Transcript

DOI: 10.5958/2319-5886.2015.00048.

X

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 27 July 2014
Research article

Coden: IJMRHS
Copyright@2014
ISSN: 2319-5886
th
Revised: 5 Dec 2014
Accepted: 5th Jan 2015

THE INFLUENCE OF PERIPHERAL NEUROPATHY AND PERIPHERAL VASCULAR DISEASE IN THE
OUTCOME OF DIABETIC FOOT MANAGEMENT – A PROSPECTIVE STUDY
Sundar Prakash S1, Krishnakumar2, Chandra Prabha3
1

Assistant Professor, Department of General Surgery, Meenakshi Medical College and Research Institute, Kanchipuram.
Final year General Surgery PG, Department of General Surgery, Meenakshi Medical College and Research Institute,
Kanchipuram.
3
Final year PG, Department of Physiology, Meenakshi Medical College and Research Institute, Kanchipuram
2

Corresponding author email: [email protected]
ABSTRACT
Objective: Peripheral neuropathy and Peripheral Vascular Disease are the risk factors for the development of diabetic foot.
The aim of this study was to evaluate differences and predictors of outcome parameters in patients with diabetic
foot by stratifying these subjects according to the severity of these risk factors. Materials and methods: This is a
prospective study conducted in 70 patients in the age group of 30-90 years diagnosed as Type II Diabetes with
foot ulcers. After detailed clinical examination the following tests were conducted in all the patients:
Complete blood count (CBC), Haemoglobin (Hb), Random Blood Sugar (RBS), Erythrocyte Sedimentation rate
(ESR), Chest X-ray(CXR), Electrocardiography (ECG), foot X-ray, pus culture, Neuropathy testing by
Semmes Weinstein Monofilament Test and Vibration Perception Threshold and Peripheral vascularity
assessment by Duplex Doppler. Then grading of the ulcers was done using Wagner's Grade. The outcome of
the patients was assessed by recording the healing time, mode of surgery and amputation rates of the patients.
Results: A total of 70 patients with diabetic foot were consecutively included into the study (65.7% male, age
(31% in 51-60 years), mean diabetes duration (5.2 years), Ulcer Grade (37% in Grade IV), Foot lesions (45.7% in
toe), Blood sugar levels (64% in 300-400 mg/dl), Neuropathy (84%), Peripheral vascular disease (67%), major
amputation (7%) and mortality (1.4%). Conclusion: All diabetic patients should undergo testing for neuropathy
and peripheral vascular disease apart from doing other tests.
Key words: Diabetic foot, ulcers, neuropathy, peripheral vascular disease.
INTRODUCTION
Complications affecting diabetes are many with
some of the most catastrophic ones affecting the
lower extremities. Levin et al [1] estimated that 20%
of all hospital admissions for diabetes were the result
of foot problems. Warren et al[2] in their survey of the
lower extremities amputations found that 91.8% of
amputations were performed secondary to gangrene,
necrosis, ulcer, nearly one half of these patients were
diabetics. Apelquist J et al[3] in their study on

importance of wound classification in the outcome of
diabetic foot ulcer stated that the ulcer was classified
on the basis of superficial, deep, minor or major
gangrene and that the healing rate of superficial
ulcer is (88%) and deep ulcers is(78%) 57%. In
abscess and osteomyelitis it was (57%) and found that
out all there was only marginal difference in primary
healing rate between the ulcer sites.
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The remarkable pathogenesis of diabetic foot is
neuropathy, microvascular and macrovascular diseases.
Their process may occur exclusively or they may occur
together in varying degrees placing patients at risk
for morbidity such as ulceration, gangrene and
infection. This is especially true if these pathological
changes are combined with a foot deformity, making
patients more vulnerable to foot problems. Bauman et
al 4 demonstrated that only slight pressure over a fixed
bony deformity, such as a prominent metatarsal
head or a hammer toe lead to ischemic necrosis and
ulceration of skin. For this reason it is necessary to
identify the patients at increased risk. Apart from
other diabetic complications, one long term
complication of diabetes is neuropathy, which
causes foot ulceration in diabetic patients, despite
considerable research; the pathogenesis of diabetic
neuropathy remains undetermined. Current
hypothesis regarding the etiology of diabetic
neuropathy are centered on a combination of
metabolic defects secondary to higher glycaemia and
vascular changes that results in nerve hypoxia.
Evidence for hypoxia as etiology is considerable
and includes reduced endoneurial blood flow,
increased vascular resistance, and decreased
endothelial production of nitric oxide. Although
microvascular dysfunction has been mainly
implicated, the role of peripheral vascular disease
remains considerable, as it appears likely that a
decrease in total limb blood flow would potentiate
nerve ischemia. Hence both peripheral
neuropathy and peripheral vascular disease are the
commonest etiology in diabetic foot ulcer, apart from
other risk factors. Tests for neuropathy and
peripheral vascular diseases were done and the
outcome was assessed.
Aims and Objectives
1. To study the influence of peripheral neuropathy
and peripheral vascular disease in the outcome of
diabetic foot management.
2. To ascertain the risk of peripheral neuropathy and
peripheral vascular disease in diabetic patients
with diabetic foot ulcer.
3. Evaluate all patients with diabetic foot ulcer for
both peripheral neuropathy and peripheral
vascularity.
4. Assessment of outcome of the diabetic foot ulcers
regarding neuropathic/neuroischemic status.

MATERIALS AND METHODS
Prospective study was conducted in 70 patients in the
age group of 30 to 90 years diagnosed as Type II
diabetes with foot ulcer attending the diabetic OPD
and surgical units of MMCH&RI during the period
October 2011 to September 2013. Permission was
sought from Ethical Committee and Informed consents
were obtained from all the patients. All patients in the
study group had detailed clinical history of their
problem and the foot ulcers were examined in
detail.
Inclusion criteria
Patients attending MMCH&RI surgery OPD and
Diabetics clinic diagnosed as diabetic foot ulcers.
Patients above 30 years.
Not previously diagnosed as neuropathy or
having peripheral vascular diseases.
Exclusion criteria
Patients below 30 years of age.
Non-diabetic foot ulcers.
Previously diagnosed to have peripheral
neuropathy and peripheral vascular diseases.
All patients had undergone Complete blood count
(CBC), Haemoglobin (Hb), Random Blood Sugar
(RBS), Erythrocyte Sedimentation rate (ESR), Chest Xray(CXR), Electrocardiography (ECG). Neuropathy
testing was done using Semmes Weinstein
Monofilament Test (Fig 1&2) and then they were
tested for nerve conduction studies. Peripheral
vascularity was assessed clinically and also by
Duplex Doppler. After all the tests, grading of the
ulcers was done using Wagner's Grade.

Fig 1:Semmes-Weinstein monofilament

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Int J Med Res Health Sci. 2015;4(2):258-264

Fig 2:Semmes-Weinstein monofilament
Wagner Grading System:
Grade 1: Superficial Diabetic Ulcer
Grade 2: Ulcer extension
1.Involves ligament, tendon, joint capsule or fascia
2. No abscess or Osteomyelitis
Grade 3: Deep ulcer with abscess or Osteomyelitis
Grade 4: Gangrene to portion of forefoot
Grade 5: Extensive gangrene of foot
The outcome of the patients was assessed by
recording the healing time, mode of surgery, pus
culture & sensitivity and amputation rates of the
patients. All the above data were analyzed.
Statistical analysis: All the data were analyzed using
Graph Pad Prism Version 6.
RESULTS AND OBSERVATION
Sex distribution Out of 70 patients enrolled for the
study, 46 (65.7%) were males and 24 (34.3%) were
females patients. Age distribution In our study all
the patients above 30 years were included. 30% of the
patients were between 51 and 70 years of age. Fig 3
shows the details of age distribution in our study.

Fig 3: Age distribution
Duration of diabetes : Out of 70 patients enrolled in
our study majority of the patients had diabetes for 4-6

years (Table 1). The mean duration of diabetes was
5.2 years.
Table 1: Duration of diabetes
Duration
Number
(%)
(in year)
of Patients
0-2
15
21.4
2-4
14
20.0
4-6
24
34.3
6-8
8
11.4
8-10
5
7.4
10-12
1
1.4
12-14
2
2.8
14-16
1
1.4
Distribution of surgeries done previously for foot
problems: Out of 70 patients enrolled in the study,
10 (14.28%) patients had history of previous minor
amputations, 2 (2.85%) patients had history of major
amputation, 3(4.3%) had undergone other surgeries
like Debridement, I & D, Fasiotomies etc (Table 2).
Table 2: Distribution of surgeries done previously
for foot problems
Foot
Number
(%)
problems
of Patients
Minor amputation
10
14.2
Major Amputation
2
2.9
Others*
3
4.3
No previous surgeries
55
78.6
*Debridement, I & D, Fasiotomies, Minor Surgery
Predisposing external risk factors :Out of 70
patients enrolled in our study, 48 (68.5%) patients
had history of minor trauma due to bare foot walking
and ill-fitting foot wear, 3 (4.3%) had toenail
infection, 13 (18.5%) had history of thorn prick (Fig
4).

Fig 4: Predisposing external risk factors
Distribution of grades of diabetic foot ulcers: Out
of 70 patients our study diagnosed with foot
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ulceration, grading was done based on Wagner’s
grading and most of the ulcers were predominantly
between grades II to Grave IV (Fig 5).

Fig 5: Distribution of grades of diabetic foot ulcers
Distribution of foot ulcers: Out of 70 patients in our
study, 32 (46%) patients had ulceration in the toes
and planter surface of toes, 28 (40%) had ulcers in
plantar surface of foot, metatarsal head, mid foot and
heel and 10 (14.0%) had ulcers in the dorsum of foot
(Table 3).
Table 3: Distribution of foot ulcers
Foot lesions

Number
of patients

(%)

Toe (Dorsal and
Plantar Surface)

32

45.7

Plantar, Metatarasal
Head,Mid Foot, Heel
Dorsum of Foot
Multiple Ulcers

28
10
0

40
14.3
0

Distribution of scores related to blood sugar
values: Out of 70 patients, 45 (64.3%) had elevated
Random Blood Sugar values ranging from 300-400
(Table 4).
Table 4: Distribution of scores related to blood
sugar values
Blood Sugar
Number
(%)
Values (RBS)*
of patients
200-300
15
21.4
300-400
45
64.3
≥400
10
1.4
Distribution of neuropathy: Out of 70 patients, all
were categorized for neuropathy using Semmes
Weinstein monofilament. Graph 4 shows 59 (84%)
patients suffered from peripheral neuropathy.

Fig 6: Distribution of neuropathy
Distribution of nerve conduction study scores: In
our study, majority of the patients (89.8%) had both
sensory and motor weaknesses (Table 5).
Table 5: Distribution of nerve conduction study
scores
Neuropathic
Number
(%)
type
of patients
Sensory
5
8.5
Motor
2
3.4
Sensory (+)
53
89.8
Motor
Distribution of peripheral vascular status scores:
In 70 patients, 23 (33%) had peripheral vascular
disease while in 47 (67%) it was not present(Table 6).
Table 6: Distribution of peripheral vascular status
scores
Peripheral
Number
Vascular Disease
of patients
(%)
Present
23
33
Absent
47
67
Distribution of score related to Doppler study:
According to our study, out of 23 patients, 18
(25.7%) had stenosis of peripheral arteries, 3 (4.3%)
had occlusion and 2 (2.9%) had both (Table 7).
Table 7: Distribution of score related to Doppler
study
B. Mode Duplex
Number
Doppler
of patients
(%)
Normal
47
67.1
Presence of stenosis
in peripheral arteries
18
25.7
Complete Occlusion
of peripheral arteries
3
4.3
Presence of both
stenosis and occlusion
2
2.9
of peripheral arteries
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Distribution of score categorized in ulcer groups:
In our study 36 (51.4%) patients had neuropathic foot
lesions and 23 (32.8%) had neuro-ischemia (Table 8).
Table 8: Distribution of score categorized in ulcer
groups
Categories

No. of patients

(%)

Neuropathic
36
51.4
Neuro-ischemia
23
32.8
Infection (Non-ischemic/
11
12.8
non-neuropathic)
Distribution of patients who had undergone
amputations: In our study majority of the patients
who had undergone both minor and major
amputations were in patients suffering from both
neuropathy and ischemia (Table 9). As per our
statistical analysis Chi square test was 21.40, 1 df and
the P value was <0.0001. Hence the proportion of
amputation cases among neuro-ischaemia patients
was significantly higher than the amputation cases in
neuropathy cases alone.
Table 9: Distribution of patients who had
undergone amputations
Categories

Minor
amputations
(Toe)

Major amputations
(Forefoot, BK,
AK)

Neuropathic (n=36)

4(11.1%)

-

Neuro-ischemia(n-23)

12 (52.2%)

4 (17.3%)

Infection(Non-ischemic
/non-neuropathic (n=9)

4 (44.4%)

1 (11.1%)

Distribution of outcome of the patients: Outcome
of the patients was calculated according to the healing
time. All patients had excellent outcome owing to
improvement in treatment modalities as seen in Table
10. Our analysis showed, Chi square 0.2658 and P
value <0.6062. Hence the treatment pattern was same
in all the cases.
Table 10: Distribution of outcome of the patients
Categories

Healed *

Unhealed
**

Mortality
***

Neuropathic (n=36)

34 (94%)
20 (87%)

2(6%)
2 (9%)

1 (4.3%)

9(82%)

2 (18%)

-

Neuro-ischemia(n-23)
Infection(Non
ischemic/Non
neuropathic(n=9)

*with in a period of 6 months either by full primary
healing or by SSG,
**healing time more than 6 months period going for
further surgeries
***patient dead due to complication of the wounds

DISCUSSION
Aksoy et al5 in their study in Istanbul (turkey) on
diabetic foot ulcerations enrolled 66 patients of which
39 (59%) men and 27 (41%) women. In another
study by Unal et al6 on diabetic foot in 200 patients in
Karachi found that the percentages of males were 65
and female were 35. In our study also the results were
similar, males 46 (56.7%) and females 24 (34.3%).
Hence the complications of diabetic foot ulcers are
more common in males. Al Mahroos et al7 in their
study on diabetic patients with foot problems in
patients in Bahrain observed that the mean age of the
patients were 57.3 + 6.32 years. Ahmed M et al8 in
their study on evaluation of diabetic foot ulcer in 100
subjects observed that the age group of patients was
between 40 - 60 years. In our study done on 70
patients with diabetic foot ulcerations majority of the
patients fall between 51-60 years of age and mean
age of these patients was 55 + 5 years. This is
relevant to the above studies and our study proved
that the complications of diabetes are more common
in the older age group. Nalini Singh et al9 in their
study on prevalence and determinants of foot
ulceration in patients with type II diabetes observed
that the mean duration of diabetes was 4.3 years.
Kumar S et al[10] in their study on prevalence of foot
ulceration and its correlation with type II diabetes
showed that the mean duration of diabetes among the
patients was 7.4 years. In our study the duration of
diabetes was for 5.2 years, which signifies that as the
duration of diabetes increases, the foot is prone for
problems. In comparison to above studies our
patients with diabetes tend to develop foot ulceration
little earlier. Apelquist J et al3 in their study on
external risk factors for foot ulcerations and the
outcome of diabetic foot lesions in 314 patients
demonstrated that the external precipitating factors
were identified in 264 out of 314. Common factors
like ill-fitting shoes, socks, acute mechanical trauma,
stress ulcers and paronychia were named. In our
study majority of the patients had history of minor
trauma, either due to bare foot walking (or) ill-fitting
foot wear, leading to minor trauma and ulceration and
minor injuries like thorn prick. This signifies the need
for education on personal care of foot by selfexaminations and general awareness of foot problems
and measures to prevent them and stressing the
importance of proper footwear in diabetic patients.
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Imran S et al11 in their study on frequency of lower
extremity amputations in diabetes with reference to
glycaemia control and Wagner's grades in Karachi
showed the following results. Grade O, 6 patients, 10
in grade I, 13 in grade II, 14 in grade III, 18 in grade
IV and 9 in grade V. Rooh-Ul-Muqim et al12 in their
study on evaluation and management of diabetic foot
by Wagner's classification, out of the 100 cases,
grade O (6), grade I (14), grade II (25), grade IV 30,
grade V (4). In our study the results were Grade O
(1), grade I (1), grade II (24), Grade III (17), grade IV
(26) and grade V (1). This shows that most of our
patients present in later part of the disease. If they
were treated in earlier grades the results would have
been much better. Apelquist J et al3 in their study of
the long term progress for diabetic patients with foot
ulcer observed that the results of patients with lesions
in the Toe (dorsal and Plantar surface) was 51%,
plantar surface, metatarsal head and foot and heel
was 28%, Dorsum of foot 14% and multiple ulcers
was 7%, out of 314 subjects. Reiber et al13 in their
study on the burden of diabetic foot ulcers based on
severity of lesions found that 52% of patients had
lesions in toe (dorsal and plantar surface), 37% had
lesions on plantar, metatarsal head, mid foot and heel
and 11 % in the dorsum of foot. In our study, 46% of
the foot lesions were in the toes (dorsal and plantar
surface) and 40% on the plantar and metatarsal head,
mid foot and heel. This shows that the toes and sole
of feet are vulnerable to ulceration, which signifies
that the diabetic foot needs frequent self-evaluations.
Oyiboso et al14 in their study on the outcome of
diabetic foot ulcers in 194 subjects observed that
67% of the ulcers were due to neuropathy and 26.3%
were neuro-ischemic. Ramani A et al15 in their study
on etiology of diabetic foot ulceration found that
peripheral neuropathy was seen in 78 % of the
subjects and vascular insufficiency was seen in
49.3%. Kumar S et al10 in their study on prevalence
of foot ulceration in type II diabetic patients showed
that the prevalence of neuropathy was 41.6% and
prevalence of PVD was 11%. In their study 20 were
purely neuropathic 13 were neuroischemic, 5 pure
vascular and 5 unclassified.
Mohan et al16 in their study on diabetic foot
ulcerations using measures of ABPI and Doppler
estimated that 21.3% of the subjects were diagnosed
to have PVD. Rooh-Ul-Muqim et al12 in their study
on diabetic neuropathy, foot ulceration, peripheral

vascular disease and their potential risk factors
among the patient with diabetes demonstrated that
diabetic neuropathy was found in 36.6% of patients
and PVD in 11.8% of cases. In our study, 84% of the
population had peripheral neuropathy in comparison
with other studies. Our patients in the study
population had higher incidence of peripheral
neuropathy compared to their study. 33% of the
patients had presence of PVD in comparison with
other studies which is higher. In the ulcer groups the
neuropathic ulcer were more common (51.4%),
compared to the group neuro-ischemic (32.87%) and
others (12.8%). In analyzing the outcome of these
patients' in the above three groups the amputation
rates were higher in neuro-ischemic group (69.4%)
when compared to other two groups and the healing
rate was better in the neuropathic group (94%)
compared to neuro-ischemic (87%). This signifies
that the presence of neuropathy increase the chance
of foot ulceration and the presence of ischemia
worsen the presentation and which further affects the
outcome of the ulcer. Hence both play an important
role in the prognosis of the disease apart from other
associated risk factors like higher glycaemia,
infection, osteomyelitis, and deformity. From our
study we confirm that peripheral neuropathy is the
predominant factor for foot ulceration, as the
insensate foot is prone for undue trauma. The
presence of ischemia due to peripheral vascular
disease increases the morbidity and mortality of the
diabetic foot. PVD also increases the amputation
rates and reduces the healing time.
CONCLUSION
Male population (65.7%) is predominantly affected
compared to female (34.3%).
The mean age of patients in the study population
with foot ulceration was between 55 + 5 years.
The mean duration of diabetes was 5.2 years in
patients who suffered from foot ulceration.
Majority of the patients present with foot problems
with G l to G IV (Wagner's Grades).
Most of the ulceration occurs in toes, metatarsal head
and mid foot. It was more common in deformed foot
due to alteration of weight bearing.
Most of the patients had blood sugar values more
than 200. The duration of diabetics more than the
level of sugar is the cause of foot disease.
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Neuropathy was present in 84% of the population in
the study. Nerve conduction study shows majority of
the patients suffer from both sensory and motor
neuropathy.
33% of the population in the study had peripheral
vascular disease.
51.4% of the ulcer were neuropathic and 32.8%
were neuro-ischemic and 12.8% were due to infection
alone. Total amputation rate was higher (69.4%) in
the neuro-ischemic group, (66.5%) in the infection
group and lowest (11.1%) in the neuropathic group.
Healing rates were higher in neuropathic ulcers
(94%) when compared with neruo-ischemic (87%)
and others (82%).
Control of diabetes with soluble insulin with
combination of antibiotics provides a better result.
Hence apart from routine foot examination, both
neuropathy and peripheral vascularity should be
assessed in all patients with foot ulcerations.
In conclusion "Prevention is better than Cure"
Hence the insensitive diabetic foot should be
protected by proper patient education, early
assessment, which timely management and proper
design of foot wear can avoid further (or) recurrent
foot ulceration.
Conflict of Interest: Nil
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DOI: 10.5958/2319-5886.2015.00049.1

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 26 Aug 2014
Research article

Coden: IJMRHS
Copyright@2014
ISSN: 2319-5886
th
Revised: 15 Sep 2014
Accepted: 25thJan 2015

A STUDY ON PRESCRIPTION OF ANTIBIOTICS UTILIZATION IN NEONATAL INTENSIVE CARE
AT A TERTIARY CARE CENTER
Subash KR1, Shanmugapriyan S2
1

Associate Professor, Department of Pharmacology, Sri Padmavathi Medical College for Women, Tirupati,
Andhra Pradesh, India
2
Assistant Professor, Department of Pharmacology, Meenakshi Medical college Hospital & Research Institute,
Kanchipuram, Tamil Nadu, India
*Corresponding author email: subbu2207@ yahoo.com
ABSTRACT
Introduction: The aim of this study is to analyze the utilization of antibiotics at our neonatal intensive care unit
(NICU). Neonatal sepsis is one of the most common causes of admission in NICU and the causative bacteria and
their respective sensitivity patterns based on the culture sensitive reports helps in achieving the antibiotic policy.
Methods: This study was done after obtaining the approval from Institutional Human Ethical Committee (IHEC)
of Sri Padmavati Medical College Hospital and Research Institute. The study was carried out during the period of
February 2013 to April 2013 at Department of Pediatrics, Neonatology division, the total number of antibiotics
used in neonatal intensive care unit (NICU) during the study period was identified and the percentage of the
antibiotic prescriptions, individual and fixed dose drug combinations is evaluated. Results: Ampicillin and
Gentamicin were the maximum (50%) empirically administered followed by the fixed dose combination of
Piperacillin and Tazobactam was used in nearly 16% of the babies. Conclusion: The study concludes the
prescription pattern at our neonatal intensive care unit complies with international studies and standards.
Key words: Antibiotics, Neonatology, Intensive care Unit, Prescription.
INTRODUCTION
The most common groups of drugs prescribed in
hospitals are antimicrobial agents. The major
admission particularly at neonatal intensive care unit
(NICU) is sepsis[1]. Major neonatal mortality and
morbidity worldwide is due to septicemia is a
recorded fact comprising various systemic infections
of the newborn such as septic shock, meningitis,
pneumonia, arthritis, osteomyelitis, and urinary tract
infections[2]. Empirical antibiotic therapy should
begin immediately on suspicion of septicemia
followed by cultures and sensitivity, later based on
report reevaluation of antibiotic treatment provided
Subash et al.,

can be done[3]. Prescriptions and drug utilization
monitoring can identify the problems and provide
feedback to physicians so as to create awareness
about irrational use of drugs[4]. These studies are
useful for obtaining information about drug usage
patterns and data for future reference to streamline
antibiotic policy5. Currently the data about drug usage
patterns is not satisfactory. There is lack of data on
prescription pattern studies and it is essential to
define prescribing
The present study was designed to assess and procure
a data of the prescription pattern in the NICU of Sri
265
Int J Med Res Health Sci. 2015;4(2):265-268

Padmavati Medical College Hospital and Research
Institute to assess the prescriptions pattern in the
context of their adherence to prescription format and
rationality of prescription.
MATERIALS AND METHODS
This study was done after obtaining the approval
from Institutional Human Ethical Committee (IHEC)
of Sri Padmavati Medical College Hospital and
Research Institute. The study was carried out in
collaboration with the Department of Paediatrics,
Neonatology division, The Inclusion Criteria were
Neonates suspected or diagnosed to have sepsis or
probable sepsis in newborn babies admitted in the
NICU. The exclusion criteria includes Neonates with
surgical problems, major congenital malformations,
on antibiotics or those whose mothers have received
antibiotics before delivery, were excluded from the
present study. The Study was Prospective and
observational conducted at SPMCH & RI. This study
was done from February 2013 till April 2013. During
this period, newborn babies admitted in the neonatal
intensive care unit diagnosed or suspected to have
sepsis or probable sepsis were analyzed for culture
and sensitivity pattern and choice of empirical
antibiotics. Details of obstetric history, maternal risk
factors, and physical examination were recorded
meticulously. Empirical antibiotics were started after
taking blood for culture and sensitivity and then
changed accordingly.
RESULTS
Gender Distribution male babies were at a slightly
higher preponderance (42.38%) in ratio than female
babies (57.62%) who were treated for neonatal sepsis.
The majority of babies who were admitted 90. %
were preterm as per the gestational age and more than
90% of babies had the onset of sepsis within 72 hrs of
birth .There were 61% Gram negative organism
which included Klebsiella pnemoniae, Escherichia
coli, enterobacter and pseudomonas. The rest 39%
included Gram Positive organisms Staph aureus,
Staph epidermidis in neonatal intensive care unit
during the study period 83% and 9.52% respectively
with 2.38% sterile culture(fig:1). The chief organisms
revealed in blood culture report are Klebsiella
pnemoniae and pseudomonas

The antibiotics used in NICU during the study period
were 6 antimicrobials and 2 fixed drug dose
combinations.They are Ampicillin, Gentamicin,
Cefotaxime,
Amikacin,
Ciprofloxacin,
and
Metronidazole, Piperacillin with Tazobactam and
Imipenem and Cilastin respectively (Table-1).

39%

G.Negative
G.Positive
61%

Fig1: Prevalence of isolated bacteria in neonatal
sepsis
Table 1: Prescription pattern of antibiotics in
NICU
Sl.
Antibiotics
Number of
No
Prescription %
n =250
1
Ampicillin
55
21.73
2
Gentamicin
55
21.73
3
Amikacin
50
20.10
4
Cefotaxime
28
11.43
5
Ciprofloxacin 16
06.52
6
Metronidazole 04
01.63
% -percentage of antibiotic utilization
Table 2: Prescription pattern of Fixed dose drug
combination Antibiotics in NICU
Sl. Antibiotics
Number of
%
No
Prescription
n =250
1
Piperacillin + 39
15.76
Tazobactam
2
Imipenem +
3
01.08
Cilastin
% -percentage of antibiotic utilization
Among the prescribed antibiotics Ampicillin,
Gentamicin and Amikacin were utilized high at
21.73%, 21.73 and 20.10% respectively, followed by
Cefotaxime 11.43%, ciprofloxacin 6.52%, and
266

Subash et al.,

Int J Med Res Health Sci. 2015;4(2):265-268

Metronidazole 1.63%. Among the fixed Dose drug
combinations piperacillin with tazobactam 15.76%
and Imipenem with cilastin 1.08%.
DISCUSSION
The infant mortality rate of India is 47/1000 live
births, of which 70 % of deaths is in neonatal period
with sepsis being one of the leading causes of
death[6].
In our study, both male and female babies were
equally affected and babies who had late onset
neonatal sepsis were predominantly male. This was
similar to a study conducted by Remington et al[7].
The present study revealed 92.85% were preterm as
per the gestational age. This is a main indicator that
preterm babies are more prone for neonatal sepsis
than the term babies and more than 90% of babies
had the onset of sepsis within 72 hrs of birth,
similarly in a study conducted by Sidiropoulus et
[8]
al ., neonatal sepsis was much predominant in
preterm babies and showed significant reduction in
mortality rate. In our study also neonatal sepsis rate
was found more than 90 % in preterm and low birth
weight babies.
The blood culture reports established Klebsiella in 4
cases followed by Pseudomonas in 2 cases. But major
portion of the isolate were sterile, confirming the
chief organisms Klebsiella and pseudomonas in our
neonatal intensive care unit during the study period.
This result adds strength to empirical treatment
provided. This was similar to a study conducted in
Bangalore by Shenoi et al[9]. Another study done by
Viswanathan et al in 2011 at Vellore, reported
Klebsiella as the chief organism causing neonatal
sepsis followed by Staphylococcus aureus[10].
The total numbers of antibiotics used in our NICU
during the study period were 6 individual drug and 2
fixed dose drug combinations. Of the 250
prescriptions, Ampicillin and Gentamicin were the
maximum with each 40 in number as they were
started empirically. This was followed by Amikacin
and Cefotaxime based on the progress of clinical
features like cyanosis, feeding difficulty, breathing
difficulty (grunting), fast breathing (respiratory rate
>60 bpm), abnormal behavior and fever/temperature
>38°C. Ciprofloxacin and metronidazole were
initiated only if the culture and sensitivity report

Subash et al.,

demands its use and not empirically for a period of 10
days.
The fixed dose combination of Piperacillin and
Tazobactam was used in 29 babies ie for nearly 16%
of the babies. Another fixed dose combination of
Imipenem and Cilastin was given for 2 babies
because of resistant strains. The above prescription
pattern of antibiotics was similar to study on
antibiotic utilization pattern done by Fanos V et
al[11].. Another study done by Liem et al [12]. by
collecting data from all tertiary care NICU s of
Netherlands, reported that 6 out of 10 NICUs used
extended-spectrum penicillins (amoxicillin and
amoxicillin/clavulanic acid), b-lactamase-resistant
and sensitive penicillins (flucloxacillin and
benzylpenicillin, respectively), amino glycosides
(gentamicin and amikacin), cephalosporins(1st and
3rd generation) and glycopeptides (vancomycin and
teicoplanin). The limitations of the study are small
group and seasonal infections may vary where in this
observation is done during a short period and not
throughout the year.
The study of antibiotic utilization pattern showed that
β lactam group of antibiotics, cephalosporins and
amino glycosides were used more in our NICU.
CONCLUSION
The study concludes the prescription pattern at our
neonatal intensive care unit complies with
international studies.
ACKNOWLEDGEMENT
We are thankful to Department of Paediatrics, NICU
Staff and Medical record Section staff of Proposed
Sri Padmavathi medical College – Renigunta for their
co-operation.
Conflict of Interest – Nil
REFERENCES
1. Lawn JE, Cousens S, Zupan J; 4 million neonatal
deaths: Lancet; 2005:365:891–900
2. Kaistha N, Mehta M, Singla N, Garg R, Chander
J. Neonatal septicemia isolates and resistance
patterns in a tertiary care hospital of North India.
J Infect Dev Ctries.2009; 41: 55- 7.
3. Yurdakök M. Antibiotic use in neonatal sepsis.
Turk J Pediatr 1998; 40: 17- 33.
267
Int J Med Res Health Sci. 2015;4(2):265-268

4. Pradhan SC, Shewade DG, Shashindren CH, et
al. Drug utilization studies. Natl Med J Ind. 1:
1988, 185-189.
5. Marshner JP, Thurmann P, Harder S, et al. Drug
utilisation review on a surgical intensive care
unit. Int J Clin Pharmacol Ther. 1994, 32:447-51.
6. Park K. Health information and basic medical
statistics. Park‘s textbook of Preventive and
Social Medicine, 21st ed. 529, 2012.
7. Remington JS, Klein JO. Infectious Diseases of
the Fetus and Newborn Infant 5th Ed. WB
Saunders, Philadelphia 2000; Page no.
8. Boehme U, Sidiropoulos, Muralt GV, et al.
Immunoglobulin supplementation in prevention
and treatment of neonatal sepsis; Pediatric
Infectious disease journal;1986;5: 193-95
9. Shenoi A, Nagesh NK, Maiya PP, Bhat SR,
Subba Rao SD. Multicenter randomized placebo
controlled trial of therapy with intravenous
immunoglobulin in decreasing mortality due to
neonatal sepsis; Indian Pediatr.J; 1999;36 (11)
:1113-8
10. Viswanathan R, Singh AK, Basu S, Chatterjee S,
Sardar S, Isaacs D; Arch Dis Child Fetal
Neonatal Ed. 2012 ;97(3):182-7
11. Fanos V, Cuzzolin L, Atzei A, and Testa M.
Antibiotics and antifungals in neonatal intensive
care units: a review. J Chemother. 2007; 19(1):5–
20.
12. Liem TBY, Krediet TG, Fleer A, Egberts TCG,
Rademaker CMA. Variation in antibiotic use in
neonatal intensive care units in the Netherlands.
J. Antimicrob. Chemother. 2010 Jun 1;
65(6):1270–5.

