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I S. Title
HEALTHCARE
Index
Authors Page
J
N. No.
01 Study of Socio-Demographic Profile of Anand Mugadlimath,
Poisoning Cases at Shri B M Patil M A Bagali and S R 80
Medical College Hospital and Research Hibare , D.I. Ingale,
Centre, Bijapur Neeraj Gupta,
Chandrashekar
Bhuyyar
C
02 Actinomycosis of Breast-A Case Report B. Arora, Sumit Giri,
D.R. Arora 85
03 Cell Adhesion Molecule Expression S. Indumathi,
Profiling of Human Umbilical Cord Rashmi Mishra, R. 89
Matrix and Adipose Stem Cells Harikrishnan, J.S.
Rajkumar
Neha Kantawala, M.
R
Dhanasekaran
04 Clinical Outcomes of AO Philos Plating Annamalai
for Proximal Humerus Fractures Regupathy 94
05 Prevalence of Overweight and Obesity Prasanna Kamath
among Adolescent School going B.T, Girish M 99
Children (12-15years) in Urban Area, Bengalorkar, Deepthi
South India. R, Muninarayan C,
Ravishankar S
R
06 Intra Rater and Inter Rater Reliability of Janakiraman
Sway Graph in Elderly Subjects Balamurugan, 106
Paulraj Anantha
Raja, Nagaraj.S
Ramachadran
Arunachalam
07 Significance of Various Sacral Mamatha H.,

“Let the science be your passion” Measurements in the Determination of Sandhya, Sushma 112
Sex in South Indian Population R.K., Suhani S.,
Naveen Kumar
08 A Study on Prevalence of Ischemic Rajesh Khoiwal,
Vol 4 / Issue 20 / Oct 2012 Heart Disease in Younger Age Group Sandeep Vaishnav 119
(<40 Years) in Patients with Metabolic
Syndrome
09 Unilateral incomplete superficial palmar Ch.Roja Rani,
arch-A case report B. Narasinga Rao, 125
M. Pramila Padmini
10 Determination of Age by Study of Skull Pragnesh Parmar,
Sutures Gunvanti B. Rathod 127

I S. Title
HEALTHCARE
Index
Authors Page
J
N. No.
11 Rate Pressure Product – A Diagnostic Sangeeta Nagpal,
Tool in Determining the Cardiovascular Kalpana Gupta, 134
Risk in Postmenopausal Women Jitendra Ahuja
12 Comparative Analysis of Communicable C.Kumaraswamy
And Non Communicable Diseases In Naidu, Y. Suneetha, 139
Rural And Urban Localities of Tirupati B. V. Sai Prasad
in India
C
13 Anomalous Origin of Hepatic Artery and Sunita Sethy, G.R.
its Relevance in Hepatobiliary Surgeries Nayak, D. Agrawal, 143
B. Mohanty,
R. Biswal
14 A Cross-Sectional Study of Awareness Ujwala U. Ukey,
About Hepatitis B among Nursing Satyanarayan Dash, 149
Students of Mims College at K. Rama Sankaram,
Vizianagaram, Andhra Pradesh N.R. Appajirao
R
Naidu, R.Sri Vidya
15 Body Sensor Network Security Using Umasankar K.,
Cryptography Approach Vetrivendan.R 156
16 Assessment of Knowledge and Yousef Aldebasi

Compliance Regarding Contact Lens 162
Wear and Care Among Female College
Students in Saudi Arabia
R
17 Variant Heads of Biceps Brachii Muscle Sharadkumar Pralhad
Sawant , Shaguphta 170
T. Shaikh, Rakhi
Milind More
“Let the science be your passion”
Vol 4 / Issue 20 / Oct 2012

STUDY OF SOCIO-DEMOGRAPHIC PROFILE OF POISONING CASES AT SHRI B M PATIL
Anand Mugadlimath et al
MEDICAL COLLEGE HOSPITAL AND RESEARCH CENTRE, BIJAPUR
STUDY OF SOCIO-DEMOGRAPHIC PROFILE OF POISONING CASES

AT SHRI B M PATIL MEDICAL COLLEGE HOSPITAL AND
RESEARCH CENTRE, BIJAPUR
IJCRR
Anand Mugadlimath1, M.A. Bagali2, S.R. Hibare1, D.I. Ingale1, Neeraj Gupta1,
Vol 04 issue 20
Chandrashekar Bhuyyar1
Section: Healthcare
Category: Research 1
Dept of Forensic Medicine and Toxicology, BLDEA’s B. M. Patil Medical College,
Received on: 11/08/12 Bijapur, Karnataka, India
Revised on:23/08/12 2
Dept of Forensic Medicine and Toxicology, Al-Ameen Medical College, Bijapur,
Accepted on:05/09/12 Karnataka, India
E-mail of Corresponding Author: dranandmdfm@gmail.com
ABSTRACT
A retrospective analysis of all poisoning cases admitted to Shri B M Patil Medical College Hospital &
Research Centre Bijapur, Karnataka from Jan 2010 to Dec 2010 was done to study the pattern of
poisoning reported. Acute poisoning is a common medical emergency and one of the important causes of
morbidity and mortality in developing countries due to easy availability of poisonous substances and its
low cost. So it was important to know the pattern of poisoning at to Shri B M Patil Medical College
Hospital & Research Centre Bijapur. Objective of the study was to evaluate the pattern of poisoning at a
tertiary care hospital in North-Karnataka (Bijapur), and to study the socio-demographic profile of the
same. Data collected using a pretested proforma and the values were analyzed and presented.
Key Words: Poisoning, organophosphrous compounds, kerosene.
INTRODUCTION which has been reported from southern and central

Massive use of pesticides in agriculture, rapid India9,10,11. According to WHO (1999) more than
industrialization and exposure to hazardous three million poisoning cases has been reported
chemical products, introduction of newer range of out of which 251,881 deaths occur world wide
drugs for treatment, , increased alcohol annually, of which, 99% of fatal poisoning occur
consumption, unhealthy dietary habits has in developing countries, predominantly among
widened the spectrum of toxic products to which farmers due to various kinds of poisoning,
people have been exposed as compared with the including poisonous toxins from natural products
early days1,2,3,4,5,6. Knowingly or unknowingly are handled 11,12. Therefore, an alarm for early
millions of people are exposed to danger by diagnosis, treatment and prevention is crucial in
hazardous occupational practices and unsafe reducing the burden of poisoning related injury in
storage3,6 of toxic chemicals products in their day any country.
to day life. Lack of specialized toxicological A comparative data revealed that in developed
services in developing countries like India has countries, the mortality rate due to poisoning is
further contributed to the higher rate morbidity only 1% to 2%, but in developing countries like
and mortality 1,4,2. Easy availability and low cost India it varies between 15% to 30% 13 and is the
of hazardous chemicals plays a major role in both fourth most common cause of mortality especially
accidental and suicidal poisoning in developing in rural India 2,14. It is very difficult to draw a
countries like India, Srilanka, South Africa etc report to say which kind of poisoning is more
1,3,4,6,7,8
. Most of the fatality rate is of intentional frequent, has the nature of poisoning varies from
poisoning by organophosphrous (OP) compound one region another depending upon the poison
Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

Page 80
availability and the knowledge and local females who admitted for poisoning 65% patients
population regarding the properties of poisons 2. were married and 35% were unmarried (Table 5).
So this study has been aimed to determine the The hospital stay of the admitted patients with
various parameters of poisoning such as type of poisoning ranged from 01 to 82 days and the mean
poisoning involved, the most vulnerable age group hospital stay was 6.9 days. During the study period
and their marital status with religions. 21 (5.55%) of the patients had mortality due to
poisoning (Table 6). 353 cases (93.3 %) with
METHODOLOGY poisoning admitted to the hospital were Hindus
The present retrospective study was conducted by followed by Muslims in 25 cases [6.61%] (Table
department of Forensic Medicine& Toxicology . 7).
Shri B M Patil Medical college, Bijapur, North Most common (51.6%) poison used for poisoning
Karnataka from Jan 2010 to Dec 2010. Data was were organophosphrous compounds 197 cases
collected from all the poisoning cases admitted (51.63%), in 118(31.21%) cases the type of poison
that were admitted & treated at BLDEAs B M was not known and were treated symptomatically
Patil Medical College Hospital & Research Centre (Table 4).
Bijapur. Information was collected into a proforma In our study 86.5% (327) of cases were from rural
on the type of poison consumed, incidence on age domicile and only 13.5 % (51) from urban
and sex, marital status, religions, hospitalization population (Table 8).In season wise distribution,
days were noted from records for each case and highest cases were recorded in the month of March
analyzed. & April (16.9% & 9.2%) (Table 9).
RESULTS DISCUSSION
In our study there were total of 378 patients Poisoning is a major public health problem in
brought to BLDEAs B M Patil Medical College Bijapur district, with thousands of poisonings and
Hospital & Research Centre Bijapur, of whom the hundreds of deaths every year cases coming to
data were collected during the 12 months study tertiary centre represent just tip of the iceberg.
period from Jan 2010 to Dec 2010 due to Keeping this background in mind, retrospective
suspected poisoning. Total number of 32904 IPD analysis of all poisoning cases admitted to Shri B
cases were registered during the study period and M Patil Medical College Hospital & Research
2197 MLC cases done, in which 378 cases Centre Bijapur, Karnataka from Jan 2010 to Dec
(6.67%) were due to poisoning (Table 1). 2010 was done to study the pattern of poisoning
Total number of male patients admitted to hospital reported. Suicide is one of the oldest and
due to poisoning was 199 (52.64%) and female considered the best trends of sacrificing their life
were 179 (47.35%) with the male: female ratio by consuming different poisonous substances
being 1.2:1 (Table 2). Majority (45.76%) of which are easily accessible to them compared
victims with suspected consumption of poison was other methods. The morbidity, mortality in any
in between 21 to 30 age group followed by the age case of acute poisoning depends upon number of
group between 11 to 20 (26.45% )( Table3). factors such as nature of poison dose consumed,
Insecticides were the most common poison used level of available medical facilities and time
for suicidal purpose by the entire victim aged interval between intake of poison and provision of
between 15-65 years irrespective of age (Table 4). medical help.
We also found that out 199 (52.64%) males came The sex incidence affected with poisoning was
with poisoning, 55 % patients were married and more with male which out numbered the female
45% patients were unmarried. Out of the 179 the ration being 1.7:1 and tallies with the other

Page 81
studies 4,8,15, 16,17,. In our study there is a male CONCLUSION

predominance (52.64%). The high incidence may We conclude that poising is a major public health
be because males are more exposed to stress, problem in Bijapur district, especially
strain and occupational hazards compared to organophosphrous poisoning. The reasons may be
females 2,11,18,19. In this study the most common – agriculture is the main occupation in this part of
age group involved was between 21-30 years country with easy availability of insecticide,
followed by the age group between 11- 20 years. illiteracy, and low socioeconomic status. young
Thus, adolescent and young adults are at more risk age persons commonly affected indicating role of
compared to other groups. Similar observations psychological counseling and by tackling their
were reported by studies in India and abroad 4, 8, problems sympathetically. We suggest the
17,20, 21, 22,
. government should regulate the import,
The hospital stay of the admitted patients with manufacture, sale, transport, distribution and use
poisoning ranged from 01 to 82 days. The mean of insecticides and pesticides with a view to
hospital stay was 6.9 days, similar findings were prevent risk to human beings. Other interventions
also observed in other studies as well20.In the can be creation of poison information centres,
present study 197 cases (51.63%) were due to introducing separate toxicological units in the
insecticidal organophosphrous poisons, which hospitals and upgrading the peripheral health
were the most commonly responsible agents for centres to manage cases of poisoning in
toxicity in poisoning cases. Similar types of emergency.
findings were noted by the authors11, 23, 24. We
observed that married person more often become ACKNOWLEDGEMENT
victim of poisoning which was found similar with Authors acknowledge the immense help received
other studies 4,15, 25.The reason of fact could be that from the scholars whose articles are cited and
the amount of stress carried by the married people included in references of this manuscript. The
on their day to day life is more than the single authors are also grateful to authors, editors and
males or females which makes them more publishers of all those articles, journals and books
vulnerable. from where the literature for this article has been
Patients who were admitted due to poisoning of reviewed and discussed.
which, 353 (93.38%) patients were Hindus
(76.35%) followed by Muslims in 25 (6.61%). REFERENCES
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percent of muslims in the rural population, served Amita Srivastava and Thomas Kaleekal. A
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Research Centre Bijapur. In our study majorly of Poisons Information Centre, All India Institute
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medical management. Trop Med Int Health. 19. Singh S, Wig N, Chaudhary D, Sood N K and
June 2005; 10(6):581- 588. Sharma B K. Changing pattern of acute
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Page 83
Tables Table 5- marital status

Table 1- Total number IPD and MLC cases during Sex Married Un -married
study period Male 109 (55%) 90 (45%)
Total Total MLC Total Female 116 (65 %) 65 (35%)
IPD Poisoning
cases cases Table 6- Survival of the victims following
32904 2197[17.20 %] 378 [6.67 %] consumption
Survived 357 [94.4 %]
Table 2- Sex wise distribution of cases Died 21- {5.55%]
Total Male Female Total 378 [100 %]
378 199 [ 52.64] 179 [ 47.35]
Table 7- Religion wise distribution of cases
Table 3- Age wise distribution of cases Religion No (%)
Age No of cases Percentage % Hindu 353 [93.38%]
< 10 7 1.85 Muslim 25 [6.61%]
11 to 20 100 26.45 Total 378 [100 %]
21 to 30 173 45.76
31 to 40 66 17.46 Table 8- Domicile wise distribution of cases
41 to 50 19 5.02 Domicile No (%)
51-to 60 9 2.38 Rural 327 [86.50%]
>60 4 1.05 Urban 51 [13.49 %]
Total 378 [100 %]
Table 4- Distribution of cases according to type of
poison consumed Table 9- Distribution of cases according to season
Type of poison No of % to total Month No of cases Percentage
as per the cases cases (%)
history January 30 7.93
Insecticides 197 51.63 February 20 5.29
Alcohol 39 10.31 March 35 9.25
Kerosene 10 2.64 April 64 16.93
Unknown 118 31.21 May 26 6.87
poison June 30 7.93
Rat poison 3 0.78 July 25 6.61
Phenol 6 1.58 August 23 6.08
Turpentine 1 0.26 September 26 6.87
Glass powder 2 0.52 October 35 9.25
Mousquito 2 0.52 November 32 8.46
repellant December 32 8.46
Total 378 100 Total 378 100

Page 84
B. Arora et al ACTINOMYCOSIS OF BREAST-A CASE REPORT
ACTINOMYCOSIS OF BREAST-A CASE REPORT
B. Arora1, Sumit Giri2 , D.R. Arora3

IJCRR
Vol 04 issue 20 1
Department of Pathology , S.G.T. Medical College, Hospital and Research Institute,
Section: Health Care Budhera, Gurgaon, Haryana, India
Category: Case Report 2
Department of Microbiology, S.G.T. Medical College, Hospital and Research Institute,
Received on: 23/08/12 Budhera, Gurgaon, Haryana, India
Revised on:13/09/12
Accepted on:24/09/12 E-mail of Corresponding Author: drarorab@rediffmail.com
ABSTRACT
Primary actinomycosis of the breast is a very rare disease and most commonly caused by Actinomyces
israelii which normally inhabits mouth, colon, and vagina. Primary forms directly affect the breast but the
etiology is unknown. Possible causes include infection of the lactiferous ducts due to trauma during breast
feeding or kissing. In secondary actinomycosis, the infection at the primary sight ultimately reaches the
breast. The purpose of the study is to present, in detail, a case of a 50 year old woman, with the complaint
of swelling in the right breast of 6 months duration which was variable in size and associated with
discharging sinuses.
Keywords: Actinomycosis, breast, Actinomyces israelii.
INTRODUCTION
Actinomycosis is a chronic granulomatous or actinomycosis is primary when inoculation occurs
suppurative disease, usually caused by through the nipple. Secondary actinomycosis of
an anaerobic bacterium called Actinomyces the breast refers to the extension of a pulmonary
israelii, which is a common organism found in the infection through the thoracic cage in a process
nose and throat, flora of oral cavity, particularly in that can affect the ribs, muscles and finally the
the periphery of decayed teeth, and in the grooves breast [5]. Breast actinomycosis may present as
of tonsils, as well as female genital tract [1, 2]. It sinus tract or with mass-like features mimicking
is a Gram-positive, non-motile, non-sporing, non- malignancy. The clinical presentation makes it
acid- fast organism[3]. Disease is characterized by difficult to distinguish primary actinomycosis
development of abscesses, draining by multiple from mastitis and inflammatory carcinoma [6].
sinus tracts containing bloody suppurative We report a case of primary actinomycosis of the
discharges and “sulphur granules” which are breast caused by Actinomyces israelii that was
composed of branched filaments. The disease is diagnosed by fine needle aspiration cytology
classified clinically to the varieties of (FNAC) and was further confirmed on
cervicofacial, thoracic, abdominal and pelvic. histopathologic study of a specimen obtained by
Clinical signs of disease are different, depending excisional biopsy, Gram stain and culture.
on the site of infection. The infection is not
contagious. Actinomycosis is seen in all age CASE REPORT
groups and regions globally, but occurs frequently A 50-year-old woman, otherwise healthy,
between 15 to 35 years, and its reported frequency presented in surgery outpatient department of our
in men is two times that in women [4]. hospital with the complaint of swelling in the right
Primary actinomycosis of the breast was first breast of 6 months duration which often increased
described by Ammentrop in 1893. Breast and decreased in size and was associated with

Page 85
episodes of on and off burst to discharge pus. No bottom. Half of these were removed with a Pasteur
history of lung disease, breast trauma, gingivitis, pipette and were crushed between two slides and
or tooth problems was found and it was diagnosed stained with Gram stain. Microscopy revealed
as chronic breast abscess and she was referred to Gram-positive filaments with Gram-negative
pathology department for FNAC. periphery (Fig.3). Remaining were crushed in a
Physical examination revealed a firm fluctuating drop of saline with a glass rod and inoculated on
swelling in upper outer quadrant of right breast brain heart infusion agar, blood agar and
measuring 6x4 cm in size, with marked thioglycollate broth and incubated both
induration in the surrounding area. The overlying anaerobically and aerobically with 5−10% carbon
skin was adherent to the swelling but the dioxide at 350−370 C for upto 14 days. The
underlying structures were free. On pressing the colonies of Actinomyces israelii were 0.5−2 mm in
swelling, pus-like discharge came out. No palpable diameter, white to grey-white, smooth, lobulated
adenopathy was found. Examination of oral cavity, resembling molar teeth.
face and neck for detecting any skin lesion or mass
was unremarkable. All other test results including DISCUSSION
blood biochemistry, hemoglobin electrophoresis, Breast actinomycosis is rare throughout the world
urine analysis and stool examination were within and only a few cases have been published so far
normal limits except for mild leukocytosis in the [5,7−11]. It has been called „the most
blood count. misdiagnosed disease‟, and it has been stated that
FNAC smears were prepared from pus-like „no disease is so often missed by experienced
discharge which oozed out on pressing the clinicians‟ [12]. Primary actinomycosis of the
swelling and stained with May Grunwald Giemsa breast is an unusual condition where the most
stain. Microscopy revelaed grains which commonly isolated pathogen has been A. israelii
comprised of hyphal fragments surrounded by a [13]. Possible causes of this condition include
peripheral zone of swollen radiating club-shaped trauma, lactation and kissing [14]. Most of the
structures presenting as sun-ray appearance in a reported cases of primary actinomycosis of the
background dense inflammatory infiltrate (Fig.1). breast were caused by A. israelii. In recent years,
Histopathology confirmed the diagnosis. Gross other strains have been found as well. For instance
examination revealed multiple grey white to grey Brunner et al. [11] reported a catalase-negative
yellow tissue pieces. The largest piece was skin strain of Actinomyces neuii as the possible
covered measuring 6x3x3cms. Cut surface was causative agent of an infected mammary
grey brown in some areas and dark tan in others. A prosthesis. Mohammed in 1993 described a case of
grain of dark colour was also seen in the dark tan actinomycosis of the accessory breast [9].
area. Haematoxylin & eosin stained sections
revealed lobules of breast tissue along with CONCLUSION
“sulphur granules” which were deeply stained with The physician should keep actinomycosis in mind
haematoxylin except in the periphery which was as a possible diagnosis and perform the
stained by eosin, which showed short, radiate, appropriate investigation, if the pathogenic
club-like structures. It was surrounded by areas of findings of a mass are in favour of granulomatous
granulation tissue comprising of predominantly inflammatory process or microabscess formation,
polymorphonuclear leukocytes, lymphocytes, and if work up for tuberculosis, and or fungal
plasma cells and fibroblasts (Fig.2). infections are negative. Actinomycosis should be
Pus was shaken with sterile water in a tube and vigorously sought and promptly treated in patients
“sulphur granules” were allowed to settle at the with chronic granulomatous disease presenting

Page 86
with uncommon and prolonged clinical signs of Diagnosis by fine-needle aspiration cytology
infection. under ultrasound guidance. Breast J 2005;
11:57–59.
ACKNOWLEDGEMENT 7. Gogas J, Sechas M, Diamantis S, Sbokos C.
Authors acknowledge the immense help received Actinomycosis of the breast. Int Surg 1972; 57
from the scholars whose articles are cited and (8):664-65.
included in references of this manuscript. The 8. Schouten A. A case of primary actinomycosis
authors are also grateful to authors / editors / of the breast. Arch Chir Neerl 1973; 25(3):
publishers of all those articles, journals and books 319-23.
from where the literature for this article has been 9. Mohammed KN. Actinomycosis of the
reviewed and discussed. accessory breast treated with cotrimoxazole.
Med J Malaysia 1993; 48(2): 229-31.
REFERENCES 10. Jain BK, Sehgal VN, Jagdish S, Ratnakar C,
1. Baron EJ, Finegold SM. 80'ed. Mosby, St. Smile SR. Primary actinomycosis of the
Louis, Baltimore 1990; P: 521-23. breast: a clinical review and a case report.
2. Brook I. Actinomycosis. In: Goldman L, Dermatol 1994; 21(7): 497-500.
Ausiello D, eds.Cecil Medicine. 24th ed. 11. Brunner S, GrafS Riegel P, Altwegg M.
Philadelphia, Pa: Saunders Elsevier; 2011:P Catalase negative Actinomyces neuii subsp.
337. Neuii isolated from an infected mammary
3. Arora DR, Arora B. Actinomycetes in prosthesis. Int J Med Microbiol 2000; 290(3):
Textbook of Microbiology, CBS Publishers 285-87.
and Distributors, New Delhi. Bangalore 3rd 12. Mandell GL, Bennett JE, Dolin R: Principles
edition 2008, pp 481-86. and Practice of Infectious Diseases, ed 6.
4. Zaini F, Mchbod ASA, Emami M. Saunders, 2005, pp 2924–31.
Comprehensive medical mycology. Tehran 13. Attar KH, Waghorn D, Lyons M, Cunnick G:
University Publication. Tehran Iran 1999; P: Rare species of actinomyces as causative
39-40. pathogen in breast abscess. Breast J
5. de Barros N, Issa FK, Barros AC, D‟Avila 2007;13:501–05.
MS, Nisida AC, Chammas MC, Pinoti JA, 14. Lloyd-Davies JA: Primary actinomycosis of
Cerri GG: Imaging of primary actinomycosis the breast. Br J Surg 1951;38:378–81.
of the breast. AJR Am J Roentgenol 2000;
174:1784–86.
6. Capobianco G, Dessole S, Becchere MP,
Profili S, Cosmi E, Cherchi PL, Meloni GB: A
rare case of primary actinomycosis of the
breast caused by Actinomyces viscosus:

Page 87
Fig. 1. Photomicrograph of FNAC smear showing grain of actinomycosis revealing sun-ray appearance in a
background of inflammatory infiltrate (May Grunwald-Giemsa 40X).
Fig. 2 Photo micrograph of histopathology slide showing sulphur granules (on left) stained with haematoxylin
in the centre and eosin at the periphery surrounded by areas of granulation tissue along with lobules of
mammary tissue (on right), (Haematoxylin &Eosin 40X).
Fig. 3 Gram-positive filaments in the centre with Gram-negative periphery (Gram 400X).

Page 88
CELL ADHESION MOLECULE EXPRESSION PROFILING OF HUMAN UMBILICAL CORD
S Indumathi et al
MATRIX AND ADIPOSE STEM CELLS
CELL ADHESION MOLECULE EXPRESSION PROFILING OF HUMAN

UMBILICAL CORD MATRIX AND ADIPOSE STEM CELLS
IJCRR S. Indumathi, Rashmi Mishra, R. Harikrishnan, J.S. Rajkumar, Neha Kantawala,

Vol 04 issue 20 M. Dhanasekaran
Section: Healthcare
Category: Research Stem Cell Department, Lifeline Multispeciality Hospital, Chennai-600 096, India
Received on: 08/08/12
Revised on:16/08/12 E-mail of Corresponding Author: dhanasekarbio@gmail.com
Accepted on:25/08/12
ABSTRACT
Introduction: The advancements and applications of redundant tissue sources such as human
subcutaneous adipose tissue (SF) and human umbilical cord matrix (HUCM) tissue are gaining
importance in recent years. Despite these advancements, certain stumbling blocks accounts for lack of
functional improvement of the diseased. One major bottleneck for the prevailing failures relies on
understanding the migratory and homing potential of stem cells. Cell adhesion molecules have been
identified to play a vital role in vascular adhesion, migration, extravasations and ultimately homing.
However, significance of cell adhesion molecules in therapeutic implications has not much concentrated
upon in recent years unlike mesenchymal stem cells. Objective: The present study showcases the
significance of cell adhesion molecules and addresses the major issue on identity of an ideal stem cell
source with maximum benefits. Research methodology: To this end, the cells obtained from the human
SF and HUCM were cultured until P3 and cultured cells were characterized for comparative expression
profile analysis of certain cell adhesion molecules. Outcome of the study: Cultured MSCs derived from
both these aforesaid sources exhibited a significant percentage of cell adhesion molecules, thereby
substantiating its efficacy on tissue homing and migration. Thus, both the sources were found superior
with regards to the expression of CAM and can be clinically exploited. However, umbilical cord matrix
serves a better therapeutic option for allogenic transplantation, which is evident from the sparse
expression of CD 34 at primary culture itself, thereby opening a gateway to circumvent the surgical
complications in clinical transplantations.
Keywords: human umbilical cord matrix, human subcutaneous adipose tissue, stem cells, cell adhesion
molecules, flowcytometry.
INTRODUCTION dynamic properties that make themselves a best

Topical research directs clinical translation of its tool for regenerative medicine and medical
findings to assist medication for various diseases therapeutics. Research focus on stem cells and its
and disorders. However, there are bouquets of multilineage potentials isolated from human
clinical conditions which are either stiff to adipose tissue and cord matrix tissues has been
treatment or give a sluggish response. Thus, there fascinating and gained wide interest in recent
emerged the replacement therapy which is again years. The rationale behind this is because of the
hindered by the shortage of donors for the selection of source on the basis of redundancy of
procurement of tissues or organs [1,2]. Thus tissue availability, allogeneic and autologous
regenerative medicine became a necessity in nature that suits well for clinical implications.
healthcare owing to its potency and ability to form Human subcutaneous adipose tissue, a redundant
any kind of cells. Stem cells possess ultimate and tissue serves as an inexhaustible source of large

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S Indumathi et al
quantity of stem cells. Accumulating evidences MATERIALS AND METHODS

report on its efficacy on the proliferative potency Sampling: Human umbilical cord matrix (HUCM)
and plasticity, thereby substantiating its samples and subcutaneous fat tissue were obtained
imperativeness in cell based therapies. Recently, from 3 subjects (n=3) each undergoing delivery or
large interest relies on using subcutaneous adipose exploratory bariatric surgery at Lifeline multi-
tissue as a cue to cure wide range of diseases [3, speciality hospital, Chennai. Sampling and
4,5]. In a similar manner, Umbilical cord matrix processing procedures were reviewed and
tissue, which is discarded during delivery, is a approved by hospital ethical committee of Lifeline
potent source of stem cells as no ethical concerns multi-speciality hospital and all samples were
are involved. In addition, the beneficial properties collected upon obtaining written informed
of umbilical cord derived MSCs for instance high consents from patients.
proliferation and multitude differentiation The HUCM samples were collected immediately
potential makes it a significant source [6,7,8]. after birth and transported in sterile collection
Reckoning on its clinical application, several bottles with 0.9% normal saline supplemented
preclinical animal models of human disease such with gentamycin and 1% antibiotic-antimycotic
as neurodegenerative disease, cancer, diabetes and solution at 4°C. The clamped cord samples were
heart disease have been reported [9,10,11,12]. later transferred to sterile phosphate buffered
However, the ability of these cells to migrate, saline (PBS) for processing. About 70-100g of
extravagate and ultimately home to the site of subcutaneous fat samples were collected and
injury has not much concentrated upon. It is of transferred to PBS. All samples were processed
prime importance to look into the credentials of with 24 hours of sample collection.
homing in tissue specific stem cells, which will Explant culture
pave way for clinical translation. To take these The cord tissue samples were washed in sterile
research pursuits to cell based therapy, it is of vital PBS (without Ca2+ and Mg2+) supplemented with
importance to study the innate property of stem antibiotic-antimycotic solution. The microbial
cells i.e. homing. Homing stands for the stem cell contaminants were further removed by washing
capture within the vasculature of a tissue followed the samples with 70% ethanol for 30 seconds. The
by transmigration across the endothelium. tissue samples were further washed in PBS and the
Potential trafficking of stem cells in-vivo is a cord vein as well as arteries was removed with the
strenuous task and hence can be studied in-vitro to help of a surgical forceps. The cord tissues so
develop the cell based curative concepts [13]. Cell obtained were washed to remove any blood clots
adhesion molecules (CAM) play a major role in and diced into fragments of 2-5mm size. The
vascular adhesion, migration, extravasations and tissue fragments were placed in 6 well plates (3-4
ultimately homing of MSCs. Studies showed explants per well) and dried for 10 minutes. The
blocking the CD29 (Integrin-β1) on MSCs led to explants were further incubated in growth medium
reduced engraftment in ischemic myocardium. (DMEM-LG supplemented with 15% fetal bovine
Study also demonstrates that CD44 is instrumental serum (FBS) and 1% antibiotic solution) at 5%
in MSC homing to damaged kidney and in CO2, 95% humidity and 37OC. The plates were left
mechanisms governing MSC trafficking [14]. undisturbed to allow the migration of cells from
Therefore this study aims at comparing the stem explants and the media were replaced twice every
cells derived from human subcutaneous fat and week. The explants were removed after 10 days
umbilical cord matrix for the expression of cell and the cells were subcultured by trypsin-EDTA
adhesion molecules (ALCAM, HCAM, Integrin method until Passage 3 (P3).
β1, CD90, CD13 and CD34) at passage 0, 1 and 3.

