Full Volume 1 Issue 1 - 30.09.2021

International Journal of Medical Sciences and
Nursing Research
(Open Accessed, Quarterly, Peer Reviewed and Interdisciplinary International Journal)
Editor-In-Chief
Mrs. Jayanthi Sureshbabu,
Formerly Lecturer in Medical Entomology,
Department of Community Medicine,
Pondicherry Institute of Medical Sciences, Kalapet, Pondicherry, India.
Email ID: editor-in-chief@ijmsnr.com
Deputy Editor-In-Chief/Guest Editor
Dr. C. K. Priyanka Raj,
Associate Professor, Department of Epidemiology and Public Health,
College of Medicine and Health Sciences,
Sohar, National University of Science and Technology,
Sultanate of Oman.
Email ID: deputyeditor-in-chief@ijmsnr.com
Associate Editor
Mrs. Sumathi Senthilvel,
Formerly Assistant Professor of Nursing,
Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala, India.
Email ID: associateeditor@ijmsnr.com
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Dr. Rami Bustami, Saudi Arabia Prof. A. Vijaya Anand, India
Dr. Heather Cook, United States Prof. Govindarajan Kandasamy, India.
Dr. Nagarajkumar Yenughadati, Saudi Arabia Prof. Murugan Natesan, India
Dr. Chandra Kala Sankarapandian, Saudi Arabia Dr. V. Ramasubramanian, India
Dr. Kavitha Sudersannadas, Saudi Arabia Dr. Bal Raj, India
Dr. Sanjeev Khanagar, Saudi Arabia Dr. Suchanda Sahu, India
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Dr. Vishnu Vardhan Rudravaram, India
Dr. B. Padmanabhan, India
Dr. M. Muthtamilselvan, India
Dr. Jamal Akhter Siddique, India
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Fairer world for a healthier and safer world
Introduction settlements or slums are facing increased challenges in preventing

infection and transmission of the coronavirus [4]
The World Health Organization (WHO) marked the celebration of
world health day on the 7th of April this year with the theme, Dangers ahead
“building a fairer, healthier world for everyone”. [1] The theme
1Senior Resident, Department of Anesthesiology, ChettinadGiven the level of world globalization, this pandemic will India.
continue
brings to the forefront some very pertinent issues especially in regard Hospital And Research Institute, Chennai, Tamilnadu,
to remain
2Assistant Professor, Department of Anesthesiology, Chettinad a major threat to not just poorer countries but also
Hospital And Research Institute, Chennai, Tamilnadu, India. the high-
to the current covid 19 pandemic situation the world is struggling
3Professor and HOD, Department of Anesthesiology, Chettinadincome
Hospitalcountries
And andInstitute,
Research the Chennai,
developedTamilnadu,
world, India.
not just
with. The current Covid 19 pandemic has magnified the stark
epidemiologically but also economically and socio-politically. On
inequalities in our world. Some people are able to live healthier lives
one hand globalization has led to the rapid spread of this pandemic
and have better access to health services while others struggle to
and on the other hand international policy measures to contain the
make ends meet with little daily income, poor housing conditions and
pandemic such as air travel restrictions, border closures,
loss or disrupted education, fewer employment opportunities,
enforcements of quarantine and limited mobility etc… have
experience greater gender inequality, and have little or no access to
disrupted international and local trade and commerce and have dealt
safe environments, clean water and air, food security and health
a severe blow to economies dependent on tourism, export of minerals
services. [1]
and oil and other commodities leading to rising unemployment, food
insecurity and extreme poverty. For the first time in 20 years, global
Unequal world
poverty levels are predicted to rise and hinder the progress towards
The Covid 19 pandemic has hit the world hard, but has hit the poorer the Sustainable Development Goals. [5] This pandemic has given rise
countries, underserved communities and families and vulnerable to socio-economic tensions between countries and within countries.
individuals the hardest. It has decimated the gains made in health This pandemic is not just a health emergency, but also a socio-
and economic development made so far and is pushing families and political and economic emergency with the potential to threaten
communities into poverty and further socio-economic disadvantages world peace and stability. The world economic forum in its global
while increasing the number of premature deaths and avoidable risks report 2021 has stated that the global economy will be
illnesses and hospitalizations. Globally, as of 3:24pm CEST, 29 May threatened by the knock-on effects of the coronavirus crisis, while
2021, there have been 169,118,995 confirmed cases of COVID-19, geopolitical stability will be critically fragile over the next 5 to 10
including 3,519,175 deaths, reported to World Health Organization years. [6] It is in this regard the WHO call for actions to eliminate
(WHO). [2] the health and social inequalities assume significant importance.
The pandemic is estimated to have driven between 119 and 124 Way forward
million more people into extreme poverty last year and there is
convincing evidence that it has widened gender gaps in employment, Equity / health equity is defined as the absence of avoidable, unfair
with women exiting the labor force in greater numbers than men over or remediable differences (in health) among groups of people,
the past 12 months. [3] More than 1 billion people living in informal whether those groups are defined socially, economically,
Article Summary: Submitted: 02-August-2021 Revised: 30-August-2021 Accepted: 03-September-2021 Published:30-September-2021
Quick Response Code: This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution-Non-Commercial-ShareAlike 4.0 International
Web Site License, which allows others to remix, tweak, and build upon the work
non-commercially, as long as appropriate credit is given and the new creations
http://ijmsnr.com/ are licensed under the identical terms.
How to cite this article: Priyanka Raj CK. Fairer world for a healthier
and safer world. Int J Med Sci and Nurs Res 2021;1(1):1–2.
International Journal of Medical Sciences and Nursing Research 2021;1(1):1-2 Page No: 1
Priyanka Raj CK. Fairer world for a healthier and safer world
geographically or by other means [7]. Ensuring equity / health equity is

a fundamental human right and is central to achieving the sustainable
developmental goals (SDGs). The WHO campaign for 2021 for 3. World health organization: World health day news release.
building a fairer and healthier world, urges leaders to monitor and track Available on: https://www.who.int/news/item/06-04-2021-
health inequities and its root causes, work together and hand in hand who-urges-countries-to-build-a-fairer-healthier-world-post-
with affected communities and individuals, and tackle inequalities and covid-19 [Last Accessed on: 2021 March 25]
to ensure that all people are able to access quality health services when 4. Goal 11 Make cities and human settlements inclusive, safe,
and where they need them. The social and health inequalities exposed resilient and sustainable. In: United Nations Department of
by COVID-19 have led to renewed interest by Member States in Economic and Social Affairs Sustainable Development.
WHO’s work on social determinants of health and the recent resolution 2020. Available on: https://sdgs.un.org/goals/goal11 [Last
adopted by the world health assembly aims to strengthen action Accessed on: 2021 April 18]
globally and within countries on the social determinants of health; to 5. Profiles of the new poor due to the COVID-19 pandemic.
reduce health inequities by involving all sectors in taking concrete World Bank; 2020 Available on:
action to improve living conditions and reduce social inequalities; and http://pubdocs.worldbank.org/en/767501596721696943/Prof
improve monitoring of social determinants and health inequities. [8] iles-of-the-new-poor-due-to-the-COVID-19-pandemic.pdf
[Last Accessed on: 2021 April 18]
The WHO urges leaders to act beyond borders in ensuring an equitable
6. World economic forum: The Davos agenda. Available on:
supply of vaccines, tests and treatments. Prioritizing health spending
https://www.weforum.org/agenda/2021/01/these-are-the-
and strengthening primary health care is vital to providing universal
worlds-greatest-threats-2021 [Last Accessed on: 2021 April
access to quality health care and quality covid care and make the health
25]
system resilient to future pandemics. The WHO recommends spending
7. Health equity and its determinants in the Western Pacific
an additional 1 % of GDP on primary health care and structuring social
Region. Manila, Philippines, World Health Organization
protection schemes to mitigate the negative social impacts of Covid 19
Regional Office for the Western Pacific. 2019. Licence: CC
pandemic. Building safer, healthier and inclusive neighborhoods and
BY-NC-SA 3.0 IGO., Available on:
ensuring the availability of timely and accurate data are key to removing
https://apps.who.int/iris/handle/10665/333944 [Last
the barriers to an equitable and sustainable society. [3]
Accessed on: 2021 April 20]
The focus should be now to stem the pandemic and rebuild and 8. World Health organization: Update from the Seventy-fourth
restructure the health systems to make it fairer for everyone. Also, there World Health Assembly. Available on:
is need to reinforce trust between governments/organizations and https://www.who.int/news/item/29-05-2021-update-from-
society during this crisis and to do that we need to guarantee social the-seventy-fourth-world-health-assembly-29-may-2021
accountability, transparency in the systems and provide safety nets for [Last Accessed on: 2021 April 30]
the marginalized and underserved groups who have been greatly
affected by the pandemic. Confidence building measures to ensure
widespread community participation in covid control measures remains
vital.
Dr. C. K. Priyanka Raj
References
1. World Health organization: World health day 2021 theme. Deputy Editor-In-Chief, IJMSNR,
Available on https://www.who.int/campaigns/world-health- Associate Professor,
day/2021 [Last Accessed on: 2021 March 8] Department of Public Health and Epidemiology
2. World health organization: corona virus (covid 19) dashboard, National University of Science & Technology,
Available on: https://covid19.who.int/ [Last Accessed on: 2021 College of Medicine and Health Sciences,
Sohar, Al Batinah North, Sultanate of Oman.
March 14]
Email ID: priyankaraj@nu.edu.om
Publish your research articles with

International Journal of Medical Sciences and Nursing Research.
Website: http://ijmsnr.com/
Comparison of addition of either dexamethasone or dexmedetomidine
to caudal ropivacaine for Post-Operative analgesia after Paediatric
Circumcision: A Randomized Controlled Study
Smyrna Gnanasekaran1 , Mohana Rangam Thirupathi2, Ashok Kulasekar3

1SeniorResident, Department of Anesthesiology, Chettinad Hospital And Research Institute, Chennai, Tamilnadu, India. 2Assistant Professor,
Department of Anesthesiology, Chettinad Hospital And Research Institute, Chennai, Tamilnadu, India. 3Professor and HOD, Department of
Anesthesiology, Chettinad Hospital And Research Institute, Chennai, Tamilnadu, India.
Abstract
Background: Over recent years, there are lots of advancements in providing adequate postoperative analgesia for pediatric patients who are
undergoing infra-umbilical surgeries. Of which, the caudal block is a type of neuraxial block that is simple, easy to administer with more
reliability, thus providing a very effective pain–free period. This study aimed to compare the efficacy of Ropivacaine with dexmedetomidine
and dexamethasone in pediatric circumcision surgeries.
Materials and Methods: The prospective, randomized, double-blinded study included 60 children (30 children in each group, assigned by
computer-generated randomization code). In Group I: 0.25% Ropivacaine 0.5 ml/kg + Dexmedetomidine 1mcg/kg. Group II: 0.25%
Ropivacaine 0.5 ml/kg + Dexamethasone 0.1 mg/kg.
Results: FLACC score was used to assess the postoperative analgesia. The mean duration of postoperative analgesia was
4 7 8 . 0 4 ± 6 1 . 2 2 m i n in Dexmedetomidine group and 5 3 0 . 0 7 ± 13 4 . 0 4 min in Dexamethasone group which was statistically significant.
The sedation score was better with Dexmedetomidine Group compared to Group Dexamethasone.
Conclusion: Our study proved that caudal administration of 0.25% Ropivacaine with Dexamethasone (0.1 mg/kg) resulted in a longer
duration (530.07 minutes) of action compared with 0.25% Ropivacaine with Dexmedetomidine (1 mcg/ kg) and the sedation was better with
Dexmedetomidine when compared to dexamethasone, without any other significant differences in the hemodynamic parameters and the
incidence of adverse events.
Keywords: Caudal, Analgesia, Postoperative, Ropivacaine, Dexamethasone, Dexmedetomidine
Article Summary: Submitted: 05-July-2021 Revised: 25-August-2021 Accepted: 02-September-2021 Published: 30-September-2021
are licensed under the identical terms.
http://ijmsnr.com/
Corresponding Author: Dr. Mohana Rangam Thirupathi,
Chettinad Hospital And Research Institute,
Rajiv Gandhi Salai OMR, Kelampakkam, Chennai, Tamil Nadu.
Email ID: drtmr79@gmail.com
Introduction
The pain perception in children is a complex phenomenon which involves behavioral, psychological, physiological and developmental factors
[1]. Pediatric anesthesia has evolved over-time in making surgical procedures much safer, lesser anesthesia-induced neurotoxicity, and much
longer postoperative analgesia. In pediatric surgeries, the caudal epidural an anesthetic technique is one of the safe, reliable & easy to
administer technique. Therefore, it is used for postoperative analgesia in below-umbilical surgeries [2]. The most frequently used method to
further prolong its action is to add adjuvant drugs to the local anesthetic solution [3].
A highly potent and selective glucocorticoid is dexamethasone which has been used as an adjuvant to local anesthetics in different nerve
blocks. The variable effect includes onset, prolonged duration of analgesia, and motor block [4]. And Dexmedetomidine, highly selective
α2-adrenergic receptor (α2 -AR) agonist [5] is known to be associated with sedation and analgesia sparing effects, perioperative
sympatholysis, cardiovascular stabilizing effects, reduced delirium and agitation and maintenance of respiratory function. Ropivacaine is a
local anesthetic that is structurally similar to bupivacaine. It has less cardiovascular side effects, motor blockade and neurotoxicity. These
effects have made Ropivacaine a better option over Bupivacaine [6]. Hence in this randomized comparative study, we compared caudal
dexmedetomidine and dexamethasone with Ropivacaine for postoperative analgesia in pediatric circumcision.
How to cite this article: Gnanasekaran S, Thirupathi MR, Kulasekar A. Comparison of addition of either dexamethasone or
dexmedetomidine to caudal ropivacaine for Post-Operative analgesia after Paediatric Circumcision: A Randomized Controlled Study. Int J
Med Sci and Nurs Res 2021;1(1):3–7.
Smyrna G et al., Dexamethasone vs Dexmedetomidine as an adjuvant in pediatric caudal block
Statistical Analysis:
Materials and Methods:
Data collected and complied by Microsoft Excel 2010 and was
Methodology: This randomized control study was conducted in the analyzed by SPSS 20.0 version software. Descriptive statistics was
Department of Anesthesiology & Critical Care, in a tertiary care Hospital reported as mean and standard deviation for continuous variables and
and Research Institute at Chennai, Tamil Nadu among children scheduled frequency and proportions for categorical variable. An independent
for circumcision. The sample needed for this study was calculated based t-test was used to find statistical significance between the groups.
on a previous observation made by Choudhary S et al., [7] The required [14] A two-sided p-value was taken as statistically significant.
sample size for this study was calculated as 30 subjects for each of groups
at alpha error (α) = 0.05 and statistical power = 80%. All the 60 Children Results:
was randomly divided into two groups (30 children in each group) using
a computer-generated randomization code. The inclusion criteria were The common presentation of the age group in our study participants
children aged 1-8 years, weighing 10-25 Kilograms and grade I – II based was between 1 – 3 years for both the groups which are about 66.7%
on the American Society of Anesthesiologists (ASA) [8]. Children with and 40% in Dexmedetomidine and dexamethasone group
neurological disorder, local infection at the caudal site, history of allergy respectively. The mean weight of the study participants was
to local anesthetics, Sacral or vertebral abnormalities, and bleeding 14.31±3.88 kgs in the Dexmedetomidine group and 14.93±4.06 kgs
diathesis was excluded from the study. Patients in each group have in the dexamethasone group as shown in Table–1a and Table–1b.
received caudal anesthesia as follows: All the 60 Children was randomly
divided into two groups (30 children in each group) using a computer- Table 1a: Demographic variables of study participants
generated randomization code. Group I received 0.25 % Ropivacaine 0.5
ml/ kg + Dexmedetomidine 1mcg/kg in normal saline (1ml) and Group II
received 0.25% Ropivacaine 0. 5 ml/kg + Dexamethasone 0.1mg/kg in Dexmedetomidine Dexamethasone
normal saline (1ml) with maximum volume of 25 ml (Armitage formula) Age- Group
in both the groups.
No. Percentage No. Percentage
The data was collected for this study was between November 2016 –
October 2018. The study was approved by the Institutional Human Ethics 1-3 years 20 66.7 12 40
Committee (64/IHEC/9-16) Informed written consent was obtained from
the parents of all study participants and only those who were willing to
sign the informed consent was included in this study. The risks and 3-5 years 3 10 9 30
benefits involved in the study and voluntary nature of participation was
explained to the participant's parents through participant information >5 years 7 23.3 9 30
sheet before obtaining written consent.
Mean ± SD 3.65 ± 2.19 4.27 ± 2.23
Procedure:
On the day of surgery, pre-medication in the form of Midazolam nasal t-value -0. 879
spray (0.3mg/kg) was administered and Glycopyrrolate injection (0.004
mg/kg) was administered if IV access was secured already. Standard p-value 0.380
monitoring including electrocardiogram (ECG), non-invasive blood
pressure (NIBP) measurement, heart rate, pulse oximetry and
capnography was applied. All patients were induced with inhalational
agent sevoflurane (1-6%) with 50% nitrous oxide in oxygen. If the IV Table: 1b Demographic variables of study participants
access has not been established prior, it was established and secured under
aseptic precautions after induction. In the left lateral position, a caudal Dexmedetomidine Dexamethasone
block was performed using 22G or 24G 1½ hypodermic needle under Variable t-value p-value
complete aseptic precaution. After confirmation and negative aspiration Mean ± SD Mean ± SD
for blood and cerebrospinal fluid, the study drug was given in the epidural
space. [9] Weight 14.31 ± 3.88 14.93 ± 4.06 -0. 601 0.550
Postoperative sedation was assessed by using Ramsay sedation score and
Postoperative pain was assessed by using the FLACC score, the Motor
blockade was assessed by a Motor block scale. [10 – 12] To eliminate any The mean HR (Heart Rate) in Dexmedetomidine and
kind of bias in the study, the anesthesiologist performing the caudal block Dexamethasone. There was a significant (p<0.05) difference
was different from the person conducting the study and both were blinded between the two groups only at 0 minutes (after premedication).
to the identity of the drug used (double-blinding). [13] The time of caudal Other timeline distribution shows no significant (p>0.05)
block was noted and the time of incision was 10 minutes after improvement in mean scores between the two groups as shown in
administration of caudal block. Table – 2.
Table: 2 Comparison of mean Heart Rate in Dexmedetomidine and The sedation score of the study participants was significantly lower
Dexamethasone: at Baseline, 0 min (after premedication), 15, 20, 60, in the dexamethasone group at postoperative 1hr and 2hr respectively.
90, 120, 150 & 180 min. The sedation score of the study participants was significantly lower
in the dexamethasone group at postoperative 1hr and 2hr respectively.
p The motor block score in the study participants was similar in the
Heart rate Dexmedetomidine Dexamethasone
value Dexmedetomidine group and the dexamethasone group as shown in
Baseline 131.03 ± 20.03 123.23 ± 15.71 0.101 Table-3.
0 min 135.86± 15.63 126.90± 16.40 0.030

