeks than basal groups. DISCUSSION Administration of amlodipine in group 4 resulted in significant lowering of LDL-C after 10 weeks when compared to group 3 rabbits receiving nifedipine. Similar effects of nicardipine in lowering LDL-C and elevating HDL-C has been reported by Ohata et al12. It is now well recognized that coronary artery disease bears a relationship through inter linkage between hypertension and dyslipidemia. The treatment of hypertension is found with potential difficulties, including the altered efficiency of medications, the increased risk of side effects and possibility for derangement of serum lipid levels. Serum cholesterol plays a central role in the atherosclerotic process, in particular, abnormal Bavane DS et al., levels of total cholesterol, low density lipoprotein cholesterol and high density lipoprotein cholesterol have been found to be predictors of coronary heart disease risk in hypertension. As the major transport vehicles for cholesterol, low-density lipoprotein particles essentially deposit cholesterol in the lining of the arterial wall; low-density lipoprotein cholesterol is often referred to as bad cholesterol. High-density lipoprotein particles function in the opposite way from low-density lipoprotein. They act as a scavenger of free cholesterol and enhance the rate of clearance of cholesterol from the arteries. Serum high-density lipoprotein cholesterol levels and subsequent development of coronary artery disease in hypertension were also found to be related, but in hypertension through the effects of diet on plasma lipids.13 The inverse proportion of the Framingham study.2 Dietary factors and clinical events of coronary artery disease are linked together with high For these reasons, high density lipoprotein cholesterol is often referred to as good cholesterol. Henry P.D in 19818 showed that calcium channel blockers like nifedipine and nicardipine reduce atherosclerotic lesions in cholesterol fed rabbits without any significant effect on serum lipids.It has been reported that calcium channel blockers including nifedipine do not adversely affect lipid profile7,14 Showed the beneficial effect of low dose felodipine on serum cholesterol of rabbits fed on atherogenic diet. The cholesterol reducing effect of felodipine, when administered early has not been explained Int J M ed Res Healt h Sci.2013;2(1):47-51 satisfactorily. Increased uptake and degradation of low density lipoprotein by skin fibroblasts, aortic endothelial cells, smooth muscle cell, induction of denovo synthesis of apoproteins and inhibition of cholesterol synthesis and reduction of cholesterol ester accumulation in smooth muscle cells are thought to be the possible mechanisms. Many studies have demonstrated that arterial compliance is improved by antihypertensive drugs that induce vasodilation in the large peripheral arteries, e.g. calcium antagonists, angiotension converting enzyme inhibitors and certain beta adrenoreceptor blockers. Amlodipine increased arterial compliance and dilated the brachial artery at prevailing and isobaric pressure. The active increase in arterial compliance with amlodipine was 26% of pretreatment values, while passive pressure dependent was only 14%.10 It has been shown experimentally that a reduced response of the arterial smooth muscle to endothelial vasodilators and an increased sensitivity to vasoconstrictor agents may be involved in the abnormal arterial reactivity seem in hypercholesterolemia. The presence of calcium and its role in plaque formation is not yet fully elucidated.6 Over the past decade, investigators have demonstrated that CCB like agents may retard plaque formation. Recent studies in patients with coronary artery disease have demonstrated that nifedipine may impede or prevent the development of atherosclerosis plaques in humans as well.15 CONCLUSION The present study shows that amlodipine plays a favourable role in the alteration of serum cholesterol profile. Further studies confirming these findings may open up new avenues for this novel group of drugs and pave way for their use in many appropriate situations for prevention of hypercholesterolemia. REFERENCES 1. Johnson BF and Margaret A, Danylchuk. The relevance of plasma lipid changes with cardilovascular drug therapy. Medical Clinics of North Americ.1989;73 (2):68 2. Castelli W.P. Anderson K: A population at risk prevalence of high cholesterol levels in the Framingham study Am. J. Medi 1980;80: 2332. 3. Dzaw VJ. Mechanism of interaction of hypertension hypercholesterolemia in atherogenesis. The effect of antihypertensive agents Am. Heart jour. 1988; 17:25-29 4. Claude K, Lardinosis MD, Sherry LN. The effects antihypertensive agents on serum lipid profile Arch Internal Medi.1988;148:1280-88 5. Ferrari P, Romsson J, Weidnann P: Antihypertesive agents, serum lipoproteins glucose metabolism Am. J.Cardio. 1991, April 22; 67 (10); 26-35. 6. Gotto Jr HM. Calcium channel blockers and prevention of atherosclerosis. Am. J. Hypertension.1990; 3: 3465-68. 7. Henry D. Antiatherosclerotic property of calcium channel blockers possible mechanism of action. Cardiovascular Drugs Ther.1990; 4:1015-20 8. Henry PD., Bentley KL.: Suppression of antherogensis in cholesterol fed rabbits treated with nifedipine. J. Clin. Invest. 1981; 68:13069. 9. Jaju JB., Moholkar AL., Rahul AR. Lipid profile in hypertension with special reference to propranolol and atenolol. Indian medical gazette-may 1998;32: (5): 132-34 10. Mehta JL. et al: Double blind evaluation of the dose response relationship of amlodipine in essential hypertension. Am. Heart J., 1993,125 (6): 1704-10 50 Bavane DS et al., Int J M ed Res Healt h Sci.2013;2(1):47-51 11. National cholesterol education program panel on detection, evaluation and treatment of high blood cholesterol in adults. Arc. Intern .Med., 1988;148:36-69. 12. Ohata N, Nagano K. Low-Density lipoprotein lowering and high-density lipoprotein elevating effects of nicardipine in rats. Bichem. Pharmacol., 1984;33:2199-205. 13. Shephered J, Cobbe SM, Ford et al: Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N.Engl. Med. 1995; 33:1301-7 14. Swain TR, Das, Kanungo S, Patanaik J: Beneficial effects of low dose felodipine on serum cholesterol of rabbits fed on atherogenic diet. Indian Journal of Pharmacology, 1996; 27:133-35 15. Vos JW. Retardation and arrest of progression or regression of coronary artery disease, A review program, Cardiovasac Dis. 1991;35:435-54. 51 Bavane DS et al., Int J M ed Res Healt h Sci.2013;2(1):47-51 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN:2319-5886 Received: 4th Nov 2012 Revised: 03rd Dec 2012 Accepted: 23rd Dec 2012 Original research article A STUDY OF PULMONARY FUNCTION TEST IN WORKERS OF SUGAR FACTORY, PRAVARANAGAR, MAHARASHTRA Nitin S Nikhade 1, Panchsheel Sharma2 1 2 Assistant Professor, PDVVPF’s College of Physiotherapy, Ahmednagar Assistant Professor, Dept. of PSM, Pravara Institute of Medical Sciences, Loni ABSTRACT Context: Repeated exposure to dusty environment in an industry causes airway diseases which may affect pulmonary function over a period of time. Aims: 1) To study the pulmonary function test parameters in workers of sub-departments in sugar factory 2) To find out the prevalence of Obstructive, Restrictive and Mixed type of pulmonary impairment and their correlation with duration of exposure to occupational environment. Study Design: An observational study was conducted on 294 permanent sugar factory workers at Urban Health Centre, Pravaranagar. Materials and Method: The pulmonary function viz. (FVC, FEV1, FEV1/FVC %, FEF25-75%) was recorded by a portable computerized RMS-Spirometer. Spirometric studies were performed in various sub-departments in sugar factory including 60 matching controls. To evaluate the effect of occupational exposure, the workers were divided into three categories i.e. those exposed for 11-20 yrs, 21-30 yrs and ≥ 31yrs to the dust. Results: The overall prevalence of pulmonary impairment was found to be 31.97%. The highest prevalence was found in Bagasse workers (40.48%) followed by Manufacturing dept. (38.24%). Amongst the type of pulmonary impairment bronchial obstruction was predominant (18.03%). FEV1/FVC was found significant in Bagasse workers and Manufacturing dept. workers. Amongst the occupational exposure sub-groups, ≥ 31yrs exposed workers were maximally affected by obstructive type (21.43%), Restrictive type (14.29%) & Mixed type (3.17%) of pulmonary impairment. Conclusions: The study demonstrated a significant association between pulmonary function abnormalities and certain sub-occupations in the sugar factory. The majority of the workers with pulmonary impairment had ≥ 31yrs of occupational exposure. Keywords: Pulmonary function test, Bagassosis, Pulmonary impairment, Spirometry INTRODUCTION Maharashtra is one of the largest sugar producers state in India. Sugarcane processing involves many workers in different sub-departments of sugar factory1. “Bagassosis” is a respiratory disease caused by inhalation of bagasse dust, which is commonly described under the heading of hypersensitivity pneumonitis2 and is also known as a variant of farmers' lung 3,4. The organic dust contains high concentrations of bioaerosols, such as bacteria, actinomycetes, and fungi of plant and animal origin. The concentration and pathogenicity of these bioaerosols depend on source materials, 52 Nikhade et al., Int J Med Res Health Sci. 2012;2(1):52-58 method of their storage, technology of processing materials and their disposal 5. One such organic dust is Bagasse. Bagasse is a byproduct of sugar cane crushing, size range from 0.5–3 microns are called as respirable dust, to which sugar factory workers are exposed by virtue of their occupation6, 7 . Vishwanathan et al8 and Nair and Das9 from India in 1970 reported reduced FVC, TLC, PEFR, and MVV in bagassosis patients. Since 1970 very few pulmonary function studies were reported in this field until recently in 2008 a study by Patil S N10 from western Maharashtra reported decrease in FVC, FEV1, PEFR and MVV in occupationally exposed groups to bagasse as compared to non exposed group. However, this study was conducted during the operational period of a sugar factory. Pandit T and Singh A et al8 identified 93 fungal types from sugar factory which are responsible for respiratory symptoms and pulmonary abnormalities in workers. They observed 40% of the symptomatic workers reported improvement in their symptoms when away from work. Hence, the present study is conducted on workers during the non-operational period of a sugar factory. MATERIALS & MEHTODS This observational study was carried out in Padmshri Dr. Vitthalrao Vikhe Patil Sahkari Sakhar Karkhana, Pravaranagar, internationally renowned as the first in Asia, started on cooperative basis with the involvement of the local farmers, during the period from August 2011 to October 2011. The permission to carry out the study was sought from the management of Sugar factory, Pravaranagar and ethical clearance was obtained from the institutional ethical committee of Pravara Institute of Medical Sciences (Deemed University) before the commencement of the study. Informed consent was taken from each subject in the study. Selection of subjects The study sample comprised of male permanent workers employed in the sugar factory, Pravaranagar. There were 349 permanent employees, out of which 331 could be interviewed and examined but only 294 were included in this study. The smokers (37 in number) were not included in this study to avoid bias while finding pulmonary impairment purely based on occupational exposure to dust. 18 permanent workers could not be examined due to various reasons but they did not differ much in age or duration of service. A control group of 60 non-smoking subjects (office workers those who are unexposed to sugar factory occupational environment) were selected, having similar age group and socioeconomic status of the sugar factory area. Inclusion criteria: 1) Age of workers between 2060 years 2) Only male workers Exclusion criteria : 1) Those have cardiovascular illness in present or past 2) Those having kyphoscoliosis deformity 3) Those predispose to allergic asthma 4) Workers addicted to smoking. As the subjects are industrial labour, there was a habit of slight intake of alcohol and tobacco chewing which does not affect or alter the pulmonary function tests. This habit was present in some workers of sub-departments as well as in controls which nullifies the effect in this study. Recording occupational and personal histories of exposed workers A complete history of the workers was recorded with respect to duration of occupational exposure and nature of occupation, respiratory symptoms, smoking habits and socio-economic status on a pre-structured proforma12. Pulmonary Function Testing The anthropometric measurement (standing height, weight etc.) was recorded. The whole maneuver was explained to the subject and they were encouraged to practice this maneuver before doing the pulmonary function test. The spirometric functions were recorded in the sitting position using an electronic computerized portable RMSSpirometer13 according to the guidelines recommended by the American Thoracic Society 14 . Each individual performed spirometry thrice to 53 Nikhade et al., Int J Med Res Health Sci. 2012;2(1):52-58 produce the best result. All the pulmonary function tests were carried out at a fixed time of the day i.e. 9:30 am to 12:30 pm. The RMS- Spirometer used was precalibrated each day prior to use. The room temperature was recorded between 34-36 0C during the period of study. Spirometric studies were performed in workers engaged in Engineering dept. (N=96), Manufacturing dept. (N=102), Bagasse workers (N=42) and Godown workers (N=54). The following respiratory parameters were studied: 1. Forced vital capacity (FVC) 2. Forced expiratory volume in 1 Sec (FEV1.0) 3. FEV1/FVC % ratio 4. Peak expiratory flow rate (PEFR) 5. FEF 25-75% The criteria for pulmonary impairment were defined on the basis of the American Thoracic Society (ATS) guidelines 14. FEV1/FVC percent values >85% predicted were considered normal and values less than <85% indicated bronchial obstruction. The pulmonary impairments were classified as per Miller’s prediction quadrant 15. RESULTS Table: 1. Anthropometric measurements of workers in different departments of sugar factory SUB-GROUPS (N) AGE (Yrs) HEIGHT (Cm) WEIGHT (Kg) Engineering dept. (N=96) Manufacturing dept. (N=102) Bagasse Workers (N=42) Godown Workers (N=54) Controls (N=60) N = Total number of subjects. 48.98 ± 5.83 50.22 ± 5.22 50.15 ± 5.61 50.27 ± 5.96 50.04 ± 6.52 165.77 ± 6.50 62.32 ± 10.29 165.72 ± 6.77 63.91 ± 10.65 167.27 ± 6.82 65.60 ± 9.14 165.90 ± 6.73 63.16 ± 10.37 167.94 ± 6.40 65.82 ± 8.83 Values are means ± S.D. By applying ‘Z’ test for difference between two mean values in Control & Study groups respectively; there is no significant difference in age, height and weight of workers i.e. P>0.05 Table: 2. Mean values & standard deviation of pulmonary function test parameters in workers of different departments in Sugar factory. Sub-Groups FVC (N) (L) 2.85±0.52‫٭‬ Engineering dept (N=96) Manufacturing dept N=102) 2.98±0.58 3.01±0.45 Bagasse Workers (N=42) 2.94±0.47 Godown Workers (N=54) 3.04±0.48 Controls (N=60) N = Total number of subjects in each dept. FEV1 (L) 2.42±0.48‫٭‬ 2.45±0.53‫٭‬ 2.38±0.39‫٭‬ 2.49±0.49 2.62±0.46 FEV1/FVC PEFR (%) (L) 85.62±11.14 5.42±1.51‫٭‬ 83.67±12.32‫ ٭‬5.41±1.71‫٭‬ 82.56±13.71‫ ٭‬5.26±1.52‫٭‬ 85.51±11.41 5.58±1.67 87.49±9.69 6.08±1.57 Values are means ± S.D. FEF25-75% (L) 2.99±0.98 2.98±0.97 2.92±0.85 3.06±1.04 3.09±0.94 By applying ‘Z’ test for difference between mean values of pulmonary function test parameters, * ‘significant’ difference between two mean values in control & study group respectively. i.e. p<0.05 PFT values in sub-occupational group: There is statistically significant difference found with respect to mean values of FVC in workers of engineering dept. as compared to controls. There was significant reduction in FEV1 in Bagasse workers, Manufacturing dept. and Engineering dept. workers as compared to controls, indicated the prevalence of obstructive type of pulmonary impairment. (Table-2) The above findings of a 54 Nikhade et al., Int J Med Res Health Sci. 2012;2(1):52-58 reduced in Bagasse workers, Manufacturing dept., and engineering dept. workers, thereby showed the maximum effect on peripheral airway obstruction. reduction of FEV1 are further supported by a reduction in their ratios FEV1/FVC which is found to be significantly reduced in Bagasse workers and Manufacturing dept. workers. The PEFR were Table: 3. Pulmonary impairment in relation to occupational exposure in workers of different departments in sugar factory. Obstructive Restrictive Mixed Total Sub-groups (N) n % N % n % N % 14 14.58 11 11.46 2 2.08 27 Engineering Dept. (N=96) 22.55 13 12.75 3 2.94 39 Manufacturing Dept. (N=102) 23 11 26.19 4 9.52 2 4.76 17 Bagasse Workers (N=42) 5 9.26 6 11.11 0 0 11 Godown Workers (N=54) 53 18.03 34 11.56 7 2.38 94 Total Workers (294) 3 5 5 8.33 0 0 8 Controls (N=60) N = Total number of subjects, n = Number of subjects with pulmonary impairment % = Percent of subjects with pulmonary impairment Pulmonary impairment in sub-occupational groups: The overall prevalence of pulmonary impairment was (31.97%) compared to (13.33%) in controls. The highest prevalence of pulmonary impairment was found in Bagasse workers (40.48%) followed by Manufacturing dept. (38.24%), Engineering dept. (28.12%) and Godown workers (20.37%). (Table-3) Among various sub-groups bronchial obstruction (18.03%) was the predominant pulmonary impairment than the restrictive (11.56%) and the mixed type (2.38%). The 28.12 38.24 40.48 20.37 31.97 13.33 obstructive type of pulmonary impairment was found highest in Bagasse workers (26.19%) followed by Manufacturing dept. (22.55%) and Engineering dept. (14.58%) as compared to controls (5%). In a restrictive type of pulmonary impairment the prevalence is highest in Manufacturing dept. (12.75%) followed by Engineering dept. (11.46%) and Godown workers (11.11%) as compared to controls (8.33%). Mixed type of pulmonary impairment showed the least number of cases 7 (2.38%). Table 4: Pulmonary impairment in relation to duration of occupational exposure Duration of Exposure Obstructive Restrictive Mixed Total n n n n % % % 8 13.79 5 8.62 0 0 13 11-20 Years (N=58) 18 16.36 11 10.00 3 2.73 32 21-30 Years (N=110) 27 21.43 18 14.29 4 3.17 49 ≥ 30 Years (N=126) Total Workers (294) 53 18.03 34 11.56 7 2.38 94 N = Total number of subjects, n = Number of subjects with pulmonary impairment % = Percent of subjects with pulmonary impairment % 22.41 29.09 38.89 31.97 55 Nikhade et al., Int J Med Res Health Sci. 2012;2(1):52-58 Pulmonary impairment according to duration of occupational exposure: The highest prevalence of pulmonary impairment was found in ≥31 yrs exposed workers (38.89%) Followed by 21-30 yrs exposed workers (29.09%) and least in 11-20 yrs exposed workers (22.41%). (Table-4) The obstructive type of pulmonary impairment showed the maximum number of cases 53 (18.03%) followed by restrictive type 34 (11.56%) and mixed type 7 (2.38%). Percentage of Subject s 25 20 15 Obst ruct ive 10 Rest rictive 5 M ixed 0 11-20 Years 21-30 Years ≥ 30 Years Durat ion of Exposure Fig:1. Pulmonary impairment in relation to duration of occupational exposure DISCUSSION Sugar processing industry involves different suboccupations, which are performed in distinct processing units necessary in the manufacturing of sugar. In view of the industrial health scenario in the sugar factory, lung spirometric studies were conducted on workers in various departments namely engineering dept., Manufacturing dept., Bagasse workers and Godown workers. In the present study, Significant reduction of FEV1.0 in Bagasse workers, Manufacturing dept. and Engineering dept. workers as compared with controls, indicated obstructive type of pulmonary abnormalities (Table-2). Reduced FEV1 has earlier been reported by Bohadana et al16 showed that workers exposed to sugar dust in the sugar cube manufacture workstation had significantly lower forced expiratory volume in 1s (FEV1) than the non-exposed ones. Goyal R.C. et al17 also observed the decrease in FEV1 in workers actively involved in various plant operations of sugar factory. A possible mechanism could be mobilization of neutrophils into the airways and the subsequent release of tissue irritating substances, either Nikhade et al., directly from neutrophils via platelets or by secretion of prostaglandins from macrophages18. There is decreased diffusion capacity of the alveolar capillary membrane due to the destruction of alveoli caused by inflammatory responses leading to decreased O2 saturation in the blood 19,20. Hypoxia due to decreased O2 saturation leads to release of leukotriens and chemokines from eosinophils resulting in broncho-constriction 21. Hypoxia along with associated hyperapnea gives rise to decrease in PACO2, resulting in further constriction of bronchial muscles22. The lymphocytic infiltration caused by inflammatory response may result in thickening of the walls of the bronchioles resulting in obstruction of the lumen by granulation tissue23. In this study, the reduction of FEV1 is further supported by a reduction in their ratios FEV1/FVC, which is found to be significantly reduced in Manufacturing dept. and Bagasse workers where the exposure to organic dust is maximized. The Peak Expiratory Flow Rate (PEFR) was reduced in all the exposed workers in sub-occupational groups Int J Med Res Health Sci. 2012;2(1):52-58 56 (Table-2) being higher in Bagasse workers followed by Manufacturing dept., and Engineering dept. workers, thereby showed the maximum effect on peripheral airway obstruction. A highly significant decrease in PEFR was also reported from western Maharashtra by Patil S.N.10. PEFR is an index of expiratory airway resistance and is more effort dependent 24. The reduction in PEFR may involve the same mechanism already explained for obstructive lesion. In addition, the inflammatory reaction releases proteins from eosinophils which might be responsible for the hyper responsiveness of airways 25. All sub-groups of sugar factory workers suffered with various profiles of obstructive (18.03%), restrictive (11.56%) and mixed type (2.38%) of pulmonary impairments totaling 31.97% Vs 13.33% in controls (Table-3). However, bronchial obstruction was the predominant pulmonary abnormality in sub-occupational groups, especially Bagasse workers (26.19%) and Manufacturing dept. workers (22.55%). A Spirometric study by Gehad Abo et al 26 in workers chronically exposed to bagasse during the manufacture of particleboards showed prevalence of Obstructive ventilatory defects in about 28.5% of the studied workers followed by Restrictive defects affecting about 19.6% of the workers, while combined defect affected about 6% of the studied group. The results in the present study may be due to the differential nature of occupational exposure e.g. Bagasse workers and Manufacturing dept. workers are coming in direct contact with the Bagasse and fine sugar dust than the Engineering dept. and godown workers. There is an increasing number of cases in each obstructive, restrictive and mixed type of pulmonary impairment from 11-20 yrs exposed worker category to ≥31 yrs exposed category, which means there is a direct correlation between the duration of exposure to dust and the pulmonary abnormalities in sugar factory workers. There are no systematic studies related to industrial dust exposure and pulmonary hazards in key processing units of sugar factory thereby, making it difficult for comparison with the present data. In conclusion, the study demonstrated a significant association between pulmonary function abnormalities and certain occupations in the sugar factory, thereby suggesting that occupational exposure to Bagasse and certain chemicals used in sugarcane processing lead to pulmonary impairment particularly of the obstructive type followed by restrictive and mixed type. The majority of the workers with pulmonary impairment had ≥ 31yrs of occupational exposure. A direct correlation was observed between duration of occupational exposure to the organic dust (Bagasse) and increase in pulmonary impairment in sugar factory workers. ACKNOWLEDGEMENTS We are grateful to Dr. Bhaskar Kharde (Chairman) & Mr. Prakash Patil (Manager) Pravaranagar sugar factory for their interest and support for this work. We are also thankful to medical and paramedical staff at urban health centre, Pravaranagar for their constant support and help REFERENCES 1. Devendrakumar Amre & Durgawale PM. Sugar Industry in Maharashtra. Ind J of Occup. & Environ. Med. 1999;56(8):548-52 2. Hur T. and Cheng C. Hypersensitivity pneumonitis: Bagassosis.1994;10 (10): 556-64. 3. Marinenko NV, Metliaev GN. Bagassosis: An occupational disease of the lungs. 1979; (5): 39-41. 4. Anthony Seaton .Crofton and Douglas's Respiratory Diseases. 2000, Vol. II, 5 th edition; 1002. 5. Ata GA, Ezzat HM. Shalaby AO. & Kholey BE. Environmental mycological and respiratory health assessment of workers chronically exposed to bagasse in Egyptian particle board industry”. Intern. Jr. of Environ. Health Research.1998; 8(4):315-34 57 Nikhade et al., Int J Med Res Health Sci. 2012;2(1):52-58 6. Nicholson D.P. Bagasse worker's lung. Am Rev Respir Diseas. 1968; 97(4): 546-60. 7. Sodeman & Pullen: Bagasse disease of the lungs. Archives of Inter Med, 1944;73(5):365. 8. Viswanathan R, De Monte AJH, Shivpuri, DN& Venkitasubramoni TA. Bagassossis- A study of pulmonary function. Ind J. of Med. Res. 1963; 51: 563 – 693. 9. Nair KV and Das KV. Bagassosis. A case report, Jr. Ass. Physc. India. 1970;18(6): 57375. 10. Patil SN, Somade PM, Joshi AG. Pulmonary function tests in sugar factory workers of Western Maharashtra (India)” J Basic Clin Physiol Pharmacol. 2008; 19(2):159-66. 11. Miller GJ. and Hearn CED. Pulmonary function at rest and during exercise following bagassosis. British Journal of Industrial Medicine. 1971; 28: 152-158. 12. Kishor Jugal. Designing questionnaire for occupational and environmental studies. Ind J of Occup & Environ Med. 2000;4:183-90 13. RMS Medspiror, Recorders & Medicare Systems, Chandigarh, India, www.rmsindia.com 14. ATS (1995) Standardization of Spirometry: 1994 update. American Jour. of respiratory and critical care med.152: 1107-136 15. Miller WF and Jhonson RL. Miller’s prediction quadrant. Anesthesiology 1956;17: 480-93 16. Bohadana AB and Massin N. Airflow obstruction in sugar refinery workers. International Arch. of Occup. And Environ. Health. 