268
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Int J Med Res Health Sci. 2015;4(2):265-268

DOI: 10.5958/2319-5886.2015.00050.8

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 20 Nov 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 10 Jan 2015
Accepted: 16th Mar 2015

EVALUATION OF RISK FACTORS FOR PRETERM DELIVERY AND CREASY’S RISK SCORING
Anand Nalini I1, *Modi Nikunj K2, Sharma Hariom M 3
1

Professor, Department of Obstetrics and gynecology, 2 Assistant Professor, Department of Biochemistry, GGG
Hospital & M P Shah Govt. Medical College, Jamnagar, Gujarat, India
3
Professor & Head, Department of Biochemistry, Sir T Hospital & Govt. Medical College, Bhavnagar, Gujarat,
India
*Corresponding author: Modi Nikunj K Email: [email protected]
ABSTRACT
Background: Preterm birth is a poorly understood domain so it is a one of the most serious problem encountered
in case of pregnant women. Because of the incomplete knowledge of biochemical and molecular reasons for
preterm birth, many authors have shown interest in various predicting risk factors of preterm birth. Aim: This
study was undertaken to know risk factors for preterm delivery and to investigate the usefulness of the most
widely used creasy scoring system in identifying the high risk group of women at the tertiary care center of India.
In this study also included observation of perinatal mortality and morbidity associated with preterm deliveries.
Material and Methods: In the present study of 175 women who gave birth to preterm babies, detail history was
taken. Then all the Data were statistically analyzed based on percentage. Result: Preterm delivery is particularly
affected by precipitating of some risk factors (Hb, weight, parity of mother etc.). Conclusion: so we can say that
such risk factors acting as a precipitating factor for preterm deliveries. Awareness of such risk factors is essential
to plan public education programs and to consider appropriate perinatal care options for women at potentially
higher risk for preterm delivery.
Keywords: Preterm birth, Creasy scoring, Perinatal death
INTRODUCTION
One of the most important unresolved issues
currently confronting obstetricians is the prevention
of preterm birth (birth before 37 completed weeks of
gestation). Preterm birth is, worldwide, the most
challenging problem in obstetrics, but the prevention
of prematurity has been difficult and ineffective
because of its multifactorial and partly still unknown
etiology. Identification of those women who are
likely to deliver before term requires use of simple
diagnostic tools that can be applied to both
asymptomatic and symptomatic pregnant women. [1]
Many healthcare providers collect data on pregnant
women for assessment of preterm birth risk. Current
technology makes possible collection of a plethora of
Nalini et al.,

data, yet a perinatal healthcare provider has no access
to a general, reliable and valid method of preterm
birth assessment. [2] Babies born before the 34th week
of pregnancy, have the highest risk for early death
and enduring health problems, but recent research has
shown that even preterm infants (at 34 to 36 weeks of
pregnancy) have greater health risks than full‐term
babies. [3]
The treatment of preterm labor, preterm delivery, and
premature birth are not only major problems in
obstetrics and pediatrics but also have major
economic, psychological, and social impact. Most
existing methods to assess preterm birth are based on
risk scoring, done manually. These methods are
269
Int J Med Res Health Sci. 2015;4(2):269-273

between 17% and 38% predictive in determining
preterm birth. This range of accuracy is obviously not
satisfactory. Some authors conclude that-in generalmanual risk screening tools are not sufficient to be
used in the prediction of preterm labor. [2] To improve
the outcome of these very preterm neonates, we need
to expand our knowledge of the etiology, prevention,
and treatment of preterm labor and preterm delivery.
However, the rate of preterm delivery has not
decreased in the past 30 years Goldenberg et al.,
2008, mainly because of failure to identify the highrisk group during routine prenatal care. [4] To identify
women at risk of spontaneous preterm birth,
clinicians use prior preterm birth, multiple pregnancy
and prior cervical surgery as major risk factors.
Useful clinical risk factors in predicting spontaneous
preterm birth in nulliparous women with a singleton
pregnancy are scant, except for a history of prior
cervical surgery. [5]
So the present study was with the aim of first, to see
the effectiveness of the routine creasy risk scoring
system in predicting the high risk group in local
population and second, to find out the common high
risk factors like Hb, weight, parity of mother
associated with preterm labor.
MATERIALS AND METHODS
The department of Obstetrics and Gynecology, of
Shri M. P. Shah Govt. Medical College and Guru
Govindsinh General Hospital, Jamnagar, carried out
the present study. Informed consent was taken from
all individual subjects included into the study. In the
present study of 175 women, who gave birth to
preterm babies (in 1 yr duration) were included and
classified as at low, medium or high risk for preterm
labor according to the Creasy scoring system which is
based on socioeconomic factors, previous medical
history, daily habits, as well as aspects of the current
pregnancy. [6] This scoring system is extensively used
to identify preterm delivery. Socioeconomic class is
assessed by Prasad’s social classification. All other
term pregnancy was excluded from the study. The
gestational age was assessed from the date of last
menstrual period, provided she had regular ovulatory
cycle previously. In others, clinical examinations like
fundal height date of quickening, appreciation of fetal
heart by stethoscope and ultrasonographic
measurements were used for gestational age
determination. Anthropometric measurements of the

mother including weight, height were carried out by
using standard techniques. Other data of
socioeconomic status, personal history, past medical
surgical, obstetric history and prenatal care were
collected by interviewing the patients. Hospital
records were also abstracted for relevant data and
used for cross-check the reliability of information
obtained during the interview.
Physical examination, Blood pressure and
hemoglobin by standardized acid haematin method
were also done. Anemia in this study was defined as
hemoglobin < 10 g/dl on one or more occasion.
Chronic or pregnancy induced hypertension was
defined as a blood pressure greater than 140/90
mmHg repeatedly, and, if the women also had
proteinuria than pre-eclampsia was considered to
exist. After delivery the newborn was examined
within 6 hours and fetal maturity was assessed. Then
all the Data were statistically analyzed based on
percentage.
RESULTS
Finding of the present study are as under –
First the relationship with the age of mother (in yrs)
and preterm delivery compared, in that the age group
are divided in < 20 yrs, 21-25 yr, 26-30 yr, 31-35 yr,
36-40 yrs and >40 yrs, out of them majority of
preterm delivery was noticed in 21-25 yrs of age
group. That is of 87 out of 175 preterm deliveries.
Then the incidence was gradually declined with
increase age. Then relationship with the gestational
age of mother (in wks) and preterm delivery
compared (Table 1), in that most of the preterm
deliveries occurred in 31-34 weeks of pregnancy.
Table: 1 Relationship of Gestational age with
Preterm delivery.
Gestational
No
of
preterm Percentage
age (in wks) delivery
(out of 175)
<30
19
10.8 %
31-34
85
48.5 %
35-37
71
40.7 %
Then out of 175 preterm delivery, 76 were primi
while 99 are multipara in that 94 were multipara and
05 were grand (>4) multipara. One of the important
relationships of weight and preterm delivery (Table
2), in that 153 preterm delivery seen in < 55 kg wt

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Int J Med Res Health Sci. 2015;4(2):269-273

(out of them 28 have < 45 kg wt) and only 22 have
preterm delivery with more than 55 kg weight.
Table: 2 Relationship of Maternal Weight and
Preterm delivery.
Maternal
Weight (in Kgs)
< 45
45-55
>55

No of preterm
delivery(out of 175)
28
85
22

Percentage
16 %
71.4 %
12.6 %

In relation to the antenatal care 118 were unbooked
and 57 were booked. In our study approximately 49%
births were females and 51% males. According to
socio economical class (Table 3), majority of preterm
delivery was noticed in low socioeconomic class
(84.57%) and that is of 148 out of the 175, and
remaining 15.43% from middle class.
Table: 3 Relationship of Socioeconomic class and
Preterm delivery.
Socioeconomic
Class
High
Middle
Low

No of preterm
delivery(out of175)
27
148

Percentage
15.4 %
84.6 %

with Hb level < 10 g/dl (in that 25 have Hb < 8.0
g/dl).
According to past history 29 have previous h/o of
abortion, 20 have H/o preterm delivery and 09 have
previous H/o both.
In this study, according to creasy risk scoring system
(primi + multi) (Table 4), in that (31 +3 = 34 in low
risk), (21 + 8 = 29 in medium), (24 + 88 = 112 in
high risk).With twin pregnancy (175 + 13 = 188)
child born. Out of them 49 were still birth, 55
neonatal deaths and hence making 104 prenatal
deaths.
Table: 4 Creasy scoring and distribution by
Parity.
Total
Gravida Low
Medium
High
risk
risk
risk
76
Primi
31
21
24
99
Multi
03
08
88
17
Total
34
29
112
DISCUSSION

Fig1: Relationship of Hb level and Preterm
deliveries.
According to Hb (Fig. 1) only 8 women have preterm
delivery with Hb > 10 g/dl, and rest of the women

The importance of preterm delivery as a major public
health problem is easily demonstrated by virtue of its
contribution to total perinatal mortality contributing
50% to 70% of all perinatal deaths in most data
sets.[7] Early detection of preterm labour is difficult
because initial symptoms and signs are often mild and
may occur in normal pregnancies. Thus, many
healthy women will report symptoms during routine
prenatal visits, whereas others destined for preterm
birth may dismiss the early warning signs as normal
in pregnancy. The traditional criteria for preterm
labour (persistent contractions accompanied by
progressive cervical dilatation and effacement) are
most accurate when contraction frequency is six or
more per hour, cervical dilatation is 3 cm or more,
effacement is 80% or more, membranes rupture, or
bleeding occurs. [8] Though preterm birth occurs in
approximately 5-15% of all deliveries, it accounts for
the major bulk of perinatal and especially postnatal
deaths. The risk of neonatal morbidity and mortality
mainly depends on the gestational age at delivery.
Survival rate increases with an increasing period of
gestation. In a developing country like ours, where
intensive care facilities are often unavailable,
mortality figures would be much higher at a lower
gestation period at delivery. [1] Some biochemical
markers like fetal fibronectin, the thrombin cascade,

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Int J Med Res Health Sci. 2015;4(2):269-273

In the present study of preterm delivery, 19 cases of
PET – pre eclamptic toxemia, 18 cases of PROM premature rupture of membrane, 18 cases of APH
(ante partum haemorrhage), 13 cases of twin
pregnancy, 11 cases of UTI - urinary tract infection,
07 cases of Eclampsia were noticed. While some
cases of fever, heart disease, cerebral malaria,
hydroamnios,
jaundice,
anemia,
congenital
anomalies, uterine anomaly and uterine prolapsed.
And 62 are from the unknown reason. In this study
out of 175, 13 were twin delivered.

0% Hb > 10 g/dl 5% Hb 08 - 10 g/dl

Hb < 08 g/dl

14%

81%

271

and maternal salivary estriol measured in
asymptomatic women with and without risk factors
for preterm birth. [8]
In our study majority of preterm births were in
mothers of age group 21-25 years and that was
gradually decreasing with increasing age. It is
comparable to many similar studies like Molly Phillip
et al. and Trivedi et. Al. inspite of very high incident
of prematurity among teenage patients, the total
number of patients in this group remains low because
of decreasing trend of teenage marriage and late age
of marriage. Higher incident of prematurity in the
older patients is likely to be due to malnutrition,
anemia, increase physical work load and increased
incidence of medical and obstetric complications. [9]
Also presence chorioamnionitis, bacterial vaginosis,
urinary tract infection were significantly associated
with preterm labor. [10] Fibronectin, an extracellular
matrix protein, acts as the “glue” that attaches the
fetal membranes to the underlying uterine decidua. A
positive fibronectin test (50 ng/mL or more) in a
patient with symptoms suggestive of preterm labor
has been associated with an increase in the likelihood
of birth before 34 weeks and birth within 7–14 days
of the test. [8]
In our study preterm birth in primipara, multipara and
grand multipara were 43.4%, 53.7% and 2.95%
respectively. This result is somewhat similar to other
work reported on this aspect. [11] In grand multipara it
is combined effect of parity, preexisting poor
maternal nutrition, anemia less spacing between two
pregnancies, lack of antenatal care, associated
medical and obstetric complication etc. also play a
role. The distributions of preterm births by gestational
age observed in the present study are quite
comparable to those of jose et.al. [10, 11]
The delivery probability profile incorporates data on
fetal fibronectin, cervical length by ultrasound and a
past history of preterm delivery to generate standard
pregnancy survival curves. This information might
also help in developing patient-specific strategies to
help prevent prematurity. [12]
It is observed that almost 87.5% preterm births were
from mothers with pregnancy weight of less than 55
kg. in another study from India 52.5% preterm births
were in mothers having weight of less than 45 kg.
Pre-pregnancy weight of mother and weight gain
during pregnancy also affects the birth weight. [13]

The effect of regular antenatal care on the incidence
of preterm birth observed in the present study is
compared with some of the other studies. Incidence
of preterm birth is markedly less in booked cases as
compared to unbooked cases (who attended less than
3 antenatal care or none). Greenberg noted that
prenatal care had a greater impact on pregnancy
outcome in socially disadvantages women, a group of
women who often obtain less prenatal care. [14] The
prevention can be based on at risk approach – (a)
Patient at high risk of preterm labour should be
monitored carefully and (b) Patient with warning
signs will go through prophylactic treatment like
antibiotics, tocolytics, bed rest etc. to prevent preterm
birth.
The higher frequency of preterm births in lower
social class might have been due to a number of
factors. More than two thirds of the patients admitted
to our hospital are from these social classes. Secondly
those who are economically at disadvantages might
be worse off as regards health, physique, knowledge
and nutrition. Present study data and that reported by
other studies clearly indicate that socio-economic
status has got direct and profound influence in the
preterm labor and birth. [15, 16, 17]
Anemia has been documented to result in higher
incidence of low birth weight babies as well as higher
preterm births. Anemia could lead to T and B cell
suppression and resulting immune suppression could
lead to increased susceptibility to infection. [18]
Similar results are also reported by kandeparker et al.
with 54% cases having Hb less than 10.0 g%. [11]
In agreement with other studies [19] we found that
history of previous abortion and previous preterm
delivery increase the risk of preterm delivery in next
pregnancy.
The ability of creasy’s score in predicting Preterm
birth is significant but it also has its limitations when
applied in Indian context, where no. of other
parameters do play a major role in predicting Preterm
birth. This study present that maternal age,
socioeconomic class, parity, past history are
important risk factors for Preterm birth. If added to
the present scoring system they will greatly improve
the predictability of the scoring system in Indian
context. Similar study was also found by another
author in India. [20]
The total perinatal deaths were 104 (49 still birth + 55
neonatal death) giving an incidence of 55.3 %

Nalini et al.,

Int J Med Res Health Sci. 2015;4(2):269-273

272

perinatal mortality. As compared to western studies it
is much higher. This is due to the fact that they have
lower rate of preterm birth and much better neonatal
services including intensive care units for preterm
and low birth weight babies. Regarding neonatal
death our results are comparable with Khandeparkar
el al study. [11]

6.
7.

CONCLUSION
Our data in this study shows the correlation with
various risk factors to the preterm birth. From the
present study, it is concluded that to make creasy risk
score more specific and effective in the Indian
context, it should be modified by giving higher score
to women with low socioeconomic status, low
pregnancy weight, physical work during pregnancy
and low maternal age. A slightly modified scoring
system needs to be devised for Indian population.
More elaborate information about the components of
the scoring system is required for understanding the
need to devise it in Indian context.

8.

9.
10.

11.
12.

ACKNOWLEDGEMENT – None
Conflict of Interest – Nil

13.

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15.
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DOI: 10.5958/2319-5886.2015.00051.X

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 18 Nov 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 20 Dec 2014
Accepted: 24th Jan 2015

ACCURACY OF LOW BIRTH WEIGHT AS PERCEIVED BY MOTHERS AND FACTORS
INFLUENCING IT: A FACILITY BASED STUDY IN NEPAL
*Shakya KL1, Shrestha N2, Bhatt MR3, Hepworth S4, Onta SR5
1,3

Department of Community Medicine and Public Health, 5Dean’s Office, Institute of Medicine, Tribhuvan
University, Kathmandu, Nepal
2
Valley College of Technical Sciences, Purbanchal University, Kathmandu, Nepal
4
Department of Health, University of Bath, Nepal
*Corresponding author email: [email protected]
ABSTRACT
Introduction: Birth weight is a key predictor for risk of childhood illnesses and chances of survival; however in
developing countries less than half of newborns are weighed at birth. In Nepal, only 36% of children born were
weighed at birth. Nearly two thirds (63%) of deliveries take place at home and birth weight may not be known for
many babies, the mother’s estimate of the baby’s size at birth could be used as an alternative. Aim and
Objective: This study assessed the accuracy of low birth weight as perceived by mothers and factors influencing
whether their perceptions were accurate. Methods: The study wasa facility based descriptive study carried out in
four hospitals with sample size of 1533. Hospital nurses interviewed mothers using a pre-tested tool. Data was
entered into EpiData 3.1 and analyzed using SPSS version 17 software package. Results: A total of 1533 mothers
were interviewed of which 75 did not respond. An overall 75% mothers accurately identified actual low birth
weight; and 25% mother perceived normal for actual low birth weight. Less percent of mothers <20years
(sensitivity=0.74), illiterate (sensitivity=0.74), and primigravida (sensitivity=0.74) identified actual low birth
weight than mothers ≥20years (sensitivity=0.75), literate (sensitivity=0.75) and multigravida (sensitivity=0.77).
Conclusion: The study concluded that 75% mothers recognized actual low birth weight of newborn, and 25%
mother’s perceived normal for actually low birth weight. The percentage of women accurately identifying actual
low birth weight was slightly lower among mothers <20years, illiterate and primigravida as compared to mothers
≥20years, literate and multigravida.
Keywords: Lowbirth weight, Mother’s perception, Facility based study, Nepal
INTRODUCTION
Birth weight indicates the health status of both
newborn and mother. Low Birth Weight (LBW), less
than 2.5 kg[1]. is the consequence of small maternal
size at conception; low gestational weight gain;
premature delivery; and pregnancy among younger
women2; and can have consequences on increasing
newborn morbidity and mortality[2]. Additionally,
knowing the birth weight can help providers and
family to take care of newborn at right time.
Shakya et al.,

Globally,15.5%ofallbirthsarebornwithLBW. Among
them 95.6% areindeveloping countries[3]. About 80%
intrauterine growth retarded (IUGR) newborns who
are LBW and full term are born in Asia[3]. Nepal has
an overall 21% LBW2 and little variation in different
studies, 12.76%[5], 21.6%[6], 11.9%[7]; similar to
prevalence of LBW in India 23%[7], 21.5%[9],
12.8%[7], and 17.3%[10]. More than half of infants in
the developing world are not weighed after birth[1] as
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Int J Med Res Health Sci. 2015;4(2):274-280

they born at home[1,11,12] and thus will not have a
recorded birth weight. In the past, most estimates of
LBW for developing countries were based on data
compiled from health facilities, these estimates did not
cover the weight of newborns who were born out of a
health facility[1]. Since birth weight may not be
known for many babies, the mother’s estimate of the
baby’s size at birth was also obtained[13].
Nepal has taken the percentage of newborns with
LBW as one of the indicators to demonstrate
achievement of nutritional wellbeing, maintenance of
a healthy life and socioeconomic development of the
nation. Many nutritional policies; principles; and
strategies are based on this indicator, such as,
increased nutrition monitoring and counseling
services at antenatal checkup to reduce LBW[2].
Hence, it is important to take birth weight of newborn
and, where formal measurements are unavailable,
validate the accuracy of mothers’ perception of birth
weight as a possible alternative source of data.
However, studies on validation on perceived birth
weight is not available for Nepal in our knowledge,
and mother’s perception about the size of baby has
not been properly verified as a reliable estimate of
birth weight. We questioned that is mother’s
perception on weight of newborn is correct? Is her
perception on weight of newborn is affected by her
socio-demographic background? This study aimed to
assess accuracy of birth weight perceived by mothers
against actual birth weight recorded in hospital; and
to find out any associated determinants.
MATERIAL AND METHODS
The study was approved by Institutional Review
Board of Institute of Medicine, Maharajgunj Medical
College. We also received approval from each
hospital board; and consent from each mother before
data collection. Hospital nurses interviewed mothers
once they were comfortable following delivery. After
interviewing, nurses gave information to mothers on
breast feeding; keeping newborn warm, special care
for infants who were LBW using Kangaroo mother
care, family planning, and baby immunization. This
was a hospital based descriptive study, carried from
August 2012 to February 2013. We chose hospitals
for this study as hospitals routinely record weight of
newborn and therefore provided a comparison against
which the accuracy of mothers’ perception on LBW
could be assessed. We carried out this study in 4

hospitals: Tribhuvan University Teaching Hospital
(TUTH), and Paropakar Maternity and Women’s
Hospital located in central Kathmandu; Seti Zonal
Hospital in Kailali district, far western region of
Nepal, 723 km away from Kathmandu city; and
Dhulikhel Hospital in Kavre district, 30 km away
from Kathmandu city. We chose these hospitals
purposively to represent geographical scope from far
western plain area to central hill areas.
Women within the reproductive age of 15-45 years
were the target population for this study. The
sampling unit was mothers who were recently
delivered, had completed 37 weeks of gestation,
single not multiple births and having a live birth. The
dependent variable for this study was perceived birth
weight, and independent variables were mothers’ age,
education, and gravida.
Sample size, data collection, management and
analysis: The sample size was calculated using
statistical formula14, 15,, at 95 percent confidence
level; 25% of LBW based on birth weight by birth
size11, and 2% confidence interval. Hence, sample
size calculated using this formulae, SS = 1800 For
sample size – finite population, where, population =
10350 (total average deliveries in 4 hospitals);
SS=sample size=1800; the sample size calculated
were1533. The tool was a structured questionnaire
with open and close ended questions. We asked to
mothers on how she felt the weight of her baby; what
her estimation was for NBW measurement in her
idea; and what causes small baby if she felt her baby
was small. Prior to collecting data, we did pre-test of
questionnaire in TUTH hospital and made corrections
as required from pre-test. Hospital nurses who
worked in maternity ward were trained in the study
tool and data collection techniques. Trained hospital
nurses briefed mothers of the objective of study; then
interviewed mothers who met selection criteria using
the pre-tested tool before they were told birth weight
of their newborn baby in their respective duty shift
from August 2012 to September 2013. The actual
birth weight of the newborn was taken from the
hospital maternity register.
Data entry program was developed in EpiData 3.1
and checked for any inconsistencies; analyzed using
the SPSS version 17 computer software package
through running simple frequency, descriptive cross
tabulations. Sensitivity and specificity was calculated.
The sensitivity is the proportion of actual LBW in the
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Int J Med Res Health Sci. 2015;4(2):274-280

selected sample who are accurately identified as
LBW by the mothers; and the specificity is the
proportion of actual normal birth weight (NBW) of
newborn who are so identified by the mothers[14,16,17,
18]
.
RESULTS
We interviewed 1533 mothers regarding their
perception on birth weight of newborn, 75 mothers
did not response.
Maternal age and perceived LBW: Referring to
table 2, out of 1458 mothers, 205 (14.1%) mothers
were age <20 years and 1253 (85.9%) were age
≥20years. Among the mothers who were <20 years
(205), 84 (41%) mothers delivered LBW babies.
Among them (84), 62 (73.8%) mothers accurately
perceived weight of their newborn baby as low for
actual LBW. Of the remaining 121 women <20 years
who delivered NBW babies, 9 (7.4%) mothers
perceived weight of their newborn baby as low, for
actual NBW. Similarly, among mothers age of ≥20
years, 404 (32.2%) delivered LBW baby, 849
(67.8%) delivered NBW baby. Among 404, 302
(74.8%) mothers perceived weight of their newborn
baby was low for actual LBW baby. Out of 849, 64
(7.5%) mothers perceived weight of their newborn
baby as low for actual NBW. Mothers were better at
estimating NBW rather than LBW.
Maternal education and perceived LBW: Out of
1458, total of 142 (9.7%) mothers were illiterate,
1316 (90.3%) mothers were literate. Among the
illiterate mothers, 57 (40.1%) delivered LBW babies
and 85 (59.9%) had NBW babies. Out of 57, 42
(73.7%) mothers perceived weight of their newborn
baby as low for actual LBW. Out of 85, 9 (10.6%)
mothers perceived weight of their newborn baby as
low for actual NBW. Among literate mothers, 431
(32.8%) delivered LBW babies and 885 (67.3%)
delivered NBW babies. Out of 431, 322 (83.4%)
mothers perceived weight of their newborn baby as
low for actual LBW. Out of 885, 64 (16.6%) mothers
perceived weight of their newborn baby as low for
actual NBW. So, illiterate women were less likely to
be accurate in identifying LBW than literate women
(83.4% vs. 73.7%).
Gravida and perceived LBW: Out of 1458, 956
(65.6%) were primigravid mothers and 502 (34.4%)
were multigravid mothers. Out of 956 primigravid
mothers, 347 (36.3%) delivered LBW babies and 609
Shakya et al.,

(63.7%) had NBW babies. Out of 347, 256 (87.7%)
mothers perceived weight of their newborn baby as
low as for actual LBW. Out of 609, 36 (12.3%)
mothers perceived weight of their newborn baby as
low for actual NBW. Among 502 multigravid
mothers, 141 (28.1%) delivered LBW babies and 361
(71.9%) delivered NBW babies. Out of 141, 108
(74.5%) mothers perceived weight of their newborn
as low for actual LBW. Out of 361; 37 (25.2%)
mothers perceived weight of their newborn baby as
low for actual NBW.
Overall diagnostic indicators of LBW: As an
overall (table number 1), out of 1458, 488 mothers
gave LBW babies, 970 mothers gave NBW babies.
Out of 488 mothers, 364 (74.6%) accurately
diagnosed baby as LBW and 124 (25.4%) diagnosed
as normal for actual LBW. Out of 970, 73 (7.5%)
mothers diagnosed birth weight as low, and 897
(92.5%) diagnosed as normal for actual NBW babies.
We found that 75% mothers identified actual LBW
babies (sensitivity=0.75), 93% mothers identified
actual NBW babies (specificity=0.93). Twenty five
percent mothers perceived NBW for actual LBW;
whereas, 8% mothers perceived LBW for actual
NBW babies.
Table 1: Concordance between low birth weight
and perceived birth weight in two categories
Perceived
birthweight

Actual
LBW (%)

Actual
NBW (%)

Total (%)

Low

364 (74.6)*

73 (7.5)

437 (30)

Normal

124 (25.4)

897 (92.5)**

1021 (70)

Total

488

970

1458

*sensitivity at 95% CI (0.71-0.78), ** specificity at
95% CI (0.91-0.94)
Maternal profile and diagnostic indicators of
LBW: We found (table #2) there were no remarkable
differences in relation to maternal age and education
with diagnostic indicators on LBW (sensitivity and
specificity). Seventy four percent mothers age <20
years (sensitivity=0.74 @ 95% CI: 0.64-0.82); and
75% mothers age ≥20 identified actual LBW babies
(sensitivity=0.75 @95% CI: 0.70-0.78). Seventy four
percent illiterate mothers (sensitivity=0.74 @ 95%
CI: 0.61-0.83) identified actual LBW and for literate
mothers were 0.75 (at 95% CI: 0.70-0.79), and 0.93
(at 95% CI: 0.91-0.94) respectively.
Our study revealed that diagnostic indicators were
varied slightly as differences in number of gravida.
Seventy four percent primigravid mothers
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Int J Med Res Health Sci. 2015;4(2):274-280

(sensitivity=0.74 @ 95% CI: 0.69-0.78), and 77%
multigravida mothers (sensitivity=0.77 @95% CI:

0.69-0.83) identified actual LBW.