Discussion:
1 min 137.38± 16.05 135.57± 13.28 0.638
In our study, patients undergoing surgery in both groups was in
5 min 129.62 ± 15.41 127.20± 12.05 0.500 similar demographic profile. The common presentation of the age
group in our study participants was between 1 – 3 years for both the
10 min 127.66 ± 14 93 123.53± 11.69 0.240 groups. The mean weight of the study participants was 14.31±3.88
kgs in the Dexmedetomidine group and 14.93±4.06 kgs in the
Intra OP 0 min 136.31 ± 12.96 133.23± 12.56 0.350 dexamethasone group which was almost the same. Participants
receiving dexmedetomidine and dexamethasone was also compared
Intra OP 15 min 125.34 ± 13.33 123.20± 11.94 0.510 for the differences in their heart rate, systolic blood pressure, diastolic
blood pressure. In this study we noticed that there was a statistically
significant difference (p<0.05) in heart rate between the groups only
Intra OP 20 min 95.62 ± 56.06 82.10 ± 59.55 0.370
at 0 minutes that is after premedication with midazolam nasal spray.
[15] The heart rate in the intra-operative period of 0, 15, and 20
Post-op 1 hr 129.72 ± 12.03 128.13± 11.61 0.600
minutes in the dexmedetomidine group and dexamethasone group did
not show significant difference between them. Similarly, no
Post-op 2 hr 125.83± 12.64 123.07± 11.91 0.390
difference was noticed in the heart rate across both the groups in the
postoperative period with p>0.05.
Post-op 3 hr 122.00± 12.98 117.97± 11.53 0.210
The systolic blood pressure at various time frames was observed at
Post-op 4 hr 118.90± 13.21 114.80± 11.44 0.200 intra-operative and post-operative periods across the
dexmedetomidine group and dexamethasone group. Results showed
Bolded p – values< 0.05 Significant that there was a statistically significant (p<0.05) higher difference in
mean systolic blood pressure in the dexamethasone group at baseline,
intra-operative period 0 min & 15min, and post-operatively at 3hrs as
Table 3: Comparison of FLACC score, duration of analgesia, shown in Figure-1.
sedation score and motor block at various time interval in
Dexmedetomidine and Dexamethasone Figure: 1 Comparison of mean SBP in Dexmedetomidine and
Dexamethasone: at Baseline, After Premedication o min, 15, 30,
Dexmedetomidine Dexamethasone t p 60, 90, 120, 150 & 180 min
Variables
Mean ± SD Mean ± SD value value
FLACC score at
1.97 ± 1. 08 1.10 ± 0.75 3.561 0.010
one hour
Duration of
286. 90 ± 102.15 530. 07 ± 134.04 -7.817 0.001
Analgesia
Sedation score at
3.00 ± 0. 98 1.70 ± 1. 08 4.850 0.001
POP first hour
Sedation score at
0.80 ± 0.80 0.13 ± 0.34 4.160 0.001
POP second hour
Motor block at first
0.17 ± 0. 37 0.10 ± 0.30 0.750 0.450
hour
Bolded p – values< 0.05 Significant
The FLACC score was comparatively less in the dexamethasone group

and was statistically significant (p<0.05). The duration of analgesia was
more in the dexamethasone group and showed statistical significance
(p<0.05).
Comparison of mean diastolic blood pressure in dexmedetomidine and agitation, and desirable cardiovascular effects. Similarly, Gurbet A et
dexamethasone group showed at baseline, after premedication, at 0 al., [19] found that dexmedetomidine intra-operatively provides
min, 15, 20, 60, 90, 120, 150 and 180 mins was done as shown in effective postoperative analgesia, and reduces postoperative
Figure-2. morphine requirements without increasing the incidence of adverse
effects.
Figure: 2 Comparison of mean DBP in Dexmedetomidine and
Dexamethasone: at Baseline, After Premedication o min, 15, 20, 60, It was also found that the sedation score of the study participants was
90, 120, 150 & 180 min significantly lower in the dexamethasone group at postoperative 1st
hr and 2nd hr (p<0.001). This shows that patients in the
dexmedetomidine group was more sedated than the dexamethasone
group. Similarly, a study conducted by Bharti N et al., [20] noticed
that patients receiving dexmedetomidine was more sedated as
compared to the other groups (p<0.01) which correlates with our
study.
Conclusion:
It is evident from our study that patients in the dexamethasone group
had less postoperative pain and the duration of analgesia was more
compared to that of dexmedetomidine. Hence dexamethasone is a
good adjuvant for post-op analgesia.
Limitations of this study:

1. This study has included only small number of patients. It needs
larger sample size to investigate the true effectiveness of adjuvants
The statistically significant higher difference in mean scores among added in caudal block.
dexamethasone group at baseline, intra-operative 0 min & 15 min, and
post-operatively at 1 hr and 3hrs respectively. 2. Since few of the patients belonged to pre-verbal age group, the
assessment of pain was observer biased.
When pain scores (FLACC) was compared between two groups, it was
observed that in the dexamethasone group (1.10±0.75), the FLACC Acknowledgement: The authors thank the parents of the
score was found to be significantly less (p<0.001) as compared to participants, members of the Department of Anesthesia, Operation
Dexmedetomidine (1.97±1.08). This infers that postoperative pain was Theatre Services and the Staff Nurses for co-operating throughout the
less in the dexamethasone group and was statistically significant. The study period.
motor block score in the study participants was similar in the
Dexmedetomidine group and the dexamethasone group. Kim EM et al. Authors Contributions: SG, MRT, AK: Conception and
[16] in their study found that FLACC scores was almost comparable design, Acquisition of Data. SG, MRT: Analysis and Interpretation
between the groups and there was no difference seen in motor block of data, all authors. SG, MRT, AK: Drafting the article, revising it for
scores among the study participants which agreed with our study Intellectual content, all authors; approval of final version of submitted
findings. manuscript.
The mean duration of analgesia in the dexamethasone group was Here, SG-Smyrna Gnanasekaran, MRT-Mohana Rangam Thirupathi,
significantly more than the dexmedetomidine group that is 530.07 ± and AK-Ashok Kulasekar.
134.04 minutes and 478.04±61.22 minutes (p < 0.0001), respectively.
Choudhary S et al., [7] revealed the same findings in his study with a
mean duration of analgesia in Group A as 248.4±54.1 minutes and Source of funding: We didn’t get any types of financial
Group B as 478.05±104.57 minutes with p = 0.001 where Group 'A' support from our parent institution and any other financial
received 0.2% ropivacaine caudally and Group 'B' received a bolus of organization.
0.2% ropivacaine with dexamethasone 0.1 mg/kg. Whereas many
studies like Isaac GA et al., [17] found that Caudal dexmedetomidine Conflict of Interest: The authors declare no conflict of interest,
1 µg/kg with 0. 25% of ropivacaine for a pediatric patient undergoing financial or otherwise.
infra-umbilical surgeries achieved postoperative pain relief up to 8
hours and the required dose of rescue analgesia was less with minimal
adverse effects. Also, Takrouri MS et al., [18] found that
dexmedetomidine, when compared with conventional sedatives and
opiates was found to be associated with both sedative and analgesic
sparing effects, minimal respiratory depression, reduced delirium and
References:
15. Manoj M, Satyaprakash MVS, Swaminathan S, Kamaladevi RK.
Comparison of ease of administration of intranasal midazolam
1. Morton NS. Pain assessment in children. Pediatric Anesthesia
spray and oral midazolam syrup by parents as premedication to
1997;7(4):267-272. PMID: 9243682
children undergoing elective surgery. J Anesth 2017;31(3):351-
2. Bajwa SJS, Kaur J, Bajwa SK, Bakshi G, Singh K, Panda A. Caudal
357. PMID: 28271228
ropivacaine–clonidine: A better post-operative analgesic approach.
16. Kim EM, Lee JR, Koo BN, Im YJ, Oh HJ, Lee JH. Analgesic
Indian J Anaesth 2010;54(3):226-230. PMID: 20885869
efficacy of caudal dexamethasone combined with ropivacaine in
3. Sabbar S, Zamir, Khalid A, Khan FA. Caudal ketamine with
children undergoing orchiopexy. Br J Anaesth 2014;112(5):885-
bupivacaine and bupivacaine alone for postoperative analgesia in
891. PMID: 24491414
paediatric inguinoscrotal surgeries. Anaesthesia 2009;15(4):207-
17. Isaac G A, Prabhavathi R, Reddy P N, Suresh J, A study to
210.
evaluate efficacy and safety of dexmedetomidine (1 Âµg/Kg) as
4. Cummings III KC, Napierkowski DE, Parra-Sanchez I, Kurz A,
an adjuvant to caudal ropivacaine (0.25%1 Ml/Kg) in paediatric
Dalton JE, Brems JJ, et al. Effect of dexamethasone on the duration
infraumbilical surgeries. Indian J Clin Anaesth 2017;4(4):453-
of interscalene nerve blocks with ropivacaine or bupivacaine. British
458.
Journal of Anaesthesia 2011;107(3):446-453. PMID: 21676892
18. Takrouri MS, Seraj MA, Channa AB, el-Dawlatly AA, Thallage
5. Khan ZP, Ferguson CN, Jones RM. Alpha-2 and imidazoline
A, Riad W, et. al., Dexmedetomidine in intensive care unit: a
receptor agonistsTheir pharmacology and therapeutic role.
study of hemodynamic changes. Middle East J Anaesthesiol
Anaesthesia 1999;54(2):146–165. PMID: 10215710
2002;16(6):587-595. PMID: 12503262
6. Khanna A, Saxena R, Dutta A, Ganguly N, Sood J. Comparison of
19. Gurbet A, Basagan-Mogol E, Turker G, Ugun F, Kaya FN,
ropivacaine with and without fentanyl vs bupivacaine with fentanyl
Ozcan B. Intraoperative infusion of dexmedetomidine reduces
for postoperative epidural analgesia in bilateral total knee
perioperative analgesic requirements. Can J Anaesth
replacement surgery. Journal of Clinical Anesthesia 2017;37:7-13.
2006;53(7):646-652. PMID: 16803911
PMID: 28235533
20. Bharti N, Praveen R, Bala I. A dose–response study of caudal
7. Choudhary S, Dogra N, Dogra J, Jain P, Ola SK, Ratre B. Evaluation
dexmedetomidine with ropivacaine in pediatric day care patients
of caudal dexamethasone with ropivacaine for post-operative
undergoing lower abdominal and perineal surgeries: a
analgesia in paediatric herniotomies: A randomized controlled
randomized controlled trial. Pediatric Anesthesia
study. Indian J Anaesth 2016;60(1):30. PMID: 26962252
2014;24(11):1158-1163. PMID: 25040840
8. Daabiss M. American Society of Anaesthesiologists physical status
classification. Indian J Anaesth 2011;55(2):111-115.
PMID: 21712864
9. Wiegele M, Marhofer P, Lönnqvist P-A. Caudal epidural blocks in
paediatric patients: a review and practical considerations. British
Journal of Anaesthesia 2019;122(4):509–517. PMID: 30857607
10. El Shamaa HA, Ibrahim M. A comparative study of the effect of
caudal dexmedetomidine versus morphine added to bupivacaine in
pediatric infra-umbilical surgery. Saudi J Anaesth 2014;8(2):155-
160. PMID: 24843324
11. Brasher C, Gafsous B, Dugue S, Thiollier A, Kinderf J, Nivoche Y,
et al. Postoperative Pain Management in Children and Infants: An
Update. Pediatr Drugs 2014;16(2):129–140. PMID: 24407716
12. Locatelli B, Ingelmo P, Sonzogni V, Zanella A, Gatti V, Spotti A, et
al. Randomized, double-blind, phase III, controlled trial comparing
levobupivacaine 0.25%, ropivacaine 0.25% and bupivacaine 0.25%
by the caudal route in children. Br J Anaesth 2005;94(3):366-371.
PMID: 15608043
13. Day SJ, Altman DG. Blinding in clinical trials and other studies.
BMJ 2000;321(7259):504. PMID: 10948038
14. Usman U. On Consistency and Limitation of independent t-test
Kolmogorov Smirnov Test and Mann Whitney U test. IOSR Journal
of Mathematics 2016;12(4):22-27. Corpus ID: 56151613 DOI:
http://doi.org.10.9790/5728-1204052227