1996;68(4): 131-34 17. Goyal RC., Adiya AN., Jejurikar ND. and Chavan UA. Study of health profile of industrial workers at Pravaranagar comlex. Ind. Jr. of Occup. Health. 1994; 36 (1): 11-13 18. Gokani VN, Rao NM, Ghosh SK. Panchal GM, Bhatt HV, Parikh JR & Kashyap SK. Bronchoconstriction in cotton dust exposed workers – Role of bacterial endotoxins. Ind. Jr. of Industrial Med. 1993; 39: 79-84 19. Buechner HA, Bhitz O and Thompson. Bagassosis: A review with further historical data, studies of pulmonary function and results of adrenal steroid therapy. American Journal of Medicine. 1958; 25:234. 20. Miller GJ. and Hearn CED. Pulmonary function at rest and during exercise following bagassosis. British Journal of Industrial Medicine, 1971;28: 152-58. 21. Govan A. D. T.: Respiratory System, In: Alasdair D. T. Govan, Peter S. Macfarlane, Robin Callander, eds. Pathology illustrated, 4 edition, Singapore: ELBS with Churchill Livingstone, Singapore Publishers Pvt Ltd 1994:342. 22. Ganong FW. Respiratory adjustments in health and disease, In:Willium F Ganong, Review of Medical Physiology. 22 editions, Singapore: McGraw –Hill; 2005:688. 23. Vishwanath P. Kurup: Farmers lung and related hypersensitivity pneuomonitis. Indian Jour. Chest diseases Alli-Scie. 1984;26 (4):242-255. 24. Virendra Singh JN. Pande GC. Khilnani. Tests for ventilatory function, In: PS. Shankar, Pulmonary function tests in health and disease, 1 edition. Indian College of Physicians. 1998;39: 46-59. 25. Pandit T. and Singh AB. Prevalence of airborne fungi in sugar factory environment. Ind. Jr. of Aerobiology. 1992;5: 145-52 26. Gehad AA El Ata Environmental, mycological and respiratory health assessment of workers chronically exposed to bagasse in Egyptian particle-board industry. International Jr. of Environ. Health Research. 1998, 8(4): 315-334 58 Nikhade et al., Int J Med Res Health Sci. 2012;2(1):52-58 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 Received:2 nd Dec 2012 Revised:20th Dec 2012 Accepted: 22nd Dec 2012 Original research article CLINICAL STUDY OF CAUSATIVE MICROBIAL AGENTS OF SUPPURATIVE KERATITIS CASES IN RURAL AREA *Suryawanshi Gaurav S, Khindria Ashish Dept of Ophthalmology, Rural Medical College, Loni, Maharashtra *Corresponding author email: thessentialg@gmail.com ABSTRACT The epidemiological pattern and causative agents for suppurative corneal ulcer vary significantly from region to region so it is important to determine the regional etiology for diagnosis and management. A prospective study was conducted to find out the specific microbial agents responsible for suppurative keratitis. 62 patients of keratitis were included in the study. Male patients (58.06%) above 40 years (69.35%), farmers (61.29%) by occupation were commonly involved. The commonest ulcer was fungal (35.48%) &the causative microorganism found on culture was Aspergillus (48.48%). In bacterial ulcer, Staphylococcus aureus (38.70%) &Pseudomonas (19.35%) were isolated as the responsible microbial agents. Keywords: Corneal ulcer, Fungal keratitis INTRODUCTION The cornea is the first and most powerful refracting surface of the optical system of the eye. The normal healthy cornea is avascular and devoid of lymphatic channels. 1Corneal cells derive its nourishment by diffusion from the aqueous,the capillaries at the limbus and oxygen dissolved in the tear film. The cornea is the most densely innervated tissue in the body. The sensory supply is via the fifth division of the trigeminal nerve. Corneal ulcer is defined as a loss of corneal epithelium with underlying stromal infiltration and suppuration associated with signs of inflammation with or without hypopyon. 2 Microbial keratitis in a previously normal eye is suspected by the onset of pain and the presence of ulceration, mucopurulent.Exudates adherent to the ulcer surface, focal stromal suppuration,diffuse cellular infiltration in the adjacent stroma and iritis.3 The epidemiological pattern and causative agent for suppurative corneal ulcer varies significantly from country to country and even from region to region within the same country.It is important to determine the “regional” etiology within the given region for a comprehensive strategy for the diagnosis and proper treatment of the corneal ulcer. 59 Gaurav SS et al., Int J M ed Res Health Sci. 2013;2(1):59-62 Several studies have addressed these questions in the Indian subcontinent. 4,5 MATERIALS AND METHODS A prospective study was carried out for the period of two years at Department of Ophthalmology, Pravara Rural Hospital. The study was approved by the ethical committee of the Institute. Patients presenting to the eye OPD with complaints of ocular trauma by vegetative matter, pain, redness, were evaluated for keratitis. 62 patients found to have suppurative keratitis were included in this study. Patients were included on the basis of detailed ocular (torch light and slit lamp) and systemic examination. Informed consent was taken. Examination of the smear Scraping of ulcer margin was done by 15 no. blade under topical anesthesia. The smear was fixed with Gram stain and KOH wet preparation. The scraping was done before starting any treatment. Smears were made from the scraping of ulcer margin using Bard-Parker blade no.15 and sent for KOH wet preparation and Gram stain. For culture, scrapped material was inoculated into blood agar and Sabouraud dextrose agar (SDA). The corneal scraping sample was transported to a microbiological laboratory in sterile nutritious broth and inoculated in blood agar, incubated at 37ºC for 24 hrs. Colonies obtained were described by their colony characteristics and growth sensitivity was done. For fungal cultures, the materials were inoculated onto Sabouraud’s dextrose agar (SDA) and incubated at room temperature, examined daily, and discarded after 2 weeks if there was no growth. RESULTS The age distribution of corneal ulcers varied from 8 years to 85 years in the study.Fungal keratitis was the most commonly seen in 22 patients out of 62 accounting for 35.48%,followed by bacterial keratitis in 32.25% case and mixed keratitis in 17.74%.Commonest fungal organism isolated in our study was Aspergillus accounting for 48.48%, followed by Fusariumat 30.30% and Candida in 21.21% of the patients. As for bacterial keratitis, the microorganisms isolated shown that Staphylococcus aureus was found to be the commonest among Gram positive organisms accounting for 38.70%, followed by Streptococcus pneumonia (25.80%), Staphylococcus epidermidis (6.45%) and Diphtheroids (3.22%). Among Gram negative organisms Pseudomonas species were found to be the commonest accounting for 19.35%, followed by Enterobactor and Moraxellaspecies both accounting for 3.22%. Table 1: Diagnosis of corneal ulcer based on smear examination Ulcer type Fungal Bacterial Mixed Sterile Total Male 16 7 8 5 36 Female 6 13 3 4 26 Total 22 20 11 9 62 Percentage 35.48% 32.25% 17.74% 14.53% 100% Total 16 10 7 33 Percentage 48.48% 30.31% 21.21% 100% Table 2: Fungal organisms isolated on culture Organism isolated Aspergillus species Fusarium species Candida species Total Male 12 7 5 24 Female 4 3 2 9 60 Gaurav SS et al., Int J M ed Res Healt h Sci. 2013;2(1):59-62 Table:3. Bacterial organisms isolated on culture (gram positive) Organism Staphylococcus aureus Staphylococcus epidermidis Streptococcus pneumoniae Diphtheroid Male 7 1 5 - Female 5 1 3 1 Total 12 2 8 1 Percentage 38.70% 6.45% 25.80% 3.22% Table:4. Bacterial organism isolated on culture (gram negative) Organism Pseudomonas Enterobactor species Moraxella species Total Male 2 0 0 15 Female 4 1 1 16 Fig:1. Central corneal ulcer with hypopyon Total 6 1 1 31 Percentage 19.35% 3.22% 3.22% 100% Fig:2. Corneal ulcer with flurescein stain DISCUSSION Special importance is given to corneal ulcer due to the fact that they leave behind a permanent opacity which interferes with visual acuity and if not attended to, may cause complications that may lead to the loss of an eye. 2 Basak et al found pure fungal growth at 42.5% , pure bacterial growth in 15.3%, mixed growth in 9.5% cases.6Bharathi et al in their study of 3183 patients found fungal growth at 34.4%, bacterial growth at 32.77%, mixed growth in 2.39%.5 Chowdhary et al and Singh et al study of 485 cases found fungal keratitis in 39%.7 Hertel et al in in their study of 50 cases, find that Pneumococci was present in 66% cases.8 McNabb et al on 25 cases found Pneumococci 64%, Staphylococci 20%, Streptococci 4%, Diplococcus 4%.9 Final outcome of the cases after full course of treatment shows that in 62.90 % of the cases with keratitis developed either nebular to macular grade of corneal opacity,followed by dense leucomatous opacity in 33.87% of the cases and corneal perforation was seen in only 3.22% of the patients.This data was supported by Saha et al in which 40.55% of the cases of keratitis healed with corneal scar formation after a full course of treatment.10 Scarring or perforation due to corneal ulcer is the major cause of corneal blindness throughout the 61 Gaurav SS et al., Int J M ed Res Health Sci. 2013;2(1):59-62 world. Among the surveys in India, corneal blindness is the third commonest cause of blindness. 4,5 A delicate balance exists between the cornea and its surrounding environment that helps the cornea maintain its integrity in spite of continuous exposure to foreign bodies and pathogens. Corneal ulceration may result when the balance is disrupted and the defense mechanisms are compromised. The associated ocular morbidity is the result of several factors and patient management is directly affected by the lack of diagnostic facilities and initiation of appropriate antimicrobial therapy. Specific treatment requires quick and accurate identity of the causative microorganism. 5. 6. 7. 8. 9. CONCLUSION In view of several such dilemmas while dealing with microbial keratitis, carrying out simple microbiological investigations can make a substantial difference to the accuracy of management of corneal suppuration. Simple Gram stain, KOH mount, culture and antimicrobial sensitivity can make a big difference to the ultimate outcome of treatment. 10. fungal keratitis: A three-year study. Indian J Ophthalmol. 2003;51; 315-21. Basak SK, Basak S, Mohanta A, Bhowmick A. Epidemiological and microbiological diagnosis of suppurative keratitis in Gangetic West Bengal, eastern India. Indian Journal Ophthalmology 2005; 53:17-22 Chowdhury A, Singh K. Spectrum of fungal keratitis in North India. Cornea 2005;24:8-15. Hertel V. Graefes Arch. About suppurative keratitis in humans. Ophthalmol.1901; 53 (2): 316-59. McNabb: Trans. Diagnosis of suppurative keratitis Ophthalmol. Soc. U.K. 1927; 47:57. SumanSaha, Debdulal Banerjee, ArchanaKhetan, JayangshuSengupta. “Epidemiological profile of fungal keratitis in an urban population of West Bengal, India”, Oman Journal of Ophthalmology: 2009, 2 (3): 114-18 Kanski J. Clinical Ophthalmology, A systemic approach” by Butterworth Heinemann Elsevier, : sixth edition, page : 205. REFERENCES 1. Robert AM, William MH, Jr Adler. Physiology of the eye, clinical application. Published by C.V Mosby Company, St. Louis, Missouri. Eighth edition, chapter 3, Pgno. 36 2. Shihota Ramanjit, Tandon Radhika. Parson’s disease of the eye. Published by Elsevier, 19th edition, chapter 15, Pgno 200. 3. Srinivasan M., Gonzales CA., George C.,Cevallos V., MascarenhasJM,Ashok B, et al. Epidemiology and an etiological diagnosis of corneal ulceration in Madurai, south India. Br J Ophthalmol. 1997;8: 965-71. 4. Bharathi MJ, Ramakrishnan R, Vasu S, Meenakshi R, Palaniappan R. Epidemiological Characteristics and laboratory diagnosis of 62 Gaurav SS et al., Int J M ed Res Healt h Sci. 2013;2(1):59-62 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 Received: 15 th Nov 2012 Revised: 13th Dec 2012 Accepted: 16th Dec 2012 Original research article COST ANALYSIS STUDY OF ORAL ANTIDIABETIC DRUGS AVAILABLE IN INDIAN MARKET *Nisharani B Jadhav1, Manisha S Bhosale2, Charles V Adhav2 1 Department of pharmacology, B. L. D. E. U.’s S B M Patil Medical College, Bijapur, Karnataka, India. Department of Pharmacology, Topiwala National Medical College and B. Y. L. Nair Charitable Hospital, Mumbai-Central, Mumbai, Maharashtra, India. 400008 2 *corresponding author email: drnishajadhav@gmail.com ABSTRACT Introduction: There exists a wide range of variation in the prices of drugs marketed in India and other countries of the world. Very few studies have been conducted to reveal such price variations in the open market. Aim & Objectives: To evaluate the cost of oral anti-diabetics of different generic classes and different brand names of one compound, To evaluate the difference in cost of different brands for the same active drug by calculating percentage variation of cost. Methods: Cost of a particular drug being manufactured by different companies, in the same strength, number and dosage form was compared. The difference in the maximum and minimum price of the same drug manufactured by different pharmaceutical companies and the percentage variation in price was calculated. Results: In Single drug therapy, among sulfonylurea group of drugs, Glimepiride (1 mg) shows maximum price variation of 655.38%, while Glipizide (10mg) shows variation of 38.88%. In Biguanides & Thizolidinediones groups of drugs, Metformin (500 mg) & Pioglitazone (15 mg) show maximum price variation of 308.33% & 542% respectively. In α-glucosidases inhibitor group of drugs, Miglitol shows maximum price variation of 135.50 %. In combination therapies, Glipizide & Metformin combination shows the maximum variation up to 399.04 %. Conclusion: The average percentage price variation of different brands of the same drug manufactured in India is very wide and the appraisal and management of marketing drugs should be directed toward maximizing the benefits of therapy and minimizing negative personal and economic consequences. Keywords: Cost analysis, anti-diabetic drugs, brands, price evaluation INTRODUCTION In the developing countries the cost of drugs is a major concern to both physician and patient; yet there are few data on prescribing patterns and expenditure1. Cost of drugs is an important factor influencing compliance with treatment2. In the context of pharmaceutical and other health 63 Nisharani et al., Int J Med Res Health Sci. 2013;2(1): 63-69 products, differential pricing (also called tiered pricing) is the adaptation of product prices to the purchasing power of consumers in different geographical or socioeconomic segments. Differential pricing could potentially be a very effective strategy to improve access to essential medicines in low and middle-income countries where most patients pay for medicines out-ofpocket and therefore cannot afford the prices compared to high income markets. 3 Diabetes is the most common non communicable disease worldwide. The International Diabetes Federation (IDF) estimates the total number of diabetic subjects to be around 40.9 million in India and this is further set to rise to 69.9 million by the year 2025.4,5 Diabetes is a chronic disorder. It requires lifelong treatment. So the cost of antidiabetic drug is the major deciding factor for the patients’ compliance. Selection of oral antihyperglycaemic agents as first-line drug or combined therapy should be based on both the pharmacological properties of the compounds (efficacy and safety profile) and the clinical characteristics of the patient (stage of disease, body weight, etc.) 6. There exists a wide range of variation in the prices of drugs marketed in India and other countries of the world. In the Indian market various antidiabetic drugs of various brands are available. This creates a lot problem with physician to decide the drug of choice for individual patients. Also in the literature very less studies are available which compare the cost of drugs of different brands. Regarding oral hypoglycemic agents, with the best of our knowledge no study is available which compares the cost of drugs of different brands. So, we decided to carry out the study which compares prices of different oral anti-diabetic drugs. Aim: To evaluate the cost of oral anti-diabetics of different brand names of one compound and the difference in cost of different brands of the same active drug by calculating percentage variation of cost. Nisharani et al., Objectives This Pharmacoeconomic study is designed with the main objectives of, 1. To find different anti-diabetics available either singly or in combination and the No. of the brands available for each. 2. To evaluate the cost of oral anti-diabetics of different generic classes and different brand names of one compound. 3. To evaluate the difference in cost of different brands of the same active drug by calculating percentage variation of cost. MATERIALS AND METHODS CIMS (current index of medical stores) & IDR (Indian drug review) [2011 issues] were reviewed for the prices of drugs used in the management of diabetes mellitus. 1. The retail cost of a particular drug being manufactured by different companies, in the same strength, number and dosage form was compared. 2. The difference in the maximum and minimum price of the same drug manufactured by different pharmaceutical companies was calculated. 3. The percentage variation in price was calculated. 4. The drugs being manufactured by only one company or being manufactured by different companies however, in different strengths were excluded. The percentage variation in price was calculated using the following formula 2 = − 100 The drugs were classified into five categories depending on the percentage (%) range of price variation. These were as follows 1) 0-25% 2) 25.1-50%, 3) 50.1-75%, 4) 75.1100% and 5) more than 100% Findings of our observational study were expressed as absolute numbers as well as percentage. 64 Int J Med Res Health Sci. 2013;2(1): 63-69 RESULTS The prices on a total of 20 drugs (11 single and 9 combination preparations), available in 54 different formulations were analyzed. These 54 formulations are manufactured by different pharmaceutical companies. Single drug therapy: In single drug therapy, Table 1 shows the price variation between a sulfonylurea group of drugs. In this group, Glimepiride (1 mg) shows maximum price variation of 655.38%, while Glipizide (10mg) shows variation of 38.88%. Table 2 shows price variation in Biguanides (Metformin) & Thizolidinediones (Pioglitazones) groups of drugs. In these groups, Metformin (500 mg) & Pioglitazone (15 mg) show maximum price variation of 308.33% & 542% respectively. Table 3 shows the price variation between αglucosidases inhibitor group of drugs. In this group, Miglitol shows maximum price variation of 135.50 %. Table 4 shows the price variation between Meglitinides group of drugs. In this group, Rapaglinide (0.5 mg) shows maximum price variation of 90.95 % Combination therapy:In Combination therapy, total 7 combination therapies were analysed. In this, Glipizide & Metformin combination shows the maximum variation up to 399.04 %. Table V shows price variation in combination drug therapy Table:1. The price varies between a sulfonylurea group of drugs. Drug Formulations Doses (mg) Manufacturing companies Min. Price (Rs) Max. Price (Rs) % price variation Glibenclamide 2 Gliclazide 4 Glimepiride 4 Glipizide 3 2.5 5 30 40 60 80 1 2 3 4 2.5 5 10 8 9 12 17 10 39 53 53 12 20 6 14 5 2.6 3.6 19 14 35 19.5 8.36 12.54 45 18.8 2.93 4.74 18 6.05 9.15 64.9 27.5 99.6 70.5 63.15 117.4 125 103.4 9.35 13.03 25 132.69 154.16 241.57 96.43 184.57 261.54 655.38 836.2 177.7 450 219.11 174.89 38.88 Table no. II: Price variation in Biguanides & Thizolidinediones groups of drugs. Drug Formulations Doses (mg) Manufacturing companies Min. Price (Rs) Max. Price (Rs) % price variation Metformin 4 Pioglitazone 2 250 500 850 1000 15 30 7 48 18 34 40 40 4.6 6 10 14 10 18 9 24.50 36 41.4 64.20 98.20 95.65 308.33 260 195.71 542 445.55 65 Nisharani et al., Int J Med Res Health Sci. 2013;2(1): 63-69 Table:3. Price variation among α-glucosidases inhibitor group of drugs. Drug Formulations Acarbose 2 Miglitol 2 Voglibose 2 Doses (mg) Manufacturing companies Min. Price (Rs) Max. Price (Rs) % price variation 25 50 25 50 0.2 0.3 11 9 8 14 12 9 32 62 50 50.3 36 54 55 89 65.82 118.47 64 84 71.87 43.55 31.64 135.50 78.05 56.74 Table:4. Price varies between Meglitinides group of drugs Drug Nateglinide Repaglinide Formulations Doses (mg) Manufacturing companies Min. Price (Rs) Max. Price (Rs) % price variation 2 60 120 0.5 1 2 4 4 6 4 4 30 50 19.90 39 75 45 70 38 62 98 50 40 90.95 58.97 30.66 Max. price (Rs) 19 26 29.9 78.25 68.50 29 60 59 69 120.4 41.75 60 73 14 26.25 59.3 70 80 70.6 86 80 128 % price variation 133.33 62.50 149.16 332.32 74.52 2.47 71.43 84.37 283.33 362.07 9.86 15.83 12.3 108.33 399.04 246.78 67.06 15.94 271.57 165.43 81.81 137.03 3 Table: 5. Price varies among combination therapy Drugs Formulation Glibenclamide + Metformin 3 Glicazide + Metformin 5 Glimepiride + Metformin 5 Glipizide + Metformin Pioglitazone + Glimepiride 2 Pioglitazone + Metformin Pioglitazone + Metformin + Glimepiride 2 3 2 Doses (mg) 2.5 + 400 2.5 + 500 5 + 500 80 + 500 60 + 500 40 + 400 40 + 500 30 + 500 1+ 500 2 + 500 1 + 1000 2 + 1000 2 + 850 5 + 500 2.5 + 400 15 + 1 15 + 2 30 + 2 15 + 500 30 + 500 15 + 500 +1 15 + 500 +2 Manufacturin g companies 8 2 19 43 5 3 3 3 50 53 2 4 2 11 3 12 15 2 34 21 12 15 Min. price (Rs) 8.15 16 12 18.10 39.25 28.3 35 32 18 26 38 51.8 65 6.72 5.36 17.1 41.9 69 19 32.40 44 54 66 Nisharani et al., Int J Med Res Health Sci. 2013;2(1): 63-69 Relationship between percent price variation & no. of Manufacturing Companies: When we draw a graph showing relationship between manufacturing companies and % price variation, it was noted that there is a linear relationship in between these two variables. As the no. of manufacturing companies increases, the percent price variation also increases. (As shown in figure no. 1) No.of manufact uring companies 80 70 60 50 40 30 20 10 0 0 - 20 20-40 % price variation 40-60 60-80 Figure 1: Graph showing relationship between percent variation & No. of manufacturing companies. DISCUSSION The Indian market has over 100,000 formulations and there is no system of registration of medicines2. The drugs are mainly sold under brand names7. A study in the United States found drug prices to be high and that price discrimination occurred across the industry7. But very less studies are available in our scenarios which compare the cost of drugs of different brands. Therefore we decided to carry out the study which compares the cost of different brands of drug of most common disorder. The drug prices available in CIIMS & IDR were compared, as they are readily available source of drug information and are updated regularly. Drugs used in the management of diabetes mellitus were selected as it is one of the major causes of morbidity and mortality & the treatment requires continuous prescription drug use. It is observed from our results that there is a wide (up to 836.20%) variation in prices of drugs manufactured by different pharmaceutical companies. The reasons for this price variation could be as follows8-14: 1. The existing market structure of the pharmaceutical industry 2. Asymmetry of information or imperfect information 3. Industry costs 4. Government regulations and pricing policies From our study it is also clear that, price variation was directly related to the number of companies manufacturing a particular drug. So it can be concluded that the price variation increases because of the increase in competition among the manufacturing companies. Pharmacists do not dispense the same brand as prescribed by the doctor and try to substitute it 67 Nisharani et al., Int J Med Res Health Sci. 2013;2(1): 63-69 with other alternatives, quoting the reason of non availability. This is often done with vested interest for economic gains as some brands have a higher profit margin. It is felt that physicians could provide better services and reduce costs of drugs if information about drug prices was readily available. Studies have shown that providing a manual of comparative drug prices annotated with prescribing advice to physicians reduced their patients’ drug expense15. Due to the long term treatment duration, diabetes patients usually have higher than average monthly out-of-pocket expenses and high out-of-pocket expenses can be a barrier to adherence to prescription drug regimens. Many chronically ill adults cut back on medications due to high prescription cost. Inadequate prescription coverage and out of pocket expenses is one of the strongest predictors of their medication adherence problems. Market structure and subsequent market segmentation provide a basis for prescription agent pricing policies leading to wide variation in prices of drugs. In the absence of information on comparative drug prices and quality, it is difficult for doctors to prescribe the most economical prescription. There is a need for concerted action from regulatory authorities, doctors, pharmacists and general public at large to address this issue of oral antidiabetic drugs price variation. At the hospital level authorities and concerned committees have to frame policies on these aspects. The situation can be improved by incorporating an analysis of prescription costs in the medical curriculum and by providing updated and complete information regarding bioequivalence, quality and cost of the pharmaceutical preparation to the doctors. Wherever possible a cheaper brand should be prescribed because the superiority of any particular brand over the others has never been proved scientifically. Currently, very few medicines are under drug prices control Nisharani et al., order16. Hence it is desired that the Government should bring all lifesaving and essential medicines under price control. CONCLUSION The average percentage price variation of different brands of the same drug manufactured in India is very wide. So it is recommended that the appraisal and management of marketing drugs should be directed toward maximizing the benefits of therapy and minimizing negative personal and economic consequences. REFERENCES 1. Kuruvilla A, George K, Rajaratnam A, John 2. 3. 4. 5. 6. 7. 8. KR. Prescription patterns and cost analysis of drugs in a base hospital in south India. Natl Med J India. 1994 Jul-Aug; 7 (4): 167-68 Ravi Shankar P, Subish P, Bhandari RB, Mishra P, Saha AC. Ambiguous pricing of topical dermatological products: A survey of brands from two South Asian countries. Journal of Pakistan Assoctn. of Dermatologists 2006; 16: 134-40 World Health Organization. Introduction to drug utilization research. Oslo: 2003 Mohan V, Sandeep S, DeepaR, Shah B, Varghese . Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res. 2007;125: 217-30 Sicree R, Shaw J, Zimmet P. Diabetes and impaired glucose tolerance. In: Gan D, editor. Diabetes Atlas. International Diabetes Federation. 3rd ed. Belgium: International Diabetes Federation; 2006: 15-103 Scheen J, Lefebvre P.J. Oral Antidiabetic Agents: A Guide to Selection : Drugs.1998; 55 ( 2): 225-36 Monaghan MJ, Monaghan MS. Do market components account for higher US prescription prices? Ann Pharmacother. 1996; 30: 1489-94 Sarkar P K. A rational drug policy. Indian J Med Ethics 2004; 12; 30-35 Int J Med Res Health Sci. 2013;2(1): 63-69 68 9. Roy V, Rewari S. Ambiguous drug pricing: a physician’s dilemma. Indian J Pharmacol 1998; 30: 404-07. 10. Wertheimer AI, Grumer SK. Overview of international pharmacy pricing. Pharmacoeco 1992; 2: 449-55. 11. Berki SE, Richards JW, Weeks HA. The mysteries of prescription pricing in retail pharmacies. Med Care 1977; 15: 241-50. 12. Rataboli P, A Dang. Antimicrobial price variation: Conundrum of medical profession. JPGM. 2007;53 (1): 72-74 13. Das SC, Mandal M, Mandal SC. A critical study on availability and price variation between differ rent brands: Impact on access to medicines. Indian Journal of pharmaceutical sciences; 2007; 69 (1): 160-63 14. Sushma Dawadi, Rao BS, Khan GM. Pattern of Antimicrobial Prescription and its Cost Analysis in respiratory tract infection. Kathmandu University Journal of Science, Engineering and Technology. 2005:;1(1):1-9 15. Frazier LM, Brown JJ, Divine GW. Can physician education lower the cost of prescription drugs? A prospective Controlled trial. Ann Intern Med. 1991; 115: 116-21. 16. Misra B, Jain SK, Mehta Y. A study on availability and prices of medicines in India. National Pharmaceutical Pricing Authority, 2002. Available from: http://nppaindia.nic.in/index1.html. 69 Nisharani et al., Int J Med Res Health Sci. 2013;2(1): 63-69 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 Received: 5th Dec 2012 Revised: 25th Dec 2012 Accepted: 29th Dec 2012 Original research article A STUDY OF ANTI-HYPERLIPIDEMIA, HYPOLIPEDIMIC AND ANTI-ATHEROGENIC ACTIVITY OF FRUIT OF EMBLICA OFFICINALIS (AMLA) IN HIGH FAT FED ALBINO RATS *Jeevangi Santoshkumar1, Manjunath S2, Sakhare Pranavkumar M3 1 Associate Professor, 3Post Graduate Student Department of Pharmacology, M.R Medical College, Gulbarga, Karnataka, India. 2 Professor, Department of Pharmacology, S. Nijalingappa Medical College, Bagalkot, Karnataka, India. *Corresponding author email: drsantoshkumar.2007@rediffmail.com ABSTRACT Background: Emblica Officinalis (Amla), belonging to the genus, Phyllanthus emblica is widely used for medicinal purpose. Its fruits have been used traditionally as a hypolipidemic. Objectives: The present study was aimed to evaluate hypolipedimic and anti-atherogenic activity of fruit of Emblica officinalis in high fat fed albino rats. Materials and Methods: For study of anti-hyperlipidemic, hypolipidemic, and anti-atherogenic activity. 5 groups of 6 animals in each received normal saline, E. Officinalis powder, high fat diet, High fat diet plus E. Officinalis powder both and Atorvastatin respectively for 8 weeks. Hyperlipidemia was induced by feeding animals with high fat diet per orally, consisting of coconut oil and vanaspati ghee, daily ad libitum. At the end of the study, blood samples of the animals were sent for the estimation of the lipid profile and effects of test drug studied by comparing levels of Total Cholesterol, Triglycerides, HDL, LDL, and Atherogenic index. The statistical significance between groups was analysed by using one way ANOVA, followed by Dunnet’s multiple comparison test. Results: Fruit of Amla showed significant anti-hyperlipidemic, hypolipidemic, and anti-atherogenic effect. All these effects may contribute to its anti-atherogenic activity. Conclusion: Present study revealed the antihyperlipidemic, hypolipidemic, and anti-atherogenic effect of Amla fruit powder and can be safely used in the treatment of mild to moderate cases of hyperlipidemia considering its easy availability, cost effectiveness, and other beneficial effects. Key Words: Emblica Officinalis, Hypolipidemic, Anti-Atherogenic, Atorvastatin, Atherogenic Index. INTRODUCTION Hyperlipidemia is one of the major culprits for various cardiovascular and central nervous system disorders. Both genetic disorders and diet enriched with saturated fats and cholesterol, 70 Sant oshkumar et al., Int J M ed Res Health Sci. 2013;2(1):70-77 contribute to the elevated lipid levels in our population as well as in many other developed countries around the world 1. Atherosclerosis is an age related disease. It is widely prevalent in industrialized countries, affecting primarily the intima of large and medium sized arteries and is characterized by fibrous-fatty plaques or atheroma 2. The cause of atherosclerosis is not known, although several risk factors have been involved in the pathogenesis of atherosclerosis. Current experimental and epidemiological evidence suggests a strong relationship between atherosclerosis and elevated levels of plasma lipids. Recent work also incriminated folic acid deficiency leading to elevated plasma levels of homocysteine and chronic infection with chlamydia pneumonia in the pathogenesis 3. Atherosclerosis, which was earlier thought to be always associated with hyper cholesterolemia, has now been proved as an inflammatory disease 4. Over the last few years the changes in the lifestyle, particularly the westernization of the diet and a relatively sedentary lifestyle have led to an increased frequency of lifestyle related disorders such as hyperlipidemia, diabetes mellitus, and atherosclerosis 5. The principle metabolic causes of atherosclerosis include hyperlipidemia, hypertension, obesity, insulin resistance, and diabetes mellitus 6. Risk factors for the above are the following, Smoking, hypertension, serum cholesterol, genetic factors, physical activity, hormones, alcohol, thyroid disease, renal disease, and liver disease 7. The current National Cholesterol Education Program (NCEP) for the management of patients with lipid disorder is of 2 types. One is population based approach, which is intended to lower blood cholesterol by dietary recommendations such as reduced total calories from fats to less than 305kCal and from saturated fats to less than 10%, consumption of less than 300mg of cholesterol per day and maintenance of desirable body weight. The second is a patient based approach described in the report 2001 report of NCEP. Adult treatment panel-III (ATP-III) which continues to focus on lowering LDL-C levels as the primary goal of the therapy 8. The ATP-III report recognizes four classes of drugs that may be used to achieve lipid goals. These include HMG-CoA reductase inhibitors (Statins), Bile Acid sequestrants, Niacin, and Fibric acid derivatives 9. The history of natural products is as old as mankind. The importance of traditional systems of medicine and of certain traditional medical practices has now been recognized all over the world. Today, it is required to have an intelligent and pragmatic approach to evaluate selective drugs of herbal origin. Therefore, it should really matter for Pharmacologists to obtain information from traditional healers, about their remedies and to extract the active principles for development into drugs 10. E. Officinalis or Phyllanthus emblica (Syn: Amla, Indian Gooseberry) is an evergreen tree which is highly prized in tropical Asia. The genus is natural to tropical Southeast Asia, particularly in Central and South India. It is commonly cultivated in gardens throughout India and grown commercially as a medicinal fruit 11. It is among the most important medicinal plants in the Ayurveda Materia Medica and widely used in Indian medicines for the treatment of various ailments 12. Apart from traditional uses, there are several reports in the pharmacological actions of Amla based on modern scientific investigations, 13 especially anti-inflammatory action , 14 15 antimicrobial action , anti-oxidant action , anticarcinogenic action 16, anti-ulcerogenic action 17, anti-diabetic action 18, analgesic action 19, and hepato protective action 20. The credit for initiating studies related to herbal extracts in our country goes to Sir Ram Nath Chopra and his team of dedicated workers, in Calcutta School of Tropical Medicine 21. 71 Sant oshkumar et al., Int J M ed Res Healt h Sci. 2013;2(1):70-77 Keeping in view of the above ideas, the present study has been undertaken to evaluate the effect of E.officinalis powder on the serum lipids level, in albino rats fed with high fat diet comparing with standard hypolipidemic drug Atorvastatin. MATERIALS AND METHODS The experimental protocol was approved by the Institutional Ethics Committee and Animal Ethics Committee of M.R Medical College, Gulbarga. The study was carried out in 30 healthy albino rats of Wister strain (Rattus norvegicus) weighing 150-200g either sex. Animals were maintained on a standard animal diet consisting of Bengal gram, Wheat, Maize, and Carrot in sufficient quantity for the entire period (8 weeks) of the study and Water adlibitum. Drugs used in the study: 1. Emblica officinalis: The powder obtained from Phytopharma Ayurvedic firm from Kolhapur, Maharashtra. The dose in humans is 6g/day, which is equivalent to 540mg/kg in rats 22. 2. Atorvastatin: Atorvastatin powder was obtained from Biocon Pharmaceuticals, Bengaluru. Human dosages 80mg, which is 7.2mg/kg in rats 22. 3. High Fat Diet: Mixture of Coconut Oil (from Marico Industries Ltd., Mumbai) and Vanaspati Ghee procured from Ruchi Industries, Mumbai. 4. Vehicle: Gum Acacia: 4%, 2ml/kg procured from Nice chemicals, Kochi Preparation of High Fat Diet for inducing Hyperlipidemia: Edible Coconut oil and Vanaspati ghee mixed together in the ratio of 2:3 v/v as per the method of Shymala MP et al 23, at a dose of 10ml/kg body weight, was fed to the animals per oral daily in addition to a normal diet for 8 weeks. Study Design For the study, the animals were weighed, recorded, numbered, and randomly divided into 5 Sant oshkumar et al., groups of 6 animals each for a period of 8 weeks according to CPCSEA (Committee for the purpose of control and supervision of experiments on animals) for laboratory animal facilities 24, 25. Grouping and Treatment Schedules Group 1: Normal Saline Group 2: E. officinalis powder 540mg/kg/day along with normal diet. Group 3: High Fat Diet (10ml/kg/day) Group 4: High fat diet (10ml/kg/day) + E. officinalis powder (540mg/kg/day) Group 5: High fat diet (10ml/kg/day) + Atorvastatin (7.2mg/kg/day) All the animals used for the study were kept under observation for daily food intake. The drugs were administered to the animals for 8 weeks by an intra-gastric feeding tube. At the end of 8th week, all the group of animals was kept for overnight fasting, After overnight fasting 2ml of blood was collected from the orbital sinus with the help of a capillary tube by pressing the thumb behind the angle of the jaw resulting in the engorgement of retro-orbital plexus 26 . The blood was centrifuged; serum was collected and used for assessing the various biochemical parameters of the lipid profile. Biochemical Estimation Biochemical parameters were estimated in the Biochemistry Laboratory of Basaveshwara Teaching and General Hospital, attached to M. R. Medical College, Gulbarga. The following parameters of Lipid Profile were measured: 1. Total Serum Cholesterol- It was estimated by using Erba Kit 27 manufactured by Transasia Bio-Medicals Ltd. 2. Serum Triglyceride- It was estimated by using a kit manufactured by AGAPPE Diagnostics 28 . 3. High Density Lipoprotein Cholesterol (HDL) It was estimated by using Erba Kit 27 manufactured by Transasia Bio-Medicals Ltd. 72 Int J M ed Res Healt h Sci. 2013;2(1):70-77 4. Low Density Lipoprotein Cholesterol (LDL) It was estimated by using Erba Kit 27 manufactured by Transasia Bio-Medicals Ltd. Atherogenic Index: The Atherogenic index was calculated by using the formula 29. Atherogenic Index = Total Cholesterol – HDL HDL Statistical Analysis The statistical significance between groups was analysed by using one way ANOVA, followed by Dunnet’s multiple comparison test. The significance was expressed by ’p’ values, as mentioned in the table. RESULTS The results obtained are summarised in table 1. The values obtained were expressed in specific units of those parameters as mentioned in the table. The results of estimation were reported as Mean ± SEM (standard error of mean) of 6 animals at a time from each group. It was seen that, there was a significant increase in all the lipid parameters (p < 0.01), except HDL, following administration of high fat diet. It was also seen that concomitant administration of the Amla powder at a dose of 540mg/kg body weight along with high fat diet in the study animals, showed a significant decrease in all the lipid parameters (p <0.01) i.e. hypolipidemic and antihyperlipidemic activity with a significant rise in the value of serum HDL (p < 0.01). Standard drug Atorvastatin at a dose of 7.2mg/kg administered along with a high fat diet, showed a significant decrease (p < 0.01) in all the lipid parameters, while there was a significant increase in serum HDL. The hypolipidemic activity of the test drug was found to be slightly less efficacious than that of the standard drug, in comparison to the control. (Figure 1) Table: 1. Effects of fruit powder of E. officinalis on serum lipids at the end of 8th week of study. Group Total Cholesterol Triglyceride (mg/dl) (mg/dl) HDL(mg/dl) LDL(mg/dl) Atherogenic Index ratio Group 1 88.7 ± 5.5 66.76 ± 3.02 26.35 ± 1.68 48.98 ± 2.96 2.42 ± 0.20 Group 2 80.4 ± 5.75* 57.5 ± 1.39* 35.5 ± 1.28* 32.70 ± 1.21* 1.27 ± 0.04 * Group 3 267.0 ± 7.56 * 218.48± 9.19* 16.0 ± 0.90* 207.25± 7.81* 15.92 ± 1.06* Group 4 99.1 ± 1.47† 83.6 ± 1.88† 25.7 ± 1.5 † 50.13 ± 3.92† 2.91 ± 0.23 † Group 5 77.5 ± 4.7† 57.03 ± 3.26† 37.05 ± 1.4† 29.0 ± 4.0 † 1.11 ± 0.16 † F 330.01 219.80 44.28 312.84 149.97 Df 25, 4 25, 4 25, 4 25, 4 25, 4 P <0.01 <0.01 <0.01 <0.01 <0.01 * : p < 0.01, when compared with the normal control group; † : p < 0.01, when compared with the hyperlipidemic control group. (One way ANOVA followed by Dunnet’s multiple comparison test) Data presented as Mean ± SEM 73 Sant oshkumar et al., Int J M ed Res Healt h Sci. 2013;2(1):70-77 300 250 mg/dl 200 150 100 50 0 Group 1 Group 2 Group 3 Group 4 Group 5 th Figure-1: Graph show ing mean serum lipid parameters in 5 groups at the end of 8 week. DISCUSSION Hyperlipidemia was induced by administering a high fat diet to the albino rats. Shyamala MP et al 23 stated that hyperlipidemia is a result of an oxidative abuse due to free radicals, formed by the interaction of high fat diet. They further stated that, an enhancement in the concentration of serum cholesterol and triglycerides of hyperlipidemia rats maybe result of lipid peroxidation evoked by high fat diet 30. In the present study, Atorvastatin was used as a standard drug 31. E. Officinalis powder, administered in hyperlipidemia rats can elicit a profound influence on the lipid metabolism. An enhancement in the concentration of total serum cholesterol, serum triglycerides, serum LDL, Atherogenic index of hyperlipidemia rats was observed, which was probably due to lipid peroxidation evoked by high fat diet. Lipid peroxidation is a free radical mediated process which has been implicated in a variety of disease states.32 HDL concentration and HDL ratio would be useful in diseases like diabetes mellitus and coronary heart disease, because of their inverse relationship.33 High LDL levels are usually associated with atherosclerosis34 Hyper triglyceridemia is also associated with metabolic consequences of hyper coagulability, hyperinsulinemia, insulin resistance, and glucose resistance, and is one of the risk factors in the coronary heart disease 35. Hypolipidemic efficacy of E. officinalis powder is revealed by attainment of values below normal in the lipid profile of group 2 rats. The anti hyperlipidemia activity of E. officinalis powder is established by the attainment of near normal values in lipid parameters of group 4 rats. The hypolipidemic effect of E. officinalis may have a protective mechanism against the development of atherosclerosis. Anti lipoperoxidative property of E.officinalis powder, maybe due to its rich flavonoids and poly phenol contents. It is well known that flavonoids and poly phenols are natural anti-oxidants 36, 37. Recent epidemiological studies have revealed that the intake of flavonoids is inversely associated with the risk of coronary heart disease. E. Officinalis powder, rich in flavonoids and poly phenols may also be contributing towards its hypolipidemic effect, due to its ability to combat oxidative stress by quenching free radicals 74 Sant oshkumar et al., Int J M ed Res Health Sci. 2013;2(1):70-77 generated in the body as a result of high fat diet. E. Officinalis powder may also act by triggering the secretion of anti-oxidant enzymes: Superoxide dismutase, Catalase, and Glutathione peroxidase in an enhanced level, which in turn stopped the oxidative damage due to hyperlipidemia. Dhuley JN et al 38 and Shyamala MP et al 23 have documented a similar observation with Cinnamonum verum bark and Amoma subulatum seeds and Syzygium aromaticum respectively in rats fed with high fat diet. The present study which was done to evaluate the effect of E. officinalis on serum lipids and atherogenesis in albino rats is in agreement with other studies 39, 40. As compared to the other studies, in the present study E. officinalis powder was used, which is easily available and inexpensive. In previous studies, E. officinalis aqueous and ethanolic extract has been used. The present study was carried out for a longer duration of time, i.e. 8 weeks as compared to the previous studies which were done for 4 week duration. As atherosclerosis is closely associated with hyperlipidemia, it is beneficial to compare it with a standard drug such as Atorvastatin. Such a comparative study was not done before. Amla has shown to possess significant hypolipidemic and anti-atherogenic activity slightly lesser as compared to Atorvastatin. But if we compare Amla with Atorvastatin in terms of adverse effect profile, Atorvastatin can cause severe adverse effects like rhabdomyolysis to mention one of them 41. CONCLUSION Amla can be safely used in the treatment of mild to moderate cases of hyperlipidemia considering its easy availability, cost effectiveness, and other beneficial effects. Not many studies have been undertaken to fully evaluate the molecular and biochemical basis of hypolipidemic action of Amla and further clinical studies are required to find out the hypolipidemic activity and molecular mechanism. 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Muthuraman A, Sood S, Singla SK. The antiinflammatory potential of phenolic compounds from Emblica officinalis L. in rat. Inflammopharmacology. 2011; 19 (6): 327-34. 11. Prachi J and Shilpa S. Antimicrobial properties and phytochemical analysis of Emblica officinalis. Asian J.Exp. Biol. Sci.2010;1(1):91-95. 12. Poltanov EA, Shikov AN, Dorman HJ, Pozharitskaya ON, Makarov VG, Tikhonov VP, Hiltunen R. Chemical and antioxidant evaluation of Indian gooseberry (Emblica officinalis Gaertn., syn. Phyllanthus emblica L.) supplements. Phytother Res. 2009; 23 (9): 1309-15. 13. Madhuri S, Pandey G, Verma KS. Antioxidant, Immunomodulatory and Anti cnacer activities of Emblica Officinalis: An overview. IRJP. 2011; 2 (8):38-42. 14. Rajeshkumar NV, Therese M, Kuttan R. Emblica officinalis Fruits Afford Protection against Experimental Gastric Ulcers in Rats. Therm Biol. 2001;39 (5): 375-80. 15. Akhtar MS, Ramzan A, Ali A, Ahmad M. Effect of Amla fruit (Emblica officinalis Gaertn.) on blood glucose and lipid profile of normal subjects and type 2 diabetic patients. Int J Food Sci Nutr. 2011; 62 (6): 609-16. 16. Sadaf H, Mohd D, Mohd A, Kunal S, Praveen KV, Asad UK. Efficacy of E. Officinalis on the Cariogenic Properties of Streptococcus mutans: A Novel and Alternative Approach to Suppress Quorum-Sensing Mechanism. PLoS ONE 7 (7): e40319 17. Anil UT, Sanjay JS, Manisha PS, and Nehal HG. Hepatoprotective effect of poly herbal formulation against various hepatotoxic agents in rats. Pharmacognosy Res. 2012; 4 (1): 50– 56. 18. Vaidya ADB. Reverse pharmacological correlates of Ayurvedic drug actions. Indian J Pharmacol. 2006: 38(5); 311-15. 19. Ghosh MN. Toxicity studies. Fundamental of Experimental Pharmacology 4th Edition, Hilton and Company, Calcutta, 2008; 178. 20. Shymala MP, Venukumar MR, Lata MS. Antioxidant potential of the Syzygium aromaticum (Gaertn) Linn (Clove) in rats fed with high fat diet. Indian Journal of Pharmacology 2003;35:99-103. 21. CPCSEA Guidelines for laboratory animal facility. Indian J Pharmacol, Special Article. 2003;35, (4): 257-274. 22. Pereira S, Tettamanti M. Ahimsa and alternatives -- the concept of the 4th R. The CPCSEA in India. Altex 2005, 22 (1): 3-6. 23. Van HH, Baumans V, Brandt CJ, Boere HA, Hesp AP, van Lith HA, Schurink M, Beynen AC. Blood sampling from the retro-orbital plexus, the saphenous vein and the tail vein in rats: comparative effects on selected behavioural and blood variables. Lab Anim. 2001; 35 (2): 131-9. 24. Sarika SS and Aarti GJ. Effects of methanolic extract of Cuminum cyminum on total serum cholesterol in ovariectomized rats. Indian J Pharmacol. 2009; 41 (2): 92–93. 25. Urmila CK, Shraddha NS, Sandesh PJ. Evaluation of hypoglycemic activity of Cassia nodosa leaves in normal and streptozotocininduced diabetic rats. Int J Green Pharm 2012; 6: 9-13. 26. Milada Dobiášová. Atherogenic Index of Plasma [Log (Triglycerides/HDLCholesterol)]: Theoretical and Practical 76 Sant oshkumar et al., Int J M ed Res Healt h Sci. 2013;2(1):70-77 Implications. Clinical Chemistry July 2004;50(7): 1113-17. 27. Park HR, Park M, Choi J, Park KY, Chung HY, Lee J. A high-fat diet impairs neurogenesis: involvement of lipid peroxidation and brain-derived neurotrophic factor. Neurosci Lett. 2010; 4 (3): 235-39. 28. Harikrishnan S, Rajeev E, Tharakan JA, Titus T, Ajit Kumar VK, Sivasankaran S, Krishnamoorthy KM, Nair K. Efficacy and safety of combination of extended release niacin and atorvastatin in patients with low levels of high density lipoprotein cholesterol. Indian Heart J. 2008;60(3): 215-22. 29. Etsuo N, Yasukazu Y, Yoshiro S , Noriko N. lipid peroxidation: Mechanisms, inhibition and biological effects. Biochemical and Biophysical Research Communications. 2005;338: 668-76. 30. Boizel R, Laporte F, Benhamou YP, Foulon T, Lardy B, Halimi S. Ratio of Triglycerides to HDL Cholesterol as an Indicator of LDL Particle Size in Patients With Type 2 Diabetes and Normal HDL Cholesterol Levels. Diabetes Care. 2000;23(11): 1679-85. 31. Montalcini T, Gorgone G, Federico D, Emanuele V, Sesti G, Ceravolo R, Pujia A, Perticone F. Association of LDL cholesterol with carotid atherosclerosis in menopausal women affected by the metabolic syndrome. Nutrition, Metabolism & Cardiovascular Diseases. 2005; 15: 368-72. 32. Byron JH, Dennis LS, Vijay N. A truly deadly quartet: obesity, hypertension, hypertriglyceridemia, and hyperinsulinemia. Cleveland Clinic Journal of Medicine.2002;69(12): 989-89. 33. Vinson JA, Liang X, Proch J, Hontz BA, Dancel J, Sandone N. Polyphenol antioxidants in citrus juices: in vitro and in vivo studies relevant to heart disease. Adv Exp Med Biol. 2002;505:113-22. 34. Pietta GP. Flavonoids as Antioxidants. J. Nat. Prod., 2000, 63 (7): 1035–42. 35. Dhuley JN. Anti oxidant effect of cinnamon (Cinnamonum verum) bark and greater cardamom (Amomum subula-tum) seeds in rats fed with high fat diet. Indian J Exp Boil 1999; 37: 238-42. 36. Mishra M, Pathak UN, Khan AB. E.officinalis Gaertn and Serum Choesterol level in experimental rabbits. Br J Exp Pathol. 1981; 62 (5): 526-28. 37. Gulati RK, Aggarwal S, Aggarwal SS. Hepatoprotective studies on Phyllanthus emblica Linn and quercetin. Indian Journal of Experimental Biology. 1995; 33: 261-68. 38. O’Sullivan S. Statins: A review of benefits and risks. TSMJ. 2007; 8: 52-56. 39. Thomas P B. Drug therapy for hypercholesterolemia and dyslipidemia. In: Laurence Burton, Bruce Chabner, Bjorn Knollman. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 12 th Edition. McGraw Hill, New York 2011; 877908. 40. Harshmohan. The Blood Vessels and Lymphatics: The Textbook of Pathology, 4 th Edition. Jaypee Brothers Medical Publisher (P) Ltd, Mumbai 2000; 252-54. 41. Satoskar RS, Bhandarkar SD, Rege NN. Appetite stimulants, Digestants, Anti flatulents, Appetite suppressants and Hypolipidemic agents. Pharmacology and Pharmacotherapeutics. 22nd Edition. Popular Prakashan Pvt Ltd, Mumbai 2011; 571-86. 77 Sant oshkumar et al., Int J M ed Res Healt h Sci. 2013;2(1):70-77 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 Received: 15 th Nov 2012 Revised: 23th Dec 2012 Accepted: 29th Dec 2012 Original research article CORONARY DOMINANCE IN SOUTH INDIAN POPULATION *Vasudeva Reddy J1, Lokanadham S2 1 Department of Anatomy, Sri Venkateswara Medical College, Tirupati, Andhrapradesh. Department of Anatomy, ViswaBharathi Medical College, Kurnool, Andhrapradesh. 2 *Corresponding author email: loka.anatomy@yahoo.com ABSTRACT Coronary artery anomalies are considered clinically insignificant and known to be associated with other congenital heart defects, myocardial ischemia and reduced life expectancy. Almost all elderly people have at least some impairment of coronary artery circulation. Therefore normal and pathological physiology of coronary circulation is one of the most important aspects in the entire field of medicine. In our study we dissected 80 human heart specimens to observe the coronary arteries from their origin to termination. We found 69 out of 80 are showing the right predominance (86.25%), 9 specimens with left predominance (11.26%) and remaining 2 of the balanced (2.5%) type of coronary circulation. The results of the study were compared with other literatures and variations are noted. In some cases we observed left predominance in males which indicates the reason for higher incidence of myocardial infarction in males when compared to females. Keywords: Coronary artery, Right dominant, Left dominant, Balanced or co- dominant INTRODUCTION Human heart supplied by two coronary arteries namely right &left coronary arteries, arise from ascending aorta. The left coronary artery divides into left anterior descending artery and circumflex artery, supplies blood to the front of the left side of the heart, lateral side and base of the heart1. The right coronary artery branches are the posterior descending artery and acute marginal arteries, supplies blood to the right ventricle, right atrium, Sino Atrial node, Atrioventricular node and a variable portion of the left ventricle2. Hettler stated the left coronary artery dominance, right coronary artery dominance and co-dominant are the three Vasudeva Reddy et al., types of coronary circulation3. Anomalous origin and distribution of the coronary arteries were shown to be a cause of sudden death in young and adult patients, often in association with physical exertion. Coronary artery anomalies when occur pose difficulty with coronary visualization, identification and present unique problems for surgical treatment. Our study determines the pattern of coronary artery dominance, balanced type of circulation in south Indian population. 