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S Indumathi et al
Adipose cell culture: Solid fat tissues were derived stem cells were isolated and expanded till
minced and collagenase digested using 0.075% passage 3 in α-MEM (Alpha- Minimal Essential
collagenase type-1, upon washing with 1x Media) based on their adherence. The in vitro
Phosphate Buffered Saline (PBS). Debris and experiments indicated that MSCs (Mesenchymal
lipocyte content from digested sample were Stem Cells) derived from both HUCM (Human
removed by centrifugation to obtain the Stromal Umbilical Cord Matrix) and SF (Subcutaneous
Vascular Fraction (SVF). Erythrocytes in cell Fat) was easily isolated due to plastic adherence.
fractions were lysed using 0.7% NH4Cl solution. The morphological appearance of the
The cells were resuspended and pelleted in PBS. mesenchymal stem cells of these two sources were
Viability and enumeration was done using Trypan initially round epithelial in nature with a transition
Blue method. 3x105 cells were seeded onto 25cm2 of long spindle shaped fibroblastic morphology at
culture flasks (Nunc) and incubated in growth P1 (Passage 1) onwards (Fig.1).
medium (DMEM-LG supplemented with 15% Phenotypic expression We examined the
fetal bovine serum (FBS) and 1% antibiotic expression of ALCAM (Activated Leukocyte Cell
solution) at 37OC, 5% CO2 and 95% humidity for Adhesion Molecule) (CD166), Integrin β1 (CD29)
2-4 days. The primary cultures were subcultured and H-CAM (Hyluronate Cell Adhesion
until passage 3 with media change twice every Molecule) (CD44), CD90 (Cluster of
week. Differentiation 90), CD13, CD34 at passage 0, 1
Phenotypic characterization using and 3 by flowcytometry. The dot plot output of the
flowcytometry About 1x105 cells of each sample flowcytometric analysis of the markers was
were phenotypically characterized for the illustrated (Fig.2). The comparison of surface
expression of following cell surface markers; antigenic expression profiles of cell adhesion
ALCAM, H-CAM, Integrin-β1, CD 13, CD 34 and molecules of these sources were comprehended in
Thy1. The cells were incubated with the antigenic the form of Mean ± SEM (Standard Error Mean)
cocktails (Table 1) at room temperature in dark for and estimated p value symbolized evidence of
20 minutes, washed with BD FACS wash buffer significant variations among the expressions of
and pelleted by centrifugation. The pellets were HUCM and SF samples (Table 2). The MSCs
resuspended in BD FACS flow and analyzed on derived from HUCM and SF shared a consistent
the flowcytometer (BD FACS Aria) using BD positivity of Cell adhesion molecules, ALCAM
FACS-Diva software. (CD166), Integrin β1 (CD29) and H-CAM
Statistical Analysis: The expression profile of (CD44). The expression of the defined MSC as
cell adhesion molecules obtained from well as cell adhesion molecule marker CD90 was
subcutaneous fat tissue and umbilical cord matrix found to possess a remarkable expression of
tissue samples (n=3) were represented as Mean ± greater than 90%. Similarly, both the sources
Standard Error Mean (SEM). The data were showed a constant positive expression for surface
analysed using two-tailed student t-test and the p- enzyme CD13 from passage 0 to passage 3. On the
values were calculated to determine the contrary, a marked variation was obtained in the
statistically significant variations. Results were expression profile of CD 34 positivity in MSCs
considered statistically significant when p<0.05, derived from either of the sources. Interestingly,
p<0.01, p<0.001, p<0.0001. CD34 was found to be negligible in HUCM right
from passage 0 opposite to the expression
RESULTS identified in SF (Fig.3), indicating imperativeness
Cell Culture: The human umbilical cord matrix of HUCM in allogenic transplantation.
(n=3) and subcutaneous adipose tissue (n=3)

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S Indumathi et al
DISCUSSION MSC. CD90, ISCT defined MSC marker as well

In the present research pursuit, we focus to as CAM was also expressed in coherence with the
showcase MSCs intriguing property of homing literature as remarkable [17]. CD13, a surface
which makes them a strong candidate for cell- enzyme was found deliberated to mimic action of
based therapy against various human diseases. a CAM and was highly expressed in MSCs from
MSC homing results in migration of stem cells to bone marrow and adipose tissue [18]. Likewise,
injured tissues, where they can encourage the CD13 showed remarkable expression for SF as
survival of damaged cells by inhibiting the release well as HUCM. It is indicative from the results
of proinflammatory cytokines. MSC homing being that both HUCM and SF equally possesses
a clinically relevant process has to be addressed in remarkable expressions of cell adhesion
context to its most suitable sources. However, in molecules, representative of an intriguing property
vivo studies for mobilization of endogenous or of homing which makes them a strong candidate
exogenous MSCs are a strenuous task. Hence in for cell-based therapy. On the other hand,
vitro studies can be drawn to evaluate the MSCs negligible expressions of CD 34 in HUCM when
on terms of their homing ability thereby providing compared to SF, indicates the MSC homogeneity
an insight on its therapeutic potential. As the exact of HUCM and its utilization for allogenic
mechanism of MSC homing is still unearth, this is transplantation as well when compared to SF.
an attempt to correlate the concepts underlined in
existing literature to the results we have arrived at. CONCLUSION
Literature reports MSC homing can be active by To conclude, this study augments in understanding
means of leukocyte-like cell-adhesion and homing property of tissue specific MSCs. Hence,
transmigration mechanisms [15]. In lieu of the this study will presumably prove beneficial to
above, we propose to fabricate in vitro study on assess its therapeutic competence. Overall, this
Human umbilical cord matrix (HUCM) and study accounts proof for trafficking behaviour of
subcutaneous adipose tissue (SF) derived MSCs HUCM and SF derived MSCs and their probable
for expression of certain ALCAM (CD166), positive role in regulating wound healing and
Integrin β1 (CD29) and H-CAM (CD44), CD90, inflammatory diseases due to homing action.
CD13, CD34 by flowcytometry.
Integrin β1 (CD29) was found to be more than 90 ACKNOWLEDGEMENT
% for both HUCM and SF at all culture time The authors thank the surgeons and theatre staffs
points under study. Literature reports that at Lifeline Multispeciality Hospital in Chennai for
upregulation of VLA-4 β1integrin on MSCs assisting in sampling. The authors acknowledge
prompt 10 folds increase in homing ability to bone the immense help received from the scholars
marrow [16], thus a remarkable expression of whose articles are cited and included in references
Integrin β1 supports homing ability in both tissue of this manuscript. The authors are also grateful to
sources. Another important cell adhesion molecule authors/ editors/ publishers of all those articles,
H-CAM (CD44) expressed remarkably (more than journals and books from where the literature for
90%) which can be related to a study stating this article has been reviewed and discussed. They
CD44 negative MSC were unable to localize also extend thanks to patients for donating and
within the injured kidney and failed to accelerate providing umbilical cord and adipose tissue for
morphological and functional recovery in contrast our study.
to CD44 positive MSCs [14]. Similarly,
remarkable expression (< 90%) of ALCAM
(CD166) also ropes to the homing property of

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S Indumathi et al
REFERENCES 10. Rachakatla RS, Marini F, Weiss ML, Tamura M,

1. Yechoor V, Chan L (2010) Minireview:β-Cell Troyer D (2007) Development of human
Replacement Therapy for Diabetes in the 21st umbilical cord matrix stem cell base gene
Century:Manipulation of Cell Fate by Directed therapy for experimental lung tumors. Cancer
Differentiation. Mol Endocrinol 24(8):1501- Gene Ther 14(10):828–835
1511 11. Breymann C, Schmidt D, Hoerstrup SP (2006)
2. Shum E, Chern A (2006) Amendment of the Umbilical cord cells as a source of
Human Organ Transplant Act. Ann Acad Med cardiovascular tissue engineering. Stem Cell Rev
Singapore 35(6):428-32 2(2):87–92
3. Deda H, Inci M, Kurekci A, Kayihan K, Ozgun 12. Chao KC, Chao KF, Fu YS, Liu SH (2008) Islet-
E, Ustunsoy G, Kocabay S (2008) Treatment of like clusters derived from mesenchymal stem
chronic spinal cord injured patients with cells in Wharton’s Jelly of the human umbilical
autologous bone marrow-derived hematopoietic cord for transplantation to control type 1
stem cell transplantation: 1-year follow-up. diabetes. PLoS ONE 3(1):e1451
Cytotherapy. 10(6):565-574 13. Rombouts WJ, Ploemacher RE (2003) Primary
4. Kumar AA, Kumar SR, Narayanan R, Arul K, murine MSC show highly efficient homing to the
Baskaran M (2009) Autologous bone marrow bone marrow but lose homing ability following
derived mononuclear cell therapy for spinal cord culture. Leukemia 17(1):160–170
injury: A phase I/II clinical safety and primary 14. Herrera M B, Bussolati B, Bruno S, Morando
efficacy data. Experimental and Clinical L, Mauriello-Romanazzi G, Sanavio
Transplantation. 7(4):241-248 F, Stamenkovic I, Biancone L, Camussi
5. Oh SH, Muzzonigro TM, Bae SH, LaPlante JM, G (2007) Exogenous mesenchymal stem cells
Hatch HM, Petersen BE (2004) Adult bone localize to the kidney by means of CD44
marrow-derived cells trans-differentiating into following acute tubular injury. Kidney
insulin-producing cells for the treatment of type International 72:430–441
I diabetes. Lab Invest 84:607-617 15. Ley K, Laudanna C, Cybulsky MI, Nourshargh
6. Guillot PV, Gotherstrom C, Chan J, Kurata H, S (2007) Getting to the site of inflammation: the
Fisk NM (2007) Human fi rst-trimester fetal leukocyte adhesion cascade updated. Nat Rev
MSC express pluripotency markers and grow Immunol 7(9):678-689
faster and have longer telomeres than adult 16. Kumar S, Ponnazhagan S (2007) Bone homing
MSC. Stem Cells 25(3):646–654 of mesenchymal stem cells by ectopic α4
7. Troyer DL, Weiss ML (2008) Wharton’s jelly- integrin expression. FASEB J 21(14):3917–3927
derived cells are a primitive stromal cell 17. Dominici M, Le Blanc K, Mueller I, Slaper-
population. Stem Cells 26(3):591–599Breymann Cortenbach I, Marini F, Krause D, Deans R,
C, Schmidt D, Hoerstrup SP (2006) Umbilical Keating A, Prockop D, Horwitz E (2006)
cord cells as a source of cardiovascular tissue Minimal criteria for defining multipotent
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8. Nekanti U, Rao VB, Bahirvani AG, Jan M, Society for Cellular Therapy position statement.
Totey S, Ta M (2010) Long-Term Expansion Cytotherapy 8(4):315-317
and Pluripotent Marker Array Analysis of 18. Dhanasekaran M, Indumathi S, Kanmani A,
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Cells. Stem Cells Dev 19(1):117-130 Sudarsanam D (2012) Surface antigenic
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Annamalai Regupathy CLINICAL OUTCOMES OF AO PHILOS PLATING FOR PROXIMAL HUMERUS FRACTURES
CLINICAL OUTCOMES OF AO PHILOS PLATING FOR PROXIMAL

HUMERUS FRACTURES
IJCRR Annamalai Regupathy

Vol 04 issue 20
Section: Health care Department of Orthopaedics, Karpaga Vinayaga Institute of medical sciences,
Category: Research Maduranthagam Tk Tamilnadu
Revised on:29/08/12
Accepted on:05/09/12 E-mail of Corresponding Author: swethnov@gmail.com
ABSTRACT
This was a retrospective analysis study done to identify the results of Philos plating for the proximal
humeral fractures. The analysis was done on 11 patients with fracture to proximal humerus. The clinical
and functional outcome based on X ray, Constant score, DASH score were analyzed and complications
were studied in detail and discussed with literature following which the conclusions were made in this
study.
INTRODUCTION AIM AND OBJECTIVES:

Trauma to proximal humerus often presents a real The main aim of the study is to in investigate the
challenge to orthopedic surgeons (Peter S Rose clinical outcomes after Philos plating for proximal
et.al). It accounts for 2% to 3 % of all fractures to humeral fractures with the Objectives 1) To
upper limb and treatment is controversy. There are perform a retrospective analysis on cohort of
various treatment options from non surgical to patients who have had internal fixation for
surgical management with numerous implants. proximal humeral fractures with Philos plate.2) To
There is no clear evidence from the literature to determine clinical outcome in terms of pain relief
state the optimal method of surgery and the best and function, using appropriate scoring systems. 3)
implant. Wide ranges of internal fixation devices To determine the incidence of implant failure and
are available for treating the proximal humeral complications with this procedure.
fractures (Bjorkenheim JM et.al). The latest
addition in the implant list is AO Philos plate MATERIALS AND METHODS
which is an anatomically contoured rounded plate The study was carried out in Ninewells Hospital
with combined holes, which will allow a case during June 2003 to March 2007. The planed
specific adaptable treatment for fractures of the detail of the study was submitted for Caldicott
proximal humerus (Baker P N et.al). The principal approval and University of Dundee’s Code of
advantage of this system is that it provides Practice for Research Ethics on Human
improved fixation using multiple screws at Participants committee approval. There were total
divergent angles which are locked to the plate via of eleven patients in the study. The inclusion
a thread in the screw head and a matching thread criteria were 1) Fractures with skeletal maturity 2)
in the screw hole in the plate. Whilst the fixed Delayed presentation 3) Closed fractures and 4)
angle locking screw design of the plate has been Osteoporotic fractures. The exclusion criteria were
designed to improve the quality of fixation in 1) Open fractures 2) Fractures without skeletal
osteoporotic bone, there have been reports in the maturity and 3) Pathological fractures. Fractures
literature of failure of fixation using the Philos were classified following Neers classification. Out
plate (D M Wright et.al). of the eleven patients, nine were females and three

Page 94
were males. The mean age in the study group was Constant score was 81.16 with minimum of 55 to
54.4 years and ranged from 17 years to 81 years. maximum of 100 (Figure 1). The results based on
In the above selected patients the nature of injury, Constant score was classified as excellent of 50%
the fracture pattern, neurovascular deficit and any cases, 16.6% of good result, 16.6% of moderate
previous significant history of hospitalization were and 16.6% of poor results. The mean DASH score
recorded in a proper performa. Patients underwent was 13.03 with minimum of 0.83 to maximum of
surgery either under regional, general or combined 41.9.
anaesthesia. Fracture was approached through the
deltopectoral approach. Long 5 holed plate or DISCUSSION
short 3 holed Philos plate was used. Standard post The results of the present study were compared
operative physiotherapy protocol was followed in with various literatures. The sex incidence, age
the study. Patients were followed up till the incidence were compared with Peter et al. 1 series,
fracture union. X rays were taken to evaluate the Baker et al.2 study, Bjorkenheim et al.3, Reto et
radiological union and Constant score, DASH al.4 study. The total revision surgery (Figure 2)
score were followed to assess the functional rate in the present study was 27.27%. Reto et al.4
outcome. reported 25.94 % of complications (Figure 3)
which included loss of reduction, screw
RESULTS perforation, loosening, implant breakage and
There were total of 11 patients in which 9 were avascular necrosis. There revision surgery rate was
females and 2 were males. The age group in the 19.6%. The complications rate reported by Sudan
study was from 18 years to 81 years with mean of et al.5 was 19.34% and included implant breakage,
54.45 years. The maximum age incidence was avascular necrosis and non union. Wright et al.6
between 41 years to 60 years. There were 8 reported 30% of fracture collapse and 10% of
patients with 2 part fractures and 3 patients with 3 revision surgery. Peter et al.1 reported 25% of
part fractures. Ten patients had fracture on right complication rate in their study and 18.75% of
side and one patient had fracture on left side. The revision surgery rate. . The mean constant score in
commonest mechanism of injury was following the study was 81.16 which ranged from 55 to 100.
trivial trauma like fall with out stretched hand in There were 50% excellent result, 16.6% good
old population and in younger group the mode of result, 16.6 % moderate result and 16.6% poor
injury was following high velocity injury. All the result. The mean Constant score in Bjorkenheim et
patients were taken for surgery and fracture was al.3 series was 73 which ranged from 30 to 93. The
approached through deltopectoral approach. For mean Constant score in Reto et al.4 series was 73
seven patients 3 holed Philos plate was used to fix and ranged from 13 to 100. In the study reported
the fracture and for four patients 5 holed Philos by Koukakis et al7. the mean Constant score was
plate was used. Patients were regularly followed 76.1 and ranged from 30 to 100 (Figure 4). The
up till fracture union. Physiotherapy was started mean DASH score in the study was 13.03 with the
from second post operative day. There were minimum of 0.83 and maximum of 41.9. The
complications seen in three patients. They mean DASH score in Baker et al. (2004) study
included impingement of screws, loss of was 33.9 and ranged from 4 to 92.
abduction, continuous pain, collapse of head and
implant back out (X-ray 1 and 2). All these CONCLUSION
patients underwent implant removal. The From the present retrospective study following
functional outcome was measured based on conclusions may be drawn
Constant score and DASH score. The mean

Page 95
1) Proximal humeral fractures are difficult implant. J shoulder and elbow surgery, 2007.
fractures to treat and that even though with the March-April:16(2) 202-7.
fixed angle screw system on the plate has been 2. Baker P N, Candal Couto J, Ranan A and
designed to avoid cut out in osteoporotic bone, the Bennison K. Clinical outcomes
failure rate is high (about 30%). followingPhilosplatefixationproximalhumerus,f
2) Due to the spherical shape of the humeral head ractures,www.bess.org.uk/meetings/archive.asp
with 2-D screening there is risk of penetration of ?aspyear=2005&abstract=218
screws into the glenohumeral joint. 3. Bjorkenheim JM, Pajarinen J and Savolaine V.
3) It is a technically demanding surgery thus a Internal fixation of proximal humerus fractures
longer learning curve. with locking compression plate, Acta Orthop
4) The results are similar to the published Scand December 2004; 75(6): 741-745.
literature in terms of complication rates. 4. Reto H Babst, Christoph Sommer, Christian
Limitations in the study: The present study is Bahrs, Rainer Heuwinkel, Christain Hafner,
from a small group with less follow up sample. Parvo Rillman, George Kohut and Mathias
Further recommendation: A further multi centric Muller, Open reduction and internal fixation of
study with large group with more representation in proximal humerus fractures with an angular
all age group and a comparative study with other stable form plate,
procedures may be necessary for better www.hwbf.org/ota/am/ota06/otapa/OTA06126
conclusion. 5.htm
5. Marc Saudan, Richard E Stern, Anne Lubbeke,
ACKNOWLEDGEMENT Robin E Peter and Pierre Hoffmeyer. Fixation
Authors acknowledge the immense help received of fractures of the proximal humerus:
from the scholars whose articles are cited and Experience with a new locking plate,
included in references of this manuscript. The www.hwbf.org/ota/ota3/otapa/OTA03634.htm
authors are also grateful to authors / editors / 6. D M Wright, A Acharya, R H Austin and J C
publishers of all those articles, journals and books Kaye. Complications and suggestions
from where the literature for this article has been encountered with the philos plating system, J
reviewed and discussed. I extend my sincere Bone Joint surgery 2004; 87-B:165e.
thanks to Dr L Cochrane, Mr. David Nicoll, Mr. C 7. Koukakis Athanasios, Apostolou Constantinos,
A Wigderowitz and Prof J Abboud, Department Taneja Tarun. Fixation of proximal humeral
of Orthopaedics, Ninewells hospital, University of fractures using the philos plate, early
Dundee, UK for their esteemed guidance and experience, Clinical orthopaedics and related
untiring help during the study. research 2006; 115-120.
REFERENCES
1. Peter S Rose, Christopher R Adam and Michael
E Torchin. Locking plate fixation for proximal
humerus fractures, initial result with new

Page 96
Figure 1 showing functional results based on Constant score
Figure 2 showing results revision surgery
30.00%
25.00%
20.00% Present study
15.00%
10.00% Wright et al (2004)
5.00%
0.00% Peter et al (2006)
Revision
surgery Reto et al (2006)
Figure 3 showing the complications rate
30.00% Present study

25.00%
20.00% Sudan et al
15.00% (2003)
10.00% Wright et al
5.00% (2004)
0.00% Peter et al
Com plicat (2006)
ions Reto et al
(2006)
Figure 4 showing the results of Constant score
100%
Present study
80%
60% Bjorkenheim et
40% al
Reto et al 13%
20%
0% Koukakis et al
Minim um

Page 97
X- Ray 1 showing fracture collapse, implant migration and screw back out
X ray 2 showing screw back out and collapse

Page 98
PREVALENCE OF OVERWEIGHT AND OBESITY AMONG ADOLESCENT SCHOOL GOING
Prasanna Kamath B.T. et al
CHILDREN (12-15YEARS) IN URBAN AREA, SOUTH INDIA
PREVALENCE OF OVERWEIGHT AND OBESITY AMONG

ADOLESCENT SCHOOL GOING CHILDREN (12-15YEARS) IN URBAN
AREA, SOUTH INDIA
IJCRR Prasanna Kamath B.T.1, Girish M. Bengalorkar2, Deepthi R.1, Muninarayan C.1,
Vol 04 issue 20 Ravishankar S.1
Section: Healthcare 1
Department of Community Medicine, Sri Devaraj Urs Medical College, Kolar,
Category: Research Karnataka, India
Received on: 22/08/12 2
Department of Pharmacology, Sri Devaraj Urs Medical College, Kolar, Karnataka, India
Revised on:29/08/12
Accepted on:03/09/12 E-mail of Corresponding Author: btpkamath@yahoo.co.in
ABSTRACT
Background: Prevalence of overweight and obesity has increased for the past few decades. World Health
Organization refers obesity as a global epidemic. There is a need to assess the prevalence and to find the
factors responsible, so as to implement timely interventions.
Aims: To assess the prevalence of overweight and obesity among school going children and the factors
responsible for the same. Method: The study was conducted in children studying at a private school in
Bangalore aged 12-15years. Obesity was assessed using International Obesity Task Force criteria based
on the body mass index. Pretested and semi structured questionnaire was used to collect the data on
physical activity, eating habits and leisure time activity.
Results: The overall prevalence of overweight was 10% and obesity was 5% among 761 adolescents
studied. The prevalence of overweight and obesity was 11% and 4% among boys and 9% and 5% among
girls respectively. Factors like junk food, chocolate eating, physical inactivity and time spent in watching
television and computer gaming were directly related to overweight and obesity.
Conclusion: Overweight and obesity are multifactorial and needs a multi pronged interventions at the
earliest for control and prevention.
What this study adds:
1. Obesity and overweight among school going children are the common nutritional problems in
developing countries including India.
2. Prevalence of overweight and obesity is more in school children in urban areas, there is no gender
difference and lack of physical activity is one of the main culprits.
3. During annual health assessment of children, equal importance has to be given for undernutrition as
well as overnutrition; policy has to be made to inculcate adequate physical activity and healthy dietary
habits compulsorily in addition to academic excellence.
Keywords: Overweight, Obesity, leisure time activity, Commutation, Body mass index, adolescence
INTRODUCTION and adolescence has adverse consequences on

Childhood overweight and obesity are global premature mortality and physical morbidity in
problems that are on the rise.1 Obesity is one of the adulthood.3 Outcome related to childhood obesity
most prevalent nutritional diseases of children and includes hypertension, type 2 diabetes mellitus,
adolescent in many developed and developing dyslipidemia, left ventricular hypertrophy, non-
countries. During the past two decades, the alcoholic steato-hepatitis, and obstructive sleep-
prevalence of overweight and obesity in children apnea, orthopaedic and psychological problems.
has increased worldwide.2 Obesity in childhood Childhood obesity is associated with a higher

Page 99
chance of obesity, premature death and disability leave the children little or no time to play or
in adulthood. In addition to increased future risks, exercise. Studies on urban Indian school children
obese children experience breathing difficulties, from selected regions report a high prevalence of
increased risk of fractures, hypertension, and early obese and overweight children.9 Hence this study
markers of cardiovascular disease, insulin was undertaken to assess the prevalence of
resistance and psychological effects.4 Once overweight and obesity among high school
considered a problem of affluent developed children (12-15years) and to determine the factors
countries, obesity is fast growing to enormous responsible for it.
proportions in many developing countries also.
Rapid economic growth has overcame the METHOD
nutritional, socio-economic and health status of Design: A cross-sectional study was conducted in
many countries.5 Obesity has increased markedly a private school in an urban fast growing city,
with this nutritional evolution in most Asian Bangalore. All the children belonging to 8th, 9th
Countries. A similar nutritional transition is and 10th standard (12-15years) were included for
underway in India as well. In addition to the the study. A prior informed consent for the study
nutritional and socio-economic transitions, the was taken from the school administration. Those
behavioural transition of children is also possibly children who were absent on those days of study
contributing significantly to the rapidly rising were called on a separate day and a sincere effort
prevalence of obesity. Unhealthy eating habits and was made to cover all children. Data regarding
physical inactivity are the major culprits physical activity, leisure time activity, mode of
There is significant increase in the consumption of commuting to school, food preferences, eating
fats, sugars and energy rich foods. Rising income chocolates, fast food and junk foods, time spent
and urbanization leads to substitution of servants for television viewing, computer gaming were
or appliances for physical household work and collected using a pre-tested, semi-structured
motor vehicles for short distance travelling, questionnaire. The anthropometric data, height and
instead of walking or cycling.6 Junk food and fast weight were also recorded for all the children
food has replaced healthy homemade meals due to using the standard equipments.
paucity of time. This attitude has altered the lives Weight was recorded using a calibrated and
of school children in terms of bad eating habits, standardized mechanical bathroom weighing scale
lack of exercise, habits like computer gaming and to nearest 100grams. Height was recorded using
television viewing replacing the outdoor games. the standard wall mounted anthropometric height
The causes of childhood obesity are multifactorial. board to the nearest 0.1 cm. Two readings of
Overweight and obesity in children and adolescent height and weight were taken and the mean was
is generally caused by a lack of physical activity, considered as final.
unhealthy eating patterns resulting in excess BMI was calculated using the standard formula-
energy intakes, or a combination of both.7 Changes weight (kilograms)/height (meter2) and BMI
in dietary and physical activity patterns are often percentile was calculated according to Barlow SE
the result of environmental and societal changes and Expert Committee recommendations.10
associated with development and lack of Assessment of overweight and obesity:
supportive policies in sectors such as health, International Obesity Task Force (IOTF)
agriculture, transport, urban planning, classification was referred for the classification of
environment, food processing, distribution, the adolescent children as overweight or obese.11
marketing and education.8 Added to this, academic Overweight was defined as children BMI value
competitiveness, overzealous parents and teachers between 85th-95thpercentile for a specific age and

Page 100
gender. Similarly obesity was defined as with BMI difference in overweight and obesity among them
value above 95th percentile for that specific age was found to be not significant statistically.
and gender. Data regarding the leisure time activity during
On completion of the study, we provided health games period at school, after school at home and
education and created awareness regarding on holidays, revealed that 70% of the children
overweight and obesity, their implication on their involved in playing outdoor games while among
health and how they can inculcate healthy lifestyle the remaining 5% were involved in household
practices. activities and the rest spent time either reading,
Statistical analysis gaming on the computer or sleeping.
Sample size was calculated as 788 considering the Regarding the mode of transportation from home
prevalence of overweight as 17.8% and e=2.67 as to school and back 45% used school bus, 20%
in the study.12 The data collected was collated were dropped by their parents in their own
using Excel spreadsheets with double checking of vehicles and the remaining walked or came by
errors. The results were assembled in tabular and cycling.
graphical formats. All data was expressed as About 55% of children brought home made food
percentage. Comparison of nutritional status for lunch, while 30% brought bakery products and
between boys and girls was done by using chi the remaining ate at the fast food centres near their
square test. P <0.05 was considered statistical school.
significant.
DISCUSSION
RESULTS The overall prevalence of overweight among
A total of 761 children in the age group of 12- children was 10% and obesity was 5%. The
15years were included in the study. Among them prevalence of overweight was 11% among boys
421children (55.32%) were boys and 340 and 9% among girls; 4% and 5% were obese
(44.68%) were girls. respectively. In a study by Kotian MS et. al, it was
The Table 1 depicts the summary of the assessed reported that prevalence of overweight was 9.9%
children’s BMI for age and their classification into and obesity was 4.8%.13 They also reported that
those who are overweight and obese as per overweight and obesity among boys was 9.3% and
International Obesity Task Force (IOTF).11 On the 5.2% and among girls was 10.5% and 4.3%. Our
whole there were 10% (76) of the children who study reflects similar findings. A similar study in
were overweight i.e. BMI value equal to or more Hyderabad showed that the prevalence of
than 85th percentile but less than 95th percentile for overweight was 7.2% among 12-17year group.14 In
that age and sex. There were 5% (38) children who this study, it was observed that there was not much
were obese i.e. BMI value equal to or more than difference in the prevalence of overweight and
95th percentile for that age and sex. Another obesity between genders. It was 11% and 4% for
incidental point of note worth is the presence of boys and 9% and 5% for girls, respectively.
19% of undernourished children. The prevalence Prevalence of overweight and obesity was more in
of overweight 11% among boys and 9% among the males as compared to females in the studies
girls and 4% and 5% were obese respectively, conducted at Delhi, India14 and Punjab.9
according to IOTF.11 Prevalence of overweight was 14.3% among boys
As observed in table1, the difference in the and 9.3% among girls and obesity was 2.9% in
nutritional status among boys and girls was boys as compared to girls which was 1.5% as
statistically significant. (p=0.002). But the reported by Ramesh Goyal et al.8 The presence of
overweight and obesity on almost same level in

Page 101
our study may be attributed to the equal amount of urban areas has been replaced by high calorie
encouragement and participation of both girls and snacks and junk foods and also that unsafe roads,
boys in the physical activities. This is to be lack of free space for playing and increased
appreciated on the part of the school television viewing and computer use has made life
administration in inculcating this attitude. sedentary comparable this study.23
One of the major reasons for childhood obesity Some of the children who were obese were found
was watching television, using computers for long to be academically low achievers, rarely mingled
durations instead of outdoor games. Physical with others and spent most of their free time
activity during leisure period either at school or at sleeping, eating junk food or reading non-
home was found to be related inversely to academic books. This may be either their low
overweight and obesity. Children with outdoor achieving nature clubbed with eating habits made
game activity in association with good eating them obese or it may be that the combination of
habits were found to be healthy and protected from obese, loneliness made them low achievers- point
obesity and overweight. Similar reports were which needs further study. The best measure
given by a study by Kotian MS et al 13, Laxmaiah available to prevent and protect the child from
A et al at Hyderabad 14 and Eisenman JC et al in overweight and obesity is to start at their young
US 16 Supreet et al in a study at Punjab.9 Moazeri age itself, for the dietary habits and practices
H et. al reported that the analysis of association instilled at their young age will last their entire
between BMI and physical activity in children lifetime.
revealed that as the amount of physical activity Limitations of this study- In our study waist-hip
increased the prevalence of overweight and ratio and skin fold thickness were not used for
obesity decreased in Tehran17 and similar findings assessing the nutritional status of overweight and
were reported by Foldmark CE et al18 Kelishadi R obesity, the application of international standards
et al.19 In our study as in table 2, 70% of the of BMI in an Indian setting may have limitations.
children have mentioned that one of the chief Quantification of physical activity and calorie
passtime is television viewing. Similarly Bar-or O intake could have been done before correlating
et al have reported that the sedentary lifestyle of with overweight and obesity. Information
children and adolescents has been attributed to regarding the parents’ and familial history of
television viewing, computer games, internet, overweight and obesity could have been
overemphasis on academic excellence and ever considered.
increasing automated transport.20
The habit of eating chocolates and junk food was CONCLUSION
more in those who were overweight and obese To conclude, among the 761 children in the study,
than other children. This is similar to the one the overall prevalence of overweight was 10% and
reported by Ramesh K Goyal et al.8 In their study obesity was 5%. Overweight and obesity were
they have stated that junk food and chocolate 11% and 4% among boys and 9% and 5% among
eating habit have positive relation with prevalence girls respectively. The prevalence was high among
of obesity and overweight. These correlate well children who were physically inactive, using
with previous reports which suggest that junk motor vehicles for commuting, eating junk foods,
food(bakery items, pizza, burger, cheese, butter, chocolates and those who were spending more
oily items) and chocolate intake tends to be more time indoor either watching television or computer
common among overweight and obese adolescents gaming. This problem of obesity and overweight is
than among normal weight adolescents.21,22 A truly a multifactorial one.
study by Bhave S et al have reported that food in