Table 2: Number of mothers with their profile, perceived low birth weight, and diagnostic indicators
Perception of
Diagnostic Indicators
Maternal
Actual
Actual
Total
mother on
Factors
LBW (%)
NBW (%)
(N=1458)(%) Sensitivity* Specificity*
birth weight
Low
62 (73.8)
9 (7.4)
71 (34.6)
0.74
0.93
Age <20 years Normal
22 (26.2)
112 (92.6)
134 (65.4)
(0.64-0.82)
(0.86-0.96)
Total
84 (41.0)
121 (59.0)
205 (14.1)
Low
302 (74.8)
64 (7.5)
366 (29.2)
0.75
0.92
Age ≥20 years Normal
102 (25.3)
785 (92.5)
887 (70.8)
(0.70-0.78)
(0.90-0.94)
Total
404 (32.2)
849 (67.8)
1253 (85.9)
Low
42 (73.7)
9 (10.6)
51 (35.9)
0.74
0.89
Illiterate
Normal
15 (73.7)
76 (89.4)
91 (64.1)
(0.61-0.83)
(0.81-0.94)
Total
57 (40.1)
85 (59.9)
142 (9.7)
Low
322 (83.4)
64 (16.6)
386 (29.3)
0.75
0.93
Literate
Normal
109 (11.7)
821 (88.3)
930 (70.7)
(0.70-0.79)
(0.91-0.94)
Total
431 (32.8)
885 (67.3)
1316 (90.3)
Low
256 (87.7)
36 (12.3)
292 (30.5)
0.74
0.94
Primigravida
Normal
91 (13.7)
573 (86.3)
664 (69.5)
(0.69-0.78)
(0.92-0.96)
Total
347 (36.3)
609 (63.7)
956 (65.6)
Low
108 (74.5)
37 (25.5)
145 (28.9)
0.77
0.90
Multigravida
Normal
33 (9.2)
324 (90.8)
357 (71.1)
(0.69-0.83)
(0.86-0.92)
Total
141 (28.1)
361 (71.9)
502 (34.4)
*calculated at 95% CI
DISCUSSION
This study assessed and analyzed perceived LBW and
the maternal factors that influence on her perception
on LBW. We asked mothers on her perception on
birth weight before she was told weight of her
newborn. We did not cover home based deliveries
because the birth weight was not recorded in home
delivery and thus cannot validate the perception of
mother on LBW. We also did not include multiple
births, preterm and still birth. Next, we are not aware
of this kind of study conducted in Nepal before. It
could be a unique study for Nepal. Though Nepal
Demographic health Survey (NDHS) uses mother’s
perception to identify low or normal birth weight, but
to date there has been no study to determine whether
this is an accurate proxy indicator. This study fills
that gap.
A study conducted in Korea to identify factors
affecting the validity of self-reported data on health
services from community health survey; and in some
other countries have done similar studies using
diagnostic indicators [11, 12, 19, 20]; UNICEF and WHO

did LBW country, regional and global estimates in
2004[1]; and an evaluation of international estimates
and updated estimation procedure11 were resources
for this study.
However, whilst it is important to know an accurate
birth weight; data on it is often difficult to obtain in
those countries where most babies are born at home,
similarly in Nepal[13,21]. Many infants are never
weighed at birth. Eighty-eight percent of newborns in
Pakistan, and 70% in India in central and other
Asia[11] were not weighed, while those weighed at
birth are often not recorded. Nepal has been also
facing a similar problem to assess an accuracy of
birth weight as it is not recorded in home deliveries.
It is difficult to evaluate the accuracy of birth weight
data because there are hardly any comparable
registration data available[12]. In Nepal, those
available data showed that only 4% children are
reported to be very small at birth, 12% were reported
to be smaller than average, and 84% were reported to
be average or larger in size on verbal autopsy[13]. Our
study revealed that 75% mothers identified actual
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LBW (sensitivity=0.75). In other word, 91% mothers
recognized actual NBW (specificity=0.91). Hence, it
showed that fewer mothers could recognize actual
LBW in compare to actual NBW. We would like to
suggest here that the next study could be “why more
mothers could identify NBW rather than LBW?” We
also found that 25% mothers perceived normal for
actual LBW babies which is crucial from a
programmatic viewpoint.
In Nepal, birth weight is still not given a priority by
family. An awareness on LBW among women who
delivered during last year in Nepal was only 12.4%
[22]
. A similar kind of study conducted in Cameroon
found that specificity for LBW (92.9%) was much
higher than sensitivity (59.9%) and the negative
predictive value (96.1%) was much higher than the
positive predictive value (44.4%)[23]. Further analysis
of data from DHS India showed that among babies
who were reported as weighing <2500 grams, 53%
were perceived by mothers as less than average size
at birth and among babies who were reported as
weighing ≥2500 grams, 91% babies were perceived
by mothers as average or more than average size at
birth. These numbers suggest that mother’s
perception about size at birth was reasonably
reliable[24].
Accuracy of perception of mothers on birth weight is
influenced by her education, number of gravida, and
her age. Maternal age, educational level correctly
predicted just over 35% of LBW[20]. Blanc and Ward
law examined these assumptions and documented that
the characteristics of infants with numerical birth
weights were not representative of all births[11]. Births
that were weighed were more likely to involve
mothers who were better educated and resided in
urban areas. They were also more likely to be in a
medical facility and with assistance from skilled
health personnel. These characteristics are generally
associated with higher birth weights and, therefore,
the resulting estimates were still likely to
underestimate the level of LBW[11]. We found that
younger mothers age <20 years had difficulty in
identifying LBW (sensitivity=0.74) as compared to
older mothers age ≥20 years (sensitivity=0.74). The
study conducted in Nepal showed 85% mother’s age
between 20-34 estimated their child’s birth weight
was average or normal[13]; maternal age was
significantly related to the incidence of LBW[8].

Our study revealed that 75% literate mothers
recognized actual LBW, which was slightly higher
than 74% illiterate mothers recognized actual LBW.
In other words, 93% literate mothers identified NBW
against 89% illiterate mothers who recognized NBW.
Studies in Nepal showed that awareness on LBW
among women who completed secondary education;
and who completed higher than it, was15.0% and
18.8% respectively in Nepal[22]; 86% mother’s having
School Leaving Certificate and above estimated their
child’s birth weight was average or normal[13].
Literate mothers can read health messages and
understand easily the advice given by health
providers. The report shown that literate mothers
visited health provider more for ANC check-ups as
well13. The occurrence of LBW decreased with rising
education level of the mother[8,25],. So, the accuracy of
perception of mothers is more among literate mothers
than illiterate mothers. A study conducted in
Cameroon found that concordant descriptions were
associated with higher education (P = 0.008) and
delivery in a health unit (P = 0.025) [23]. Analysis of
population-based data from 10 centers in Burma,
Thailand, China and Vietnam, have also shown a
strong associations with LBW were found with
maternal education[26].
The knowledge of mother on health increase as she
delivers more. The study found that frequency of
LBW infant is high at birth order 1 and 29. Our study
revealed that recognition of actual LBW was higher
among multigravida mothers (sensitivity=0.77) than
in primigravida mothers (sensitivity= 0.74).
Mother’s perception of birth weight as a proxy
indicator: There is a strong debate on the use of
mothers’ estimate of birth weight in developing
countries where there is low formal measurement
data. A possible solution to it is to use a proxy
variable13; putting question on size of the infant at
birth (i.e. low, normal or high). This approach is
being used in DHS and Multiple Indicator Cluster
Surveys. In these surveys, mothers are asked to
classify the size of their newborn[12].
In many countries, birth weight information is
collected through applying retrospective surveys [27]
especially in DHS. Cambodia, Kazakhstan and
Malawi the responses to this question using DHS
surveys, were assessed to indicate the relationship
between birth weight and mother’s perception12. The
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results indicated that mother’s perception on size of
newborn is a good proxy for birth weight12. Other
surveys such as Multiple Indicator Cluster Surveys,
Pan Arab Project for Child Development and
Reproductive Health Surveys, a question is asked to
the mother regarding the size of her child at birth,
which has been considered as a proxy indicator for
birth weight11. Further analysis of data from DHS
India suggest that mother’s perception about size at
birth was reasonably reliable[24].
As in other developing countries, still two-thirds of
births (63%) take place at home in Nepal[25]. Only
36% of children were weighed at birth as the majority
of births do not take place in a health facility in
Nepal13. Nepal DHS has been using verbal autopsy
from mothers on their newborn baby’s size; and birth
weight was recorded in the questionnaire if available
from either a written record or the mother’s recall.
Since birth weight may not be known for many
babies, the mother’s estimate of the baby’s size at
birth was also obtained and useful proxy for the
weight of the child[26].
Based on our study, 93% mothers recognized actual
normal birth weight, and 75% mothers recognized
actual LBW, and still 25 percent mothers could not
recognize actual LBW. Hence, perceived birth weight
could be used as proxy indicator when birth weight
data are not available. We noticed that proxy
indicator could be more reliable if mother were
literate, aged ≥20 years. A study conducted in
Cameroon indicated that recall of size, in
Cameroonian women and in other low resource
settings, should be used only in the absence of other
sources of data [27]. A further similar study among
mothers who delivered in home with an intervention
of birth measurement is recommended to cover
broader area and to ensure accuracy of perceived
birth weight.
CONCLUSION
An overall, 75% mothers recognized actual LBW,
and still 25% mothers perceived normal were actual
LBW babies, which is crucial from programmatic
view. A percent of identifying actual LBW was
slightly lower among mothers <20 years, illiterate and
primigravid as compared to mothers ≥20 years,
literate and multigravida. Mothers’ perception on
birth weight can be considered as proxy indicator for

Shakya et al.,

birth weight of newborn as and when birth weight is
not available.
ACKNOWLEDGEMENTS
We are grateful to University Grant Commission
(UGC), Sanothimi, Bhaktpur for providing grant for
this study; Seti Zonal Hospital,Kailali; TUTH,
Kathmandu;Paropakar Maternity and Women’s
Hospital, Kathmandu; Dhulikhel Hospital, Kavre for
permitting us to collect data; thankful to the
respective team in each hospital for collecting data
for this study; and also thankful to Department of
Community Medicine and Public Health, Institue of
Medicine, Maharajgunj for technical and logistic
support.
Conflict of Interest: Nil
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26. Golding J, Shenton T. Low birth-weight and preterm delivery in South-east Asia. The WHO
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Int J Med Res Health Sci. 2015;4(2):274-280

DOI: 10.5958/2319-5886.2015.00052.1

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 20 Nov 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 10 Dec 2014
Accepted: 30th Jan 2015

WATER ADSORPTION CHARACTERISTICS OF NEW DENTAL COMPOSITES
Rafed. M Al-Bader1,*Kareema M.Ziadan2, M. S Al-Ajely3
1

PhD. student, College of Dentistry, 2 Professor in polymer physic, Department of Physics, college of science,
University of Basrah, Basrah, Iraq.
3
Professor in polymer, Department of Chemistry, college of Education, University of Mosul, Mosul, Iraq.
*Corresponding author email: [email protected]
ABSTRACT
Water sorption of dental composites affects dimensional stability, mechanical properties and bonding strength
with tooth structures. The diffusion coefficient of water through the resin should be identified. Methods: Ten new
composites fillings (M1-M10) were prepared from new Fluoroaluminosilicate powder composition and
BisGMA/TEGDMA together with the related compounds such as tri ethylene glycol dimethacrylate, N,NDimethyl amino ethyl methacrylate and Camphorquinone. Five disk shapes were prepared for each composite
using a stainless steel mold 15 mm in inner diameter and 1 mm in thickness, according to ISO 4049, the curing of
each composite disk for 40 sec. Each disk was immersed separately in water for 90 day all at (37 ±1). Water
sorption and solubility were calculated by using these measurements, Diffusion coefficients were also measured
with the solution of Fick’s second law. Results: The water sorption (g/mm3) after 90 day immersion ranged from
14.98 g/mm3 (±0.90) for M10 to 36.81g/mm3 (±0.46) for M6. The solubility ranged from 3.3 g/mm3 (±0.90) for
M6 to 8.55 g/mm3 (±0.31) for M7, the equilibration time for water sorption was reached at 20 day. M6 had the
highest diffusion coefficient 6.25 ×10-9 cm2/s (±3.46). Conclusion: This investigation revealed that M6 composite
filling was the best one due to the lowest water solubility while the other investigated fillings showed moderate to
high solubility values but all are in accordance with the International Standard ISO 4049.
Keywords: Water sorption, Solubility, Composites, Diffusion coefficient, Calcium Fluoroaluminosilicate.
INTRODUCTION
Materials left for long time in the oral environment
will undergo an interaction with oral fluids. Visible
light-curable polymeric composites are now routinely
used as filling materials for dental restorations. These
materials are based on polydimethacrylate matrix
resins along with silane-coated inorganic fillers. They
possess many advantages such as mechanical
properties comparable to commercial dental
amalgams and dental ceramics, excellent esthetic
quality and the ability to bond to enamel surface.
However, in aqueous environment they absorb water
and release unreacted components.
There are two different mechanisms that occur when
the previously mentioned dental restorative materials
Kareema et al.,

are exposed to or stored in water: the first is gaining
weight from water uptake, and the second is losing
weight from dissolution in water[1].
Water sorption has been studied in several glassy
polymers used in dentistry. Composite resins[2,3], soft
lining and poly(methyl methacrylate) denture bases[4]
have all been shown to absorb water and, at the early
stages, this sorption follows Fick’s law of diffusion.
Studies have mostly been focused on determining the
water sorption characteristics of epoxy-based
polymers [5-7]. However, data are scanty on the resins
that are employed as adhesives for bonding to
hydrated dentin.
The importance of composite-water interaction has
been acknowledged in the ISO standard 4049 which
281
Int J Med Res Health Sci. 2015;4(2):281-286

states that the maximum values for water sorption and
concurrent solubility for resin-based materials
(composites and cements). In order to comply with
this ISO standard, resin-based materials must
have water sorption and solubility values equal or
lower than 40 micrograms per cubic millimeter
(sorption) and 7.5 micrograms per cubic millimeter
(solubility) for specimens 15 mm in diameter and 1
mm thick[8].
Fluoride (F-) releasing restoratives are frequently
studied because the F- ions could increase the
dissolution resistance of the tooth structure, enhance
remineralization and hinder demineralization[9,10].
Efforts have been made to develop a composite
consist of an aluminosilicate glass matrix modified
with other elements, and they contain large quantities
of fluorine. Calcium Fluoroaluminosilicate glass
powder is treated with a fluoride in an amount of
from 0.01 to 5 parts by weight based on 100 parts by
weight of the glass powder, The Calcium
Fluoroaluminosilicate glass powder of the
investigation is improved in not only physical
properties such as crushing strength but also mixing
workability without impairing the inherent
characteristics thereof for the dental use[11]. So
Calcium Fluoroaluminosilicate glass will be suitable
as filler for resin-based dental composites because it
is interact with the bone structure makes them useful
materials for bone replacement in implants, naturally
radiopaque and highly resistant to moisture.
The aim of the present study is to determine the water
sorption characteristics of light-cured resins made
from new composites of Calcium Fluoro
aluminosilicate glasses filler with various weight
ratios.
MARERIAL AND METHODS
The compositions of the 10 composite resins tested,
The ethoxylated bisphenol A glycol dimethacrylate
Bis_GMA was purchased from Sigma Aldrich (UK)
and TEGDMA (triethylene glycol dimethacrylate)
manufactured from Sigma Aldrich (UK), N,NDimethyl aminoethyl methacrylate (DMAEMA) and
camphor Quinone (CQ) were purchased from Aldrich
(UK), Those materials were used to prepare the
monomer phase.
Calcium fluoroaluminosilicate glass was synthesized
and sintered in our laboratory [12]. It was ball-milled
and sieved to powder with a particle size < 25 μm.

The particle size distribution was measured using a
BET analysis (CHEMBET 3000 QUANTA
CHROME). The average particle size was 2.64 μm.
This Calcium fluoroaluminosilicate glasses was
treated with γ -methacryloxypropyltrimethoxy-silane
(γ-MPS) known as A-174 which was supplied by
Sigma Aldrich (UK).
Preparation of composite: Ten types composites
formulations,containing the resins BisGMA/TEGD
MA in a w/w ratio of 70/30 as the base resins. Resins
were activated for visible light polymerization by CQ
(0.5 wt %) and DMPT (0.5 wt %). Matrix resins were
loaded (76 wt% ~ 60% Vol) and were then silanized.
This Calcium Fluoroaluminosilicate glasses hand
mixing. The compositions of the studied dental
composites are shown in Table 1. Water absorption
was determined on disc specimens, 15 mm diameter
and 1 mm thick, for up to 90 days using the method
outlined in ISO 4049. The discs were prepared
between glass plates and were cured by exposure to
dental curing lamp for 40sec on each side. Samples
were measured, weighed and placed in individual
sealed containers of water at 37ºC. The specimens
were removed from the storage water at regular
intervals, blotted dry and re-weighed. After 90 days
specimens were placed in a desiccator containing dry
silica gel and re-weighed at regular intervals over a
period of 2 weeks.
Table1: Composition (W%) of Calcium Fluoroaluminosilicate Glass
Glass

SiO2

Al2O3

M1

22

18

M2

22

19

M3

29

M4

CaF2

Al2PO4

AlF3

NaF

22

15

23

10

39

13

7

16.6

34.2

9.9

5.3

5

35

25

20

8

6

6

M5

39.52

23.6

13.65

3.62

9.7

9.91

M6

24.3

27.5

14.0

19.1

15.1

M7

33.9

17.5

8

15

10

M8

56.5

33.5

M9

48.9

29.1

15

M10

36.3

22

12

15.6
10
7

9

14.3

6.4

Preparation of specimens: Water sorption and
solubility tests were determined according to the
specification standard for composite (ISO 4049:
2000). Specimen discs approximately 15±0.2 mm in
diameter and 1±0.1 mm in thickness were fabricated
282

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Int J Med Res Health Sci. 2015;4(2):281-286

in an aluminum mold between two glass slides they
were irradiated for 40sec on each side using a quartz–
tungsten–halogen light-curing unit (Optilux 500,
Demetron Research Corporation, Danbury, CT,
USA). The light-curing unit had an exit-window
diameter of 8 mm and was operated at 400 mW/cm2
with the curing tip placed 1 mm from the glass plate.
Four specimen discs were prepared for each for the
ten experimental resin formulations. The thickness of
the samples was measured accurately at three points
using a micrometer. Also their diameters were
measured, and their volumes were then calculated in
mm3.
water sorption and solubility: All the specimens
were placed in a desiccator and transferred in a
preconditioning oven at 37ºC. After 24 hrs they were
removed, stored in the desiccator for 1 hr and
weighted to an accuracy of 0.0001 g using a KERN
770 Germany. This cycle was repeated until a
constant mass (m0) was obtained. Following, the
discs were immersed in distilled water at 37ºC. At
fixed time intervals they were removed, blotted dry to
remove excess water, weighted and then back to the
water. The time intervals were more during the first
four day, preceding daily as the uptake slowed at
more extended intervals. The uptake of water was
recorded until there was no significant change in
weight, i.e. equilibrium was attained. This took about
30-40 days.
Sorption, desorption, and material net loss
percentages were calculated as follows:
=

=

−

−

(1)

(2)

Where M1 is the weight of the sample after immersion
and M2 is the original weight of the sample before
immersion.
Diffusion coefficients: According to the Fick’s Law,
the equation for diffusion in three dimension, when
the diffusion coefficient D is constant, is expressed as
=

+

+

Here, x (m), y (m), z (m) is the coordinates, c (%) is
the concentration where of the diffusing species at
time t (s) is the time, and D (m/s) is the diffusion
coefficient. For the one-dimensional model of linear

flow of mass in the solid bounded by two parallel
planes, the differential equation is expressed as
follows:
=

(3)

The differential equation is solved for the region h<x<h with zero initial concentration of water and
with surfaces x=±h kept at constant concentration c0
for t > 0: It should be noted here that the solution to
the Fick’s second law (Eq. (3)) might alternatively be
expressed as
=

4

(

)

⁄

⁄

+ 2

=2

(−1)

,

(

2(

)

⁄

)

(4)

where Mt was the mass uptake (g) at time t (s), Me
was the mass uptake (g) at equilibrium, l was the
specimen thickness (cm) such that D is the diffusion
coefficient (cm2s-1) calculated from the gradient of
Mt/Me against t1/2. If the uptake Mt is measured at
convenient intervals of time until equilibrium is
reached, then a plot of M ⁄M∞ against t1/2 should
provide a straight line for the earlier stages with the
slope, S

For which

RESULTS

=2

=

,

/4

(4)

All of the studied composite resins increased in
weight during immersion in water. The means of the
percentage values for sorption, solubility and
diffusion coefficient of the ten different types of
Calcium Fluoroaluminosilicate materials were
illustrated in Figure 1. During sorption, M9 and M10
showed significantly lower and no significant
differences among them respectively, While M6, M5,
M2 and M1 showed the highest sorption, which is
lower than those required by ISO 4049 standard, 40µ
g/mm3. Water solubility also showed differences
within the studied groups. Four main groups of
fillings can be classified: M9, M10, showed moderate
solubility while M4 showed less than the above two
283

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Int J Med Res Health Sci. 2015;4(2):281-286

M1, M3, M8 were the filling materials with the
highest mean water solubility value .Finally M6 was
found the best filling.
For all studied composites, the equilibration time for
water uptake was of the order of 15-20 days
depending on material and the volume of specimens.
The rate of change in weight over the selected time
intervals is presented in Figure 2 for all studied
composites. Figure 3 the plots of Mt/Me versus
square root of time, it can be seen that the plots are
almost linear for M10 composites. The plots had
linear increase in earlier stage and became balanced
at the end of the process when the composites were
completely saturated, that mean no more water can be
absorbed or desorbed by the studied composites. The
diffusion coefficients controlled process was
confirmed by the linear part. Figure 4 shows the
diffusion coefficients of the studied resins ranged
between 0.87 and 6.2 ×10-10cm2/sec for M10 and M6
respectively.

Fig. 3: Mt/M∞ against t1/2 (sorption) for M10 composites
after immersion in water.

Fig.4:Mean diffusion coefficients
composite materials tested.

values

for

DISCUSSION

Fig. 1: Mean water sorption (μg/mm3) and water
solubility obtained for composite materials (teeth
filling) tested.

Fig. 2: Changes in weight over 90 days for
composite materials.

The water sorption and solubility of dental restorative
materials are of considerable clinical importance and
cannot be neglected. Several data for water sorption
and solubility for composite materials have been
published, but it is difficult to correlate them as the
results are often for different time periods and are
expressed in different units. Moreover comparisons
are difficult to make due to differences in reported
specimen size, since different sizes of specimen will
take different periods of time for water to completely
infiltrate throughout the polymer matrix. Water
molecules are able to diffuse through the inter-chain
spaces of the resin matrix because of their smaller
size of radius, which is less than 0.158 nm and
smaller than the inter-chain spaces [13]. According to
ISO 4049:2000 standard for dental restorative resins,
a resin in order to be suitable for use as dental
material must show water sorption lower than 40
µg/mm3 and solubility lower than 7.5 μg/mm3. The
284

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Int J Med Res Health Sci. 2015;4(2):281-286

values of water sorption for all studied composites,
except that M6, are within the range of the ISO’s
standard. On the contrary, the values of solubility are
within the range of the ISO’s standard only for resin
M7. Several factors, such as the polymeric matrix
composition, filler particle type, mean particle sizes,
and the degree of curing reached after the
polymerization reaction can influence the solubility
and sorption behavior of dental resin composites
[14,15].
The studied resins used in this study have a
great similarity in the filler particle content
approximately 60% by volume. The Low water
sorption values of resin are due to the method of
preparation of Calcium Fluoroaluminosilicate glass,
Filler particle size which was within 1 to 2 µm[12].
While the water solubility range was found between
2.9– 8.1 µg/mm3 .These results were similar to those
obtained by Oysaed and Ruyter (1.4– 9.0 µg/mm3)
[16]
.
Plots of Mt/M∞ against t1/2 Figure 3 for M10 filling
(similarly for all studied resin) were linear in the
initial stages of absorption and desorption cycles,
which shows that the uptake process for these
composites is diffusion controlled. The diffusion
coefficients which have been determined in this study
is within the range of 0.7–6.2 × 10-10 cm2/sec figure 4,
in good agreement with other works and comparable
to those reported for composite resins soaked in
water, despite the difference in the form of the water
and hence in the driving force for sorption [3,17].

CONCLUSIONS
In this work, we conclude that the sorption and
solubility values are in accordance with the ISO
4049:2000. The studied dental material (teeth filling)
has shown that they have optimal physico-chemical
properties for an adequate behavior in the oral
aqueous environment, making it suitable for indirect
composite restorations.
ACKNOWLEDGMENT
Rafed M. extend his appreciation to Dr M. Atai for
his assistance and consultation in this work, thanks to
university of Basrah Dentistry College for their help.
Conflict of Interest: Nil

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F, Meyer-Lueckel H. Initial in situ secondary
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K, Tomioka
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Fluoroaluminosilicate glass powder for dental
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DOI: 10.5958/2319-5886.2015.00053.3

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
st
Received: 21 Nov 2014
Research article

Coden: IJMRHS
Revised: 20th Dec 2014

Copyright @2014
ISSN: 2319-5886
Accepted: 27th Jan 2015

CARCINOMA CERVIX SCREENING – A CLINICOPATHOLOGICAL STUDY
*Vissa Shanthi1, Bhavana Grandhi2, Nandam Mohan Rao3, Byna Shyam Sundara Rao4, Vangala
Chidananda Reddy5, Swathi Sreesailam6
1,3,4

Associate professor, 2,5,6Assistant Professor, Department of pathology, Narayana Medical college and
Hospital, Nellore, Andhrapradesh, India

*Corresponding author email: [email protected]
ABSTRACT
Background: Cervical carcinoma, the pathogenesis of which includes multiple factors was the leading cause of
death 50 years ago and the mortality rate has been reduced to two thirds due to the effective screening by Pap
smears which detected the cancers and precancerous conditions. Objective: The study was undertaken to analyze
the routine cervical cancer screening on an age specific basis and to study the various predisposing factors of
cervical carcinoma. Methods: We conducted an observation study on 1000 patients. The cervical smears collected
were examined and predisposing factors were studied in these patients. Results: 1000 women above 20 years of
age group were screened. There were 242 cases(24.2%) of dysplasia of which 133 cases (13.3%) were of mild
dysplasia, 59 cases (5.9%) were of moderate dysplasia and 50 cases (5%) were of severe dysplasia. 29 cases
(2.9%) showed invasive carcinoma. There were 564 (56.4%) inflammatory smears and 168 (16.8%) normal
smears. Maximum number of dysplasia’s and carcinomas were found in the age group above 40 years. These
patients were from low income group, had no formal education, attained menarche at the age of 13-14 years,
married at the age of 15-17 years, had three or more children and had marital life for more than 30years.
Conclusion: Cervical cytology has been main stay of prevention and early diagnosis of cervical carcinomas. Due
to its simplicity and low cost, pap smears can be used for mass screening. Cervical carcinoma has multiple
etiological factors which play role in its pathogenesis.
Key words: Pap smear, Cervical carcinoma, Cytology
INTRODUCTION
Cervical carcinoma is the sixth most common
visceral cancer in women and contributes to 5% of all
cancer deaths in women worldwide. It accounts for
approximately 15% of all cancers diagnosed in
women world wide1. In the developing world 1.7
million cases of carcinoma cervix and 5-13 million
cases of precancerous lesions were recorded 2,3. The
highest crude mortality rate is recorded in Southern
Africa. In North America, Western Europe and
Australia, the incidence of cervical cancer is low 4.
China has the least mortality rate 1. Death rate due to
the cervical cancer has declined in the recent years

Shanthi et al.,

due to early detection of cancers and precancerous
conditions. Cervical cancer screening by pap smears
has reduced the morbidity due to cervical cancer by
53%. Susceptibility of cervical cancer for prevention
by screening programme is determined by its high
prevalence, a long detectable preclinical phase and
benefit from early treatment. The Pap smear
screening test if carried out properly is sufficiently
sensitive and has high specificity, is of low cost and
low risk to the patient 5.
Mass cytological screening has shifted the
presentation of cervical carcinoma from the clinical
287
Int J Med Res Health Sci. 2015;4(2):287-293

to the preclinical stage. Though the incidence of
cervical cancer has decreased significantly since
1960, age specific rates; however show an increase in
young women, particularly those aged 25-29 years. It
is not due to less effective screening of the younger
population but the rise in incidence would be due to
predisposition to risk factors 6. In this study we tried
to analyze the predisposing factors for carcinoma
cervix and the age related incidence of cervical
cancer in around Tirupathi.
MATERIAL AND METHODS
This cross sectional study includes 1000 patients who
attended the gynecologic outpatient department in our
hospital during the period of two years. Institutional
ethical committee approved the study protocol.
Informed consent was obtained from all the study
participants. Pap smear from 1000 patients who were
in the age group above 20 years was collected. The
etiological and risk factors like age, parity, age at
menarche, age at marriage, use of oral contraceptive
pills, socio economic status and educational status of
patients whose smears showed dysplastic changes
were studied. The patients whose smears showed only
inflammatory changes without dysplasia were
excluded.
Smears were obtained from the patients with the help
of Aylesbury spatula7. These smears were stained
with Papanicolaou stain. Patient was placed in

dorsal lithotomy or left lateral position. Nonlubricated (self-retaining) speculum
was
introduced into the introitus to visualize the
cervix. Aylesbury spatula is placed in position
and rotated in 3600 clock wise direction, so that
sample from the ectocervix and endocervix
including squamocolumnar junction are obtained.
Specimen is spread evenly on glass slides. The
smears collected were fixed in 95% of isopropyl
alcohol for 15-30 minutes. These smears are
stained with Papanicolaou stain. Smears of the
patients which revealed dysplastic cells on
microscopic examination were studied in detail.
Patients which revealed dysplastic cells on
microscopic examination were studied in detail.
OBSERVATION AND RESULTS

Shanthi et al.,

Cervical smears from 1000 women aged above 20
years who attended gynaecology out patient
department were studied .A detailed history was
recorded which included age, age of menarche,
married life, number of pregnancies, age of last child,
duration of menopause, use of oral contraceptive pills
(OCP’s), tobacco chewing or cigarette smoking,
socio-economic status and educational status of
women. The gynecological symptoms and clinical
status of cervix was also studied. The women were
grouped in 9 groups depending upon the age and
various cytological features were studied (Table 1).
There were 242 cases (24.2%) of dysplasias, of which
133 cases (13.3%) were of mild dysplasia, 59 cases
(5.9%) were of moderate dysplasia and 50 cases (5%)
were of sever dysplasia. 29 cases (2.9%) showed
invasive carcinomas. There were 564 (56.4%)
inflammatory smears and 168 (16.8%) normal smears
(Table 1).
Highest incidences of mild and moderate dysplasia
were seen in the age group of 40-50 years. Severe
dysplasia and carcinomas were seen in the age group
of 50-60 years. One case of invasive carcinoma was
noted in the age group of 20 -30 years (Table 1).
Maximum cases of invasive carcinoma, mild
dysplasia, moderate dysplasia and severe dysplasia
were noted in the menopausal age group when
compared to reproductive age group (Table 2).
Epithelial changes in relation to age at menarche were
studied and the highest incidence of dysplasia was
noted in patients who attended menarche at the age of
13 years and invasive carcinoma in the patients who
attained menarche at the age of 14 years (Table 3).
When the incidence of dysplasia in relation to the age
at marriage was studied, it showed highest incidence
of moderate, severe dysplasia and carcinoma in the
patients who were married at the age of 15-17 years
(Table 4). The incidence of carcinomas was found to
be high in patients who had marital life of 31years
and above (Table 5). The study on parity of these
patients showed that highest incidence of invasive
carcinoma, moderate and severe dysplasias were
noted in women who had three or more children. In
nulliparous women only three cases were found to
have mild dysplasia but there were no cases of
moderate, severe dysplasia and invasive carcinoma
(Table 6). Epithelial abnormalities in relation to
economic status were also studied, which showed that
incidence of dysplasia and invasive carcinomas was
288
Int J Med Res Health Sci. 2015;4(2):287-293

maximum in the lower income group (Table 7) and
these patients did not have formal education (Table
8).
Most of the patients with dysplasias presented with
irregular vaginal bleeding and invasive carcinomas
presented as post menopausal bleeding (Table 9). On
clinical examination, mild and moderate dysplasia

cases presented as cervical erosion where as the cases
with severe dysplasia and carcinoma presented as
either growth on cervix or bleeding on touch (Table
10).Though the cigarette smoking, tobacco chewing
and use of immunosuppressive drugs are considered
as risk factors, in our study it did not reveal
significant correlation (Table 11).