International Journal of Medical Sciences and Nursing Research
Blood transfusion incidence in primary Total Knee Arthroplasty of
Unilateral vs Bilateral group with high prevalence of low
haemoglobin concentration: A Retrospective Observational Study
Jai Thilak Kailathuvalapil1, Madhusudhan Tammanaiah2 , Nabeel Mohamed Therakka Parambil3, Sujith Paliath
Shaju4, Senthilvel Vasudevan5

1, 2, 3, 4
Department of Orthopaedics, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India. 5Assistant
Professor of Statistics, Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Science, Riyadh,
Saudi Arabia.
Abstract
Background: Blood transfusion is one of the major concerns following Total Knee Arthroplasty (TKA). We assessed the incidence rate of
blood transfusion (packed red cells) in our geographical group based on age, gender, preoperative haemoglobin(Hgb) and following both
unilateral and bilateral primary TKA done either in single stage or sequentially after a week.
Materials and Methods: This was a retrospective observational study which included 200 patients who underwent primary TKA unilateral,
bilateral done in single stage and sequential from June 2015 to May 2016. Two doses of parenteral Tranexamic acid and periarticular cocktail
injection given. Transfusion was indicated with postoperative Hgb below 8 g/dl associated with or without clinical signs of tissue
hypoperfusion.
Results: The study group was 200 patients with age group of 50-81 years, of which 154 (77%) were female and 46 (23%) were male and
had a mean preoperative Hgb level of 12.6 g/dl. 88 (44%) unilateral, 40 (20%) bilateral and 72 (36%) sequential TKA were performed and 7
(7.95%), 12 (30%) and 26 (36%) patients received blood transfusion respectively. Among the transfused 45 patients, 38 patients were
bilateral group, of which 30 (66.6%) patients had a preoperative Hgb levels of 10–12 g/dl, indicating high incidence of transfusion in bilateral
cases compared to unilateral and with preoperative Hgb levels of 10–12g/dl which was statistically significant with p-value <0.05.
Conclusion: In our study, age and gender were not the major factors for blood transfusion, but low preoperative Hgb levels and bilateral
single stage and sequential TKA showed significantly higher incidence of blood transfusion.
Keywords: total knee arthroplasty, blood transfusion, preoperative Hgb
http://ijmsnr.com/ are licensed under the identical terms.
Corresponding Author: Dr. Madhusudhan Tammanaiah,

Consultant Orthopaedic Surgeon, Kamakshi Hospital,
Mysore, Karnataka, India.
Email ID: madhusudhan.doc@gmail.com Cell No: +918333873990
Introduction
Total knee arthroplasty (TKA) is an elective procedure widely used for treating osteoarthritis of knee which is a disease of inflammatory and
degenerative nature that causes knee joint cartilage destruction leading to pain and variable deformities. It is one of the most common
procedures performed in the orthopedic department in recent years. The frequency of TKA has shown a growth projection of 601% between
2005 and 2030. [1] Like other major surgeries, there are several complications also noticed during and after TKA such as persistent knee
pain, stiffness, blood loss and thromboembolism. [2–4] The bleeding is mainly noticed after release of the tourniquet. [5] The amount of
blood loss is variable and sometimes it leads to scenarios where blood transfusion becomes inevitable. [6] Surgical blood loss and transfusion
is a concern for both patients and surgeons despite advances in blood conservation techniques. While the popularity of preoperative
autologous donation has declined for logistical reasons, erythropoietin (EPO) and perioperative autologous blood salvage strategies have
increased in popularity. [7] Still, homologous blood transfusion remains the gold-standard approach for increasing blood cell count in
anaemic patients in the perioperative period.
An incidence rates of 9-84% blood transfusion have been reported following TKA [8] and several factors were found associated with
increased risk of blood transfusion which includes patient related factors like gender, body mass index (BMI), preoperative haemoglobin
(Hgb) level, American Society of Anesthesiologists (ASA) score, and associated medical comorbidities and surgery related factors like
How to cite this article: Kailathuvalapil JT, Tammanaiah M, Parambil NMT, Shaju SP, Vasudevan S. Blood transfusion incidence in
primary Total Knee Arthroplasty of Unilateralvs Bilateral group with high prevalence of low haemoglobin concentration. Int J Med Sci and
Nurs Res 2021;1(1):8–11.
Tammanaiah M et al., Blood transfusion incidence in primary Total Knee Arthroplasty of Unilateral vs Bilateral group
operation time, technique, usage of tourniquet and amount of blood loss patients and 25 (23.5%) patients were transfused respectively. No
during perioperative period. [9-12] Though blood transfusion is statistically significant relationship between age and blood
lifesaving, it is associated with several complications such as hemolytic transfusion noted with p-value 0.696. Gender: Out of 154 females
reactions, transfusion-related lung injury (TRALI), transmission of and 46 males, 37 (24%) patients & 8 (17%) patients received blood
infectious pathogens and overall high risk of morbidity and mortality. [13, transfusion respectively. And the relationship between gender and
14] The aim of this study is to fill the knowledge gap on blood transfusion blood transfusion in TKA was not statistically significant with p-
(packed red cells) following TKA in a variant geographical and ethnic value 0.231.
group by estimating its incidence rate based on demographic parameters
such as age, gender, preoperative Hgb and following both unilateral and Unilateral / Bilateral / Sequential: Out of 200 TKA performed, 88
bilateral TKA done either in single stage or sequentially. (44%) unilateral, 40 (20%) bilateral single stage and 72 (36%)
sequential TKA.Among them, 7 (7.95%), 12 (30%) and 26 (36%)
patients received blood transfusion respectively. Patients who
Materials and Methods: underwent bilateral single stage and sequential TKA received high
blood transfusion in comparison to unilateral TKA, which was
This is a retrospective observational study which includes 200 patients statistically highly significant with p-value <0.0001.
who underwent primary TKA - unilateral, bilateral single stage, bilateral
sequential (one week apart) from June 2015 to May 2016. Patients with Relation to preoperative Hgb: On further evaluation, the need of
coagulation disorders, thrombocytopenia, disturbances of platelet blood transfusion based on preoperative Hgb was classified under 10–
function, or other hematological diseases were excluded from the study. 12g/dl and >12g/dl. 101 patients (50.5%) had preoperative Hgb level
Gender, age, preoperative Hgb, unilateral, bilateral(single stage and of 10–12 g/dl and 99 patients (49.5%) >12 g/dl. 45 (22.5%) patients
sequential) were evaluated for their relationship to blood transfusion in were transfused and of which 30 (66.6%) patients had preoperative
the perioperative period. All TKA were performed by a single senior Hgb levels of 10–12 g/dl. In unilateral and bilateral single stage TKA
arthroplasty surgeon. All patients received intravenous tranexamic acid the incidence of blood transfusion in patients with 10–12g/dl didn’t
1gm before incision and 4 hours after the surgery unless contraindicated. show statistical significance with p-value 0.676 and 0.494 respectively
Tourniquet was used at the time of exposure and cementation only. whereas in sequential TKA statistical significance noted with p-value
Periarticular cocktail injection of 30 ml consisting of Bupivacaine, 0.027. Overall transfusion rate in patients with preoperative Hgb
Morphine, epinephrine, antibiotics diluted in normal saline given for all levels of 10–12g/dl was high and results were statistically significant
patients. Drain was not used, and compression bandage was applied for with p-value 0.019 (<0.05) as shown Figure-1.
adequate tamponade. Hgb levels assessed in the post-anesthesia care unit
on postoperative day-1. The trigger for bloodtransfusion was Hgb ≤8 g/dl Figure 1. Chart showing incidence of blood transfusion with
with or without presence of symptoms of tissue hypoperfusion. [15] In variable preoperative Hgb levelsin unilateral/ bilateral/ sequential
patients undergoing sequential TKA, subcutaneous Enoxaparin sodium TKA patients.
was given in the interimperiod between the two surgeries and stopped the
day prior. Aspirin orally was given in all patientsas DVT prophylaxis for
a period of 4 weeks.
Statistical analysis: All data were procured retrospectively from a

prospectively maintained electronic database (AHMS version 6.0.7) by
an independent investigator not involved in the surgery. Institutional
review board (IRB) approval was taken. Results were analyzed using
SPSS 20.0 version. Quantitative data were expressed as the mean ± SD.
Categorical data were analyzed with Chi-Square test / Fisher’s Exact test
wherever applicable. p-value less than 0.05 was considered as statistically
significant.
Results
221 patients underwent TKA from June 2015 to May 2016, of which 21
(9.5%) patients were excluded from the study (Revision TKA,
coagulation disorders). Of the 200 patients, 46 (23%) were males and Discussion
154 (77%) were females. 88 (44%), 40 (20%) and 72 (36%) patients
underwent unilateral, bilateral (single stage) and sequential TKA Blood loss during total knee arthroplasty is variable. Several studies
respectively. Mean preoperative Hgb was 12.6 g/dl with overall didn’t consider "hidden" blood loss, including loss due to
incidence of blood transfusion in 45 (22.5%) patients and mean extravasation into the tissues; residual blood in the joint; and loss due
postoperative Hgb level with or without transfusion was 11.28 g/dl. to hemolysis, hematoma formation, or bleeding around the prosthesis
for assessment of actual blood loss during the surgery. The inability
Age: To analyze the relationship between age and incidence of blood to predict the need for transfusion in these patients has clinically and
transfusion, patients were divided into two age groups, 94 (47%) patients economically important consequences. During unpredicted clinical
with age less than 65 and 106 (53%) patients with age more than 65, of scenarios, patients often receive allogeneic blood which increases the
which 20 (21%) risk of allergic reactions, transmission of infectious agents, and
immunomodulatory effects. Beirbaum et al [16] reported rates of 39% of Authors Contributions: JTK, MT: Conception and design.
TKA patients received transfusion and, in our study, the mean incidence of JTK, MT, SPS: Acquisition of Data. SV, MT: Analysis and
blood transfusion was 22.5%. There was no statistically significant Interpretation of data. All authors-JTK, MT, NMTP, SPS, and SV:
relationship in specific age groups or gender who were transfused in Drafting the article, revising it for Intellectual content. All authors
unilateral or bilateral TKA. In one of the recent studies by Abdullah A. Al- were checked and approved of the final version of the manuscript.
Turkiet al [17] conducted in a tertiary care centre, Riyadh, Saudi showed
high incidence of blood transfusion in older females with high BMI. In our Here, JTK-Jai Thilak Kailathuvalapil, MT-Madhusudhan
study BMI was not included. Tammanaiah, NMTP-Nabeel Mohamed Therakka Parambil, SPS-
Sujith Paliath Shaju and SV-Senthilvel Vasudevan.
Beirbaum et al [16] prospectively evaluated the need for autologous or
homologous blood transfusion in patients undergoing both Total hip
arthroplasty and Total Knee arthroplasty based on preoperative Hgb level Source of funding: We didn’t get any types of financial
and found that patients with Hgb level less than 13gm/dl, particularly 10- support from our parent institution and any other financial
13 g/dl needed transfusion. Gerardo Alvarez-Uria et al [18] analyzed the organization.
prevalence of anemia in our geographical area and noted a mean
haemoglobin concentration of 11.3g/dl. In our study group also >50% of
patients had preoperative Hgb levels of 10–12g/dl and in turn the need for Conflict of Interest: The authors declared no conflict of interest
blood transfusion was high. David W. Fabi et al [19] retrospectively
analyzed the complications rate of unilateral TKA and bilateral References:
simultaneous TKA and found 4 times higher rate of single stage or
sequential compared to unilateral TKA, blood transfusion in bilateral 1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of
simultaneous TKA. In our study cohort also, blood transfusion rate was high primary and revision hip and knee arthroplastyin the United States
in bilateral TKA done either single stage or sequential compared to from 2005 to 2030. J Bone Joint Surg 2007; 89(4):780-785. PMID:
unilateral TKA. 17403800
2. Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P.
Joshua B. Holt et al [20] conducted a prospective study in which 488 What proportion of patientsreport long-term pain after total hip or
patients underwent primary TKA with a multimodal, multidisciplinary knee replacement for osteoarthritis? A systematic review of
approach to perioperative blood loss management and in turn reducing the prospective studies in unselected patients. BMJ Open 2012;2(1):
blood transfusion which included preoperative hemoglobin optimization, e000435. PMID: 22357571
minimization of perioperative blood loss and evidence-based transfusion 3. Januel JM, Chen G, Ruffieux C, Quan H, Douketis JD, Crowther
guidelines. This approach was also substantiated by Sara Moráis et al [21] MA, et al. Symptomatic in-hospital deep vein thrombosis and
which also included femoral canal obturation; peri and intra-articular pulmonary embolism following hip and knee arthroplasty among
cocktail injection; and two doses of parenteral tranexamic acid (TXA). In patients receiving recommended prophylaxis: a systematic
our study group we also followed many of these protocols for reducing review. JAMA 2012; 307(3): 294-303. PMID: 22253396
blood loss. 4. Ritter MA, Harty LD, Davis KE, Meding JB, Berend ME.
Predicting range of motion after total knee arthroplasty.
Complications like blood borne disease, allergic reaction, Clustering, log-linear regression, and regression tree analysis. J
immunomodulatory reactions, post-operative infection, DVT post Bone Joint Surg Am 2003; 85(7): 1278-1285. PMID:12851353
transfusion were also observed in the study group. Nicholas B. Frisch et al 5. Burke DW, O’Flynn H. Primary total knee arthroplasty. In:
[22] reported DVT rate of 1.99% and deep surgical site infection (DSSI) Chapman MW, editor. Chapman’s orthopedic surgery: 3rd edition.
rates of statistically higher in the transfused patients. Bierbaum et al [16] Lippincott Williams & Wilkins; Philadelphia: 2001:2870-2895.
reported infection rates of 7% in transfused patients. But no such
complications noted in our transfused patients. Though DVT prophylaxis 6. Lotke PA, Faralli VJ, Orenstein EM, Ecker ML. Blood loss after
was given in all patients, assessment of DVT in the form of ultrasound total knee replacement. Effects of tourniquet release and
continuous passive motion. J Bone Joint Surg Am. 1991;
doppler was done only in symptomatic patients. Hence actual incidence of
73(7):1037-1040. PMID: 1874765
DVT or pulmonary embolism in asymptomatic patients not assessed.
7. So-Osman C, Nelissen RGHH, Koopman-van Gemert AWMM,
Conclusion Kluyver E, Pöll RG, Onstenk R et al. Patient blood management
in elective total hip and knee-replacement surgery (Part 1): A
In conclusion age and gender variability were not the major confounding randomized controlled trial on erythropoietin and blood salvage
factors for blood transfusion but low preoperative Hgb levels in between as transfusion alternatives using a restrictive transfusion policy in
10–12g/dl found in above half of our geographic population had increased erythropoietin-eligible patients. Anesthesiology 2014;
incidence of blood transfusion. In comparison with unilateral vs bilateral, 120(4):839-851. PMID: 24424070
bilateral TKA done either single stage or sequential showed a higher 8. Barr PJ, Donnelly M, Cardwell C, Alam SS, Morris K, Parker M,
incidence of blood transfusion and more significantly in the group with Hgb et. al. Driversof transfusion decision making and quality of the
10–12g/dl. evidence in orthopedic surgery: a systematic review of the
literature. Transfus Med Rev 2011;25(4):304–316. PMID:
Acknowledgement: The authors thank the participants, members of the 21640550
Department of Orthopaedics and Anesthesia, Operation Theatre and 9. Maxwell MJ, Wilson MJA. Complications of blood transfusion.
Nursing staff for co-operating throughout the study period. Continuing Education in Anaesthesia Critical Care & Pain 2006;
6(6):225-229. https://doi.org/10.1093/bjaceaccp/mkl053
10. Rawn J. The silent risks of blood transfusion. Curr Opin Anaesthesiol
2008;21(5):664-668. PMID: 18784496
11. Park JH, Rasouli MR, Mortazavi SM, Tokarski AT, Maltenfort MG,
Parvizi J. Predictors of perioperative blood loss in total joint
arthroplasty. J Bone Joint Surg Am 2013;95(19):1777-1783.
PMID: 24088970
12. Carling MS, Jeppsson A, Eriksson BI, Brisby H. Transfusions and
blood loss in total hip and knee arthroplasty: a prospective
observational study. J Orthop Surg Res 2015;10:48. PMID: 25889413
13. Prasad N, Padmanabhan V, Mullaji A. Blood loss in total knee
arthroplasty: an analysis of risk factors. Int Orthop 2007;31:39-44.
PMID: 16568327
14. Salido JA, Marín LA, Gómez LA, Zorrilla P, Martínez C.
Preoperative hemoglobin levels and the need for transfusion after
prosthetic hip and knee surgery: analysis of predictive factors. J Bone
Joint Surg Am 2002;84(2):216-220. PMID: 11861727
15. World Health Organization: Haemoglobin Concentrations for the
Diagnosis of Anaemia and Assessment of Severity, WHO, Geneva,
Switzerland, 2011. Available on:
http://www.who.int/vmnis/indicators/haemoglobin/en/ [Accessed on
15th December 2020]
16. Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE,
Welch RB. An analysis of blood management in patients having a
total hip or knee arthroplasty. J Bone Joint Surg Am 1999;81(1):2-
10. PMID:9973048
17. Al-Turki AA, Al-Araifi AK, Badakhan BA, Al- Nazzawi MT,
Alghnam S, Al-Turki AS. Predictors of blood transfusion following
total knee replacement at a tertiary care center in Central Saudi Arabia.
Saudi MedJ 2017;38(6):598-603. PMID: 28578438
18. Gerardo Alvarez-Uria, Praveen K.Naik, Manoranjan Midde, Pradeep
S.Yalla and Raghavakalyan Pakam. Prevalence and Severity of
Anaemia Stratified by Age and Gender in Rural India. Anemia,
2014:176182. DOI: http://doi.org/10.1155/2014/176182
19. Fabi DW, Mohan V, Goldstein WM, Dunn JH, Murphy BP.Unilateral
vs Bilateral Total Knee Arthroplasty. Risk Factors Increasing
Morbidity. The Journal of Arthroplasty 2011;26(5):668-673. PMID:
20875943
20. Holt JB, Miller BJ, Callaghan JJ, Clark CR, Willenborg MD, Noiseux
NO. Minimizing Blood Transfusion in Total Hip and Knee
Arthroplasty through a Multimodal Approach. J Arthroplasty
2016;31(2):378–382. PMID: 26391927
21. Moráis S, Ortega-Andreu M, Rodríguez-Merchán EC, Padilla-
Eguiluz NG, Perez-Chrzanowska H, Figueredo-Zalve R, et al. Blood
transfusion after primary total knee arthroplasty can be significantly
minimized through a multimodal blood-loss prevention approach.
International Orthopaedics (SICOT) 2014 38(2):347–354. PMID:
24318318
22. Frisch NB, Wessell NM, Charters MA, Yu S, Jeffries JJ, Silverton CD.
Predictors and Complications of Blood Transfusion in Total Hip and
Knee Arthroplasty. J Arthroplasty 2014;29(9 Suppl):189–192. PMID:
25007727