Page 102
The obese adolescents reach adulthood and add to reviewed and discussed. No financial funding was
the spiralling problem of diabetes, heart disease taken for preparation of this manuscript.
and hypertension. The impact of this on the health ETHICS COMMITTEE APPROVAL
scenario of our country will be devastating and Name of committee- Institutional Ethics
alarming. Obesity does not have any mentioning in Committee of Sri Devaraj Urs Medical College,
the nutritional health status of school children, Kolar, Karnataka, India. Approval reference
may be, due to the large number of number-No:DMC/KLR/MEU/IEC/CER/229/2011-
undernourished children in our country even to 12. DATED 16-05-2012.
this day of commendable growth and development
in other fields. REFERENCES
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level, the present increasing trend of obesity Report.Geneva: World Health Organization;
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health assessment of children annually. Measures 3. Reilly, J.J.; Kelly, J. Long-term impact of
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development has to be made a part of the overall Obes 2011; 35: 891-98.
personality development on par with academic 4. Raj M, Sundaram KR, Paul M, Deepa AS,
excellence. Kumar RK. Obesity in Indian children: Time
If done at the earliest with right earnest, our trends and relationship with hypertension. Natl
children can grow up into healthy young adults Med J India 2007; 20:288-93
with better health indices and parameters for a 5. WHO Technical Report Series 916. Diet,
better India. nutrition and prevention of chronic diseases.
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ACKNOWLEDGEMENTS 2010, at http://whqlibdoc.who.int/
We would like to thank the head of the institution, trs/who_trs_916.pdf)
the teachers and more so the students for having 6. Waker H. Simple obesity in children. A study
been very co-operative in the collection of the on the role of nutritional factors. Med Wieku
data. We thank our entire department faculty for Rozwoj 2006; 10:3-191.
being encouraging and supportive throughout this 7. US Department of Health and Human Services.
study. Authors acknowledge the immense help Childhood Obesity. (Accessed January 4, 2010,
received from the scholars whose articles are cited at
and included in references of this manuscript. The http://aspe.hhs.gov/health/reports/child_obesity
authors are also grateful to authors / editors / /htm)
publishers of all those articles, journals and books 8. Goyal RK, Shah VN, Saboo BD, Phatak SR,
from where the literature for this article has been ShahNN, Gohel MC, et al. Prevalence of

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school going children: Its relationship with 16.Wiseman JC, Bartee RT, Wang MQ. Physical
socio- economic status and associated lifestyle activity, television viewing and weight in US
factors. J Assoc Physicians India 2010; 58:151- youth: Youth risk behavior survey. Obes Res
58. 1999; 10:379-85.
9. Chhatwal J, Verma M, Riar SK. Obesity among 17.Moazeri H, Bidad K, Zadhoush S, Gholami N,
pre-adolescent and adolescents of developing Anari S. Increasing prevalence of iron
country(India). Asia Pac J ClinNutr 2004; deficiency in overweight and obese children
13:231-5 and adolescents (Tehran Adolescent Obesity
10.Barlow SE. Expert Committee study). Eur J Pediatr 2006; 165:813-14.
recommendations regarding the prevention, 18.Foldmark CE, Marcus C, Britton M.
assessment and treatment of child and Interventions to prevent obesity in children and
adolescent overweight and obesity: Summary adolescents: a systematic literature review. Int J
report. Pediatrics 2007; 120 (suppl 4):164-92. Obes 2006; 30:579-89
11.Cole JC, Mary CB, Katherine MF, William 19.Kelishadi R, Pour MH, Sarraf-Zadegan N,
HD. Establishing a standard definition for child Sadry GH, Ansari R, Alikhassy H, et al.
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Karnataka, India. Indian J Community Med longitudinal analysis of accelerated weight gain
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Nair M. Factors affecting prevalence of 22.Wolfe WS, Campbell CC, Frongillo EA, Haas
overweight among 12-17year old urban JD, Melink TA. Overweight school children in
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15:1384-90. Am J Public Health 1994; 84:807-13
15.Supreet Kaur, Sachdev HRS, Dwivedi SN, 23.Bhave S, Bavdekar A, Otive M. IAP National
Lakshmy R, Kapil U. Prevalence of overweight task force for childhood prevention of adult
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India. Asia Pac J Clin Nutr 2008; 17:592-96. 2004; 41:559-75.

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Table 1. Nutritional Status of children according to IOTF 11

Boys (%) Girls (%) Total (%)
Total Children Studied 421(100) 340(100) 761(100)
Undernourished (BMI<5th percentile ) 101(24) 47(14) 148(19)
Normal (BMI 5th -85th percentile) 255(61) 244(72) 499(66)
Overweight (BMI 85th-95th percentile ) 47(11) 32(9) 79(10)
Obesity ( BMI >95th percentile ) 18(4) 17(5) 35(5)
χ2 is 14.36, df-3, p=0.002
Table 2. Transportation, physical activity and food preferences

Sl. Transportation Leisure time activity Food Preferences
No.
1 School bus (45%) Outdoor games (70%) Homemade food (55%)
2 Parents vehicles (20%) Household activities (5%) Bakery products (30%)
3 Walking/Cycling (35%) Read, Computer, sleep (25%) Fast food (15%)
Figure1. Showing distribution of children and nutritional status

Page 105
Janakiraman Balamurugan et al INTRA RATER AND INTER RATER RELIABILITY OF SWAY GRAPH IN ELDERLY SUBJECTS
INTRA RATER AND INTER RATER RELIABILITY OF SWAY GRAPH

IN ELDERLY SUBJECTS
Janakiraman Balamurugan1, Paulraj Anantha Raja1, Nagaraj S.1
IJCRR Ramachadran Arunachalam2
Vol 04 issue 20
Section: Health care 1
Dept of Physiotherapy, Madha Medical College and Hospital, India
Srichandrasekarendra Saraswathi Vishwa Maha Vidyalaya University, India
Revised on:03/09/12
E-mail of Corresponding Author: bala77physio@gmail.com
ABSTRACT
Background: Accurate quantification of clinically significant changes of balance impairment is a key
factor in understanding the effects of various disorders and treatment techniques on balance, the sway
graph instrument is designed to measure the shift in COG in standing posture.
Objective: To test the reliability of sway graph and to develop it as an accurate outcome measure of
balance impairments.
Subjects: One hundred and eighty nine community dwelling older adults (Mean age: 66 years)
participated.
Study design: Prospective study design
Methods: Subjects were tested twice with sway graph by the same examiner on consecutive days to
evaluate intra rater reliability and Subjects were tested by two examiners with sway graph to evaluate
inter rater reliability. The reliability was calculated using intra class correlation coefficients (ICC).
Results: The ICC result for inter rater reliability and Intra rater reliability of sway deviation variables
were r-0.98, r-0.96 for A-P swing and r- 0.96, r-0.97 Lateral swing. The SDD of the variable were
19.391& 19.828 for A-P swing and 13.837&14.281 for Lateral swing. Cronbach’s alpha index score were
very proximal to 1(0.983, 0.981) proving excellent internal consistency.
Conclusion: The study showed good reliability results for sway graph and notably minimal systematic
error in measuring sway with in elderly subjects.
Key words: Centre of gravity (COG), Balance, Reliability, Sway
INTRODUCTION which attempts to slow down the decline in

The ability to balance and maintain a non- postural control, retraining balance is yet
swaying posture in standing underlies the level unclear. One major obstacle to the researches
of performance of physical activities and also involved in examining the impact of treatments,
minimizes the incidence of fall in potentially age and diseases on balance is lack of an ideal
susceptible group of subjects. The capacities to tool to quantitatively measure balance. Health
hold and align body segments specifically care professional have thrived to invent a
depends on the ability to fix and restore Centre measuring tool/device, which can detect and
of gravity in optimal position.2 There are three quantify even a very minimal change in balance.
systems that give input to the CNS regarding An ideal clinical tool would be the one which
status and maintenance of balance which has reproducibility, sensitivity, cost effective,
includes Vestibular, Visual and Somatosensory. safe and uncomplicated in procedures. Measure
During rehabilitation of postural and balance of balance may be highly related to other
impairments the exact role of various protocols variable such as lower extremity strength due to

Page 106
its force generating capacity and a thorough this study is to test the reliability of sway graph
evaluation of the independent contribution of in elderly population. If proven to be reliable
balance requires evaluating these other
this tool could very easily become a major
relationship to accurately determine the true
magnitude of effect1 innovative step towards development of new
Several tools have been reported in literatures to tool to measure balance in various postures.
measure balance which includes centre of
pressure (COP), Brunel balance assessment, METHODS
Berg balance scale, Trunk impairment scale, arm Subjects
A total of 189 subjects were selected from a
raise and forward reach tests, step/tap and step- population of 562 community dwelling old
up tests reached and Time up and Go (TUG) aged subjects with a mean (S.D) age of 66 years
tests.6 A recent review of literatures shows (4.0), the mean height was 159 (5.5) cm, the
mean weight was 59 (10.3) kg.
dissatisfaction with parameters of static postural
The scholars involved in the study were all
recordings has led researchers to develop faculties of our medical college and none of the
dynamic testing protocols using moveable plat- subjects reported any neurological condition,
postural hypotension, musculoskeletal
forms, visual images and weighted pulleys, all
impairments and psychological disorders. The
designed to test subjects reaction to external study was approved by the institutional ethical
forces.3, 4, Hausdortt JM states that there seems committee and all the subjects provided written
informed consent.
to be a need to perform reliability
assessments of postural control in groups Raters
with identified fallers and non-fallers. No The study involved four raters (I, II, III, and IV)
reliability studies have been reported that to record sway graph. The rater I and III were
post graduate students of the institution and they
specifically included fallers. However, since possess an under graduate degree with at least 1
one-third of community-dwelling people years of clinical experience and rater II &IV
over 65 years of age experience one or more were consultant physiotherapist of the institution
with vast experience.
falls each year, it seems important to include
Procedure
elderly subjects in reliability studies on As an initial step in the beginning session, all
balance measuring tools.15Clinical studies need raters tested all subjects. The order in which the
raters tested the subjects was randomly assigned
an objective and valid measure of balance to
from a series of order obtained from a numbers
compare groups of patient, effectiveness of encoded Latin square design. The test was
treatments, prognosis and progression. We have demonstrated to subjects prior to
commencement and standardized instructions
attempted to develop a safe, less expensive and
were given. The subjects were made to wear the
accurate outcome measuring tool (sway graph) sway graph device, which consist of a lumbar
which can quantitatively measure swaying in belt, a back pointer with pen holder (matching
standing postures and the primary objective of S2 spinous process) and graph sheet to record
the sway readings with two degree of freedom

Page 107
which measures Anterior-Posterior swing and similarity between the data of the raters and the
Lateral swing. Now, the subjects were made to smaller value of SE is indicating very minimal
stand on a static platform e.g. floor for 45 systematic error. Cronbach’s alpha reliability
seconds with their back facing the table with estimates were 0.981
graph, so that the pen is in contact with the Intra rater reliability
graph sheet, a standard foot position (4 inches There was no significant difference between
apart) and angle (150 toe out) was used and the Test 1 and Test 2 of rater I in both variables. The
table height is adjustable in par with the subjects ICC value (0.96, 0.97) and small SE value (0.5,
height. After the first reading the subjects were 0.5) of table 01 clearly indicates existence of
turn over to the next rater and the procedures minimal random and systematic error. The
were repeated. Each rater was unaware of the standard deviation value of both variable were
scores of other raters and the marks on subjects A-P swing 19.828 and Lateral swing 14.281.The
are removed following each rater, the subjects data of both Test 1 and Test2 of the rater showed
were not shown their graph pattern after the test. excellent similarity as suggested by r value.
To obtain intra rater data’s the test was Cronbach’s alpha reliability estimates were
conducted again after a week period by rater I. 0.983
STATISTICAL ANALYSIS:
All data were analyzed statistically using SPSS DISCUSSION
20 for windows software. The Intra class Though impairment in balance is acknowledged
correlation coefficient was used as parameter of as a major predictor of falls, there have always
reliability and ICC model 3 was used to been limitations in recommending specific
determine intra rater reliability, inter rater clinical assessment scales of balance.8, 9, 10, 11 Our
reliability was computed using ICC model 2. study suggests that Antero-Posterior swing and
The 95% confidence interval was used to Lateral swing measurement by sway graph
determine statistical significance. Cronbach’s device can be reliably performed by the same
alpha reliability estimates were used as an index therapist and also by different therapist with
to determine internal consistency or average accuracy. The amount of measurement error
correlation and higher the score, the more being reasonably low is indicative of an
reliable the generated scale is. Nunnaly (1978) evidence to support the use of sway graph as an
has indicated 0.7 to be an acceptable reliability objective measurement tool among other scales
coefficient but lower thresholds are sometimes in practice.
used in the literature.18 The clinical assessment of balance is used as a
means for measuring the integrity of the postural
RESULTS stability system, which involves the integration
Inter rater reliability of information from somatosensory,
The mean value of Anterior –Posterior swing musculoskeletal, visual, and vestibular systems
deviation and Lateral swing deviation for both and cognition.12 According to Horak and
the raters were shown in Table 01.Inter rater Shumway-Cook evaluating balance by
reliability was excellent with a high ICC value observing subjects response under given
of 0.98 for Anterior –Posterior swing deviation conditions of varying sensory input provides
and ICC of 0.96 for Lateral swing deviation. information on the mechanism of postural
The standard deviation for both variables A-P control and this approach provides a systematic
swing and LAT swing were 19.391 & 13.837 evaluation. According to David Levine Chattecx
respectively. There was a statistically significant balance system (CBS) has a least reliability in

Page 108
antero-posterior direction because the base of The authors are also thankful to the engineers of
support is relatively short in this position, but Anna University for helping us in constructing
the postural sway occurs about the ankle joint, the device.
which is physically separated by a large distance
from the centre of gravity of the body.17 The REFERENCES
reliability found in our study may be due to the 1. Horak FB. Postural orientation and
fact that the displacement of COG is recorded equilibrium: what do we need to know about
from close proximity to S2 unlike pressure neural control of balance to prevent falls.
distribution recorder which is used to measure Age Ageing. 2006; 35 (suppl 2):ii7–ii11.
balance, error can be introduced from foot 2. Berg K.Balance and its measure in the
movements without COG displacement. The elderly: a review Physiother can 1989;
most important characteristic feature of the 41:240-246.
device has been though, there is a difference in 3. Nashner .Adapting reflexes controlling the
the skill levels and experience of the therapists human posture. Exp Brain Res 1976;26:59-
(raters) there exist no short fall in the 72
repeatability of balance measurements by Sway 4. Nashner LM.Fixed patterns of rapid postural
graph. The sway graph device constructed by responses among leg muscles during
our team measure with only two degree of stance.Exp Brain res 1977; 30:13-24.
freedom and it allows only static balance 5. Nashner LM, Black FO, Wall C.Adaptation
measure in standing posture, which makes it to altered support surfaces and visual
rather odd to be used in certain population of conditions in patients with vestibular deficits
patient with severe impairments. But, with the neurosci 1982; 2:536-544.
given potential uses and reproducibility of this 6. SF Tyson LA Connell, How to measure
tool to all health care professionals, further balance in clinical practice Clinical
development and testing are in order. rehabilitation September 2009; 23: 824-840.
7. Shumway-Cook A, Horak F.B Assessing the
CONCLUSION influence of sensory interaction on balance.
This study clearly demonstrates the potential of Suggestion from the field. Phys Ther 1986;
the device as a clinical tool with good 66:1548-1550.
reproducibility; sway graph device will 8. Scott V, Votova K, Scanlan A, Close J.
definitely add more cost effective objectivity to Multifactorial and functional mobility
static balance measurements in standing posture. assessment tools for fall risk among older
More over these results may form a basis for adults in community, home-support, long-
further research examinations of this tool with term and acute care settings. Age Ageing.
more added features and to investigate validity 2007; 36: 130–139.
issues. 9. Perell KL, Nelson A, Goldman RL, et al.
ACKNOWLEDGEMENT Fall risk assessment measures: an analytic
Authors acknowledge the immense help review. J Gerontol A Biol Sci Med Sci.2001;
received from the scholars whose articles are 56:M761–M766.
cited and included in references of this 10. American Geriatrics Society; British
manuscript. The authors are also grateful to Geriatrics Society, and American Academy
authors / editors / publishers of all those articles, of Orthopaedic Surgeons Panel on Falls
journals and books from where the literature for Prevention. Guideline for the prevention of
this article has been reviewed and discussed.

Page 109
falls in older persons. J Am Geriatr 15. Hausdortt JM, Edelberg HK, Mitchell Sl,
Soc.2001; 43:664–672. Goldberger AL Increased gait unsteadiness
11. National Institute of Clinical Excellence. in community dwelling elderly fallers. Arch
Clinical Guideline 21: The Assessment and Phys Med Rehabil1997, 78:278-283.
Prevention of Falls in Older People, 2004. 16. Byl NN. Spatial orientation to gravity and
www.nice.org.uk. Accessed June 21, 2005. implications for balance training.
12. Susan W. Muir, Katherine Berg, Bert Orthopedic Physical Therapy Clinics of
Chesworth, et al. Balance Impairment as a North America, October 1992:207-40.
Risk Factor for Falls in Community- 17. David Levine, Michael W.Whittle, MD,
Dwelling Older Adults Who Are High Jeannette A. Beach et al Test-retest
Functioning: A Prospective StudyJ Apta reliability of the Chattecx Balance System in
Phys ther. 2010; 90: 338-347. the patient with hemiplegia Journal of
13. Berg KO, Maki BE, Williams JI, et al. Rehabilitation Research and development,
Clinical and laboratory measures of postural Vol.33, February 1996, 36-44.
balance in an elderly population. Arch Phys 18. J.Reyanldo A.Santos Cronbach’s Alpha: A
Med Rehabil. 1992; 73:1073–1080. tool for assessing reliability scale.Vol.37,
14. Berg KO, Wood-Dauphineé SL, Williams April 1999.22-25.
JI, Maki B. Measuring balance in the
elderly: validation of an instrument. Can J
Public Health. 1992; 83(suppl 2):S7–S11.
Table: 01 Intra Correlation coefficient and description of intra and inter rater reliability in Anterior –
Posterior swing scores
MEASUREMENTS INTER RATER INTRA RATER

(A-P Swing) RELIABILITY(N=189) RELIABILITY(N=189)
ICC 0.98 0.96
Mean 36.41 37.34
Std Dev 19.391 19.828
95% CL 0.94 - 0.97 0.95-0.98
ICC –Intra correlation coefficient, SDD-standard deviation
Table: 02 Intra Correlation coefficient and description of intra and inter rater reliability in Lateral swing
scores
MEASUREMENTS INTER RATER INTRA RATER
(Lateral-Swing) RELIABILITY(N=189) RELIABILITY(N=189)
ICC 0.96 0.97

Mean 27.02 27.32
Std Dev 13.837 14.281
95% CL 0.95 - 0.97 0.96-0.98

Page 110
FIGURE 01
SWAY GRAPH DEVICE
HOLDER
PEN
BELT
FIGURE 02
FIGURE 03
SWAY GRAPH
RECORDING
AND CALCULATIONS

Page 111
SIGNIFICANCE OF VARIOUS SACRAL MEASUREMENTS IN THE DETERMINATION OF SEX IN
Mamatha H. et al
SOUTH INDIAN POPULATION
SIGNIFICANCE OF VARIOUS SACRAL MEASUREMENTS IN THE

DETERMINATION OF SEX IN SOUTH INDIAN POPULATION
Mamatha H.1, Sandhya2, Sushma R.K.1, Suhani S.1, Naveen Kumar3
IJCRR 1
Vol 04 issue 20 Department of Anatomy, Kasturba Medical College, Manipal, Manipal University,
Section: Healthcare Manipal , KA, India
2
Category: Research MVJ Medical College, Bangalore, KA, India
3
Received on: 28/08/12 Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal, KA,
Revised on:03/09/12 India
Accepted on:07/09/12 E-mail of Corresponding Author: naveentonse@gmail.com
ABSTRACT
Introduction: In the identification of sex in human skeletal remains, sacrum is an important bone of the
human skeletal system. Being a component of axial skeleton and because of its contribution to the pelvic
girdle and in turn to the functional differences in the region between the sexes, it has an applied
importance in determining the sex and related disorders with the help of measurements carried upon it.
Therefore a study for sex determination was carried on 50 sacra, in the department of Anatomy Kasturba
medical college, Manipal. India
Materials and methods: The parameters used for the study were the different dimensions of the sacrum.
Using the same the sacral index, auricular index were calculated. The morphology of the sacral hiatus and
the extensions of the auricular surface were also studied. All the measurements were carried out using the
digital vernier calliper. The readings were recorded and their mean and standard deviations were
calculated.
Results and conclusion: All the parameters chosen for the study were found to be reliable in sexing the
sacra and identifying the related disorders.
Keywords: Sacrum, sacral index, auricular index, sacral hiatus, auricular surface, sex determination
INTRODUCTION Otherwise, a female bone could be classified as a

Sex determination of a skeleton is a problem of male when the series to which it belonged was
concern to paleoanthropologists, particularly robust. (Kanika et al, 2011)
paleodemographers, forensic scientists and It has long been customary among anatomists,
anatomists. Pelvic bones are most important for anthropologists and forensic experts to judge the
sex determination, followed by skull & the long sex of the skeletal material by non-metric
bones. Forensic expert is often faced with a single observations. Lately, sexual divergence has been
specimen on whom he is asked to pronounce an based upon actual measurements in different bones
opinion about its origin in general terms; or it may (Mishra SR et al, 2003). Sacrum is one such
be necessary to establish as probably belonging to important bone for the identification of sex in
a given person when the identity is already human skeletal system. Since it is a component of
suspected on circumstantial evidence (Kanika et axial skeleton and because of its contribution to
al, 2011) the pelvic girdle and in turn to the functional
The sex classification of a bone is possible with a differences in the region between the sexes, it has
degree of certainty only when it can be compared an applied importance in determining sex with the
to a series of bones of known sexual dimorphism.

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Mamatha H. et al
help of measurements carried upon it (MM Patel et are from Agra, Varanasi and Burdwan and regions
al, 2003). respectively. Therefore, the present study was
Sacrum is a large, triangular bone formed by undertaken with a view to study the sex-
fusion of five vertebrae and forms postero-superior differences in the South Indian population.
wall of pelvic cavity, wedged between the two
innominate bones. Its blunted caudal apex MATERIALS AND METHODS
articulates with the coccyx and its superior wide The present study was performed on 50 adult sacra
base with the fifth lumber vertebra at the (25 male and 25 female) obtained from the
lumbosacral angle. Since it is a component of axial Department of Anatomy, Kasturba Medical
skeleton and because of its contribution to the College, Manipal, India. All the sacra were normal
pelvic girdle and in turn to functional differences and fully ossified.
in the region between the sexes, it has an applied The following parameters of sacrum were
importance in determining the sex with the various measured using digital Vernier calliper. (Figure I)
measurements carried upon it (Standrig et al, 1. Maximum width of the sacrum: was
1988). measured on the anterior surface with the
The sacral hiatus is an opening present at the sliding calliper by taking two points at the
caudal end of the sacral canal. It is formed due to upper part of auricular surface anteriorly (or
the failure of fusion of laminae of 5th sacral lateral most part of alae of sacrum).
vertebra. Sacral hiatus has been utilized for 2. Maximum height / length of sacrum:
administration of epidural anaesthesia in obstetrics measured along the midline from the antero-
as well as in orthopaedic practice for treatment and superior margin of the promontory to the
diagnosis. The area of auricular surface defines the middle of antero-inferior margin of last sacral
magnitude of weight transmission to the hip bones vertebra.
(Standrig et al, 1988). 3. Width of base / transverse diameter of the
Though sacrum is often considered to be an body of 1st sacral vertebra: measured by
important bone, while dealing with sex differences taking one point on each side of the lateral
in skeletal material, there is paucity of metrical most part on the superior surface of the body of
data available for this bone. Metrical study of 1st sacral vertebra.
sacrum has been done by various authors (Wilder 4. Transverse diameter of the wing (ala):
H. in 1920, Faweet E. in 1938, Davivongs V. measured on both the sides by taking one point
in1963). Jit I et al, (1968) and Singh S et al (1968) on the lateral most part of superior surface of
advocated the demarking point, which identify the the body of 1st sacral vertebra and another
sex with 100% accuracy. Singh S et al (1968) have point on the lateral most part of the alae.
reported that even within the same general 5. Auricular surface length: It is the vertical
population, mean value may be significantly auricular length, measured on the lateral aspect
different in bones from different zones. Singh and of sacrum by taking one point on the upper
Singh have shown that demarking point should be most part of auricular surface and another point
calculated separately for different regions of on the lower most part of the auricular surface.
population because the mean of a parameter 6. Extensions of auricular surface in relation to
differs in values in different regions. The available the sacral segments and morphology of the
literature clearly shows that the Indian sacra have sacral hiatus were also observed.
not been studied widely except by Mishra et al Using the above parameters sacral index, auricular
(2003), Singh et al (1988)and Raju et al (in 1981), index on either side were calculated.
Jana et al (1988). The materials studied by them 7. Sacral index: Width × 100 / Height.