Table 1: Epithelial abnormalities in relation to age
Age in
years

Total

Normal
smears

Inflammatory
smears

LSIL Mild
dysplasia

20-30

203 (20.3%)

31-40

24 (2.4%)

150 (15%)

25 (2.5%)

2 (0.2%)

2 (0.2%)

-

304 (30.4%)

53 (5.3%)

187 (18.7%)

36 (3.6%)

14 (1.4%)

11 (1.1%)

3 (0.3%)

41-50

287 (28.7%)

51 (5.1%)

148 (14.8%)

44 (4.4%)

22 (2.2%)

13 (1.3%)

8 (0.8%)

51-60
61 and
above

128 (12.8%)

22 (2.2%)

17 (1.7%)

11 (1.1%)

14 (1.4%)

9 (0.9%)

78 (7.8%)

15 (1.5%)

11 (1.1%)

10 (1%)

10 (1.0%)

9 (0.9%)

56 (5.6%)
23 (2.3%)

HSIL Moderate
severe dysplasia

Invasive
carcinoma

P<0.001.
Table 2: Epithelial abnormalities in menopausal and reproductive age group women
Age groups

Total

Normal
smears

Inflammatory
smears

LSIL mild
dysplasia

HSIL Moderate Severe
dysplasia

Invasive
carcinoma

Menopausal

449 (44.9%)

90 (9%)

192 (19.2%)

73 (7.3%)

37(3.7%)

33 (3.3%)

24 (2.4%)

Reproductive

551 (55.1%)

75 (7.5%)

372 (37.2%)

60 (6%)

22(2.2%)

17 (1.7%)

5 (0.5%)

P<0.001
Table 3: Epithelial abnormalities in relation to age at menarche
Normal

Inflammatory

LSIL mild

HSIL Moderate

Invasive

smears

smears

dysplasia

severe dysplasia

carcinoma

Total

Age at menarche
in years
10-11 Years

40 (4%)

4 (0.4%)

24 (2.4%)

2 (0.2%)

5 (0.5%)

-

5 (0.5%)

12 years

276 (27.6%)

38 (3.8%)

153 (15.3%)

43 (4.3%)

17 (1.7%)

21 (2.1%)

4 (0.4%)

13 years

418 (41.8%)

69 (6.9%)

230 (23%)

64 (6.4%)

25 (2.5%)

23 (2.3%)

7 (0.7%)

14 years

185 (18.5%)

39 (3.9%)

114 (11.4%)

13 (1.3%)

7 (0.7%)

3 (0.3%)

9 (0.9%)

15 years and above

81 (8.1%)

15 (1.5%)

43 (4.3%)

11 (1.1%)

5 (0.5%)

3 (0.3%)

4 (0.4%)

P<0.005
Table 4: Epithelial abnormalities in relation to age at marriage
Age at
marriage
10-14 yrs
15- 17 yrs
18yrs and
above

Total
151
(15.1%)
406
(40.6%)
443
(44.3%)

Normal
smears
31 (3.1%)

Inflammatory
smears
69 (6.9%)

LSIL Mild
dysplasia
21 (2.1%)

HSIL Moderate severe
dysplasia
16 (1.6%) 8 (0.8%)

Invasive
carcinoma
6 (0.6%)

50 (5.0%)

210 (21 %)

55 (5.5%)

33 (3.3%)

39 (3.9%)

19 (1.9%)

84 (8.4%)

285 (28.5%)

57 (5.7%)

10 (1 %)

3 (0.3%)

4 (0.4%)

P<0.001
Table 5: Epithelial abnormalities in relation to marital life
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Married life

Total

Normal
smears

Inflammatory
smears

LSIL mild
dysplasia

HSIL Moderate
severe dysplasia

Invasive
carcinoma

0-5 years

41 (4.1%)

7 (0.7%)

30 (3%)

4 (0.4%)

-

-

-

6-10 years

93 (9.3%)

18 (1.8%)

58 (5.8%)

15 (1.5%)

2 (0.2%)

-

-

11-20 years

267 (26.7%)

31 (3.1%)

187 (18.7%)

32 (3.2%)

5 (0.5 %)

10 (1%)

2 (0.2%)

21-30 years

285 (28.5%)

48 (4.8%)

165 (16.5%)

37 (3.7%)

19 (1.9%)

13 (1.3%)

3 (0.3%)

31 years and
above

314 (31.4%)

61 (6.1%)

124 (12.4%)

45 (4.5%)

33 (3.3%)

27 (2.7%)

24 (2.4%)

P<0.001
Table 6 Epithelial abnormalities in relation to parity
Parity

Total

Normal
smears

Inflammatory
smears

LSIL mild
dysplasia

HSIL Moderate
severe dysplasia

Invasive
carcinoma

0

56 (5.6%)

22 (2.2%)

31 (3.1%)

3 (0.3%)

-

-

-

1

83 (8.3%)

17 (1.7%)

51 (5.1%)

11 (1.1%)

1 (0.1%)

3 (0.3%)

-

2
3and
above

368 (36.8%)

53 (5.3%)

240 (24%)

53 (5.3%)

11 (1.1%)

8 (0.8%)

3 (0.3%)

493 (49.3%)

73 (7.3%)

242 (24.2%)

66 (6.6%)

47 (4.7%)

39 (3.9%)

26 (2.6%)

P<0.001
Table 7: Epithelial abnormalities in relation to economic status
Economic
status
Lower income
group
Middle income
group
Upper
group

Normal
smears

Inflammatory
smears

LSIL mild
dysplasia

HSIL Moderate severe
dysplasia

Invasive
carcinoma

701
(70.1%)

119 (11.9%)

374 (37.4 %)

83 (8.3%)

50 (5%)

47(4.7%)

28 (2.8%)

289
(28.9%)

42 (4.2%)

185 (18.5%)

49 (4.9%)

9 (0.9%)

3 (0.3%)

1 (0.1%)

10 (1%)

4 (0.4%)

5 (0.5%)

1 (0.1%)

-

-

-

Total

income

P<0.001
Table 8: Epithelial abnormalities in relation to education status
Education status
No Formal
education
Primary
education
Higher education

Total

Normal
smears

Inflammatory
smears

LSIL mild
dysplasia

665 (66.5%)

HSIL Moderate
severe dysplasia

Invasive
carcinoma

103 (10.3%)

345 (34.5%)

88 (8.8%)

52(5.2%)

50 (5%)

27 (2.7%)

279 (27.9%)

51 (5.1%)

180 (18%)

39 (3.9%)

7 (0.7%)

-

2 (0.2%)

56 (5.6%)

11 (1.1%)

39 (3.9%)

6 (0.6%)

-

-

-

P<0.001
Table 9: Epithelial abnormalities and gynecological symptoms
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Clinical
symptoms

Total

Normal
smears

Leucorrhoea

307 (30.7%)

Dysuria
Irregular
vaginal bleeding
Post menopausal
bleeding
Pain in Lower
abdomen
Mass per vagina
Routine
check up

Inflammatory
smears

LSIL Mild
dysplasia

HSIL Moderate
severe dysplasia

Invasive
carcinoma

16 (1.6%)

219 (21.9%)

56 (5.6%)

13(1.3%)

2 (0.2%)

1 (0.1%)

35 (3.5%)

8 (0.8%)

24 (2.4%)

3 (0.3%)

-

-

-

192 (19.2%)

15 (1.5%)

90 (9%)

31 (3.1%)

25(2.5%)

24(2.4%)

7 (0.7%)

71 (7.1%)

1 (0.1%)

13 (1.3%)

8 (0.8%)

8 (0.8%)

22(2.2%)

19 (1.9%)

194 (19.4%)

41 (4.1%)

121 (12.1%)

23 (2.3%)

8(0.8%)

1 (0.1%)

-

78 (7.8%)

25 (2.5%)

39 (3.9%)

7 (0.7%)

5(0.5%)

-

2 (0.2%)

123 (12.3%)

59 (5.9%)

58(5.8%)

5 (0.5%)

-

1 (0.1%)

-

P<0.001
Table 10: Epithelial abnormalities in relation to clinical lesions
Clinical lesions

Erosion cervix
Hypertrophied
cervix
Suspicious cervix
(growth/ bleeding
on touch)

Total

Normal
smears

230 (23%)

Inflammatory
smears

6 (0.6%)

LSIL mild
dysplasia

137 (13.7%)

HSIL Moderate
severe dysplasia

55 (5.5%)

19 (1.9%)

Invasive
carcinoma

13 (1.3%)

-

63 (6.3%)

10 (1%)

34 (3.4%)

12 (1.2%)

5 (0.5%)

1 (0.1%)

1 (0.1%)

82 (8.2%)

-

3(0.3%)

10(1%)

10 (1%)

32 (3.2%)

27 (2.7%)

Senile vaginitis

41 (4.1%)

9 (0.9%)

22 (2.2%)

4 (0.4%)

4 (0.4%)

2 (0.2%)

-

Polyp

4 (0.4%)

1 (0.1%)

2 (0.2%)

1 (0.1%)

-

-

-

155 (15.5%)

5 (0.5%)

123 (12.3%)

18 (1.8%)

8 (0.8%)

1 (0.1%)

-

87(8.7%)

29(2.9%)

40 (4%)

12(1.2%)

5(.5%)

-

1 (0.1%)

338 (33.8%)

105(10.5%)

203 (20.3%)

21 (2.1%)

8 (0.8%)

1 (0.1%)

-

Endocervicitis
Prolapsed
Normal

Table 11: Epithelial abnormalities in relation to risk factors
Risk factors

Total

Normal
smears

Inflammatory
smears

LSIL mild
dysplasia

HSIL Moderate severe
dysplasia

Invasive
carcinoma

Cigarette smoking

-

-

-

-

-

-

-

Tobacco chewing

105(10.5%)

16 (1.6%)

41 (4.1%)

18 (1.8%)

12 (1.2%)

10 (1%)

8 (0.8%)

Immunosuppressive
drugs

1 (0.1%)

1 (0.1%)

-

-

-

-

-

DISCUSSION
The etiology of cervical neoplasia, which is
considered to be the third most common cancer in
women, has been studied epidemiologically for over
150 years 8. Epidemiologically cervical cancer
behaves like a sexually transmitted disease and is
more common in women who have multiple sexual
partners 9, or whose partners are promiscuous 10 and
is absent in virgins. Epidemiological data has shown

that cervical carcinoma is caused by sexually
transmitted agent, Human Papilloma virus (HPV)
which plays an important role in oncogenesis.
Though HPV is considered to be an important
etiological factor, the presence of other risk factors
along with HPV infection are important in deciding
the outcome of the disease i.e. whether HPV infection
will regress or progress to cervical cancers 11 .
291

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The U.S. Preventive Services Task Force (USPSTF)
has recommended that women aged 21 to 65 years
should undergo cytological screening for every 3
years. If the women (30 to 65 years) want to lengthen
the interval for Pap smear screening, then the
combination of Pap smear test and HPV testing for
every 5 years is recommended. The UPSTF does not
recommend the cervical cancer screening in women
younger than 21 years, for women elder than 65 years
whose previous cytology smears were normal,
women who had undergone hysterectomy with
removal of the cervix without any previous
precancerous lesion or cancers and testing for HPV
alone or along with cytology in women who are
younger than 30 years 12.
Most of the patients who attended the Government
Maternity Hospital, Tirupathi were of low socio
economic group. Low, moderate and high income
groups differ in various aspects like nutritional and
vitamin deficiencies, parity, married life, age at
marriage. Hence socioeconomic group is the index of
all the above factors which share their contribution in
the genesis of cancer cervix.
The incidence of invasive cancer in our study was
2.9% which coincided with the results of JS Misra
(2001) 13. In our study, severe dysplasia and invasive
carcinomas were common after 50 years because of
altered hormonal balance that are usually seen in the
female genital tract. The role of hormonal factors in
the etiology of cervical cancer had been underscored
by recent studies which identified several
independent risk factors like multiple births, early age
at marriage and marital life.
In our study, highest incidence of invasive
carcinomas and dysplasias were found in women who
had more than 30 years of married life. This shows
that there is intimate relationship between married
life and incidence of cancer cervix. Parazzini et al
(1989) suggested that with every pregnancy, women
would have double the risk compared to women
without children and the risk was ten times more than
unmarried women14. Other studies have shown that
the incidence was high in women who marry early
and tend to conceive more number of times as they
are exposed to longer duration in sexual activity.
The cigarette smoking /tobacco chewing was
attributed as one of the risk factors of cervical
neoplasia. In our study out of 29 cases of invasive
carcinoma, cases were found to be associated with

Shanthi et al.,

tobacco chewing and also few cases of dysplasias had
association with tobacco chewing. Cigarette smoking
has been associated with increased risk of cervical
cancer, especially among long term or high intensity
smokers 15. Smoking constituents have been found in
cervical mucous, but the biologic mechanisms
underlying the smoking-cervical cancer relationship
have not been identified.
The use of oral contraceptive pills (OCPs) is also
another risk factor. But because most of the patients
attending outpatient department are low socioeconomic group without formal education, the
number of patients, using OCP’s were very few. After
elaborate study it is clearly evident that no single
factor can be named as the cause of cancer cervix.
Many factors may play part and contribute to the
causation of cancer like prolonged sexual life,
multiple sexual partners, parity, low socio-economic
status, the virus infections and genetics.
Immunosuppression has been found to be associated
with dysplastic changes in the cervix. HPV DNA is
detected more often in pregnant women who have
transient depression of cell mediated immunity. More
recently, an increased risk of cervical neoplasia has
been noted in patients infected with HIV 16.
Immunosuppression is considered to inhibit clearance
of papilloma virus and promote their reactivation 17.
Most of the frank invasive carcinomas presented as
growth on cervix or cervix which bleeds on touch
which has also been found to be the same in study by
JS Misra. Many cases of dysplasias presented as
erosion cervix. Other symptoms are leucorrhoea,
dysuria, irregular vaginal bleeding, pain in lower
abdomen and mass per vagina.
For the prevention of cervical carcinoma and
precursor lesions American Cancer Society (ACS)
recommends Human Papilloma virus vaccines for
females aged 11 to 12 years. It also suggests that
females as young as 9 years may receive HPV. For
the females aged 13 to 18 years, HPV vaccination
should be given to catch up missed vaccination or
complete the vaccination series. Vaccination is not
recommended for women over age of 26 years
because ideally the vaccination should be done prior
to genital HPV exposure as the benefit is likely to
diminish with increasing number of lifetime sexual
partners. Even after the vaccination, screening for the
cervical intraepithelial neoplasia and cancer should
continue. Two prophylactic HPV vaccine are
292
Int J Med Res Health Sci. 2015;4(2):287-293

available i,e. Gardasil which protects against HPV
types 6, 11, 16 and 18 (quadrivalent) and Cervarix
which protects against types 16 and 18 (bivalent) 18.

8.

CONCLUSION
Cervical carcinoma is caused not due to single
etiological factor but multiple independent risk
factors like age, age at menarche, age at marriage,
parity, educational and economic status, use of oral
contraceptives, cigarette smoking play role in the
pathogenesis. Due to simplicity, low cost and validity
of the Pap smear screening, it becomes apparent that
this test could be effectively used to detect early
cancer and premalignant changes in cervix uteri.
ACKNOWLEDGEMENT

9.

10.

11.

We are thankful to Dr.Sarela Jothi Bai, professor of
pathology and Dr.Bharathi, professor of Gynecology
for their assistance in completing the project.

12.

Conflict of Interest: Nil.

13.

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DOI: 10.5958/2319-5886.2015.00054.5

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 28 Nov 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 25 Jan 2015
Accepted: 16th Feb 2015

REPARATIVE OSTEOGENESIS DURING TREATMENT OF FRACTURE UNDER TRANSOSSEOUS
OSTEOSYNTHESIS AND INTRAMEDULLARY INSERTION OF WIRES WITH HYDROXYAPATITE
COATING
Iurii M. Irianov1, Arnold V. Popkov1, Nikolay A. Kiryanov2 *, Tatiana Iu. Karaseva1, Evgenii A. Karasev1
1

Russian Ilizarov Scientific Center Restorative Traumatology and Orthopaedics (RISC RTO), Ul'ianova Street, 6.
Kurgan, 640014. Russia,
2
Izhevsk state medical academy, Kommunarov str., 281, Izhevsk, Russia.
*Corresponding author email: [email protected]
ABSTRACT
Background: The problem of improving medical care for patients with the locomotor system injuries is very
important especially last time. Material and Methods: Canine open comminuted tibial fractures modelled
experimentally, wires with hydroxyapatite coating inserted intramedullary, osteosynthesis performed with the
Ilizarov fixator. Regenerated bones investigated 14-360 days after surgery using the techniques of light
microscopy, scanning and transmission electron microscopy, and X-ray electron probe microanalysis for
histologic sections . Results: It has been found that a zone of active reparative osteo- and angiogenesis forms
around the wires, as well as a bone sheath with the properties of osteogenesis conductor and inductor. Fracture
consolidation occurs early according to the primary type without cartilaginous and connective tissue formation in
bone adhesion. Presented morphological characteristics endovasal angiogenesis. Conclusion: The results of the
study evidence of the positive effect of intramedullary wires with hydroxyapatite coating on the course and
intensity of reparative osteogenesis during fracture healing
Key words: Transosseous osteosynthesis, Intramedullary wires, Hydroxyapatite coating, Fracture healing,
Reparative osteogenesis, Angiogenesis.
INTRODUCTION
The problem of improving medical care for patients
with the locomotor system injuries every year is
becoming increasingly important due to the increase
of injured persons in number, to that of disability and
mortality from injuries not having downward
tendency. However, osteosynthesis real terms remain
to be significant. The technique of directed
stimulation of bone tissue regeneration process is
practiced by using intramedullary wires with calcium
phosphate coating in order to optimize the conditions
for regenerated bone formation, as well as for
treatment period reduction, and complication
prevention [1, 2]. At the same time, the process of
reparative osteogenesis using those or other implants

inserted into the regenerated bone is poorly
understood, as well as both their effectiveness
characterization and mechanism of action are absent.
The purpose of the present work consists in studying
the morphological features of osteogenesis process
for consolidation of long tubular bone fractures under
transosseous osteosynthesis and intramedullary
insertion of wires with hydroxyapatite bioactive
calcium phosphate coating.

Irianov et al.,

Int J Med Res Health Sci. 2015;4(2):294-298

MATERIAL AND METHODS
16 mongrel dogs, males and females, at the age from
one to five years with the body weight of 20±2.9 kg
were used for experiments. The keeping, surgical

294

interventions, and euthanasia of the animals were
made in compliance with European Convention for
the Protection of Vertebrate Animals (Strasbourg,
1986); they were approved by the Ethics Committee
of RISC RTO.
Procedures: The animals underwent intramedullary
reinforcement of right tibia with two wires under
general anesthesia. Wires of titanium alloy were used
with bioactive coating of hydroxyapatite of 20-40-µm
thickness and 2-8% porosity; the alloy was obtained
by the technique of anodic oxidation in the arc mode.
The coating presented a multilevel ultraporous system
consisting of macro- and micropores of the diameter
from 50-100 nm to 1-2 µm. Osteosynthesis was
performed with the Ilizarov fixator, and an open
comminuted fracture of leg bones was modeled in the
shaft middle third. The Ilizarov fixator dismounting
made after 28 or 35 days of fixation. Radiography
performed in the course of the experiment. The
animals were divided into four groups: 14, 21; 28, 35;
42, 90; 180, 360 days after surgery, four animals in
each group and two ones – for each time point.
Clinical observation of the animals carried out
throughout the experiment. Radiography was made
using «Premium Vet» X-ray machine (Sedecal,
Spain) in direct and lateral views immediately after
surgery and during the experiment. Tibias of three
intact adult dogs were investigated for comparison.
After euthanasia of the animals the shaft portions of
the operated bones were sawed lengthwise, fixed in
2% solution of paraformaldehyde and glutaraldehyde,
embedded in celloidin (after decalcification) and
Araldite (without decalcification). Histotopographic
sections were prepared using Reichert microtome
(Germany) and stained with hematoxylin-eosin, and
with picrofuchsin by Van Gieson. Research and
photomicrography of histological sections were
performed using «Stemi 2000-C» stereomicroscope
and «AxioCam ERc 5s» digital camera completed
with «Zen blue» software (Carl Zeiss MicroImaging
GmbH, Germany). Araldite blocks were smoothed
and investigated with INCA-200 Energy X-ray
electron probe microanalyser (Oxford instruments,
England). Facture zone image was obtained in
characteristic X-ray radiati characterizing the degree
bone tissue maturity was calculated. The index of
compactness was calculated as well (bone tissue/nonmineralized structure content ratio).The blocks are
then sawed ultra thin sections were prepared

prepared on an ultra microtome LKB-8800 (Sweden),
contrasted and examined using a transmission
electron microscope JEM-2010 (Jeol, Japan). Then
Araldite blocks were treated in sodium ethyolate 2%
solution in order to remove the embedding medium,
and they were investigated with scanning electron
microscope JSM-840 (Jeol, Japan). The results of
quantitative studies were processed using standard
methods of variation statistics. The significance of
differences between the values was estimated using
nonparametric Mann-Whitney U-test. Differences
were considered statistically significant for р ≤ 0.05.

Irianov et al.,

Int J Med Res Health Sci. 2015;4(2):294-298

RESULTS
Transverse fractures have been produced in tibial
shaft middle third of all the animals after surgery
(Figure 1, a). The height of diastasis between the
fragments is 0.5-1.0 mm. The signs of periosteal
reaction as cloud-like shadows appear in close
proximity to the fracture line by 8-10 days after
surgery. The formation of new bone cortex is
determined by X-rays 35 days after surgery (Figure 1,
b).

Fig: 1a

Fig: 1b

295

Fig 1: X-rays of canine tibia after fracture
modeling and intramedullary osteosynthesis: a –
shaft middle third fracture, immediately after
surgery; b – newly formed cortex at the fracture
site 35 days after surgery

other from the periosteal and endosteal surfaces in the
intermediary zone, and they form strata on the ends
of fragments. Primary endosteal-periosteal and
intermediary union is formed. The content of calcium
and phosphorus in the intermediary zone of
regenerated bone is 19 % and 20 %, respectively, and
that of bone tissue – 26 % of the values of the shaft
cortex
in
normal
intact
dogs
(Table1)

The regenerated bone is located all over the bone
diameter. Numerous anastomosing trabeculae of
reticulofibrous bone tissue in grow towards each
Table1: Content of calcium, phosphorus, and bone tissue in the intermediary zone of regenerated bone, and
in the cortex of intact shaft (M±m,%)
Measures
Calcium
Phosphorus
Bone tissue
Са/Р
Index of compactness

Period of experiment, days
14, 21
28, 35
4.96±0.31
11.02±0.65

42, 90
17.27±1.08

180, 360
23.30±1.31

25.82±1.10

2.95±0.181
5.74±1.531
1.68±0.131

6.44±0.36
53.43±2.89
1.72±0.14

9.06±0.56
80.07±4.90
1.91±0.18

11.07±0.69
94.13±5.49
2.10±0.14

11.75±0.53
96.15±4.44
2.20±0.13

0.35±0.02

1.15±0.07

4.02±0.26

16.04±0.67

Significant changes comparing with the measures of
intact animal shaft cortex.
By 28, 35 days after surgery the ends of fragments
lose clear boundaries due to massive deposits in the
intermediary space of mature lamellar bone tissue.
Periosteal strata of 2.5-3-mm height become
compacted, and they combine the ends of fragments
in fracture zone by the flattened fusiform “sleeve”.
Ribbon-like spreads are formed in the periosteal area
near fragmental ends as small-looped network of
lamellar-structured bone trabeculae bridging fracture
line.
The regenerated bone in the intermediary zone is
represented by spongy and compact bone tissue
closely adhered with cortex of bone fragments. The
phase of organogenesis and remodeling is observed
evidenced by reorganization of primary trabeculae
into organotypical osteon structures forming cortex
(Figure 2, a, b). Gradual reorganization of the
trabecular structures of coarse-fibered bone tissue
into more mineralized and mature lamellar ones is
also observed in the bone sheath round the wires. The
content of calcium and phosphorus in the
intermediary zone of regenerated bone in this period
increases up to 43-55 %, and that of bone tissue – up
to 56-57 % of the measures of the shaft cortex in
normal intact dogs (Table 1).

Cortical layer

24.97±1.28

Fig: 2b

Fig 2: The newly formed cortex at fracture site 35
days after surgery: a – staining according to Van
Gieson. Lens 2.5, eyepiece 10; b – the map of
electron probe microanalysis, the image in
characteristic X-ray radiation of calcium,
magnification x15.

296
Irianov et al.,

Int J Med Res Health Sci. 2015;4(2):294-298

By 42, 90 days after surgery the ends of fragments in
the intermediary space are connected by narrowlooped network of bone trabeculae, as well as by
osteons of different maturity with compaction signs
all over cortex width, and practically complete
periosteal, intermediary, and endosteal bone union is
revealed. The fracture healing occurs by the type of
primary consolidation due to the fact that osteogenic
cells of Haversian canals forming bone trabecular and
osteons across the fracture line grow into the diastasis
from the ends of fragments along blood vessels. The
bone sheath around the wires is formed by compact
bone of lamellar structure with forming osteons and
spongy bone tissue which spreads not only into the
diastasis but it also fills the medullary cavity of
fragments thereby binding them like a pin. Both
osteogenesis intense process and bone tissue
remodeling is also seen in the periosteal parts of
regenerated bone where numerous osteoblasts and
functionally active osteoclasts are located,
reorganization of the cortex of the fragmental ends is
observed with vascular channel expansion and
extensive stratification on the fragmental ends of the
bone trabeculae surrounded by some layers of large
osteoblasts. Secondary osteons of lamellar bone
tissue are formed in the new cortex at fracture site,
however, the intermediary zone of regenerated bone
still differs significantly from the cortical layer of
animals’ intact shaft by mineralization degree and
organospecificity (Table 1). The content of calcium in
the intermediary zone of regenerated bone during this
period is 66-67 %, that of phosphorus – 76-77 %, and
that of bone tissue – 83-84 % of the values of intact
shaft cortex.
By 180, 360 days after surgery the endosteal part of
regenerated bone is rather small being represented by
web-like network of thin lamellar-structured bone
trabeculae in the expanded intertrabecular spaces of
which vascular channels with wide lumens are
located, as well as hematopoietic-and-fatty bone
marrow. The bone sheath around the wires sharply
becomes thinner, and it is fragmented, multiple
functionally active hypertrophied osteoclasts and
resorption lacunae are located on its outer surface.
The content of calcium, phosphorus, and bone tissue
in newly formed cortex at this stage of the experiment
approximates to the measures of the shaft cortex in
intact animals (Table 1).

The investigations of the content of bone tissue and
of the main mineral components in the intermediary
zone of regenerated bone evidence of the fact that as
far as the experiment duration increases, calcium and
phosphorus content in the newly formed bone
increases steadily as well thereby reflecting gradual
prolonged mineralization of the regenerated bone
throughout the experiment. The rise of Ca/P
coefficient with increasing the experiment duration
indicates qualitative changes in the mineral phase of
regenerated bone tissue which are characterized by
gradual decreasing the proportion of soluble calcium
phosphate, as well as by increasing the proportion of
hydroxyapatite and bone tissue maturity degree
thereby approximating for these measures to the shaft
cortex of intact animals. The index of bone tissue
compactness in the newly formed part of regenerated
bone cortex increased gradually as well, reflecting the
rise in its organospecificity degree. At the same time,
the index of bone tissue compactness in the
regenerated bone intermediary zone amounted to
64.24±3.73 % of the values of intact shaft cortex even
by the end of the experiment thereby evidencing of
incompleteness of remodeling processes.