Impact of lockdown on sleep wake cycle and psychological wellbeing
in South Indian population: A Cross-Sectional and Descriptive Study
Sonali Devarajan1, Samyuktha Mylsamy2, Tamizhini Venkatachalam3, Gobinath Veerasamy4
1, 2, 3Third year BSC Psychology, PSGR Krishnammal College for Women, Peelamedu, Coimbatore, Tamil Nadu, India. 4Assistant Professor,
Department of Psychology, PSGR Krishnammal College for Women, Peelamedu, Coimbatore, Tamil Nadu, India.
Abstract
Background: The COVID-19 pandemic has created a wide range of crises affecting many nations, resulting in adverse health consequences.
The implementation of the lock down upended the lifestyle of mostly all people and was associated with disturbed sleep. Our study is to
estimate the variation of the sleep-wake cycle during lockdown and after lock down among people aged 15-60 years and its impact on
Psychological wellbeing.
Materials and Methods: We have done a cross-sectional and descriptive study with a sample of 304 participants formed using convenience
sampling method by online google form. They were administered with The Munich Chronotype Questionnaire (MCTQ) and The Flourishing
scale. The responses were collected during and after lock down. The data obtained is subjected to descriptive analysis.
Results: In this study we have recruited and included 304 participants. Out of 304 participants, 151 (49.7%) were male and 153 (50.3%)
were female. Flourishing scale scores mean during lockdown was 28.83 ± 4.75 and after lockdown was 41.50 ± 4.42 and the mean value
was more in after lockdown period and a paired-t test showed statistically highly significant difference at p-value<0.01.
Conclusion: The variation in the sleep-wake cycle was more in adolescents than in other age groups and the Psychological wellbeing of
women was affected more than men in all age groups during lockdown.
Keywords: lockdown, sleep-wake cycle, psychological wellbeing, age difference, gender difference
Keywords: non-commercially, as long as appropriate credit is given and the new creations
http://ijmsnr.com/
Corresponding Author: Dr. Gobinath Veerasamy,
Assistant Professor, Department of Psychology,
PSGR Krishnammal College for Women, Peelamedu, Coimbatore,
Tamil Nadu, India. Email ID: gobinath@psgrkcw.ac.in
Introduction
The World Health Organization (WHO) on 31 December 2019, was informed of a new case of pneumonia in Wuhan City, China. On 7
January 2020, a novel coronavirus was identified in China and was temporarily named “2019-nCoV ". Coronaviruses are a kind of dreadful
virus causing a wide range of illnesses that even leads to death. The first case of the Covid case in India was identified in Kerala. Seeing the
rapid negative effect of this virus, numerous countries have implemented curfews to safeguard the people. In Tamil Nadu, the first case was
confirmed in a resident from Kanchipuram in Chennai on 7 March 2020. On 23 March 2020, to prevent the spread of the virus, The
Government of Tamil Nadu announced a state-wide lockdown. There was an association between decreased sleep quality and increased
negative mood due to the outbreak of COVID-19. [1] COVID-19 pandemic resulted in home quarantine which had a detrimental effect on
sleep quality. [2] There was a reduction in night-time sleep and an increase in daytime napping due to shifts to a later bedtime and waking
time. [3] Sleep disturbances during the pandemic harmed the immune system function by affecting the regulation of immunological markers
and their cells. [4]
Increased sleep duration and decreased daytime functioning were observed even though there was longer sleep latency, worse sleep
efficiency, and massive sleep medication use during forced confinement. [5] There was a differential impact on the sleep wake cycle due to
excessive digital media exposure among Indians during the lockdown. [6] Hence is this study to estimate the variation in the sleep-wake
cycle during the lockdown and after lock down among people of age group 15 to 60 and to compare the psychological wellbeing scores of
How to cite this article: Devarajan S, Mylsamy S, Venkatachalam T, Veerasamy G. Impact of lockdown on sleep wake cycle and
psychological wellbeing in South Indian population: A Cross-Sectional and Descriptive Study. Int J Med Sci and Nurs Res 2021;1(1):12-16.
Int J Sci and Med Res 2021;1(2):1–9
Inrnational Journal of Medical Sciences and Nursing Research 2021;1(1):12-16 Page No: 12
Devarajan S et. al. Impact of lockdown on sleep wake cycle and psychological wellbeing
different groups of people during and after lockdown. The main measure of the respondent's self-perceived success in important areas
objectives of our present study was to find the variations in the sleep- such as relationships, self-esteem, purpose, and optimism. [9] The
wake cycle between genders; to find the variations in the sleep-wake scale provides a single psychological well-being score. Once the
cycle between adolescents, adults and middle Ages; to find the variations form was filled up, the responses of each individual was recorded.
in the sleep-wake cycle between males and females of different age The same procedure of administration was made in March 2021 with
groups in workdays and free days; to find the difference in the the same participants as before. Both the responses were collected
Psychological wellbeing scores of people of different age groups during and recorded. Data Management: Data were entered and complied
and after lockdown; and to compare the difference in the Psychological using Microsoft Excel 2010 [Microsoft Ltd., USA]. Data were
wellbeing scores of males and females during and after lockdown. analyzed using SPSS 20.0 version [IBM Ltd., USA].
Need for the study: There was much research, finding the association Statistical Analysis: The categorical variables were presented using
of COVID-19 with major psychological distress and significant descriptive analysis like frequency and percentages. Measures of
symptoms of mental health illness. The sudden implementation of a central tendency like mean. Paired t-test was used to find the
nationwide curfew by the government of India on 24 March 2020 had difference between flourishing scale scores during and after
put a barrier in the daily functioning of every individual. The lifestyle of lockdown. p<0.05 was taken as statistically significant.
every human, right from kids to old age people was upended and the
focus was on social distancing, quarantine, and other health care Ethical Consideration: This study was done with proper permission
measures. They had no chance to avail themselves of much of the social and willingness from all study participants.
settings (educational institutions, working places, sacred sites, etc...)
which made them remain in their home. Some studies have concluded Results:
that there is no uniform effect of the lock down on sleep quality. [7, 8]
Hence the need of our study is to specify the effect of lock down on the In our present study, we have recruited and incorporated 304
sleep-wake cycle based on age differences and gender differences and its participants. Out of 304 participants, 151 (49.7%) were male and 153
impact on the Psychological wellbeing of the common population. (50.3%) were female. More or less equal no. of the participants in all
age-groups. Age group among gender classification as shown in
Materials and Methods: Table – 1.
In our present cross-sectional and descriptive study, we have included Table - 1 Distribution of demographic data among gender
304 participants belonging to Coimbatore, South India including males classification
and females with an inclusion of aged between 15 and 60 years were
selected using convenience sampling method. Our study assessed the Age groups Gender Classification No. of Responses
same participants in 2 different time ranges. Those who were not willing
they were excluded from this study. The first response was collected ( %)
during May 2020 (during lockdown) and the second response was
collected during March 2021 (after the lockdown). In May 2020 an Males 50 (16.4)
Adolescence
informed consent was taken from the participants and the questionnaire
was administered through social media using google forms. First, the (15 to 18 years) Females 52 (17.1)
participants were asked to fill up their socio-demographic details and
were asked to read the questions carefully before answering them. They
were also asked to answer the questions one by one as in the order in the Adulthood Males 50 (16.4)
questionnaire.
(19 to 40 years) Females 51 (16.8)
Assessment tools and its descriptions:
(1). The Munich Chronotype Questionnaire (MCTQ) and Males 51 (16.8)

(2). Flourishing Scale Middle age
1. The Munich Chronotype Questionnaire (MCTQ): This (41 to 60 years) Females 50 (16.4)
questionnaire was developed by Till Roenneberg and Martha Merrow at
Ludwig- Maximillian’s University (LMU). It is a self-rated scale to find
out the differences in the sleep wake pattern in work days and free days The patterns of variations seen in the Sleep wake cycle of the
for ages 6 to 65 years. It is a tool to collect information regarding sleep Participants in terms of (a). Time at which they get ready to sleep, (b).
time, sleep latency, and sleep inertia. Time at which they go to bed, (c). Time needed to fall asleep, (d).
Time at which they wake up, (e). The time taken to get out of the bed
2. Flourishing Scale: The Flourishing Scale is a brief 8-item summary after waking up as shown Table – 2.
Table – 2 Variations in sleep - wake time among different Table – 3 Flourishing scale scores – During Lockdown and
age-groups during and after lock down after lockdown
During Lockdown After Lockdown
Adolescent Males 24 Adolescent Males 36
Adolescent Females 22 Adolescent Females 45
Adult Males 34 Adult Males 47
Adult Females 30 Adult Females 44
Middle age Males 32 Middle age Males 38
Middle age females 31 Middle age females 39
The average Flourishing scale scores during and after lockdown

was 28.83 ± 4.75 and 41.50 ± 4.42. The mean value was more in
after lockdown period and a paired t-test showed statistically
significant difference with a critical value of -5.240 at p-value <0.01
as shown in Figure – 1.
Figure – 1 Distribution and comparison of average of

Flourishing scale scores between during and after
lockdown
Discussion:
This present cross-sectional and descriptive study was done with a
sample of 304 participants. They were administered with The
Munich Chronotype Questionnaire (MCTQ) and The Flourishing
The Flourishing scale score was very high in adult males and very low scale. The responses were collected during and after lock down.
score in adolescent females in during lockdown. The Flourishing scale Middle-aged people get ready to sleep earlier, both during and after
score was very high in adult males and low in adolescent males in after lockdown.
Gender difference: On workdays, both during and after lockdown
lockdown as shown in Table – 3.
Males get ready to sleep later. On free days, during the lockdown
both Males and Females get ready to sleep relatively at the same time 5. GETTING OUT OF BED:
whereas, after lock down, Females get ready to sleep later. From
adolescence through early adulthood, sleep duration is Age difference: Adolescents get out of bed late, Middle-aged get out
developmentally patterned. [11] of bed soon, both during and after lockdown. A finding suggests that
there is an increased risk of late -onset of dementia due to short sleep
2. GOING TO BED duration in midlife. [18]
Age difference: During workdays there is a shift of bedtimes to late Gender difference: On workdays, during lock down males got out
hours [12] which supports our finding - During the lockdown, Early of bed late, and after lockdown, Females got out of bed late. On free
adults go to bed later and adolescents go to bed earlier. After lock days, both during and after lockdown, Males got out of bed late. As
down, adolescents go to bed later whereas Middle-aged people go to women with Chronic Insomnia Disorder (CID) get older, they
bed-earlier. increase time spent in bed to maintain the sleep time, but remain with
a resultant increase in the wake. [19]
Gender difference: On workdays, during lock down Males goes to
bed late whereas after lock down Females go to bed late. All age groups 6. PSYCHOLOGICAL WELL BEING:
show increased usage of digital media, especially males. On free days,
during lock down Females go to bed late whereas, after lock down, Age difference: The Psychological wellbeing of adolescents seem to
Males go to bed late. In comparison to other circadian – types during be profoundly affected when compared to that of adults and middle
pandemic evening – types had an alarming increase in sleep and mental aged due to lock down. [20]
health problems. [13]
Gender difference: The Psychological wellbeing of women of
3. TIME NEEDED TO FALL ASLEEP: different age groups seem to be profoundly affected when compared
to that of men due to lock down. [20]
Age difference: Adolescents took more time to fall asleep, both during
and after lockdown. Middle-aged took less time to fall asleep, both Conclusion:
during and after lockdown. Changes in both the weekend bedtime and
wakeup time had detrimental effects on the brain which led to poor Sleep wake problems were found to be present commonly during the
school performance. [14] COVID-19 lock down. From our study, we could infer that there was
a variation of sleep-wake cycle among males than in females. The
Gender difference: On workdays, both during and after lock down variation of the sleep-wake cycle was more in adolescents, relatively
Males took more to fall asleep. On free days, both during and after less in adults and much less in middle aged. The variation of the
lockdown Females took more time to fall asleep. Certain adverse sleep-wake cycle could be seen more during free days rather than on
childhood experiences such as physical, sexual, and emotional abuse working days. The Psychological wellbeing of individuals of different
and neglect have a lasting impact on sleep quality in adulthood, age, Gender is found to be better after lockdown than during lockdown
highlighting the need to mitigate their impact to prevent negative health
outcomes associated with poor sleep quality. [15] Implications: Our study has a diverse group for assessment,
consisting of gender and age difference along with the variation in the
4. WAKE UP TIME: sleep-wake cycle during workdays and free days, which helps to
determine the severity of the physical and psychological problem for
Age difference: Middle-aged people woke up early and early a particular group of people which would help to improve the work-
adulthood woke up late, both during and after lockdown. Sleep profiles life balance. It further helps in addressing the problems created by the
are associated with cardio metabolic health in adults and children. The varied sleep wake cycle of students in adolescence in their academic
overall good sleeper pattern is associated with more favorable cardio performance.
metabolic health. Middle-aged woke up early. A study concludes a
sleep loss on free days (resulting from more overall sleep during
workdays in non-system relevant jobs on adulthood of well-educated
Limitations:
participants aged between 25 – 65 years and Adolescent woke up late,
both during and after lock down. [16] 1. Our study comprises people belonging only to a particular part of
India – living in southern part of the country.
Gender difference: On workdays, both during and after lockdown 2. Our study comprises people belonging only to the age group of
Females woke up early. In free-days, both during and after lockdown adolescence, early adulthood, and middle adulthood.
Females woke up early. Reports from 3,778 young adults (20.6±0.86 3. This study was cross-sectional, conducted at a specific period
years) indicate a higher prevalence of poor sleep quality in females than which comprises a single phase of lock down.
males (65.1% vs 49.8%). [17] On workdays, both during and after lock 4. The present study estimates the variation of the sleep-wake cycle
down Males get up early. On free days, during lock down Males woke among participants but does not infer any health effects.
up early but after lock down, Males and Females woke up at a relatively
similar time.
Recommendations: 7. Sinha M, Pande B, Sinha R. Impact of COVID-19 lockdown on