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Mamatha H. et al
8. Auricular index: Length of auricular surface × regions. Comas & Charles (1961) reported a wide
100 / Width variation between the male and female in the
The readings were recorded, tabulated and Chinese, Negroes and Bushmen. Davivongs
subjected for statistical analysis. (1963) in his study of Australian aboriginal sacra
has re-ported mean length of sacrum to be
RESULTS 96.52mm and 88.12mm in the male and female
The mean and standard deviations of various respectively, which is very much in agreement
parameters are given in Table1. with the measurements in the present study.
The mean values of width and height of the The mean width (Table 1) of the male sacra in the
sacrum, transverse diameter of the wing and the present study is 100.1mm which is close to similar
auricular surface length was more in males as observations made by Mishra et.al (2003).in the
compared to females. However the width of the Agra region (105.34mm) and Raju et al. (1981) in
base was higher in females than in males. the Varanasi region (105.33mm) respectively.
The mean values of sacral index (Table 2) and However, in the females the present study showed
auricular index (Table 3) is higher in females than a lesser value (99.6mm) than that of Agra and
in males. Varanasi regions. In the Australian aboriginal
The extension of the auricular surface females, the maximum width of sacrum was
corresponding to the sacral segments was also 101.24mm, which is higher than that of males
noted. (Table 4) (99.92mm) of the same race (Davivongs V, 1963).
Morphology of the sacral hiatus was also studied Thus there exists a regional and racial difference
(Figure II, III, IV) and tabulated in Table 5. Also in the length and width of the sacrum. The female
complete agenesis of dorsal bony wall of sacral ranges of transverse diameters of body of S1
canal (Figure V) was observed in one of the sacra. (Table 1) are narrower than that of males and fall
within the corresponding male ranges. The result
DISCUSSION is that the separation of any female sacrum from
The sacrum has always attracted the attention of the males by the above measurements alone is
the medico-legal experts for establishing the sex, impossible. The differences in the length of
because of its contribution to pelvic girdle and auricular surface (Table 1) between the males and
associated functional sex differences. females is significantly higher in male than in
While teaching sex differences in bones much female supporting the normal description in the
stress is laid on the importance of sacrum. text books of Anatomy that the auricular surface
Actually, very little data is available to test the for articulation with ilium is shorter in females
validity of the number of parameters described to than that of males.
identify the sex of sacra (Devivongs V, 1963). Based on the sacral index, anthropologists have
The demarking points of various parameters will classified the sacra into specific groups. The mean
help to identify the sex with certainty, which is of sacral index (Table 2) of the male and female
paramount importance in medico-legal cases. sacra in the present series are 115.92mm and
The mean length (Table1) of the male sacra in the 125.2mm respectively falls under the platyheiric
present study is 87.2mm, which is lower when group (sacral index>106). Similar observation was
compared to that of Agra region (107.53mm) reported by Martin (1960) (males: 112.4mm and
studied by Mishra et al. and the Varanasi region females: 114.8mm), Raju et al (1981) and
(104.96mm) studied by Raju et al (1981). The Davivongs (1963). However Mishra et al., in his
mean length of the female sacra (81.65mm) is also study has classified the male sacra (sacral index:
shorter when compared to Agra and Varanasi 98.22mm) under dolichoheiric group (narrow

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Mamatha H. et al
sacrum with sacral index up to 99.9) and female CONCLUSION

sacra (sacral index: 125.2 mm) under platyheiric Since sacrum is a component of pelvic girdle with
group similar to the present study. Any way an functional differences between the two sexes, it
attempt to use the sacral index for ethnic itself becomes important for identification of sex
discrimination is very doubtful (Davivongs, 1963). in the human skeletal system.
However, its importance in sex determination All the parameters used in the present study
cannot be denied since the differences between the contribute to the sex determination in a positive
males and females are highly significant. way, the most significant being the sacral index
The mean auricular index (Table 3) is more in and the auricular index. However a single
females (Left: 69.28mm; Right: 70.26mm) than parameter may not be of much use in sexing the
males (Left: 62.52mm; Right: 62.69mm), unlike sacra. Hence, it can be concluded that for the
the observations made by Mishra et.al. in the Agra determination of sex of sacrum, maximum number
region wherein the latter had reported the auricular of parameters should be taken to attain 100%
index to be higher in males (59.78mm) and accuracy.
females (51.69mm). In addition to sex differences, regional and racial
The extensions of the auricular surface (Table 4) differences of the sacra are also stressed upon in
when observed, a majority of 55% was found to the present study.
extend up to S2 vertebral level. The available The extension of the auricular surface varies in
literature does not mention about length and the human sacra. These variations are associated with
extensions of the auricular surface in any of the differential load bearing at the sacral joints. The
sacra. position of the auricular surface can explain or
The study on the morphology of the sacral hiatus possibly predict low back pain situations.
(Table 5) revealed the most common to be is the The anatomical variations of the sacral hiatus are
inverted V shaped hiatus in 54.2% of males and to be understood for it may be useful in improving
inverted U in 37.9% of females. Elongated V, U the success of caudal epidural anaesthesia. In the
and irregular shapes were also observed. Nagar present study inverted U and inverted V shapes
S.K (2004) in his study had noted the shapes of were found in a significant percentage, which
sacral hiatus, most common being inverted U should be kept in mind while giving caudal
(41.5%) and inverted V (27%) similar to our anaesthesia in the South Indian population.
study. In 13.3% its outline was dumbbell shaped, Therefore to conclude, this study will be useful for
while in 14.1% it was irregular. Bifid hiatus was the anatomists, anthropologists and experts in
seen in 1.5% which was not present in our study. forensic medicine for accurate sexing of sacra and
Vinod Kumar et al (1992) had also observed various other clinical tenacities.
various shapes of sacral hiatus, most common
being inverted V and inverted U in 76.23% of REFERENCES
sacra, 7.43% were dumb bell shaped. There was 1. Kanika Sachdeva, Rajan Kumar Singla,
complete agenesis of dorsal bony wall of sacral Gurdeep Kalsey, Gaurav Sharma (2011),
canal in 2% sacra of the present study. This is Role of Sacrum in Sexual Dimorphism- A
similar to that reported by previous workers Morphometric Study, J Indian Academy
namely Nagar S.K. (2004) 1.5%, Trotter Forensic Med., 33(3): 0971-0973
(1947)1.8% and Vinod Kumar et al (1992) 1.49%. 2. Mishra SR, Singh PJ, Agarwal AK, Gupta
RN (2003), Identification of Sex of Sacrum of
Agra Region, J Anat. Soc. India, 52(2):132-
136

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Mamatha H. et al
3. MM Patel, BD Gupta, TC Singel (2005), 11. Singh, S, Raju PB (1977), Identification of

Sexing of Sacrum by Sacral index and sex from the hip bone-demarking points,
Kimura’s Base Wing Index, J Indian Journal of Anatomical Society of India, 26 :
Academy Forensic Med., 27(1):0971-0973 111- 117.
4. Standring Susan, Borley NR, (1988), Collins 12. Jana TK, Koley T K, Saha SB, Basu D, Basu
Patricia, Crossman AR et al, Gray’s SK (1988), Variation and sexing of adult
Anatomy, 40th edition, London Press, 724 – human sacrum, Journal of Anatomical
728, 1359. Society of India, 37 : 2-3
5. Wilder HH (1920), A laboratory manual of 13. Raju PB, Singh S, Padmanabhan R (1981),
anthropometry, P. Blakistons sons & Co. Sex determination and sacrum, Journal of
Philadelphia, 193. Anatomical Society of India, 30 : 13-15
6. Faweet E, (1938). The sexing of the human 14. Comas J, Charles C, Manual of Physical
sacrum, Journal of Anatomy London, 72: anthropology (revised and enlarged English
638. edition) 1961, Thomas Springfield, Illinois,
7. Davivongs V (1963), The pelvic girdle of the USA, 415-416
Australian aborigines- Sex difference and sex 15. Martin, Cited by Comas J, Manual of
determination, American Journal of Physical Physical Anthropology (1960) 2nd Edition,
Anthropology, 21: 443-455. Charles C, Thomas Springfield, Illinois
8. Jit I, Singh S (1966), Sexing of the adult U.S.A., 415
clavicle, Indian Journal of Medical Research, 16. Nagar S K, Study of sacral hiatus in dry
54: 551-571. human sacra, Anatomical Society of India
9. Singh S, Gangrade KC (1968), Sexing of (2004), 53(2): 18-21
adult clavicle verification and applicability of 17. Vinod Kumar, Pandey SN, Bajpai RN, Jain
demarking point, Journal of Indian Academy PN, Longia GS. Morpho-metrical study of
of Forensic Science, 7: 20-30 sacral hiatus, Journal of Anatomical Society
10. Singh H, Singh J, Bargotra RN (1988). Sacral of India,(1992), 41 (1):7-13.
index as observed anthropometrically in the 18. Trotter M .Variations of the sacral canal; their
region of Jammu, Journal of Anatomical significance in the administration of caudal
Society of India, 37:1. analgesia, Anaesthesia and analgesia, (1947),
26 (5): 192-202.
Table 1: Showing the mean and standard deviation of various parameters included in this study
Parameters Sex Mean (mm) S.D
Width of sacrum M 100.1 1.47
F 99.6 1.0
Length M 87.2 1.17
F 81.65 1.26
Transverse diameter of alae M 31.2 0.5
F 30.0 0.3
Auricular surface length M 56.4 0.7
F 54.2 0.5
Width of base M 49.8 0.5
F 50.0 0.6

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Mamatha H. et al
Table 2: Showing the mean and standard deviation of the sacral index calculated in males and females. (Mm-
millimeter)
Male(mm) Female(mm)
Mean 115.92 125.2

SD 19.09 25.10
Table 3: Depicting the mean and standard deviation of the auricular index calculated in males and females on
both sides. (Mm- millimeter)
Male(mm) Female(mm)
Left Right Left Right
Mean 62.52 62.69 69.38 70.26
S.D 10.02 9.67 11.58 10.27
Table 4: Extensions of the auricular surfaces. (Higher incidence is boldfaced.)

Sacral %
bone
S-2 55
S-3 42.5
S-4 2.5
Table 5: Morphology of the sacral hiatus. (Higher incidence in males and females are boldfaced.)
Morphology Male Female
% %
Inverted V 54.5 24.1
Inverted U 18.2 37.9
Elongated V 9.1 10.3
Elongated U 9.1 10.3
Irregular 9.1 17.2
Fig I: Showing pattern of taking various Figure II: Showing irregular sacral hiatus
measurements using Vernier calliper

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Mamatha H. et al
Figure III: Showing inverted V shaped sacral Figure V: Showing complete agenesis of dorsal
hiatus bony wall of sacral canal
Figure IV: Showing inverted U shaped sacral

hiatus

Page 118
A STUDY ON PREVALENCE OF ISCHEMIC HEART DISEASE IN YOUNGER AGE GROUP (<40
Rajesh Khoiwal et al
YEARS) IN PATIENTS WITH METABOLIC SYNDROME
A STUDY ON PREVALENCE OF ISCHEMIC HEART DISEASE IN

YOUNGER AGE GROUP (<40 YEARS) IN PATIENTS WITH
METABOLIC SYNDROME
IJCRR
Vol 04 issue 20
Rajesh Khoiwal, Sandeep Vaishnav
Section: Health Care
Category: Research
Dept. of Medicine, Geetanjali Medical College and Hospital, Udaipur, RJ, India
Revised on:19/08/12
E-mail of Corresponding Author: khoiwalrajesh@yahoo.com
ABSTRACT
Objective: we estimate the prevalence of ischemic heart disease in younger age group (< 40 years)
patients with metabolic syndrome. Research Design and Methods: 100 patients who satisfied the
selection criteria were thoroughly examined and undertook relevant routine investigation to assess the
diabetic status, hypertension, and lipid profile. Anthropometry i.e. height, weight, Body Mass Index,
waist circumference and diabetic complication, were selected for Tread Meal Test. Those who are Tread
Meal Test positive were taken for study. Results: The mean value of metabolic syndromes of Waist
Circumference, Triglyceride, High Density Lipoproteins, Systolic Blood Pressure , Diastolic Blood
Pressure and Fasting Blood Sugar in ischemic heart disease patients was (95.67+8.22), (193.10+36.92),
(36.63+3.2), (148.04+12.63), (89.43+4.94) and (130.60+25.83) respectively. All criteria of metabolic
syndrome were significantly different in between Ischemic Heart Disease and non Ischemic Heart Disease
group. Conclusions: The finding of the present study clearly reveals that high prevalence of Ischemic
Heart Disease in younger metabolic syndrome patients.
Keywords: acute ischemic stroke, C- reactive protein, Serum lipid profile
INTRODUCTION CVD in developing countries, there is an urgent

Customary health variations are a worldwide need to describe the disease in the health plan of
problem. Lessening of preventable human these countries.
suffering caused by insufficient access to A cost effective preventive approach will
healthcare amenities is being advocated necessitate to center on plummeting risk factors
worldwide. But what is the scenario for human both in the individual and in the population at
being health in developing countries where there is large. Therefore, it is vital to carry out some
an increased risk of adult chronic diseases against prospective studies in developing countries such as
a backdrop of persistent catastrophe of infectious India to identify CAD risk factors, particularly
diseases, environmental degradation, and political modifiable. However, scientific evidence for
apathy? (1)A major pattern is that of modifiable CAD risk factors (elevated serum total
cardiovascular disease (CVD). Studies showed and low density lipoprotein cholesterol) [LDL-C],
that CVD has arrived at epidemic peak in many low high-density lipoprotein cholesterol [HDL-C],
developing countries. In India, mortality attribute smoking, diabetes, hypertension, low level of
to CVD is anticipated to go up by 103% in men physical activity, and obesity) in this population
and by 90% in women from 1985 to 2015 (2). may be supportive in inventing a straight CAD
More importantly, the disease grabs Indians prevention policy. (3)
young. Therefore, to stop the callous attack of

Page 119
The occurrence of Ischemic Heart Disease(IHD) 100 patients who satisfied the selection criteria
has increased noticeably for the period of last were thoroughly examined and underwent relevant
decade, not only in urban areas but in rural areas routine investigation to assess the diabetic status,
also, but it is not that abrupt because life style hypertension, lipid profile. Anthropometry i.e.
variation have affected populace in urban areas height, weight, BMI, waist circumference and
more than in rural areas.(4) diabetic complication were selected for TMT.
This syndrome is often related with obesity, Those who are TMT positive were taken for study.
diabetes mellitus, dyslipidemia, and hypertension.
All of these abnormalities promote a RESULTS
cardiovascular disease risk, and collectively they Age of the patients varied between 29 - 40 years.
are categorizing as the insulin resistance syndrome Mean age of patients was 36.05 years. Out of 100
or the metabolic syndrome. (5) patients, 62 were males and 38 were females.
Although the all entities of the metabolic Mean age of male patients was 36.30 and mean
syndrome are evidently connected with increased age of female patients was 35.57 years. There was
risk for coronary heart disease (CHD), we wanted no case found below 29 years. All age group had
to quantify the increased prevalence of CHD male predominance except 29-31 years of age
among people with metabolic syndrome. group where all the patients were females. This
The current study was designed to evaluate the can be due to less number of patients studied.
cross sectional relationship between the metabolic Maximum numbers of patients were in age group
syndrome (defined by the ATP III criteria) and the 38-40 years.
prevalence of ischemia heart disease in Indian Out of 100 patients 46 were Tread Meal Test
subjects. positive (having Ischemic Heart Disease). Out of
these 46 patients, 24 (52.17%) were male and 22
MATERIAL AND METHOD (47.83%) were female. In non-IHD group out of
This study was conducted in the Department of 54 patients, 38 (70.37%) were male and 16
Medicine and Cardiology, JLN Medical College (29.62%) were female. The prevalence of IHD
and Hospital, Ajmer. The study included the among males was found to be 38.70% (24/62) and
patients who attended the medical OPD and get that in females was 57.89% (28/38).P value is
admitted in the wards during June 2008 to May 0.0674 denote that ischemic heart disease is
2009. equally distributed in male and female and there is
Selection Criteria: no sex correlation. As in our study 52.17% male
1. Asymptomatic patient having no history of and 47.83% female had ischemic heart diseases
chest pain suggestive of coronary artery disease. those were fulfilling the criteria for metabolic
2. Obese personalities. syndrome.
3. Age less than 40 years. Out of 100 patients with metabolic syndrome, 31
4. Patient irrespective of blood sugar / blood (31.00%) had both IHD and blood sugar level
pressure level but fit for TMT. >110 mg/dl. Out of 46 patients with IHD, 31
(67.39%) had blood sugar level >110 mg/dl. In
Exclusion Criteria males with IHD, out of 41 patients, 15 (36.58%)
1. Follow up patient of myocardial infarction / had blood sugar >110 mg/dl. In females with
CVA / angina. IHD, out of 38 patients, 16 (42.10%) had blood
2. Patient of valvular heart disease. sugar >110 mg/dl. Female patients having high
3. Patient of conduction defect. blood sugar level and IHD was more in
4. Patient of COPD / bronchial asthma. comparison to male.

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Out of 100 patients with metabolic syndrome, 44 >150 mg/dl.In males out of 62, 23 (37.09%) had
(44.00%) had both IHD and high blood pressure TG >150 mg/dl and in females out of 38, 19
(BP >130/85 mmHg).Out of 46 patients with IHD, (50.00%) had TG >150mg/dl. Percentage of
44 (95.65%) had blood pressure >130/85 mmHg. females with increased TG (50.00%) was more
In male patients 24/62 (38.70%) had IHD and than males (37.09%).
hypertension. In female patients 20/38 (52.63%) Out of 100 patients with metabolic syndrome, 26
had IHD and hypertension. Percentage of females (26.00%) had both IHD and increased waist
having high blood pressure and IHD was more circumference. Out of 46 patients with IHD, 26
than males. (26/46 - 56.52%) had both IHD and waist
Out of 100 patients with metabolic syndrome, 45 circumference more than cut off value. In male
(45.00%) had both low High Density Lipoprotein patients, out of 62, 10 (10/62 - 16.12%) had both
(HDL) level and IHD. Out of 46 patients with IHD and increased waist circumference above cut
IHD, 45 (97.83%) had low HDL level (below cut off value. In female patients out of 38, 16 (16/38 -
off value).In male patients, 23/62 (37.1%) had 42.10%) had both IHD and increased waist
both IHD and low HDL level (<40 mg/dl). In circumference above cut off value. Percentage of
female patients, 22/38 (57.89%) had both IHD and females with increased waist circumference and
low HDL level (<50 mg/dl).Percentage of female having IHD (42.10%) was more than the
patients having low HDL level was more in percentage of males (16.12%).
comparison to male patients.
Out of 100 patients with metabolic syndrome, 42

(42.00%) had both IHD and TG >150 mg/dl. Out
of 46 patients with IHD, 42 (91.30%) had TG
Table 1: MEAN+SD OF VARIOUS METABOLIC SYNDROMES CRITERIA BETWEEN PATIENTS

WITH IHD AND NON-IHD
Mean+SD
Metabolic
IHD non IHD P value Signification
syndromes criteria
(n=46) (n=54)
WC (cm) 95.67+8.22 91.38+9.89 0.0253 Significant
TG (mg/dl) 193.10+36.96 131.59+27.61 < 0.0001 Significant
HDL (mg/dl) 36.63+3.2 41.53+3.95 < 0.0001 Significant
SBP (mmHg) 148.04+12.63 133.73+11.12 0.0001 Significant
DBP (mmHg) 89.43+4.94 82.81+3.91 0.0001 Significant
FBS (mg/dl) 130.60+25.83 108.5+29.65 0.0002 Significant
The mean value of metabolic syndromes of Waist Pressure (SBP), Diastolic Blood Pressure (DBP)
Circumference (WC), Triglyceride (TG), High and Fasting Blood Sugar (FBS) in ischemic heart
Density Lipoprotein (HDL), Systemic Blood disease patients was (95.67+8.22),

Page 121
(193.10+36.92), (36.63+3.2), (148.04+12.63), was 36.05 years. The mean age among male was
(89.43+4.94) and (130.60+25.83) respectively. It 36.30 years and mean age of female patients was
was observed that mean values of 4 criteria of 35.57 years.
metabolic syndrome except HDL were higher in Out of 100 patients with metabolic syndrome 46
IHD patients group as compared to non IHD (46%) were found to have IHD. Among these 46
patient group. Mean value of HDL was lower in IHD patients 24 (52.17%) were male and 22
IHD patients as compared to non IHD patients. All (47.83%) were female. The prevalence of IHD
criteria of metabolic syndrome were significantly among male was found to be 38.70% (24/62) and
different in between 2 groups (IHD/non IHD that in female was 57.89% (22/38). There is no
group). significant correlation between sex and IHD
(P=0.0674). In contrast to our observation a
DISCUSSION study carried out by NCHS (8) showed prevalence
The study was carried out in the Department of of IHD is 38%. In our study it was 46% because in
Medicine and Cardiology, JLN Medical College & our study all criteria of metabolic syndrome were
Associated Group of Hospitals, Ajmer on the present.
patients who were referred for TMT. All patients A study carried out by R. Gupta (2002) (4) showed
who fulfill the NCEP ATP III criteria were the prevalence rate of IHD in urban males was
included in this study. 60.98 per thousand and rural males was 67.01 per
This study was conducted on 100 patients, thousand while in urban females prevalence rate
attending Medicine outdoors and wards found to was 30.82 per thousand and rural females was
have metabolic syndrome. In our study we 27.33 per thousand. But in our study the
categorized metabolic syndrome group patients prevalence of IHD among male and female was
into two groups TMT positive patients and TMT comparable. This was due to less number of
negative patients. patients studied.
Metabolic syndrome is very common with 44% of Among 46 IHD patients maximum numbers of
the western countries population over 50 years of patients were present between age group 38 - 40
age meeting the NCEP ATP III diagnostic years. In our study, criteria of age is restricted to
criteria.(5)It is estimated that it affect 65% male only younger patients (<40 years age).
and 47.8% female in India (6).Recent study Mukherjee (1968) (9), Bhargava (1966) (10) and
showed that the metabolic syndrome is associated Naik CH (1968) (11) have reported premature
with an increased prevalence of IHD. One possible ischemic heart disease as 26.5%, 15.2% and 20%
reason for the high prevalence of IHD associated respectively.
with metabolic syndrome is the direct effect of Comparing blood sugar and IHD in metabolic
insulin resistance on the heart and arteries (7). syndrome we found that, out of 100 patients with
A study was conducted by the National Centre for metabolic syndrome, 31 (31.00%) had both IHD
Health Statistics (NCHS) 3 Centre for Disease and blood sugar level >110 mg/dl and out of 46
Control and Prevention in two phases - Phase I patients with IHD, 31 (67.39%) had blood sugar
(1988-1995) and Phase II (1991-1994) showed >110. In male with IHD out of 41 patients, 15
that excess prevalence of IHD was attributed to (36.58%) had blood sugar >110 mg/dl and in
metabolic syndrome and/or diabetes was 37.4% in female with IHD, out of 38 patients, (42.10%) had
the group with metabolic syndrome. blood sugar >110 mg/dl.
In our study, there were 100 patients with Out of 100 patients with metabolic syndrome 44
metabolic syndrome, out of which 38 were female (44.00%) had both IHD and high blood pressure.
and 62 were male. Mean age among total patients Out of 46 patients with IHD, 44 (95.65%) had

Page 122
blood pressure >130/85 mmHg. In males patients In comparing IHD and WC, out of 100 patients
24/62 (38.70%) had IHD and hypertension. In with metabolic syndrome, 26 (26.00%) had both
females 20/38 (52.63%) had IHD and IHD and increased WC. Out of 46 patients with
hypertension. Percentage of females having high IHD, 26 (26/46 - 56.52%) had both IHD and WC.
blood pressure and IHD was more than males. In males, out of 62, 10 (16.12%) had both IHD
Elevated blood pressure is a risk factor of prime and increased WC (>102 cm) and in females out
importance and established association with of 38, 16 (42.10%) had both IHD and increased
coronary atherosclerosis. Naik (1968) (11) WC (>88 cm). Percentage of females with
reported that 36% cases of IHD were increased WC and having IHD (42.10%) was more
hypertension, But in our study high blood pressure than the percentage of males (16.12%).
was present in 44 (95.65%) with IHD because in Philip WJT (2005) (14) studied prevalence of IHD
our study all metabolic syndrome criteria were in patients with increased WC (female >88 cm,
present which increases coronary atherosclerosis. male >102 cm) and showed that prevalence was
Out of 100 patients with metabolic syndrome 45 16%. But in our study prevalence of IHD was
(45.00%) had both low HDL and IHD. Out of 46 26%; this was because of presence of all criteria of
patients with IHD, 45 (97.83%) had low HDL metabolic syndrome.
(below cut off value). In males, 23/62 (37.1%) had In comparison of mean of various criteria for
both IHD and low HDL level (<40 mg/dl). In metabolic syndrome patients among IHD and
females 22/38 (57.89%) had both IHD and low Non-IHD patients (Table 1). We found that the
HDL level [<50 mg/dl (F>M)]. mean values of metabolic syndrome criteria for
In the Framingham Heart Study (1986) (12), IHD waist, TG, HDL, SBP, DBP and BS in IHD
was present in 44% patients with low HDL level patients was (95.67+8.22), (193.10+36.96),
(<40 mg/dl). But in our study low HDL level was (36.63+3.2), (148.04+12.63), (89.43+4.94),
found in 97.83% patients, high prevalence in our (130.60+25.83) respectively.
study was due to presence of all criteria of It was observed that mean value of metabolic
metabolic syndrome. syndrome criteria (except HDL) were higher
This study revealed that 42 patients out of 100 among IHD patients as compared to Non-IHD
with metabolic syndrome i.e. 42% had both IHD patients. Whereas the mean value of HDL was low
and TG >150 mg/dl and out of 46 patients with in IHD compared to Non-IHD patients.
IHD, 42 (91.30%) had TG >150 mg/dl. Further in
males out of 62, 23 (37.09%) had TG >150 mg/dl CONCLUSION
and in females, out of 38, 19 (50.00%) had TG From this study it is concluded that TMT positive
>150 mg/dl. Percentage of females with increased ischemic heart disease in metabolic syndrome
TG (50.00%) was more than males (37.09%). patients have more waist circumference, high
A prospective cohort study was carried out by fasting plasma glucose, high blood pressure and
Nordegestgard BG et al (2007) (13) in 7857 high TG level but low HDL level. So there is a
women and 6394 men with high TG levels (>150 high prevalence of IHD in younger metabolic
mg/dl) and were followed up from 1976 to 2004. syndrome patients.
They found that 1567 women (19.94%) and 1912
men (29.90%) developed IHD. But in our study REFERENCES
prevalence of IHD was 37.09% in males and 50% 1. Sharma M, Ganguly N K. Premature
in females with high TG levels. High prevalence Coronary Artery Disease in Indians and its
in males and females in our study was due to Associated Risk Factors. Vasc Health Risk
presence of all metabolic syndrome criteria. Manag. 2005 September; 1(3): 217–225.

Page 123
2. Bulatao RA, Stephens PW. Global estimates 9. Mukherjee AB: Precious ischemic heart
and projections of mortality by cause, 1970- disease. IMA 1968; 512: 207.
2015. Preworking paper 1007. Washington: 10. 10.Bhargava RK, Husain SA, Dave AS,
Population Health and Nutrition Department, Narang NK, Banerjee A, Gupta U. Incidence
World Bank; 1992. of heart diseases in Rajasthan. J Assoc
3. Aggarwal A, Aggarwal S, Goel A, Sharma V, Physicians. India. 1966; 14 (1):15-23
Dwivedi S.A retrospective case-control study 11. Naik CH. Incidence and epidemiology of
of modifiable risk factors and cutaneous coronary artery disease in Gujarat. Indian
markers in Indian patients with young Heart J. 1968 Jan; 20(1):3-10.
coronary artery disease. J R Soc Med Cardio 12. Castelli WP, Garrison RJ, Willson PW,
2012; 1: 8 Abbot RD, Kannel WB : Incidence of
4. Gupta R, Gupta VP, Sama M et al: coronary heart disease and lipoprotein
Prevalence of coronary heart disease and cholesterol levels; the Framinghan Study.
coronary risk factor in urban Indian JAMA 1986; 256: 2835-2838.
population: Jaipur Heart Watch-2. India Heart 13. Nordestgaard BG, Benn M, Schnohr P,
2002; 54: 59-66. Tybjaerg-Hansen A. Nonfasting triglycerides
5. Adult Treatment Panel III, Executive and risk of myocardial infarction, ischemic
summary of third report of the National heart disease, and death in men and women.
Cholesterol Education Program (NCEP) JAMA. 2007; 298(3):299-308.
Expert Panel on Detection, Evaluation and 14. James WPT. The SCOUT study: risk-benefit
treatment of high blood cholesterol in adult. profile of sibutramine in overweight high-risk
JAMA, 2001; 285: 2486-2497. cardiovascular patients. Eur Heart J
6. Coronary Heart Disease in India.Park a 2005;7(Suppl. L):L44–L48.
Textbook of Preventive and Social Medicine,
17th ed, 2001: 274.
7. Stout RW: Insulin and atheroma, 20 year
prospective study. Diabetes Care, 1990;
13:631-54.
8. Alexander EM, Landsman PB, Teutehsm, and
Hattner SM: NCEP defined metabolic
syndrome diabetes and prevalence of
coronary heart disease among NHANES III
participants aged 50 years and older. Diabetes
2003; 52: 1210-1214

Page 124
Ch.Roja Rani et al UNILATERAL INCOMPLETE SUPERFICIAL PALMAR ARCH - A CASE REPORT
UNILATERAL INCOMPLETE SUPERFICIAL PALMAR ARCH-

A CASE REPORT
IJCRR Ch. Roja Rani, B. Narasinga Rao, M. Pramila Padmini

Vol 04 issue 20
Section: Healthcare
Dept. of Anatomy, MIMS Medical College, Vizianagaram, Nellimarla
Category: Case Report
Revised on:23/08/12 E-mail of Corresponding Author: rojarani.ch827@gmail.com
ABSTRACT
Superficial palmar arch (SPA) is an arterial arcade and a dominant vascular structure of the palm. In hand
surgeries like vascular graft applications arterial repairs, free and pedicled flaps, clinicians should be
aware of these variations, because in most of the traumatic events and the surgical procedures of the hand
the SPA plays an important role. In the present case, the superficial palmar arch is incomplete and there is
no communication between the superficial branches of radial and ulnar arteries. The ulnar artery is giving
a proper digital and two common palmar digital branches and the superficial branch of radial artery is
giving a common palmar digital branch to supply the half of radial side of middle finger and ulnar side of
index finger and radialis indicis supplying the radial side of index finger.
Keywords: anastomosis, arteria princeps pollicis, flexor retinaculum, radialis indicis, superficial palmar
arch
INTRODUCTION MATERIAL AND METHODS

Superficial palmar arch (SPA) is an arterial arcade Anatomical variations of the vessels of the palm
and a dominant vascular structure of the palm. region are carried out on 20 cadavers (18 male and
Superficial palmar arch is localized just deep to 02 female during the years 2009-2012.
palmar aponeurosis and is superficial to digital
branches of the median nerve, long flexor tendons CASE REPORT
of the forearm and lumbricals of the palm. The The present variation is observed in an adult male
arch is formed by the superficial terminal branch cadaver during routine dissection in the
of the ulnar artery with superficial palmar branch Department of Anatomy, MIMS, and
of the radial artery or arteria princeps pollicis Vizianagaram. In the present case, there is a
(APP) or arteria radialis indicis (ARI) from the unilateral variation of superficial palmar arch seen
radial artery. An incomplete arch exists due to in the left hand. There is no anastomosis between
absence of anastomosis between the vessels the superficial branches of Radial artery & Ulnar
constituting the arch. Knowledge in variations of artery in the left hand. The superficial branch of
vascular pattern in hand surgeries like vascular ulnar artery entered the palm superficial to flexor
graft applications, arterial repairs, free and retinaculum and divide into two common and one
pedicled flaps is important, and clinicians should proper palmar digital braches supplying the ulnar
be aware of these variations. In most of the side of middle & radial side of ring finger, ulnar
traumatic events and the surgical procedures of the side of ring & radial side of little finger and proper
hand the SPA plays an important role. branch supplying ulnar side of little finger. The
superficial branch of radial artery entered the hand
deep to thenar muscles and dividing into two

Page 125
Ch.Roja Rani et al UNILATERAL INCOMPLETE SUPERFICIAL PALMAR ARCH - A CASE REPORT
common palmar digital braches and one proper CONCLUSION

palmar digital branch supplying the adjacent sides Patients with coronary artery disease should be
of thumb & index finger, index and middle finger screened before RA harvesting to confirm the
and proper palmar digital branch supplying radial presence of viable collateral circulation. Currently
side of the thumb (fig.1). In the right hand the SPA the methods of assessing hand circulation include
is having a normal course. the modified Allen test, Doppler ultrasonography,
photoplethysmography. Doppler study is a useful
tool in preoperative screening for RA harvesting
for myocardial revascularization (Pola P5 1996)
ACKNOWLEDGEMENT
Authors acknowledge the immense help received
from the scholars whose articles are cited and
included in references of this manuscript. The
authors are also grateful to authors / editors /
publishers of all those articles, journals and books
from where the literature for this article has been
reviewed and discussed.
REFERENCES
1. Coleman SS, Anson BJ. Arterial patterns in the
Fig.1-Showing incomplete superficial palmar arch hand based upon a study of 650 specimens.
Surg Gynecol Obstet. 1961; 113: 409–424.
DISCUSSION 2. Gellman H, Botte MJ, Shankwiler J,
The superficial arteries of the hand formed several Gelberman RH. Arterial patterns of the deep
diversified patterns that permitted into well- and superficial palmar arches. Clin Orthop
defined categories. According to Coleman’1 Relat Res. 2001; 383: 41–46.
(1961) classification, in type A: Both superficial 3. Al-Turk M, Metcalf WK. A study of the
palmar branches of UA and RA take part in superficial palmar arteries using the Doppler
supplying the palm and fingers, but in doing so fail Ultrasonic Flowmeter. J Anat. 1984; 138: 27–
to anastomose and seen in 3.6% of cases. In the 32.
present case also there is a similar observation. 4. Ruengsakulrach P, Brooks M, Hare DL,
Ikeda et al. conducted stereoscopic arteriography Gordon I, Buxton BF. Preoperative assessment
of 220 cadaver hands and reported complete SPA of hand circulation by means of Doppler
in 96.4% of cases and 3.6% as incomplete arch. ultrasonography and the modified Allen test. J
Gellman et al2.2001 reported 84.4% of cases as Thorac Cardiovasc Surg. 2001; 121: 526–531.
complete SPA and 15.5% of cases as incomplete 5. Pola P, Serricchio M, Flore R, Manasse E,
SPA. Al Turk and Metcalf 3 (1984) showed Favuzzi A, Possati GF. Safe removal of the
complete SPA in 84% of cases and incomplete in radial artery for myocardial revascularization: a
16% using Doppler flow meter. Harvesting RA for Doppler study to prevent ischemic
use as arterial by-pass conduits needs to look complications to the hand. J Thorac Cardiovasc
specifically for variation in collateral circulation Surg. 1996; 112: 737–744.
like presence of incomplete SPA (Ruengsakulrach
P4 2001).