Irianov et al.,

Int J Med Res Health Sci. 2015;4(2):294-298

DISCUSSION
Intramedullary osteosynthesis is known to provide
little-damage fixation of fractures, to allow earlier
weight-bearing of the operated limb, and to be one of
the main standard techniques for treating femoral and
tibial shaft fractures in most countries [3,4]. The main
disadvantage of intramedullary osteosynthesis is
considered the risk of damaging vessels and
circulation system of medullary canal which weakens
the osteogenic and osteoinductive potential of bone
marrow stromal pluripotent cells [5]. Experimental
studies have demonstrated that insertion of even thin
implant into the medullary cavity results in
significant blood supply disorders of the medullary
canal and cortex inside [6]. The possible mechanism of
the stimulating effect of intramedullary wire insertion
is connected with prolonged formation of the local
foci of granulation tissue in the medullary cavity. The
characteristic feature of the granulation tissue is the
expression of endotheliocyte migration phenotype,
and as a consequence – angiogenesis activation
evidenced by intense formation of numerous
endothelial sprouts which generate capillary buds and

297

endovasal spreads localizing in vascular lumens
(endovasal angiogenesis).
The creation of such foci provides the increase of
osteoproducing cell population in fracture zone both
endocrinally and paracrinally, as well as it stimulate
regeneration angiogenesis, and thereby contribute to
osteoreparation process activation. The additional
coating of titanium implant surface with
hydroxyapatite nanostructured high-porosity layer
provides high biocompatibility with the tissue
structures
of
regenerated
bone,
increases
osteointegration rate, decreases the output of metal
ions, and prevents the formation of fibrillary
connective tissue and cartilage in the regenerated
bone [6,7]. The zone of active appositional
osteogenesis and angiogenesis is formed around the
wires, as well as the bone sheath with osteogenesis
conductor and inductor properties, which provide
directed growth of bone tissue, prolonged stimulation
of angiogenesis and reparative osteogenesis. Fracture
consolidation occurs by the primary type early
without cartilaginous and connective tissue formation
in bone adhesion.

CONCLUSION
Thus, the results of the study evidence of the
positive effect of intramedullary wires with
hydroxyapatite coating on the course and
intensity of reparative osteogenesis during
fracture healing. The data obtained allow
recommending this relatively little-invasive
method of osteoreparation optimization to be
used in combination with other methods of
conservative and surgical treatment of bone
fractures, especially for sluggish reparative
processes in children, elderly and senile persons,
as well as in debilitated patients.

2.

3.

4.

5.

6.

7.

complications. A review of the prospective
literature. Can J Surg. 2000; 43(4): 256-62.
Griffith LE, Cook DJ, Frulke JP.
Intramedullary reaming of long bones.
Practice of intramedullary locked nails.
Springer Verlag, 2006: 43-57.
John VZ, Alagappan M, Devadoss S,
Devadoss A. A completely shattered tibia. J
Bone Joint Surg. Br. 2005 Nov; 87(11):
1556-59.
Lin CM, Yen SK. Biomimetic growth of
apatite on electrolytic TiO2 coatings in
simulated body fluid.Materials Science
Engineering. 2006; 26: 54-64.
Joseph В, Rebello G. B CK. The choice of
intramedullary devices for the femur and the
tibia in osteogenesis imperfecta. J Pediatr
Orthop. 2005 Sep; 14(5): 311-19.
Schemitsch EH, Kowalski MJ, Swiontkowski
MF. Cortical bone blood flow in reamed and
undreamed locked intramedullary nailing: a
fractured tibia model in sheep. J Orthop
Trauma. 1994; 8(5): 373-82.
Liu X, Chu PK, Ding C. Surface
modification of titanium, titanium alloys, and
related materials for biomedical applications.
Materials Science Engineering. 2004; 47: 4921.

ACKNOWLEDGEMENT
We thank the staff of our institutions for their
help in carrying out experiments and supervision
over animals during all stages of work.
Conflict of Interest: Nil
REFERENCES
1. Coles CP, Gross M. Closed tibial shaft
fractures: management and treatment
298
Irianov et al.,

Int J Med Res Health Sci. 2015;4(2):294-298

DOI: 10.5958/2319-5886.2015.00055.7

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
Coden: IJMRHS
Received: 2nd Dec 2014
Revised: 6th Jan 2015
Research article

Copyright @2014
ISSN: 2319-5886
Accepted: 16th Jan 2015

INFARCTION IN NORMAL AND INTRAUTERINE GROWTH RETARDATION [IUGR] PLACENTA
*Pooja Dhabhai1, Ghanshyam Gupta2
1,2

Department of Anatomy, R.N.T. Medical College, Udaipur, Rajasthan, India

*Corresponding author email: [email protected]
ABSTRACT
Background and Purpose: The purpose of the study is to compare the presence of Infarction in normal placentas
and IUGR placentas. Study design and setting: Research study, Department of Anatomy, R.N.T. Medical
College, Udaipur. Study Sample: 100 control and 100 IUGR Placentas Inclusion criteria: 100 Placentas from
normal control Pregnancies and 100 Placentas from mother who Delivered Intra Uterine Growth Retarded
(IUGR) babies Exclusion Criteria: we refer only uncomplicated Pregnancies without any previous diseases
Results: Chi Square test was used for statistical analysis. Conclusion: Increased incidence of extensive infarction
associated with low fetal weight
Keywords: Infarction, Placenta, Intrauterine Growth Retardation
INTRODUCTION
Fetal growth depends on the proper development and
function of the placenta, which serves to maintain
mater no fetal interference for the exchange of blood
gases, nutrients, and waste [1]. The architecture of the
placenta is altered in many maternal diseases such as
diabetes mellitus[2], hypertension[3], preeclampsia
[PE] [4], and eclampsia[5]., Although the placenta is a
vital organ, its systemic study has been neglected;
however, in recent times, it has evoked great interest,
and much work is being conducted to understand the
unique biological status of this complex organ[6].
Placental examination has clinical value in cases of
PE and intrauterine growth retardation (IUGR), both
of which are associated with high perinatal morbidity
and mortality accompanied with gross pathological
changes in the placenta.
Placental infarcts are usually wedge shaped and
always have a point of contact with the basal plate,
when fresh they are well demarcated, dark red and
moderately firm [7]. Placental infarctions are zone of

ischaemic necrosis of group villi due to complete
interference with their blood supply in the deciduas or
in the local state by thrombosis of a spiral arteriole or
a retroplacental haemorrhage[8]. Small areas of
infarction, involving less than 5% of the parenchyma,
were found in almost a quarter of placentas from
normal pregnancies and are of no clinical
significance. Extensive infarction, that is involving
more than 10% of villous substance is associated with
a high incidence of fetal hypoxia, low birth weight
and fetal death and is virtually confined to placentas
from patients suffering from the hypertensive
complications of pregnancy. Extensive infarction is
[7]
due to occlusion of multiple maternal arterioles . It
was found that extensive infarction in cases of
toxaemia were associated with low birth weight,
[7]
placental weight and increased foetal death
MATERIAL AND METHODS
299

Pooja et al.,

Int J Med Res Heath Sci. 2015;4(2):299 -301

The study of placenta in normal and IUGR cases
was carried out at R.N.T. Medical College &
Hospital, Udaipur. The cases were studied from 1-713 to 1-5-14. The study plan was approved by
institution Ethical Board and consent form was filled
by patients.
The placenta were collected from 200 women
admitted to the labour Rooms of the hospital
(either directly or through the antenatal wards).
All the cases were within the age group of 18-40
years, of average height and weight. Group 1normal pregnancy 100 patients included in this
group, normal Hb and urine analysis, not associated
with any disease.
Group 2-IUGR cases 100 cases of IUGR were
included. After the delivery placenta were collected
for gross studies, washed and surface dried between
blotting papers. Presence of Infarction noted as
Mild(less than 5% of total placental area)
Moderate(more than5% less than 10% of total
placental area) Severe(more than 10% of total
placental area) [7]
Area of infarction on the maternal surface varied
from no Infarcted area to 5-10 % of the total surface
(as calculated from combined area of the infarcts as
seen on the maternal surface.) [7]

Mild(less than 5%
of total placental
area)
Mod(more than5%
less than 10% of
total placental
area)
Severe(more than
10% of total
placental area)

9

51

4

20

0

24

*Highly significant p<0.0001
Table2.Statistical comparison of
present in control and research group
Author

Place

No.
of
case
s

GangaR
Singal
(2013)9
Kotgirwar
(2011)10
PradeepS
Londhe11
Figen Barut12
Gediminas
Meèëjus13
Nayereh
Ghomian14
Günyeli 15
Present
Study

Bhavnagar

100

Bhopal

55

nil

1.8

<0.01

Andhra
Pradesh
Turkey
Lithuania

374

5.4

10.6

<0.01

110
120

nil
4.2

92.7
49.2

<0.01
<0.01

Iran

46

8.7

39.1

<0.0001

Turkey
IndiaUdaipur

52
200

4
13

58
96

<0.05
<0.0001

*Highly
significant
p<0.01,p<0.05

RESULTS

Infarction

Infarction
Result
present in % of
cases
Contro Resea
l
rch
5
10
<0.01

p<0.0001,*Significant

DISCUSSION

Area of Infarction

Fig.1 Photograph of maternal surface of placenta
showing area of Infarction
Table 1 Analysis for Infarction
Infarction
type

Normal
pregnancies
group
(n = 100)

IUGR
pregnancies
group
(n = 100)

87

4

Nil

p value

<0.0001
*

Present study shows that infarction is present in
higher % of cases in IUGR group and the difference
is highly significant in our study. The p value
(<0.0001) is highly significant. The present study is
consistent with Nayereh Ghomian et al 14 also shows
Highly significant values of infarction in research
group.
Among Indian studies the present study is consistent
with study of Ganga R Singal[9], Kotgirwar[10].
Pradeep S Londhe[11] also studied higher percentage
of infarction in research group. The p value (<0.01) is
significant and thus favours the present study. Among
western studies the present study is consistent with
Figen Barut[12], Gediminas Meèëju[13] ,Günyeli et
al[15] as they also showed higher occurrence of
infarction in IUGR group. In present study infarction
was seen in 13 cases of normal terms pregnancy but
300

Pooja et al.,

Int J Med Res Heath Sci. 2015;4(2):299 -301

extent of infarction was less than 10% of placental
tissue. It was seen in 96% cases of IUGR , in 24% of
these extent of infarction was more than 10% of
placental tissue on gross examination.

6.

CONCLUSION
Increased incidence of extensive infarction was seen
in cases of IUGR. These cases were associated with
low foetal weight. Every placenta shows many
degenerative features. Presumably these are to an
extent, physiologic sequence of evolution. However,
when they occur in excess, they must be considered
as pathological, particularly when they affect foetal
growth deleteriously.

7.

8.

9.

ACKNOWLEDGEMENT
Conflict of Interest-NIL

10.

REFERENCES
1. Vogel P. The current molecular phylogeny of
Eutherian
mammals
challenges
previous
interpretations of placental evolution. Placenta.
2005; 26:591–96.
2. Pardo F, Arroyo P, Salomón C, Westermeier F,
Guzmán-Gutiérrez E, Leiva A, Sobrevia L.
Gestational diabetes mellitus and the role of
adenosine in the human placental endothelium
and central nervous system. J Diabetes Metab.
2012; 2:10-11.
3. Barker DJ, Bagby SP, Hanson MA. Mechanisms
of disease: in utero programming in the
pathogenesis of hypertension. Nat Clin Pract
Nephrol. 2006;2:700–07.
4. Sankar KD, Bhanu PS, Kiran S, Ramakrishna
BA, Shanthi V. Vasculosyncytial membrane in
relation to syncytial knots complicates the
placenta in preeclampsia: a histomorphometrical
study. Anat Cell Biol. 2012; 45:86–91.
5. Akhlaq M, Nagi AH, Yousaf AW. Placental
morphology in pre-eclampsia and eclampsia and

11.

12.

13.

14.
15.

the likely role of NK cells. Indian J Pathol
Microbiol. 2012; 55: 17–21.
Murphy VE, Smith R, Giles WB, Clifton VL.
Endocrine regulation of human fetal growth: the
role of the mother, placenta, and fetus. Endocr
Rev. 2006; 27: 141–69.
Fox,H.in Post graduate obstetrical and
Gynecological Pathology by Fox,H and
Langley,F.a.1stEd. 1973;409-37,
Zeek PM,Assali NS Vascular changes in the
deciduas associated with eclamptogenic toxaemia
of pregnancy.American Journal of clinical
Pathology,1950;20:1099-09.
Dr.Ganaga R Singal et al
,Placental
Morphometry in Relation to Birth Weight of Full
Term Newborn ; SEAJCRR 2013; 2(5) 334-42
S kotgirwar, M ambiye, S athavale,V gupta, S
trivedi, Study of Gross and Histological features
of placenta in intrauterine growth retardation ;J.
Anat. Soc. India 2011 60(1) 37-40
Londhe, pradeep s.et al Placental morphometry in
relation to birth weight of full term newborn
babies. ,National journal of integrated research in
medicine . 2012; 3( 1): 67-72.
Figen Barut et al;Intrauterine growth restriction
and placental angiogenesis; Diagnostic Pathology
2010,5:24
Gediminas meèëjus, Influence of placental size
and gross abnormalities on intrauterine growth
retardation in high-risk pregnancies, Acta medica
lituanica. 2005;12 (2)14–19
Ghomian, Nayereh et al 2014 Iranian Journal of
Pathology;Winter2014; 9 (1): 9
Günyeli et al. Placental examination in IUGR and
Stillbirth ; J Turkish-German Gynecol Assoc
2011; 12: 75-9

301
Pooja et al.,

Int J Med Res Heath Sci. 2015;4(2):299 -301

DOI: 10.5958/2319-5886.2015.00056.9

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 7 Dec 2014

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 4 Feb 2015
Accepted: 20th Feb 2015

Research article
COMPARISON OF ENDOSCOPIC SINUS SURGERY AND ANTRAL WASH OUT IN THE
MANAGEMENT OF SUBACUTE AND CHRONIC MAXILLARY SINUSITIS
*MuthuBabuK, Srinivasan MK., Sakthivel M, Kiran kumar C, Arvindh kumar G
Department of ENT, Meenakshi Medical College and Research Institute, Kanchipuram, Tamil Nadu, India
*Corresponding author: MuthuBabu. K ; Email: [email protected]
ABSTRACT
Introduction: Sub acute and chronic maxillary sinusitis is commonly encountered in day to day ENT practice.
Here we compare the management options available in the treatment of these two conditions. Methodology:
Endoscopic sinus surgery and antral wash out are two well known and authentic procedures used in the
management of maxillary sinusitis. Here we evaluate the effectiveness and advantages of both the procedures in
the management of sub acute and chronic maxillary sinusitis. 40 patients were evaluated. 20 patients underwent
antral lavage and the remaining 20 underwent Endoscopic sinus surgery. Equal number of patients with sub acute
and chronic maxillary sinusits underwent both the procedures. Result: Evaluation was done based on the
symptoms, anterior rhinoscopy finding and radiological finding. Conclusion: Endoscopic sinus surgery is an ideal
management tool for chronic maxillary sinusitis. But sub acute maxillary sinusits can be treated as a day care
procedure by antral washout.
Keywords: Antral wash out, Endoscopic sinus surgery, Maxillary sinusitis.
INTRODUCTION
Sinusitis is classified as acute sinusitis – 7days to 4
weeks duration, sub acute sinusitis – 4 weeks to 12
weeks duration and chronic sinusitis – more than 12
weeks duration, acute exacerbation of chronic
maxillary sinusitis and recurrent sinusitis – more than
4 episodes per year [1]. Here we limit our study to sub
acute and chronic maxillary sinusitis. The differential
diagnosis is based upon the duration of symptoms and
sinus endoscpic finding [2]. We compare the
effectiveness of two authentic procedures, antral
washout and endoscopic sinus surgery. Sub acute
maxillary sinusitis usually clears up by repeated sinus
washout [3].
MATERIAL AND METHODS
Patients from the outpatient and inpatient Department
of ENT and head and neck surgery, Meenakshi
Medical College and Research Institute were taken up

for the study after getting the approval. Patients in the
age group of 20 to 45 years of both sexes were taken
up for the study. Only patients who were suffering
from exclusive maxillary sinusitis were evaluated.
Exclusions: Involvement of other paranasal sinuse,
Presence of nasal polyps, Allergic rhinitis, Acute
exacerbations of chronic diseases, Fungal sinusitis,
Presence of any tumours in the nose. Randomized
separation study was done after getting the written
consent from the patients.
40 patients with symptomatic maxillary sinusitis were
evaluated. 20 patients underwent antral wash out.10
patients were suffering from sub acute maxillary
sinusitis and the rest 10 patients were suffering from
the chronic form of the disease. Similarly 20 patients
underwent endoscopic middle meatal antrostomy out
of which 10 were suffering from sub acute maxillary
sinusitis and the other 10 patients with chronic

302
Muthu Babu et al.,

Int J Med Res Health Sci. 2015;4(2):302-304

Disease

Percentage of
patients improved
following antral
wash

Chronic
maxillary
sinusitis
Subacute
maxillary
sinusitis

Percentage of
patients improved
following endoscopic
sinus surgery

20%

90%

90%

90%

RESULTS
9 out of 10 patients who underwent antral wash out
for sub acute maxillary sinusitis were relieved of the
symptoms that they complained off. Anterior
rhinoscopy and nasal endoscopic evaluation also

revealed complete normalcy after the procedure.
Radiological appearance of sinuses also showed
improvement with decrease in the opacification.
Similarly 9 out of 10 patients who underwent
endoscopic surgery with sub acute symptoms showed
similar improvement.
On the other hand 9 out of 10 patients who were
suffering from chronic maxillary sinusits and who
underwent endoscopic sinus surgery showed
improvement based on the symptoms, signs and
radiologic comparisons. But only 2 out of 10 patients
with chronic maxillary sinusits showed symptomatic
improvement following antral wash out (Fig 1).

improved

10

No. of patients

maxillary sinusitis. Evaluation was then done based
on the symptoms like nasal discharge, headache,
anterior rhinoscopic examination, endoscopic
examination of the nose, X-ray of the paranasal
sinuses, CT scan of the paranasal sinuses. The
evaluation of all these parameters was done before
the procedure and after the procedure. In few patients
who had purulent secretions the pus was sent for
culture and sensitivity. Antral lavage: Under local
anaesthesia, 4% xylocaine was used to anaesthetize
the nasal cavity through the inferior meatus[4]. A
Lichtwitz trocar and canula was inserted into the
maxillary antrum through the inferior meatus and the
antrum washed with normal saline. By doing so the
antrum was washed out and the patency of the natural
maxillary sinus ostium was established thus helping
in the treatment of the disease. Endoscopic sinus
surgery: Using 0 degree nasal endoscope, under local
or general anaesthesia the procedure was performed
depending on the ability of the patient to withstand
the procedure [5]. A middle meatal antrostomy and
complete toileting of the maxillary antrum was done.
Pus if present was sent for culture and sensitivity.
Patients were followed up every week for six weeks
and the patient’s response to treatment was evaluated
depending on the symptoms like headache, nasal
discharge, and nasal obstruction and from the anterior
rhinoscopy and nasal endoscopic findings.
Preoperative and post operative X-ray and CT scan of
the patients were compared to come to a conclusion
regarding the results of both the procedures.
Table1: Showing percentage of patients improved
following antral wash and endoscopic sinus
surgery.

8
6

Subacute

4

Chronic

2
0
Antral wash

FESS

Fig 1: Comparison of antral wash-out with FESS
for sub acute and chronic diseases.
DISCUSSION
It was Messerklinger who made us understand about
the physiology of the nose and sinuses and also in
recognizing the mucociliary transport mechanism in
the nose and sinus mucosa. The mucociliary transport
of mucous occurs in a definite genetically
predetermined system. The transport is always
towards the natural ostium. In sinusitis the pathology
is not in the major sinuses but secondary to impaired
drainage caused by disease in the ethmoidal
infundibulum blocking the natural ostium in the
middle meatus. This leads to stagnation and impaired
ventilation causing damage to the respiratory
epithelium with consequent inflammation and further
occlusion of the ostium. Functional endoscopic
surgery is aimed in tackling the pathology in the
natural ostium. Antral wash out aims at washing out
the stagnated contents in the antrum through a trochar
and canula inserted through the inferior meatus and is
washed out through the natural ostium. So any
minimal pathology in the ostium may be cleared of in

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this procedure itself. Hence we were induced to make
such a comparative study. The predisposing factors
for sinusitis are Upper respiratory tract infections,
anatomic variations, allergic rhinitis, immuno
deficiency diseases, inhalation of irritants etc[2].Dental
infections are also a common cause for maxillary
sinusitis. Here two of our patients had dental
infection. Typical organisms in an odentogenic
sinusitis include anaerobic streptococci, streptococci
sanguis, streptococcus salivarius, streptococcus
mutans, bacteroides, proteus and coliform bacilli [3].
In sub acute cases antral wash out is frequently
carried out as a first line of management. Antral
washouts are also done in some centres at the time of
polypectomy [4].local anesthesia is usually preferred.
We use 4% xylocaine surface anesthesia. In some
centres Propandid as the sole anaesthetic agent for
antral wash out in adult day case is described [5,6].
One of the main benefits of antral wash out in sub
acute cases is that the tap provides material for
culture and sensitivity to guide antibiotic selection
especially in immunocompromised patients in the
intensive care units. The commonest organism being
gram positive organisms responding to amoxicillin
and clavalunic acid [7]. If penicillin group is to be
avoided due to hypersensitivity then cefpodoxime and
cefuroxime can be used [8-11]. In our study no such
limitations were present.
CONCLUSION
From the above study we came to a conclusion that in
the management of sub acute maxillary sinusitis both
antral was out and endoscopic sinus surgery provides
equal relief. Since Antral wash out is a simpler
procedure and doesn’t require hospital stay and can
be done as a day case, antral wash out still holds good
in the treatment of sub acute maxillary sinusitis. But
functional endoscopic sinus surgery still remains the
gold standard in the treatment of chronic maxillary
sinusitis.
ACKNOWLEDGMENT

Conflict of interest: Nil
REFERENCES
1. Ian S Mackkay , Valerie J Lund classification
and differential diagnosis of rhinosinusitis,ScottBrowns otorhinolaryngology and head and neck
surgery.7th edition 2008; 1380.
2. A.Masood, Loannis Moumoulidis,Joan Panesar
Predisposing factors for sinusitis. Postgraduate
Medical journal 2007 83(980) 402 – 08.
3. Legret.KG, Zimmerman,Stierna P Sinusitis of
odontogenic origin. Pathophysiological impli
cations of early treatment. Acta otolaryngol.
2004.124(655) 662 -63.
4. Dowel.M,Pahor AL Antral wash out in nasal
polypectomy The journal of laryngology and
otology 1992,106(8) 695-96.
5. D.L.Scott Propandid as the sole anaesthetic agent
for antral wash out in adult. British journal of
anaesthesia 1970 .42 (10):889 – 90.
6. Pang YJ,WillatDJ, Do antral wash out have a
place in the current management of chronic
sinusitis.J of Laryngol and otoln 1996:110:92628.
7. Garau .J, DaganR, Accurate diagnosis and
appropriate treatment of acute bacterial rhino
sinusitis: Minimising bacterial resistance Clin
Ther 2003:25 (7):1936-51.
8. Melen I, Lindal L, Andreasson.L, Rundcrantz H
chronic maxillary sinusitis. Definition, diagnosis
and relation to dental infections and nasal
polyposis: Acta otolaryngo 1986. 101(3-4): 3207.
9. G.E.Archer The treatment of subacute maxillary
sinusitis especially in children: Proc.R.Soc.Med.
1947 40(4); 854-58.
10. Mochloulis G, HernJD, Hollis LJ, Tolley NS,
Maxillary antral lavage using inferior meatus
anaesthesia J laryngol otal 1996 110(8) : 763-4.
11. Young JJ, Liw Y, Jil Q, Wang ZY, Sun J, Wang
QP, Liz Q, Xu JG local aneasthesia for functional
endoscopic sinus surgery employing small
volumes of epinephrine containing solutions of
lidocaine produces profound hypertension: Acta
Anaesthesiol Scan 2005: 49(10): 1471-6.

I would like to thank Dr. K.Nithyananthan, M.S.,
DEAN Meenakshi Medical College and Hospital
Research Institute for giving us this opportunity to
conduct this study. I would also like to thank the
medical and paramedical staff of the Dept of ENT for
their assistance.

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DOI: 10.5958/2319-5886.2015.00057.0

International Journal of Medical Research
&
Health Sciences

www.ijmrhs.com
Volume 4 Issue 2
nd
Received: 22 Dec 2014
Research article

Coden: IJMRHS
Revised: 5th Jan 2015

Copyright @2014
ISSN: 2319-5886
Accepted: 1stMar 2015

COMPARISON OF THE KNOWLEDGE, ATTITUDE AND PRACTICES OF ESSENTIAL MEDICINES
AMONG MEDICAL PRACTITIONERS OF A MEDICAL COLLEGE VERSUS PRIVATE MEDICAL
GENERAL PRACTITIONERS OF AN URBAN PLACE OF SOUTH INDIA

*Vidyarthi SurendraK1, Nayak RoopaP2, Gupta Sandeep K3, Dandekar Rahul H4
1

Associate Professor, 2Professor and Head, 3Assistant Professor, Department of Pharmacology, Dhanalakshmi
Srinivasan Medical College and Hospital, Siruvachur, Perambalur, Tamil Nadu
4
Assistant Professor, Department of Community Medicine, Dhanalakshmi Srinivasan Medical College and
Hospital, Siruvachur, Perambalur, Tamil Nadu
*Corresponding author email: [email protected]
ABSTRACT
Background: India is the third largest producer and exporter of medicines to most of the countries. The World
Medicine Situation Report 2011 states that 65% persons in India do not have access to essential medicines. While,
huge unethical prescribing ofdrugs for monetary gains has been a second major cause of rural indebtedness. Aims
and Objectives: The primary objective of the study was to compare the Knowledge, Attitude and Practices of
Essential Medicines among Medical Practitioners of a Medical College and Private Medical General Practitioners
of an urban place, e.g. Perambalur District of South India. Materials and Methods: After ethical approval, the
study was started, in Dhanalakshmi Srinivasan Medical College and Hospital (DSMCH), Siruvachur-621113,
Perambalur, Tamil Nadu. It was a questionnaire based study. The faculties of the DSMCH and Medical Private
Practitioner of Perambalur district included as participants in the study. We distributed knowledge, attitude and
practice (KAP) based 15multiple choice questions on National Essential Medicine List, 2011 (NEML) to each
healthcare professionals (HCPs) to attempt within 15 minutes. Results: Overall, Knowledge, attitude and
practices regarding NEML 2011 were 57.06%, 38.36%; 51.16%, 51.82%; 21.73%, 28.7% to HCP from DSMCH
and HCP from Perambalur district, respectively. Whereas, 42.2 % HCPs from DSMCH and 44.7 % HCPs from
Perambalur district were prescribed branded and generic drugs both. Conclusion: The result’s data shows that
regular awareness programmes should be conducted to update knowledge, change attitude and practices regarding
essential medicines to serve the society as best as possible.
Key words: Essential Medicine List (EML), National Essential Medicine List (NEML), Knowledge, Attitude,
Practice, (KAP), Essential medicine.
INTRODUCTION
Access to essential medicines is a fundamental
human right. India is the third largest producer and
exporters of medicines to most of the
countries.[1]Whereas, huge unethical prescribing of
unnecessary drugs for monetary gains by health
service providers has been a second major cause of
rural indebtedness.[1] While, the World Medicine
Situation Report 2011 states that 65% persons in

India do not have access to essential
medicines.[2]Therefore, an earlier attempt of
establishing low cost quality generic medicines,
motivating providers to prescribe generic medicines
and follow standard treatment protocols partially
succeeded and Provision of free medicines to all
patients seeking care in government hospitals has
improved access to health care many folds. The
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WHO has defined “Essential medicines (drugs) those
that satisfy the priority healthcare needs of the
population. They are selected with due regard to
public health relevance, evidence on efficacy and
safety, comparative cost effectiveness and it should
be available at all time, in adequate amounts, in
appropriate dosages forms, with assured quality and
adequate
informations”[3]Though,
healthcare
professionals play an important role to prescribing
essential medicines, so question arises what about
their awareness on essential medicines. Thus, the
present survey conducted to compare the Knowledge,
Attitude and Practices regarding Essential medicines
among Medical practitioners of a Medical College
and Private Medical General Practitioners of an urban
place, e.g. Perambalur District of South India.
Aims and objectives: The primary objective of the
study was to compare the Knowledge, Attitude and
Practices of Essential medicines among Medical
practitioners of a Medical College and Private
Medical General Practitioners of an urban place, e.g.
Perambalur District of South India.
MATERIAL and METHODS
After getting approval from the ethics committee, the
present study was conducted in the month of
February 2014, in Dhanalakshmi Srinivasan Medical
College and Hospital (DSMCH), Siruvachur-621113,
Perambalur, Tamil Nadu. The study was
questionnaire based comparison among two groups of
the healthcare professionals. The Professors,
Associate Professor, Assistant Professor, senior and
junior resident (SR, JR), pharmacist, dentist and
casualty medical officer (CMO) of DSMCH included
in group ‘A’ and they are abbreviated as
“A_DSMCH_HCP” and Medical General Practitioner
of Perambalur district included in group ‘B’ and they
are abbreviated as “B_Perambalur_GP”. We
distributed 5-knowledge, 5-attitude and 5-practice
(KAP) based, i.e. 15 multiple choice questions which
was based on National Essential Medicine List, 2011
(NEML) to each healthcare professionals (HCPs) to
attempt within 15 minutes.
Statistics: After evaluation of each paper, we
analyzed the data by using Epi Info Free available
online/offline software and statistical calculations
done; like percentage, chi-square test, p-values.