78 Int J Med Res Health Sci.2013;2(1):78-82 MATERIALS AND METHODS arteries from their origin to termination. With regards to coronary predominance out of 80 specimens 69 (male-48, female-21) of right predominance (Figure-I), 9 specimens(male-8, female-1) of left predominance(Figure-II) and 2 specimens (male-1, female-1) of balanced or codominance (Figure-III) type of coronary circulation was observed. The percentage of incidence 86.25% in right predominance, 11.25% left predominance and balanced 2.55% were tabulated (Table-I). We also photographed the arteriogram of the right predominance and balanced or co – dominance type coronary circulation is labelled and we also observed the course of the posterior interventricular artery from its sulcus to the apex of the heart and noted. A total (n=80) heart specimens were collected with a portion of ascending aorta from relatively fresh bodies that came for post-mortem at the Forensic Department, SV Medical College, Tirupati. Each specimen thoroughly washed to free it from the blood clots and dissected anatomically and ethical committee of our institute permitted to do the work. The arterial pattern of heart from the origin of the coronary arteries to their termination observed and variations are recorded. And also the arteriograms of types of coronary circulation with labelled photographs are collected from the cardiology department. RESULTS In the present study 80 human heart specimens were dissected and observed for the coronary Table: 1. Distribution of specimens with type of Coronary circulation Dominance Right dominance Male 48 Female 21 Total 69 Percentage (%) 86.25 Left dominance Balanced 8 1 1 1 9 2 11.25 2.5 The termination of right coronary artery reaches and half of the posterior inter ventricular septum the crux and beyond crux in 73.3%, and right to in 9% of hearts were tabulated. The data were the crux 20% and at the right border in 6.6% of analyzed through descriptive statistics to calculate the specimens was observed, whereas left percentages. Qualitative statistics were used to coronary artery terminates at 1/3 of posterior inter analyze arteriogram. (Table-II) ventricular septum 61% of hearts, at the apex 30% Table- II: Termination of Coronary arteries (PIVS: Posterior Inter Ventricular Septum) Termination Crux & Beyond Crux of Heart Specimens with Right Coronary dominance Specimens with Left Coronary dominance 73.3% - Right to Crux 20% - Right border Lower1/3 of PIVS 6.6% - 61% Apex - 30% Half of PIVS - 9% Vasudeva Reddy et al., Int J Med Res Health Sci.2013;2(1):78-82 79 DISCUSSION The present study shows 86.25% of right coronary predominance, 11.25% left predominance and 2.5% of balanced type of coronary circulation were observed. Most of the literatures stated the right predominance is seen in 70%of hearts left dominance in 20% of hearts and 10%of balanced type of coronary circulation.1,12 Balanced type of circulation is more common in females.4 According to James 1961, the left coronary artery predominance is seen in males.5 The incidence of right predominance in 90%of hearts, left predominance in10% and balanced type in few hearts.6 In a study revealed on the basis of 6000 selective arteriogram, the right coronary predominance was present in 60% of persons. 7 Most common form of coronary circulation was found to be the right dominant.8,12 The arterial pattern was found to be right dominance based on crux cordis and the subsinuosal interventricular branch.9 In Kenya sum of the population right coronary artery was found to be dominant in 82% of the hearts.10 The right coronary artery dominance was most prevalent, followed by the balanced type and the left coronary artery dominance in Brazilian population as well.11 However, the data are inadequate to study the coronary predominance in relation to sex in our population. The incidence of right predominance 57%,left dominance 10% and balanced 33% of circulation out of 30 cases.12,13 LCX RCA M CV PD Figure:1. Dissection of human Heart & Antero posterior view of arteriogram showing right coronary dominance (PD: posterior descending branch, RCA: right coronary artery, MCV: middle cardiac vein, LAD: left anterior descending branch, LCX: left circumflex, D: diagonal, LMA&RMA: right and left marginal branches) 80 Vasudeva Reddy et al., Int J Med Res Health Sci.2013;2(1):78-82 LCX PD Figure:2. Dissection of human heart showing Left coronary dominance (PD: posterior descending branch-interventricularartery, LCX:leftcircumflexbranch) RCA LCX PD PD Figure:3. Dissection of human Heart & Antero posterior view of arteriogram showing Balanced circulation (PD: posterior descending branch-interventricular arteries, RCA: right coronary artery, LCA: left coronary artery, LAD: left anterior descending branch, LCX: left circumflex branch) 81 Vasudeva Reddy et al., Int J Med Res Health Sci.2013;2(1):78-82 CONCLUSION Our study reveals the majority of the cases observed with right coronary artery dominance compared to left coronary artery dominance and also the incidence of right coronary dominance are higher in males than females. In some cases we observed left predominance in males which indicates the reason for higher incidence of myocardial infarction in males when compared to females. ACKNOWLEDGEMENT Authors are thankful to Dr R V Subhakar, Professor, for his able guidance and special thanks to Dr R Sekhar, Professor, for his constant encouragement for this work. REFERENCES 1. Williams PL, Bannister LK, Berry MM, Collins P, Dyson M, Dussek JE, Ferguson MWJ; Grays Anatomy. 2000; 38th Ed., Edinburgh, Churchill Livingstone: 1505-1510. 2. Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald; Heart Diseases a text book of Cardiovascular Medicine. 2008; 8th Ed: 478. 3. Gawlikowska SA, Miklaszewska D, Czerwi ÅF, Folia O. Analysis of the influence of heart size and gender of coronary circulation. Folia Morphol. 2010; 69 (1): 35-41. 4. Schlesinger MJ; Relation of anatomic pattern to pathological conditions of the coronary arteries. Arch. Path. 1940; 30:403-415. 5. James TN. Anatomy of the coronary arteries, New York. Paul B Hoeber. 1961; 12-150. 6. Anderson RH, Becker AE; Cardiac anatomyAn integrated text and colour atlas. 1980; 2123. 7. Effler, Groves DB, Suarez LK, Favdoro EL; Direct coronary artery surgery with end arterotomy and patch - graft reconstruction. Journal of thoracical cardiovascular surgery. 1967; 53-93. 8. Abuchaim DC, Spera CA, Faraco DL, Ribas Filho JM, Malafaia O; Coronary dominance patterns in the human heart investigated by corrosion casting. Rev Bras Cir Cardiovasc. 2009; 24 (4):514-8. 9. Vieira TH, Moura PC Jr, Vieira SR, Moura PR, Silva NC, Wafae GC et al; Anatomical indicators of dominance between the coronary arteries in swine. Morphology. 2008; 92(296):3-6. 10. Side HS, Olumbe AO, Kalebi A; Anatomy and pathology of coronary artery in adult black Kenyans. East Afr MED J. 2002; 79(6):323-7. 11. Balci B, Yilmaz O. Atherosclerotic involvement in patients with left or right dominant coronary circulation. Kardiol Pol. 2004; 60(6):564-6. 12. Ayer, A Rao YG; A Radiographic investigation of the coronary arterial pattern in human hearts. Journal of anatomical society of India. 1957; 6:63-67. 13. Jain.SP, Hazary S; Coronary arterial patterns in man and some other animals. Journal of Anatomical Society of India.1958;7: 1-4. 82 Vasudeva Reddy et al., Int J Med Res Health Sci.2013;2(1):78-82 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 Received: 15 th Nov 2012 Revised: 23th Dec 2012 Accepted: 29th Dec 2012 Original research article CORONARY DOMINANCE IN SOUTH INDIAN POPULATION *Vasudeva Reddy J1, Lokanadham S2 1 Department of Anatomy, Sri Venkateswara Medical College, Tirupati, Andhrapradesh. Department of Anatomy, ViswaBharathi Medical College, Kurnool, Andhrapradesh. 2 *Corresponding author email: loka.anatomy@yahoo.com ABSTRACT Coronary artery anomalies are considered clinically insignificant and known to be associated with other congenital heart defects, myocardial ischemia and reduced life expectancy. Almost all elderly people have at least some impairment of coronary artery circulation. Therefore normal and pathological physiology of coronary circulation is one of the most important aspects in the entire field of medicine. In our study we dissected 80 human heart specimens to observe the coronary arteries from their origin to termination. We found 69 out of 80 are showing the right predominance (86.25%), 9 specimens with left predominance (11.26%) and remaining 2 of the balanced (2.5%) type of coronary circulation. The results of the study were compared with other literatures and variations are noted. In some cases we observed left predominance in males which indicates the reason for higher incidence of myocardial infarction in males when compared to females. Keywords: Coronary artery, Right dominant, Left dominant, Balanced or co- dominant INTRODUCTION Human heart supplied by two coronary arteries namely right &left coronary arteries, arise from ascending aorta. The left coronary artery divides into left anterior descending artery and circumflex artery, supplies blood to the front of the left side of the heart, lateral side and base of the heart1. The right coronary artery branches are the posterior descending artery and acute marginal arteries, supplies blood to the right ventricle, right atrium, Sino Atrial node, Atrioventricular node and a variable portion of the left ventricle2. Hettler stated the left coronary artery dominance, right coronary artery dominance and co-dominant are the three Vasudeva Reddy et al., types of coronary circulation3. Anomalous origin and distribution of the coronary arteries were shown to be a cause of sudden death in young and adult patients, often in association with physical exertion. Coronary artery anomalies when occur pose difficulty with coronary visualization, identification and present unique problems for surgical treatment. Our study determines the pattern of coronary artery dominance, balanced type of circulation in south Indian population. 78 Int J Med Res Health Sci.2013;2(1):78-82 MATERIALS AND METHODS arteries from their origin to termination. With regards to coronary predominance out of 80 specimens 69 (male-48, female-21) of right predominance (Figure-I), 9 specimens(male-8, female-1) of left predominance(Figure-II) and 2 specimens (male-1, female-1) of balanced or codominance (Figure-III) type of coronary circulation was observed. The percentage of incidence 86.25% in right predominance, 11.25% left predominance and balanced 2.55% were tabulated (Table-I). We also photographed the arteriogram of the right predominance and balanced or co – dominance type coronary circulation is labelled and we also observed the course of the posterior interventricular artery from its sulcus to the apex of the heart and noted. A total (n=80) heart specimens were collected with a portion of ascending aorta from relatively fresh bodies that came for post-mortem at the Forensic Department, SV Medical College, Tirupati. Each specimen thoroughly washed to free it from the blood clots and dissected anatomically and ethical committee of our institute permitted to do the work. The arterial pattern of heart from the origin of the coronary arteries to their termination observed and variations are recorded. And also the arteriograms of types of coronary circulation with labelled photographs are collected from the cardiology department. RESULTS In the present study 80 human heart specimens were dissected and observed for the coronary Table: 1. Distribution of specimens with type of Coronary circulation Dominance Right dominance Male 48 Female 21 Total 69 Percentage (%) 86.25 Left dominance Balanced 8 1 1 1 9 2 11.25 2.5 The termination of right coronary artery reaches and half of the posterior inter ventricular septum the crux and beyond crux in 73.3%, and right to in 9% of hearts were tabulated. The data were the crux 20% and at the right border in 6.6% of analyzed through descriptive statistics to calculate the specimens was observed, whereas left percentages. Qualitative statistics were used to coronary artery terminates at 1/3 of posterior inter analyze arteriogram. (Table-II) ventricular septum 61% of hearts, at the apex 30% Table- II: Termination of Coronary arteries (PIVS: Posterior Inter Ventricular Septum) Termination Crux & Beyond Crux of Heart Specimens with Right Coronary dominance Specimens with Left Coronary dominance 73.3% - Right to Crux 20% - Right border Lower1/3 of PIVS 6.6% - 61% Apex - 30% Half of PIVS - 9% Vasudeva Reddy et al., Int J Med Res Health Sci.2013;2(1):78-82 79 DISCUSSION The present study shows 86.25% of right coronary predominance, 11.25% left predominance and 2.5% of balanced type of coronary circulation were observed. Most of the literatures stated the right predominance is seen in 70%of hearts left dominance in 20% of hearts and 10%of balanced type of coronary circulation.1,12 Balanced type of circulation is more common in females.4 According to James 1961, the left coronary artery predominance is seen in males.5 The incidence of right predominance in 90%of hearts, left predominance in10% and balanced type in few hearts.6 In a study revealed on the basis of 6000 selective arteriogram, the right coronary predominance was present in 60% of persons. 7 Most common form of coronary circulation was found to be the right dominant.8,12 The arterial pattern was found to be right dominance based on crux cordis and the subsinuosal interventricular branch.9 In Kenya sum of the population right coronary artery was found to be dominant in 82% of the hearts.10 The right coronary artery dominance was most prevalent, followed by the balanced type and the left coronary artery dominance in Brazilian population as well.11 However, the data are inadequate to study the coronary predominance in relation to sex in our population. The incidence of right predominance 57%,left dominance 10% and balanced 33% of circulation out of 30 cases.12,13 LCX RCA M CV PD Figure:1. Dissection of human Heart & Antero posterior view of arteriogram showing right coronary dominance (PD: posterior descending branch, RCA: right coronary artery, MCV: middle cardiac vein, LAD: left anterior descending branch, LCX: left circumflex, D: diagonal, LMA&RMA: right and left marginal branches) 80 Vasudeva Reddy et al., Int J Med Res Health Sci.2013;2(1):78-82 LCX PD Figure:2. Dissection of human heart showing Left coronary dominance (PD: posterior descending branch-interventricularartery, LCX:leftcircumflexbranch) RCA LCX PD PD Figure:3. Dissection of human Heart & Antero posterior view of arteriogram showing Balanced circulation (PD: posterior descending branch-interventricular arteries, RCA: right coronary artery, LCA: left coronary artery, LAD: left anterior descending branch, LCX: left circumflex branch) 81 Vasudeva Reddy et al., Int J Med Res Health Sci.2013;2(1):78-82 CONCLUSION Our study reveals the majority of the cases observed with right coronary artery dominance compared to left coronary artery dominance and also the incidence of right coronary dominance are higher in males than females. In some cases we observed left predominance in males which indicates the reason for higher incidence of myocardial infarction in males when compared to females. ACKNOWLEDGEMENT Authors are thankful to Dr R V Subhakar, Professor, for his able guidance and special thanks to Dr R Sekhar, Professor, for his constant encouragement for this work. REFERENCES 1. Williams PL, Bannister LK, Berry MM, Collins P, Dyson M, Dussek JE, Ferguson MWJ; Grays Anatomy. 2000; 38th Ed., Edinburgh, Churchill Livingstone: 1505-1510. 2. Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald; Heart Diseases a text book of Cardiovascular Medicine. 2008; 8th Ed: 478. 3. Gawlikowska SA, Miklaszewska D, Czerwi ÅF, Folia O. Analysis of the influence of heart size and gender of coronary circulation. Folia Morphol. 2010; 69 (1): 35-41. 4. Schlesinger MJ; Relation of anatomic pattern to pathological conditions of the coronary arteries. Arch. Path. 1940; 30:403-415. 5. James TN. Anatomy of the coronary arteries, New York. Paul B Hoeber. 1961; 12-150. 6. Anderson RH, Becker AE; Cardiac anatomyAn integrated text and colour atlas. 1980; 2123. 7. Effler, Groves DB, Suarez LK, Favdoro EL; Direct coronary artery surgery with end arterotomy and patch - graft reconstruction. Journal of thoracical cardiovascular surgery. 1967; 53-93. 8. Abuchaim DC, Spera CA, Faraco DL, Ribas Filho JM, Malafaia O; Coronary dominance patterns in the human heart investigated by corrosion casting. Rev Bras Cir Cardiovasc. 2009; 24 (4):514-8. 9. Vieira TH, Moura PC Jr, Vieira SR, Moura PR, Silva NC, Wafae GC et al; Anatomical indicators of dominance between the coronary arteries in swine. Morphology. 2008; 92(296):3-6. 10. Side HS, Olumbe AO, Kalebi A; Anatomy and pathology of coronary artery in adult black Kenyans. East Afr MED J. 2002; 79(6):323-7. 11. Balci B, Yilmaz O. Atherosclerotic involvement in patients with left or right dominant coronary circulation. Kardiol Pol. 2004; 60(6):564-6. 12. Ayer, A Rao YG; A Radiographic investigation of the coronary arterial pattern in human hearts. Journal of anatomical society of India. 1957; 6:63-67. 13. Jain.SP, Hazary S; Coronary arterial patterns in man and some other animals. Journal of Anatomical Society of India.1958;7: 1-4. 82 Vasudeva Reddy et al., Int J Med Res Health Sci.2013;2(1):78-82 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 Received: 9th Dec 2012 Revised: 25th Dec 2012 Accepted: 29th Dec 2012 Original research article BODY FRIENDLY, SAFE AND EFFECTIVE REGIMEN OF MgSO4 FOR ECLAMPSIA *Gautam S. Aher 1, Urmila Gavali2 1 Professor, Dept of OBGY; 2Assistant Professor, Padmashree Dr. Vithalrao Vikhe Patil Medical College & Hospital, Ahmednagar, Maharashtra. *Corresponding author email: drgsaher@gmail.com ABSTRACT Pre-eclampsia and eclampsia are major health problems in developing countries. MgSO4 is the standard drug in the control of convulsions in eclampsia. Our study carried out at PDVVPF’s hospital is based on the low dose regimen than Pritchard, which is suitable for Indian women who are of smaller built than women in western world. This prospective study included 50 eclampsia patients receiving low dose MgSO4 therapy. The loading dose of MgSO4 was 9gm. Following this 2.5 gm was given intramuscularly every 6 hourly for 24 hours after administration of the loading dose. Patients were monitored hourly by observing their respiratory rate, knee jerk and urine output. Out of 50, two patients required Pritchard regimen, rest completely recovered from eclampsia. The maternal and perinatal morbidity and mortality were comparable to those of the standard Pritchard regime. The study did not find a single case of magnesium related toxicity with low dose MgSO4 regime. Low dose magnesium sulphate regime was found to be safe and effective in eclampsia. Key Words : Eclampsia, Pritchard Regime, Low dose MgSO4. INTRODUCTION Eclampsia is a common cause of maternal mortality worldwide particularly in the developing countries. It is estimated that every year eclampsia is associated with about 50,000 maternal deaths worldwide, most of which occur in developing countries.1 The incidence of eclampsia in our country varies from 0.5%-1.8%. The major breakthrough in the management of eclampsia came when Dr. J. A. Pritchard published his standardized MgSO4 treatment regime in 1984. The collaborative Eclampsia Trial which was a large multicentric trial in 27 centres in 9 developing countries, found magnesium sulphate to be a better anticonvulsant in the management of eclamptic seizures when compared to phenytoin and diazepam.2 There has been a constant discussion in literature regarding dose of Magnesium sulphate and therapeutic serum Magnesium levels. J A Pritchard commented that if a woman is known to be or appear to be small, the dose should probably be limited.3 Winit Phauapradit et al commented that is appropriate to take into account body weight when considering the dosage of drug for Asian women with body 83 Aher GS et al., Int J Med Res Health Sci. 2013;2(1):83-86 weight less than 7okg. The aim of the present study was to evaluate the effectiveness of low dose magnesium sulfate in control of convulsions in eclampsia, to assess the magnesium related toxicity and to analyze the maternal and perinatal outcome. MATERIALS AND METHODS During the study period of 2009 to 2011, at Dr. Padmashree Vithalrao Vikhe Patil Hospital, 50 cases of antepartum eclampsia were included in the present study after human ethical committee approval. Patients with a history of generalized tonic-clonic convulsions, elevated blood pressure and proteinuria with no previous history of seizure disorders like epilepsy were included in the present study. Patients were excluded from study if there was doubt about the diagnosis because the accompanying relatives did not witness the seizure, there was no elevated blood pressure on admission or had received diazepam as anticonvulsant prior to admission. After taking written informed consent from each patient that fulfilled the inclusion criteria patients received loading dose of 4 grams of magnesium sulphate (20%) i.v. with 2.5 grams (50%) i.m. in each buttock. Subsequently, maintenance dose of 2.5 grams (50%) was given i.m. in alternate buttock every 6 hours up to 24 hours after delivery or after last convulsion, whichever was later. Serum Mg++ level was measured 12 hours after the first dose. If convulsions were not controlled by the low dose regime, then the case was shifted to the standard Pritchard regime. Patients were monitored for respiratory rate, Urine output (30ml/ hour) & deep tendon reflexes same as that of Pritchard regimen. All the principles of management of eclampsia are followed. After stabilization of patients, labour was induced or augmented. Cesarean section was performed for obstetric indications. RESULTS During the study period, 57 (2.4%) cases of antepartum eclampsia were noted among the 2375 deliveries. Among these, 50 cases were included in the study. Most of the patients (36 cases; 72%) had not taken antenatal care. The patients were from 17 years to 35 years with a mean age of 21 years. 78% cases were primigravidas. The total dose of magnesium sulphate, required for control of convulsions was less than 20 grams ie.56.82% less than that is required in standard Pritchard regime. The serum magnesium levels were monitored in all cases for evidence of magnesium toxicity. The mean serum magnesium value ranged between 4.1 to 4.35meq/lit during the low dose regime. There was no maternal mortality due to eclampsia or its complication in the present study. In present study Microsoft excel was used for statistical analysis. Table: 1. Comparison of our regime with Pritchard’s regime MgSO4 regime 96% Control of convulsions 4% Recurrence Rate 4% Cases requiring a shift to the standard Pritchardt regime 12% Perinatal mortality 4.1 to 4.35meq/lit Serum Magnesium level 0 Signs of drug toxicity Pritchard’s regime 93.33% 6.67% 33.84% 3.74-6.14mg/dl 2% 84 Aher GS et al., Int J Med Res Health Sci. 2013;2(1):83-86 Table:2. Comparison of total dose of MgSO4 in different regimes Name of regime Pritchard regime Low dose Padhar regime Low dose Dhaka regime MgSO4 low dose regime Loading dose MgSO4 (20%) IV Loading dose MgSO4 (50%) IM Maintenance dose (50%) IM 4gm 10gm 5gm 4 hrly 3gm 5gm 2.5gm 4hrly 4gm 6gm 2.5gm 4 hrly 4gm 5gm 2.5gm 6 hrly 30 23 25 19 Total dose (gm) in 24 hrs DISCUSSION The incidence of eclampsia within the study period was 2.4% which underscores the magnitude of the disease. Other factors found associated with eclampsia in this study were young maternal age; primigravidity and lack of prenatal care which are similar to what have been reported by other workers. 5, 6 Also majority of these patients belongs to the lower socioeconomic group. 84% patients had body weight less than 50kg. Pritchard regime was standardized for western women, having total bodymass index much higher than women from developing countries, including India. In present study convulsions were controlled in 96% of cases with total dose less than 20 gms (43.18% of pritchard regime. In present study intramascular dose was reduced to 2.5gms at 6 hr interval. This did not affect the efficacy of regime as evidenced by serum Mg levels at 12 hrs. However this significantly decreased incidence of pain at injection site, tissue necrosis and abscess formation. Rashida Begum et al7 in their study, reported that eclamptic convulsions were controlled in 98% cases with modified (Dhaka) regime of magnesium sulphate. Results of the present study were comparable with above mentioned studies. Begum MR et al8 suggested a small body mass index to be the reason for effectiveness of low dose regimen in women in developing countries. There was no maternal mortality in the present study. Perinatal mortality in the present study was 12%. The majority (66.7%) of deaths were stillbirths and 33.3% Aher GS et al., were neonatal deaths. Prematurity, placental abruption and growth restriction were common causes of perinatal deaths. Sardesai Suman et al reported 33.90% perinatal mortality.9 The mean serum magnesium levels remained in the range of 4.1 to 4.35meq/lit during low dose magnesium sulphate regime. Therefore low dose regimens, might significantly improve the safety. Moreover, low dose MgSO4 might be used in cases with mild renal impairment which is usually present in these patients. CONCLUSION Associated with similar efficacy in controlling convulsions and potentially more favorable toxicity and complication rates, the use of low dose MgSO4 protocols is a viable alternative to standard dose therapy. The dose required for control of a convulsion with the low dose magnesiumsulphate regime was less than half of the standard Pritchard regime making it a body friendly regime. However multi-center, randomized controlled trials are recommended to test this proposed regimen to support routine clinical use low dose protocols. ACKNOWLEDGEMENT We could not have been able to work this low dose MgSO4 regime of ours without studying Prichard’s regime and established low dose regimes like Padhar regime and Dhaka regime. 