Page 126
Pragnesh Parmar et al DETERMINATION OF AGE BY STUDY OF SKULL SUTURES
DETERMINATION OF AGE BY STUDY OF SKULL SUTURES
Pragnesh Parmar1, Gunvanti B. Rathod2

IJCRR
1
Vol 04 issue 20 Department of Forensic Medicine, Mahatma Gandhi Medical College and Research
Section: Healthcare Institute, Pillaiyarkuppam, Pondicherry
2
Category: Research Department of Pathology, Mahatma Gandhi Medical College and Research Institute,
Received on: 18/08/12 Pillaiyarkuppam, Pondicherry
Revised on: 29/08/12
Accepted on:10 /09/12 E-mail of Corresponding Author: prag84@yahoo.co.in
ABSTRACT
Objectives: The objectives of this study are to determine the age by study of skull sutures and comparing
the age with standard data mentioned in different textbooks and previous studies.
Material and Method: Present study based on closure of skull sutures among 220 cases between age
group of 15 - 70 years with age interval of 5 years and 20 cases from each age group were studied, who
were exposed to digital X-ray of skull for closure of suture ecto-cranially for age estimation. The closure
of sagittal, coronal, lambdoid, parieto-mastoid, parieto-temporal (squamous) and baso-occiput with baso-
sphenoid sutures were studied and compared with standard data mentioned in different textbooks and
previous studies. Age of each individual studied was confirmed from birth certificate, service record,
driving license, passport, ration card or voter’s card.
Result: Each suture was found to close at particular age group. Suture closure occurred for sagittal,
lambdoid, coronal, parieto-mastoid, parieto-temporal and baso-occiput with baso-sphenoid at age group
of 50-60 years, 45-55 years, 50-60 years, 55-70 years, 60-70 years and 18-25 years respectively.
Conclusion: Age of closure of sagittal, coronal, lambdoid, parieto-mastoid, parieto-temporal and baso-
occiput with baso-sphenoid suture was matching with standard data given in most of the textbooks and
other studies. Sutures closure occurred from their endo-cranial to ecto-cranial aspects. Closure of skull
sutures occurred earlier in male than in females. The most successful estimate was done from sagittal
suture, next lambdoid suture and then coronal suture.
Keywords: Skull sutures, Age estimation, Sagittal suture, Coronal suture, Lambdoid suture.
INTRODUCTION Age determination is a very difficult task as the

Age estimation, either in living, dead or human age advances, with conventional methods. In
remains, is a complex problem in medical justice adulthood and old age, opinion is given in the
in both civil and criminal matters such as form of age range instead of any particular age. As
identification, senior citizen concession, retirement the age advances, this range becomes wide. In
benefits, competency as witness, attainment of order to decrease this wide age range, combined
majority, marriage, impotency, sterility, consent, study of physical examination along with closure
juvenile offender, kidnapping, rape etc. In general, of skull sutures should be done. Other factors also
age estimation is done by team of forensic expert affect the age like nutritional, hereditary, racial,
and radiologist. If proper opinion regarding the endocrine etc. Epiphyses of bones unite and
age is not given then injustice may occur to the sutures of skull close at a particular age for a given
patient. Age estimation by means of closure of population. Determination of age from skull
skull sutures is a very important tool to solve sutures has great medico legal importance as it is
above mentioned cases. [1]

Page 127
the most reliable evidence for estimating the age given in Table – 7. [1, 2, 3, 4, 7, 14, 15]
of person. [2] Comparison of time of closure of baso-occiput
with baso-spheoid suture was given in Table – 8.
MATERIAL AND METHODS [2, 3, 4, 5, 6, 7, 8, 17, 18]
In this study, 220 cases (male and female both),
between age group of 15 - 70 years with age DISCUSSION
interval of 5 years and 20 cases from each age Identification means determination of individuality
group were studied who were exposed to digital of a person. Study of closure of skull sutures is a
X-ray of skull both antero-posterior and lateral very important tool for age estimation in adult.
view for closure of suture ecto-cranially. Age of The most commonly studied aspect of cranial
each individual studied was confirmed from birth sutures is the degree of their obliterations as an
certificate, service record, driving license, indicator of age. Suture closure scoring system as
passport, ration card or voter’s card and compared per Buikstra and Ubelaker [19] was given in Table
with radiological findings for accuracy. In this – 9. Meindl and Lovejoy scoring system (1985)
study, we considered only complete union of the [20] was given in Table – 10. Acsadi and
sagittal, coronal, lambdoid, parieto-mastoid, Nemeskeri scoring system (1970) [21] and
parieto-temporal (squamous) and baso-occiput Perizonius (1984) [22] scoring system was given
with baso-sphenoid sutures instead of taking into in Table – 11. In our study, we considered only
account other scoring system of suture closure and complete union of sutures instead of taking into
compared with standard data mentioned in account other scoring system of suture closure.
different text books and previous studies. Observations of cranial suture closure were first
observed as far back as the 1st century in the work
OBSERVATION of Hippocrates, but were not utilized as an
In our study, age of earliest union for sagittal, ‘identification tool’ with relation to age until a
lambdoid, coronal, parieto-mastoid, parieto- much later date. [11, 12, 13] Vesalius and his pupil
temporal and baso-occiput with baso-sphenoid Fallopius were credited for the first noting the
suture was 46 years, 38 years, 46 years, 43 years, apparent progression of suture obliteration with
54 years and 17 years respectively and age group age in 1542. [11, 12, 23, 24, 25, 26] Despite some
for sagittal, lambdoid, coronal, parieto-mastoid, early descriptions of the variability of cranial
parieto-temporal and baso-occiput with baso- suture closure, scientific studies addressing its
sphenoid suture was 50-60 years, 45-55 years, 50- relationship with age have been published in great
60 years, 55-70 years, 60-70 years and 18-25 years number from the 19th century to present [10]. This
respectively as per Table – 1. Different sutures continued popularity has survived not due to its
closure in different age groups were given in Table validity but rather the idea that, if it has been
– 2. Comparison of time of closure of sagittal studied for so long, surely there has to be
suture was given in Table – 3. [2, 3, 4, 5, 6, 7, 8, 9, something to it, and thus it becomes a traditional
10, 11, 12, 13] Comparison of time of closure of research obsession. [26]
lambdoid suture was given in Table – 4. [1, 2, 3, 4,
5, 6, 8, 14, 15] Comparison of time of closure of CONCLUSION
coronal suture was given in Table – 5. [1, 2, 3, 4, Age of closure of sagittal, coronal, lambdoid,
5, 6, 7, 8, 14, 15, 16] Comparison of time of parieto-mastoid, parieto-temporal and baso-
closure of parieto-mastoid suture was given in occiput with baso-sphenoid suture was matching
Table – 6. [1, 2, 6, 14, 15] Comparison of time of with standard data given in most of the textbooks
closure of parieto-temporal (squamous) suture was and other studies. Sutures closure occurred from

Page 128
their endo-cranial to ecto-cranial aspects. Closure 9. Dwight T., The closure of the sutures as a sign
of skull sutures occurred earlier in male than in of age, Boston Medical surgery Journal, 1890,
females. The most successful estimate was done 122: 389-392.
from sagittal suture, next lambdoid suture and then 10. Parsons FG and Box CR, The relation of
coronal suture. Studies of the ecto-cranial suture cranial sutures to age, Journal of the Royal
closure have the potential to underestimate age Anthropology Institute, 1905, 35: 308.
and to overcome this, study of both endo-cranial 11. Todd TW and Lyon DW, Endo-cranial suture
and ecto-cranial suture closure should be done. closure, its progress and age relationship, Part
I, American Journal of Physical Anthropology,
ACKNOWLEDGEMENT 1924, 7: 325-384.
Authors acknowledge the immense help received 12. Todd TW and Lyon DW, Cranial suture
from the scholars whose articles are cited and closure, its progress and age relationship, Part
included in references of this manuscript. The II, American Journal of Physical
authors are also grateful to authors / editors Anthropology, 1925, 8: 23-25.
/publishers of all those articles, journals and books 13. Mc Kern TW and Steward TD, Skeletal age
from where the literature for this article has been changes in young American males, analysed
reviewed and discussed. from the stand point of identification,
Headquarter QM. Res and Dev Command,
REFERENCES Natick, MA, 1957.
1. Pradeep et al, Age estimation in old 14. Krogman, The Human skeletal in Forensic
individuals by CT scan of skull, Journal of Medicine, 1st edition, Charles C. Thomas,
Indian Academy of Forensic Medicine, 2004, 1962, Page 18-71, 76-89, 92-111.
26(1): 10-13. 15. Parikh C.K., Textbook of Medical
th
2. Reddy K.S.N., The essentials of Forensic Jurisprudence and Toxicology, 5 edition,
Medicine and Toxicology, 26th edition, CBS Publishers, 1990, Page 39-50.
Medical Book Company, 2007, Page 62-70. 16. Ramachandran C, Skeletal anatomy: Medico-
3. Dikshit P.C., Textbook of Forensic Medicine legal radiological age determination, 1st
and Toxicology, 1st edition, Peepee publishers, edition, Paras Medical Publishers, 2003, Page
2007, Page 55-60. 15-31, 79-87, 92-96.
4. Nandy A., Principles of Forensic Medicine, 17. David Dolinak, Evan W Matshes, Emma O
2nd edition, New Central Book Agency, 2001, Lew, Forensic Pathology: Principles and
Page 78-80. Practice, Elsevier, 2005, Page 585 – 586.
5. Mukherjee J.B., Forensic Medicine and 18. Pekka Saukko, Bernard Knight, Knight’s
Toxicology, 4th edition, Academic publishers, Forensic Pathology, 3rd edition, Arnold, 2004,
2011, Page 141-142. Page 120-121.
6. Karmakar R.N., Forensic Medicine and 19. Buikstra J, Ubelaker DH, Standards for Data
Toxicology: Oral, Practical and M.C.Q., 3rd Collection from Human Skeletal Remains,
edition, Academic Publishers, 2010, Page 13. Fayetteville, AR: Arkansas Archaeological
7. Pillay VV, Textbook of Forensic Medicine Survey, 1994.
and Toxicology, 15th edition, Paras Medical 20. Meindl, Richard S. And C. Own Lovejoy,
Publisher, 2008, Page 77. Ecto-cranial suture closure: a revised method
8. Vij K., Textbook of Forensic Medicine and for the determination of skeletal age at death
Toxicology, 5th edition, Elsevier, 2011, Page based on the lateral-anterior sutures, American
42-43.

Page 129
Journal of Physical Anthropology, 1985, 24. Singer R., Estimation of age from cranial
68(1): 57-66. suture closure: Report on its unreliability,
21. Acsadi G.Y. and J. Nemeskeri, History of Journal of Forensic Medicine, 1953, 1: 52-59.
human lifespan and mortality, Budapest, 25. Masset C., Age estimation on the basis of
Akademiai Kiado, 1970. cranial sutures in age markers in human
22. Perizonius W.R.K., Closing and non closing skeleton, 1st edition, Springfield III, Charles C.
sutures in 256 crania of known age and sex Thomas, 1989, Page 71-103.
from Amsterdam (A.D. 1883-1909), Journal 26. Hershkovitz et al., Why do we fail in ageing
of Human Evolution, 1984, 13: 201-216. the skull from the sagittal suture? American
23. Ashley-Montagu M.F., Ageing of the skull, Journal of Physical Anthropology, 1997, 103:
American Journal of Physical Anthropology, 393-399.
1938, 23(3): 355-375.
Table - 1: Ages for suture closure

Sr. Age of fusion in majority of Age of earliest union in
Name of suture
no cases (Age group) years
1 Sagittal 50 to 60 46
2 Lambdoid 45 to 55 38
3 Coronal 50 to 60 46
4 Parieto-mastoid 55 to 70 43
5 Parieto-temporal (squamous) 60 to 70 54
6 Baso-occiput with baso-sphenoid 18 to 25 17
Table - 2: Suture closure in different age group

Age group Sagittal Lambdoid Coronal PM PT BO - BS
(in years) 20 % 20 % 20 % 20 % 20 % 20 %
15-20 --- --- --- --- --- --- --- --- --- --- 11 55
20-25 --- --- --- --- --- --- --- --- --- --- 17 85
25-30 --- --- --- --- --- --- --- --- --- --- 18 90
30-35 --- --- --- --- --- --- --- --- --- --- 19 95
35-40 --- --- 2 10 --- --- --- --- --- --- 20 100
40-45 --- --- 9 45 --- --- --- --- --- --- 20 100
45-50 4 20 15 75 6 30 --- --- --- --- 20 100
50-55 15 75 15 75 18 90 7 35 2 10 20 100
55-60 14 70 17 85 18 90 16 80 8 40 20 100
60-65 18 90 18 90 17 85 18 90 16 80 20 100
65-70 18 90 18 90 18 90 18 90 18 90 20 100
[PM – Parieto-mastoid, PT – Parieto-temporal, BO - BS – Baso-occiput baso-sphenoid]

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Table – 3: Comparison of time of closure of sagittal suture (in years)

Author Year Race Method Time of closure
Reddy K.S.N. [2] 2007 Indian X-ray Posterior 1/3 – 30 to 40
Anterior 1/3 – 40 to 50
Middle 1/3 – 50 to 60
Dikshit P.C. [3] 2007 Indian X-ray Start – 25
Complete – 35 to 40
Nandy A. [4] 2001 Indian X-ray Start – 24 to 25
Mukherjee J.B. [5] 2011 Indian X-ray 35 to 40
Karmakar R.N. [6] 2010 Indian X-ray Start – 25
Pillay VV [7] 2008 Indian X-ray 30 to 40
Vij K. [8] 2011 Indian X-ray Posterior 1/3 – 30 to 40
Anterior 1/3 – 40 to 50
Middle 1/3 – 50 to 60
Dwight T. [9] 1890 USA X-ray Start – 22
Complete – 35
Parsons FG and Box CR [10] 1905 USA X-ray Start – 22
Complete – 35
Todd TW and Lyon DW [11, 12] 1924-1925 USA X-ray Start – 22
Complete – 35
Mckern TW and Stewart TD [13] 1957 USA X-ray Start – 18
Present 2012 India X-ray 50 to 60
Table – 4: Comparison of time of closure of lambdoid suture (in years)

Krogman [14] 1962 USA Gross skeletal 31
Parikh C.K. [15] 1990 Indian X-ray 45 to 50
Vij K. [8] 2011 Indian X-ray Start – 25 to 30
Complete – 55
Pradeep et al [1] 2001 - 2004 Punjab CT scan 45 to 50
Dikshit P.C. [3] 2007 Indian X-ray Start – 25 to 35
Reddy K.S.N. [2] 2007 Indian X-ray 45
Mukherjee J.B. [5] 2011 Indian X-ray Upper part – 30 to 35
Lower part – 45 to 50
Karmakar R.N. [6] 2010 Indian X-ray Start – 30
Present 2012 Indian X-ray 45 to 55

Page 131
Table – 5: Comparison of time of closure of coronal suture (in years)

Krogman [14] 1962 USA Gross skeleton Type 1, 2 – 24 to 38
Type 3, 4 – 26 to 41
Parikh C.K. [15] 1990 Indian X-ray 35 to 40
Reddy K.S.N. [2] 2007 Indian X-ray Lower half – 40 to 50
Upper half – 50 to 60
Vij K. [8] 2011 Indian X-ray Lower half – 40 to 50
Ramachandran C. [16] 2003 Indian X-ray Lower half – 40 to 60
Pradeep et al [1] 2001-2004 Punjab CT scan 45 to 50
Dikshit P.C. [3] 2007 Indian X-ray Start – 25 to 30
Complete – 40
Mukherjee J.B. [5] 2011 Indian X-ray Lower half – 25 to 30
Karmakar R.N. [6] 2010 Indian X-ray Start – 25 to 30
Table – 6: Comparison of time of closure of parieto-mastoid suture (in years)

Parikh C.K. [15] 1990 Indian X-ray 55
Reddy K.S.N. [2] 2007 Indian X-ray 40 to 50
Karmakar R.N. [6] 2010 Indian X-ray 60 to 70
Table – 7: Comparison of time of closure of squamous (parieto-temporal) suture (in years)

Parikh C.K. [15] 1990 Indian X-ray 60
Reddy K.S.N. [2] 2007 Indian X-ray 60
Dikshit P.C. [3] 2007 Indian X-ray 70
Nandy A. [4] 2001 Indian X-ray 70

Page 132
Table – 8: Comparison of time of closure of baso-occiput with baso-spheoid (in years)

Dikshit P.C. [3] 2007 Indian X-ray 18 to 20
Reddy K.S.N. [2] 2007 Indian X-ray 18 to 21
Nandy [4] 2001 Indian X-ray Female – 18 to 20
Male – 20 to 22
Mukherjee J.B. [5] 2011 Indian X-ray Female – 19 to 22
Male – 19 to 24
Karmakar R.N. [6] 2010 Indian X-ray Female – 19 to 22
Male – 19 to 24
Vij K. [8] 2011 Indian X-ray Female – 18 to 20
Male – 20 to 22
David Dolinak [17] 2005 USA X-ray 18 to 23
Bernard Knight [18] 2004 USA X-ray 20
Table – 9: Suture closure scoring system as per Buikstra and Ubelaker

Score Suture
0 Open
1 Minimum closure
2 Significant closure
3 Completely obliterated
Table – 10: Meindl and Lovejoy suture scoring system (1985)

Score Description
0 Open, there is no evidence of any ecto-cranial closure at site.
1 Minimal closure, Some closure has occurred. This score is given for any minimal to moderate closure,
i.e. from a single bony bridge across the suture to about 50% synostosis at the site.
2 Significant closure, there is a marked degree of closure but some portion of the site is still not
completely fused.
3 Advanced closure. Only pits indicate where the suture is located.
Table – 11: Acsadi and Nemeskeri (1970) and Perizonius (1984) scoring system
Score Description
0 Open suture. There is little space left between the edges of adjoining bones.
1 Incipient closure. Suture is closed, but clearly visible as a continuous, often zigzagging line.
2 Closure in process. Suture line becomes thinner, has fewer zigzags and may be interrupted by
complete closure.
3 Advanced closure. Only pits indicate where the suture is located.
4 Closed suture. Suture completely obliterated, even its location can’t be recognized.

Page 133
RATE PRESSURE PRODUCT – A DIAGNOSTIC TOOL IN DETERMINING THE
Sangeeta Nagpal et al
CARDIOVASCULAR RISK IN POSTMENOPAUSAL WOMEN
RATE PRESSURE PRODUCT – A DIAGNOSTIC TOOL IN

DETERMINING THE CARDIOVASCULAR RISK IN
POSTMENOPAUSAL WOMEN
IJCRR
Vol 04 issue 20 Sangeeta Nagpal1, Kalpana Gupta2, Jitendra Ahuja3
Department of Physiology, Geetanjali Medical College and Hospital, Manwa Khera,
Category: Research
Udaipur (Rajasthan)
Received on: 25/08/12 2
Department of Skin, Geetanjali Medical College and Hospital, Manwa Khera, Udaipur
Revised on:01/09/12
(Rajasthan)
Accepted on:07/09/12 3
Department of Biochemistry, Geetanjali Medical College and Hospital, Manwa Khera,
Udaipur (Rajasthan)
E-mail of Corresponding Author: dr.sangeeta10@gmail.com
ABSTRACT
Objective: Rate pressure product (RPP) is an indirect measure of Myocardial oxygen
consumption (MVO2).It increases progressively with exercise and the RPP at peak of exercise is
Peak rate pressure product (PRPP). The low value of PRPP suggests significant compromise of
coronary perfusion. In the present study effect of exercise on RPP of Pre menopausal women and
Post menopausal women were compared.
Research Design and Methods: The study was conducted on a total of 50 healthy volunteer
women. They were subjected to treadmill exercise test and baseline and maximum RPP was
calculated.
Results: The RPP in premenopausal women increased significantly from 10.83 ± 2.11 to 28.98 ±
2.93 mm of Hg beats / min x 10-3 during exercise and in postmenopausal from 12.52 ± 2.69 to
28.03 ± 4.14. The percentage increase in RPP was significantly more in Premenopausal women
(63%) as compared to postmenopausal women (55%).
Conclusions: It can be concluded that Rate pressure product reaches the critical value before the
symptoms appear and the percentage increase in Rate pressure product was less in
postmenopausal women. The results also suggest that the measurement of Peak rate pressure
product in response to exercise can detect Coronary Artery Disease (CAD) even before the
appearance of clinical signs and symptoms in postmenopausal women and thus can be used as a
diagnostic tool.
INTRODUCTION usually be expected in the age range of 42–58(1).

Menopause is a period used to express the Menopause is associated with increased risk of
permanent cessation of the prime function of the Coronary Artery Disease (CAD) due to loss of
human ovaries, the ripening and release of ova and cardio protective effect of estrogen. Estrogen
the release of hormones that cause both the deficient state affects myocardial efficiency by
creation of the uterine lining and the subsequent enhancing cardiovascular response to mental
shedding of the uterine lining. Menopause signals stress, by changing lipid profile, decreasing
the end of the fertile phase of a woman's life. vascular reactivity (2) and by increasing
Menopause has a wide starting range, but can homocysteine levels (3). Moreover there is

Page 134
accelerated cell death in the aging myocardium MATERIAL AND METHODS

leading to depletion of functional myocytes that The present study was done to access the
decreases the contractile performance (4) cardiovascular performance in postmenopausal
Myocardial oxygen consumption (MVO2) is a women by measuring various hemodynamic
good indicator of the response of the coronary parameters like Heart rate, Systolic blood pressure
circulation to increased oxygen demand. and Rate pressure product. The study was
Coronary blood flow (CBF) increases in direct conducted in 50 volunteer women. They were
proportion to the myocardial oxygen requirements. divided into two groups. The Group A consisted of
Thus the determinants of MVO2 are also the 25 healthy postmenopausal women with no
determinants of CBF (5). Direct measurement of systemic disorder and Group B consisted of 25
MVO2 is difficult in routine clinical practice but it postmenopausal women with and no systemic
can be easily measured indirect methods like disorder .the study protocol was approved by the
stroke work, Fick’s principle ,the tension time Institutional ethics committee. Written informed
index and rate pressure product (RPP) (6) consent was taken from all the volunteers before
RPP is the product of heart rate and systolic blood enrollment.
pressure. It reflects the work of the heart and The study included recording of anthropometric
correlates well with MVO2 .It is calculated as parameters like age, height and weight. All the
[RPP = Heart rate (HR) x Systolic blood pressure subjects were first thoroughly examined and those
(SBP) / 1000].The value is divided by 1000 to having systemic disease were excluded. The
make the number more manageable. (7). It baseline heart rate, systolic blood pressure and
increases with the increase of stress or work load ECG were recorded. SBP was recorded by
on the heart. It is a simple non invasive easily auscultatory method. .Baseline RPP was
measurable index, which defines the response of calculated.
coronary circulation to myocardial metabolic RPP, which is the product of systolic blood
demand. It is a good index of MVO2in patients pressure and heart rate, was computed as (7):
with ischemic heart disease (8). It has been shown RPP = SBP in mm Hg x HR beats /min x 10-3
that in any particular patient with CAD, the onset Exercise stress test was performed on Treadmill,
of angina appears at a constant RPP. Most patients which is the most commonly used dynamic
would complaint of some pain at a constant RPP exercise device for this test. The subject was
of 20,000. (9) Rate pressure product is also called subjected to graded exercise. The treadmill is
as Robinson index (10). The internal myocardial started at a relatively slow speed. The treadmill
work performed is represented by RPP and speed (km/hr) and its grade of slope (%) or
external myocardial work performed is generally inclination are increased every three minutes
expressed as stages of exercise. according to a preprogrammed protocol. Bruce
Many comparative studies have been done to protocol is the commonest protocol used. The
know the influence of hormones on hemodynamic protocol dictates the precise speed and slope of
parameters in postmenopausal women but there treadmill. According to this, each three minute
are few reports on the effect of exercise on RPP in interval is called as a stage. The treadmill is set
postmenopausal women. Hence this study was with the stage I, speed (2.74km/hr) and grade of
designed to evaluate the effect of exercise on RPP slope (10%) and subject commences the test. At
in postmenopausal women and determine the the appropriate times during the test, the speed and
importance of RPP in the diagnosis and the slope of treadmill are adjusted. So after 3 minutes,
prevention of CAD in postmenopausal women. the speed is adjusted to 4.02km/hr and slope to
12%. After 6 minutes, the speed is adjusted to

Page 135
5.47km/hr and slope to 14%. The subject was Statistical analysis

made to run on a treadmill till exhaustion. Data was represented as mean and standard
Treadmill exercise variables of HR, SBP and ECG deviation (SD).Analysis was done using Student’s
were determined. The ECG was constantly paired t-test and Wilcoxon Signed Ranks Test. P-
displayed on the monitor. It was also recorded on value<0.05 was considered as statistically
paper at one minute interval. The patient’s blood significant.
pressure was recorded during second minute of
each stage. The maximum RPP was calculated. OBSERVATIONS AND RESULTS
The maximum RPP at maximum exercise is called The subjects of group A and Group B were
as Peak RPP (PRPP). The exercise test is said to comparable for demographic characteristics (Table
be maximal when the subject appears to give true I). The mean age of Group A was 40 years and
maximal effort i.e. Effort done to the point of Group B was also 57 years.
body exhaustion or when other clinical end points
are reached. The exercise stress test was Table I showing Demographic profile of
terminated in the subjects if the target heart rate subjects at baseline in both groups
was achieved or they complained of fatigue. Characteristics Group A Group B
Exercise was also discontinued if there were Age (years) 39.6 ± 6.0 56.5 ± 6.1
abnormal changes like decrease in SBP of 10mm Weight (kg) 73.7 ± 20.9 67.4 ± 10.7
Hg along with evidence of ischemia, abnormal Height (cm) 157.0 ± 6.2 156.3 ± 4.8
ECG pattern like ST segment displacement, Group AI = 25, Group B = 25
appearance of arrhythmias, bundle branch block or All values are mean ±SD
if subject complains of chest pain.
Table II shows changes in hemodynamic parameters (SBP, HR and RPP) in both the groups
Characteristics Baseline Maximum Percentage change
Heart rate
Group A 84.32±11.18 168.96 ± 11.40# 59
Group B 88.92±18.06 157.6 ±21.14* # 43*
SBP
Group A 128 ± 14.71 172.08 ± 18.96# 25
Group B 141.12 ± 12.01* 178.08± 13.74 #* 21
RPP
Group A 10.83± 2.11 28.98 ± 2.93# 63
Group B 12.52 ± 2.69* 28.03± 4.14# 55*
All values are mean ±SD
* P < 0.05 as compared to group A
# P < 0.05 as compared to baseline value
All the baseline hemodynamic parameters were significant increase in RPP from 12.52 ± 2.69 to
significantly more in healthy postmenopausal 28.03 ± 4.14. The percentage increase in RPP was
women as compared to healthy Premeopausal significantly more in Premeopausal women (63%)
women. There was significant increase in SBP, as compared to postmenopausal women (55%).
HR and RPP during exercise in both the groups. Maximum HR was significantly less in group B as
The RPP in Group A increased significantly from compared to group A. The percentage increase in
10.83 ± 2.11 to 28.98 ± 2.93 mm of Hg beats / HR was significantly more in Premeopausal
min x 10-3 during exercise. Group B also showed a

Page 136
women (59%) as compared to Premeopausal present study the PRPP was 28.98 and 28.03 mm
women (43%). Hg x Beats / min x 10-3 in pre menopausal women
There was no statistically significant difference in and post menopausal women respectively. The
percentage change in SBP between the groups. percentage increase in RPP was 63% in
premenopausal women and 55% in
DISCUSSION postmenopausal women. The peak RPP is an
Abnormal hemodynamic response to exercise may accurate reflection of the myocardial oxygen
indicate an increased risk of CAD, even if signs demand and myocardial work load. The higher
and symptoms of ischemia are absent. Both HR the RPP, the higher will be the MVO2. The ability
and SBP are important variables determining to reach high RPP is associated with more
changes in myocardial oxygen consumption adequate coronary perfusion. Reaching the high
between rest and exercise (9).During exercise HR, RPP without symptoms or evidence of severe
SBP and RPP increases with increase work load ischemia suggests adequate left ventricular
on the heart to provide adequate blood supply to functions and the low value of PRPP suggests
the active myocardium. significant limitation of coronary perfusion and
All the hemodynamic parameters increase decreased LV function leads to angina. .
significantly with exercise in both the groups. This Maximum RPP is reported to range from 10th
is due to increase in sympathetic discharge during percentile value of 25,000 to a 90th percentile of
exercise(11,12) .RPP increases progressively with 40,000(15). RPP exceeding 22 is commonly
exercise and attained the peak value of 28.98 ± associated with myocardial ischemia and angina
2.93 mm Hg x beats per minute x 10-3 in (8).
premenopausal women and 28.03± 4.14 in Both HR and SBP are also useful in the diagnosis
postmenopausal women. The percentage increase of ischemic heart disease in postmenopausal
in RPP was significantly less in postmenopausal women. In our study there was a significant
women (55%) as compared to premenopausal increase in HR and SBP in both the groups during
women (63%). The less percentage increase in exercise. The percentage increase in SBP was
postmenopausal women is due to age related comparable in both the groups. On the other hand
depletion of functional myocytes, cardiac the percentage increase in HR was significantly
receptors and increased myocardial stiffness that less in postmenopausal women as compared to
decreases the ventricular pumping and premenopausal women. The less increase in HR is
cardiovascular response of the heart to exercise. due to age related depletion of cardiac myocytes
(13) which has been proposed as a mechanism for
Angina results from imbalance between oxygen decreased contractile performance and decrease
supply and demand and is precipitated due to hemodynamic responses (3).
increase in work of myocardium to a critical level The baseline HR, SBP and RPP were more in
which is fixed in each patient. The work of the postmenopausal women than premenopausal
myocardium is measured by RPP. Most normal women. It may be attributed due to marked
individuals develop a RPP of 20 to 35 mm Hg x sympathetic activation and decrease
beats / min x 10-3. In many patients with parasympathetic activity due to low estrogen. The
significant Ischemic Heart Disease, RPP value increased sympathetic activation in
exceeding 25 mm Hg x beats / min x 10-3 are postmenopausal women is due to endothelial
unusual (14). Studies reported the rate pressure dysfunction Also with menopause, there is
product exceeding 22,000 is commonly associated increased level of vasoconstriction and oxidative
with myocardial ischemia and angina (9). In the stress. All these factors contribute to hyperkinetic