sleep-wake schedule and associated lifestyle related behavior: A
1. For much more precise results people from different temperatures, national survey. Journal of Public Health Research
zones be included in the study. 2020;9(3):1826. DOI: 10.4081/jphr.2020.1826.
2. Future studies can include people from the age groups of childhood 8. Kocevska D, Blanken TF, Van Someren EJ, Rösler L. Sleep
and old age for better results. quality during the COVID-19 pandemic: not one size fits all. Sleep
3. Studies could be made longitudinal, for an extended period medicine 2020; 76:86-88. DOI: 10.1016/j.sleep.2020.09.029.
comprising multiple phases of lock down. 9. Martin CA, Hiscock H, Rinehart N, Heussler HS, Hyde C, Fuller-
4. Detrimental health effects due to variations in sleep wake patterns Tyszkiewicz M, et. al. Associations between sleep hygiene and
could be inferred with the future study. sleep problems in adolescents with ADHD: A cross sectional
study. Journal of attention disorders 2021;24(4):545-554. DOI:
Acknowledgement: Authors are very much thankful to the 10.1177/1087054718762513.
participants for their cooperation in the Covid-19 pandemic period. They 10. Maslowsky J, Ozer EJ. Developmental trends in sleep duration in
have acknowledged that the study is an original work and isn’t submitted adolescence and young adulthood: evidence from a national
for publication in any other form of Literature other than this. United States sample. Journal of Adolescent Health
2014;54(6):691-697. DOI: 10.1016/j.jadohealth.2013.10.201.
Authors Contribution: Conceptualization: GV, SD; Data 11. Florea C, Topalidis P, Hauser T, Angerer M, Kurapov A, Leon
curation: SD, SM, TV; Formal analysis: GV; Investigation: SD, SM, CAB., et. al. Sleep during COVID-19 lockdown: A cross-cultural
TV; Methodology: GV; Software: SD; Supervision: GV Writing – study investigating job system relevance. Biochemical
original draft: SD, SM, TV, and GV; Writing – review & editing: GV. Pharmacology 2021;114463. DOI:10.1016/j.bcp.2021.114463
12. Merikanto I, Partinen M, Kortesoja L, Benedict C, Chung F,
Here, SD – Sonali Devarajan, SM – Samyuktha Mylsamy, TV – Cedernaes J, et. al. Evening-types show the highest increase of
Tamizhini Venkatachalam, GV – Gobinath Veerasamy. sleep and mental health problems during the COVID-19
pandemic-Multinational study on 19,267 adults. Sleep, 2021;
Source of funding: The study wasn’t funded by any DOI:10.1093/sleep/zsab216
source/institutions other than that of the authors. 13. Urrila AS, Artiges E, Massicotte J, Miranda R, Vulser H, Bézivin-
Frere P, et. al. Sleep habits, academic performance, and the
Conflict of interest: Authors declared that they have no conflict of adolescent brain structure. Scientific reports 2017;7(1):1-9. DOI:
interest in this study. 10.1038/srep41678
14. Chighaf Bakour, Jill Desch, Fahad Mansuri, Skai W Schwartz.
References: Sleep 2021;44(2):A132-A133. DOI: 10.1093/sleep/zsab072.330
15. Matricianni L, Pacquet C, Fraysee F, Grobler A, Wang Y, Baur L,
1. Targa AD, Benítez ID, Moncusí-Moix A, Arguimbau M, de Batlle et. al. Sleep and cardiometabolic risk: a cluster analysis of
J, Dalmases M, et. al. Decrease in sleep quality during COVID-19 actigraphy-derived sleep profiles in adults and children. Sleep
outbreak. Sleep and Breathing 2021;25(2):1055-1061. DOI: 2021;44(7):zsab014. DOI: 10.1093/sleep/zsab014.
10.1007/s11325-020-02202-1. 16. Fatima, Y., Doi, S. A., Najman,J. M., & Al Mamun, A. Exploring
2. Salehinejad MA, Majidinezhad M, Ghanavati E, Kouestanian S, gender difference in sleep quality of young adults: findings from
Vicario CM, Nitsche MA, et. al. Negative impact of COVID-19 a large population study. Clinical medicine & research 2016;4(3-
pandemic on sleep quantitative parameters, quality, and circadian 4):138-144. DOI:10.3121/cmr.2016.1338
alignment: Implications for health and psychological well-being. 17. Sabia S, Fayose A, Dumurgier J, van Hees VT, Paquet C,
EXCLI journal 2020;19:1297-1308. DOI: 10.17179/excli2020- Sommerlad A, et. al. Association of sleep duration in middle and
2831. old age with incidence of dementia. Nature Communications
3. Gupta R, Grover S, Basu A, Krishnan V, Tripathi A, Subramanyam 2021;12(1):1-10. DOI: s41467-021-22354-2
A, et al. Changes in sleep pattern and sleep quality during COVID- 18. J J Hong, H Lee, I Yoon. 0845 The Difference in Sleep
19 lockdown. Indian journal of psychiatry 2020;62(4):370-378. Characteristics of Chronic Insomnia Disorder According to
DOI: 10.4103/pschiatry.IndianJPsychiatry_523_20. Gender and Age. Sleep 43(Suppl_1):A322. DOI:
4. Ono BHS, Souza JC. Sleep and immunity in times of COVID-19. 10.1093/sleep/zsaa056.841.
Revista da Associação Médica Brasileira 2020; 66:143-147. DOI: 19. Lee Di Milia, Ana adan, Vincenzo Natale, Christoph Randler.
10.1590/1806-9282.66.S2.143. Reviewing the Psychometric Properties of Contemporary
5. Alfonsi V, Gorgoni M, Scarpelli S, Zivi P, Sdoia S, Mari E, et. al. Circadian Typology Measures, Chronobiology international
COVID‐19 lockdown and poor sleep quality: Not the whole story. 2013;30(10):1261-1271. DOI: 10.3109/07420528.2013.817415
Journal of Sleep Research 2021;e13368. DOI: 10.1111/jsr.13368. 20. Marelli S, Castelnuovo A, Somma A, Castronovo V, Mombelli S,
6. Staller N, Randler C. Changes in sleep schedule and chronotype Bottoni D, et. al. Impact of COVID-19 lockdown on sleep quality
due to COVID-19 restrictions and home office. Somnologie in university students and administration staff. Journal of
2021;25(2):131-137. DOI: 10.1007/s11818-020-00277-2. Neurology 2021;268(1):8-15.DOI:10.1007/s00415-020-10056-6.