85 Int J Med Res Health Sci. 2013;2(1):83-86 REFERENCES 1. Duley L. Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean. Br J ObstetGynaecol. 1992;99:547-53. 2. The Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence from Collaborative Eclampsia Trial.Lancet. 1995; 345:1445-63 3. Jack A. Pritchard, Cunningham G et al. The Parkland Memorial Hospital Protocol for treatment of eclampsia: Evaluation of 245 cases. Am. J. ObstetGynacol. 1984;148:95163. 4. Phaupradit Winit, Saropala N et al, Serum level of Magnesium attained in Magnesium Sulphate therapy for severe preeclampsia. Asia Oceania J. Obstet& Gyn. 1993; 194:38789 5. Ekele BA, Bello SO, Adamu AN. Clusters of eclampsia in a Nigerian teaching hospital. Int J Gynecol Obstet. 2007;96:62–66. 6. Bugalho A, Bacci A, Bergstrom S. Risk factors in Mozambican women with Eclampsia: A case-referent study. Afr J Repro Health. 2001;5:30–35. 7. Rashida Begum. Anowara Begum, Richard Johnson et al. A low dose (Dhaka) magnesium sulphate regime for eclampsia. Acta Obstetricaet Gynecologica Scandinavica 2001; 80(1):998. 8. Begum MR, Begum A, Quadir E. Loading dose versus standard regime of magnesium sulphate in the management of eclampsia: a randomized trial. J ObstetGynaecol Res. 2002;28:154–59. 9. Sardesai Suman, MairaShivanjali, PatilAjit et al. Low dose magnesium sulphate therapy for eclampsia and imminent eclampsia- Regime tailored for Indian women. J. Obstet Gynecol India 2003; 53-6: 546-550 86 Aher GS et al., Int J Med Res Health Sci. 2013;2(1):83-86 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 Received: 15 th Nov 2012 Revised: 13th Dec 2012 Accepted: 16th Dec 2012 Original research article LIPID INDICES IN TYPEII DIABETES MELLITUS AND THEIR ASSOCIATION WITH MACRO AND MICRO VASCULAR COMPLICATIONS *Imran Ahmed Siddiqui MD 1, Laxmikanth B MD2, Mariya MD3, Rama Rao J MD4. 1 Specialist, Department of Biochemistry ESIC Super Specialty Hospital, Hyderabad Asst Professor Department of Biochemistry Shri Sathya Sai Medical College & Research Institute, Chennai. 3 Asst Professor, Department of Anatomy, Shadan Institute of Medical Sciences, Hyderabad 4 Professor & Head Department of Biochemistry, Osmania Medical College, Hyderabad 2 *Corresponding author email: write2drimran@gmail.com ABSTRACT Background: Type II Diabetes Mellitus patients can develop complications over a prolonged period of time. The alterations in lipid indices can be associated with these complications. Aims:To identify changes in lipid metabolism in type 2 DM in context with the glycemic status, its relative impact on the macro & micro vascular events, and the effects of insulin therapy on the lipid indices. Methods and Material: 158 Type II diabetics were selected as cases and 30 subjects without any coincidental illness as controls were selected for the study. Total cholesterol, Triglyceride, HDL-C, Cholesterol/ HDL-C ratio and Atherogenic Index (AI) were estimated and the data was statistically analyzed. Results: Atherogenic index and CHOL/HDL-C levels were significantly higher in diabetics than in controls. Both the indices were also found to be lowered in patients on treatment with insulin. The AI in patients with complications was also significantly higher than those without complications; however CHOL/HDL-C was not significantly different. Thus using the best cutoff values AI can be used as a better indicator for complications than using the ratio of CHOL/HDL-C. Conclusion: AI can be used to indicate the presence of increased cardiovascular risk in patients with type II DM, and as a guide for the aggressive therapeutic approach. Keywords: Type II DM, Lipid indices, Atherogenic index, Micro and Macro vascular complications. INTRODUCTION Diabetes a metabolic disorder is characterized by hyperglycemia and a predisposition to micro and macro vascular diseases1,15,19. In patients with diabetes atherosclerosis occurs at an earlier age and is the chief cause of mortality in them 2,14. Diabetes leads to impaired carbohydrate metabolism in association with derangement in lipid metabolism, virtually every lipid and 87 Imran et al., Int J Med J Res Health Sci. 2013;2(1):87-92 lipoprotein is affected in type II DM1. Elevated triglycerides associated with low HDLc levels, preponderance of small dense lipoproteins and increased apolipoprotein B in diabetics is the most prevalent pattern of dyslipidemia3,4,5,16,17,18. Hypertriglyceridemia, decrease in HDL are independent risk factors for coronary heart disease4,17, small dense LDLc are also atherogenic as they are more likely to form oxidized LDL and are less readily cleared. Recently rather than the concentration of cholesterol in various lipoproteins the size and composition are shown to be important in atherogenesis. However as the sub fractionation of lipoproteins by the present method cannot be undertaken in all the clinical laboratories and recently as the AIP has been shown to correlate with the size and composition of lipoproteins3,18; Hence in the present study we observed the lipid profile and AIP and CHOL/HDL ratio, in type II diabetic patients in context with glycemic status and its relation to macro and micro vascular events and effects of insulin therapy on lipid indices. MATERIALS &METHODS After permission from the Institutional Ethical Committee, Total 178 subjects in between 30-80 yrs age were selected for the present study. 148 known diabetics on regular treatment as cases and 30 healthy subjects without any coincidental illness as controls. Patients with a history of smoking and alcoholism were excluded from the study; Cases were divided based on the level of glycemic control into HBA1c < 7 as good control (group I n=46), HBA1c 7-8 fair control (group II n=50) and HBA1c > 8 as poor control (group III n=52). The above same Cases 148 were also categorized into group 1 consist of cases who had a history of complication in the past 10 years (n=62) and group2 who never had a history of complication in the past 10 yrs (n=86), to see its relation to the study parameters The above same 148 cases were also divided into 2 groups, group I was the cases who were on oral therapy ( i.e. oral hypoglycemic) (n = 95). Group II were patients who were on insulin therapy ( n = 53). After an overnight fast, peripheral venous blood samples were collected in two vaccutainers 5ml in gel vaccutainer and 2 ml in the EDTA vaccutainer. Serum separated after centrifuge; was used to analyze fasting & the post prandial blood sugar by GOD-POD method, Total cholesterol by CHOD-POD method 6, Triglycerides by GPO-PAP method and HDL-c fraction which was assayed using the cholesterol CHOD-POD method6. The EDTA sample was used to measure HbA1C that was determined by HPLC method. LDL was calculated from Frieldwalds formula7, CHOL/HDL-C ratio, AIP log (TG/HDL-C) 3 was calculated in different groups. Data obtained was analyzed by SPSS statistical software (v 17.0); ANOVA was used to compare the 3 groups and significance was estimated using the F value in between different groups. RESULTS Table 1: Mean ± SD of Various Parameters in Cases and Controls Controls Group I Group II Group III F value Sig T.Chol 153.6 ± 25.16 164.7 ± 27.2 172.2 ± 22.9 178.7 ± 35.67 5.414 <.001 HDL LDL VLDL TG 38.5 ± 4.39 96.4 ± 15.27 18.6 ±0.42 93.1 ± 9.49 35.6 ± 4.54 96.4 ± 20.8 32.5 ± 5.05 163.3± 25.65 36.08 ± 3.5 96.6 ± 20.11 38.7 ± 11.24 194.71 ±56.8 34.78 ± 4.4 103.04 ± 32.6 40.93 ± 13.4 205.3 ± 67.2 5.16 0.83 38.70 38.93 .002 .478 <.001 <.001 AIP 0.38 ± 0.06 0.659±0.059 0.71 ± 0.11 0.75 ± 0.1 127.14 <.001 CHOL/HDL 4.02 ± 0.85 4.59 ± 0.30 4.76 ± 0.29 5.15 ± 0.89 20.46 <.001 88 Imran et al., Int J Med J Res Health Sci. 2013;2(1):87-92 Table 1 shows the mean and SD of different lipid fractions, studied. The mean of total cholesterol, triglycerides, VLDL, AIP, CHOL/ HDL ratio was significantly increased in patients than controls (p<0.001). There was no significant increase in LDLc in patients compared to controls (p=0.478). Serum HDLc was significantly decreased in patients when compared to controls (p=0.002). Multiple comparison ANOVA shows that Total Cholesterol was significantly higher in group III (p=0.003), than group I(=0.422) and group II (=0.092)compared to controls; the increase was not significant in comparison of group I with group II(0.701) and group III(0.095),and group II with group III (p=0.784). HDL-c was significantly decreased in group III (p=0. 002), than group I (0.036) and group II (0.150) when compared to controls; the decrease was not significant in comparison of group I with group II (0.981) and group III (0.0740), and group II with group III (p=0. 580). TG and VLDL was significantly higher in group III (p=0. 001), than group I (=0. 001) and group II (=0. 001) compared to controls; and in comparison of group I with group II (=0. 031) and group III (=0. 001), and group II with group III (p=0. 001). LDL-c was not significantly higher in patients compared with controls(p=0.7333) and in between the groups (p=0.717) ANOVA for AIP shows that AIP was significantly more in group III (<0.001), group II (<0.001), & group I (<0.001) when compared to controls; and in group III (<0.001) and group II (<0.025) compared to group I but the increase was not significant between group II and group III (0.231). The CHOL / HDL-c ratio was significantly more in group III (<0.001), group II (<0.001), & group I (<0.001) when compared to controls, and in group III compared to group I (<0.001) but the increase was not significant between group I and group II (0.700) and group II and group III (0.086). ANOVA in relation to insulin therapy shows that total cholesterol (0.002), LDL-c (<0.001) was significantly more in patients on insulin than patients with other oral hypoglycemic (OHA), increase in total cholesterol was significant in relation to controls (<0.001) than LDL-c (0.062). There was no significant increase in HDL-c in patients on insulin compared to patients on OHA (0.702). Insulin therapy showed a significant decrease in TG (0.033), VLDL (0.031), AIP (<0.001), CHOL/HDL ratio (0.046) in patients on insulin therapy than on OHA. ANOVA in relation to complications shows that patients with complications showed no increase in total cholesterol (0.934) & LDL-c (0.652) than patients without complications, but the increase in total cholesterol (0.019) was significantly more compared to controls, but the increase in LDL-c was not significant when compared to controls (0.633). Patients with complications showed no significant decrease in HDL than patients without complications (0.652), but the decrease was significant when compared to controls (0.006). TG and VLDL showed a significant increase in patients with complications than without complications (<0.001), and controls (<0.001). AIP was significantly more in patients with complications than without complications (<0.001), and controls (<0.001). CHOL/HDL-c ratio was not significantly different in patients with and without complications. At the best cutoff value AIP is a much better marker in identifying complications (sensitivity 80%, specificity 70%) than CHOL/HDL-c ratio (sensitivity 50%, specificity 55%). 89 Imran et al., Int J Med J Res Health Sci. 2013;2(1):87-92 Table 2: Area under the curve, sensitivity and specificity, of various lipoproteins, AIP and CHOL/HDL-c ratios; calculated from best cut off value using ROC curve. PARAMETER T.CHOL HDLC LDL VLDL TG AIP CHOL/HDL AUC 0.552 0.531 0.603 0.747 0.747 0.810 0.564 COMPLICATION SENSITIVITY SPECIFICITY 52% 56% 27% 70% 41% 64 % 40 % 99.94% 64 % 78 % 80 % 69.7% 50 % 55 % DISCUSSION Diabetes mellitus is the commonest metabolic disorder, a social and economic burden to the society because of the increased morbidity and mortality associated with its complications3, 8, 9, 10. Many markers are studied for their association in the development of diabetic complications. The most common amongst them are various lipids, lipoproteins and different ratios involving these complications3, 8, 10. Recently lipid particle sub fractions have also been implicated in the atherogenic process18. The major phenotypic feature of diabetes mellitus, the hyperglycemia is shown to be directly or indirectly associated with the pathogenesis of complications; insulin therapy is shown to be associated with decreased incidence of complications2. The present study was undertaken to assess the value of different markers. All Lipoproteins are shown to be affected in diabetes mellitus. The most prevalent pattern being increased TG, decreased HDL-c with an increase in the LDL-c3,4,5,16,17,18, present study confirms the changes in TG and HDL-c, but the increase in LDL-c was not significant and not to the extent of TG, this can be expected as TG is most affected lipid component, increase in TG level may lead to increase in LDL-c and cholesterol10 . The abundance of free fatty acids appears to play an important role in the pathogenesis of low HDL in DM. In liver free AUC 0.654 0.597 0.285 0.625 0.625 0.712 0.628 INSULIN SENSITIVITY SPECIFICITY 57% 67% 35% 79% 55 % 75 % 24 % 90 % 25.6 % 87 % 62.8% 75.7% 61.4% 62.8% unsaturated fatty acid stimulate the TG synthesis and VLDL production. Low HDL and increased TG are also markers of beta cell toxic metabolic situation and beta cell failure11,16,18. Hyperlipidemia is associated with hyperglycemia and glycemic control reduces the risk for all complications from DM. Good glycemic control requires a continual combination of proper diet, daily physical activity, and usually antiglycemic drug therapy9. Poor control of blood glucose levels impairs endogenous insulin production, resulting in a vicious cycle, that affects both the carbohydrate and lipid metabolisms in patients with diabetes2, 9. Hyperglycemia is shown to induce similar intracellular signals in endothelial cells as hyperlipidemia3. In the present study we observed significantly higher total cholesterol, TG, VLDL and significantly lower HDL-c in poor diabetics compared to controls, however TC, HDL-c, are not significantly different in different grades of glycemic status. TG and the TG associated ratio paralleled glycemic status. In the present study we observed significantly lower TG, VLDL and ratios in diabetics on insulin compared to other modes of treatment. However total cholesterol and LDL-c is significantly higher in patients on insulin therapy with no significant increase in HDL-c. Insulin treatment was shown to be associated with improvement in 90 Imran et al., Int J Med J Res Health Sci. 2013;2(1):87-92 dyslipidemia of DM. Insulin therapy increases the expression of Apo A1 gene and inhibits the production of VLDL12. Various lipid and lipoprotein fractions are shown to be associated with diabetic 2,13,14,18 complications . In the present study we found a significantly higher concentration of total cholesterol, TG, VLDL and AIP, and Lower HDL-c in patients with complications. However LDL-c and Chol/HDL-c ratios are not significantly different. To assess the significance of these various markers the best cutoff values were calculated using ROC analysis. The AIP is the only indicator which showed significant sensitivity and specificity in identifying diabetic complications, TG is the next relatively better marker. All other markers showed poor sensitivity. CONCLUSION The present study confirms that the abnormalities in TG and VLDL are more prominent than Cholesterol and LDL in patients with diabetes and HDL is a better indicator of lipid abnormalities than total cholesterol and LDL. AIP is a good marker in identifying complications associated with diabetes, and is better correlated with glycemic status in diabetics on insulin therapy. And as AIP can easily be calculated from routine lipid investigations, AIP can be routinely be used as a marker for prediction of complications. Acknowledgement. : we acknowledge our patients who have participated in the study 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. REFERENCES 1. 2. Brown. WV. Lipoprotein disorder in diabetes mellitus. Medical clinics of North America 1994:. 78, 143-61. Jenny EK et al. Do glucose and lipids exert independent effects on atherosclerotic lesion Initiation or progression to advanced plaques? Circ. Res. 2007;100:769-81 13. Meng HT et al. Pioglitazone reduces atherogenic index of plasma in patients with type 2 diabetes. Clin Chem. 2004; 50:7;118488 Michael HD. Global risk management in patients with type 2 diabetes mellitus. Am J Cardiol 2007; 99:41–50. Sandra JL. Prevention and treatment of atherosclerosis: A practitioner’s guide for 2008 The American Journal of Medicine. 2009; 122:38-50 Allan et al, enzymatic determinations of total serum cholesterol. Clin Chem. 1974; 20: 47075. Friedwald, Levy WT. Estimation of concentration of LDL-c in plasma without the use of preparative ultracentrifuge. Clin Chem. 1972; 18; 499-02. Steven M Haffner etal. Mortality from coronary heart disease in subjects with type 2 Diabetes and in nondiabetic subjects with and without prior Myocardial infarction. N Engl J Med 1998;339:229-34. Standards of medical care in diabetes; diabetes care: 2012; 35,11-S49. David Snipelisky, Paul Ziajka. Diabetes and hyperlipidemia: a direct quantitative analysis. World Journal of Cardiovascular Diseases, 2012; 2: 20-25. Lucia Rohrer. High density lipoproteins in the intersection of diabetes mellitus, Inflammation and cardiovascular disease. Current Opin Lipidol.2004; 15:269–27 Maxime N. Insulin-Mediated DownRegulation of Apolipoprotein A5 Gene Expression through the Phosphatidylinositol 3-Kinase Pathway: Role of Upstream Stimulatory Factor. Mol Cell Biol. 2005 February; 25 (4): 1537–48. Auni Juutilainen etal. Type 2 Diabetes as a Coronary Heart Disease Equivalent: An 18year prospective population-based study in Finnish subjects. Diabetes Care December 2005;28(12): 2901-07. 91 Imran et al., Int J Med J Res Health Sci. 2013;2(1):87-92 14. 15. 16. 17. 18. 19. Diane M Erdman etal. The Impact of Outpatient Diabetes Management on Serum Lipids in Urban African-Americans With Type 2 Diabetes. Diabetes Care January 2002; 25(1): 9-15. Edward JB etal. Does diabetes always confer coronary heart disease risk equivalent to a prior myocardial infarction? Implications for prevention. Diabetes care. 2011;34(3): 782-84. Tangvarasittichai etal. Association of serum lipoprotein ratios with insulin resistance in type 2 diabetes mellitus. Indian Council of Medical Research, May 2010 Volume: 131, Issue: 5. Byambaa Enkhmaa etal. Postprandial Lipoproteins and Cardiovascular Disease Risk in Diabetes Mellitus. Curr Diab Rep. 2010 February; 10(1): 61–69. Richard WN. LDL Cholesterol Lowering in Type 2 Diabetes: What Is the Optimum Approach? Clinical Diabetes January 2008;26(1): 8-13. W Todd Cade. Diabetes-Related Microvascular and Macrovascular Diseases in the Physical Therapy Setting. Physical Therapy November. 2008;88(11):1322-35. 92 Imran et al., Int J Med J Res Health Sci. 2013;2(1):87-92 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 Received: 26 th Nov 2012 Revised: 13th Dec 2012 Accepted: 30th Dec 2012 Original research article PHYTOCHEMICAL SCREENING AND ACUTE TOXICITY STUDY OF ETHANOLIC EXTRACT OF ALPINIA GALANGA IN RODENTS. Subash K.R*, Muthulakshmi Bhaarathi G, Jagan Rao N, Binoy Vargheese Cheriyan Department of Pharmacology, Meenakshi Medical College and Research Institute, Kanchipuram, Tami Nadu. *corresponding author email: subbu2207@yahoo.com ABSTRACT Introduction: Alpinia galanga is an important ingredient in various herbal formulations has reached extensive acceptability as therapeutic agents for several diseases. The investigation of authentic analytical methods, which can reliably profile the phytochemical composition and studies on toxicity profile, including hematological and biochemical parameters is an important initial step for the establishment of standardization to screen further in search of consistent biological activity. Aim: To screen ethanolic extract of Alpinia galanga for its phytochemical constituents and acute toxicity profile. Methods: Acute toxicity studies done in rodent by OECD guideline 423 and phytochemical analysis by standard laboratory grade reagents. Results The present study revealed the presence of complex phytochemical constituents including phenols and flavanoids. The acute toxicity results has classified the test material to fall under the hazard category 2000mg/kg<LD50<5000mg/kg according to globally harmonized classification system. Conclusion The present study concludes the safety of ethnobotanical use of Alpinia galanga from acute toxicity results and the presence of various phytochemical constituents in Alpinia galanga may be responsible for its various pharmacological actions documented in traditional medicine. Key words: Phytochemical screening, Alpinia galanga, Acute toxicity, Ethanolic extract. INTRODUCTION The use of medicinal plants and preparations derived from them as dietary supplements, Nutraceuticals, functional foods and herbal medicinal products has become more widely accepted in developing countries. Therefore, it is important to evaluate the adverse effects of these plants and their preparations to increase the confidence in its safety to human, particularly for use in the development of pharmaceutical products. Based on Strobel and Daisy 20031 there should be some Rationale for plant selection like plants from unique environmental settings especially those with an unusual biology, plants that have an ethno botanical history, plant that are 93 Subash KR et al., Int J M ed res Health Sci. 2012;2(1):93-100 endemic that has an unusual longevity and plant growing in areas of great biodiversity. The medicinal plant selected and investigated for present study Alpinia galanga has a very strong ethno botanical history endemic in south east Asia and still available as an Ayurvedic preparation for wider therapeutic application including inflammatory disorders. It is used as a constituent of the following Ayurvedic preparations. Rasandi gugluva, Ashvagandaoil, Karpasadi oil, Mahanarayaoil, Mahabalaoil, Vishagananeelaoil, Chyathya ghathya, Vruhathjagaladighathaya, Kakubdhadi powder, Ashvagandadi powder, Ranagigru kvathaya, Ranavishvadiya (Rasna dashamula), Rasna sapthayakaya, Bilvorasnadi kvathaya, Dashamul Iguruadi kvathaya, 2 Dashamuladi kvathaya, Kumaraguliya . Apart from traditional Ayurvedic preparation modern pharmaceutical companies manufacture and provide these preparations in the form of capsules and tablets with standardized packing, few hit products containing Alpinia galanga in the formulary includes Rumalaya forte and Orthocare-B for the treatment of arthritis. Based on a review of the literature the present study is an effort to screen phytochemical constituent and study acute toxicity activity of ethanolic extract of Alpinia galangal MATERIALS AND METHODS Plant Materials The rhizomes from the plant Alpinia galanga were collected from the local areas of Coimbatore (Tamil Nadu, India). The collected material was authenticated by Dr Sasikala Ethirajulu, Assistant Director (Pharmacognosy), Siddha Central Research Institute, Chennai, India. Experimental animals Colony inbred animal strains of swiss albino mice of female sex weighing 20-25 g three in each group control and test were used for the toxicological studies according to OECD guidelines. The animals were kept under standard conditions 12:12 (day/night cycles) at 22 0C room temperature, in polypropylene cages. The animals were fed on standard pellet diet and tap water ad libitum. The animals were housed for one week in polypropylene cages prior to the experiments to acclimatize to laboratory conditions. The experimental protocol was approved by the Institutional Animal Ethical Committee (IAEC). Preparation of Plant Material The collected rhizome materials were thoroughly washed under running water, shade dried for a week at 35-40oC, pulverized in an electric grinder and exhaustively extracted successively in a Soxhlet apparatus by using the solvent, ethanol. The extracts were concentrated under reduced pressure and were then powdered. Qualitative Phytochemical Analyses The phytochemical tests below were carried out on the ethanolic extract of Alpinia galanga to determine the active constituents according to the procedures and methods outlined in Barnes, J. (1999) and Harborne3,4. These phytochemical tests were done to detect the presence of secondary metabolites, such as alkaloids, tannins, saponins, resins, flavonoids, steroid, glycosides and terpenoids in the plant under investigation. Test for Alkaloids A quantity (0.2g) of the sample was boiled with 5ml of 2% HCl on a steam bath. The mixture was filtered and 1ml portions of the filtrate was measured into four test tubes. Each of the 1ml filtrate was treated with 2 drops of the following reagents. i. Dragendorff’s test: A red precipitate indicates the presence of alkaloids. ii. Mayer’s test: A creamy-white colored precipitate indicates the presence of alkaloids. iii. Wagner’s test: A reddish-brown precipitate indicates the presence of alkaloids. iv. Picric Acid (1%): A yellow precipitate indicates the presence of alkaloids. Test for Flavonoids A quantity (0.2g) each of the extracts was heated with 10ml of ethyl acetate in boiling water for 3 94 Subash KR et al., Int J M ed res Healt h Sci. 2012;2(1):93-100 minutes. The mixture was filtered differently and the filtrates used for the following tests: i. Ammonium Test: A quantity (4ml) each of the filtrates was shaken with 1ml of dilute ammonia solution (1%). The layers were allowed to separate. A yellow coloration was observed at the ammonia layer, which indicates the presence of flavonoids. ii. Aluminum Chloride Test: A quantity (4ml) each of the filtrates was shaken with 1ml of 1% aluminum chloride solution and observed for light yellow coloration. A yellow precipitate indicates the presence of flavonoids. Test for Phenols i. Ferric chloride test: The fraction of the extract was treated with 5 % ferric chloride and observed for the formation of deep blue or black colour. ii. Liebermann’s test: The extract was heated with sodium nitrite, added H2SO4 solution diluted with water and excess of dilute NaOH was added and observed for the formation of deep red or green or blue colour. Test for Glycosides Dilute sulphuric acid (5ml) was added to 0.1g each, of the extracts in a test tube and boiled for 15 minutes in a water bath. It was then cooled and neutralized with 20% potassium hydroxide solution. A mixture, 10ml of equal parts of Fehling’s solution A and B was added and boiled for 5 minutes. A more dense red precipitate indicates the presence of glycoside. Test for Steroids and Terpenoids A quantity (9ml) of ethanol was added to 1g each of the extracts and refluxed for a few minutes and filtered. Each of the filtrates was concentrated to 2.5ml in a boiling water bath. Distilled water, 5ml was added to each of the concentrated solution, each of the mixtures was allowed to stand for 1 hour and the waxy matter was filtered off. Each of the filtrates was extracted with 2.5ml of chloroform using a separating funnel. To 0.5ml each of the chloroform extracts in a test tube was carefully added 1ml of concentrated sulphuric acid to form a lower layer. A reddish-brown interface shows the presence of steroids. To another 0.5ml each of the chloroform extract was evaporated to dryness on a water bath and heated with 3ml of concentrated sulfuric acid for 10 minutes in a water bath. A grey colour indicates the presence of terpenoids. Test for Saponins A quantity (0.1g) each of the extract (ethanol) was boiled with 5ml of distilled water for 5 minutes. The mixture was filtered while still hot and the filtrates used for the following tests: i. Emulsion Test: A quantity (1ml) each of the filtrates was added drops of olive oil. The mixture was added to another two drops of olive. The mixture was shaken and observed for the formation of emulsion. ii. Frothing Test: A quantity (1ml) of the different filtrates was diluted with 4ml of distilled water. The mixture was shaken vigorously and then observed in standing for a stable froth. Test for Tannins A quantity (2g) each, of the extracts (n-hexane and water) was boiled with 5ml of 45% ethanol for 5 minutes. Each of the mixtures was cooled and filtered. The different filtrates were subjected to the following tests. i. Lead Sub-acetate Test: To 1ml of the different filtrates was added 3 drops of lead sub-acetate solution. A cream gelatinous precipitate indicates the presence of tannins. ii. Ferric Chloride Test: A quantity (1ml) each of the filtrates was diluted with distilled water and added 2 drops of ferric chloride. A transient greenish to black color indicates the presence of tannins. Test for Proteins A quantity (5ml) of distilled water was added to 0.1g each, of the extracts. This was left to stand for 3 hours and then filtered. To 2ml portion of the filtrate was added 0.1ml Millon’s reagent. It was shaken and kept for observation. A yellow precipitate indicates the presence of proteins. 