Page 137
circulation characterized by elevated HR and SBP. 5. John Ross, Jr. Cardiovascular system. In: Best
Menopause also increases aortic stiffness. and Taylor’s physiological basis of medical
practice. West JB(Ed).12th edition. New Delhi:
CONCLUSION B.I .Waverly Pvt. Ltd; 1990 p. 265.
Results from this study indicate that HR x SBP, 6. Sarnoff SJ, Braunwald E. Hemodynamic
easily measurable hemodynamic parameters are valid determinants of oxygen consumption of heart
predictors of MVO2 during exercise in a population with special reference to the tension-time index
of postmenopausal women. It can be concluded that .Am J Physiol 1958; 192: 148-156.
RPP reaches the critical value before the symptoms 7. Navalta JW, Sedlock DA, Park K-S.
appear and the percentage increase in RPP was less Physiological responses to downhill walking in
in postmenopausal women. The results also suggest older and younger individuals. Journal of
that the measurement of PRPP in response to exercise physiology 2004;7(6):45-51
exercise can detect CAD even before the appearance 8. Zargar JA, Naqash IA, Gurcoo SA, Mehraj-Ud-
of clinical signs and symptoms in postmenopausal Din. Comparative evaluation of the effect of
women and thus can be used as a diagnostic tool. metoprolol and esmolol on rate pressure product
and ECG changes during laryngoscope and
ACKNOWLEDGEMENT endotracheal intubation in controlled
We acknowledge the immense help received from hypertensive patients. Indian J Anaesth 2002;
the scholars whose articles are cited and included in 46: 365-368.
references of this manuscript. We are also grateful to 9. Robinson B F. Relation of heart rate and
authors / editors / publishers of all those articles, systolic blood pressure at the onset of pain in
journals and books from where the literature for this angina pectoris. Circulation 1967; 35:1073-
article has been reviewed and discussed. 1083
10. Siegelova J, Fier B, Duek J, Placheta Z,
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Page 138
COMPARATIVE ANALYSIS OF COMMUNICABLE AND NON COMMUNICABLE DISEASES IN
C. Kumaraswamy Naidu et al
RURAL AND URBAN LOCALITIES OF TIRUPATI IN INDIA
COMPARATIVE ANALYSIS OF COMMUNICABLE AND NON

COMMUNICABLE DISEASES IN RURAL AND URBAN
LOCALITIES OF TIRUPATI IN INDIA
IJCRR
Vol 04 issue 20 C. Kumaraswamy Naidu1, Y. Suneetha1, B. V. Sai Prasad2
Section: Healthcare
1
Category: Research Department of Zoology, Sri Venkateswara University, Tirupati, India
2
Received on: 04/08/12 Department of Pathology, Sri Venkateswara Medical College, Tirupati, India
Revised on:21/08/12
Accepted on:04/09/12 E-mail of Corresponding Author: ysuneethareddy4@gmail.com
ABSTRACT
Communicable diseases (CD) are the main cause of death around the world for years followed by non-
communicable diseases (NCD) causing major problems in industrialized countries. Among all NCDs and
CDs, Cancers (NCD) and Tuberculosis (CD) constitute the major cause of morbidity and mortality in
developing countries, including India. The specific aim of this study is to quantify the prevalence of
communicable (Tuberculosis) and non communicable diseases (Cancers) in urban and rural areas of
Tirupati and to analyze the relative epidemic using a comparable framework. The data was analyzed
statistically using Chi-Square test and Odds ratio with 95% confidence interval. All analyses were
performed with SPSS version 13 software. Compared to rural areas, people from Urban areas of Tirupati
(52.1% Vs 47.9%) has increased risk of NCDs: patients with Breast Cancer (33% ), Cervical Cancer
(35%), Oral Cancer (8.9%), Prostrate Cancer (6.3%), Skin Cancer (4%) and Other Cancers (12.9%) like
Bladder, Colon, Lung, Rectal, Stomach, Uterine. There was a significant urban-rural difference in having
Tuberculosis in the years 2010 to 2011 (71.4% vs 28.6%, respectively; P < 0.001) and there was a
significant urban-rural difference in Communicable and non communicable diseases in the years 2010-
2011(54.1% vs 45.9%, respectively; P = 0.03). These finding suggests that there is an increasing
prevalence of Communicable and non communicable diseases in Tirupati as a result of lifestyle changes
and urbanization. These are the challenges that are to be tackled in new millennium.
Keywords: Communicable diseases, Non-communicable diseases, Rural, Urban
INTRODUCTION countries. The spread of non-communicable

India is one of the famous countries around the diseases (NCDs) principally heart disease, stroke,
world for cultural activities. In India, one of the diabetes, cancers, and chronic respiratory disease
major pilgrimage cities is Tirupati which is located represents a global crisis; in almost all countries
at the foothills of Eastern Ghats, Andhra Pradesh. and in all income groups, men, women, will
Being a major pilgrimage, millions of people visit account for 80% of the global burden of disease,
Tirupati daily. Being a famous tourist spot in causing seven out of every ten deaths in
Andhra Pradesh, Tirupati is prone to disease developing nations, compared with less than half
exposure. Diseases can be broadly categorized into today [1] .Globally, around 57 million people died
two types: Communicable and Non and children are at risk of these diseases [2].
Communicable. Communicable diseases (CD) Epidemics of non-communicable diseases (NCD)
were the main cause of death around the world for are presently emerging or accelerating in most
years followed by non-communicable diseases developing countries [3]. In 2008, 33 million
(NCD) causing major problems in industrialized (58%) of the deaths were due to chronic (non-

Page 139
communicable) diseases (mainly cardiovascular examination data containing Biopsy number,

disease, diabetes, cancer, and chronic respiratory Disease type, age, sex, Locality, Height, Mark
diseases) [4]. In 2004, 4.8 million (59.4 percent) of section, cut section, Histopathological examination
the estimated 8.1 million Indian deaths were due and Microscopic examination. Among these
to NCDs [5]. Communicable diseases (CDs) like variables only disease type, age, sex, locality was
tuberculosis (TB), cholera, meningitis, hepatitis, considered for the study. The reference date for
malaria, dengue, yellow fever, AIDS, Ebola, recording information was the date of diagnosis
SARS and others in parallel also continue to be the for cases.
major cause of mortality in developing countries
[6]. Statistical Methods
Even Asian countries like India have a major The data was analyzed statistically using Chi-
public health challenge of growing magnitude of Square test and Odds ratio with 95% confidence
non communicable and communicable diseases in interval. All analyses were performed with SPSS
the present century. In India, among all NCDs and version 13 software.
CDs, Cancers (NCD) [7] and Tuberculosis (CD)
[8] constitute the major cause of morbidity and RESULTS AND DISCUSSION
mortality. In this paper, we use the term chronic Non communicable diseases
non-communicable disease to refer to major Among the various NCDs like cardiovascular
chronic disorder such as Cancer and diseases, Diabetes and Cancers, only cancers were
communicable disease to refer Tuberculosis; other used for this study. Cancers that are used in the
disorders are not covered in this paper. The study includes Breast, Cervical, Colon, Bladder,
specific aim of this study is to estimate and Lung, Oral, Prostrate, Rectal, Skin, Uterine and
compare the relative incidence of communicable Stomach Cancer. Among 3000 patients biopsied in
and non communicable diseases in Urban and the year 2010 to 2011, 303 patients were seen
Rural areas of Tirupati. A comparison was made affected with these cancers. Compared to rural
of the age-specific incidence rates in Tirupati areas ( i.e., 10 villages surrounding Tirupati),
region at 2-year intervals from 2010 to 2011. people from Urban areas of Tirupati (i.e., People
living in Tirupati town) (52.1% Vs 47.9%) has
MATERIALS AND METHODS increased risk of NCDs: patients with Breast
Study site Cancer (33% ), Cervical Cancer (35%), Oral
This study was conducted based on data from Cancer (8.9%), Prostrate Cancer (6.3%), Skin
Bharath, Diagnostic Center, Tirupati. All the Cancer (4%) and Other Cancers (12.9%) like
newly diagnosed cases in the years 2010 and 2011 Bladder, Colon, Lung, Rectal, Stomach, Uterine (
were included as the study cases. Among 3000 P=0.07, Table 1). The prevalence of the non
patients’ biopsy data in the lab, only cases having communicable diseases in urban and rural areas is
Cancers (CD) and Tuberculosis (NCD) were diagrammatically represented in the chart (Chart
included in this study. The data was a clinical 1) given below.

Page 140
Table 1: Non communicable diseases in urban and rural areas of Tirupati (2010-2011)
Cancer Type Patients, n (%) df χ2 P

Rural Urban
Breast 43 (14.19) 57 (18.81) 5 10.1 0.07
Cervical 62 (21.7) 44 (15.4)
Oral 14 (1.24) 13 (1.15)
Prostrate 6 (0.77) 13 (1.67)
Skin 6 (0.24) 6 (0.24)
Other 14 (1.8) 25 (3.2)
*Abbreviations: df – degrees of freedom, χ2 used to test categorical variables for statistical significance, P
refers to the probability
Bar Chart
70 LOCALITY
RURAL
URBAN
60
50
Count
40
30
20
10
0
BREAST CERVICAL ORAL OTHER PROSTRATE SKIN
CANCER TYPE
Chart 1: Prevalence of the non communicable diseases in urban and rural areas
Non communicable diseases

Among 3000 patients biopsied in our laboratory 35 patients were seen affected with Tuberculosis. There
was a significant urban-rural difference in having Tuberculosis in the last 2 years (71.4% vs 28.6%,
respectively; P < 0.001) (Table 2).
Table 2: Tuberculosis in Urban- rural communities of Tirupati (2010-2011)

Cancer Type Tuberculosis Patients, n (%) Difference (95% CI) df t P
Rural Urban
Age 10 (28.6) 25 (71.4) 30.743 (25.58 to 35.91) 34 12.102 <0.001

Page 141
Comparison of communicable and non communicable diseases

There was a significant urban-rural difference in burden to Communicable and non communicable
diseases in the years 2010-2011(54.1% vs 45.9%, respectively; P = 0.03) (Table 3).
Table 3: Communicable and Non Communicable diseases in Urban- rural communities of Tirupati
(2010-2011)
Disease Type Patients, n (%) df χ2 P
Rural Urban
Communicable 10 (4.59) 25 (13.5) 1 4.699 0.03
Non Communicable 145(66.5) 158 (85.4)
CONCLUSION 3. Murray CJL, Lopez AD. Global Health

Our findings suggest that the observed differences Statistics: Global Burden of Disease and
between urban and rural women could be Injury Series. Volumes I and II. Boston:
substantially reduced by changing the lifestyle or Harvard School of Public Health, 1996.
proper detection in the early stages. It is also 4. A. Alwan, D. R. MacLean, L. M. Riley, E.
important to educate the public and health care Tursan d’Espaignet, C. D. Mathers, G. A.
professionals in rural and urban areas in order to Stevens, D. Bettcher. Monitoring and
promote early detection. Overall, our study surveillance of chronic non-communicable
concludes that people residential of Tirupati are diseases: progress and capacity in high-burden
more exposed to both communicable and non countries. Lancet., 2010, 376: 1861.
communicable diseases compared to those from 10 5. A. Mahal, A. Karan, M. Engelgau. Existing
villages surrounding Tirupati. Evidence on the Economic Impact of NCDs in
India and its Limitations. HNP Discussion
ACKNOWLEDGEMENT paper., 2010.
C. Kumaraswamy Naidu is grateful to UGC, New 6. World Health Organization. Cholera: the
Delhi for providing financial help under UGC- prototype “global” disease. In: Global defence
RFSMS scheme. against the infectious disease threat. Geneva:
Ethical Approval WHO, 2003 (WHO/CDS/2003.15).
The study has ethics approval from Sri 7. T. Seth, A. Kotwal, R. Thakur, P. Singh, V.
Venkateswara Medical College, Tirupati. Kochupillai. Common cancers in India:
knowledge, attitudes and behaviours of urban
REFERENCES slum dwellers in New Delhi. Public Health.,
1. A. Boutayeb, The double burden of 2005, 119: 87.
communicable and non-communicable 8. M. S. Pednekar, P. C. Gupta. Prospective
diseases in developing countries, Transactions study of smoking and tuberculosis in India.
of the Royal Society of Tropical Medicine and Preventive Medicine, 2007, 44: 496.
Hygiene., 2006, 100, 191.
2. Ala Alwan. Global status report on
noncommunicable diseases 2010. World
Health Organization, 2011.

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ANOMALOUS ORIGIN OF HEPATIC ARTERY AND ITS RELEVANCE IN HEPATOBILIARY
Sunita Sethy et al
SURGERIES
ANOMALOUS ORIGIN OF HEPATIC ARTERY AND ITS

RELEVANCE IN HEPATOBILIARY SURGERIES
IJCRR Sunita Sethy1, G. R. Nayak1, D. Agrawal2, B. Mohanty2, R. Biswal1

Vol 04 issue 20
Department of Anatomy, SCB Medical College, Cuttack, Odisha, India
Department of Anatomy, IMS and SUM Hospital, Bhubaneswar, India
Revised on:27/08/12 E-mail of Corresponding Author: sunitachunu@gmail.com
ABSTRACT
Background: Introduction of laparoscopic cholecystectomy, hepatobiliary surgeries and liver
transplantations has stimulated a renewed interest in hepatic arterial anatomy. The variant arterial
anatomy recognized during routine cadaveric dissection offers great learning potential. This imparts the
concept of patient individuality and subsequent individualization of medical and surgical therapies and
helps the surgeons for safe surgery and low morbidity. Objective of the study: To report on hepatic
artery variations observed in the dissecting room and to find out the different pattern of hepatic arteries by
cadaveric dissection. Materials and Methods: Twenty five human cadavers of SCB Medical College
were dissected to study the source and pattern of hepatic arterial supply to liver. Results: Twenty four
cadavers exhibited typical common hepatic arterial supply from the celiac trunk. Only one female body
out of twenty five cadavers had an anomalous origin of common hepatic artery. Common hepatic artery
originated from the superior mesenteric artery. Conclusion: Aberrant hepatic vascularisation should be
assessed preoperatively to avoid fatal complications in hepatobiliary surgeries.
Keywords: Hepatic artery, Superior mesenteric artery, Hepatobiliary surgeries.
INTRODUCTION branches before these run into the parenchyma of

In adults the Common Hepatic Artery (CHA) is the liver.
intermediate in size between the left gastric and A replaced hepatic artery is a vessel that does not
splenic arteries. In fetal and early postnatal life it originate from an orthodox position and provides
is the largest branch of the coeliac axis. The the sole supply to that lobe. Rarely a replaced
hepatic artery gives off right gastric, common hepatic artery arises from the superior
gastroduodenal and cystic branches as well as mesenteric artery and is identified at surgery by a
direct branches to the bile duct from the right relatively superficial portal vein (reflecting the
hepatic and sometimes the supraduodenal artery. It absence of a common hepatic artery that would
may be subdivided into the common hepatic normally cross in front of the vein). More
artery, from the coeliac trunk to the origin of the commonly a replaced right hepatic artery or an
gastroduodenal artery, and the hepatic artery accessory right hepatic artery arises from the
‘proper', from that point to its bifurcation. It passes superior mesenteric artery. In this case they run
anterior to the portal vein and ascends anterior to behind the portal vein and bile duct in the lesser
the epiploic foramen between the layers of the omentum and can be identified at surgery by
lesser omentum. Within the free border of the pulsation behind the portal vein. The presence of
lesser omentum the hepatic artery is medial to the replaced arteries can be lifesaving in patients with
common bile duct and anterior to the portal vein. bile duct cancer: because they are away from the
At the porta hepatis it is divided into right and left bile duct and hence not affected by cancer, making

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Sunita Sethy et al
SURGERIES
excision of the tumour feasible. Knowledge of condition. The dissection of arteries were done and
these variations is also important in planning the then coloured and photographed. The
whole and split liver transplantation. (Grays measurement of length and external diameter of
Anatomy-40th edition, Liver, 1169-70). arteries were done by sliding Vernier Callipers.
The hepatic arteries may arise from the abdominal
aorta, the left gastric or the superior mesenteric RESULT
arteries (2). The hepatic arterial anatomy is After a careful dissection of twenty five cadavers,
aberrant in almost 33-41% individuals (1, 2, 3, 4). we analyzed the variation pattern of celiac axis,
The most common anomalies include, the right superior mesenteric artery and the source and
hepatic artery arising from superior mesenteric distribution of hepatic arteries.
artery (25%) and left hepatic artery arising from Celiac trunk: Except one, all the cadavers
the left gastric artery (25%) (4) . Anomalies of the exhibited classical (Hepatoleinogastric) pattern of
common hepatic artery, usually a branch of the celiac trunk's origin and distribution. In a study of
celiac trunk, are relatively uncommon (5). twenty five celiac trunks, the length of celiac trunk
However, Kadir et al., (1991) demonstrated varied from 6 to 25mm and the width from 9 to 20
angiographically a 5% incidence of the replaced mm. The celiac trunk was constricted at its site of
common hepatic artery (6) whereas Woods and origin from the abdominal aorta. The distance on
Traverso (1993) found the replaced common the aorta between the sites of origin of celiac and
hepatic artery, branching off the superior superior mesenteric arteries varied from 10 to
mesenteric artery in 2.5% of the cases (7). 15mm. In twenty three cases, splenic artery was
An aberrant hepatic artery may cause a potential the largest branch of celiac trunk, whereas in two
error in the angiographic diagnosis of traumatic cases common hepatic was the largest branch.
liver hematoma (8). Moreover the existence of However left gastric was found as the first and
aberrant hepatic arteries emphasizes the mode of smallest branch of celiac trunk in all cases.
development of liver during perinatal period (9). Anomalous celiac trunk had only 2 branches [Fig-
Liver transplantation and peripancreatic surgery 1],[Fig-2]
needs extensive, adequate and clear knowledge of (1)Left gastric artery
varied blood supply of liver. (2)Splenic artery
MATERIALS AND METHODS Hepatic arteries: Five cadavers exhibited three

We carefully dissected twenty five cadavers of hepatic arteries, i.e., right, left and middle hepatic
SCB Medical College Cuttack origin (twenty arteries for the right, left and quadrate lobes of the
males and five females), aged between 45-65 years liver respectively. Twenty cadavers had two
and randomly assigned to medical students for hepatic arteries, i.e., right and left. Hepatic arteries
dissection over a period of three years. We took had normal celiac origin in twenty four cadavers.
the task of dissection from origin to termination of One common hepatic artery had a superior
all the major arteries supplying the liver. To study mesenteric origin (4%) [Fig-1&2].
the variational anatomy of hepatic arterial supply, The width of the anomalous common hepatic
we decided to follow all the branches of celiac and artery (16mm) was relatively wider than that of
superior mesenteric arteries. Especially all hepatic classical celiac common hepatic artery (12mm).
vessels were painstakingly dissected from origin to The anomalous common hepatic artery routed to
ultimate distribution in the substance of liver. the posterior of the head of the pancreas and,
We selected only those bodies, which were entered the right margin of hepato-duodenal part
properly embalmed and having arteries in good of lesser omentum, where it was lying medial to

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Sunita Sethy et al
SURGERIES
the common bile duct and anterior to the portal It was routing to posterior of the head of pancreas
vein. [Fig-1, Fig-2]. The CHA then gave a branch- and first part of the duodenum. Later it had normal
Gastroduodenal artery and continued as the Proper course. Another classification method is the one
Hepatic artery. The proper hepatic artery was adopted by Michel et.al in 1955
further divided into 2 branches-right and left
hepatic artery. The right hepatic artery further I. standard anatomy : 55 - 61 %
gave cystic artery. II. replaced LHA : 3 - 10 %
Cystic artery: In twenty cases the cystic artery III. replaced RHA : 8 - 11 %
was single and arising from the right hepatic IV. replaced RHA and LHA : 0.5 - 1 %
artery. The left hepatic artery was found in one V. accessory LHA from LGA : 8 - 11 %
case and proper hepatic artery in four cases. VI. accessory RHA from SMA : 1.5 - 7 %
Superior mesenteric artery: Except one, all 24 VII. accessory RHA and LHA : 1 %
cadavers exhibited normal branching pattern. In VIII. accessory RHA and LHA and replaced
one case the Common Hepatic Artery was the 1st LHA or RHA : 2 - 3 %
branch and middle colic artery arose from the right
IX. CHA replaced to SMA : 2 - 4.5 %
X. CHA replaced to LGA : ~ 0.5 %
colic artery [Fig-1, 2 & 3].
XI. Others
DISCUSSION o CHA separate origin from aorta : ~ 2 %
Aberrant hepatic arterial anatomy occurs in 33- o double hepatic artery§ : 3.7 %
41% of reported literature (3), (6), (10). The o PHA replaced to SMA; GDA origin from
common hepatic artery is usually a branch of the aorta : 0.3 %
celiac trunk (2). This classical "Michels type -I"
pattern with right and left hepatic arteries Anomalous CHA seen in our study was similar to
originating from the common hepatic artery (of Michels, IX type. Moreover the existence of such
celiac origin) occurs in about 55% of the an arterial variant in patients having liver
population (7). Although the normal pattern of metastasis carries the risk of misperfusion of intra-
arterial supply of hepatic parenchyma and biliary arterial chemotherapeutic agents (14). The intra-
tract is well described (11), there is a considerable arterial chemotherapy technique for isolated, non-
variation in the relative contribution of normal and resectable liver metastasis achieves complete
abnormal arteries to parenchyma and biliary tree perfusion of whole liver only in patients with
in the presence of anomalies (12),(13). classical arterial anatomy. Patients having variant
The replaced hepatic arteries (replaced right arterial anatomy need vascular reconstruction prior
hepatic and replaced common hepatic arteries) to intra-arterial chemotherapy or the use of double
usually do not occupy the same position in the port catheter pumps, for ideal, uniform perfusion
hepatoduodenal ligament as the normally (15).
occurring hepatic artery. Those typically lie lateral The knowledge of hepatic arterial variations can
to the portal vein behind the head of the pancreas be useful in the selection of donors for partial
and enter the lesser omentum posterolateral to the hepatic grafts in living related liver transplantation
common bile duct (6), (7). In Michels 200 liver (LRLT) (16). Such anomalies should be ruled out
dissections, he found half of the replaced common preoperatively (17) by angiography, Axial CT
hepatic arteries (RCHA) actually passed through and/or DCEMRI (18). Hepatic arterial anatomy
the pancreatic substance while the other half must be defined precisely to ensure optimal donor
passed posterior to it. In our case the common hepatectomy and graft arterialization (19).
hepatic artery never entered the pancreatic tissue. Moreover the preoperative knowledge of

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Sunita Sethy et al
SURGERIES
anomalous vessels is also helpful for modification authors/editors/publishers of all those articles,
of surgical approach (20). Arterial anomalies journals and books from where the literature for
preserved and managed appropriately do not this article has been reviewed and discussed.
necessarily compromise graft outcome.
To our knowledge a unique case of aberrant REFERENCES
common hepatic artery (of superior mesenteric 1. Michels NA. Variations in blood supply of
origin) with a anomalous celiac trunk, having only liver, gallbladder, stomach, duodenum and
two branches-left gastric and splenic artery was pancreas. Year book of the Am Philosophical
found in this study. The persistence of lower half soc, 1943: 150.
of ventral longitudinal anastomosis between the 2. Last RJ. Vessels and nerves of the gut. In:
10th to 13th splanchnic (vitelline) arterial roots that Sinnatamby CS, editor. Last's Anatomy:
normally disappear may be the possible Regional and Applied. 10 th Ed. Edinburgh:
embryological explanation for this variability. Churchill Livingstone, 1999: 236-238, 254-
Such variations may be attributed to the rotation of 6.
gut, caudal displacement of abdominal viscera and 3. Kemeny MM, Hogan JM, Goldberg DA et al.
hemodynamic changes taking place during Continuous hepatic artery infusion with an
organogenesis and differentiation (21), (22). implantable pump: problems with hepatic
artery anomalies. Surgery. 1986
CONCLUSION Apr;99(4):501–504.
In our study we found a variant of celiac trunk, 4. Rosse C, Gaddum-Rosse P. The gut and its
replaced common hepatic artery taking origin from derivatives. In: Hollinshead's textbook of
superior mesenteric artery in (4%) of our Anatomy. 5` h Ed. Philadelphia: Lippincott-
dissections which is not very uncommon. Raven, 1997: 568-80.
Vascular injuries are the most lethal technical 5. Michels NA. Newer anatomy of the liver and
injuries encountered in laparoscopic its variants blood supply and collateral
cholecystectomy (24). Injury to hepatic blood circulation. Am J Surg 1966; 112: 337-47.
supply is more common in the presence of 6. Kadir S, Lundell C, Saeed M. Celiac, Superior
aberrant arterial anatomy. Preoperative knowledge and inferior mesenteric arteries. In: Kadir S,
of normal and variant arterial anatomy can prompt editor. Atlas of normal and variant
to take measures to preserve the vessels and avoid angiographic anatomy. Philadelphia: WB
fatal injury (25). The aberrant vessels can be Saunders, 1991: 297-308.
identified on visceral angiography, dynamic 7. Woods MS and Traverso LW. Sparing a
contrast enhanced magnetic resonance imaging replaced common hepatic artery during
(DCEMRI) and/or spiral CT [18]. pancreaticoduodenectomy. Am Surg 1993; 59:
719-21.
ACKNOWLEDGEMENTS 8. Konstam MA, Novelline RA, Athanasoulis
The authors thank all the students of SCB Medical CA. Aberrant hepatic artery: a potential cause
College, Cuttack, Odisha who were assigned to for error in the angiographic diagnosis of
dissection of cadavers for their efforts in data traumatic liver hematoma. Gastrointest Radiol
collection and those authors and scholars 1979; 4: 43-5.
mentioned in the reference for their enlightening 9. Severn CB. A morphological study of the
and informative articles, journals and books that development of the human liver (II),
helped to draw inferences of the study. The establishment of liver parenchyma,
authors are also grateful to

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Sunita Sethy et al
SURGERIES
extrahepatic ducts and associated venous endoscopic US, CT and MR imaging. Radiol
channels. Am J Anat 1972; 133: 85. Soc N Am 1994; 190: 745-51.
10. Lygidakis NJ, Makuuchi M. Pitfalls and 19. Takayama T, Makuuchi M, Kawarasaki H, et
complications in the diagnosis and al. Hepatic transplantation using living donors
management of hepatobiliary and pancreatic with aberrant hepatic artery. J Am Coll Surg
disease. Thieme Med Inc, 1993: 113, 231. 1997; 184: 525-8.
11. Padbury R, Anatomy AD. In: Toouli J, editor. 20. Volpe CM, Peterson S, Hoover EL, Doerr RJ.
Surgery of the biliary tract. Edinburgh: Justification for visceral angiography prior to
Chuchill Livingstone, 1993: 3-19. pancreaticoduodenectomy. Am Surg 1988; 64:
12. Makisalo H, Chaib E, Krokos N, Calne R. 758-61
Hepatic arterial variations and liver related 21. Reuter ST, Redman HC. Vascular anatomy.
diseases of 100 consecutive donors. Transpl In: Gastrointestinal angiography, 2nd Ed.
Int 1993; 6: 325-9. Philadelphia, London, Toronto: W B
13. Shaw BWJ, Wood RP, Stratta RJ et al. Saunders, 1977: 31-65.
Management of arterial anomalies 22. Arey LB. Developmental Anatomy: A
encountered in split liver transplantation. textbook and laboratory manual of
Transplant Proc 1990; 22: 420-2. embryology. 7 th Ed. Philadelphia: W B
14. Civelek AC, Sitzmann JV, Chin BB et al. Saunders, 1974.
Misperfusion of the Liver during hepatic 23. Gray’s Anatomy: The Anatomical Basis of
artery infusion chemotherapy. Am J Clinical Practice by S Standring, Elsevier
Roentgenol 1993; 160: 865-70. Health Sciences, 40th edition, 1169-70.
15. Eid A, Reissman P, Zamir G, Pikarsky AJ. 24. Deziel DJ, Millikan KW, Economou SG,
Reconstruction of replaced right hepatic Doolas A, Ko ST, Airan MC. Complications
artery, to implant a single-catheter port for of laparoscopic cholecystectomy: A national
intra-arterial hepatic chemotherapy. Am Surg survey of 4292 hospitals and an analysis of
1998; 64: 261-2. 77604 cases. Am J Surg 1993; 165: 9-14.
16. Daly JM, Kemeny N, Oderman P, Botet J. 25. Biehl TR, Traverso LW, Hauptmann E, Ryan
Long term hepatic arterial infusion JA Jr. Preoperative visceral angiography alters
chemotherapy. Arch Surg 1984; 119: 936- intraoperative strategy during the whipple
41. procedure. Am J Surg 1993; 165: 607-
17. Dooly WC, Cameron JL, Pitt HA et al. Is 12.
preoperative angiography useful in patients
with periampullary tumors? Ann Surg 1990;
211: 649-55.
18. Muller MF, Meyenberger C, Bertschinger P et
al. Pancreatic tumors: Evaluation with

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Fig. 1 : Showing Anomalous Origin of Common Hepatic Artery from Superior Mesentric Artery
(upon dissection of abdomen) (Author-Dr Sunita Sethy)
Fig.2- Showing Anomalous Origin of Common Hepatic Artery from Superior Mesentric Artery
(after removal of Stomach)- (Author-Dr Sunita Sethy)
Fig.3- Showing branching pattern of Superior Mesentric Vessels (Author-Dr Sunita Sethy)
Abbreviations :LGA-Left gastric artery, SMA-Superior Mesentric Artery, SMV-Superior Mesentric

Vein, MC-Middle Colic Artery, RC-Right Colic Artery, IC-Ileocolic Artery.

Page 148
A CROSS-SECTIONAL STUDY OF AWARENESS ABOUT HEPATITIS B AMONG NURSING
Ujwala U. Ukey et al
STUDENTS OF MIMS COLLEGE AT VIZIANAGARAM, ANDHRA PRADESH
A CROSS-SECTIONAL STUDY OF AWARENESS ABOUT

HEPATITIS B AMONG NURSING STUDENTS OF MIMS
COLLEGE AT VIZIANAGARAM, ANDHRA PRADESH
IJCRR
Vol 04 issue 20 Ujwala U. Ukey1, Satyanarayan Dash1, K. Rama Sankaram1, N.R. Appajirao
Section: Healthcare Naidu1, R.SriVidya2
Category: Research
1
Received on: 14/08/12 Department of Preventive and Social Medicine, Maharajah’s Institute of Medical
Revised on:01/09/12 Sciences, Vizianagaram, Andhra Pradesh, India
2
Accepted on:11/09/12 MIMS College of Nursing, Vizianagaram, India
E-mail of Corresponding Author: ujwalaukey@yahoo.co.in
ABSTRACT
Context: Hepatitis B is an inflammatory disease of the liver caused by Hepatitis B virus and is a global
public health problem. In India the carrier rate of hepatitis B is higher among health care personnel.
Nurses are probably the most commonly exposed health care staff exposed to needle prick,
injuries and contact with infectious fluids. They are exposed to this risk right from there student career.
Objectives: To determine the awareness about HBV, Hepatitis B, its transmission and prevention.
Methods: A descriptive cross sectional study was conducted among 119 nursing students with the help of
prestructured questionnaire having questions about HBV, Hepatitis B, its transmission and Hepatitis B
vaccine. The statistical tools like Z test of difference between two proportions, mean and standard
deviation (SD) values were employed.
Results: Overall 77% of all the students knew that Hepatitis B is a member of Hepadnavirus family. On
an average 81.27% of the students were correct regarding knowledge on Hepatitis B infection. After
considering all the statements, answer to transmission of Hepatitis B was observed to be correct in
71.01% of students. Prevention of Hepatitis B by vaccine administration was correctly known to 104
(87.39% of 119) respondents.
Conclusions: Majority of the nursing students were aware about Hepatitis B. The knowledge regarding
most of the parameters was significantly higher among BSc nursing students as compared to GNM
students. It was also observed that there is a lack of knowledge about the hazards of Hepatitis B, its
transmission and efficacy of vaccine.
Keywords: Hepatitis B, Hepatitis B virus, Awareness, Nursing students,
INTRODUCTION the total population). 5, 6 HBV is a DNA virus

Hepatitis B is a leading cause of chronic hepatitis, belonging to the virus family Hepadnaviridae.
cirrhosis and hepatocellular carcinoma.1-4 Hepatitis HBV enters the liver via the bloodstream and
B previously known as serum hepatitis is an replication occurs only in the liver tissue. The
inflammatory disease of the liver caused by virus is 42-47 nm in diameter and circulates in the
Hepatitis B virus (HBV) and is a global public blood in concentrations as high as 108 virions per
health problem. Nearly two billion people in the ml. HBV is transmitted by per cutaneous or
world have been acutely infected by HBV and mucosal exposure to infected blood or other body
there are nearly 350 million people chronically fluids through numerous routes: perinatal, mother
infected. 1 In South East Asian Region, there are to child, sexual, needle-sharing, and
4, 7
estimated 80 million HBV carriers (about 6% of occupational/health-care-related.