Research 2021;1(2):19-23 Page No: 19

A study of modifiable and non-modifiable risk factors associated with
of diabetic nephropathy - A preliminary observational study in
Eastern Odisha, India
Suchanda Sahu1 , Manish Taywade2, Sujata Devi3, Saurav Nayak4, Dipti Sudha M5
1Associate Professor, Department of Biochemistry, 2Assistant Professor, Department of Community Medicine and Family Medicine, 3Assistant
Professor, Department of Medicine, 4Second year Junior Resident, Department of Biochemistry, 5First year Junior Resident, Department of
Biochemistry, All India Institute of Medical Sciences, Bhubaneswar, India
Abstract
Background: One of the commonest complications of poorly controlled Type 2 diabetes mellitus (T2DM) is Diabetic nephropathy (DN),
1Senior
which Resident, Department
occurs in 30-40% of Anesthesiology,
of DM Chettinad
cases. It is important Hospital
to identify theAnd Research
high-risk Institute,
group who areChennai,
likely toTamilnadu,
develop DN with 2the
India. Assistant Professor,
modifiable and
non-modifiable risk factors. This study had the objectives to estimate and correlate 3Professor
Department of Anesthesiology, Chettinad Hospital And Research Institute, Chennai, the levels of India.
Tamilnadu, the urine albumin creatinine
and HOD,ratio (UACR)of
Department
with age, anthropometric
Anesthesiology, measures,
Chettinad Hospital Andglycaemic
Researchcontrol markers,
Institute, Chennai,lipids and renal
Tamilnadu, function. To estimate each variable as independent and
India.
multivariate risk factors.
Materials and Methods: It was an observational and cross-sectional study conducted in a tertiary care centre in Eastern India. Totally, 221
consecutive ambulatory T2DM subjects were recruited after obtaining their written consent.
Results: The diabetics were classified as having diabetic nephropathy by the urine albumin creatinine ratio (ACR) of >30 mg/gm. 53.4% of
our study group had DN. There was a significant risk associated with PPBS with p=0.043 (<0.05), serum creatinine with p=0.032 (<0.05),
and urine albumin with p=0.0001 (<0.001). The multivariate regression analysis of all these variables there was a highly significant likelihood
ratio for predicting DN with p=0.0001 (<0.001) with a predictive value of 74.5% in females and 75% in males.
Conclusion: The additive factors contributed by the risk factors in prediction of DN will benefit the DM in prevention of DN.
Key words: diabetic nephropathy, risk factors, diabetic kidney disease, Asian Indian
SQuick Response Code: This is an open access journal, and articles are distributed under the terms of the
http://ijmsnr.com/
Corresponding Author: Dr. Suchanda Sahu,
Associate Professor, Department of Biochemistry, All India Institute of Medical
Sciences, Sijua, Dumduma (Post), Bhubaneswar, Odisha, India.
Email ID: biochem_suchanda@aiimsbhubaneswar.edu.in
Introduction
Diabetic nephropathy (DN) affects approximately 40% of the type 2 diabetes mellitus (T2DM) patients. [1] DN is diagnosed by the presence
of albumin in urine. They are classified as microalbuminuria and macroalbuminuria with urine albumin: creatinine ratio of 30 - 300 mg/gm
in the former and > 300 mg/gm in the latter. Microalbuminuria stage of renal involvement was termed as incipient nephropathy which may
already be present in T2DM at the time of diagnosis. [2] Progression of normo-albuminuria to micro and macroalbuminuria can occur silently
and faster with associated risk factors like dyslipidaemia, smoking habit, hypertension and poor glycaemic control. [3] In the South-Asian
population, there is an increased predisposition to DN irrespective of the central obesity, [4] hence the need to point causal factors to body fat
distribution initiating insulin resistance and inflammation. In routine management of diabetic patients, their blood and urine tests are done
annually to monitor the disease control and to screen for DN. Microalbuminuria is also associated with increased risk for cardiovascular
diseases and death. [1] Hence, it is imperative to adopt strategies for preventing the development of microalbuminuria and in delaying the
progression to advanced stages of DN. That can be achieved by good glycaemic control by maintaining glycated haemoglobin (HbA1C) at
7%, treating comorbidities like hypertension and dyslipidaemia.
Though microalbuminuria is the gold standard for screening and detection of DN, its determination in clinical laboratories are inconsistent
because of the immunoassay techniques used [5, 6]. In diabetics, the albumin in urine can be modified by non- enzymatic glycation and
How to cite this article: Sahu S, Taywade M, Devi S, Nayak S, Sudha DM. A study of modifiable and non-modifiable risk factors associated
with of diabetic nephropathy – A preliminary observational study in Eastern Odisha, India. Int J Med Sci and Nurs Res 2021;1(1):17-21
Sahu S et al., A study of modifiable and non-modifiable risk factors associated with of diabetic nephropathy
hydrolysis during its passage in the renal tubules. These modifications can decreased eGFR. The study participants were classified as having
underestimate the albumin by the antibodies used for assay [7, 8], thereby diabetic nephropathy by the UACR.
delay the detection of DN and its treatment. In this study we assessed the
correlation of ACR with non-modifiable risk factors like age and gender Table 1: Distribution of general characteristics of the study
of patient and with modifiable risk factors like body mass index (BMI), population (N=221)
waist hip ratio (WHR), atherogenic index (AI) calculated from fasting
blood lipid levels and HbA1C. No. of
Covariates Percentage
Patients
Age (in years) < 60 172 77.8
Material and Methods:
≥ 60 49 22.2
It was a cross-sectional comparative study on 221 ambulatory T2DM Gender Male 143 64.7
subjects conducted in a tertiary care centre in Eastern India after the Female 78 35.3
approval of the Institutional Ethical Committee (IEC- T/IMF/18-19/32). BMI <23 61 27.6
The cases were from our Non – Communicable Diseases (NCD) Out-
≥23 160 72.4
patients clinic (OPD), All India Institute of Medical Sciences,
Bhubaneswar, India, who attended for routine follow-up clinic during the WHR M, <0.90 8 5.6
month of March 2020. Convenient sampling was done due to the COVID- M ≥0.90 135 94.4
19 pandemic. Their clinical and anthropometric data were noted after F < 0.80 1 1.3
obtaining their written consent. 5ml of blood in fasting state and 10 ml of F ≥0.80 77 98.7
midstream spot urine was collected in different vacutainers and urine vials
for estimation of the following: serum creatinine, glycated haemoglobin HbA1C <7.0% 46 20.8
fasting (FBS) and post prandial blood sugar (PPBS), urine creatinine and ≥7.0% 175 79.1
albumin. The lipid profile included total cholesterol (TC), triglycerides AIP <0.24 20 9.1
(TG), high density lipoprotein (HDL) and low-density lipoproteins ≥0.24 201 90.9
(LDL). All the estimations were done the same day using the Beckman
ACR < 30 mg/gm 94 42.5
Coulter Chemistry Analyzer AU5800 (Beckman Coulter, Brea, USA).
≥ 30 mg/gm 127 57.5
The calculated parameters were body mass index (BMI), waist hip ratio eGFR > 90 ml/min 60 27.2
(WHR), atherogenic index of plasma (AIP) [9], urinary albumin: < 90ml/min 161 72.8
creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR). DN Absent 103 46.6
[10] The statistical analysis was done to compare the diabetics with and
Present 118 53.4
without DN. The comparison was done by Mann Whitney U test.
The relative risk estimates were calculated and the correlation was The comparison of the two groups by Mann Whitney U test. There
estimated for the independent variables by Spearman’s correlation as the was a significant difference in PPBS (p=0.013), HbA1C (p=0.041)
data were not normally distributed which was seen by the Kolmogorov- and UACR (p<0.001). There was no significant difference in the
Smirnov test. The comparisons between gender groups and those with and age, gender, BMI, WHR, FBS, lipid profile, AIP, serum creatinine
without DN were by Kruskal Wallis Test and post hoc test by Tukey’s and eGFR between the groups as shown in Table-2.
test. The multivariate regression was estimated for the independent
variables. All these were done using SPSS 19.0 version [IBM, Armonk, Association of risk factors with DN:
NY, USA]. p-value <0.05 was considered as statistically significant.
The risk estimate calculated using the cut off values for each
variable relevant to our population and as per gender wherever
Results:
applicable. Though there was a 10–20% increased risk for age >60
years, male gender, BMI, WHR, FBS, HbA1C, AIP and LDL
Clinical characteristics: There were 221 diabetic patients who consented
among the serum lipids and a 20% decrease in HDL had increased
to participate in the study. There were 143 males and 78 females. Table-
risk of DN, none were statistically significant as shown in Table-3.
1 shows the general clinical characteristics of the study participants.
Considering the anthropometric cut-off levels for Asian Indians, 72.4%
This may be because of the consecutive convenient sampling of one
were overweight and obese; 94.4 % of males and 98.7 % females had high
month evaluated as a preliminary study here. There was a
WHR. 79.1% had poor glycaemic control as seen by HbA1C and 90.9%
significant risk associated with PPBS (p=0.043), serum creatinine
had a high-risk dyslipidaemia as seen by the AIP. Though 53.4 % of our
(p=0.032), and urine albumin (p=0.0001).
study group had DN, a larger proportion of the total that is 72.8% had
Table 2: Differences Between Diabetic Nephropathy Group for Table 3: Risk Factors (Modifiable & Non-Modifiable) for Diabetic
Various Risk Factors Nephropathy
Diabetic
Diabetic Nephropathy Nephropathy
p Factors Parameters Classifications
Relative P
Parameters Risk Value
Absent Present value Absent Present
(n = 94) (n = 127)
Age 52 (43 – 60) 50 (43 – 58) 0.636 Non - Age (in <60 74 108
Modifiable 1.218 0.284
Male 62 (65.96%) 76 (59.84%) years) ≥60 20 19
Sex 0.353 Male 62 76
Female 32 (34.04%) 51 (40.16%) Sex 1.165 0.400
Female 32 51
25.30 25.34
BMI (kg/m2) 0.434 Modifiable BMI <23 20 41
(23.46 – 27.69) (22.22 – 28.06) 1.250 0.048
(kg/m2) ≥23 74 86
WHR 0.948 (0.91 – 0.99) 0.946 (0.91 – 0.98) 0.439
<0.9(M)/<0.85
FBS (mg/dl) 141.5 (121 – 179) 152 (122 – 221) 0.187 1 1
(F
WHR 1.177 1.000
PPBS (mg/dl) 208.5 (185 – 290) 245 (189 – 321) 0.013 ≥0.9(M)/
93 126
≥0.85(F)
HbA1C (%) 7.875 (7.08 – 8.8) 8.3 (7.2 – 10.3) 0.041
FBS <110 9 22
S. Creatinine 1.284 0.119
1 (0.8 – 1.1) 1 (0.8 – 1.2) 0.393 (mg/dl) ≥110 85 105
(mg/dl)
PPBS <140 3 0
eGFR 82.53 74.77 2.396 0.043
0.142 (mg/dl) ≥140 91 127
(ml/min) (66.67 – 94.31) (64.94 – 91.08)
<7 23 23
TC (mg/dl) 187 (161 – 210) 190 (159 – 227) 0.613 HbA1C (%) 1.232 0.315
≥7 71 104
TG (mg/dl) 153 (119 – 204) 149 (108 – 204) 0.648 ≤1.2(M)/
Serum 87 105
HDL (mg/dl) 44 (38 – 51) 46 (39 – 53) 0.160 Creatinine ≤1.1(F) 1.877 0.032
LDL (mg/dl) 110 (91 – 135) 114 (92 – 136) 0.740 (mg/dl) >1.2(M)/>1.1(F) 7 22
eGFR <90 67 94
AIP 0.557 (0.43 – 0.69) 0.529 (0.37 – 0.69) 0.280 1.062 0.650
(ml/min) ≥90 27 33
UACR 14.41 82.5
<0.001 <200 60 80
(mg/gm) (6.53 – 22.23) (46.95 – 190.43) TC
1.021 1.000
Bolded p-value < 0.05 Statistically Significant (mg/dl) ≥200 34 47
TG <150 44 65
1.077 0.587
The Spearman’s correlation (Table 4) of ACR with FBS, PPBS, HbA1C (mg/dl) ≥150 50 62
and u. albumin were positive with (p=0.028, <0.001, 0.001 and <0.001 HDL >35(M)/>39(F) 77 112
respectively) on overall estimation of all cases (not shown here). But on 0.767 0.246
(mg/dl) <35(M)/<39(F) 17 15
estimating the correlation in females, only PPBS correlated <100 36 42
LDL
significantly and in males there was significant positive correlation with 1.138 0.477
(mg/dl) ≥100 58 85
FBS, PPBS, HbA1C, serum creatinine and spot urine albumin was
≤0.24 6 14
negative with eGFR with p=0.028. The other individual independent AIP 1.245 0.343
factors like age, BMI, WHR, serum lipids and AIP did not correlate >0.24 88 113
significantly with ACR in both sexes. On doing a multivariate logistic Urine
regression analysis of all these variables [Table 5a and 5b] there was a Albumin <30 70 33 3.341 0.0001
(mg/L)
significant likelihood ratio for predicting DN (p=0.014 and 0.001 in
Bolded p-value < 0.05 Statistically Significant
females and males respectively) with a substantial predictive value of
74.5% in females and 75% in males by Cox and Snell R square. control (PPBS and HbA1C), more so in males as compared to females.
Similar results have been reported by authors in Asia [12] among Asians
Discussion: in Europe [4], and from heterogenous populations from 20 cohorts. [13]
Though strict glycaemic control decreased the risk for DN b 40%, it
Diabetic nephropathy is a common complication of T2DM. It is usually alone cannot prevent the initiation and progression of DN. [1] Majority
detected in late stages from where it rapidly progresses to end stage of our patients were overweight or obese and had higher WHR than
renal disease (ESRD). Early detection, good glycaemic control and normal. Though BMI associated significantly as a risk factor for DN
nephro-protective treatment can prevent ESRD. [11] Apart from this it with UACR, WHR didn’t. Neither of them was different in the two
is important to identify the subgroup among T2DM, likely to develop groups. There was no difference in gender as a risk factor for DN.
DN considering the modifiable risk factors like body fat, serum However, studies among Asians have shown that women who have DN
lipids, kidney function and glycaemic control. From our preliminary rapidly progress to ESRD as compared to their male counterparts. [14,
it is evident that there is a risk associated with biomarkers of glycaemic 15]
Table 4: Correlation of ACR with independent factors in the The baseline eGFR and kidney function are important factors in DN
diabetics grouped according to gender (N=221) risk and progression. [1] In our study though eGFR was not
significantly different in the two groups; with and without DN,
Females Males serum creatinine levels were a risk in both sexes and eGFR
Parameters Spearman's rho p Spearman's rho p negatively correlated with UACR in males as shown in Table-4. As
value value eGFR is closely related to age, baseline eGFR at the time of
Age (years) -0.137 0.228 0.032 0.703 diagnosis of T2DM and further monitoring to see the rate of decline
BMI (kg/m2) 0.05 0.661 -0.095 0.262 [16] is imperative for initiating treatment with antidiabetic agents
which will protect the kidneys also. [12]
WHR 0.008 0.947 -0.083 0.329
FBS (mg/dl) 0.085 0.455 0.176* 0.036 In our study, the serum lipids were not statistically different in the
PPBS (mg/dl) 0.267* 0.017 0.213* 0.011 two groups, yet studies have shown that HDL and TG are
HbA1C (%) 0.161 0.156 0.248** 0.003 independent risk factors for cardiovascular disease, systolic blood
pressure (SBP) being the measure. [13] As we have not considered
S. Creatinine 0.076 0.508 0.191* 0.022
the treatment naïve T2DM patients and we have not taken in account
(mg/dl)
the drug history of each participant, our statement for or against the
eGFR (ml/min) 0.043 0.705 -0.185* 0.028
association of serum lipids in DN will not be exact.
TC (mg/dl) 0.172 0.129 -0.005 0.956
TG (mg/dl) 0.060 0.601 -0.070 0.406 As T2DM involves multiple organs and its complications can
HDL (mg/dl) 0.111 0.332 0.030 0.724 coexist to varying degrees in individuals, multiple factors affect the
course of the disease. The multivariate regression analysis showed
LDL (mg/dl) 0.176 0.120 -0.011 0.901
significant predictive value of the risk factors considered in our
AIP -0.015 0.895 -0.073 0.387 study. Studies on identification of risk factors have identified similar
U. Albumin 0.752** 0.001 0.658** 0.001 factors and others like SBP, duration of disease, rate of decline in
(mg/L) eGFR, age and presence of diabetic retinopathy. [3, 12]
** Correlation is significant p<0.01; * Correlation is significant p<0.05
The strength of our study is that, though it is a preliminary study
Table 5a: Multivariate Regression of the independent variables as conducted during the lockdown for pandemic, the conjoined effect
risk factors for DN of the modifiable and non-modifiable risk factors showed substantial
predictive value. Our study is limited by the sample number and the
Model Fitting Information lack of drug history such as lipid lowering agents, antihypertensives,
insulin or oral hypoglycaemic agents.
Model Fitting Likelihood Ratio
Criteria Tests Conclusion:
Sex Model
Chi-
-2 Log Likelihood df Sig.
Square In conclusion, the findings of our study have implications in the
Intercept clinical scenario of diabetes. As the disease, T2DM is not only about
Female 107.981
Only current glycaemic control, but involves constant clinical and lab
Final 0 107.981 78 0.014 monitoring to evade complications. Patient education about disease
and empowering them with the knowledge and ability is more
Intercept important that medications alone. An overall change in diet,
Male 196.741
Only physical activity, and other lifestyle modifications should benefit
Final 0 196.741 141 0.001 each patient. Larger cohort studies are suggested to understand the
additive effects of risk factors.
Bolded p-value < 0.05 Statistically Significant
Table 5b: Predictive value of the multivariate analysis Acknowledgment: We acknowledge the consent and
Pseudo R-Square cooperation of our study participants and the help of other
department staff and colleagues.
Female Cox and Snell 0.745
Nagelkerke 1 Authors’ Contributions: SS, MT and SDM conceived the
McFadden 1 study design and initial draft of the manuscript. SD, SN and DSM
collected clinical data. SS and SN analysed the data. All the authors
Male Cox and Snell 0.75 edited and approved of the final draft of the manuscript.
Nagelkerke 1
Here, SS - Suchanda Sahu, MT - Manish Taywade, SD - Sujata
McFadden 1 Devi, SN - Saurav Nayak and, Dipti Sudha M - DSM
Source of funding: This study was done as intramural research 10. Cockcroft DW, Gault MH. Prediction of creatinine clearance
grant for Faculty from my Institute; All India Institute of Medical from serum creatinine. Nephron 1976;16(1):31–41. PMID:
Sciences (AIIMS), Bhubaneswar, India. 1244564
11. Żyłka A, Dumnicka P, Kuśnierz-Cabala B, Gala-Błądzińska A,
Conflict of Interest: The authors declare that there was no Ceranowicz P, Kucharz J, et al. Markers of Glomerular and
conflict of interest. Tubular Damage in the Early Stage of Kidney Disease in Type
2 Diabetic Patients. Mediators Inflamm 2018;2018:7659243.
References: DOI: https://doi.org/10.1155/2018/7659243
12. Huang CH, Chen CP, Huang YY, Hsu BRS. Modifiable factors
1. Gross JL, de Azevedo MJ, Silveiro SP, Canani LH, Caramori related to 7-year renal outcomes in subjects with type 2 diabetes
ML, Zelmanovitz T. Diabetic Nephropathy: Diagnosis, and chronic kidney disease stage 3. J Postgrad Med
Prevention, and Treatment. Diabetes Care 2005;28(1):164–176. 2020;66(4):187–193.
Available from: 13. Jiang W, Wang J, Shen X, Lu W, Wang Y, Li W, et al.
http://care.diabetesjournals.org/cgi/doi/10.2337/diacare.28.1.16 Establishment and Validation of a Risk Prediction Model for
4 Early Diabetic Kidney Disease Based on a Systematic Review
2. Van JAD, Scholey JW, Konvalinka A. Insights into Diabetic and Meta-Analysis of 20 Cohorts. Diabetes Care.
Kidney Disease Using Urinary Proteomics and Bioinformatics. 2020;43(4):925–933. PMID: 32198286
Journal of the American Society of Nephrology 14. Shen Y, Cai R, Sun J, Dong X, Huang R, Tian S, et al. Diabetes
2017;28(4):1050–1061. DOI: mellitus as a risk factor for incident chronic kidney disease and
http://doi/10.1681/ASN.2016091018 end-stage renal disease in women compared with men: a
3. Viswanathan V, Tilak P, Kumpatla S. Risk factors associated systematic review and meta-analysis. Endocrine
with the development of overt nephropathy in type 2 diabetes 2017;55(1):66–76. PMID: 27477292
patients: A 12 years observational study. Indian Journal of 15. Liu J-J, Liu S, Choo RWM, Wee SL, Xu A, Lim SC. Sex
Medical Research 2012;136:46–53. modulates the association of fibroblast growth factor 21 with
4. Chandie Shaw PK, Baboe F, van Es LA, van der Vijver JC, van end-stage renal disease in Asian people with Type 2 diabetes: a
de Ree MA, de Jonge N, et al. South-Asian type 2 diabetic 6.3-year prospective cohort study. Diabet Med 2018;35(7):880–
patients have higher incidence and faster progression of renal 886. PMID: 29653030
disease compared with Dutch-European diabetic patients. 16. Kerschbaum J, Rudnicki M, Dzien A, Dzien-Bischinger C,
Diabetes Care 2006;29(6):1383–1385. Winner H, Heerspink HL, et al. Intra-individual variability of
5. Greive KA, Eppel GA, Reeve S, Smith AI, Jerums G, Comper eGFR trajectories in early diabetic kidney disease and lack of
WD. Immuno–unreactive albumin excretion increases in performance of prognostic biomarkers. Sci Rep
streptozotoin diabetic rats. AM J Kidney Dis 2001;38:144–152. 2020;10(1):19743. DOI: https://doi.org.10.1038/s41598-020-
PMID: 11431194 76773-0
6. Qsicka TM, Comper WD. Characterization of
Immunochemically Non-reactive urinary albumin. Clin Chem
2004;50(12):2286–2291. PMID: 15388637
7. Burne MJ, Panagiotopoulus S, Jerums G, Comper WD.
Alterations in the renal degradation of albumin in early
experimental diabetes in the rat: a new factor in the mechanism
of albuminuria. Clin Sci (Lond) 1998;95(1):67–72. PMID:
9662487
8. Qsicka TM, Honlihas CA, Chan JG, Jerums G, Comper WD.
Albuminuria in patients with type 1 diabetes is directly linked to
changes in the lysosome-mediated degradation of albumin
during renal passage. Diabetes 2000;49:1579–1584. PMID:
10969843
9. Dobiásová M, Frohlich J. The plasma parameter log (TG/HDL-
C) as an atherogenic index: correlation with lipoprotein particle
size and esterification rate in apoB-lipoprotein-depleted plasma
(FER(HDL)). Clin Biochem 2001;34(7):583–588. PMID:
11738396