95 Subash KR et al., Int J M ed res Healt h Sci. 2012;2(1):93-100 Burette Test: A quantity (2ml) each of these extracts was put in a test-tube and 5 drops of 1% hydrated copper sulphate was added. A quantity, 2ml of 40% sodium hydroxide was also added and the test-tube shaken vigorously to mix the contents. A purple coloration shows the presence of proteins (presence of two or more peptide bonds). Test for Carbohydrate A quantity of 0.1g each of the extracts was shaken vigorously with water and then filtered. To the aqueous filtrate was added a few drops of Molisch reagent, followed by vigorous shaking again. Concentrated sulphuric acid, 1ml was carefully added to form a layer below the aqueous solution. A brown ring at the interface indicates the presence of carbohydrate. Acute oral toxicity study Acute oral toxicity was conducted as per the Organization of Economic Cooperation and Development (OECD) guidelines 423 (Acute Toxic Class Method). The acute toxic class method is a stepwise procedure with 3 animals of a single sex per step. Depending on the mortality and /or moribund status of the animals, on the average 2-4 steps may be necessary to allow judgment on the acute toxicity of the test substance. This procedure results in the use of a minimal number of animals while allowing for acceptable data based scientific conclusion. The method uses defined doses (5, 50, 300, 2000 mg/kg body weight) and the results allow a substance to be ranked and classified according to the Globally Harmonized System (GHS) for the classification of chemicals which cause acute toxicity. Wistar albino rats of either sex weighing 200-250 g were fasted overnight, but allowed water ad libitum. Since Alpinia galanga is relatively nontoxic in clinical practice where the rhizome powder 1-3 gm is used5. The highest dose of 2000mg/kg/p.o. directly (as per OECD guidelines “Unclassified”) was used in the acute toxicity study6. The animals were observed closely for behavioral toxicity, if any by using functional observation battery which includes central nervous system signs of excitation, depression, motor activity and autonomic nervous system. Biochemical studies The procedures were followed as per standard laboratory technology. Estimation of glucose Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Alkaline phosphatase (ALP) Urea was estimated using a commercial Glucose estimation kit (Span Diagnostics) by standard methods 7. Haematological studies Erythrocyte count, Total Leukocyte Count (WBC) and Hemoglobin was estimated by Hemocytometer method8. Statistical analysis Total 3 rodents are used as per the guidelines provided by OECD 423 and the results were expressed as mean ± standard error of mean (S.E.M.) RESULTS AND DISCUSSION Phytochemical analysis Alpinia galanga belongs to the family Zingiberaceae. The ethanolic extract of Alpinia galanga had an extractive yield of 2.24% with total ash value of 6.17 %, water soluble ash 2.26 % and acid insoluble ash of 3.78% (Table-1). Qualitative phytochemical analysis revealed the presence of various constituents such as alkaloids, carbohydrates, saponins, tannins, protein, glycosides, flavonoids, steroids and terpinoids. Quantitative Phyto chemical analysis of ethanolic extract of Alpinia galanga is reported to have maximum total phenol and flavonol content9. The results for qualitative Phyto chemical analysis were tabulated in Table no -2. 96 Subash KR et al., Int J M ed res Healt h Sci. 2012;2(1):93-100 Table:1. Physical properties extractive values of ethanolic extract of A. galanga S. No Parameters Results 1 Loss of drying @ 100 degree Celsius 0.42 % 2 Total ash value 6.17 % 3 Water soluble ash 2.26 % 4 Acid insoluble ash 3.78 % 5 pH at 10% aqueous solution 3.04 % 6 extractive yield - solvent ethanol 2.24% Table: 2. Preliminary Qualitative Phytochemical study of ethanolic extract of A.galanga Sl No Constituents 1 Alkaloids 2 Carbohydrates 3 Steroid& Terpenoids 4 Protein 5 Phenols 6 Tannins 7 Flavanoids Test Observation Inference Intensity Mayer’s reagent Wagner’s reagent Picric Acid (1%) Dragendorff’s test Molisch reagent Fehling A&B Benedict’s reagent Liebermann Burchard Burette Test Milky precipitate Reddish brown precipitate Yellow precipitate Red precipitate Dull violet colour Red precipitate Dark green colour Purple coloration + + + + +++ ++ +++ +++ ++ Ninhydrin test Ferric chloride test Liebermann’s test 10% lead acetate Braymer’s test Ammonium Test Aluminum Chloride Glacial acetic acid, FeSO4 , Con H2SO4 Purple coloration Deep blue colour Deep green colour No changes No changes Yellow colouration Yellow precipitate Red precipitate +++ ++ + _ _ + ++ +++ & Glycosides Foam test No foam _ 8 Saponin Emulsion test No emulsion _ 9 (+) denotes the presence of the respective class compound, (-) denotes the absence of the respective class compound From this study, the presence of phenolic compounds such as terpenoids, steroids (phytosterols i.e. ß-sitosterol) in ethanolic extract of Alpinia galanga may contribute to the antioxidant properties benefited by traditional medicine use. For many years now, it has been 97 Subash KR et al., Int J M ed res Healt h Sci. 2012;2(1):93-100 known that plant polyphenols (steroids, terpenoids, flavonoids etc) are antioxidants in vitro10. These antioxidants are compounds that reduce the formation of free radicals or react with and neutralize them thus potentially protecting the cell from oxidative damage 11. The tannins and resins in the extract are employed as astringent both in the gastrointestinal tract and on skin abrasions by traditional medicine. The flavonoids and phenolic compounds in plants have been reported to exert multiple biological effects including antioxidant, free radical scavenging abilities, anti inflammatory, an anti carcinogenic activity which are detected in extract 12. Acute Toxicity The acute toxicity study was done as per the guidelines laid by The Organization for Economic Co-operation and Development (OECD). The OECD Test Guidelines are recognized world-wide as the standard reference tool for chemical testing. Since available literature information suggests that mortality is unlikely at the highest starting dose level (2000 mg/kg body weight), the limit test is performed as explained in materials and methods. There was no gross difference in body weight of the control and extract treated group, observed for over the period of 14 days (Table-3). .. Table:3. Body weight, Death and Toxicity observations of EE Alpinia galanga Animal identity (markings) BODY WEIGHT (gm) Signs of toxicity (Day 0-14) Body Weight changes(gm) (Day 0 & 14) Day-7 23.30 23.35 24.95 Day-14 23.30 24.37 24..95 No death No death No death Nil Nil Nil 00.06 00.05 00.05 EE Alpinia galanga 24.80 HEAD 24.80 24.86 No death Nil 00.06 25.50 25.55 25.57 No death Nil 00.07 HEAD NECK TAIL NECK Initial 23.24 23.32 24.90 Date of death prior to sacrifice 24.00 24.05 24..08 No death Nil 00.08 TAIL observed for first four hours, twenty four hours, Similarly all six animals three in each group are day 7 and day 14 for central nervous system individually observed daily for position, activity, excitation, depression, autonomic nervous system food, water intake and signs of toxicity like and motor activity. The extract revealed normal hyperactivity, circling, jumping/hopping, behavioral activity. At the end of 14 days the excessive grooming, kicking of rear legs, standing on front legs and gait abnormalities. The control and ethanolic extract of A.galanga treated observation revealed normal activity in both group was sacrificed and investigated for groups (Table -4) haematological, biochemical and necropsy analysis. The results revealed no significant Behavioral hematological and biochemical difference in haematological, biochemical studies Gross behavioural studies of ethanolic extract of parameters (Table-5 & 6) and in necropsy A.galanga – 2000mg/kg and control group observation of sacrificed animals did not show any gross abnormalities in tissues and major organ. 98 Subash KR et al., Int J M ed res Healt h Sci. 2012;2(1):93-100 Table:4. Individual cage -side observations Animal identity (markings) Position Onset of toxicity Activity Food and Water Signs of toxicity intake Control HEAD Normal Normal Adequate Nil Nil NECK Normal Normal Adequate Nil Nil Normal TAIL EE Alpinia galangal Normal Adequate Nil Nil HEAD Normal Normal Adequate Nil Nil NECK Normal Normal Adequate Nil Nil TAIL Normal Normal Adequate Nil Nil Table:5. Effect of EE Alpinia galanga rhizome on hematological parameters after 14 days of acute toxicity testing in Swiss albino mice Groups Hb % RBC WBC Differential leukocyte count (%) (n=3) (gm) (milli/cu.mm) (cells/cu.mm) Control 15.03 + 2.49 10.85 + 1.63 EE Alpinia 15.61 + 3.46 11.68 + 1.48 Lymphocytes Monocytes Granulocytes 7.05 + 0.56 71 19 8.9 7.96 + 1.59 75 15 9 galanga Table:6. Effect of EE Alpinia galanga rhizome on biochemical markers after 14 days of acute toxicity testing in Swiss albino mice Groups AST (IU/L) ALT (IU/L) Urea (mg/dl) Creatinine Glucose (mg/dl) (mg/dl) Control (D. W) 45.50 + 3.19 14.40 + 0.73 56.07 + 2.06 0.48 + 0.40 286.04 + 3.96 EE Alpinia galangal 47.45 + 2.44 13.78 + 1.65 54.04 + 1.78 0.48 + 0.35 279.71 + 18.39 CONCLUSION Selection of scientific and systematic approach to the biological evaluation of plant products based on their use in the traditional system of medicine forms the basis for an ideal approach in the development of new drugs from the plant 13. Phytochemical screening of Alpinia galanga has revealed the presence of many complex substances including phenols and flavanoids Subash KR et al., which are responsible for many biologic activity and acute toxicity test in the present study has revealed that the ethanolic extract of Alpinia galanga substance is classified in the hazard category 2000mg/kg < LD50 < 5000mg/kg according to globally harmonized classification system. 99 Int J M ed res Healt h Sci. 2012;2(1):93-100 ACKNOWLEDGEMENTS The Author profoundly thanks the Vice principal Dr M. Chandrasekhar Meenakshi Medical College and Research Institute, and Mr. Purushothaman, for providing assistance in utilizing central research lab facilities. REFERENCE 1. Strobel G, Daisy B. Bioprospecting for microbial endophytes and their natural products. Microbiology and Molecular Biology Review.2003, 67: 491-02. 2. Ayurveda Pharmacopoeia. Department of Ayurveda, Colombo, Sri Lanka. 1979,l: Part 2 & 3:11-25 3. Barnes J. Trease and Evans' Pharmacognosy. Focus on Alternative and Complementary Therapies. 1999, 4: 151–152. 4. Harborne JB. Phytochemical methods: a guide to modern techniques of plant analysis. London: Chapman & Hall. 1998, 3rd ed:302 . 5. Khare CP. Encyclopedia of Indian Medicinal Plants. Springer, 2007, 1st edition, 44-45. 6. Ecobichon DJ. The basis of toxicity testing. CRC Press, New York, 1997, 43-86. 7. Kanai L. Mukherjee. A text book of medical laboratory technology. A procedure manual for routine diagnostic tests. Tata McGraw Hill Publishing company ltd. 1999; 1:265-76. 8. Miale JB. Laboratory Medicine: Haematology. 4th Ed. C.V. Mosby co, St.Louis, 1972; 1198-09 9. Dhanabal SP, Satish kumar MN, Parth Kumar H, Bavadia, Srividya . Antioxidant and Antidiabetic Activity of Alpinia Galanga. IJPPR.2011, 3(1):6-12 10. Rice-Evans CA, Miller NJ, and Paganga G. The relative antioxidant activity of plant derived polyphenolic flavonoids. Free Rad Res. 1995; 22(4): 375-83 11. Delanty N, and Dichter MA. Antioxidant therapy in neurological disease. Arch Neurol., 2000; 57(9): 1265-70. 12. Prashant Tiwari, Bimlesh Kumar, Mandeep Kaur, Gurpreet Kaur, Harleen Kaur Phytochemical screening and Extraction: A Review International Pharmaceutica Sciencia . 2011;1(1): 98-106. 13. Kar DM, Maharana L, Parrnik S, Dash GK. Studies on hypoglycemic activity of solanum xanthocarpum schrad & Wendl fruit extract in rats. Journal of Ethnopharmacology. 2006; 108: 251-56. 100 Subash KR et al., Int J M ed res Healt h Sci. 2012;2(1):93-100 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 Received: 9th Dec 2012 Revised: 25th Dec 2012 Accepted: 31st Dec 2012 Original research article DEHYDROEPIANDROSTERONE LEVELS AND COGNITIVE FUNCTION IN AGING *Rathna Kumari U1, Padma K2 1 PG Resident, 2 Director, Institute of Physiology and experimental medicine, Madras Medical College, Chennai-03 * corresponding author email: uratna_1986@yahoo.co.in ABSTRACT Background: Dehydroepiandrosterone (DHEA) is a steroid hormone secreted by the adrenal cortex. Recent research reports show that DHEA has various beneficial effects including neuro protective effects and that the decline in its production with aging may contribute to neuronal dysfunction and degeneration, and thus cognitive decline.Aim: To assess the cognitive functions and estimate the levels of DHEA in subjects of the same age group. Materials and Methods: A cross sectional comparative study of sixty healthy male participants between 60 to 70 years of age was done. They did not have other medical disorders likely to affect cognitive function. Their performance in the principal domains of cognition, i.e. memory, attention and concentration, verbal fluency, language and visuospatial functioning was observed. Serum levels of DHEA were estimated for all the participants by ELISA method. Results: A significant positive correlation was observed between DHEA level and three domains of cognition viz., visuospatial skills (r = 0.95), verbal fluency (r = 0.49) and short term memory (r = 0.28). No association was found with other domains of cognition. Conclusion: Subjects with low levels of serum DHEA among the same age group showed a significant decline in visuospatial skills, short term memory and verbal fluency. Keywords: Dehydroepiandrosterone sulphate, Cognitive function. INTRODUCTION Dehydroepiandrosterone (DHEA) is a steroid, mainly of adrenal origin, that is found in relatively high concentrations in human plasma. It serves as a precursor of both androgenic and estrogenic steroid hormones. In the circulation, DHEA exists both free and bound to sulphate (DHEA-S). Thus, DHEA-S serves as the principal storage form of DHEA. DHEAS – has many intrinsic effects like antiaging, antiobesity, antidiabetic, anti 1 atherogenic and neuroprotective effects . A progressive decrease in circulating levels of DHEA with age has long been recognized, with peak levels occurring between the third and fourth decades of life and decreasing progressively thereafter by about 90% over the age of 85. Though DHEAS levels peak at around 25 years of age and starts declining with increase in age, it is subject to wide inter-individual variations. Its levels are also affected by factors like gender, physical activity etc. Recent research reports show Rathna et al., Int J Med res Health Sci. 2013; 2(1):101-106 101 that decline in DHEA production with aging may contribute to neuronal dysfunction and degeneration, and thus cognitive decline. Animal experiments showed that DHEAS can enhance neuronal and glial survival and differentiation in culture2, 3. Administration of DHEA has been reported to have striking beneficial effects on memory. Their cognitive performances were directly related to increases in plasma levels of DHEA and DHEA-S4. The present study thus was performed to investigate possible associations between DHEA levels and cognitive performance in healthy elderly men. MATERIALS AND METHODS , After the institutional ethical approval the present study was conducted in the Institute of Physiology and Experimental medicine, Madras Medical College, Chennai. After obtaining informed consent, sixty healthy male subjects (who had completed at least 10 years of basic school education) aged between 60 and 70 years were selected randomly from the urban population of Chennai city. They did not have other medical disorders likely to affect cognitive function. We explained the scope and details of the study to the subjects. The subjects underwent routine clinical examination and biochemical tests to satisfy the selection criteria. . Fasting blood samples of the subjects were obtained for estimation of DHEA-S. Fasting blood samples were obtained under strict aseptic precautions, by venepuncture of the antecubital vein. The serum was separated and stored in the deep freezer at -20 0 C. The serum levels of DHEA-S was measured using ELISA kits viz. serum Dehydroepiandrosterone sulphate estimation supplied by Cal biotech Inc (California). The Addenbrooke's Cognitive Examination- Revised (ACE-R) 16 was applied to all the participants. It is a brief and simple cognitive screening tool. It is established as a sensitive screening test for Mild Cognitive Impairment, dementia and Alzheimer’s disease. It takes about 15 minutes to administer this test for each participant. Table: 1. ACE-R five major domains of cognition and normal values. Attention Memory Verbal fluency Language Visuospatial functioning Nor mal Values Below nor mal/ poor 16 and above 17 and above 9 and above 22 and above 14 and above <16 <17 <9 <22 <14 RESULTS In our study the mean DHEA level (µg/dl) of the subjects was (142.9 ± 36). We observed a significant positive correlation between DHEA level and three domains of cognition viz., visuospatial skills (r = 0.95), verbal fluency (r = 0.49) and short term memory (r = 0.28). No significant association was found with other domains of cognition 102 Rathna et al., Int J Med res Health Sci. 2013; 2(1):101-106 Fig:1.Correlation between DHEA (µg/ dl) and verbal fluency. Fig:2.Correlation between DHEA (µg/ dl) and visuospatial skills. Fig:3. Correlation between DHEA (µg/dl) and short term memory. 103 Rathna et al., Int J Med res Health Sci. 2013; 2(1):101-106 Table: 2. Correlation between DHEA and Visuospatial skills DHEA Pearson Correlation DHEA VISUOSPA DHEA VISUOSPA DHEA VISUOSPA Sig. (2-tailed) N **. VISUOSPA 1.000 .952** . .000 60 60 .952** 1.000 .000 . 60 60 Correlation is significant at the 0.01 level Table: 3. Correlation between DHEA and Short Term Memory. DHEA Pearson Correlation DHEA STM DHEA STM DHEA STM Sig. (2-tailed) N *. STM 1.000 .279* . .031 60 60 .279* 1.000 .031 . 60 60 Correlation is significant at the 0.05 level Table: 4. Correlation between DHEA and Verbal Fluency DHEA Pearson Correlation DHEA FLUEN DHEA FLUEN DHEA FLUEN Sig. (2-tailed) N **. FLUEN 1.000 .487** . .000 60 60 .487** 1.000 .000 . 60 60 Correlation is significant at the 0.01 level Table 5: Correlation between DHEA and Long Term Memory. DHEA Pearson Correlation Sig. (2-tailed) N DHEA LTM DHEA LTM DHEA LTM LTM 1.000 .059 . .655 60 60 .059 1.000 .655 . 60 60 No significant correlation Table 6: Correlation between DHEA and Language skills. DHEA Pearson Correlation Sig. (2-tailed) N DHEA LANG DHEA LANG DHEA LANG LANG 1.000 .068 . .604 60 60 .068 1.000 .604 . 60 60 No significant correlation 104 Rathna et al., Int J Med res Health Sci. 2013; 2(1):101-106 DISCUSSION Debonnel et al in the year 1996 showed that DHEA acts on the central nervous system to increase the effects of the excitatory neurotransmitter, glutamate, and decrease the effects of the inhibitory neurotransmitter, GABA5. DHEA and its sulfated form are considered neuroactive because they affect the GABA-A receptor complex and NMDA-mediated glutamate transmission via sigma receptors12. Studies have also shown that DHEA increases neuronal excitability, enhances neuronal plasticity and acts as a neuroprotective agent 6. Blauer et al in 1991observed that both the immunological and neural effects of DHEA/S may be related to their powerful 7. antiglucocorticoid action It has been proved that very high levels of cortisol can cause damage to neurons, particularly in the hippocampus8. The adverse effects of cortisol which might be seen during stress or trauma may be counteracted by the high levels of DHEA. Lower levels of DHEA in older adults may make them more vulnerable to the damaging effects of cortisol9. In vitro studies have proved that DHEA can increase the proliferation of human neural stem cells and the number of neurons. Some research studies showed lower levels of DHEA in the serum of patients diagnosed with dementia10. DHEA and DHEA sulfate are proved to be neurosteroids that modulates learning and memory11. Wolf et al in 1997 found significant improvement following DHEA administration compared with placebo in both immediate recall and delayed recall memory test13. Higher endogenous DHEAS levels were independently and favorably associated with better executive function, concentration, and working memory15. Crosssectional studies have reported a relationship between the prevalence of Alzheimer’s disease and low dehydroepiandrosterone sulphate (DHEA-S) plasma levels14. CONCLUSION In an aim to find an association between DHEA levels and cognitive functions in healthy ageing, we found that higher levels of DHEA was linked to better visuospatial skills, verbal fluency and short term memory. Recently, there has been a resurgence of interest in DHEA, because it has been suggested that it might have anti-ageing effects. It has also been suggested that serum DHEA may be represented as a biomarker of healthy aging and physiological methods of improving its levels by physical activity, diet etc., are topics of recent research. Hence, age related cognitive decline, Alzheimer’s disease and its associated complications which are considered as an expanded spectrum of accelerated ageing can attribute a part of its pathogenesis to lowering DHEA levels. Further research on this topic can derive clues to pathogenesis of ageing. REFERENCES 1. Adams JB. Control of secretion and function of C19-delta 5-steroids of the human adrenal gland. Mol Cell Endocrinol 1985; 41:1–17. 2. Roberts E, Bologa L, Flood JF, Smith GE. Effects of dehydroepiandrosterone and its sulfate on brain tissue in culture and on memory in mice. Brain Res. 1978; 406:357– 62. 3. Bologa L, Sharma J, Roberts E. 1987 Dehydroepiandrosterone, and its sulfated derivative reduce neuronal death and enhance astrocytic differentiation in brain cell cultures. J Neurosci Res.1987; 17:225–34 4. Wolkowitz, Owen M., et al. Dehydroepiandrosterone (DHEA) treatment of depression. Biological Psychiatry.1997; 41(3): 311-18. 5. Debonnel G, Bergeron R, and de Montigny C. Potentiation by dehydroepiandrosterone of the neuronal response to N-methyl-D-aspartate in the CA3 region of the rat dorsal hippocampus: 105 Rathna et al., Int J Med res Health Sci. 2013; 2(1):101-106 an effect mediated via sigma receptors. Journal of Endocrinology 1996;150:S33-42. 6. Kimonides VG, Khatibi NH, Svendsen CN, Sofroniew MV, Herbert J. Dehydroepiandrosterone (DHEA) and DHEAsulfate (DHEAS) protect hippocampal neurons against excitatory amino acid-induced neurotoxicity. Proceedings of the National Academy of Sciences USA 1998; 95:1852-57. 7. Blauer KL, Poth M, Rogers WM, Bernton EW. Dehydroepiandrosterone antagonises the suppressive effects of dexamethasone on lymphocyte proliferation. Endocrinology 1991; 129:3174-79. 8. Lupien SJ, de Leon M, de Santi S, Convit A, Tarshish C, Nair NPV. Cortisol levels during human aging predict hippocampal atrophy and memory deficits. Nature Neuroscience 1998; 1(1):69-73. 9. Herbert J. Stress, the brain, and mental illness. BMJ 1997; 315:530-35. 10. Hillen T, Lun A, Reischies FM, Borchelt M, Steinhagen TE, Schaub RT. DHEA-S plasma levels and incidence of Alzheimer's disease. Biological Psychiatry 2000; 47(2):161-163. 11. Baulieu EE, Robel P. Dehydroepiandrosterone and dehydroepiandrosterone Sulfate as neuroactive neurosteroids. J Endocrinol 1996; 150:S221–39 12. Bergeron R, Montigny CD, Debonnel G. Potentiation of neuronal NMDA response induced by dehydroepiandrosterone and its suppression by progesterone: effects mediated by sigma receptors. J Neurosci 1996; 16(3):1193–202. 