Page 149
India has the intermediate endemicity of year to fourth year present in the classrooms of the
Hepatitis B with Hepatitis B surface antigen college in the campus on the day of study were
(HBsAg) prevalence between 2% and 10% included. Ultimately there were a total of 119
among the population studied. The number of students i.e. 71 from Bachelor of Science (BSc)
carriers in India has been estimated to be over 40 nursing and 48 from General Nursing Midwifery
millions. 5, 6 In India the carrier rate is higher (GNM) streams. The participants were fully
among health care personnel (10.87%) as informed about the design and purpose of the
compared to the blood donors (6%) and general study. Anonymity of the participants was
public (5%). Among healthcare workers maintained throughout the study. The data
seroprevalence is two to four times higher than collection was done with the help of a pre-tested
that of the general population.8 structured questionnaire distributed among these
Hepatitis B infections may occur in the health students in the classroom and they were asked to
care settings due to lapse in the sterilization fill the questionnaire. The questionnaire consisted
technique of instruments or due to the improper of closed ended questions to assess the knowledge
hospital waste management because 10 to 20% and awareness about HBV and Hepatitis B, its
of health care waste is hazardous which may transmission and Hepatitis B vaccine. Data entry
create a variety of health risks.9 The majority of was done in Microsoft excel 2007 software.
the infections are subclinical, so approximately Statistical analysis was done with help of SPSS
80% of all HBV infections are undiagnosed.4 software. The statistical tools like Z test of
Among the health care personnel, HBV is difference between two proportions; mean and
transmitted by skin prick with infected, standard deviation (SD) values were employed.
contaminated needles and syringes or through Statistical significance was considered at p values
accidental inoculation of minute quantities of <0.05.
blood during surgical, gynecological and dental
procedures.6 Nurses are probably the most RESULTS
common health care staff exposed to needle A total of 119 nursing students were included in
prick injuries and contact with infectious fluids. the study. Bachelor of Science (BSc) nursing
They are exposed to this risk right from there students were 71 (i.e. 59.66%) and General
student career. Hence it is important that nurses as Nursing Midwifery (GNM) students were 48 (i.e.
well as nursing students should have a thorough 40.34%). The mean age of BSc nursing students
knowledge regarding Hepatitis B to minimize was 20.11 ± 2.23 years and that for the GNM
the health care settings acquired infections students was 21.06 ± 2.28 years. The details
among them and other health personnel. regarding the number and age of the study
With this background, the present study was participants according to the academic year is
conducted among the nursing students to shown in Table 1. The mean age of the GNM
determine the awareness about HBV, Hepatitis B, nursing students was significantly more than that
its transmission and prevention. of the BSc nursing students (p=0.0237).
Table 2 shows the observations regarding this
MATERIALS AND METHODS knowledge about Hepatitis B virus (HBV) in the
The study was conducted at the College of study participants. The different aspects like
Nursing of Maharajah’s Institute of Medical family of Hepatitis B virus (HBV), its structure
Sciences (MIMS), Nellimarla during July 2012. and size were included in it. The study participants
The type of study was descriptive cross sectional were grouped according to their study courses as
study. All the nursing students ranging from first BSc nursing and GNM nursing and comparison

Page 150
between them on various parameters was made. increased risk for Hepatitis B. Only 15 (21.13% of
Overall 77% of all the students knew that Hepatitis 71) of Bsc nursing students and 16 (33.33% of 48)
B is a member of Hepadnavirus family. GNM students which accounts for total
Significantly higher proportion of BSc nursing 31(26.05% of 119) students were correct regarding
students had a knowledge about it (Z=2.32, knowledge that HBV infection was previously
p=0.0203). Overall 56% students had a knowledge known as serum hepatitis.
that diameter of HBV is 42 mm. It was also found The correct knowledge regarding transmission of
to be statistically highly significant in BSc nursing Hepatitis B considering all the statements was
students (Z=2.11, p=0.0348). The total students observed in an average of 71.01% students
having knowledge about 4 genotypes of HBV whereas 29.99% of the students had an incorrect
were 68%. Significantly higher number of GNM knowledge about Hepatitis B transmission as
nursing students had knowledge about this shown in Table 4. Overall 58% of the respondents
parameter (Z=2.14, p=0.0324). The number of had correct knowledge about sexual transmission
respondents who could answer correctly that HBV of Hepatitis B. Significantly higher number of BSc
is not a retrovirus was 61 (51.26% of 119) nursing students were correct about it (Z=2.59,
including 30 (42.25% of 71) Bsc and 31 (64.58 % p=0.0096).However Hepatitis B is not transmitted
of 48) GNM. Thus higher number of GNM by hand shaking was known correctly to higher
respondents knew about this parameter and this number of GNM students and is statistically
difference was found to be statistically significant highly significant (Z=3.25, p= 0.0012).
(Z= 2.391, p= 0.0168). The knowledge that HBV Transmission of HBV by needle prick injuries
is one amongst smallest enveloped viruses and it being more common than Human
can be detected in clinical specimens by Immunodeficiency Virus (HIV) was correctly
Polymerase chain reaction (PCR) was present in known to a total of 85(71.43% of 119) respondents
respectively 49% and 51% of the respondents. which included 55(77.46% of 71) BSc nursing and
There was no statistical difference between the 30(62.5% of 48) GNM students.
BSC and GNM nursing students regarding this Regarding the awareness about prevention of
parameter. Hepatitis B by vaccine, 104 (87.39% of 119)
The awareness of respondents about Hepatitis B respondents had correct knowledge and only 15
infection is shown in Table 3. On an average (12.61%) were incorrect. The dose schedule of the
81.27% of the students were correct and remaining vaccine was known correctly to 99 (83.19% of
18.73% were incorrect regarding knowledge on 119) respondents and remaining 20 (16.81%) had
Hepatitis B infection. Except for statements about incorrect knowledge of the doses. The correct
liver inflammation due to acute HBV infection and knowledge regarding vaccine gives 85-90%
increased risk of doctors and nurses for Hepatitis protection against HBV was observed in only 28
B, there was no statistically significant difference (39.44% of 71) and 25(52.08% of 48))
in the knowledge between Bsc and GNM students respectively of BSc nursing and GNM students
regarding other statements. After applying Z test thus amounting to a total of 53 (44.54% of 119)
for difference between two sample proportions, respondents.
significant difference was noted among Bsc and
GNM students regarding awareness that acute DISCUSSION
illness is due to HBV causing liver inflammation In the present study considering all the statements
(Z= 1.98, p=0.0468). Similarly significantly higher about HBV, correct knowledge about HBV was
proportion of BSc nursing students had a correct observed in about half of the respondents. Half of
knowledge that Doctors and nurses are at an the students being unaware about the details of

Page 151
HBV structure and characters may be due to its Eighty-eight percent of the participants were
theoretical importance only and less practical aware regarding the prevention of Hepatitis B by
application. This observation is in coherence with vaccine. Whereas other studies reported that
another study among the dental students which awareness about Hepatitis B vaccine was present
revealed that on an average, 59.23% of the among only 66% 10 of first year nursing students,
students were correct regarding knowledge about sixty-five percent among medical students11 and
HBV.4 However this knowledge is less in thirty-five percent11 among non medical students.
comparison with another study among the medical Requirement of screening test for detection of
students in which 86.7 % of them had correct Hepatitis B surface Antigen (HBsAg) among
knowledge about HBV.6 patients undergoing surgery was not known to
About three-fourths of the study participants were one-fourth of the nursing students. Whether nurses
aware that HBV infection resulted in Hepatitis B. are at the risk of contracting Hepatitis B or not was
Another study among the first year nursing also not known to one-fourth of the students. This
students from North India revealed that only 42% lack of awareness about the above two aspects
of the students had correct knowledge regarding may increase the risk of Hepatitis B transmission.
etiology of hepatitis B.10 The higher knowledge in This has been proved by another study.12
the nursing students in the present study could be Studies conducted in the general public in India13
due to the reason that the study group included and abroad14, 15 have revealed that the awareness
students from all the academic years of the nursing about HBV and Hepatitis B is less. These studies13,
14
course and Hepatitis B is covered in classes also showed that awareness level is significantly
extensively as a part of study curriculum. more in those with higher education levels and
Transmission of Hepatitis B on exposure to blood source of knowledge about Hepatitis B is mainly
or other body fluids, needle prick injuries and public media like newspapers and Television. In
unprotected sexual exposure was correctly known the present study awareness among the nursing
to respectively four-fifth, three-fourth and half of students was observed to be better than that among
the participants. These findings are coherent with the general public. This could be easily explained
another study among the dental students wherein that the nursing students were a part of health team
majority of them knew about transmission of and Hepatitis B was covered in the study
Hepatitis B by blood borne, needle injuries or curriculum for them. However the importance of
sexual exposure.4 In the present study the number the subject is to be emphasized, so that
of correct answers about this statement is more transmission of Hepatitis B can be decreased
than that observed in another study among the first among the patients as well as among the health
year nursing students where 35.2% were aware personnel including nurses.
that unsafe blood transfusion could lead to
Hepatitis B. The awareness was further found to CONCLUSION
be less among them regarding unprotected sex and The present study concludes that overall majority
reusing of needle-syringes as a potential risk factor of the nursing students were aware about Hepatitis
for Hepatitis B.10 Correctness of the statement that B. The knowledge regarding most of the
Hepatitis b is not transmitted by hand shaking was parameters was significantly higher among BSc
observed among 68% of the respondents. This nursing students as compared to GNM students. It
observation is in contrast to the study4 by other was also observed that there was a lack of
investigators who obtained 95% correct answers knowledge about the hazards of Hepatitis B, its
among the respondents. transmission and efficacy of vaccine. It is also
alarming that screening of patients for HbsAg was

Page 152
not known to many. Thus there is a need to http://www.whoindia.org/en/section6%5Csect

increase the awareness about Hepatitis B in ion8.htm (Accessed on 24 July 2012).
consideration of these facts. In addition to this, it 6. Singh A, Jain S. Prevention of Hepatitis B;
is recommended that routine health education and knowledge and practices among Medical
complete vaccination of nursing students should students. Healthline 2011; 2 (2):8-11.
be carried out so that the occurrence of Hepatitis B 7. Shepard CW, Simard EP, Finelli L, Fiore AE,
among them can be minimized. Bell BP. Hepatitis B virus infection:
epidemiology and vaccination. Epidemiol
ACKNOWLEDGEMENTS Rev 2006; 28:112-25.
The authors acknowledge the constant 8. Singhal V, Bora D, Singh S. Hepatitis B in
encouragement of the Management and Dr TAV health care workers: Indian Scenario. J Lab
Narayan Raju, the Dean of Maharajah’s Institute Physicians.2009; 1:41–8.
of Medical Sciences, Vizianagaram to engage in 9. Taneja N, Biswal M .Safe disposal of
research work with grateful thanks. The authors infectious waste, Indian perspective Journal
extend their profound sense of gratitude to the of Hospital Infection. 2006; 62(4): 525-26.
study participants. Authors acknowledge the 10. Maroof KA, Bansal R, Parashar P, Sartaj A.
immense help received from the scholars whose Do the medical, dental and nursing students
articles are cited and included in the references of of first year know about hepatitis B? A study
this manuscript. The authors are also grateful to from a university of North India. J Pak Med
authors / editors / publishers of all those articles, Assoc. 2012; 62(1):25-7.
journals and books from where the literature for 11. Al-Jabri AA, Al-Adawi S, Al-Abri JH, Al-
this article has been reviewed and discussed. Dhahry SH. Awareness of hepatitis B virus
among undergraduate medical and non-
REFERENCES medical students; Saudi Med J;
1. Lee WM Hepatitis B virus infection. N Engl J 2004;25(4):484-7.
Med 1997; 337:1733-45. 12. Maung M, Win KK, Oo KM, Htwe T.
2. Liaw YF, Chu CM. Hepatitis B virus Hepatitis B surface antigen carriage in
infection. The Lancet. 2009; 373 (9663):582– students of Institute of Nursing, Yangon.
92. Mynammar Journal of Current Medical
3. Zheng Y, Huang Z, Chen X, Tian Y, Tang Practice; 2003; 7(2):75-8.
J, Zhang Yi et al. Effects of Telbivudine 13. Misra B, Panda C, Das HS, Nayak KC, Singh
Treatment on the Circulating CD4+ T-Cell SP. Study on awareness about Hepatitis B
Subpopulations in Chronic Hepatitis B viral infection in coastal Eastern India. Hep B
Patients. Mediators of Inflammation. 2012; Annual 2009;6:19-28.
2012: 789859. 14. Cheung J, Lee TK, Teh CZ, Wang CY, Kwan
4. Saini R, Saini S, Sugandha RS. Knowledge WC, Yoshida EM. Cross-sectional study of
and awareness of Hepatitis B infection hepatitis B awareness among Chinese and
amongst the students of Rural Dental College, Southeast Asian Canadians in the Vancouver-
Maharashtra, India. Ann Nigerian Med. 2010; Richmond community. Can J Gastroenterol
4:18-20. 2005;19:245-9.
5. World Health Organization, Country Office
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15. Wai CT, Mak B, Chua W, Tan MH, Ng S, Singapore. World J Gastroenterol
Cheok A, et al. Misperceptions among 2005;11:5002-5.
patients with chronic hepatitis B in
Table 1. Distribution of study participants according to the course of nursing
Mean and Standard

Nursing study
Number Percentage deviation of age in
year
years
BSc 1st year 17 14.29 % 17.47 ± 0.51

BSc 2nd year 15 12.61 % 18.36 ± 0.50
BSc 3rd year 14 11.76 % 20.6 ± 0.63
BSc 4th year 25 21.01 % 22.6 ± 0.76
GNM 1st year 25 21.01 % 19.2 ± 0.91
GNM 2nd year 10 8.40 % 21.7 ± 0.82
GNM 3rd year 13 10.92 % 24.15 ± 0.56
Total 119 100 % 20.51 ± 2.29
Table 2: Knowledge of respondants about Hepatitis B virus (HBV)

Statement regarding knowledge of Correct response Number (%) p- value
HBV
BSc GNM Total
(n=71) (n=48) (n=119)
Hepatitis B Virus (HBV) is a
member of Hepadnavirus family 53 (74.65) 26 (54.17) 79 (66.39) 0.0203*
HBV has a diameter of 42 mm
45 (63.38) 21 (43.75) 66 (55.46) 0.0348*
There are 4 genotypes of HBV 43 (60.56) 38 (79.17) 81 (68.0)7 0.0324*
HBV is one amongst smallest
enveloped animal viruses 36 (50.7) 22 (45.83) 58 (48.74) 0.6031
HBV in clinical specimens can be
detected by PCR
35 (49.3) 25 (52.08) 60 (50.42) 0.7641
*
indicates significant p-values

Page 154
Table 3 Awareness of respondents about Hepatitis B

Statement regarding awareness Correct response Number (%) p- value
about Hepatitis B
BSc GNM Total
(n=71) (n=48) (n=119)
Hepatitis B is an infectious illness
caused due to HBV 64 (90.14) 38 (79.17) 102 (85.71) 0.0929
The acute illness due to HBV causes
liver inflammation 62 (87.32) 35 (72.92) 97 (81.51) 0.0468*
Chronic Hepatitis results in Cirrhosis
of liver and Hepatocellular carcinoma 64 (90.14) 39 (81.25) 103 (86.55) 0.1645
Hepatitis b surface antigen (HBsAg)
is most commonly used to screen
against HBV infection 65 (91.55) 38 (79.17) 103 (86.55) 0.0524
Patients undergoing surgery should be
screened for HBsAg 55 (77.46) 36 (75) 91 (76.47) 0.7566
Doctors and nurses are high risk
population for HBV infection 54 (76.06) 26 (54.17) 80 (67.23) 0.0124*
*
Table 4 Awareness of respondents about transmission and vaccine against Hepatitis B

Statement regarding awareness Correct response Number (%) p- value
about transmission of Hepatitis B
BSc GNM Total
(n=71) (n=48) (n=119)
Transmission of HBV results from
exposure to blood or body fluids 64(90.14) 37(77.08) 101(84.87) 0.5118
needle stick injuries 56(78.87) 36(75) 92(77.31) 0.6214
unprotected sexual exposure 48(67.61) 21(43.75) 69(57.98) 0.0096*
Hepatitis B is not transmitted by
hand shaking 37(52.11) 39(81.25) 76(63.87) 0.0012*
Hepatitis B infection is preventable
by vaccination 63(88.73) 41(85.42) 104(87.39) 0.5961
Vaccine is administered in 2 or 3
dose schedule for protection against
HBV 58(81.69) 41(85.42) 99(83.19) 0.5961
*

Page 155
Umasankar.K et al BODY SENSOR NETWORK SECURITY USING CRYPTOGRAPHY APPROACH
BODY SENSOR NETWORK SECURITY USING CRYPTOGRAPHY

APPROACH
IJCRR Umasankar K.1, Vetrivendan R.2

Vol 04 issue 20
1
Section: Health care Department of CSE, Prist University, Kumbakonam, TN, India
2
Category: Research Department of CSE, As-Salam College of Eng and Tech, Thirumangalakudi, TN, India
Revised on:04/09/12 E-mail of Corresponding Author: vetriascet@gmail.com
ABSTRACT
A body sensor network (BSN), is a network of sensors de-ployed on a person’s body, usually for health
care monitoring. Since the sensors collect personal medical data, security and privacy are important
components in a body sensor network. At the same time, the collected data has to readily available in the
event of an emergency. In this paper, we present IBE-Lite, a lightweight identity-based encryption
suitable for sensors, and developed protocols based on IBE-Lite for a BSN.
Keywords: Security, Body Sensor Networks, Identity-based cryptography
INTRODUCTION focus on a BSN deployed for medical monitoring.

Applying wireless sensors toward health care We term the person wearing the BSN as the
monitoring allows for new ways to provide quality Permission to make digital or hard copies of all or
health care to pa-tents. A diverse array of part of this work for personal or classroom use is
specialized sensors can be de-ployed to monitor, granted without fee provided that copies are not
for instance, at-risk patients with history of heart made or distributed for profit or commercial
attacks, or senior citizens living independently at advantage and that copies bear this notice and the
home. These sensors provide continuous, long full citation on the first page. To copy otherwise,
term monitoring in an unobtrusive manner, to republish, to post on servers or to redistribute to
allowing doctors to diagnose problems more lists, requires prior specific permission and/or a
effectively. A body sensor network, or BSN, is a fee. The term “doctor” is used loosely, and refers
network of sensors deployed on a person’s body to to any person wanting to access the data.
collect physiological information. In this paper, we
Figure 1: A Body Sensor Network

Page 156
Motivating Example derive the following security and privacy

Privacy and security for a BSN is important since requirements for a BSN.
the data collected is directly associated with a 1. Protect patient privacy from the storage site.
particular patient. At the same time, the data must Since the data is stored on a third party storage
be easily accessible to relevant personal in the site, we cannot trust the storage site with the
event of an emergency. The following scenarios data. We assume an honest-but-curious storage
serve to better illustrate such concerns. site that will not maliciously delete the data,
1. Alice wears a BSN that monitors her EKG data but may attempt to learn the contents of a
when she is working out. One day, Alice suddenly patient’s data.
falls un-conscious and is sent to the emergency 2. Tolerate compromised BSN sensors. The BSN
room. The data collected by the BSN should be sensors may be misplaced or stolen, and a
stored in a public place and made easily accessible compromised BSNsensor should not allow an
in an emergency. adversary from obtaining the patient’s data.
2. After the incident, Alice instructs her BSN to 3. Prevent unauthorized access to information.
collect some additional data. Alice would like to This includes a doctor with permissions to
restrict this information to only physicians in an access some data and not others. We assume
ER. However, Al-ice cannot predict which doctor that a doctor may attempt to obtain additional
or hospital will treat her. Alice may not be data about a patient beyond what was
physically competent to authenticate anybody authorized. Since storage site is not trusted,
when she is admitted to a hospital. ABSN security access control can only be performed by the
scheme should be able to tolerate this form of CA.
ambiguity. 4. Flexibility in granting permissions. The patient
3. Furthermore, due to privacy reasons, a doctor may decide to allow different people to access
requiring two days worth of data prior to Alice’s the BSN data, and the BSN should be able to
illness should only be able to obtain data collected generate keys on-the-fly without additional
within those two days. However, since Alice does interaction with the CA.
not know when she might have a relapse, a BSN
should be able to limit access to the collected data, Identity-based encryption
even when the data is stored in a public space. Our solutions are based on a type of cryptographic
4. Alice’s family and friends are worried about her primitive known as identity-based encryption
condition. To allay their concerns, Alice would (IBE). After an initial setup phase, IBE allows a
like some other family members to be able to have public key to be generated from an arbitrary string.
partial access to her BSN data. Since the data The corresponding secret key can be derived
collected by the BSNbelongs to Alice, a security separately by a trusted party. For example, Al-ice
scheme should be flexible may want to encrypt a message for the doctor in
Enough to allow Alice to easily add additional charge on Monday. Alice can independently
access permissions to people she chooses. generated a public key using the strings “Monday”
BSN security requirements and “doctor” to encrypt her data without further
While a complete BSN system will have many contact with the trusted party. To decrypt the
different components, a crucial factor is that any message, a doctor will have to convince the trusted
security design must be lightweight enough to be party that he is a doctor in charge on Monday. The
executed by a sensor in a BSNsince a sensor can same doctor working on Tuesday cannot decrypt
be lost or stolen, leaving the data stored within the messages encrypted using the string “Tuesday”
sensor exposed. From the scenario presented, we and “doctor” even if he knows the secret key from

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Monday. The simple example cannot be easily MATERIALS AND METHODS

accomplished with- OUR SOLUTION
out using IBE. Alice can try to generate many Our protocols are based on a lightweight IBE
public/secret key pairs, one for each occasion. scheme IBE-Lite. IBE-LIE shares two properties
However, Alice will have to store the secret key with conventional IBE, namely the ability to use
created with the trusted party each time a new an arbitrary string to generate public key, and the
public/secret key pair is generated. Otherwise, the ability to generate a public key separately from the
trusted party cannot derive the secret key on its corresponding secret key. We begin by first
own. This is inefficient. Another possible reviewing Elliptic Curve Cryptography (ECC), a
alternative is for Alice to include some public key primitive suitable for BSN [18],
instructions with each of her message, and encrypt followed by the modifications made to derive IBE-
every-thing with the trusted parties’ public key. Lite. Finally, we present our protocols based on
When a doctor receives an encrypted message, the IBE-Lite.
doctor will forward it to the trusted party. The Basic ECC Primitives
trusted party can decrypt can obtain Alice’s To setup ECC, we first select a particular elliptic
instructions. The trusted party will release the curve over GF(p), where p is a big prime number.
message to the doctor only if he meets Alice’s We also denote P as the base point of E and q as
instructions. This solution is also inefficient since the order of P, where q is also a big prime. We
a BSN may generate many pieces of data, each of then pick a secret key expand the corresponding
which has to be forwarded to the trusted party for public key y, where y = x · P, and cryptographic
decryption. Using IBE, the doctor only needs to be hash function h(). Finally, we have the secret key
given a single secret key once. x and public parameters (y, P, p, q, h(.)).We
Our contributions denote encrypting a message m using public key
In this paper, we design protocols based on asEccEncrypt (m, y). The resulting cipher text is
identity-based encryption (IBE) that provide denoted. The decryption of cipher text c using the
security and privacy protections to a body sensor secret key x is given as Eyck Decrypt(c, x). The
network, while allowing flexible access to stored algorithms for Eyck Encrypt and EccDecrypt are
data. However, conventional IBE cannot be found in Alg. 1 and Alg. 2 respectively.
efficiently implemented on sensors used in a BSN. Algorithm 1 EccDecrypt (m, y)
In this paper, we propose IBE-Lite, lightweight 1: Generate a random number r ∈ GF (p). Encrypt
IBE scheme that is suitable for sensors. We m with, Er (m)
implement a proof-of-concept of our schemes 2: Calculate Ar = h(r) · y
based on IBE-Litton commercially available 3: Calculate Br = h(r) · P
sensors similar to the ones used in a BSN. While 4: Calculate _r = r ⊕ _(Ar), where _(Ar) is the x
IBE schemes have been suggested by previous coordinate of Ar
researchers to protect medical data, we are the first 5: Return cipher text c = h_ r, Br, Er (m) i
to present a lightweight IBE suitable for body Algorithm 2 EccDecrypt(c, x)
sensor networks. The rest of the paper is as 1: Calculate x · Br = x · h(r) · P = h(r) · y = Ar
follows. The next section presents our protocols 2: Determine the x coordinate, _(Ar)
and Section 3 contains the security analysis. Our 3: Derive symmetric key r with _r ⊕_(Ar) = r
schemes are evaluated in Section 4, with related ⊕_(Ar)⊕ (Ar) = r
work presented in Section 5. Section 6 concludes. 4: Apply r to Er(m) to return m
IBE-Lite

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From the basic ECC primitives, we derive the from string str, the sensor does Encrypt(m, str) to
following BE-Lite primitives, setup, and keygen, determine the cipher text c. Alg. 3 shows the
encrypt and decrypt. For ease of explanation, we process.
assume in this subsection that all primitives are BSN Security Protocols
executed by the patient. The actual protocols We first describe the initialization phase where the
involving the patient, CA and doctor are explained patient configures the BSN, followed by the data
in the next subsection. The intuition behind is to collection phase which outlines how a sensor
let a sensor independently generate a public key encrypts the collected data. The data transfer phase
on-the-fly using an arbitrary string. For example, a describes how a BSN transfers data to storage site,
sensor collecting EKG readings on Monday 1 and finally, the query phase which occurs when a
Powell first create a string str = (monday|1 doctor needs to obtain data from the storage site.
pm|EKG). Using this string, the sensor can derive We assume that an agreed upon syntax is used to
a public key, ystr to en-crypt the data and send it describe the string needed to derive a public key,
to the storage site. There is no corresponding and this descriptions termed as STR. For example,
secret key created. In fact, the sensor cannot create the patient deciding to collect data on a hourly
the secret key needed to decrypt the message. basis will set the sensors in the BSN to affix
When the patient wishes to release this timestamp rounded to the nearest hour when
information to a doctor, the patient can derive the creating strain other words, two EKG readings
corresponding secret key,xstr, by using the same collected on Monday at1:05 pm and 1:20 pm will
string str = (monday|1pm|EKG). both be described using the same string star =
This secret key only allows the doctor to decrypt {monday|1 pm|EKG}.As mentioned earlier, we
messages encrypted by a sensor using the same assume an honest-but-curious storage site which
string. This simplifies the key management, since will try to learn the contents of the stored data, but
the patient can generate the secret key on-demand will otherwise not delete the stored data. We also
without keeping track of which keys were used to assume a separate security mechanism is in place
encrypt which data. The only requirement is that so that only the patient can store BSN data onto
the string used to describe the event is the same. the storage site. Initialization: The patient first
Setup: We select an elliptic curve E over GF(p), executes Setup to obtain the master secret key X =
where p is a big prime number. We also denote P (x1, · · · , xn), and public parameters hay, P, p, q,
as the base point of E and q as the order of P, h(.)i. The patient loads the parameter shy, P, p, q,
where q is also a big prime. Asset of n secret keys h (.)i into every sensor in the BSN. The patient
x1, · · · , xn ∈ GF(q) is chosen to generate the then registers the master secret key together with
master secret key = (x1, · · · , xn).The n public additional instructions with the CA. Data
keys are then generated to make up the master collection: Let the sensor collect data d at events.
public key = (y1, · · · , yn)where yi = xi · P, 1 ≤ i <
n. Finally, a collision resistant one-way hash SECURITY ANALYSIS
function h: {0, 1}_ → {0, 1}n is chosen. The We begin by examining the basic primitives,
parameter shy, P, p, q, h(.)i followed by an analysis of the protocols
are released as the system public parameters. themselves.
Eigen: To derive a secret key xstr corresponding to Analysis of Basic Primitives
public key generated by a string str, the patient Our Setup is similar to that of the basic ECC setup
executes Eigen (str) = xstr, xstr =nXi=1hi (str) · xi, scheme, except that instead of picking a single
where hi(str) is the i-th bit of h(str).Encrypt: To secret x, our Setup picks n secrets and n
encrypt a message m using a public key derived corresponding public keys. Knowing only one star

Page 159
and h(str), the doctor cannot determine the protocols provide flexibility. The string strcan be
patient’s master secret X since there are n used to specify access to the data, without using
unknown xi. The doctor is only able to determine additional certificates. For instance, consider the
X when he has in this pos-session n different string str ={Date | ER | Doctor} used to encrypt
secret keys x1str, · · · , xnstr.The use of star and data. A doctor wanting to obtain the corresponding
yet as the private key and public key derived from secret key will have to convince the CA that he is
string str does not violate the discrete logarithm indeed an ER doctor on the given date. The
property of ECC where, given a y = x · P, it is process of specifying what str to construct can be
infeasible to determine x given y and P, since both programmed by the patient without additional
are simply the result of addition of points. Also, permissions from the CA.
both Encrypt and Decrypt are secure since both
rely on well established ECC encryption and RELATED WORK AND RESULT
decryption methods. The motivation behind a BSN is to place low cost
Analysis of Protocols sensors directly on the patient for health care
Our protocols protect the privacy of the patient’s monitoring. With this in mind, several research
data by encrypting all the information before prototypes have been developed [18, 28, 8, 19].
forwarding the data to the storage site. After a The use of identity-based cryptography (IBE) [25,
sensor collects the data, the sensor encrypts the 2, 5] for medical applications was also suggested
data using Encrypt, resulting in the tupleSince all by [22, 21], but our work presents practical
tulles are in cipher text; the storage site learns implementation actual sensors rather than a
nothing about the patient’s data. The protocols general architecture. Other applications of IBE
also prevent unauthorized access to the patient’s include [13, 1, 11].Sensor network security is a
data. Each piece of data collected by a sensor is widely researched area [24, 12], with solutions
encrypted with a yet, the public key derived from focusing on key deployment [7, 14, 17, 16, 4],
the strings. When the doctor receives permissions public key cryptography [15, 23, 9] and
to access data encrypted under star, the doctor management [6, 20, 3]. Unlike prior work, our
receives the secret key star, which cannot be used security protocols incorportateidentity-based
to decrypt any other cipher text not encrypted cryptography primitives.
using yet. A compromised sensor does not allow
the adversary to obtain any useful data about a CONCLUSION
patient from the storage site since the sensor only In this paper, we presented IBE-Lite, a lightweight
stores the publicly known parameters. identity based encryption method suitable for a
At most the adversary obtains the cipher text pair body sensor net-work. We provided protocols
(c1, c2).The adversary can try to launch a based on IBE-Lite to provide security and privacy
matching attack by first creating many public keys support for a BSN. We evaluated our protocols
using different strings str. The adversary then using a combination of security analysis,
encrypts all possible values using the different simulations, and practical implementation on
public keys to determine whether there is a match actual sensors.
forth tuple (c1, c2). This is possible since the
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value of, the matching attack fails. Finally, our networking. In MobiOpp 2007.