Patients’ Knowledge Regarding Cardiac Catheterization at Cardiac Specialty
Hospital in Slemani City of Iraq: A Descriptive Study
Bayan Omar1, Nian Hamaamin Ahmed2, Dlawer Dhufr Farhad3

1SpecialistNurse, Cardiac Specialty Hospital, Slemani City, Iraq. 2Manager–Cum–Specialist nurse, Cardiac Specialty Hospital, Slemani City,
Iraq. 3Cardiologist, Cardiac Specialty Hospital, Slemani City, Iraq.
Abstract
Background: Coronary heart disease refers to different condition of failing circulation of the heart and includes myocardial infarction (MI).
Cardiac catheterization (CC) is the inserting of a thin, hollow catheter into a chamber or vessel; it is done for diagnostic and intervention
purposes. Death charge from coronary heart disease have decreased in recent decennium, however coronary heart disease is still a major cause
of morbidity and mortality worldwide especially in developed country. In this study, we assessed the patients' knowledge regarding CC.
Materials and Methods: A descriptive study was conducted with a purposive sample of 250 patients were selected and included from
Cardiac Specialty Hospital in Slemani City, Iraq. This study was carried out in between November 2017 and October 2018. A self-conductive
questionnaire was used for data collection.
Results: Totally 250 patients were included in this study. Among 250 patients, 176 (70.4%) were males and 74 (29.6%) females. The validity
of questionnaire was estimated through a panel of experts related to the field of the study, and its reliability was determined through a pilot
study which was carried out on 105 patients who were selected purposively from the patient were admitted those who were undergone the
procedure at Cardiac Specialty Hospital in Slemani city. The majority of the participants were Kurdish 212 (84.8%) and more than a quarter
of the patient's age was in group 60 years and above. Among 250 patients, 202 (80.8%) were married and 117 (46.8 %) of study participants
were illiterate, 171 (68.4%) of them were unemployed, and 148 (59.2%) were lived in urban area.
Conclusion: Our present study showed that the majority of participants had low level of knowledge regarding CC as well as level of
knowledge from post-CC was higher than pre-CC procedure.
Key Words: patients’ Knowledge, cardiac catheterization, pre and post cardiac catheterization, Slemani City, Iraq
http://ijmsnr.com/
Corresponding Author: Mrs. Bayan Omar,
Specialist Nurse, Cardiac Specialty Hospital,
Slemani City, Iraq.
Email ID: omerbayan82@gmail.com
Introduction
“Cardiac catheterization (CC) is the inserting of a thin, hollow catheter into a chamber or vessel; it is done for diagnostic and intervention
purposes”. [1] Death charge from coronary heart disease have decreased in recent decennium, however coronary heart disease is still
a major cause of morbidity and mortality worldwide especially in developed country. Coronary heart disease refers to different
condition of failing circulation of the heart and includes myocardial infarction (MI), which is the one coronary heart disease that causes
most deaths. [2] Functions of the circulatory system and the heart are adversely affected by cardiovascular diseases such as
coronary thrombosis artery disease, cerebrovascular disease and peripheral vascular disease but coronary artery disease is a multifactorial
disease in the heart and Its occurrence depends on the bed cover of risk element, therefore, the more frequent risk factors for
atherosclerosis has a largest morbidity and mortality that occur by this disease. [3]
Percutaneous coronary intervention (PCI) is the gold methods for treating coronary artery disease and it is recommended to treat ST-
segment elevation myocardial infarction (STEMI) and unstable or chronic stable angina. [4] Percutaneous coronary intervention
is a non-surgical intervention and referred to coronary angioplasty that done for manage the narrowing of the coronary artery branches
of the heart resulting from accumulation of cholesterol plaques, this procedure must be done by cardiac specialist. [5] This process
How to cite this article: Omar B, Ahmed NH, Farhad DD. Patients’ Knowledge Regarding Cardiac Catheterization at Cardiac Specialty
Hospital in Slemani city Iraq. Int J Med Sci and Nurs Res 2021;1(1):22–28.
Omar B et al., Patients’ Knowledge Regarding Cardiac Catheterization
must be done in emergent, lanned or rescue condition for includes (patient’s age groups, gender, marital status, nationality,
revascularization strategy for coronary artery disease. [6] Opening monthly income, level of educational, residential area). And some
the blocked artery of the heart lead to improving blood flow for the question regarding cardiac catheterization (box- 1). Permission was
heart tissue and absence of chest pain, reoccurring myocardial infarction taken from the Slemani Directorate of Health to carry out this study
also sudden death may be prevented. [7] Coronary angioplasty is at the Slemani Cardiac Specialty Hospital in Slemani city. A 21
relatively considered as a low-risk procedure and has a rapid recovery, points scale was used to assess the knowledge of patients about
also it is useful to improve prognosis, relieve symptoms, decrease the 21 questions or recommendations that the patient must know
ischemic events, and improve functional capacity in the heart. [8] An before undergoing the procedure. One score was given for
expert nursing care delivered within an interdisciplinary team must be each correct answer, so the total was 21 scores. It was divided
present in the cardiac catheterization unit during performing percutaneous into three equal parts. Accordingly, those who scored 1–7 were
coronary intervention. [9] Monitoring vital signs, the sheath entrance considered as having low level of knowledge, those who scored 8-
site, peripheral pulses, capillary refill and chest pain must be measured 14 were considered as having medium level of knowledge, and
by the nurses because they have an important role in this procedure. [10] those scored 15–21 were considered as having high level of
All these observations are done while maintaining a patient’s sufficient knowledge. Data were enter in Microsoft excel 2010 [Microsoft
periods of rest, providing required perfusions of drugs, and monitoring Ltd., USA] and were analyzed by using Statistical Package for
the patient for their amounts of fluid intake and output. [11] Social Sciences (SPSS, version 22.0, IBM, USA). Chi- Square
test was used to find association between proportions. Fisher’s
Hemodynamic instability in response to invasive procedures is a exact test was used when the expected count of more than 20%
consequence of patients’ experience of anxiety and stress without any of the cells of the table was less than 5. A p-value <0.05 was
previous knowledge about it. The patients report feelings of discomfort considered as statistically significant.
and intolerance due to prolonged bed rest in a fixed position after
the procedure. [12] Nurses play a critical and important role in Results:
promotion of the patient’s information before and after the procedure.
[13] Psychological problems may decreased by Patient’s knowledge Two hundred fifty patients scheduled for cardiac catheterization had
about the procedure. [14] Giving verbal information for the patients been included in our present study. Their mean age (Mean + SD)
by nurses and physicians is considered as common routine useful way for was 59.54±10.56 years, ranging from 30 to 90 years. The median
educating the client’s pre coronary angioplasty in many hospitals and this was 60 years. It is evident that more than two thirds of patients aged
meaningfully leads to decrease the nursing work load, and also elevate 50-69 years, 15.6% aged less than 50 years, and 15.2% aged 70 years
the patients and nurses’ gratification, rest and forgiveness that related or older than 70. More than two thirds (70.4%) were males, and the
to the procedure. [15] However occurrence some complication by male: female ratio was 2.4: 1. Table –1 shows also that the majority
coronary angioplasty such as seudoaneurysm, hematoma, bleeding and of the patients (84.8%) were Kurdish, and 80.8% were married.
arterial occlusion, that as recorded not reach to more than 14% but in Regarding the income, 63.6% believe that their income was not
general it is a safe procedure. [16] Many studies recorded that age, sufficient for their daily needs, and around half (46.8%) of the
gender and body weight are considered as a common predisposing patients were illiterate. It is evident in the same table that 68.4%
factor for vascular complications. [17] Furthermore, types of were unemployed (or housewives), and only 16.8% were employed.
medications that administered during the coronary angioplasty and Finally, the table shows that 59.2% were living in urban areas. More
chronic disease elevate the risk of vascular complications. [18] Some than half (52%) of the studied sample had low level of knowledge,
patient during coronary angioplasty has a chance of a disaster 47.2% had medium level of knowledge, and only two patients
situation because experience life-threatening complications however most (0.8%) had high level of knowledge as shown in Figure–1. Results
of them are discharged successfully without any complications within a showed that the mean knowledge score was 7.2, ranging from 1 to
day. Managing complication need trained nurses to use critical 16. The median knowledge was found as 7.
assessment skills, and detect any vascular problem and apply suitable
interventions. [19] In our study the main objectives were to describe Nearly most of 99.6% the patients believe that the information
socio-demographic characteristics of the study sample; to find out regarding cardiac catheterization are necessary for them, but on
level of patients’ knowledge regarding cardiac catheterization the contrary, the proportions of patients who had knowledge
procedure; to find out the association between level of knowledge and about this information was low. More than 67.6% of the patients
some socio-demographic characteristics such as age groups, gender, had knowledge about the pain during the procedure, 58.4% of the
nationality, income, level of education, residential area and occupation patients knew that they would be awake during the procedure, and
status of the study sample and to find out differences between patient’s 57.2% had information about the area of insertion of the cardiac
level of knowledge in pre and post cardiac catheterization procedure. catheter. Less than 50% of the patients had information about the
other items presented in Table–2. It is evident in the table that
Materials and Methods: small proportion of the patients had information ‘when to eat
and drink after the procedure’, ‘when to take a shower’, ‘the period
This descriptive cross sectional- based study was carried out at Cardiac of rest after the procedure’, ‘when to resume heavy physical
specialty Hospital in Slemani City for the period of about eight months activities including sexual intercourse’ in addition to the other
from November 14th, 2017 to October 20th, 2018. The main sample of information mentioned in the table.
this study involved 250 patients which admitted there. A self-
conductive questionnaire was used for data collection was used to record In Table – 3, two patients with high knowledge score were combined
information about the patients such as: socio demographic data, which with those of medium knowledge for the sake of the statistical
analysis.
Table 1. Socio-demographic characteristics of the patients (N = 250) analysis. Lower the age, less proportions of medium knowledge, but
the differences were not significant with p-value=0.144 (p>0.05). It
Number of is evident in the table that 49.4% of males had medium knowledge
Socio-demographic
Patients Percentage compared with 44.6% of females had no significant with p=0.485
characteristics
(n) (>0.05). Regarding nationality, the highest proportion of medium
Age Groups (in years) knowledge was among the Arabs (63.9%) but the differences were not
< 50 39 15.6 significant with p=0.066 (>0.05). No significant association was
50-59 82 32.8 detected between marital status and knowledge with p=0.272 (>0.05).
The highest proportion of knowledge was among those with barely
60-69 91 36.4 sufficient income (60%), and the lowest (42.1%) was among those
≥ 70 38 15.2 with insufficient income with p=0.038 (<0.05). Significant with
Gender p=0.009 association was detected between knowledge and educational
Male 176 70.4 level, but the distribution was not consistent where the highest
Female 74 29.6 proportions of medium knowledge was among graduates of primary
Nationality and secondary schools (62.5%, and 59.2% respectively), while it was
54.5% among MSc holders. No significant association was detected
Kurdish 212 84.8 between occupation and the level of knowledge with p-value=0.613.
Arabic 36 14.4 Regarding residency, 54.1% of those living in urban areas had
Others 2 0.8 medium knowledge, compared with 44.9% and 27.3% among those
Marital status living in suburban and rural areas respectively and the test showed
Single 5 2.0 significant with p-value=0.017 (<0.05).
Married 202 80.8
More than half (60.5%) of the studied sample had low level of
Divorced 3 1.2 knowledge, (39.5%) had medium level of knowledge, but only two
Widowed 40 16.0 patients had high level of knowledge (1.6), (54.6%) of them had a medium
Monthly Income level and (43.7%) had a low level of knowledge. Results showed that
Sufficient 16 6.4 the post cardiac catheterization knowledge was more than pre cardiac
Barely sufficient 75 30.0 catheterization as shown in Figure–2.
Insufficient 159 63.6
Educational status Discussion:
Illiterate 117 46.8
Regarding socio-demographic characteristics of the study sample;
Primary 56 22.4 table one showed that most of the participants’age ranged between
Secondary 49 19.6 sixty years and above; most of them were male, majority of them were
Diploma 17 6.8 married and nearly a quarter of the patients had insufficient income
Degree and above 11 4.4 and unemployed. More than half of them were illiterate and lived in
Occupation Status urban area. The result regarding age, gender, marital status is agreed
with the study done in Australia 2009 which mentioned that the
Employed 42 16.8
number of female patients with coronary heart disease is generally
Unemployed 171 68.4 much lower than male. [20] Regarding level of knowledge figure one
Retired 37 14.8 in our results indicated that more than half of the participants had a low
Residence Areas level of knowledge, nearly half of them had a moderate level but
Urban 148 59.2 Alarmingly indicated that only two patients has a high level of
Semi Urban 69 27.6 knowledge, The results agree with the study done in Pakistan which
showed that majority of the patients who were booked for cardiac
Rural 33 13.2
catheterization were unable to properly describe the procedure. These
high points that the cardiac patients are not well alert with coronary
Figure: 1 Distribution of the patients’levels of knowledge heart disease. Also finding of the study demonstrate that more than
half of the participants had no any information about these questions
60% 52% which asked about; information regarding cardiac catheterization,
47.20% taking medications such as Aspirin, Plavix before the procedure,
50%
cardiac catheterization therapeutic procedure for opening the
40% narrowing of coronary artery, about time that should take rest after the
30% procedure and time of avoiding oral intake after the procedure, but
20% Worryingly the results indicated that the majority of the patients had
10% no any information about these questions; indication of existing some
0.80%
investigations such as: blood urea, serum creatinine, time of taking a
0%
shower after the procedure, avoid doing heavy activities after the
Low (1-7) Medium (8-14) High (≥15) procedure especially sexual intercourse, complications of cardiac
Knowledge Scores catheterization, such as bruising, bleeding, and allergic reactions to the
dye or medications, theaim and amount of drinking clear fluid
preferably water after the process.
Table 2. Distribution of patients’ knowledge about the regulations and guidelines (N = 250)
I don’t know Uncertain I know
Knowledge Questions
n (%) n (%) n (%)
Do you have any information about cardiac catheterization? 148 (59.2) 85 (34.0) 17 (6.8)
Do you know checking vital signs is necessary before the

98 (39.2) 54 (21.6) 98 (39.2)
procedure?
Do you know the ECG need before the procedure? 93 (37.2) 47 (18.8) 110 (44.0)
Do you know about continuation or stoppage of your medications before the

110 (44.0) 54 (21.6) 86 (34.4)
procedure?
Do you have information about taking medications such as Aspirin, Plavix before
167 (66.8) 25 (10.0) 58 (23.2)
the procedure?
Do you understand that Cardiac catheterization is a diagnostic procedure for
coronary artery occlusion? 124 (49.6) 10 (4.0) 116 (46.4)
Do you know that cardiac catheterization is a therapeutic procedure for opening

the narrowing of coronary artery? 139 (55.6) 10 (4.0) 101 (40.4)
Do you know that you will be awake during the procedure?

71 (28.4) 33 (13.2) 146 (58.4)
Do you know you should do these investigations such as (blood urea, serum
creatinine, Hepatitis and HIV before procedure and there aims? 223 (89.2) 21 (8.4) 6 (2.4)
Do you have information about existing pain during cardiac catheterization?