13. Wolf OT, Neumann O, Hellhammer DH, Geiben AC, Strasburger CJ, Dressendorfer RA, et al. Effects of a 2-week physiological dehydroepiandrosterone substitution on cognitive performance and well-being in healthy elderly women and men. J Clin Endocrinol Metab 1997; 82(7):2363–67. 14. Hillen, Thomas, et al. DHEA-S plasma levels and incidence of Alzheimer’s disease. Biological psychiatry.2000; 47(2): 161-63. 15. Davis SR, Shah S, McKenzie D, Kulkarni J, Davison S, Bell R. Dehydroepiandrosterone Sulfate Levels Are Associated with More Favorable Cognitive Function in Women. Clinical Endocrinology and Metabolism 2008; 93(3):801–08. 16. Mioshi, Eneida, et al. The Addenbrooke's Cognitive Examination Revised (ACE‐R): a brief cognitive test battery for dementia screening. International journal of geriatric psychiatry. 2006; 21(11): 1078-85. 106 Rathna et al., Int J Med res Health Sci. 2013; 2(1):101-106 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 Received:2 nd Dec 2012 Revised: 20 th Dec 2012 Accepted: 25 th Dec 2012 Review article TRANSGENIC ANIMALS AND THEIR APPLICATION IN MEDICINE *Bagle TR1, Kunkulol RR2, Baig MS3, More SY4. 1 Assistant Professor, 2 Associate Professor, Department of Pharmacology, Pravara Institute of Medical Sciences-Deemed University(PIMS-D), Loni, Maharashtra.-413736. 3 Assistant Professor, Government Medical College, Aurangabad, Maharashtra. 431001 4 Research Student, Department of Pharmaceutical Chemistry, Prin.K.M.Kundnani College of Pharmacy, Colaba, Mumbai, Maharashtra.400005. *Corresponding author email: tusharbagle@gmail.com ABSTRACT Transgenic animals are animals that are genetically altered to have traits that mimic symptoms of specific human pathologies. They provide genetic models of various human diseases which are important in understanding disease and developing new targets. In early 1980 Gordon and co-workers described the first gene addition experiment using the microinjection technology and since then the impact of transgenic technology on basic research has been significant. Within 20 years of its inception, ATryn the first drug approved by USFDA from transgenic animals was developed and it has opened door to drugs from transgenic animals. In addition, they are looked upon as potential future donors for xenotransplantation. With increasing knowledge about the genetics and improvements in the transgenetic technology numerous useful applications like biologically safe new-generation drugs based on human regulatory proteins are being developed.Various aspects of concern in the coming years are the regulatory guidelines, ethical issues and patents related to the use of transgenic animals. This modern medicine is on the threshold of a pharmacological revolution. Use of transgenic animals will provide solutions for drug research, xenotransplantation, clinical trials and will prove to be a new insight in drug development. Keywords: Transgenic animals, Xenotransplantation, Ethics, Patent. INTRODUCTION With the advent of transgenic technology and its application in many laboratories around the world, there is an increase in the generation and use of genetically modified animals in biomedical, pharmaceutical research and safety testing. This development has been additionally accelerated by the decoding the genome of man, mouse and rat.1 Pharmaceutical companies are faced with the challenge that about 10% of compounds tested in clinical trials make to the market and, out of these, a minority will generate significant profit. The cost 107 Bagle TR et al., Int J Med Res Health Sci. 2012;2(1):107-116 of identifying new drug is immense, about United States (US) $ 800 million and 80% of this cost is spent in clinical trials and development. Transgenic technology has potential to influence the attrition rate in pharmaceutical research by increasing the quality of both targets and compounds. 2 To date most of the medicines are synthetically produced and will continue in future. However, the challenge for the pharmaceutical industry is the development of ‘Biotech medicines’ which include therapeutic proteins such as enzymes and antibodies. 3 The global market for recombinant proteins from domestic animals is expected to exceed US$1 billion in 2008 and reach US$18. 6 billion in 2013.4 The two major animal systems of production are pharmaceutical proteins in milk and egg white from transgenic animals. 1 Since the first transgenic mice were generated in 1982, transgenic animal models have been used extensively to investigate biomedical important mechanisms underlying a variety of diseases, to develop and evaluate new therapies. 5 Thus transgenic animals have the ability to fulfill the needs of the pharmaceutical industry and in coming years they are looked as potential contributors to the drugs and research in medicine. Making of Transgenic Animals There are three types of laboratory animal models mentioned in the literature. They are spontaneous, induced and transgenic. Spontaneous models shape up as a result of naturally occurring mutations. Induced models are produced by a laboratory procedure like administration of a drug or chemicals, feeding of special diets or surgical procedure. The third category includes transgenic models.6Transgenic refers to insertion of cDNA (complimentary deoxyribonucleic acid) made from specific mRNA (messenger ribonucleic acid) into cells.7 A transgenic animal is defined as an animal which is altered by the introduction of recombinant DNA through human intervention. 8 Following sequence is generally adopted for the development of transgenic animals irrespective of species: 1, 9  Identification and construction of the foreign gene and any promoter sequences  Introduction of DNA directly into the pronucleus of a single fertilized egg by various methods  Implantation of these engineered cells into surrogate mothers  Bringing the developing embryo to term, proving that the foreign DNA has been stably and heritably incorporated into the DNA of at least some of the newborn offspring.  Demonstrating that the gene is regulated well enough to function in its new environment. The foreign DNA can be inserted into the pronucleus or cytoplasm of the embryo using microinjections or transposon. Other methods of DNA transfer are by lentivirus, sperms, pluripotent cells and cloning. The last three methods allow random gene addition and targeted gene integration via homologous recombination or gene 1,6 replacement thus causing mutation. Targeted mutation refers to a process whereby a specific gene (removal of a gene or part of a gene) is made nonfunctional (knocked-out) or less frequently made functional (knocked-in). 4, 7 A transgenic organism carrying more than one transgenes is known as multiple transgenic. 4These methods do not create new species, but only offer tools for producing new strains of animals that carry novel genetic information. 10 Transgenic Animal models of various diseases An animal model is a living, non-human animal used for research and investigation of human disease, for the purpose of better understanding the disease without the added risk of causing harm to a human being during the entire drug discovery and development process. Transgenic animal models are created by the insertion of a particular human DNA into fertilized oocytes which are then allowed to develop to term by implantation into the oviducts of pseudo pregnant females.6 There are 108 Bagle TR et al., Int J Med Res Health Sci. 2012;2(1):107-116 different models of transgenic animals for various diseases. A. Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome (HIV/AIDS): Tg26 HIVAN Mouse Model was the first transgenic model developed in 1991 for HIV. Since than many models have developed, Rosenstiel et al gives summary of 32 transgenic murine HIVAN models developed. 11 These transgenic animals can express HIV-1 proteins; develop symptoms and immune deficiencies similar to the manifestations of AIDS in humans. 12 Other models are AIDS Mouse and Smart Mouse. 6 B. Alzheimer’s disease: No animal models existed for the disease before transgenic technology was employed. Immunization of Amyloid precursor protein A42 in transgenic mice showed that vaccination against Alzheimer’s disease could have potential as a therapeutic approach.2, 6 Different animal models like Alzheimer’s mouse, amyloid pathology mouse models like PDAPP mice, Tg2576 mice, 13, 14 TAU transgenic mouse models like ALZ7 mice, 7TauTg mice and presenilin transgenic models like ApoE knockout are developed to study Alzheimer’s disease. 13, 15 C. Cardiovascular disease: Various transgenic animal models for gain and or loss of function of angiotensin, endothelin, natriuretic peptides, catechoalmines, Calcium binding-signaling, sodium channel transporters, and nitric oxide synthesis involved in cardiovascular regulation are used to study cardiovascular diseases.16 Transgenic models of heart failure and hypertrophy like Gene overexpression of Calmodulin, Gene mutation of alpha cardiac myosin heavy chain and Knockout gene model of transforming growth factor are developed.17 Mutation of the ApoE gene that is critical for uptake of chylomicrons and very lowdensity lipoprotein particles, results in a model that develops atherosclerotic lesions histologically similar to those found in humans.2 D. Diabetes Mellitus: Transgenic models are developed for studying the genes, and their role in peripheral insulin action. Models of insulin Bagle TR et al., secretion such as glucokinase, islet amyloid polypeptide, and hepatic glucose production in type 2 diabetes are developed. 18A transgenic mouse model that expressed Insulin Dependent Diabetes Mellitus by inserting a viral gene in the animal egg stage is also developed.19 There are other models like beta receptor knockout mouse, uncoupling protein (UCP1) knockout mouse,acute and chronic models for the evaluation of antidiabetic agents. 18, 20, 21, 22 E. Angiogenesis: Mouse models of angiogenesis, arterial stenosis, atherosclerosis, thrombosis, thrombolysis and bleeding addresses techniques to evaluate vascular development.23 Inhibition of angiogenesis is currently one of the biggest opportunities for new cancer therapies. With the help of angiogenesis transgenic animal models inhibitors are identified which act on specific mechanisms of angiogenesis. 2 F. Cancer diseases: Oncomouse was first transgenic animal to be patented. Its germ cells and somatic cells contain an activated human oncogene sequence introduced into the animal at an early embryonic stage to ensure that the oncogene is present in all the animal cells.6 Mechanisms for tumor progression and metastasis via E-cadherin, and other adhesion molecules is possible by various transgenic knockout models. 7 Transgenic animal models are used in the assessment of mutagenicity, carcinogenicity and tools for understanding metabolic enzymes and receptors. 24 There are transgenic animal models for mutagenicity assays approved by the World Health organization like LACItransgenic model (Big Blue® construct) and LACZ transgenic model (Muta™Mouse construct). 25Variety of transgenic animals have been generated by different strategies in experimental immunotherapy of cancer, each aims to activate different immune system components. Some of them are transgenic rodent models expressing tumor associated antigens like MUC1 transgenic mice, Oncogene transgenic mice to study immunotherapeutic strategies, transgenic mice expressing immune effector cell molecules like Fc-receptor transgenic Int J Med Res Health Sci. 2012;2(1):107-116 109 mice 5 The preclinical transgenic model of Matrix Metalloproteinase (MMP) inhibitors studies the bioactive products of MMP and their possible effects on cell physiology. 26 Animal models for Huntington’s disease, skeletal muscle disease and other diseases are also developed.27, 28 Disease models are needed in medicine so that one can discover the targets for drug development. Adding and deleting genes in these animals provide them new properties that make them useful for better understanding of disease or manufacturing a cure. It is not ethical or safe to perform the initial tests in humans, so transgenic animals are used. As the testing of new vaccines and drugs must first be performed on animals, these disease models are indispensable. 6 Products from Transgenic Animals Most transgenic species are studied for research applications as well as potential commercial pharmaceutical productively. Here are some of the transgenic animals and their products in development. Goats: Monoclonal Antibodies (MAbs) , Ig fusion proteins, tPA (tissue Plasminogen Activator), ATryn (recombinant human antithrombin III) is the first transgenic recombinant protein from transgenic animal approved by the United States Food and Drug Administration (USFDA) in January 2009. 9,29 Chickens and Eggs: vaccines; interferons, cytokines; Human Serum Albumin (HSA), insulin, MAbs. 9 Pigs: organs for xenotransplantation, human hemoglobin, human protein C. 9,30,31 Cows: Factors VIII and IX, protein C, recombinant antithrombin III (rATIII), recombinant HSA, and human milk protein. 9 Mice: expression of malaria protein for vaccine development; MAbs, ATIII, beta interferon; cystic fibrosis transmembrane regulator; Factor X, HSA, tPA, myelin basic protein; prolactin; fibrinogen and antineoplastic urinary protein. 9 Rabbits: recombinant human C1 inhibitor, human erythropoietin, human alpha antitrypsin, human interleukin 2, tPA, alpha glucosidase, and human growth hormone. 9 Sheep: sheep milk includes fibrinogen (major constituent, with thrombin and Factor XIII) human Factor VII, Factor IX, activated protein C and alpha-1-antitrypsin. 9,31 Other Species: Frogs, nematodes, and marine invertebrates have been used to study various promoter elements and gene transfer technology. 9 Currently in most pharmaceutical companies, relatively large numbers of targets are validated to varying extents and progressed to the high throughput screening stage. The drugs acting on these targets are then used in clinical trials where the attrition rate is generally high, this makes it extremely costly. It is believed that the greater use of transgenic models could reduce the required throughput for achieving success and thereby significant impact on costs.10 Drugs from Transgenic Animals and Other Applications: Proteins started being used as pharmaceuticals in the 1920s with insulin extracted from pig pancreas. In the early 1980s, human insulin was prepared in recombinant bacteria and is now used by most of the diabetic patients. This success was limited as bacteria cannot synthesize complex proteins such as monoclonal antibodies or coagulation blood factors that must be matured by post-translational modifications to be active or stable in vivo. These can be fully achieved only in mammalian cells which can be cultured in fermenters or used in living animals. Several transgenic animals can produce recombinant proteins but presently two systems started being implemented. The first is milk of transgenic mammals and the second system are chicken egg white. A variety of recombinant proteins which includes antibodies, vaccines, blood factors, hormones, growth factors, cytokines, enzymes, milk proteins, collagen, fibrinogen and others are being developed in transgenic animals. 1,3,31 The mammary gland is the preferred production site, because of the quantities of protein that can 110 Bagle TR et al., Int J Med Res Health Sci. 2012;2(1):107-116 be produced in this organ and established methods for extraction and purification of these proteins.Products derived from the mammary gland of transgenic goats and sheep are ATIII, αantitrypsin and tPA. ATIII is employed for the treatment of heparin-resistant patients undergoing cardiopulmonary bypass. The enzyme αglucosidase from the milk of transgenic rabbits has been successfully used for Pompe’s disease. 4, 31 Blood, seminal plasma, urine, silk gland and insect larvae haemolymph are other theoretically possible systems. Blood most of the time cannot store high levels of recombinant proteins which are naturally unstable also biologically active proteins in blood may alter the health of the animals. Milk avoids essentially these problems and is presently the most mature systems to produce recombinant proteins from transgenic organisms. Now experiments validate egg white as a source of foreign proteins including recombinant vaccines. 1, 31 Blood replacement The current production system for blood products is donated human blood, and this is limiting because of disease concerns, lack of qualified donors, and regulatory issues. Genetically engineered animals, such as cattle carrying human antibody genes which are able to produce human polyclonal antibodies, have the potential to provide a steady supply of polyclonal antibodies for treatment of various infectious and medical conditions like organ transplant rejection, cancer, and autoimmune diseases and other diseases. 32 There are currently at least 33 different drugs in clinical testing including several in pivotal trials that contain variable regions from transgenic mice encoded by human sequences. Also there are 17 therapeutic MAbs approved by the USFDA which are in different phases of drug development. 33 Functional human haemoglobin has been produced in transgenic swine. The transgenic protein purified from the porcine blood showed oxygenbinding characteristics similar to natural human haemoglobin but only a small proportion of porcine red blood cells contained human form of haemoglobin. 4 Xenotransplantation of porcine organs to human patients Today more than 250,000 people are alive only because of the successful transplantation of an appropriate human organ (allotransplantation). However, progress in organ transplantation technology has led to an acute shortage of appropriate organs, and cadaveric or live organ donation does not meet the demand. To close the growing gap between demand and availability of appropriate human organs, porcine xenografts from domesticated pigs are considered to be the best alternative.4 Essential prerequisites for a successful 4, 34 xenotransplantation are: 1. Prevention of transmission of zoonoses 2. Compatibility of the donor organs in anatomy and physiology 3. Overcoming the immunological rejection of the transplanted organ. The immunological hurdles are: (a) Hyperacute rejection response (HAR) occurs within seconds or minutes. (b) Acute vascular rejection occurs within days. (c) Cellular rejection occurs within weeks after transplantation. (d) Chronic rejection is a complex immunological process resulting in the rejection of the transplanted organ after several years. Due to demand and unavailability of appropriate organs, xenotransplantation is considered as the solution of choice. The pig seems to be the optimal donor animal because their organs have a similar size as human organs, porcine anatomy and physiology is same and maintenance is possible at high hygienic standards at relatively low costs. 34, 35 Two main strategies have been successfully explored for long-term suppression of HAR, the knockout of α-gal epitopes which are the antigenic structures on the surface of the porcine cells that cause HAR and synthesis of human complement regulatory proteins in transgenic pigs. 31, 34, 36 111 Bagle TR et al., Int J Med Res Health Sci. 2012;2(1):107-116 Problems with drugs from transgenic animals: Erythropoietin could not be expressed in the mammary gland of transgenic cattle. The recovery rates of Factor VIII protein were low. 34 Another concern is leakage of a target protein into the circulation by way of the mammary epithelial cells and as measured by increased plasma levels of the protein designed to be expressed only in the animal’s milk. 9 There is also a risk of transmission of infection from animal to man. 31 There are some unique concerns such as premature lactational shut down observed in some animals expressing recombinant proteins in their mammary gland. 37 While there are problems associated with transgenic animals, the benefit derived from them is far superior and with the increase in technology this could be solved. Drugs from Transgenic Animals in Clinical Trials The approval of ATryn (rATIII) by USFDA has opened gates for other drugs from transgenic animals. 29 Recombinant C1 inhibitor produced in the milk of transgenic rabbits has completed phase III trials and is expected to receive registration. 4, 31 A topical antibiotic against Streptococcus mutans, for prevention and treatment of dental caries, has completed phase III trials. 34 Vaccine used in Alzheimers disease has restored neurological performance in the mice, and is currently in phase II human clinical trials. 6α-Glucosidase from the rabbit is in clinical trial phase II/III for Pompe’s disease. 31, 34 Products such as α-anti-trypsinused for cystic fibrosis, α-AT deficiency and tPA used for coronary clots are currently in phase II/III clinical trials and are expected to be on the market within the next few years. 34 Ethics in Transgenic Animals Genetic modification of micro-organisms and plants has least concern with regards to ethics but when it comes to genetic modification of animals and particularly humans, more objections are registered. There remains concern that with advances in transgenic animal technologies the number of animals used for research may actually increase rather than reduced because of a wider range of diseases and conditions. 38 Ethical concern with oncomouse is that it usually suffers in order to collect relevant information, which contradict the principles of animal rights.6Adenopolyposis coli knock-out mutant mice are clinically normal until the intestinal polyps develop, after which mice become anemic and lose weight. Each newly created transgenic strain has the potential to cause poor health and suffering in the animals hence measures need to be undertaken to minimize animal suffering. 39 Other ethical concerns are breaching species barriers and animal life should not be regarded as a chemical product subject to genetic alteration and patentable for economic benefit. Also genetic engineering of animals interferes with the integrity or telos of the animal. Telos is defined as the set of needs and interests which are genetically based, environmentally expressed, and which collectively constitute or define the form of life or way of living exhibited by that animal, and whose fulfillment or thwarting matter to that animal. 37 In India attitude towards animals is tinged with religious and ethical colour which makes religious sentiments and public awareness necessary to be taken in consideration.40 The 3R (Reduction, Refinement, Replacement) aim to minimize pain experienced by the animals used in 29 experiments. Inspite of the problems listed above, transgenic animals may represent a “refinement” in comparison to some other traditional experimental models of disease where animals bear a heavy load of suffering. A genotype is an excellent model of disease for selected body functions at the molecular or cellular level while the corresponding phenotype is completely healthy. Thus it becomes necessary to consider the moral implications of producing such a species as well as measures of reducing animal suffering. 39 Patents on Transgenic animals Patenting of animal models is the need of hour, because it is an indispensable tool for screening of novel molecule to various diseases. A human 112 Bagle TR et al., Int J Med Res Health Sci. 2012;2(1):107-116 pathological condition in animals is most important to determine the therapeutic efficacy of novel molecule. They allow facilitation of the screening process to eliminate inactive moieties and assess the pharmacologist to identify the therapeutic potential and characterize the toxicological profile of novel chemical or biological entities. 6 The two major aspects in granting patents to animal model are morality and reproducibility. 6 Other concerns like restrictive licensing of the patents can hinder transfer of knowledge. 41 Preclinical animal models are important in drug discovery, because they lay the fundamental for human trials. Patents remain one of the important ways of recovery of the investments made by the Pharmaceutical companies in research. The Indian Patent Law section 3i and 3 j states that all the surgical processes and animals are not patentable, hence animal models are not patentable in India. If the suitable amendments are made then animal models can be patentable in India and it would open novel vistas in the research arena in India. 6 Regulation in Transgenic Animals Pharmaceutical research on animals in India depends on Department of Biotechnology, National Institute of Immunology and Environment Protection Act. An Animal Welfare Board is constituted, with a Committee for the Control and Supervision of Experiments Animals (CPCSEA) which is in charge of legal and ethical aspects or animal research. General Guidelines on caring for animals in research are in accordance with the International Committee for Laboratory Animal Science (ICLAS) Guidelines. However there is no specific law or guidelines for cloned and transgenic animals. In 2000, Indian Council of Medical Research Report promotes transgenic animal research as long as it would pursue a higher scientific goal. 40, 42 With changes in the overall process of drug discovery, US patents of animal models encourage scientists in America and Europe to produce animal models which are very close to human disease and hence contribute significantly to the process of drug discovery. 6 The Indian regulatory authorities need to be prepared for such challenges of ethics, regulation and patents in transgenic animals. Future prospects Xenogenic cells, in particular from the pig, hold great promise with regard to successful cell therapy for human patients. Porcine islet cells transplanted to diabetic patients has shown to be partially functional over a period of time. Porcine fetal neural cells have been transplanted into the brain of patients suffering from Parkinson’s disease, Huntington’s disease, stroke and focal epilepsy. The advantages of porcine neural cells over their human counterparts are the abundant availability. 