RESULTS
We formed two groups, 61 healthcare professionals
from DSMCH in group ‘A’ (A_DSMCH_HCP) and
in group ‘B’ (B_Perambalur_GP) 61 general
practitioners from Perambalur District. The
demography of the participated HCPs were the 11professor,
4-associate
professor,
22-assistant
professor, 4-senior resident (SR), 9-junior resident
(JR), 1-casualty medical officer (CMO), 7-pharmacist
and 3-dentist were participated in group “A”, out of
61 HCPs. While all 61 HCPs of group “B” were
General practitioners from various medical subjects.
Average age of the included HCPs was 39 years
and45 male, 16 female HCPs were from DSMCH,
while 49 male, 12 female HCPs were from
Perambalur District. We analyzed knowledge,
Attitude and Practices (KAP) about essential
medicines of 61 HCPs of A_DSMCH_HCP and 61
HCP of B_Perambalur_GP; Perambalur District.
Obtained responses data shown in table1, 2 and 3
respectively. Statistics: We used Epi. Info free
available online/offline software to calculate the
obtained responses in percent and applied Chi- square
test and calculated p-value of each questions’
response.
Knowledge on National Essential Medicine & its
List2011: Overall, 57.06% HCP from DSMCH and
38.36% HCP from Perambalur district were aware
about EML 2011, while 21.98%, 28.86% HCP were
do not know about EML2011 from DSMCH and
Perambalur district respectively and even 20.98%,
32.82% HCP from DSMCH and Perambalur district
were not sure about knowledge of EML2011
respectively(Table 1).
Attitude about HCP for National Essential
Medicine & its List2011: Overall, 51.16% HCPs
from DSMCH attitude were strongly agree or
strongly like to attend/refer NEML2011, while;
51.82% HCPs from Perambalur district attitude was
strongly agree or strongly like to attend/refer
NEML2011. One side, 44.94% HCPs from DSMCH
were like to refer NEML, whereas 40.62% HCPs
from Perambalur district were like to refer
NEML(See details on Table 2).
Practices about National Essential Medicine & its
List2011 for HCPs:8.2 % HCPs from DSMCH
always prescribed generic drugs, whereas, 14.8%

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prescribed branded drugs, while 62.3% HCPs
drugs, respectively, while; 20.9 % HCPs from
prescribed branded as well as generic drugs both.
DSMCH and20.9%HCPs from Perambalur district
6.6% HCPs from Perambalur district always
were frequently prescribed old essential drugs,
prescribed generic drugs, whereas, 36.1% prescribed
respectively. Whereas, 42.2% HCPs from DSMCH
branded drugs, while 55.7 % HCPs prescribed
and 44.7% HCPs from Perambalur district were
branded as well as generic drugs both. Overall, 21.73
prescribed branded and generic drugs both (See
% HCPs from DSMCH and 28.7 %HCPs from
details on Table 3)
Perambalur district were always prescribed branded
Table1: Knowledge Based Questions and obtained Responses of Both Group ‘A’ and ‘B’ HCPs
Knowledge Based Questions
Know

Indian Essential Medicine list 2011 is
the List of drugs by generic names and
it is required to satisfy the priority
healthcare needs of a population.
Q.2 *NLEM2011 incorporated with twenty
seven sections with 348 drugs.
Q.3
Indian EML2011 formulary has Basic
drug informations like Dose, Generic
name, Clinical indications.
Q.4
Essential medicines selection criteria
are Pattern of prevalent diseases,
Relative efficacy, cost and suitability of
drugs and treatment facilities.
Q.5
WHO revise and publish essential
medicine list in every two years
interval, while Govt. of India, θMOHFW
published EML in 1996, 2003, 2011.
Knowledge about NEML2011 (Total
Percentage in Average):

A-DSMCH_HCP
Don’t
Not
Know
Sure

B-Perambalur_HCP
Know
Don’t
Not Sure
Know

Q.1

39
(63.9%)

7
(11.5%)

15
(24.6%)

34
(55.7%)

30
(49.2%)
40
(65.6%)

20
(32.8%)
8
(13.1%)

11
(18%)
13
(21.3%)

6
(9.8%)
26
(42.6%)

46
(75.4%)

10
(16.4%)

5
(8.2%)

19
(31.2%)

22
(36.1%)

57.06%

21.98%

0

27 (44.3%)

Chisquared

PValue

10.8

0.005

38
17
(62.3%) (27.9%)
18
17(27.9%)
(29.5%)

22.9

0

7.3

0.03

32
(52.5%)

12
(19.7%)

17
(27.9%)

9.2

0.01

20
(32.8%)

19
(31.2%)

20
(32.8%)

22
(36.1%)

0.2

0.9

20.98%

38.36%

28.86%

32.82%

Abbreviations: *NLEM= National list of Essential Medicine, θMOHFW= Ministry of Health and Family Welfare.

Table 2: Attitude Based Questions and obtained responses of both groups ‘A’ and ‘B’HCPs
Attitude Based Questions

Q.6

Q.7

Have you ever refer essential Strongly
Like to
Medicine list 2011 or your like to refer
refer
Hospital formulary in last three
19 (31.2%) 42(68.9%)
years?
Strongly
Like to
Have you ever read any article
read/
regarding essential medicines or like to read/
attend
attend
attended any seminar,
conferences, symposium, CME,
workshop etc. on it?

Q.8

A-DSMCH_HCP

Do you think prescribing essential
medicines should be made
mandatory?

Q.9

Do you think prescribing Generic
drugs should be made
mandatory?

Q.10

I Strongly like, like, dislike, to
select essential medicines as per
its relative efficacy, cost and
suitability for the treatment.

Attitude for θEML2011 (Total Percentage )

B-Perambalur_GP

Dislike to
refer
0

Strongly
like to refer
17 (27.9%)

Like to
refer

Dislike to
refer

41(67.2%) 3(4.9%)

Dislike to
read/
attend

Strongly
like to read/
attend

Like to
read/
Attend

Dislike to
read/
attend

42
(68.9%)

1
(1.6%)

37
(60.7%)

19
(31.1%)

5
(8.2%)

Strongly
agree

Agree

Disagree

Strongly
agree

Agree

Disagree

40(65.6%)

18(29%)

3(4.9%)

37(60.7%)

19(31%)

5(8.2%)

Strongly
agree

Agree

Disagree

Strongly
agree

Agree

Disagree

18
(29.5%)

35(57.4%) 19(31%)
Strongly
Like
like
44
16
(72.1%)
(26.2%)
51.16%

44.94%

7(11.5%)
Dislike
1
(1.6%)
3.9%

25(40.9%) 29(47%)
Strongly
Like
like
42
16
(68.9%)
(26.2%)
51.82%

40.62%

7(11.5%)

Chisquared
3.1

17.9

0.6

PValue

0.2

0.000

0.7

3.8

0.2

1.05

0.6

Dislike
3
(4.9%)
7.54%

Abbreviations:*CME = Continue medical Education , θEML2011: Essential Medicine List2011

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Table3: Practice Based Questions and obtained responses of both groups ‘A’ and ‘B’HCPs
Practice Based
Questions
Q.11. Have you
presented / not
presented ……numbers
of articles / posters on
Essential Medicine in last
three years?
Q 12. I prescribe/

don’t
prescribe Generic /
branded /
both drugs.
Q 13. I always /
frequently / occasionally
prescribe /
don’t prescribe essential
drugs.
Q 14. I prescribe/ don’t
prescribe New drugs /
Old drugs /
both drugs.
Q15. I prescribe/ don’t
prescribe
Zinc supplements
always / frequently
occasionally
to acute diarrhoeal
children.
Practice about EML2011
(Total percentage)

A-DSMCH_HCP

B-Perambalur_GP

Presented

Not Presented

Presented

Not Presented

1
(1.6%)

60
(98.4%)

0

61
(100%)

Branded
drugs

9
(14.8%)
Always
26
(42.6%)
new drugs
6
(9.8%)

Generic
drugs

Both (Branded
& Generic
drug)

5
38
(8.2%)
(62.3%)
Frequentl
y
Occasionally
30
(49.2%)
old
drugs
2
(3.3%)

Don’t
Both
drugs

Branded
drugs

Generic
drugs

9
(14.8%)

22
(36.1%)

4
(6.6%)

Don’t both
drugs

Always

3
(4.9%)
Prescribe
both drugs
43
(70.5%)

2
15
(3.3%)
(24.6%)
Don’t both
new drugs
drugs
10
0
(16.4%)
Don’t
Occasionally prescribe
Always
prescribe
Both
prescribe
drugs

Both (Branded
& Generic
drugs)

1
(1.6%)

Frequently
Prescribe

Occasionally
prescribe

Don’t both
drugs

29
(47.5%)

9
(14.8%)

old drugs

both drugs

8
(13.1%)
Don’t both
drugs

0

61
(100%)

Frequently
Prescribe

Occasionally
prescribe

Don’t
prescribe
Both
drugs
5
(8.2%)

Freque
ntly

12
(19.7%)

14
(22.9%)

19
(31.2%)

16
(26.2%)

33
(54.1%)

18
(29.5%)

5
(8.2%)

21.73 %

20.9 %

42.2%

15.2%

28.7 %

20.9 %

44.7%

“An essential medicines list (EML) is a limited
number of carefully selected medicines by the
authorized committee. For many decades, such lists
have been published as formularies and institutional
lists of medicines that are made available to health
facilities and health workers. These may not be called
EMLs but they serve the same function. EMLs have
been one of the cornerstones of public health delivery
and the basis for efforts to ensure consistent medicine
supply and management”.[4] The characteristic
features of Essential medicines (drugs) those that
satisfy the priority healthcare needs of the population,
they are selected with due regard to public health
relevance, evidence on efficacy and safety,
comparative cost effectiveness and it should be
available at all time, in adequate amounts, in
appropriate dosages forms, with assured quality and
adequate information. [5] Thus, EML is an important
strategy in improving access to and use of medicines,
especially for the vulnerable segment of a population.
Furthermore, an EML can be used as an

PValu

e

-

-

12.2

0.007

9.6

0.02

21.1

0.0001

24.2

0

Don’t
both drugs

34
(55.7%)

Always

DISCUSSION

Chisqua
red

0

5.7%

advocacy tool to help countries spend their limited
resources on the medicines that are most needed and
offer the best value for money. [6] So, on this juncture,
awareness programmes targeting various stakeholders
like doctors, patients, consumer groups, and the
media are needed.[7] The present study compares the
knowledge, attitude and practices about Indian
National essential medicines list 2011among HCPs of
DSMCH as well as Perambalur district. We observed
that, overall, 57.06% HCPs from DSMCH and
38.36% HCPs from Perambalur district had
knowledge in EML 2011, while (55% Hettihewa LM,
2010), though 21.98% HCPs from DSMCH and
28.86% HCPs from Perambalur district were do not
know about EML2011 and even 20.98% HCPs from
DSMCH and 32.82% HCPs from Perambalur district
were not sure about knowledge of EML2011.
Whereas, (54% Hettihewa LM, 2010of his study
group and 29% Hettihewa LM, 2010 MPs had fair
knowledge in EDL and 17 % Hettihewa LM, 2010)
were not aware about EDL in their own study). Thus,
obtained data in the present study indicate that timely
interval evaluation needed to check and update
knowledge regarding EML of HCPs that will help to
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improve patients’ safety and teaching curriculum of
pharmacology. The similar suggestion was also given
by Hettihewa LM, 2010 in his study. Overall, 51.16%
HCPs from DSMCH attitude were strongly agree or
strongly like to attend / refer NEML2011, while;
51.82% HCPs from Perambalur district attitude was
strongly agree or strongly like to attend/refer
NEML2011. Even, 44.94% HCPs from DSMCH
were like to refer NEML, whereas 40.62% HCPs
from Perambalur district were like to refer NEML.
The 65.6%HCPs from DSMCH and 60.7% HCPs
from Perambalur district attitude were prescribing
essential
medicines
should be
mandatory,
respectively. Whereas, the 57.4 % HCPs from
DSMCH and 40.9 % HCPs from Perambalur district
attitude was prescribing generic drugs should be
mandatory, respectively.
The72.1%HCPs from DSMCH and 68.9% HCPs
from Perambalur district attitude was strongly like to
select essential medicines as per its relative efficacy,
cost and suitability for the treatment, respectively.
The 1.6%, i.e., only one out of 61 HCPs from
DSMCH have presented an articles / posters related
to Essential Medicine in last three years. While, no
one HCPs from Perambalur district presented an
article / poster which was related to essential
medicine.
The 14.8 %, 8.2 % and 62.3 % HCPs from DSMCH
were prescribed branded drugs, generic drugs and
branded as well as generic drugs both, respectively,
whereas, 36.1 %, 6.6 % and 55.7 % HCPs from
Perambalur district were prescribed branded drugs,
generic drugs and branded as well as generic drugs
both, respectively. While, Mahajan R, et al, 2010
reported in his study that only 15.1% clinicians wrote
the generic drugs. [8]
The 42.6%, 49.2% and 4.9% HCPs from DSMCH
were prescribed essential drugs always, frequently
and occasionally, respectively, while, 24.6%, 47.5%
and 14.8% HCPs from Perambalur district were
prescribed essential drugs always, frequently and
occasionally, respectively.
The 9.8%, 3.3% and 70.5% HCPs from DSMCH
were prescribed new essential drugs, old essential
drugs and new as well as old both essential drugs,
respectively, while, all 61 HCPs from Perambalur
district, i.e., 100% HCPs were prescribed new as well
as old both essential drugs.

The 19.7%, 22.9% and 31.2% HCPs from DSMCH
were prescribed zinc supplements always, frequently
and occasionally in acute diarrhoeal children,
respectively, though, 54.1%, 29.5% and 8.2% HCPs
from Perambalur district were prescribed zinc
supplements always, frequently and occasionally in
acute diarrhoeal children, respectively.
CONCLUSION
The primary responsibilities of the healthcare
professionals, that many awareness programmes
should be conducted to increase knowledge about
essential drugs, and attitude of the healthcare
professionals should be changed to promote use of
essential medicines as well as generic medicines and
this changed attitudes of healthcare professionals
should be practiced in routine working environment,
then it will be possible to provide medicines to almost
all needy people. Even, it is well known information
that, “The enjoyment of the highest attainable
standard of health is one of the fundamental rights of
every human being without distinction of race,
religion, political belief, economic or social
condition”.
Limitations: The obtained data in the present study
was based on the responses of the healthcare
professionals from the given questionnaire on
National Essential Medicine List 2011 only.
ACKNOWLEDGEMENT
We acknowledge with gratitude to Chhaya Pachuli;
Mudit Mathur; Ritesh Laddha: “Prayas Centre for
health equity”, including their entire team
members(Prayas Centre), who allowed to use their
few text lines in this present study. We also
acknowledge heartily to Dr. Hettihewa LM, and Dr.
Mahajan R. including his colleagues who
allowedusing his few texts.
Conflict of Interest: Nil
REFERENCES
1. Samit Sharma; Indian Administrative Service,
Chhaya Pachauli; Mudit Mathur; Ritesh Laddha;
Prayas Centre for Health Equity, Avinash Kumar;
Oxfam India, S. Srinivasan; All India Drug
Action Network, Narendra Gupta; Prayas Centre
for Health Equity, Prayas: Free Access to
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Essential Medicines in Rajasthan. South Asia
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2013,
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Medical Practitioners and Medical Students in
Galle, Sri Lanka”.Online Journal of Health and
Allied Sciences. Jul-Sep 2010;9( 3): 1-5.
Mahajan R, Singh NR, Singh J, Dixit A, Jain A,
Gupta
AEncephale.J
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Bioallied
Sci.2004;30 (5):437-46.
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Int J Med Res Health Sci. 2015;4(2):305-310

DOI: 10.5958/2319-5886.2015.00058.2

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 20 Dec 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
rd
Revised: 23 Jan 2015
Accepted: 7th Feb 2015

PHENOTYPIC DETECTION OF MBL, AMPC BETA-LACTAMASE AND CARBAPENEMASES IN
MULTI DRUG RESISTANT ISOLATES OF ACINETOBACTER BAUMANNII
Richa Hans1, *Dakshina Bisht2, Ritu Agarwal3, M.Irfan4
1

MD Student, 2Professor, 3Assistant Professor, 4PhD student, Department of Microbiology, Santosh Medical
College, Ghaziabad, U.P, India
*Corresponding author email: [email protected]
ABSTRACT
Introduction: Acinetobacter baumannii is one of the major pathogens causing nosocomial infections due to
emergence of resistance to various antimicrobial agents. Resistance due to antimicrobial degrading enzymes is
now a worldwide problem and a major reason of concern for the treating physicians. Keeping this in mind, the
present study was designed to isolate Acinetobacter baumannii and study various antimicrobial resistance
mechanisms in them. Materials and methods: A total of 50 A.baumannii isolates from various clinical samples
were screened for meropenem resistance for the detection of Carbapenemase and MBL production.
Carbapenemase production was confirmed by Modified Hodge Test whereas MBL by Disk Potentiation Test.
Cefoxitin resistance was used as a screening test for AmpC beta-lactamase production which was confirmed by
AmpC disk test. Results: Maximum isolation of A.baumannii was found in patients admitted in the Intensive care
unit with respiratory tract infection. Among the 50 A.baumannii strains, Carbapenemase production was observed
in 26.4%, MBL production in 52.9% and AmpC beta lactamase production in 56%. Conclusion: Our study
emphasizes on multi-drug resistant A.baumannii highlighting the antibiotic crisis as a result of emergence of
various bacteria that show resistance to various antibiotics. Acinetobacter epitomises this trend, as it is an
important nosocomial pathogen with a capability of cross-infection particularly in ICUs and a grave limitation of
treatment options, thus, requiring an urgent need to control the spread of MDR strains in the hospitals.
Keywords: Acinetobacter, Modified Hodge Test, Metallo-beta-lactamse, AmpC beta-lactamse
INTRODUCTION
For many years, Acinetobacter species were
considered to be saprophytic in the environment,
found as a major constituent of the flora of soil, water
and sewage and within the hospital environment.
However, due to a number of agents as well as host
factors, they have now emerged as important
nosocomial pathogens predominantly in ICU settings
most commonly affecting immuno-compromised
patients, although they have also been isolated as the
etiological agent of pneumonia in healthy individuals
[1].
Multi drug resistance in A.baumannii is not a new
phenomenon. They are known to be intrinsically

resistant to various antibiotics along with the ability
to acquire genes that encode for resistance
determinants.[2]Production
of
beta-lactamases,
aminoglycoside-modifying enzymes, diminished
expression of outer membrane proteins [OMP] and
up-regulation of efflux pumps play a crucial role in
antibiotic resistance. Newer beta lactamases causing
antimicrobial resistance include Extended-spectrum
beta-lactamases (ESBL), AmpC beta-lactamses and
Metallo-beta-lactamases (MBL). [3]
Beta-lactamases
act
on
many
penicillins,
cephalosporins, carbapenems and monobactams.
311

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Int J Med Res Health Sci. 2015;4(2):311-316

Metallo-beta-lactamases also referred as Class B
beta-lactamases act on penicillins, cephalosporins and
carbapenems but not on monobactams.[4] MBLs have
zinc as metal ion which is linked to cysteine or
histidine residue and it reacts with the carbonyl group
of the amide bond of penicillins, cephalosporins and
carbapenems.[5]
AmpC beta-lactamases are known to bestow
resistance to cephalosporins in the oxyimino group
and are not affected by available available betalactamase inhibitors. [6] The presence of MBLs and
AmpC beta lactamases in a single isolate confer
resistance to carbapenems which are usually the drug
of choice in Acinetobacter infections.
A. baumannii also possess an intrinsic class D
oxacillinase belonging to the OXA-51-like group of
enzyme. OXA-51-like enzymes are able to hydrolyze
penicillins (benzylpenicillin, ampicillin, ticarcillin
and piperacillin) and carbapenems (imipenem and
meropenem). Accumulation of multiple resistance
mechanism leads to the development of pan-resistant
strains limiting the therapeutic options.
Many multidrug resistant bacteria including
A.baumannii produce combinations of different
enzymes responsible for drug resistance. With the
increasing number of MBL, ESBL and AmpC
producing bacteria along with porin loss and efflux
mechanisms, an increase in carbapenem resistance
has been observed. Carbapenems being the drug of
choice for highly resistant Acinetobacter species, its
increasing resistance pattern limits therapeutic
options. Keeping this in mind, present study was
undertaken to isolate Acinetobacter baumannii and
study various antimicrobial resistance mechanisms
prevalent amongst the isolates in one of the tertiary
care hospitals in North India.

method, as per the guidelines of the Clinical
Laboratory Standards Institute (CLSI).[8]
Susceptibility to the following antibiotics (disc
concentration) were tested: Ofloxacin(5 µg); Erythro
mycin(15µg);Gentamcin(10µg);Cotrimoxazole(1.25+
23.75 µg); Doxycycline(30 µg); Cefoxitin(30 µg);
Ceftazidime(30µg); Piperacillin/Tazobactam (100+10
µg):Colistin(10µg);Tigecycline(15µg); Aztreonam(30
µg); Imipenem(10 µg) and Meropenem(10 µg).
Quality control strains used were Escherichia coli
ATCC 25922 and Pseudomonas aeruginosa ATCC
27853. Meropenem resistance was used to screen for
beta-lactamase production and Cefoxitin resistance
for AmpC beta lactamase production.
Detection of Carbapenemase
Modified Hodge Test: It was used to detect
carbapenemase production in meropenem resistant
strains. A culture suspension of Escherichia coli
ATCC 25922 adjusted to 0.5 McFarland’s standard
was inoculated on the surface of Muller-Hinton Agar
plate using a sterile cotton swab. After drying, 10μg
meropenem disc was placed at the centre of the agar
plate and test strains were streaked from the disc’s
edge to the periphery of the plate in four different
directions. The plate was then incubated overnight at
37°C.
Presence of a clover leaf shaped zone of inhibition
along the growth of test strain was considered as
positive for carbapenemase production. [9] (Figure 1)
Quality control strains used were, K. pneumoniae
ATCC® BAA-1705—MHT positive, K. pneumoniae
ATCC® BAA-1706—MHT negative.

MATERIALS AND METHODS
A total of 50 consecutive non-duplicate Acinetobacter
baumannii isolates from various clinical samples and
patients from all age groups and both sexes from
March 2013 till Feb 2014 were included. The
samples comprised of sputum, urine, wound swabs,
tracheal aspirates, blood, pus, bronchial lavage and
endotracheal tubes. A.baumannii strains isolated
were identified by standard microbiological
methods.[7]The anti-microbial susceptibility testing
was performed using antibiotics obtained from HiMedia, Mumbai, by the Kirby Bauer disk diffusion

Fig 1: Modified Hodge Test
Detection of MBL
Disc Potentiation Test: The test organism adjusted to
0.5 McFarland’s opacity standards was inoculated on
Muller-Hinton agar plate. Two 10µg imipenem discs,
312

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Int J Med Res Health Sci. 2015;4(2):311-316

100%
80%
60%
40%
20%
0%

ANTIBIOTICS

Cefepime

Of the 50 isolates, 28 (56%) strains were isolated
from the respiratory secretions (sputum, tracheal
secretions, endotracheal tips and BAL), 12 (24%)
from pus (including wound swabs) and 9 (18%) from
blood samples and only 1 (2%) from urine. Intensive
care unit (ICU) had the most isolation rate of 34
(74%) A.baumannii followed by medicine ward 5
(10%), surgery ward 4 (8%), paediatric ward 3 (6%)
and ENT ward 1 (2%).
In our study, all the strains were found to be resistant
to
gentamicin,
erythromycin,
trimethoprimsulphamethaxole,piperacillin/tazobactam,ceftazidime,
cefoxitin and aztreonam. 40 (80%) of the isolates
were resistant to ofloxacin while 34 (68%) to
doxycycline. Colistin and tigecycline showed 50
(100%) sensitivity towards all the strains. Graph 1
depicts the antibiogram of A.baumannii.(Fig 4)

Cefpodoxime

alone was considered as a positive result.[10] (Fig 2)
Fig 2: Disc potentiation test
Detection of AmpC beta-lactamases
The AmpC Disc Test: Cefoxitin resistant strains were
subjected to AmpC disc test for the production of
AmpC beta-lactamase production. A culture
suspension of Escherichia coli ATCC 25922 adjusted
to 0.5 McFarland’s standard was lawn cultured on
Muller-Hinton Agar plate. A cefoxitin disc (30µg)
was placed on the surface of the agar and a blank disc
moistened with sterile saline and inoculated with few
colonies of test strain was placed besides cefoxtin
disc in such a way that it was almost touching it. The
plate was incubated overnight at 37ºC. Flattening or
indentation of zone of inhibition around cefoxitin disc
in the vicinity of the disc with the test strain was
considered as positive for the AmpC beta lactamase
production. An undistorted zone was considered as
negative.

RESULTS

Ofloxacin
Imipenem
Meropenem
Gentamycin
Erythromycin
Piperacillin/tazob…
Doxycycline
Colistin
Trimethoprim-…
Tigecycline
Cefoxitin

one containing 750 µg EDTA, obtained from
Himedia, Mumbai were placed on the inoculated
plate and incubated for 24hrs at 37°C. The zones of
inhibition around the imipenem disc alone and
imipenem-EDTA disc were recorded. An increase in
the zone of inhibition of at least 7mm around the
imipenem-EDTA disc as compared to imipenem

RESISTANT

INTERMEDIATE
SENSITIVE

Fig 4: Antibiogram of A.baumannii
Of the 50 isolates, 34 (68%) isolates expressed
resistance to meropenem and only 26 (52%) to
imipenem. Of these 34 meropenem resistant strains, 9
(26.4%) were positive for Carbapenemase production
by Modified Hodge test and 16 (52.9%) were positive
for MBL production by EDTA disc potentiation test
(EDTA-DPT). Of the 50 cefoxitin resistant isolates,
28 (56%) were confirmed for AmpC beta lactamase
production by AmpC disc test. Table 1 depicts the
results for MHT, MBL and AmpC production in
A.baumannii isolates.

Fig 3: AmpC Disc test
313
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Int J Med Res Health Sci. 2015;4(2):311-316

Table 1: Modified Hodge Test, Disc Potentiation Test and AmpC Disc Test
MBL
CARBAPENEMASE
AMPC
Screen Test
(Meropenem
resistance)

Confirmatory
Test (EDTA- disk
potentiating test)

Screen Test Confirmatory
(Meropenem Test (MHT)
resistance)

Screen Test
(Cefoxitin
resistance)

Confirmatory Test
(AmpC disk test)

34 (68%)

16 (47.05%)

34 (68%)

50 (100%)

28 (56%)

9 (26.4%)

Of the 50 A.baumannii isolates, co existence of
Carbapenemase and MBL production was observed
in 8 (16%) isolates. There were 2 isolates which
expressed all three resistance mechanism whereas
only 7 isolates expressed no resistance mechanism.
Fig 5 depicts co-existence of various resistance
mechanisms in MDR A.baumannii.
60.00% 47.05%
50.00%
26%
40.00%
16% 18%
30.00%
10%
20.00%
2%
2%
10.00%
0.00%

56%
26%

RESISTANCE MECHANISMS

Fig 5: Existence of Multi Resistance Mechanisms
in MDR A.baumannii
Of the 50 isolates, 47.05% were found to be MBL
producers, out of which 16% also co-produced
carbapenemase and 18% co-produced AmpC.
However, there were 2% strains which only
expressed
MBL
production.
Carbapenemase
production was found in 26% of the total strains, of
which 10% also co-produced AmpC beta lactamase
and 2% strains were positive only for carbapenemase
production. However, 26% of the isolates were
positive for only AmpC beta lactamase production,
suggesting AmpC beta lactamase being a more
expressed resistance mechanism in our study.
DISCUSSION
A.baumannii is an effective human colonizer in the
hospital. Combination of its environmental flexibility
and presence of multiple resistance determinants
makes it a successful nosocomial pathogen. MDR
A.baumannii infections tend to occur more frequently
in immune-compromised individuals, patients on

broad spectrum antibiotics and with underlying
diseases and those subjected to invasive
procedures.[12]According to Ambler Classification,
Beta lactamases are grouped into 4 major molecular
classes; A, B, C and D. A, C and D are referred as
serine-beta-lactamases, whereas group B beta
lactamases are called MBL. Newer beta lactamases
that
hydrolyse cephamycins, cephalosporins,
monobactams and carbapenems are of increasing
concern as they limit therapeutic options leading to
treatment failures and poor prognosis. [13]
We observed that 56% of the A.baumannii isolates
were from the respiratory secretions which included
sputum samples, endotracheal secretions, bronchioalveolar lavage and endotracheal tips, 24% from pus
samples, 18% from blood and only 2% from urine. In
a study by Muthusamy et al.[11] conducted in
Coimbatore, South India isolation rate was found to
be 73% from respiratory secretions. In yet another
study by Jaggi et al. [14] in Gurgoan, Haryana, 57.4%
of the A.baumannii isolates were from respiratory
secretions, 23.8% from blood, 13.5% from pus and
2.5% from urine, an observation similar to ours,
suggesting thereby that respiratory tract would be the
most common site of isolation in our geographical
area.
It is a well documented fact that a lot of risk factors
associated with Acinetobacter infections exist in the
ICU like potential environment reservoirs,
opportunities for cross transmission, sick, immunecompromised patients who are colonized, patients
with multiple wounds and indwelling devices, heavy
use of broad spectrum antibiotics and frequent
contamination of the hands of health care workers
employed in patient care.
This fact was supported by our results, where 74% of
the A.baumannii isolates were from the ICU followed
by medicine ward (10%), 8% from surgery ward, 6%
from paediatric and 2% from ENT ward. Sinha N et
al. [15] also noted similar findings with maximum
isolation from the ICU of 22.14% followed by
314