70 (28.0) 11 (4.4) 169 (67.6)
Do you know when you can take a shower after the procedure? 218 (87.2) 12 (4.8) 20 (8.0)
Do you know for how long you should take rest after the procedure?
135 (54.0) 44 (17.6) 71 (28.4)
Do you know for how long you should avoid oral intake after the procedure?
155 (62.0) 60 (24.0) 35 (14.0)
Do you know for how long you should avoid doing heavy activities after the
procedure especially sexual intercourse? 202 (80.8) 30 (12.0) 18 (7.2)
Do you know any complications of cardiac catheterization, such as bruising,

bleeding, heart attack and allergic reactions to the dye or medication? 207 (82.8) 38 (15.2) 5 (2.0)
Do you know the procedure avoided if you have severe uncontrolled

hypertension? 94 (37.6) 54 (21.6) 102 (40.8)
Do you believe that the information regarding cardiac catheterization are
necessary for you? 0 (0) 1 (0.4) 249 (99.6)
Do you know the aim and amount of clear fluid preferably water after cardiac
catheterization? 234 (93.6) 10 (4.0) 6 (2.4)
Do you know the cardiologist administer mild sedative medication before the
procedure? 95 (38.0) 49 (19.6) 106 (42.4)
Do you know the area for performing a cardiac catheterization insertion in the
human body? 28 (11.2) 79 (31.6) 143 (57.2)
Table: 3 Association between severity and demographic variables Figure: 2 Differences of pre and post cardiac catheterization
procedure with patients’ level of knowledge
Medium
High Total
and Low
Variables p-value 70%
n % n % N % 60.50%
130 52.0 120 48.0 250 100 60% 54.60%
Age Groups (in Years)
50% 43.70%
< 50 17 43.6 22 56.4 39 100.0 39.50%
40%
50 – 59 41 50.0 41 50.0 82 100.0
0.144 30%
60 – 69 46 50.5 45 49.5 91 100.0
20%
≥ 70 26 68.4 12 31.6 38 100.0
Gender 10% 1.60%
0%
Male 89 50.6 87 49.4 176 100.0 0%
0.485 Low (1-7) Medium High (≥15) Low (1-7) Medium High (≥15)
Female 41 55.4 33 44.6 74 100.0 (8-14) (8-14)
Nationality
Pre Cardiac Catheterization Post Cardiac Catheterization
Kurdish 116 54.7 96 45.3 212 100.0 Procedure Procedure
Arabic 13 36.1 23 63.9 36 100.0 0.066
Others 1 50.0 1 50.0 2 100.0 catheterization and angioplasty and our nurses has no enough time for
Marital status explain pre and post procedure for the patients however explaining and
Single 3 60.0 2 40.0 5 100.0 understanding patients regarding the procedure is considered as the
heart of the science of nursing and it is a comprehensive ideal of caring
Married 100 49.5 102 50.5 202 100.0 [21]. Table-3 showed that the lower the age, the less the proportions
0.272
Divorced 1 33.3 2 67.7 3 100.0 of medium knowledge, but the differences were not significant (p=
0.144) the reason of this result related to performing this procedure
Widowed 26 65.0 14 35.0 40 100.0
previously.
Income
Sufficient 8 50.0 8 50.0 16 100.0 There are very highly significant association with p–value=0.009
Barley (p<0.001) between knowledge and educational level, but the spreading
30 40.0 45 60.0 75 100.0 0.038
sufficient was not regular where the highest proportions of medium knowledge
Insufficient 92 57.9 67 42.1 159 100.0 was among graduates of primary and secondary schools while more
Educational Status than of half of them was among MSc holders. No significant
Illiterate 74 63.2 43 36.8 117 100.0 association was discovered between occupation and the level of
Primary 21 37.5 35 62.5 56 100.0 knowledge with p–value=0.613 (p>0.05). Concerning residency, more
Secondary 20 40.8 29 59.2 49 100.0 0.009 than half of those living in urban areas had medium knowledge,
Diploma 10 58.8 7 41.2 17 100.0 matched with nearly half and nearly a quarter among those living in
suburban and rural areas respectively p=0.017 (<0.05). The
B.Sc. &more 5 45.5 6 54.5 11 100.0
consciousness regarding post angioplasty complications and factors
Occupation Status
that raises chance of restenosis will increase clients’obedience to drugs
Employed 21 50.0 21 50.0 42 100.0 and will also decrease morbidity and mortality rates among coronary
Unemployed 87 50.9 84 49.1 171 100.0 0.613 heart disease patients [22].
Retired 22 59.5 15 40.5 37 100.0
Residence Areas There are only two patients had a high level of knowledge, more than
Urban 68 45.9 80 54.1 148 100.0 half of them had a medium level and nearly half of them had a low level
Sub-urban 38 55.1 31 44.9 69 100.0 0.017 of knowledge in post-CC procedure but in pre -CC procedure more than
Rural 24 72.7 9 27.3 33 100.0 half of the participants had low level of knowledge, less than half had
Bolded p-value < 0.05 Significant medium level of knowledge. Results showed that the post cardiac
catheterization knowledge was more than pre cardiac catheterization.
This result related to many reasons; first of all we have to say that the This result related to understanding the procedure after doing it and they
cardiac specialty hospital in Slemani prepared most of this information sow and heard many thing during the procedure.
by handout for every patients but as a result showed than two thirds of
patients were old age and nearly half of them were illiterate. So, they Conclusion:
cannot read the instructions and their relative did not read for them, or
some patient obtain information from physician but forget it Our study finding results showed that more than half of the
furthermore we have a many patient which planned cardiac participants had a low level of knowledge but surprisingly indicated
that only two patients has a high level of knowledge regarding Association Task Force of Practice Guidelines (ACC/AHA/SCAI
pre and post cardiac catheterization. Most of participants were Writing Committee to Update the 2001 Guidelines for
believed that the information regarding cardiac catheterization is Percutaneous Coronary Intervention). Circulation
necessary for them. Nevertheless, this outcomes could be of great 2006;113(1):156-175 PMID: 16391169
help to higher specialists as we have recognized subset of population 5. Oberhauser JP, Hossainy S, Rapoza RJ. Design Principles
that specially needs to be directed through alertness programs as well and Performance of Bioresorbable Polymeric Vascular
as suggest that urgent and Targeted awareness programs must be Scaffolds. Euro Intervention 2009;5SupplF:F15-22. PMID:
introduced, so a special person must be selected to explain full 22100671
cardiac catheterization procedure for every patient who planned this 6. Rolley JX, Salamonson Y, Wensley C, Dennison CR, Davidson
process. Also more than half of them had information about the area PM. Nursing clinical practice guidelines to improve care
for performing a cardiac catheterization insertion in the human body. for people undergoing percutaneous coronary interventions.
The study demonstrated that the lower the age, the less the Aust Crit Care 2011;24(1):18-38. PMID: 20833062
proportions of medium knowledge, but there is no differences between 7. Alhalaiqa F, Abu-Shbeeb I, Batiha AM, Masa’Deh R, Amarneh
them. B. The Relation of Demographic Characteristics with Fatigue
Levels among Coronary Heart Disease Patients: A Jordanian
Implications for practice: Study. Adv Studies in Biology 2015;7:301-322. DOI:
10.12988/adb.2015.5418
1. Every physician must be explain the patients regarding pre and 8. Fraker TD Jr, Fihn SD, 2002 Chronic Stable Angina Writing
post CC in his clinic before the procedure. Committee, American College of Cardiology, American Heart
2. Nurses should be given more opportunities to participate Association, Gibbons RJ, et al. 2007 Chronic Unstable Angina
symposia regarding coronary heart disease to increase ability of Working Committee. Chronic angina focused update of the
advice and giving instruction for patients regarding CC process, and ACC/AHA 2002 guidelines for the management of patients with
put a special person for that goal. chronic unstable angina: A report of the American College of
3. This field needs to much more scientific research to provide Cardiology/American HeartAssociation Task Force on Practice
adequate knowledge for patients during preparation of patients Guidelines Working Group to develop the focused update
regarding cardiac catheterization. of the 2002 guidelines for the management of patients with
chronic stable angina. J Am Coll Cardiol 2007;50(23):2264-
Authors’ Contributions: BO, NHA: Study conception and 2274. PMID: 18061078
design; BO: Data collection; BO and NHA: data analysis, draft 9. Rezaei-Adaryani M, Ahmadi F, Asghari-Jafarabadi M. The
manuscript preparation. BO, NHA and DDF authors reviewed the effect of changing position and early ambulation after cardiac
results and approved the final version of the manuscript. catheterization on patients' outcomes: A single-blind randomized
controlled trial. Int J Nurs Stud 2009;46(8):1047-1053. PMID:
Here, BO – Bayan Omar; NHA – Nian Hamaamin Ahmed; and DDF – 19296949
Dlawer Dhufr Farhad 10. Saifan A, Bashayreh I, Batiha AM, AbuRuz M. Patient- and
Family Caregiver-Related Barriers to Effective Cancer Pain
Source of funding: We didn’t get any kind of funding from any Control. Pain Manag Nurs 2015;16(3):400-410. PMID: 26025799
other financial institutions or organizations. 11. Hirsch AT, Duval S. Effective Vascular Therapeutics for Critical
Limb Ischemia: A Role for registry-based clinical
investigation. Circulation: Cardiovascular Interventions
Conflict of interest: The authors declare no conflict of interest. 2013;6(1):8-11. DOI:
10.1161/CIRCINTERVENTIONS.113.000127
References: 12. Ruffinengo C, Versino E, Renga G. Effectiveness of an
informative video on reducing anxiety levels in patients
1. Cardiac Catheterization. Available on: undergoing elective coronarography: an RCT. Eur J Cardiovasc
heartattack/diagnosing-a-heart-attack/cardiac-catheterization Nurs 2009;8(1):57-61 PMID: 18502689
[Last Accessed on: 20th November 2019] 13. Jamshidi N, Abbaszadeh A, Kalyani MN. Effects of video
2. Larsson, C.A. Common risk factors associated with acute information on anxiety, stress and depression of patients
myocardial infarction: Population-based studies with a focus undergoing coronary angiography. Pak J Med Sci
on gender differences. Department of Clinical Sciences, Lund 2009;25(6):901-905. Available on:
University 2011; ISBN: 978-91-86871-53-6 https://pjms.com.pk/issues/octdec209/article/article5.html
3. Girotto E, Andrade SM, Cabrera MAS, Ridão EG. Prevalência 14. Chair SY, LI KM, Wong SW. Factors that affect back pain
de fatores de risco para doenças cardiovasculares em among Hong Kong Chinese patients after cardiac catheterization.
hipertensos cadastrados em unidade de saúde da família. Acta Eur J Cardiovasc Nurs 2004;3(4):279-285 PMID: 15572016
Scient Health Sci 2009;31(1):77-82. DOI: 15. Steffenino G, Viada E, Marengo B, Canale R, Nursing and
10.4025/actascihealthsci.v3li1.4492 the Medical Staff of the Cardiac Catheterization Unit.
4. Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ and Effectiveness of video-based patient information before
King SB: ACC/ AHA/SCAI, Guideline update for percutaneous cardiac interventions. J Cardiovasc Med
percutaneous coronary intervention-summary article: a report (Hagerstown) 2007;8(5):348-353. PMID: 17443101
of the American College of Cardiology / American Heart 16.
16. Chhatriwalla AK, Amin AP, Kennedy KF, House JA, Cohen
DJ, Rao SV. National Cardiovascular Data Registry.
Association between bleeding events and in-hospital mortality
after percutaneous coronary intervention. JAMA
2013;309(10):1022-1029. DOI: 10.1001/jama.2013.1556
17. Burzotta F, Mariani L, Trani C, Coluccia V, Brancati MF,
Porto I, et al. Management and Timing of Access-Site Vascular
Complications Occurring after Trans-Radial Percutaneous
Coronary Procedures. Circ Cardiovasc Interv
2015;8:e002863 DOI:
10.1161/CIRCINTERVENTIONS.115.002863
18. Burzotta, F, De Vita M, Lefevre T, Tommasino A,
Louvard Y, Trani, C. Radial Approach for Percutaneous
Coronary Interventions on Chronic Total Occlusions:
Technical Issues and Data Review. Catheter Cardiovasc
Interv 2014;83(1):47-57 PMID: 23832527
19. Batiha AM, Obead KA, Alhalaiqa FN, Kawafha MM, El-
Razek, AA, Albashtawy M, et al. Quality of Life and Fatigue
among Jordanian Cancer Patients. Iran J Public Health
2015;44(12):1704-1705 PMID: 26811823
20. Corones K, Coyer FM, Theobald KA. Exploring the
information needs of patients who have undergone PCI. British
Journal of Cardiac Nursing 2009;4(3):123-130. Available at:
https://eprints.qut.edu.au/20857/1/c20857.pdf
21. Zamanzadeh V, Jasemi M, Valizadeh L, Keogh B, Taleghani
F. Effective factors in providing holistic care: A qualitative
study. Indian J Palliative Care 2015;21(2):214-224 DOI:
10.4103/0973-1075.156506
22. Belardinelli R, Paolini I, CianciG, Piva R, Georgiou D,
Purcaro A. Exercise training intervention after coronary
angioplasty: the ETICA trial. J Am Coll Cardiol
2001;37(7):1891-1900 PMID: 11401128


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International Journal of Medical Sciences and

Prof. Selvaraj Balasubramani, Malaysia Prof. Aswathy Sreedevi, India

Electronic – ISSN: New (Applied) Frequency: Quarterly Mode: Online

Introduction settlements or slums are facing increased challenges in preventing

Article Summary: Submitted: 02-August-2021 Revised: 30-August-2021 Accepted: 03-September-2021 Published:30-September-2021

geographically or by other means [7]. Ensuring equity / health equity is

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Smyrna Gnanasekaran1 , Mohana Rangam Thirupathi2, Ashok Kulasekar3

Keywords: Caudal, Analgesia, Postoperative, Ropivacaine, Dexamethasone, Dexmedetomidine

0 min 135.86± 15.63 126.90± 16.40 0.030

The FLACC score was comparatively less in the dexamethasone group

Limitations of this study:

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Shaju4, Senthilvel Vasudevan5

Corresponding Author: Dr. Madhusudhan Tammanaiah,

Statistical analysis: All data were procured retrospectively from a

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Int J Sci and Med Res 2021;1(2):1–9

(1). The Munich Chronotype Questionnaire (MCTQ) and Males 51 (16.8)

During Lockdown After Lockdown

Adolescent Males 24 Adolescent Males 36

Adolescent Females 22 Adolescent Females 45

Adult Males 34 Adult Males 47

Adult Females 30 Adult Females 44

Middle age Males 32 Middle age Males 38

Middle age females 31 Middle age females 39

The average Flourishing scale scores during and after lockdown

Figure – 1 Distribution and comparison of average of

Recommendations: 7. Sinha M, Pande B, Sinha R. Impact of COVID-19 lockdown on

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Research 2021;1(2):19-23 Page No: 19

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Bayan Omar1, Nian Hamaamin Ahmed2, Dlawer Dhufr Farhad3

I don’t know Uncertain I know

Do you know checking vital signs is necessary before the

Do you know about continuation or stoppage of your medications before the

Do you know that cardiac catheterization is a therapeutic procedure for opening

Do you know that you will be awake during the procedure?

Do you have information about existing pain during cardiac catheterization?

Do you know any complications of cardiac catheterization, such as bruising,

Do you know the procedure avoided if you have severe uncontrolled

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