34The pig could be a useful model for studying defects of growth-hormone releasing hormone, which are implicated in conditions such as Turner syndrome, hypochrondroplasia, and intrauterine growth retardation.4 Eggs provide other non-invasive harvesting medium. Significant quantities of two human proteins, interferon beta-1a and a humanized monoclonal antibody (miR24) were expressed in the whites of eggs laid by transgenic hens. miR24 is being developed for malignant melanoma. 3 There are transgenic animals for the development of unique biological materials like polymers based on spider silks that may be useful as suture or plastic materials in facial and orthopedic restorative surgery. 43,37 It is impractical to obtain sufficient quantities of plasma butylcholinesterase (BChE) to treat humans exposed to organophosphorus agents in agriculture and chemical warfare, the production of recombinant BChE in milk of transgenic animals is under investigation. 44 It is proven that the amount of human antithrombin III obtained per year from transgenic goats is equivalent to this resulting from 90,000 human blood samplings. 1 Thus transgenic animals have the capacity of mass production and an effective alternative to various human byproducts. Improvements in transgenic technology include inducible gene expression, 113 Bagle TR et al., Int J Med Res Health Sci. 2012;2(1):107-116 artificial chromosomes and advancement in nuclear transfer. 34, 45, 36 Emerging transgenic technologies: 4, 31, 45  Lentiviral transfection of oocytes and zygotes,  Chimera generation via injection of pluripotent cells into blastocysts  Culture of spermatogonia and transplantation into recipient males  Ribonucleic acid interference Researchers are using transgenic animals to develop therapies for a wide range of diseases discussed above and other diseases like Anaemia, Emphysema, Haemophilia, Malaria and 3 Rheumatoid arthritis. CONCLUSION Major prerequisites for success and safety of transgenic animals will be a continuous refinement of reproductive biotechnologies. In coming years genetically modified animals will play a significant role in the field of biomedicine especially in drug development, animal disease models, xenotransplantation, antibody production, gene pharming and blood replacement. 4 The regulatory aspects and ethics should be given due consideration while using transgenic animals. From research, pigs and transgenic animals derived products like milk, eggs seems to be promising in developments of therapeutic strategies. Drugs from transgenic animals can minimize the attrition rate in clinical trials by increasing the quality of the target and compound combinations making the transition from discovery into development. Transgenic technology can impact at many points in the discovery process, including target identification and target validation. It also provides models designed to alert researchers early to the potential problems with drug metabolism and toxicity which will help in providing better models for human diseases. 2 Transgenic in general is a rapidly advancing field, and within 20 years of its inception it has produced the first USFDA approved drug for transgenic animals. Thus the use of transgenic animals has the capacity to overcome the current and future needs in medicine and is now a necessity rather than a matter of choice. REFERENCES 1. Houdebine LM. Production of pharmaceutical proteins by transgenic animals. Comparative Immunology Microbiology and Infectious Diseases. 2009;32:107-21 2. Snaith MR, Tornell J. The use of transgenic systems in pharmaceutical research. Briefings in Functional Genomics and Proteomics.2002; 1 (2): 119-30. 3. RDS: Understanding Animal Research in medicine and coalition for medical progress. Medical Advances And Animal Research The contribution of Animal Sciences to the Medical Revolution: Some Case Histories. [Serial on the Internet]. 2007. [Cited 2012 Nov 21]; Available from http://www.protest.org.uk/MAAR.pdf 4. Niemann H, Kues W, Carnwath JW. Transgenic farm animals: present and future. Rev.sci.tech. Off. Int. Epiz. 2005;24(1):285-98 5. McLaughlin PMJ. Kroesen BJ, Harmsen MC. Lou FMH. Cancer immunotherapy: insights from transgenic animal models. Critical reviews in Oncology/Hematology.2001; 40:5376 6. Kandhare AD, Raygude KS, Ghosh P, Gosavi TP, Bodhankar SL. Patentability of Animal Models: India and the Globe. International Journal of Pharmaceutical and Biological Archives. 2011; 2(4):1024-32. 7. Applied Research Ethics National Association. Institutional Animal Care and Use Committee Guidebook. [Homepage on the Internet]. 2002. [Cited 2012 Oct05]. Available from http://grants.nih.gov/grants/olaw/guidebook.pd f 8. United States Food and Drug Administration. 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HIV-1 transgene expression in rats induces differential expression of tumour necrosis factor alpha and zinc transporters in the liver and the lung. AIDS Research and Therapy. 2011;8(36):1-11. 13. Spires TL. Bradley TH. Transgenic Models of Alzheimer’s disease: Learning from Animals. The Journal of the American Society for Experimental Neurotherapeutics.2005; 2 (3): 423-37. 14. Gotz J, Streffer JR, David D, Schild A, Hoerndli F, Pennanen L etal. Transgenic animal models of Alzheimer’s disease and related disorders: histopathology, behaviour and therapy. Molecular Psychiatry. 2004; 9:664-83. 15. Schenk D. Amyloid-β immunotherapy for Alzheimer’s disease: the end of the beginning. Nature Reviews/Neuroscience. 2002; 3:824-28. 16. Bader M, Bohnemeier H, Zollmann FS, LockleyJones OE, Ganten D. Transgenic animals in cardiovascular disease research. Experimental Physiology.2000; 85(6):713-31. 17. Hasenfuss G. Animal models of human cardiovascular disease, heart failure and hypertrophy. Cardiovascular Research. 1998; 39:60-76. 18. Srinivasan K. Ramarao P. Animal models in type 2 diabetes research: an overview. Indian J Med Res. 2007; 125: 451-72. 19. Etuk EU. Animal models for studying diabetes mellitus. Agri. Bio. J. N. Am. 2010; 1(2): 13034. 20. Henson MS. Timothy DO. Feline Models of type 2 Diabetes Mellitus. ILAR Journal. 2006; 47(3):234-42. 21. Kumar S. Singh R. Vasudeva N. Sharma S. acute and chronic animal models for the evaluation of antidiabetic agents. Cardiovascular Diabetology. 2012; 11(9):1-13. 22. Eddouks M. Chattopadhyay, Zeggwagh NA. Animal models as tools to investigate antidiabetic and anti-inflammatory plants. Evidence based Complementary and Alternative Medicine. 2012. 1-14. 23. Carmeliet P. Moons L. Collen D. Mouse models of angiogenesis, arterial stenosis, atherosclerosis and hemostasis. Cardiovascular Research. 1998;39:8-33. 24. Boverhof DR. Chamberlain MP. Elcombe CR. Gonzalez FJ. Heflich RH. Lya GH. Transgenic animal models in Toxicology: Historical Perspectives and Future Outlook. 2011;121(2):207-33. 25. World Health Organization. Transgenic Animal Mutagenicity Assays. [Homepage on the Internet]. 2006. [cited 2012 Nov 03]; Available from http://www.inchem.org/documents/ ehc / ehc/ehc233.pdf 26. Pavlaki M, Zucker S. Matrix Metalloproteinase inhibitors (MMPIs): The beginning of Phase I or the termination of phase III clinical trials. Cancer and metastasis reviews. 2003; 22:17703 27. Ramaswamy S. McBride JL, Kordower H. Animal Models of Huntington’s Disease. ILAR Journal. 2007; 48(4):356-73. 28. Horton WA. Skeletal development: insights from targeting the mouse genome. Lancet. 2003; 362:560-69. 115 Bagle TR et al., Int J Med Res Health Sci. 2012;2(1):107-116 29. Ormandy EH. Dale J, Griffin G. Genetic engineering of animals. Ethical issues, including welfare concerns. CVJ.2011; 52:54452 30. Prather RS. Shen M, Dai Y. Genetically modified Pigs for medicine and Agriculture. Biotechnology and Genetic Engineering Reviews. 2008; 25:245-66. 31. Hunter CV, Tiley LS, Sang HM. Development in transgenic technology: applications for medicine. TRENDS in Molecular Medicine.2005; 11 (6): 293-98. 32. Alison VE. Genetically Engineered Animals: An overview. [Serial on the Internet]. 2008. [Cited 2012 Nov 25]; Available from http://animalscience.ucdavis.edu/animalbiotech /Outreach/Genetically_engineered_animals_ov erview.pdf 33. Lonberg N. Human antibodies from transgenic animals. Nature Biotechnology. 2005;23(9):1117-1125 34. Niemann H, Kues WA. Application of transgenesis in livestock for agriculture and biomedicine. Animal Reproduction Science. 2003;79:291-317. 35. Fung J, Rao A, Starzl T. Clinical trials and Projected future of Liver Xenotransplantation. World Journal of Surgery.1997; 21:956-61. 36. Cooper DK. Clinical Xenotransplantation-how close are we?. Lancet. 2003; 362:557-59. 37. Alison LE. What is the future of animal biotechnology?. California Agriculture. 2006; 60( 3):132-139. 38. Einsiedel EF. Public perceptions of Transgenic animals. Rev. Sci. tech. Off. Int. Epiz. 2005; 24(1):149-157. 39. Special Issue: Mertens C, Rulicke T. Welfare Assessment and Phenotype Characterisation of Transgenic Mice. Altex. 2007;24: 46-48 40. Indian Council of Medical Research. The Use of Animals in Scientific Research. [Homepage on the Internet]. 2008. [Cited 2012 Dec 03]; Available from http: //icmr. nic. in/bioethics/Animals_biomedical%20research. pdf Bagle TR et al., 41. The Parliamentary Office of Science and Technology. Biomedical Patents. [homepage on the Internet]. 2012. [cited 2012 Dec 01]; Available from http://www.parliament.uk/ Templates/BriefingPapers/Pages/BPPdfDownl oad.aspx?bp-id=POST-PN-401 42. Rigaud N. OECD International Futures Project on “The Bioeconomy to 2030: Designing Policy Agenda”. Biotechnology: Ethical and social debates. [homepage on the Internet]. 2008. [cited 2012 Dec 01]; Available from http://www.biotechnologie.de/BIO/Redaktion/ PDF/de/laenderfokus/indien-oecd-vollberichtmitanhang,property=pdf,bereich=bio,sprache=de,r wb=true.pdf 43. Goldman IL, Kadulin SG, Razin SV. Transgenic animals in medicine: Integrations and expression of foreign genes, theoretical and applied aspects. Med SciMonit. 2004;10 (11): RA274-285. 44. Huang YJ, Huang Y, Baldassarre H, Wang B, Lazaris A, Leduc M. Recombinant Human Butyrylcholinesterase from the milk of transgenic animals to protect against organophosphate poisoning. PNAS. 2007; 104(34):13603-13608. 45. Park F. Lentivirus vectors: are they the future of animal transgenesis?. Physiol. Genomics. 2007; 31:159-173 116 Int J Med Res Health Sci. 2012;2(1):107-116 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 th Received: 4 Dec 2012 Revised: 20th Dec 2012 Accepted: 26th Dec 2012 Case report CASE OF CHOLEDOCHAL CYST PRESENTING AS PERFORATION ABDOMEN Gobbur RH1, *Baradol RV 2, Nyammannavar3 1 Professor, 2Asst Professor, 3Asso Professor Dept. of Pediatrics, BLDEU’s Shri B M Patil Medical College, Bijapur, Karnataka. *Correspondence author email: ravikumar8901@gmail.com ABSTRACT Introduction: Choledochal cyst is an uncommon congenital anomaly of Hepoatobiliary system. It is a case of choledocal cyst presenting as perforation and biliary ascites which is rare in infants. Clinical picture: An infant was admitted at BLDE hospital with history of convulsion and breathlessness, on examination child had abdominal distension. Investigations like erect X ray abdomen done which revealed ascites with features of peritonitis, so exploratory laparotomy done which showed a choledochal cyst with perforation causing biliary ascites. Treatment: Child was treated in the pediatric intensive care unit for convulsion. Exploratory laparotomy done and the perforated choledochal cyst was sutured and drain placed in situ. The child improved from 2nd post operative day. Conclusion: Choledochal cyst can present as perforation, biliary ascites and peritonitis in infants. Therefore treatment should be oriented to this aspect also. Keywords: Choledochal cyst, Bliary ascites INTRODUCTION Choledochal cysts are congenital bile duct anomalies. These cystic dilatations of the biliary tree can involve the extrahepatic biliary radicles, the intrahepatic biliary radicles or both. Cystic disorders of the bile ducts are rare entity but they are well defined malformations of pancreatic biliary systems involving intra hepatic bile ductile, extra hepatic or both. No strong unifying etiologic theory exists for choledochal cysts. The pathogenesis is probably multifactorial1. In many patients with choledochal cysts, an anomalous junction between the common bile duct and the pancreatic duct can be demonstrated. This abnormal union allows pancreatic secretions to reflux into the common bile duct, where the pancreatic proenzymes become activated, damaging and weakening the bile duct wall. Defects in epithelialization and recanalization of the developing bile ducts and congenital weakness of the ductal wall also have been implicated. The result is the formation of a choledochal cyst. Since Vaten first described the entity in 1723, many cases have been reported worldwide. The incidence in the western population is 1:100000 to 117 Gobbur RH et al Int J Med Res Health Sci. 2013;2(1):117-120 1:150000 and in our population it is about 0.7% 2. Choledochal cysts are three to four times more common in females than in males3. Their origin is unknown; however, they are considered congenital. These anomalies can be classified using various systems. The most widely used subdivision of choledochal cysts are Todani’s classification (Fig 1), which is a modification of the Alonso-Lej classification4 Generally the patient with choledochal cyst presents with cholestatic jaundice and abdominal pain. A palpable abdominal mass may be found in less than 20% of the cases. In adults, chronic and intermittent abdominal pain is the most common symptom. Children with choledochal cyst generally present with the triad of abdominal pain, abdominal mass and jaundice. Recurrent cholangitis and jaundice may also occur5. A choledochal cyst is rarely symptomatic, but should be considered if dilatation of the bile duct or the ampulla is demonstrated. Here we are presenting a case of congenital choledocal cyst presented with biliary ascites as a complication. CASE An infant, known case of seizure disorder was well controlled on anticonvulsants like phenytoin and valproate. This patient was brought into hospital with c/o fever, convulsions, cough, breathlessness and abdominal distension. On the 1 st day, the patient was started on i.v. antibiotics like Ceftriaxone and Azithromycin, Inj Deriphylline was administered. Convulsions were well controlled on anticonvulsants. All routine blood and urine investigation along with chest X-ray were done. Haemogram showed neutriphilia with thrombocytosis. Haemoglobin was 12.8gm%. Bleeding time & clotting time were 2 & 4.45 min respectively. Serum sodium, potassium, chloride and calcium levels were 150meq/lit, 3meq/lit, 114 meq/lit and 9.5 mg/dl respectively. All reports were in normal range. On 2nd day of admission there was progressive distension of the abdomen causing respiratory compromise. Emergency erects x-ray abdomen was taken which showed dilated bowel loops with features of peritonitis secondary to bowel perforation (Free air under the diaphragm). The child was taken for emergency explorative laparotomy. Intraoperatively choledochal cyst with perforation was found. Then the edges of perforation were sutured. 1 liter of bilious fluid was drained. Abdomen was closed with a drain in situ. Baby required ventilator support for 2 days and was oxygen dependent for 7 days. Culture report was found to be sterile. The child was put on Piperacillin. As improvement was inadequate, Meropenem was started on the 4th postoperative day. The child showed improvement with a spontaneous eye opening on the 4th post operative day. Abdominal drain was removed on 5 th Post operative day. RT is fed with milk was started on 6th POD. The child was afebrile, conscious and comfortable by 9th POD. RT feeds was gradually increased along with oral feeds. DISCUSSION This is the case report study of choledochal cyst presenting as abdominal perforation which is an uncommon complication and it is first reported by Weber in 1934.11 Choledochal cysts are rare abnormalities of the biliary tree. Choledochal cysts are generally classified using Todani’s classification, which is as follows; Classification by Todani and co workers 4 (as shown in figure no.1)  I: Dilatation of hepatic and common bile duct (40% to 85%).  II: Diverticulum of the common bile duct (2% to 3%).  III: Intraduodenal common bile duct dilatation (1.4% to 5.6%).  IV: Intra- and extrahepatic bile duct dilatation (18% to 20%).  V: Intrathepatic bile duct dilatation (Carolis disease). 118 Gobbur RH et al Int J Med Res Health Sci. 2013;2(1):117-120 Fig: 1. Types of choledochal cyst (Classification by Todani and coworkers) Patients with choledochal cyst commonly present with jaundice, abdominal pain and abdominal mass. Infants frequently present with jaundice and acholic stools. In early infancy, this may prompt a work-up for biliary atresia. In addition, infants with choledochal cysts often have a palpable mass in the right upper quadrant of the abdomen, accompanied with hepatomegaly. Children diagnosed after infancy typically have a clinical picture of intermittent biliary obstruction or recurrent bouts of pancreatitis6. The main diagnostic tool for detection of a choledochal cyst, especially in childhood, is ultrasonography. In adults, computer tomography can confirm the diagnosis; however, endoscopic retrograde cholangiography or magnetic resonance cholangiography is the most valuable diagnostic method and can accurately show cystic segments of the biliary tree7. Complications of choledochal cyst are mainly ascending cholangitis, intrahepatic bile duct stones, intrapancreatic terminal choledochal calculi, pancreatic duct calculus, bowel obstruction, cholangiocarcinoma, liver dysfunction and pancreatitis8. Surgery is the treatment of choice for a choledochal cyst. Complete excision of all cystic tissue is recommended because of the risk of recurrent cholangitis and the high risk of malignant degeneration9. Excision of the cyst and reconstruction of the biliary tree by choledochal/hepato-jejunostomy with a Roux-en Y-loop is the standard procedure. Another procedure includes excision of the distal common bile duct, excision of the common hepatic duct, dilatation of the intrahepatic bile duct, intraoperative endoscopy10. CONCLUSION This case report study gives an idea of rare presentation of choledochal cyst as perforative abdomen with biliary ascites. So whenever a patient of abdominal perforation presents, choledochal cyst should keep in mind as a possible cause of perforation. The patient should be treated according to the cause of perforation. 119 Gobbur RH et al Int J Med Res Health Sci. 2013;2(1):117-120 REFERENCES 1. Idress K, Ahrendt S. Cystic Disorders of Bile Ducts. In: John L. Cameron, Andrew M. Cameron, editors. Current surgical Therapy. 10 th edition 2010: Elsevier Publication; 353-57. 2. Singham J, Yoshida EM, Scudamore CH. Choledochal cysts: part 1 of 3: classification and pathogenesis. Can J Surg. Oct 2009; 52(5):434-40. 3. Shah OJ, Shera AH, Zargar SA, Shah P, Robbani I, Dhar S, et al. Choledochal cysts in children and adults with contrasting profiles: 11-year experience at a tertiary care center in Kashmir. World J Surg. Nov 2009;33(11):2403-11 4. Todani T, Watanabe Y, Narusue M, Tabuchi K, Okajima K. Congenital bile duct cysts: Classification, Operative procedures and review of thirty seven cases. Am J Surg; Aug 1977: 34(2): 263-69 5. Ahmad Rahmoony, Basaam Samawii. Choledochal cyst in children an experience at the Royal Medical Services; JRMS. Dec 2006; 13 (2): 67-70 6. Beata Jablonska. Biliary cysts: Etiology, diagnosis and management. September 2012; Volume 18,Issue 35: 4801-10 7. Kim MJ, Han SJ, Yoon CS, Kim JH, Oh JT, Chung KS et al. Using MR cholangiopancreatography to reveal anomalous pancreaticobiliary ductal union in infants and children with choledochal cysts. AJR Am J Roentgenol: 2002, 179: 209-214. 8. Nyamannawar B M, Das K. Spontaneous infantile choledochal cyst perforation. Indian J Pediatric; 2007; 74(3): 299-300. 9. Kobayashi S, Asano T, Yamasaki M, Kenmochi T, Nakagohri T, Ochiai T. Risk of bile duct carcinogenesis after excision of extrahepatic bile ducts in pancreaticobiliary maljunction. Surgery; 1999, 126: 939-44. 10. Treem W R, Hyams J S, Mc Gowman G S, Sziklas J. Spontaneous rupture of a choledochal cyst: clues to diagnosis and etiology. J Pedatr Gastroenteraol Nutr.1991; 13(3):301-06. 11. Weber FP. Cystic dilatation of common bile duct. Br J Chid Dis 1934, 31:27-29. 120 Gobbur RH et al Int J Med Res Health Sci. 2013;2(1):117-120 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 2 Issue 1 Jan-Mar 2013 Coden: IJMRHS Copyright @2013 ISSN: 2319-5886 Received: 4thDec2012 Revised: 25th Dec 2012 Accepted: 29th Dec 2012 Case report AN INTERESTING CASE OF COR PULMONALE *Bagrecha Manish V1, Kunkulol Rahul R2 1 Post graduate student, Department of Medicine, Pravara Institute of Medical Sciences, Loni Associate Professor, Department of Pharmacology, Secretary, Research cell, PIMS, Loni, Maharashtra 2 *Corresponding author email:manish.bagrecha@gmail.com ABSTRACT A 14 yrs old boy presented with a history of breathlessness since 1 yr which had increased from 2 days, cough with expectoration and pedal edema since 7 days. In the past patient had history of kyphoscoliosis since birth and had a history of repeated URTI. On examination he had tachycardia, tachypnea, raised JVP, kyphoscoliosis, bilateral pitting edema. Respiratory auscultation revealed bilateral fine crepitations and wheezes. On investigation haemoglobin: 14.6, T.L.C: 20,000,chest X-ray: kyphoscoliosis with cardiomegaly. Clinical diagnosis of corpulmonale due to kyphoscoliosis was achieved and was confirmed with 2D echo. ECG showed RVH. The patient was treated with oxygen, diuretics, antibiotics, bronchodilators. Patient improved and was discharged on bronchodilators and was asymptomatic on follow up. Key words: Corpulmonale, Kyphoscoliosis. INTRODUCTION Kyphoscoliosis is a disorder characterized by progressive deformity of Spine consisting of lateral and posterior curvature.In majority, it is of idiopathic etiology. Deformity results in shortening of height. Patients can be asymptomatic. Mobility of the chest wall is impaired, the chest wall is stiff and lung volumes are restricted. Hypoventilation can occur due to small tidal volumes and increased dead space Bagrecha et al., ventilation. V/Q mismatch leads to significant hypoxia, and can progress to symptoms of Corpulmonale.1Certain persons with longstanding dorsal kyphoscoliosis develop pulmonary hypertension and corpulmonale. We had a young patient presenting with the same. Respiratory failure due to kyphoscoliosis, leading to corpulmonale, has rarely been reported, in spite of the fact that kyphoscoliosis is common. This fact led us to report this case.2 Int J M ed Res Health Sci. 2013;2(1):121-123 121 CASE A 14 yrs boy presented with a history of breathlessness since 1 yr which was initially on exertion but had increased to breathlessness at rest since 2 days, cough with expectoration and pedal edema since 7 days. In the past patient had kyphoscoliosis since birth and had a history of repeated URTI. On examination he had tachycardia (120 bpm), tachypnea (28/min), raised JVP (6cm), kyphoscoliosis, and bilateral pitting edema. Respiratory ascultation revealed bilateral fine crepitations and polyphonic wheezes. The cardiac auscultation revealed loud P2 and there was also evidence of ejection systolic murmur in pulmonary area. On investigation haemoglobin: 14.6, T.L.C: 20,000/cmm, ABG was suggestive of type II respiratory failure (pH 7.37,pO2 22mm Hg pCO2 52 mm Hg.,spo2:84%), 2D Echo showed severely dilated RA and RV , grade III TR, severe pulmonary hypertension 78mm Hg. Fig:1. Chest X-ray showing Kyphoscoliosis with Cardiomegaly Fig: 2. ECG was showing ‘P’ Pulmonale, right axis deviation and right ventricular hypertrophy 122 Bagrecha et al., Int J M ed Res Health Sci. 2013;2(1):121-123 Treatment Controlled oxygen therapy, intermittent positive pressure respiration, digitalis, diuretics, antibiotic, bronchodilators (inhalational and intravenous). The patient improved with treatment and was discharged on bronchodilators and diuretics. Follow up The patient is doing well with bronchodilators and diuretics. DISCUSSION Several pathophysiologic features contribute to respiratory dysfunction in kyphoscoliosis. Underlying problem is increased work of breathing resulting from poorly compliant chest wall. Distortion of chest wall causes under the ventilation of some regions of lungs, microatlectasis, ventilation perfusion mismatch and hypoxemia. 3 Common complication of kyphoscoliosis is pulmonary hypertension and corpulmonale. Hypoxemia and hypercapnia are important for the development of pulmonary hypertension. However increased resistance of pulmonary vessels results from compression especially in areas where chest wall is distorted. Exertional dyspnea is the most common symptom. PFT shows decreased TLC, VC and FRC. Chronic respiratory insufficiency and corpulmonale are the end results of severe kyphoscoliosis, the level of respiratory difficulty correlates with severity of chest wall deformity.4Cor pulmonale is associated with kyphoscoliosis when the external angle of the scoliosis is more than 100" and the kyphosis is more than 20°, with a vital capacity less than one liter5. In contrast to chronic pulmonary emphysema, the alveolar hypoventilation in kyphoscoliosis is due to anatomic striction of the chest rather than to bronchial obstruction and uneven distribution of inspired air. The factors responsible for the increased pulmonary resistance is believed to be mechanical compression of the vascular bed, anatomic thickening of the precapillary vessel wall, and effects of hypoxemia. 6 ACKNOWLEDGEMENTS Many thanks to Dr. Tewari SC, Prof&Head, Dept. of Medicine for his guidance and encouragement. REFERENCES 1. ChandrashekharA.,Kyphoscoliosis,www.med dean.luc.edu/lumen/MedEd/medicine/pulmon ar/diseases/pdis22.htm,Loyala University medical education network. 2. RL Naeye. CorPulmonale. Kyphoscoliosis American and journal of pathology, 1961;38 (5): 561-73 3. Steven EW, Barbar AC, Jess M: Principles of pulmonarymedicine, (ed) Weinberger, Cockrill, Mandel, Mosby Elsevier,5th edition 2008; 248-49. 4. Bergofsky EH, Turino GM, Fishman AP. Cardiorespiratory failure in kyphoscoliosis. Medicine. 1959; 38: 263-317 5. Wanderrnun KL, Gomein MS, Faber I, Cor Pulmonale Secondary Kyphoscoliosis in to Marfan's Severe Syndrome. Chest, 1975; 67 (2): 250-51. 6. Israel Steinberg, Corpulmonale in kyphoscoliosis, The American journal of Roentgenology, radium therapy and nuclear medicine, 1966;97 (3); 658-63 123 Bagrecha et al., Int J M ed Res Healt h Sci. 2013;2(1):121-123