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Int J Med Res Health Sci. 2015;4(2):311-316

paediatrics (20.71%), neurosurgery (15.71%) and
general surgery wards (12.85%).
In our study, high resistance of 68% was observed
against meropenem, which was in contrast to a study
conducted earlier by Sinha N et al.[15] where only
20% resistance was observed. Taneja et al,[16]
observed 18.5% and Dheepa M et al [11] observed
35% resistance. However, in Brazil, the resistance to
carbapenemase was found to be ranging from 71.4%
to 100% in various hospitals of that region. [17]
Thus, the aforementioned observations could only
suggest that Carbapenemase-producing Acinetobacter
spp might be on a rise worldwide which could be due
to indiscriminate carbapenemase usage and selection
pressure in hospitals.
In our study, 26.4% organisms were carbapenemase
producers as evidenced by the Modified Hodge Test.
The prevalence of carbapenemases as reported by
Noyal et al.[9] was 14.3% whereas another study by
Kumar et al.[18] documented a very high prevalence of
71%. A very low prevalence of 2.96% was also
reported by Patwardhan et al.[19]
No established phenotypic methods are available for
detection of specific serine carbapenemases.
However, for zinc based carbapenemases (MBL)
various methods like EDTA-disc potentiation test,
MBL E-test and EDTA based microbiological assay
are available.
In our study, 47.05 % of meropenem resistant strains
were confirmed to be MBL producers, whereas
Dheepa Muthusamy et al [11] detected 10% of the
strains to be MBL producers in her study conducted
in South India and John S et al [20] detected 14.8%.
Noyal MJC et al [9] did a similar study in Pondicherry,
South India and identified 6.5% MBL producers. In a
study done at AIIMS, New Delhi, 48.72% of
A.baumannii strains were ascertained to be MBLenzyme producers by the same method, thus implying
rapid spread of resistance amongst this pathogen. [21]
Although there are no CLSI guidelines for the
detection of AmpC beta lactamase production, but we
followed AmpC disk test to detect AmpC production
and observed 28 (56%) of 50 cefoxitin resistant
isolates of A.baumannii showed production of AmpC
beta-lactamase enzyme. Noyal et at [9] and Sinha et
al[22] also reported 67.4% and 42.9% respectively, in
their studies.
Although carbapenems are the drugs of choice for A.
baumannii infections, such resistance profile limits

therapeutic options to polymyxins and tigecycline,
which showed 100% sensitivity to A.baumannii in
our study. These drugs have their own grave side
effects, limiting their routine usage for patients in
hospitals.
Thus, it is recommended to perform these simple tests
like Modified Hodge Test for carbapenemase, Disc
Potentiation test for MBL and AmpC disk test for
AmpC beta lactamase production in microbiology
laboratories to determine resistance mechanisms and
prevent indiscriminate use of antibiotics.
CONCLUSION
A.baumannii is becoming a global medical challenge
due to the emergence of multi-drug resistance. Newer
beta lactamase are a matter of concern as they are
developing rapidly and lead to treatment failure.
Carbapenems are known to be effective therapeutic
agents for A.baumannii infections and its resistance
limits the use to polymyxins and tigecycline.
Disappointingly, there are limited antibiotics for the
treatment of infections caused by MDR A.baumannii
on the horizon. Several new medicines are still in
research and combination of drug therapy is being
currently used in the hospitals including ours to treat
MDR A.baumannii infections.
Thus, due to such high prevalence of resistance,
antibiotics must be used judiciously by the clinicians
and appropriate infection control measures need to be
implemented to control the spread of infections in
hospitals.
ACKNOWLEDGMENT: None
Conflict of Interest: Nil
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DOI: 10.5958/2319-5886.2015.00059.4

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
rd
Received: 23 Dec 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 27 Jan 2015
Accepted: 10th Feb 2015

PREVALENCE OF HEALTH CARE ASSOCIATED INFECTIONS IN A TERTIARY CARE HOSPITAL IN
DAKSHINA KANNADA, KARNATAKA: A HOSPITAL BASED CROSS SECTIONAL STUDY

*Animesh Gupta1, Divya C V1, Diwakar K Singh1, Krutarth B2, Maria N2, Srinivas R1
1

Postgraduate, 2Assistant Professor, Department of Community Medicine, A J Institute of Medical Sciences &
Research Centre, Mangalore, Karnataka, India
*Corresponding author email: [email protected]
ABSTRACT
Background: Health Care-Associated Infections (HCAI) affect millions of people each year and raise a great risk
for patients in health care settings, leading to high rates of morbidity and mortality. Objective: To estimate the
prevalence of HCAI and to explore the association between certain socio-demographic factors, invasive
procedures and mean duration of hospital stay with HCAI in a tertiary-care hospital. Materials and Methods:
Data was obtained from the patients who were admitted for more than 48 hours in the general wards and their
records in tertiary-care hospital for duration of 3 months (February 2014 to April 2014). Results: Among 290
patients, the prevalence of HCAI was estimated to be 11.7%. The prevalence of HCAI was proportionately less
among men (10.2%) than in women (14.2%), was more (15.6%) among patients who underwent invasive
procedures after admission and with mean duration of hospital stay of 12.47 days. Conclusion: Health CareAssociated Infections (HCAIs) were found to be significantly associated with increased duration of hospital stay
and invasive procedures done after admission. Prevalence was higher in patients aged more than 40 years.
Keywords: Health Care-Associated Infection, Prevalence
INTRODUCTION
Health Care-Associated Infections (HCAI) are the
infections acquired during hospital care which are not
present or incubating at admission. Infections
occurring more than 48 hours after admission are
usually considered hospital associated. [1]
HCAIs are an important public health problem in
developing as well as in developed countries.
Hospital-wide prevalence of HCAI in low- and
middle-income countries varied from 5.7% to 19.1%
with a pooled prevalence of 10.1% and even as high
as 15.5% in high quality studies.[2] Over 1.4 million
people worldwide suffer from HCAI at any given
time.1 The risk is 2 to 20 times higher in developing
than in developed countries.2

Animesh et al.,

Some of the factors responsible for HCAI are
prolonged and inappropriate use of invasive devices
and antibiotics, high-risk and sophisticated procedure,
immuno-suppression and other severe underlying
patient conditions, insufficient application of standard
and isolation precautions. [3]
The fight against HCAI as a public health priority
was promoted through the World Health
Organization's 'Clean Care is Safer Care' campaign.
HCAIs are multi-factorial, which are related to
healthcare systems and procedures as well as
behavioral practices. [4] At any given time, out of
every 100 hospitalized patients, 7 in developed and
10 in developing countries will acquire at least one
health care-associated infection. [2]
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The most common types of HCAIs are urinary tract
infection, surgical tract infection, lower respiratory
tract infection, blood stream infection, skin and soft
tissue infection. Gastroenteritis is the most common
HCAI in children[1].
HCAI is a great risk for patient safety and its impact
can result in prolonged hospital stay, long-term
disability, increased resistance of microorganisms,
and additional financial burden for the health system,
patients and their families, as well as excess deaths.2
It is estimated that 80% of all hospital deaths are
directly or indirectly related to HCAIs[5].
Some of the common determinants of HCAI are
inadequate environmental hygienic conditions, poor
infrastructure, insufficient equipment, understaffing,
overcrowding, inadequate infection control measures,
unsafe injection practices, absence of local and
national guidelines and policies[3]. The main modes of
transmission of HCAI are contact, droplet, air-borne,
common vehicle and vector-borne.
The risk of contracting HCAI is universal and
percolates every health-care facility and system
worldwide, but the true burden remains unknown,
particularly in developing countries [2].
HCAIs usually receive public attention only when
there is epidemic [1].
Although often hidden from public attention, no
institution or country can claim to have solved this
very real ongoing endemic problem, despite many
efforts[2].
Objectives
1. To estimate the prevalence of HCAI.
2. To estimate the association of HCAI with
certain risk factors.
MATERIALS AND METHODS
Study setting: A Hospital based cross-sectional study
was conducted in a tertiary-care hospital in Dakshina
Kannada district of Karnataka, India for duration of 3
months from February 2014 to April 2014. All inpatients admitted in the wards of Medicine, Surgery,
Orthopedics, OBG, and Pediatrics in a tertiary-care
hospital for more than 48 hours were included in the
study irrespective of their age & Sex. Patients who
were critically ill and those admitted in ICUs were
excluded from the study.

Animesh et al.,

Sample size calculation: Taking the prevalence of
26% from a study done by Saleem M et al[6] and with
20% of allowable error, the sample size was
calculated by using the formula n = 4pq/ L². The
sample size was estimated was 290.
Method of data collection
Ethics clearance from the institution was obtained. A
pretested structured proforma was used to collect the
data after obtaining written informed consent from
the patients by interview method. The proforma
included name, age, gender, IP number, name of the
ward, date of admission and discharge, diagnosis,
treatment and procedures done. History and physical
examination were conducted for each patient from the
date of admission until discharge. All the patients in
the study were visited at least once a day. Laboratory
results and medical charts were reviewed. The study
subjects were followed up from the day of admission
till the day of discharge.
Statistics: The data was entered in Microsoft excel
7.0 and analyzed in SPSS Trial Version 16.
Descriptive statistics and tests of significance like
Pearson Chi-square test were used and the statistical
significance level was fixed at p<0.05.
RESULTS
The mean age of study population was found to be
41.8 years (SD-15.4, Range- 4 to 85 years) and the
mean age of patients who developed HCAI was 42.2
years (SD-16.5, Range- 7 to 75 years).
Table 1: Prevalence of HCAI in relation to age
Age
No. of Patients HCAI
group
Examined
No. (%)
(in years)
0-15
11
1 (9.1)
16-30
69
6 (8.7)
31-45
89
14 (15.7)
46-60
90
10 (11.1)
>61
31
3 (9.7)
290
34 (11.7)
Total
Fisher’s exact test value = 1.986, p value = 0.742
(non significant)
The maximum patients were 31% in the age group
46-60 years followed by 30.7% in the age group 3145 years as shown in Table 1. The prevalence rate of
HCAI was 11.7%, of which thrombophlebitis, urinary
tract infection (UTI) and fever were found to be
5.86%, 4.14% and 1.82%, respectively. Out of the 34
318
Int J Med Res Health Sci. 2015;4(2):317-321

patients who had developed HCAI, 41.2% and 29.4%
corresponds to age groups 31-45 and 46-60 years,
respectively.
200
150

n=177
159 (89.8%)

100

n=113

N

97 (85.8%)

50
0

18(10.2%)

MALE
HAI

16 (14.2%)

FEMALE
NO INFECTION

Fig1: Prevalence of HCAI in relation to gender
(n=290)
In this study, 61.0% were males, but the prevalence
of HCAI was found to be proportionately higher in
females (14.2%) compared to males (10.2%) as
shown in Figure 1.
Table 2: Association of HCAI in relation to
multiple variables (n=290)
Health
care- Chi
P
Variables
associated infection square value
value
Present Absent
Age
< 40 14
112
0.081
0.776
(in
(11.1%) (88.9%)
years)
> 40 20
144
(12.2%) (87.8%)
Duration < 7 4
135
20.18
0.000*
of stay days (2.9%)
(97.1%)
in
>7
30
121
hospital days (19.9%) (80.1%)
Invasive Yes
21
113
145.16 0.000*
procedur
(15.7%)
(84.3%)
es
No
13
143
(8.3%)
(91.7%)
*significant
Table 2 shows the association of HCAI in relation to
age, duration of stay in hospital and invasive
procedures done. In this study, it was found that the
patients who were more than 40 years had higher
prevalence of HCAI (12.2%) compared to those less
than 40 years (11.1%), though it was not found to be
statistically significant (p>0.05). This finding was
probably due to the higher number of invasive
procedures done among those above 40 years of age
leading to longer duration of stay in the hospital. The

Animesh et al.,

patients who had undergone invasive procedures had
significantly high prevalence of HCAI with 21
(15.6%) compared to those who had not undergone
invasive procedures with 13 (8.3%). The prevalence
of HCAI was higher in patients who stayed in
hospital for more than 7 days compared to less than
or equal to 7 days, which is statistically significant.
The mean duration of hospital stay for the patients
with HCAI was found to be 12.47 days and for those
without HCAI was 7.98 days.
DISCUSSION
Majority of patients in this study were males (61.0%).
Similarly, in a study by Dileep Kumar S et al[7] and
Rahim B et al[8], showed that 53.0% and 53.6% of the
study subjects were males, respectively.
The prevalence of HCAI in this study was 11.7%.
Similar findings were observed in studies conducted
by Malhotra S et al[9] and Razine R et al[10]. The mean
age of patient was high among who developed HCAI
which was similar to the study done by Satpathy et al
[11].

Females had proportionately higher prevalence of
HCAI than males in this study, which was also found
in study done by Dileep Kumar S et al[7] and Saleem
M et al. [6] Prevalence of HAI was insignificantly
high among patients above 40 years of age which was
similar to the findings from the study done by Dileep
Kumar S et al[7].
In this study the prevalence of HCAI was
significantly higher in patients who stayed for more
than 7 days which showed, longer the duration of
hospital stay, more the chances of developing HCAI.
Similar facts were observed in multiple studies
analyzed by World Health Organization were hospital
stay more than 7 days was found to be a risk factor
for the development of an HCAI[2].
The patients who developed HCAI had presented as
thrombophlebitis (5.8%), UTI (4.1%) and fever
(1.8%). Thrombophlebitis was the commonest HCAI.
Askarian M et al12 showed the prevalence of blood
stream infection as 2.5% and UTI as 1.4%, which
concluded that blood stream infection was more
compared to other HCAIs. These findings were
similar to those in this study.
The prevalence of HCAI was significantly higher in
patients who underwent any invasive procedures like
intravenous lines, urinary catheterization and any
319
Int J Med Res Health Sci. 2015;4(2):317-321

surgical procedures. Similar trend was observed in
most of the studies analyzed by World Health
Organization[2].
CONCLUSION
The present study of Health Care-Associated
Infections (HCAIs) in the tertiary care hospital
showed a prevalence rate of 11.7%. HCAI were
found to be significantly associated with increased
duration of hospital stay and invasive procedures
done after admission. The prevalence was higher
among patients aged more than 40 years and
proportionately more among female patients. HCAI
was common in hospital patients in medical and
surgical wards.
Recommendations: In India, however, hospitals
often do not follow infection control practices, and
this leads to the spread of disease. In response to the
growing burden of HCAIs in India, the Global
Antibiotic Resistance Partnership (GARP) is issuing
several key recommendations that aim at reducing the
prevalence of HCAIs, including increased handwashing, use of isolation rooms for infected patients,
increased availability and uptake of diagnostic tests,
reminders to limit catheter use, and use of gloves and
gowns.
The Ministry of Health & Family Welfare Task Force
also recommends that all hospitals create an infection
control plan, committee and team. Surveillance of
antibiotic resistance, combined with tracking
physician prescribing patterns, can be the foundation
of successful infection control programmes in
hospitals. A large proportion of these hospital
infections are easily preventable with increased
hospital infection control, including stepping up
hygiene practices, such as frequent hand-washing.
Limitations: The study was conducted for duration
of 3 months to estimate the prevalence of HCAI,
since the number of study subjects was small, so it is
possible that the prevalence rates may not be
extremely precise.
Acknowledgement: The authors are thankful to Dr.
(Prof) Manohar Rao, Dr. (Prof) Jayaram S, Dr. (Prof.)
P V Kurulkar, Dr. (Prof.) Prasanna K S and Dr.
(Prof.) Hemant Kumar of the Community Medicine
department for their valuable guidance and support.

Animesh et al.,

Conflict of interest: The authors declare no conflict
of interest & not funded by any agency.
REFERENCES
1. Prevention of hospital-acquired infections; A
Practical Guide; 2nd edition, World Health
Organization.[Available at http://www.who.int/
csr/resources/publications/whocdscsreph200212.
pdf]
2. World Alliance For Patient Safety. Global Patient
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patientsafety/events/05/GPSC_Launch_ENGLIS
H_FINAL.pdf]
3. World Health Organization. Health careassociated infections Fact Sheet. [Available on
http://www.who.int/gpsc/country_work/gpsc_ccis
c_fact_sheet_en.pdf]
4. Gignon M, Farcy S, Schmit J L, Ganry O.
Prevention of healthcare-associated infections in
general practice: Current practice and drivers for
change in a French study. Indian J Med Microbiol
2012;30:69-75
5. Hughes AJ, Ariffin N, Huat TL, Abdul Molok H,
Hashim S etal., Prevalence of nosocomial
infection and antibiotic use at a university
medical center in Malaysia. Infect Control Hosp
Epidemiol 2005; 26:100-4
6. Saleem M, Vaish AK, Idris MZ, Sonkar AA,
Agarwal J, Singh M, etal., Pattern of Nosocomial
Infection among patients admitted in Medical and
Surgical wards of a secondary care hospital in
north India: An epidemiological evaluation.
Indian Journal of Community Medicine, 2012;
24(4): 285-90
7. Dileep Kumar Sharma, Yogendra Kumar Tiwari,
Nitya Vyas and Rakesh Kumar Maheshwaril. An
investigation of the incidence of nosocomial
infections among the patients admitted in the
intensive care unit of a tertiary care hospital in
Rajasthan, India. International Journal of Current
Microbiology and Applied Sciences, 2013; 2(10):
428-35
8. Rahim Baghaei, Peyman Mikaili,, Davood
Nourani,
Hamid
Reza
Khalkhali.
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epidemiological study of nosocomial infections in
the patients admitted in the intensive care unit of
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9.

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investigation. Annals of Biological Research,
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Malhotra S, Sharma S, Hans C. Prevalence of
Hospital Acquired Infections in a tertiary care
hospital in India. Int. J. Med. Med. Sci., 2014;
1(7): 91-94
Razine R, Azzouzi A, Barkat A, et al. Prevalence
of hospital-acquired infections in the university
medical center of Rabat, Morocco. International
Archives of Medicine 2012;5:26
Satpathy. P261: Study of hospital associated
infections (HAI) at tertiary hospital in India;
economic implication for developing countries.
Antimicrobial Resistance and Infection Control
2013, 2 (Suppl 1):P261
Askarian M. Point prevalence and risk factors of
hospital acquired infections in a cluster of
university-affiliated hospitals in Shiraz, Iran.
Journal of infection and public health, 2012;
5:169-16.

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321
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DOI: 10.5958/2319-5886.2015.00060.0

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 24 Dec 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 20 Jan 2014
Accepted: 9th Feb 2015

STUDY OF THE BASELINE WIDAL TITRES AMONG HEALTHY INDIVIDUALS OF RURAL
POPULATION IN PUDUCHERRY
*Jeyakumari D1, Jaberlin Sneha AJ2, Gopal R2
1

Department of Microbiology, Tagore Medical College & Hospital, Chennai, Tamil Nadu, India
Department of Microbiology, Sri Manakula Vinayagar Medical College & Hospital, Puducherry, India

2

*Corresponding author email: [email protected]
ABSTRACT
Background: Enteric fever is endemic in developing countries like India. Widal test in a single serum sample is
often the only test relied upon for laboratory diagnosis. The test is considered positive if the antibody titres are
higher than the cut - off value in a single test or a rising titre in paired sera. But normal baseline titres in healthy
population and cutoff values have not been established in our area. So the aim of our study was to determine the
base line titres of antibodies among apparently healthy populations and to define the significant titres of widal
test. Materials and Methods: Samples were initially screened by Widal slide agglutination test and further
confirmed by the Quantitative tube agglutination test. Results: Among the 500 samples from apparently healthy
individuals, 260 samples were positive for agglutinins. 141 were positive for ‘O’ agglutinin and 163 were positive
for ‘H’ agglutinin of Salmonella typhi. Among 141 samples, 30 showed agglutination up to 1in 20 titre, 100 up to
1in 40 and 25 (4.8%) up to 1in 80. Among 163 samples, 18 showed a titre of 1 in 20, 120 showed a titre of 1 in
40 and 21(4.2%) up to 1 in 80. Conclusion: When a single widal titre is used for the diagnosis of enteric fever in
our locality, it will be more appropriate to change the currently used cutoff levels against S.typhi to ≥ 1 in 160 for
anti-O and ‘H’ agglutinins remains the same of ≥ 1 in 160.
Keywords: Baseline titer, Widal test, Healthy population
INTRODUCTION
Enteric fever continues to be a global health problem,
especially in tropics and subtropics [1] and enteric
fever is a major endemic health problem in
developing countries like India. The global estimation
of typhoid fever was about 21.6 million in 2000 and
5412,744 illness were due to paratyphoid fever.
These fevers are considered as a major cause of
morbidity and mortality in developing countries with
more than 90% of cases found in Asia only. [2, 3]
Enteric fever is caused by Salmonella enterica
subspecies enterica serotype Typhi and Salmonella
enterica subspecies enteric serotype Paratyphi A and
Paratyphi B. In contrast to other Salmonella
serotypes, these enteric fever serotypes have no

known hosts other than humans. The mode of
transmission is by close contact with the patients or
carriers. Since the clinical presentation of enteric
fever is non-descript, laboratory tests are essential for
diagnosis. The gold standard and definitive diagnosis
is by isolation of Salmonella enterica serotype Typhi,
ParatyphiA and Paratyphi B from blood, bone
marrow, stool or urine etc. which is about 90% in the
first week of illness and decreases to about 50% by
the third week from blood sample. Culture facilities
are not available in the rural set up where Widal
agglutination test has a greater scope for diagnosis of
enteric fever in developing countries. Widal test
though in vogue for more than hundred years is still
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Int J Med Res Health Sci. 2015;4(2):322-326

plagued with controversy about its usefulness in
diagnosis of enteric fever. [4] The use of Widal test in
the diagnosis of typhoid fever during the acute phase
of the illness has largely been abandoned in
developed countries. [5] Due to practical difficulties in
the management of a patient the results of a single
test performed at the end of the first week is often the
only test relied upon for laboratory diagnosis. The
significant titres of antibodies to ‘O’ and ‘H’ antigens
varies from place to place and with time since
antibodies that react with Salmonella ‘O’ and ‘H’
antigens appear in a variety of other conditions like
malaria, dengue, other gram negative infections and
in healthy persons in endemic areas. [6, 7] In endemic
areas the use and interpretation of single Widal test
depends on result of the baseline titres among the
healthy population. It is therefore necessary to
establish the baseline titres periodically in each
region to define the significant titres of ‘O’ and ‘H’
antibodies for proper interpretation of the results.
Objectives
1. The objective of the present study is to determine
the base line titres of antibodies for each of the
‘O’ and ‘H’ antigens of Salmonella enterica
serotype Typhi, Paratyphi ‘A’ & Paratyphi‘B’
among apparently healthy blood donors and
patients attending the Microbiology laboratory
for various investigations other than for enteric
fever.
2. To define the significant titres of widal test for
diagnosis of enteric fever in a single serum
sample.
MATERIAL AND METHODS
Type of study: Cross sectional
Subjects: Total samples (n = 500) were collected in
which, Serum samples of Healthy blood donors (n =
300) who voluntarily donated blood to our hospital
blood bank during the study period.
Inclusion criteria: Donors who had no history of any
illness suggestive of enteric fever in the preceding six
months. Negative for all screening tests routinely
done in donors includes Malaria parasite antigen,
HBsAg, and antibodies to HIV 1 and 2, HCV and
Treponema pallidum. No history of typhoid
vaccination in the preceding three years was included.
Serum samples (n=200) received in the Microbiology
laboratory for various serological tests accept widal.
These samples were from the seemingly healthy

individuals who came for Medical checkup and
Antenatal visits.
Only samples of serum with negative results for the
requested serological tests were included in the study.
Patients without fever or gastroenteritis or any illness
suggestive of enteric fever in the preceding six
months and not vaccinated for typhoid in the
preceding three years were included in the study.
Exclusion criteria: Subjects who did not meet the
above criteria were excluded.
Methods: Informed consent was obtained from all
the donors and patients and approval of the
institutional ethics committee was obtained.
Questionnaires were given to evaluate the present and
past clinical conditions. About 5ml of blood was
collected in a clean dry test tube from each of the
subjects and allowed to clot. Serum was separated
and stored in the refrigerator at 2-8º C for no more
than seven days. All samples were initially screened
by rapid slide agglutination test using the standard
colored Salmonella antigen supplied by ‘SPAN
DIAGNOSTICS’, Surat, India. Samples showing
agglutination with undiluted serum were retested by
the standard tube agglutination test of Widal for
antibodies against all the four antigens of Salmonella
typhi ‘O’ and ‘H’, Salmonella paratyphi ‘AH’and
‘BH’ as per the standard procedure. Serial dilutions
of serum were done starting from 1/20 to 1/640 and
one drop of the appropriate antigen suspension was
added. Incubate ‘H’ agglutinations for 4 hours at
37ºC in a water bath and read after standing on the
bench for half an hour and ‘O’ agglutinations for 4
hours at 37ºC and read after overnight refrigeration at
4C. The highest dilution of serum showing visible
agglutination was taken as the endpoint and titre
expressed as reciprocal of the dilution.[8] For quality
control a known positive and negative control sera
was also included with each run. The results were
analyzed for age, sex and base line titre taken was the
highest titre shown by any of the study samples.
Statistical analysis by using SPSS – version 20 was
also carried out. In which one sample T-test was done
to compare the current titre value with the observed
titre values. All samples of blood donors (n=300)
were screened by Immunochromatography strip for
Malaria parasite, HBsAg, antibodies to HIV (Tri dot
ELISA), HCV (Dot ELISA), and Treponema
pallidum (RPR). Samples of donors negative for all
the above cited infections alone were included in the
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Int J Med Res Health Sci. 2015;4(2):322-326

study. In the patients group all serum samples
(n=200) other than those requested for Widal test and
which were negative for the respective tests were
included in the study.
RESULTS

41-50 years

25

5

Samples were analyzed by using SPSS. Among the
500 samples, 260 samples were positive and 240
were negative for agglutinins to Salmonella serotypes
typhi and paratyphi A & B. In these positive samples,
143 (28.7%) were positive for ‘O’ agglutinin and 157
(31.5%) were found positive for ‘H’ agglutinin of
Salmonella typhi. Only 14 (2.8%) and 11 (2.2%)
samples were positive for agglutinins to paratyphi
AH & BH respectively. Amongst 143 samples
positive for ‘O’ agglutinins, 30 (6%) showed
agglutination up to 1in 20 titre, 93 (18.7%) up to 1in
40 and 18 (3.6%) up to 1in 80 and in 157 samples
positive for ‘H’ agglutinins, 18 (3.6%) showed a titre
of 1 in 20, 120 (24.1%) showed a titre of 1 in 40 and
15 (3.0%) up to 1 in 80. Among 14 samples (2.8%)
were positive for anti ‘AH’ in the titre of 1in 20 and 7
(1.4%) were in 1 in 40 whereas among 11 samples
positive for anti ‘BH’, 8 (1.6%) were in the titre of 1
in 20 and 3 (0.6%) were in 1 in 40. (Table 2)

Among the total of 500 blood samples, 300 samples
were collected from healthy blood donors who
donated blood to our hospital blood bank and 200
samples from patients who reported to the
Microbiology laboratory for various serological tests
except for Widal. Demographic distribution of
individuals according to age group and sex is given in
the [Table 1]
Table: 1. Demographic distribution of individuals
according to age group and sex.
Total Participants
Frequency
%
500
100
Sex
Male
380
76
Female
120
24
Age
16- 20 years
55
11
groups
21- 30years
270
54
31- 40years
150
30
Table: 2. Number and percentage of samples positive for agglutinins with end titres against different
serotypes of Salmonella enterica.
Serotype

Antibody
type

No and % of
positive
samples

Dilution
(1 in 20)

Dilution
(1 in 40)

Dilution
(1 in 80)

Dilution
(1 in 160)

Dilution
(1 in 320)

S. typhi
Anti- TO
143 (28.7)
30 (6)
93 (18.7)
18 (3.6)
2 (0.4)
NIL
S. typhi
Anti-TH
157 (31.5)
18 (3.6)
120 (24.1) 15 (3.0)
3 (0.6)
1 (0.2)
S. paratyphi A
Anti-AH
14 (2.8)
7 (1.4)
6 (1.2)
NIL
NIL
NIL
S. paratyphi B
Anti-BH
11 (2.2)
7 (1.4)
4 (0.8)
NIL
NIL
NIL
The one sample T test showed that the observed value is different from the present recommended value and it is
statistically significant (P value < 0.01). (Table 3)
Table: 3. one sample T – test
Name of the
agglutinins

Salmonella ‘O’ab
Salmonella ‘H’ab
Salmonella ‘AH’ab
Salmonella ‘BH’ab

N

Mean

Std. Deviation

Sig - ( 2 tailed)
‘P’ value

500
500
500
500

11.66
12.72
.76
.60

22.300
20.722
4.926
4.252

< 0.01
< 0.01
< 0.01
< 0.01

DISCUSSION
Bacterial culture remains the gold standard for
definitive diagnosis of enteric fever but lack of the
facility and cost limits its use in the developing
countries. [2] The widal test which detects
agglutinating antibodies to Salmonella enterica

subspecies enteric serotype Typhi ‘O’ and ‘H’
antigens and ‘H’ antigens of Salmonella enterica
subspecies enteric serotype Paratyphi A and B is
widely used in the developing countries due to the
ease of performing the test, low cost and relatively
rapid results. Widal test is also useful for diagnosis of
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Int J Med Res Health Sci. 2015;4(2):322-326

patients already on antibiotics which may inhibit the
growth in culture.
The present study showed that frequency of
agglutinins to Salmonella typhi ‘O’ and ‘H’ is more
than that of Salmonella paratyphi AH and BH. This
indicates that exposure to Salmonella paratyphi A &
B is less than Salmonella typhi among the population
in Puducherry which is similar to that of other regions
in our country. [9, 10]
In the present study the highest dilution of
agglutination against ‘O’ antigen of S. typhi was
1:160 in two out of 500 samples (0.4%) tested ie) less
than 1% while it was 3.6% at a titre of 1 in 80 which
hitherto has been assumed as the significant titre for
‘O’ in this region. The highest titre for Salmonella
typhi ‘H’ was 1in 320 in 1 out of 500 (0.2%) of the
study population and 3 out of 500 (0.6%) showed a
titre of 1in 160 which is the presumed significant titre
in this region. The study shows that a titre of ≥ 1 in
160 for ‘O’ and ‘H’antibodies of Salmonella typhi
holds good as the percentage of positivity of these
titres is significantly less (<1%) among the
population screened. Nevertheless the majority of the
screened population were having a titre of 1 in 40 (18
– 24%) for both ‘O’ and ‘H’ antibodies of Salmonella
typhi, the titre ≥ 1 in 80 should also be considered as
a significant titre with clinical correlations. Also the
highest dilution against ‘AH’ antigen was 1in 40 in 6
out of 500 samples (1.2%) and 1in 20 in 7 out of 500
samples (1.4%) against BH antigen.
Recent study done by Aruni et al and Sreenath etal
[11,12 ]
showed the significant titres should be greater
than 1: 80 for anti – O and greater 1: 160 for anti – H
for a presumptive diagnosis of typhoid fever. In the
study done by Senewiratne B etal [13] a titre of ≥ 1 in
160 against ‘H’ and ‘O’ antigens of Salmonella typhi
was seen in only 1% of patient with non typhoidal
fever. In the study by ‘ Frimporg and others at Ghana
[14]
the anti ‘O’ titre was ≥ 1 in 160 in 1% of the 307
healthy food handlers while anti ‘H’ titre of ≥ 1 in
320 for S. typhi was 2.6%. In a study at Jordan by
Shehabi AA,[15] during an outbreak of typhoid fever,
92% of patients with positive blood culture developed
agglutinins against TO and TH in titres of 1 in 80 or
more indicating the utility of a single widal test in the
acute stage of the disease.
In the study by Zailani SB etal, [16] the base line titre
for Salmonella typhi and paratyphi for both ‘O’ and
‘H’ antibodies was 1 in 80 among the healthy

individuals of the community at Ile - Ife, Nigeria. In
the study by
El-Shafie S [17] 10.5% of healthy
individuals in Sudan showed a titre of 1 in 320
against S. typhi ‘O’ and 4.3% and 5.3% showed a
titre of 1in 160 for S.paratyphi ‘A’ and ‘B’
respectively. In the study by Ibadin MO [18] at Benin
City, Nigeria 1.1% of the healthy school children
tested showed a titre of 1 in 160 for either antigens of
S.typhi.
Studies conducted in various regions of the world at
different periods of time and even within the same
region showed a variable baseline titre. It is therefore
imperative to estimate the baseline titres among the
healthy population in every region at regular intervals
and interpretation of single Widal test result must
take into account of the baseline titres in their
respective areas. In the present study the baseline
titres in the majority was less than 1 in 160 for
Salmonella typhi‘O’ (99.6%) and ‘H’ (99.4%)
antibodies. The significant titre for ‘O’ and ‘H’
antigens of S.typhi could therefore be assumed to be
≥ 1 in 160 in this part of the country. None of them
had the baseline titre of ≥ 1in 80 (100%) for S.
paratyphi ‘AH’ and paratyphi ‘BH’. The baseline titre
for anti ‘AH’ was found to be 1 in 40 (1.4%) and for
anti ‘BH’ was 1in 20(1.6%). Hence the significant
titre could be presumed to be ≥ 1in 80 for ‘AH’ and ≥
1in 40 for ‘BH’ antibodies of our region.
CONCLUSION
More than fifty percent of healthy participants (52%)
were positive to agglutinins for serotypes of
Salmonella. This indicates that enteric fever is
strongly endemic in our region which would be the
sanitation index of a country. Our study disclosed
that periodic evaluation of baseline titres of
Salmonella serotypes agglutinins, particularly in
endemic areas is necessary to avoid false positive
results. Based on the results of our study it is
recommended to change the currently used cut - off
value, that is ≥ 1 in 80 for ‘O’ agglutinins of
Salmonella typhi to ≥ 1 in 160. The significant titre
for ‘H’ agglutinins of Salmonella typhi remains the
same, which is ≥ 1 in 160. The significant titre for
‘AH’ of Salmonella paratyphi A is considered to be
of ≥ 1in 80 and for Paratyphi B is ≥ 1in 40. The
baseline titre for ‘TO’ is same in most of the regions
while the titres against ‘TH’ is variable in the
different studies.
325

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Int J Med Res Health Sci. 2015;4(2):322-326

ACKNOWLEDGEMENT
We would like to acknowledge and thank the Indian
council of Medical Research for sanctioning this
project (ICMR – STS project – 2012) to MS. Jaberlin
Sneha JA.

10.

11.

Conflict of Interest: Nil
REFERENCES
1. Abdul Razak SH, Abbas Abood AD, Adawia
Fadil A. The distribution of anti – salmonella
antibodies in the sera of healthy blood donors in
baquba city. irqui j comm. med 2011; 24: 241-44.
2. Deepak P, Komal Raj R, Bimala S, Suresh Raj K,
Bishnu Raj T. baseline titre and diagnostic cut off
value for widal test: A comparative study in
healthy blood donors and clinically suspected of
enteric fever. JHAS 2012; 2:22-26.
3. Crump JA, Luby Sp, Minz ED. The global
burden of typhoid fever. Bulletin world health
organization 2004; 82:346-53.
4. Lateef AO, Aprileona LK. Widal agglutination
test-100 years later: Still plagued by controversy.
Postgrad Med J 2000; 76: 80-84.
5. Cammie F, Lesser SI Miller. Salmonellosis. In:
Dennis LK, Eugene B, Anthony SF, Stephen LH,
Dan LL etal., eds, Harrison’s Principles of
Internal Medicine. 16th edn. Newyork: McGraw –
Hill, Medical Publishing division, 2006; 897-02.
6. Bharat M P, Rajendra K, Shyam KM, Janak K.
Distribution of antibody titer against Salmonella
enterica among healthy individuals in Nepal.
Annals of Clinical Microbiology and Antimicrobials 2009; 8: 1-7.
7. Collee JG, Fraser AG, Marmion BP, Simmons A.
Mackie and Mc Cartney Practical Medical
Microboiology. 1996; 14th ed, New York,
Churchill Livingston; 38.
8. Kok TW, Worswick D, Gowans E. Some
serological techniques for microbial and viral
infections: In: Collee JG, Fraser AG, Marmion
BP, Simmons A, eds, Mackie & McCartney
Practical Medical Microbiology. 14th edn. Delhi:
Elsevier, a division of Reed Elsevier India Pvt
Ltd, 2007. 179-83.
9. Punia JN, Joshi RM, Gupta V, Arora RK.
Determination of Baseline widal titres from

12.

13.

14.

15.

16.

17.

18.

Chandigarh. Indian J Med Microbiol 2003;
21:144.
Patil AM, Kulkarni ML, Kulkarni AM. Baseline
Widal titres in healthy children. Indian J
Paediatrics 2007; 74: 1081-83.
Aruni I.S, Prabakaran P, Kumaran J. Study of
baseline widal titre against Salmonella species
amongst healthy individuals in Thiruvananthapuram district of Kerala, South India. The
Experiment 2014; 20:1380-83.
Sreenath K, Sujeesh S, Deepa R. Detection of
baseline widal titres among the blood donors: A
population based study. Int. J. Curr. Microbiol.
App.Sci 2014; 3:428-31.
Senewiratne B, Senewirante K. Reassessment of
the Widal test in the diagnosis of typhoid.
Gastroenterology 1977; 73: 233- 36.
Frimpong EH, Feglo P, Essel - Ahum M, Addy
PA. Determination of diagnostic Widal titres in
Kumasi, Ghana. West Afr J Med 2000; 19:34-38.
Shehabi AA. The value of a single Widal test in
the diagnosis of acute typhoid fever. Trop Geogr
Med 1981; 33: 113- 16.
Zailani SB, Oylelese AO, Aboderin AO.
Determination of baseline antibody titre to S.
typhi/ paratyphi in Ile- Ife, Nigeria. Afr J Med
Med Sci 2003; 32: 307-10.
El- Shafie S. The Widal test in a normal healthy
population in the Sudan. East Afr Med J 1991;
68:266- 69.
Ibadin MO, Ogbimi AO. Anti- typhoid
agglutinins in school aged African children. East
Afr Med J 2002; 79: 92-95.

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DOI: 10.5958/2319-5886.2015.00061.2

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2 Coden: IJMRHS
Copyright @2015
th
th
Received: 9 Jan 2015
Revised: 6 Feb 2015
Research article

ISSN: 2319-5886
Accepted: 12th Feb 2015

COMPARISON OF POTENCY OF ANTIFUNGAL ACTION OF DANDRUFF SHAMPOOS AND
DIFFERENT PLANT EXTRACTS
*Naga Padma P, Anuradha K, Divya K
Dept of Microbiology, BVB, Bhavan’s Vivekananda College, Secunderabad, Telangana, India
*Corresponding author: Naga Padma; Email: [email protected]
ABSTRACT
Context: Dandruff a very common scalp disorder with high prevalence in population is caused by numerous host
factors in conjunction with Malassezia furfur. Most of the commercially available anti-dandruff hair shampoos
contain some form of antifungal agent(s) that appear to reduce the incidence of the disease. There are no good
scientific studies done to prove the antifungal activity of commercially available hair shampoos. Aim: In this
study commercially available shampoos were assessed for antifungal activity against a human dandruff isolate of
M. furfur. The shampoos were Head & Shoulders, Clinic All Clear, and Pantene etc. The results demonstrated that
all six of the assayed hair shampoos have some antifungal effect on growth of M. furfur. These products have
poor efficacies, more side effects and give scope for recurrence of symptoms. Methods and Materials: Therefore
different plant extracts that possess various active compounds which have antifungal activity could help to
overcome the incidence of the disease and also avoid the emergence of resistance in the pathogen. The plant
extracts were tested in different concentrations like 1:5, 1:10, 1:20 and they were hibiscus, neem, soap nut, etc.
The inhibitory action was studied using agar well assay and disc diffusion method and the results indicated in
percentage of inhibition. Conclusion: The study was significant as not only efficient known plant products with
anti-dandruff activity could be compared with commercially available shampoos but also their better efficacies at
minimum concentrations could be identified. This can help make a polyherbal mixture that could be incorporated
in hair oil or shampoos for better anti-dandruff activity.
Keywords: Malassezia furfur, Dandruff, plant extracts, anti-dandruff hair shampoos
INTRODUCTION
Malassezia species formerly known as Pityrosporum
is a lipophilic, dimorphic opportunistic yeast causing
skin and hair infections like Pityriasis versicolar,
seborrheic dermatitis and dandruff, etc[1][2] . Dandruff
medically described as Pityriasis capitis is caused by
Malassezia species like M.furfur, M.globosa,
M.restricta [3]. It is a common scalp disorder and also
a major cosmetic problem as it causes hair fall [4]. It
has been investigated and reported that there was no
complete cure for this disease. This disease is of
global prevalence and needs effective therapeutic

remedy. There are natural effective remedies to
control dandruff in Ayurveda [5] but presently people
are depending on commercial shampoos containing
some antifungal compounds like miconazole,
ketoconazole, selenium sulphide etc. Plant products
contain various compounds like alkaloids, flavanoids,
tannins, terpenoids etc which have efficient
antifungal activity [6] [7]. These compounds can be
used in combination as polyherbal mixtures for
controlling dandruff. The present work was a
comparative study of the effect of commercial anti
327

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Int J Med Res Health Sci. 2015;4(2):327-331

dandruff shampoos and natural plant products to
evaluate their anti fungal efficacy. There are no
reports of such comparative study and this study
gives significant information about the higher
antifungal efficiency of natural products at low
concentration which can be exploited for commercial
poly herbal preparations.
Aim: The present study was undertaken to find the
comparison of efficacy of different types of plant
extracts verses chemical shampoos.

by using gelatin hydrolysis test, litmus milk reaction,
fermentation of carbohydrates like dextrose, xylose,
rhamnose, raffinose and mannitol and the results were
recorded [11].
Inoculum preparation:
The inoculum of
Malassezia furfur was prepared by inoculating in 5ml
of Sabouraud’s broth and incubated at 300C such that
there are 106 cell/ ml[12].
Dilution of shampoos: The commercially available
shampoos as mentioned in (Table 1) along with their
active ingredient were diluted with sterile distilled
MATERIALS AND METHODS
water to get 10 fold, 20 fold dilution. These were
used for antifungal assays.
Isolation of culture: In the clinical study the
Table 1: Active ingredients in different
organism was isolated from scalp of person suffering
commercially available shampoos
from Dandruff and maintained on Sabouraud’s
[8]
Active antidandruff
Shampoos
media (which is a defined selective media for
ingredients
medically significant fungi and inhibits growth of
Zinc Pyrithione
Head and shoulders,
normal flora) slants and stored in refrigerator at 40C
Pantene, Garnier, Loreal
for one month.
Selinium
sulphide
Head and Shoulders,
Growth and Identification: The isolate was
Nuetrogena
screened by plating the scalp swab on Sabouraud’s
Ketoconazole
Nizoral , Vivel Ultra Pro
media enriched with 2 % lipid source like olive oil.
Preparation of plant extracts: The different plant
The organism was identified based on cultural,
sources tested are mentioned in (Table 2) along with
microscopic and biochemical methods.
their generic names, appropriate plant part used and
Cultural: Growth pattern and colony morphology
[7]
was observed on Sabouraud’s media enriched with a
dosage . The plant part was collected from the plant
[9]
source washed thoroughly, cut into smaller pieces and
lipid source like olive oil/ butter .
ground into fine paste. The fine paste was made into a
Microscopic: Gram stained smear of the culture was
[10]
solution with sterile distilled water, centrifuged at
observed under microscope for cell morphology ..
5000 rpm and the supernatant was used as sample for
Biochemical: The organism was biochemically tested
anti fungal assays.
Table 2: Different plant extracts used and their common names[7]
Scientific name

Plant part used for extraction
of active compound

Part used

Extracted
i.e. Alcohol/ aqua

Dose
used
for
antifungal activity

Azadirachta indica
Piper betle
Ocimum tenuiflorum
Murraya koenigii
Hibiscus rosasinensis
Aloe vera
Coriandrum sativum
Mentha asiatica
Phyllanthus emblica
Citrus limon
Sapindus mukorossi
Alpinia galangal
Lawsonia inermis
Hibiscus rosasinensis

Neem
Betel leaf
Tulsi
Curry leaf
Hibiscus flowers
Aloevera
Coriander
Mint
Amla
Lemon
Soapnut
Dumparashtram
Henna
Hibiscus leaves

Leaf
Leaf
Leaf
Leaf
Flower
Leaf
Leaf
Leaf
Fruit
Fruit
Fruit
Root
Leaf
Leaf

Water
Water
Water
Water
Water
Water
Water
Water
Water
Water
Water
Water
Water
Water

1:10
1:5
1:5
1:5
1:5
1:20
1:5
1:5
1:20
1:20
1:20
1:5
1:10
1:5
328

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Int J Med Res Health Sci. 2015;4(2):327-331

zone of inhibition. The highest was for Vivel
followed by Head and Shoulders and Dove (Fig3).

Zone of Inhibition Using Different
Shampoos

Fig 1: Microscopic observation of Malssezia furfur
Effect of lipid source on the growth of M. furfur:
Among the fatty substances tested, M. furfur grew
well in Sabouraud's dextrose broth and agar medium
containing olive oil followed by butter, coconut oil
etc (Fig 2 A and B) .

Fig 2 A and B: Growth of Malassezia furfur on
Olive oil (A) and butter (B)
Antifungal Assay: Among the Antidandruff
shampoos tested every shampoo showed a very good

10

Dove

Zone of
inhibition (1:40)

Nizoral

0

Vivel

Zone of
inhibition (1:20)
Pantene

5

Head…

Malassezia furfur grew as white to tan cream colored
colony
with smooth pasty consistency on
Sabouraud’s media and the cells appeared bottling
shaped when observed microscopically (Fig 1). The
Biochemical studies indicated that fermentation of
dextrose and xylose produced acid but no gas.
Maltose, lactose, rhamnose, raffinose and mannitol
were not fermented by M. furfur. Liquefaction of
gelatin was observed and there was acidification of
litmus milk.

Inhibition zones in cm

RESULTS

Clear

Antifungal Assays: The antifungal activity of
antifungal shampoos and plant extracts was tested by
[13]
disc diffusion method and agar well assay .

Shampoo

Fig 3: Anti fungal activity of different shampoos,
represented by zone of inhibition (in cm)
The zones of inhibition of different plant extracts
indicated significant antifungal activity on
Malassezia furfur (Fig 4).

Fig 4: Plates showing zone of inhibition for
different plant extracts

Fig 5: Anti fungal activity of different plant
extracts, represented by zone of inhibition (in cm)
on Malassezia furfur
329

Naga Padma et al.,

Int J Med Res Health Sci. 2015;4(2):327-331

Among the plant extracts tested Lemon showed the
highest zone followed by Soap nut, Henna, Aloevera
and Neem (Fig 5). Comparatively the plant extracts
shampoos showed a high zone of inhibition than the
shampoos. The inhibition zones of antidandruff
shampoos at low concentrations almost matched with
those of plant extracts.
DISCUSSION
Dandruff is a common disease caused by Malassezia
species especially Malassezia furfur. The lipolytic
activity of these organisms induces hydrolysis of
human sebum tri-glycerides in to free fatty acids that
cause both hair loss and scalp [14]. Medically
significant fungi are known to grow on Sabouraud’s
agar medium. The present isolate being lipolytic grew
well on olive oil and Butter enriched medium this is
in accordance with other reports on growth of
Malassezia [15].
All the antidandruff shampoos had good antifungal
activity but there is considerable variation in the
potency of their antifungal activity depending on the
active compound and its concentration. In the present
study the best antidandruff shampoo was Vivel Ultra
Pro as it contains Ketokanozole which is reported to
be anti-malassezial agent [16]. This was followed by
Dove and Head and Shoulders as they contain
antifungal compounds like Zinc Pyrithione. Most of
the plant extracts were showing good antifungal
activity almost equivalent to that of commercially
available shampoos. Lemon, Henna, Soap nut, Amla
had more antifungal activity and this could be
because of their active compounds like Citric acid in
Lemon and Amla and Saponins in Soap nut [17]. As
there are no reports of such comparative aspect the
present study gives significant information about the
higher antifungal activity of natural products at low
concentration which can be exploited for commercial
poly herbal preparations. Use of natural plant
products is not only cost effective but also negligible
side effects. [18] [19].
CONCLUSION
The present study was significant as not only efficient
known plant products with anti-dandruff activity
could be compared with commercially available
shampoos but also their better efficacies at minimum

concentrations could be identified. Further this
research work can help make a polyherbal mixture
that could be incorporated in hair oil or shampoos for
better anti-dandruff activity.
ACKNOWLEDGMENTS
The authors (P. Naga Padma , K.Divya and
K.Anuradha) are grateful to the management of BVB
Bhavan’s Vivekananda College for encouraging to
carry out this work.
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2. Vijayakumar R, Muthukumar C, Kumar T,
Saravanamuthu
R.
Characterization
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Malassezia Furfur and its control by using plant
extracts. Indian J Dermatol. 2006; 51:145-8.
3. Shuster S. The aetiology of dandruff and the
mode of action of therapeutic agents. Br J
Dermatol. 1984; 111: 235-42
4. Ravichandran G, Shivaram,Kolhapur SA.
Evaluation of the clinical efficacy and safety of
“Antidandruff Shampoo” in treatment of
Dandruff. The Antiseptic.2004; 201(1): 5-8
5. Sonica Krishnan. Effective home remedies for
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http://completewellbeing.com/article/naturecures/andhttp://www.herboveda.co.in/2011/7/14/
ayurveda-cure-for-fungal- infections-combat-thefungus-naturally/. 2011.
6. Agrawal DP. Medicinal properties of Neem: New
Findings, Available from: http://www.infinity
foundation.com/mandala/t_es/t_es_agraw_neem.
htm. 2001.
7. Saneesh Kumar. Analysis on the Natural
Remedies to Cure Dandruff/Skin Disease-causing
Fungus - Malassezia furfur. Adv Bio Tech.
2013;12 (07) : 01-05
8. Sabouraud R. Contribution a l'etude de la
trichophytie
humaine.
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clinique,
microscopique et bacterioloqique sur la pluralite
des trichophytons de l'homme (French). Ann.
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9. Kaw Bing Chau, I-Ly Chau, I-Ee Chau, Kwai
Hoe Chong and Kerk Hsiang Chau. A modified
mycological medium for isolation and culture of
Malassezia furfur. Malaysian J Pathol 2005.
27(2) : 99 – 105.
10. Kindo A.J, Sophia S.K.C, Kalyani J and Anandan
S. A identification of Malassezia species. Ind J.
Medical Microbiol. 2004;22(3):179-181.
11. Nakabayashi A, Sei Y, and Guillot J.
Identification of Malassezia species isolated from
patients with seborrhoeic dermatitis, atopic
dermatitis, pityriasis versicolor and normal
subjects. Med. Mycol. 2000; 38: 337-41
12. Nakamura Y, Kano R, Murai T, Watanabe S, and
Hasegawa A.
Susceptibility
Testing
of Malassezia Species Using the Urea Broth
Microdilution Method. Antimicrob. Agents
Chemother. 2000; 44 (8):2185-86
13. Finn RK. Theory of agar diffusion methods

19. Krishnamoorthy J, Ranganathan S. Gokul
Shankar S and Ranjith M.S. Dano: –A herbal
solution for dandruff. Afr J Biotechnol.
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for bioassay. Anal Chem1959: 31: 975-7
14. Yvonne M, De Angelis, Christina M. Gemmer,
Joseph R. Kaczvinsky, Dianna C. Kenneally,
James R. etal.,
Three Etiologic Facets of
Dandruff and Seborrheic Dermatitis: Malassezia
Fungi, Sebaceous Lipids, and Individual
Sensitivity. J Investig Dermatol Symp Proc.
2005; 10: 295 –297.
15. Vijayakumar R, Muthukumar V, Kumar T, and
Saravanamuthu
R.
Characterization
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Extracts. Indian J Dermatol. 2006:51(2):145-8.
16. Nikam SR, Khanvilkar VV, Jagdale DM, Jadhav
AP, More SH and Kadam VJ. Evaluation of
antibacterial and antifungal activities of marketed
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17. Prabha Manju M, Gokul Shankar S, Navin
Kumar Sharma, Babu K and Chiranjeevi A.
Antifungal activity of selected plant extracts
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18. Krishnamoorthy J, Ranganathan S. Anti –
Pityrosporum ovale activity of a herbal drug
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DOI: 10.5958/2319-5886.2015.00062.4

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 25 Dec 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 27 Jan 2015
Accepted: 22nd Feb 2015

ASSESSMENT OF AWARENESS AND BELIEFS REGARDING INTRA UTERINE DEVICE
AMONGST ITS FORMER USERS ATTENDING TERTIARY CARE CENTRE IN GUJARAT
*Jogiya Priyanka D1, Lodhiya Kaushik K2, Chavada Paras3
Department of Obstetrics & Gynaecology, Pandit Deendayal Upadhyay Govt. Medical College, Rajkot, Gujarat
*Corresponding author email: [email protected]
ABSTRACT
Background: Only 1.8% of married women of reproductive age in India use IUDs despite its advantages over
Hormonal pills or permanent methods. The present study was done to study the awareness of the mothers about
IUD which affects its utilisation. Method: This was a descriptive cross sectional analytical study was carried out
at obstetrics and gynecology department of PDU Government medical college and civil hospital, Rajkot, Gujarat,
from January 2014 to June 2014. Post natal mothers who had delivered in the hospital, who had previously used
intrauterine contraceptive device (IUCD) for a period of more than one month & who agreed to be a part of the
study were included in the study. Results: A total of 110 women who agreed to be a part of the study, were
interviewed. The mean age of study participants was 29.2±3.3 years & over half of them resided in urban areas
(56.36%) & were housewives (74.54%). Over 90% of the participants were aware of barrier or hormonal methods
of contraception & 25 to 50 % of them had also used them in the past. Mean duration of IUD use amongst the
study participants was 36.9 ± 18.9 months. While over three fourth of the participants reported to have been
provided some sort of counselling before IUD insertion only 64% of them agreed that their pelvic examination
was done simultaneously. Awareness about IUD was significantly higher among graduate & working women
while there was no significant association of knowledge with other independent variables. Conclusion: There was
lack of knowledge amongst participants regarding IUDs as well as many myths which needs to be addressed in
order to improve its utilisation by the community.
Key words: Adverse events, Attitude, Awareness, Beliefs, Intra Uterine device, Knowledge
INTRODUCTION
According to the Population Reference Bureau1,
about 17% (100 million) of all married women in less
developed countries (LDCS) would prefer to avoid a
pregnancy but are not using a contraceptive method.
In Africa, 22 countries have levels of unmet need of
20 percent or higher, and in Latin America and Asia,
most countries have levels of unmet need of 10
percent of women or higher.[1]
Worldwide, 61% of women aged 15–49 years who
were married or in a consensual union (635 million
women) used some form of contraception in 2003. In
Priyanka et al.,

developed countries, women relied mostly on oral
contraceptives (16%), female or male sterilization
(15%) and condoms (13%); only 9% of women used
long-acting reversible contraceptive (LARC)
methods. The respective percentages in developing
countries were 6, 25, 3 and 18% (United Nations,
2003).[2]
India’s population, which crossed one billion in 2000,
is projected to reach 1.53 billion by 2050, making it
the most populous country in the world. Women of
reproductive age group (15-49 years) make up
332
Int J Med Res Health Sci. 2015;4(2):332-338

approximately 248 million. As per NFHS –3, the
contraceptive prevalence rate in India is 56.3 %,
which varies widely among different states and the
unmet need for family planning is high at 13% (6%
for spacing).[3]
Although oral contraceptives can be very effective in
preventing unintended pregnancies, they have been
associated with poor compliance which often results
in contraceptive failure.
In contrast, female
sterilization does not depend on users’ adherence, is
highly effective, but it has a permanent contraceptive
effect. Notably, LARC methods combine reversibility
with particularly high effectiveness, which does not
rely (or relies at a small degree only) on users’
compliance or correct use.[2, 4-7]
Intrauterine contraception is the most widely used
amongst the long-acting reversible contraceptives
(LARC) in the world today, especially in developing
countries. The majority of devices used are copper
intrauterine devices (Cu-IUDs) with 1 150 million
women users.[8]
The evolution of the intrauterine device (IUD) has led
to a safe and effective contraceptive choice for many
women. The efficacy in pregnancy prevention far
surpasses other daily and scheduled methods such as
pills, patches, and contraceptive rings.[9,10]
Satisfaction rates rank high among IUD users in the
United States (US) compared to other methods, and
complication rates have been shown to be low.[11]
Since the mechanism of action of IUDs is localized to
the uterus and cervix, with little if any systemic
effect,[12] they are an optimal method for women with
multiple medications or medical co-morbidities. In
addition to its high efficacy over other contraceptives,
additional advantage of its use in women with
contraindications to other systemic contraceptives[13]
makes IUDs a standout among contraceptive choices.
IUCD services are offered free of cost by the
government in India. Yet despite this favourable
profile, only 1.8% of married women of reproductive
age in India use IUDs.[3] So the present study was
carried out with the objective to assess the knowledge
& beliefs of post – natal mothers about IUD & their
attitude towards the use of the same.
MATERIAL AND METHODS
Type of study: This was a descriptive cross sectional
analytical
Priyanka et al.,

Place of research: Study was carried out at obstetrics
and gynecology department of PDU Government
medical college and civil hospital, Rajkot, Gujarat.
Inclusion criteria: Post natal mothers who had
delivered in the hospital, who had previously used
intrauterine contraceptive device (IUCD) for a period
of more than one month & who agreed to be a part of
the study were included in the study. The present
study was conducted over a period of 6 months from
January 2014 to June 2014.
Sampling Method: The subjects were selected by
convenient sampling method based on availability of
mothers (N=110). The consent of all the subjects was
taken prior to the study. Permission from the ethical
committee of the institution was sought before the
starting of the study.
Method: Data on socio-demographic profile,
awareness & use of different contraceptives, their
preference for IUCD, their attitude & beliefs
regarding IUCD was collected using a pretested,
semi-structured questionnaire. Independent variables
were Age, education, occupation & obstetric profile
of the woman. Dependent variables were awareness
& beliefs of women regarding IUCD use.
For each of the ten knowledge based questions about
IUD asked to participants, each correct response was
given a score of one. Their performance was
classified as Good, average or poor if their score was
8-10, 5-7 & 0-4 respectively.
Statistics: Data entry and analysis was done using
MS-Excel 2007. Chi-square test was used to find the
association
between
knowledge
scores
&
demographic variables for an alpha error of 5%.
RESULTS
Depending on the inclusion criteria & consent given
by mothers, interview of a total of 110 post-natal
mothers was taken. The mean age of study
participants was 29.2±3.3 years & over half of them
resided in urban areas (56.36%) & belonged to joint
families (54.64%). Majority of the participants
belonged to Hindu religion (76.36%) & were
housewives by occupation (74.54%). Although none
of the participants were illiterate only 20% of the
participants had graduated. The mean parity of the
participants was 2.4±0.6.
Over 90% of the participants were aware of barrier or
hormonal methods of contraception & 25 to 50 % of
333
Int J Med Res Health Sci. 2015;4(2):332-338

them had also used them in the past. Mean duration
of IUD use amongst the study participants was
36.9±18.9 months. While over three fourth of the
participants reported to have been provided some sort
of counselling before IUD insertion only 64% of
them agreed that their pelvic examination was done
simultaneously. This highlights the laps in duty on
the part of service providers & could lead to flare up
of cervical infection have it been present at the time
of insertion of IUD. (Table 1)
The proportion of mothers giving correct responses to
each of the ten knowledge based questions about IUD
is shown in table 2. Majority (93.6) of the participants
were aware of at least other methods of
contraception. Over three fourth of them knew the
type of IUD used & its duration of effectiveness.
Around one third of the mothers were aware of at
least two of the adverse events as well as changes in
menstrual bleeding pattern following its insertion.
Nearly half of the participants did not know the
importance of regularly feeling the thread of IUD or
its follow up criteria following IUD insertion. Very
few of the mothers knew of newer IUDs available or
that IUD can also be used in a nulligravida. These
findings highlight serious gaps in the knowledge of
the participants about IUDs. (Table 2)
In the present study, the major reasons for preference
of IUD over other methods as per the participants
were minimum user interference (46%) & its long
lasting contraceptive efficacy (40%). Other reasons
were its ability to be discontinued at any time when
needed, less cost, easily controlled by women, no
consuming drugs & fewer side effects. (Table 3)
The main side effect reported by participants was
abdominal pain/cramps after insertion in around 40%
cases. The other were Leucorrhea (25%),
Dysmenorrhea (21%), changes in bleeding pattern
during menstruation (14%), expulsion of IUD (8%),
infection (3%). About 17% of the participants
reported no occurrence of any adverse events. (Table
4) The mothers who were interviewed also had many
myths & beliefs about IUD as can be seen in table 5.
Participants above thirty years of age had higher
levels of knowledge than those under thirty. However
this difference was not statistically significant.
Residents from urban areas had significantly higher
knowledge scores than their counterparts in rural
areas. Participants belonging to Hindu religion had