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2. D. Boneh and M. Franklin. Identity-based 12. C. Karlof, N. Sastry, and D. Wagner. Tinysec:
encryption from the Weil pairing. In CRYPTO a link layer security architecture for wireless
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Hubaux.Self-organized public-key Anonymity and security in delay tolerant
management for mobile adhoc networks. IEEE networks. InSecureComm 2007.
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IEEESP 2003. 15. A. Liu, P. Kampanakis, and P. Ning. Tinyecc:
5. C. Cocks. An identity based encryption Elliptic curve cryptography for sensor
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2260 (2001). 16. D. Liu and P. Ning. Establishing pair wise
6. W. Du, R. Wang, and P. Ning. An efficient keys in distributed sensor networks. In CCS
scheme for authenticating public keys in 2003.
sensor networks. InMobiHoc 2005. 17. D. Liu, P. Ning, S. Zhu, and S. Jajodia.
7. L. Eschenauer and V. D. Gligor. A key- Practical broadcast authentication in sensor
management scheme for distributed sensor networks. InMobiQuitous 2005.
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In Mobisys2006. 19. D. Malan, T. Fulford-Jones, M. Welsh, ands.
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Araki.Tinypeds: Tiny persistent encrypted network infrastructure for emergency medical
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ASSESSMENT OF KNOWLEDGE AND COMPLIANCE REGARDING CONTACT LENS WEAR AND
Yousef Aldebasi
CARE AMONG FEMALE COLLEGE STUDENTS IN SAUDI ARABIA
ASSESSMENT OF KNOWLEDGE AND COMPLIANCE REGARDING

CONTACT LENS WEAR AND CARE AMONG FEMALE COLLEGE
STUDENTS IN SAUDI ARABIA
IJCRR Yousef Aldebasi
Vol 04 issue 20
Section: Healthcare
Department of Optometry, College of Applied Medical Sciences, Qassim University,
Category: Research
Kingdom of Saudi Arabia
Revised on:26/06/12 E-mail of Corresponding Author: dbasy@qu.edu.sa
ABSTRACT
Background: The regular use of contact lens for improving vision has seen an increasing trend
worldwide and this can be attributed to increase in awareness through better advertisement, easy
availability and handling, better products through advanced manufacturing strict guidelines. Our
Objectives was to assess knowledge and compliance regarding contact lens wear and care among female
college students in Saudi Arabia. Methods: A cross-sectional descriptive study was conducted from
March to May, 2010, among randomly selected 50 female students of King Saud University, Riyadh, who
were aged between 18 – 25 years. Data were collected through pre-designed, pre-tested self- explained
questionnaire with the help of optometrist. Results: It was found that significant number of the study
population (88%) was regularly cleaning the lens case. However, only 58 percent of them cleaned their
hands before putting the contact lens in the lens case while the remaining either did not clean at all (18%)
or cleaned irregularly (24%). There were findings related to the habit of immersing the lens, only half the
lens in the cleaning solution (34%). Regular visit to eye practitioners (38%) and use of contact lens
beyond the expiry date (10%). Conclusion: It appears that primarily it is poor hand hygiene, inadequate
care of the lens and the lens case, improper use of the cleaning solution and irregular follow up visits to
the eye practitioners for eye check among the young female population.
Keywords: Contact lens, Saudi Arabia, eye infections, lens care.
INTRODUCTION contact lens has also been used for prosthetic and
Contact lens use for the correction of refractive cosmetic reasons for example to enhance eye
error is gaining momentum world-wide. This colour. There are lots of different designs available
could be attributed to the advancement in contact in terms of lens type and materials and at an
lens manufacturing technology; improved lens affordable cost. These have made contact lens
materials, production techniques as well as storage wear popular among the young people particularly
and care products. There have also been females in Saudi Arabia.
improvements on awareness and/or education on Contact lens can act as a vector for
the proper use of contact lenses and contact lens microorganisms to adhere to and transfer to the
care products. In Saudi Arabia, contact lens use ocular surface if not used and cared properly. In
has also been on the increase.[1] Apart from its the presence of reduced tissue resistance,
use for the correction of refractive error and microorganisms or transient pathogens can invade
management of problem of ocular adnexa such as and colonize the cornea or conjunctiva to produce
in exophthalmos to prevent exposure keratopathy inflammation or infection.[4] Noncompliance has
or cornea problems such as keratoconus,[2, 3] been implicated as one of the causes of

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Yousef Aldebasi
complications in contact lens wear; the inadequate related to contact lens use, cleaning and
adherence to the practitioner’s instructions on the maintenance.
use of contact lenses and care products.[5] These
complications which range from mild eye MATERIALS AND METHODS
irritations to keratitis have in most cases posed a A cross sectional descriptive study was conducted
threat to the oculo-visual function. Studies,[6, 7] using a structured questionnaire among the female
have identified several risk factors associated with students at King Saud University in Riyadh aged
lens wear complications in an attempt to 18-25. The study got clearance from the
encourage successful lens wear and to minimize University Ethics Committee and was
disease burden. Amongst the identified risk implemented among the female students. Any
factors, some are non-modifiable such as gender or female who has ever worn contact lens for any
age,[8] of which we cannot influence whereas period of time and for whatever reason was
others are modifiable such as poor hand cleaning enrolled in this study. To get a better
and lens case hygiene[9] hence can be targeted in understanding of some questions and to capture
minimizing vision loss and maximizing successful appropriate information, a pilot study (pre- test)
lens wear. was conducted on 10 students a week prior of
Ocular health education or knowledge in the starting research work and after review few
correct and careful practice regarding contact lens modifications were done in the questionnaire for
wear can prevent complications resulting from the the final research work. A total of 50 contact lens
wearer's inappropriate behavior. One of the ways wearers were identified and a structured
of investigating this is from the person's questionnaire was introduced to collect the
perception regarding his own knowledge of information from March to May 2010 after getting
contact lens wear.[10] There are three primary the informed consent for the participation in this
areas of concern namely: contact lens wear study. The questionnaire was in Arabic language
schedule, lens care, and contact lens replacement and had 35 questions. The tool was validated by
schedule. Consequently the study of knowledge of three Optometry experts working in the
compliance can contribute to the planning of Department of Optometry before using in this
educational and health campaigns aimed at present study. For analysis purpose the
reducing some of the ocular complications questionnaire was also back translated in English
associated with contact lens wear. to ensure the same meaning is conveyed.
Whilst many eye care practitioners are familiar The questionnaire was based on the knowledge
with the notion that many contact lens wearers are and practices of contact lens wear, care and its
non-compliant, there is very little up-to-date possible complications. All the questions were
objective data available to support this belief in prepared in Arabic language and the answers were
Saudi Arabia. In this report we present also given in Arabic language by the participants
independent research which describes the lens who participated in the study. The questionnaire
wear and care habits of female contact lens was designed in a very comprehensive manner
wearers in Riyadh, Saudi Arabia. Educational which consisted of 35 questions related to general
status of patients is one of the factors thought to demographic data, socio economic status, contact
influence compliance.[11] The current study was lens hygiene and hand cleaning, compliance to eye
conducted among the female college students with care provider's instructions and behavioral aspects.
a primary objective to assess the knowledge and The tool was objective type which was not time
compliance of contact lens care and their practice consuming as the participant has to tick her answer
on the appropriate box (answers being 'Yes',

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Yousef Aldebasi
'NO'&/ 'Sometimes'). The data that was collected problem while on changing the cleaning solution,
in the questionnaires was coded and it was 24% (12) were using the same brand and the
analyzed using Epi_info software version 3.5.1 remaining 2 (4%) uses water temporarily.
2008, (CDC Atlanta). Compliance associated with Contact lens wear:
Regarding history of lens related complications,
RESULTS 10% (5) reported having experienced a contact
Demographic characteristics: Fifty females lens related complication. Patients were also
participated in the study and their age distribution queried on their knowledge of complications
was as follows; 54% were under age group of 18- associated with contact lens wear. More than half
21 years and the remaining 46% were between 22- of the patient surveyed (65%) reported that they
25years (Table-1). 74% (37) students were single had not experienced a contact lens-related
while the rest 26% (13) were married (Graph -1). complication.
Out of the fifty contact lens users, 92% (46 Pearson Chi square test was used to find out the
females) were using soft lens and 8% (4 females) association between the age, level of education
were RGP lens users. Majority of the participants and compliance of contact lens care based on the
66% (33) were using contact lens for cosmetic subject’s responses. There was a statistically
purposes while the remaining 34% (17) were using significant association between age and Cleaning
for refractive purpose. It was observed that 52% the lens cases (p=0.002), washing hands before
(26) of them got their contact lenses from cosmetic inserting contact lenses (p=0.054), cleaning hands
center while 38% (19) got theirs from optical shop before keeping the lens in the lens cases
and only 10% (5) got their lenses prescribed from (p=0.000), Immersing lens in cleaning solution
hospital (Table 2) (0.000), whereas no statistically significant
Lens supply: It was also found that 82% (41) of association noted between age and follow up with
the lens users were cleaning the lens case the eye care practitioner among our subjects
regularly. Out of fifty participants, 46 (92%) of (p=0.109). The level of education showed
them clean their hands before using contact lens statistically significant association with cleaning
and 4 (8%) of them doesn’t clean their hands of lens case (p=0.005), cleaning hands before
before inserting contact lens in the eye. Only 58% keeping lens in the lens case (p=0.000), Immersing
(29) of them clean the hands before putting the lens in cleaning solution (p=0.002) and Follow up
contact lens in the lens case and remaining either visits with the eye care practitioner (p=0.004),
do not clean at all 6 (12%) or clean sometimes 15 whereas washing hands before inserting contact
(30%) (Table 3) lenses in the eye does not showed any significant
Lens care: Other significant finding of the study association with level of education (p=0.295).
is that 74% (37) immerse the lens in cleaning (Table 5)
solution completely while 26% (13) of them place
the lens half immersed in the cleaning solution. It DISCUSSION
was also established that only 62% (31) of them Contact lenses are a convenient alternative to
visit the eye practitioner regularly. There was also eyeglasses and it is considered as a better option
usage of expired contact lens by 10% (5) for certain eye conditions, such as keratoconus and
participants regularly, and 16% (8) of them use the irregular astigmatism. Contact lenses usually
expired contact lens sometimes (Table-4). provide better vision and freedom of movement
The distribution of subjects according to the usage for some users, but improper care and cleaning of
of cleaning solution was shown in Graph 2. It these products can cause discomfort, blurred
showed 72% (36) subjects don’t have any ocular vision and pain. Contact lenses are not only worn

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Yousef Aldebasi
to correct vision and it can be worn for cosmetic or replacing the lenses in the case. In the present
therapeutic purposes. In this study, 34% of study also, 74% of the participants immerse their
females were found to be wearing CLs to correct lenses completely in the solution while cleaning
refractive error and 66% were using CLs for the the lenses. In a similar study conducted by Mayers
cosmetic purposes. et al,[14] 71% of contact lens wearers put their
In this study patient’s compliance on the use and lenses directly into the lens case without rinsing
care of contact lenses were weighed against lens and rubbing the lenses to clean them; 11 percent
supply, lens care regimen and contact lens rinsed only, and only 7 percent performed rinse-
replacement schedule. The place of contact lens and-rub” cleaning technique. The lack of hands’
supply; cosmetic centers, Optical showrooms and cleaning before touching the lens could introduce
hospitals, has been found to be associated with dirt on the lens surface which can be transferred to
contact related complications,[9] as there are the eye, resulting in irritation and/or infection
limited instructions given to patients on the use of especially where the lenses are not properly
contact lenses. In this study, 52% of the cleaned. This study also found that 31% of contact
participants agreed to have purchased their contact lens wearers wait up to 12 months to replace their
lens from the cosmetic centers while only 10% had lens case and most the lens wearers reported to
obtained there lenses from an optometrist from visit the optometrist regularly. A study done by
hospitals. This is contrary to the recent study in Hickson-Curran et al,[15] among 787 contact lens
Australia by Wu and Stapleton,[12] where wearers revealed that 48 percent replaced their
majority (66%) of the participants was said to have case annually.
obtained their lenses from the optometrist. This Compliance with contact lens care and
disparity between these studies reflects the maintenance instructions is considered to be the
difference in years of contact lens practices and most important aspect of the safe and comfortable
laws on who can and cannot fit contact lenses as use of lenses. The use of contact lenses is known
well as level of education given to patients in the to increase the microbial load in the eye which can
two countries. In Saudi Arabia for instance, adversely affect corneal health (16), ranging from
contact lens practice is more recent compared to a mild ocular redness and irritation to a very
Australia. Another reason for the differences in the severe sight threatening situation like
two studies could have stemmed from the sample Acanthamoeba keratitis. Poor contact lens hygiene
size and the demography of this study as the study and microbial contamination of the lens storage
had considered only female contact wearers. case have been observed to be related to microbial
According to Claydon et al,[13] the major areas of keratitis (17,18,19) .A proper hand wash and
non-compliance in contact lens wear have been hygiene plays an important role in controlling the
highlighted as the lack of hand and lens-case risk of infection while handling contact lenses. In
hygiene, the over wearing of contact lenses, the this study, 30% of subjects’ clean their hands
poor attendance of patients at aftercare before inserting CLs in the eye and remaining 12%
appointments and the inadequate use of care and doesn’t wash their hands at all. This may cause
maintenance systems. In our study, majority of the risk of ocular infections secondary to CL wear.
participants cared for their lens cases regularly and Appropriate counseling regarding contact lens
92% of lens wearers reported cleaning their hands care, maintenance instructions and personal
before putting on the lenses in the eye, and this hygiene should be given to the subjects in the clear
was also seen in the study by Wu and manner by eye care practitioners. Proper lens care
Stapleton.[12] However, over half of the subjects is essential for safety and success, but so is
(58%) actually cleaned their hands before adherence to prescribed replacement schedules

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Yousef Aldebasi
and recommended wearing schedules, as well as Eye care practitioners should equally educate
regular return visits to the eye-care practitioner. patients on the replacement schedule of their
In our study, 92% of subjects were using soft CLs lenses. It is relatively easy to blame patients for
and 8% were using RGP CLs. Soft contact lenses poor compliance but experience has shown that
deteriorate over time as they become worn, dirty poor compliance can be avoided or at least
and accumulate protein deposits that cannot be reduced by proper training at the initial fitting of
removed even by elaborate cleaning. This can contact lenses and reinforcement at the follow up
affect visual acuity and increase discomfort. There visits. While some contact lens patients are
are chances of infection of the lens leading to noncompliant on purpose, most patients would be
corneal ulcer. Regular visit to the optometry clinic more compliant with their replacement schedule if
is believed to encourage prompt replacement of they had reminders or a way of remembering when
lenses as faults or abnormalities would be to replace their lenses. There should be a place on
identified on time and appropriate management an eye care practitioners written contact lens
initiated. Also, each patient encounter is an prescription for the recommended wearing time,
opportunity to review and reinforce proper replacement schedule.
wearing and replacement time and contact lens
care. Continually educating patients that contact CONCLUSION
lenses are medical devices and reviewing proper Contact lenses are the safest forms of vision
lens wearing and replacement schedules is the best correction when patients follow the proper care
way to avoid noncompliance. and wearing instructions. Contact lens wearers
could be damaging their eyes by not using proper
RECOMMENDATIONS hygiene in caring for their lenses. Poor hand
Many patients see contact lens solely as a cosmetic hygiene, inadequate lens care and not
item and not as a medical device. This attitude remembering when to come back for aftercare
leads to the purchase of contact lens and care visits are the common non-compliant behaviors in
products from the cosmetic shops and over the lens wearers. Higher educational status does not
internet. Therefore, there is need to enact laws that always mean higher compliance amongst contact
will regulate dispensing of contact lenses by lens wearers. Proper contact lens care and regular
unqualified persons as well as purchase or sale of follow-up visits to their eye care practitioner are
contact lenses and care products over the internet. essential for a patient’s safety and wearing
Education, improving communication, behavioral success. Appropriate counseling regarding contact
modifications are the main factors that helps to lens wear and care should be given to the subjects
improve the compliance level in any population. by contact lens dispensers or Optometrists or
When eye care practitioners dispense contact Ophthalmologists. Clean and safe handling of
lenses, there is need to educate patients on the contact lenses is one of the most important
proper wearing schedule; for example not to sleep measures where contact lens wearers should
in lenses that are not approved for overnight wear. follow to protect their ocular health and sight.
This gives patients the opportunity to ask to be However, due to the limitation of the study to only
fitted in a higher-Dk lens if overnight wear is an females, this may not be generalized to the general
option. Patients should also be given helpful tips population in Saudi Arabia. Therefore, there is
or written instruction on the steps to follow while need for more studies that will involve both, male
cleaning the lenses as well as while fitting and and females.
replacing the lens in the case.

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Yousef Aldebasi
REFERENCES 12. Wu, Y. and F. Stapleton, Contact lens user

1. Briggs, S. and A. Oduntan, Contact lenses in profile, attitudes and level of compliance to
Saudi Arabia: an overview. International the lens care. Contact Lens & Anterior Eye,
Contact Lens Clinic, 1996. 23: p. 46-49. 2010. 33: p. 183-188.
2. Briggs, S. and A. Nacer, Contact lens status 13. Claydon, B., N. Efron, and C. Woods, A
in ametropia correction: a prospective study. prospective study of non-compliance in
Clin Exp Optom., 1999. 82: p. 196-199. contact lens wear. Journal of British Contact
3. Assiri, A., et al., Incidence and severity of lens Assoc, 1996. 19: p. 133-140.
keratoconus in Asir province, Saudi Arabia. 14. Mayers, M., Callan B., and R. Borazjani, et
Br J Ophthalmol, 2005. 89: p. 1403-1406. al. , Complaince and contamination in contact
4. Gray, T., et al., Acanthemoeba, bacterial, and lens wear., After American Academy of
fungal contamination of contact storage cases. Optometry meeting, 2010; San Francisco.
Br J Ophthalmol, 1995. 79: p. 601-605. 15. Hickson-Curran, S., R. Chalmers, and S.
5. Morgan, P., The science of compliance: a Sencer, Making the case for daily disposable
guide for eye care professionals. 2008. contact lenses: patient non compliance with
6. McLaughlin-Borlace, L., et al., Bacterial storage case hygiene and replacement., 2010.
biofilm on contact lens storage cases. Br J 16. Dart JK, Stapleton F, Minassian D. Contact
Ophthalmol, 1998. 84: p. 827-838. lenses and other risk factors in microbial
7. Collins, M. and L. Carney, Compliance with keratitis. Lancet 1991;338:650-53
care and maintenance procedures amongst 17. Radford CF, Minassian DC, Dart JK.
contact lens wearers. Clin Exp Optom, 1986. Acanthamoeba keratitis in England and
69: p. 174-177. Wales: incidence, outcome, and risk factors.
8. Dart, J., et al., Risk factors for microbial Br J Ophthalmol 2002;86:536-42
keratitis with contemporary contact lenses: a 18. Butler TK, Males JJ, Robinson LP, Wechsler
case study. Ophthalmology, 2008. 115: p. AW, Sutton GL, Cheng J, Taylor P,
1647-1654. McClellan K. Six-year review of
9. Stapleton, F., et al., The incident of contact Acanthamoeba keratitis in New South Wales,
lens-related microbial keratitis in australia. Australia: 1997-2002. Clin Exp Ophthalmol
Ophthalmology, 2008. 115: p. 1655-1662. 2005;33(1):41-6
10. De Oliveira, P., et al., self evaluation of 19. Szczotka-Flynn LB, Pearlman E, Ghannoum
contact lens waering and care by college M. Microbial contamination of contact lenses,
students and health care workers. eye and lens care solutions, and their accessories: a
Contact Lens Journal, 2003. 29: p. 164-167. literature review. Eye Contact Lens
11. Claydon, B. and N. Efron, Non compliance in 2010;36(2):116-29
contact lens wear. Ophthal Physiol Opt, 1994.
14: p. 356-364.
Table 1 – Distribution of the study participants according to the age-group

Age group No. of students Percentage %
18-21 27 54%
22-25 23 46%
Total 50 100%

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Yousef Aldebasi
Table 2 - Distribution of the study group by characteristic of the lens

S. Characteristics of Categories Total (%)
No. the study group
1. Contact lens Hospital 05 (10%
purchased from Cosmetic Centre 26 (52%)
Optical Shop 19 (38%)
2. Type of Contact lens Soft lens 46 (93%)
Hybrid lens 4 (8%)
3. Lens used for Cosmetic purpose 33 (66%)
Refractive purpose 17 (34%)
Table 3- Distribution of the cleaning characteristics of lens users

S. Lens Users Cleaning Total (%)
No. Characteristics
1. Cleaning the lens case Regularly 41 (82%)
Irregularly 9 (18%)
2. Washing hands before using Wash hands 46 (92%)
contact lens Do not wash 4 (8%)
hands
3. Clean hands before putting Regularly 29 (58%)
lens in the lens case
Sometimes 15 (30%)
Not at all 6 (12%)
Table 4 - Distribution of the study population according to lens care

S. No. Lens Care Characteristics Total (%)
1. Immersing lens in cleaning Completely 37 (74%)
solution immersed
Partially immersed 13 (26%)
2. Follow up visit to the eye Regular 31 (62%)
practitioner
Irregular 19 (38%)

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Yousef Aldebasi
Table 5 - Age and Level of Education vs Compliance
Parameters Age Level of Education

p-value p-value
Cleaning the lens case 0.002* 0.005*
Washing hands before using contact

0.054* 0.295
lens
Clean hands before putting lens in the 0.000* 0.000*

lens case
Immersing lens in cleaning solution 0.000* 0.002*
Follow up visit to the eye practitioner 0.109 0.004*
Graph 1- Marital Status of The Study Participants
Graph 2 – Distribution of the Study Population According To Use of Cleaning Solution

Page 169
Sharadkumar P. Sawant et al VARIANT HEADS OF BICEPS BRACHII MUSCLE
VARIANT HEADS OF BICEPS BRACHII MUSCLE
IJCRR Sharadkumar Pralhad Sawant , Shaguphta T. Shaikh, Rakhi Milind More

Vol 04 issue 20
Section: Healthcare
Department of Anatomy, K.J.Somaiya Medical College, Somaiya Ayurvihar, Eastern
Category: Research Express Highway, Sion, Mumbai, MS, India
Revised on:06/09/12
Accepted on:21/09/12 E-mail of Corresponding Author: dr.sharadsawant@yahoo.com
ABSTRACT
Aim: To study the occurrence of the variant heads of biceps brachii muscle.
Materials and Methods: The 50 specimens of the 25 donated embalmed cadavers (20 males & 5
females) were dissected and observed for variations in the origin and insertion of biceps brachii muscle
bilaterally in the department of Anatomy at K.J.Somaiya Medical College, Sion, Mumbai, INDIA. The
dissection of arm and forearm was done meticulously in all the 50 specimens. The photographs of the
supernumerary head of biceps brachii muscle were taken for proper documentation and for ready
reference.
Results / Observations: Out of 50 specimens, the supernumerary head was found in six specimens. The
humeral head was taking origin from the anteromedial surface of the shaft of the humerus in three
specimens and from the anterolateral surface of the shaft of the humerus in three specimens. In all six
specimens, the supernumerary head joined with the other two heads and form a common tendon which
got inserted into the radial tuberosity of the radius and bicipital aponeurosis. In the present study the
incidence of supernumerary head of biceps brachii was 12%. In all the six specimens, the supernumerary
head was found unilaterally (5 males & 1female specimen). In three specimens (50%) the supernumerary
head was supplied by median nerve, the musculocutaneous nerve was absent in that specimen while in all
other specimens the muscles of front of arm were supplied as usual by musculocutaneous nerve. The
blood supply of the supernumerary head was from the brachial artery and vein. There were no variations
in the vascular pattern of arm and forearm in all the specimens.
Conclusion: Topographical anatomy and variations in the heads of the biceps brachii muscle is clinically
important for surgeons, orthopaedicians and radiologists.
Key words: Biceps Brachii Muscle, Supernumerary Head, Musculocutaneous Nerve, Median Nerve,
Surgeons, Orthopaedicians, Radiologists.
INTRODUCTION the forearm (1). This mode of insertion makes it an

The biceps brachii is the muscle of the anterior efficient and important supinator of the forearm. It
compartment of the arm having two heads of is the only flexor of the arm that crosses the
origin proximally, a long head originating from the shoulder as well as the elbow joint thereby acting
supraglenoid tubercle and glenoid labrum and a on both joints. It is innervated by the
short head from the coracoid process of the musculocutaneous nerve and vascularized by
scapula. Distally these two heads unite to form a brachial and anterior circumflex humeral arteries
common tendon that inserts into the posterior and brachial vein (1). Biceps brachii has been
rough part of the radial tuberosity and bicipital stated as one of the muscles that shows frequent
aponeurosis which merges with the deep fascia of anatomical variations (2, 3, 4, 5). Some of its

Page 170
reported anomalies have been manifested as cadavers varied between 65-80 years. Te skin is
supernumerary fascicles that originate from the reflected by making a longitudinal incision on the
coracoid process, tendon of pectoralis major, anterior aspect of the arm extending from the level
articular capsule and head of the humerus or from of acromian process to a point 2.5 cm below the
humerus itself (6). Among those variations, the elbow joint & horizontal incisions on both
presence of a supernumerary fascicle arising from proximal and distal ends of the longitudinal
the shaft of the humerus, which is known as the incision. The arms were then dissected carefully to
humeral head of biceps brachii, is known to be the expose the full length of the biceps brachii muscle
most common anomaly (3, 7, 8). Multiple from its proximal to distal attachment. The
supernumerary heads of four to seven have also presence of supernumerary heads, their origins and
been reported to a lesser extent (1, 3, 4, 5). A large insertions were recorded. The photographs of the
body of evidence suggests a wide range of racial supernumerary head of biceps brachii muscle were
variations in the occurrence of humeral head of taken for proper documentation and for ready
biceps brachii muscle. It was shown to have an reference.
incidence of 7.1% in Indians, 8% in Chinese, 10%
in European whites, 10 % in Sri Lankans, 12% in RESULTS / OBSERVATIONS
African Blacks, 15% in Turkish, 18% in Japanese, Out of 50 upper limbs of 25 cadavers,
21.5% in South African Blacks and 8.3% in South supernumerary heads of the biceps brachii were
African Whites, and 37.5 % in Colombians (3, 8, present in 6 specimens. The supernumerary head
9, 10, 11,12, 13, 14, 15, 16). From a clinical was taking origin from the anteromedial surface of
standpoint of view, muscle anomalies are difficult the shaft of the humerus in three specimens and
to differentiate from soft tissue tumors (5). High from the anterolateral surface of the shaft of the
median nerve compression around the elbow joint humerus in three specimens. In all the six
has been described as resulting from a number of specimens, the supernumerary head joined with
clinical and anatomical entities. The existence of the other two heads and form a common tendon
an anomalous muscle in and around the elbow which got inserted into the radial tuberosity of the
region may cause high median nerve palsy and radius and bicipital aponeurosis. In the present
compression of the brachial artery (5). Further, study the incidence of supernumerary head of
knowledge of the incidence of humeral head of biceps brachii was 12%. In all the six specimens,
biceps brachii will facilitate preoperative diagnosis the supernumerary head was found unilaterally (3
as well as the surgical procedures of the upper male & 3 female specimens). In three specimens
limb (5,9). (50%) the supernumerary head was supplied by
median nerve, the musculocutaneous nerve was
MATERIALS AND METHODS absent in that specimen while in all other
This study was carried out on a total of 25 donated specimens the muscles of front of arm were
embalmed cadavers (20 males and 5 females) supplied as usual by musculocutaneous nerve. The
during routine gross anatomy dissections in the blood supply of the supernumerary head was from
Department of Anatomy at K.J.Somaiya Medical the brachial artery and vein. There were no
College, Sion, Mumbai, India. The cadavers were variations in the vascular pattern of arm and
preserved in 10% formalin. The age group of the forearm in all the specimens.

Page 171
Fig. 1: The right supernumerary head was taking origin from the anteromedial surface of the shaft of the
humerus and was supplied by the musculocutaneous nerve.
Fig. 2: The left supernumerary head was taking origin from the anteromedial surface of the shaft of the
humerus and was supplied by the musculocutaneous nerve.
Fig. 3: The left supernumerary head was taking origin from the anteromedial surface of the shaft of
the humerus and was supplied by the musculocutaneous nerve.

Page 172
Fig. 4: The right supernumerary head was taking origin from the anterolateral surface of the shaft of the
humerus and was supplied by the median nerve.

Page 173
DISCUSSION the branching pattern of musculocutaneous nerve

Anatomy is a morphological science which cannot (13,18). The median nerve supplying the
fail to interest the clinicians. The present study supernumerary head was rare and not found in
documents the incidence and morphological literature. In the past many variations have been
characteristics of supernumerary heads of biceps described regarding the course of the
brachii. The standard Anatomy text states the musculocutaneous and median nerves. Le Minor
incidence of this variation as 10% (1). Although (19) described five types of variations: Type 1:
this is based on some European populations (10), There is no communication between the median
it ignores a large body of evidence with reference and musculocutaneous nerve. Type 2: The fibers
to other populations (3, 8, 9, 11, 12, 13, 14, 15, of medial root of median nerve pass through the
16). Furthermore, racial variation of the incidence musculocutaneous nerve and join the median
of the supernumerary head of biceps brachii has nerve in the middle of the arm. Type3: The lateral
been clearly demonstrated by comparative studies root fibers of medial root of median nerve pass
between Brazilian whites and black subjects. The through the musculocutaneous nerve and after
incidence of supernumerary head of biceps brachii some distance, leave it to form the root of the
in blacks was found to be significantly lower than median nerve. Type 4: The musculocutaneous
in whites (17). The variations of the incidence of fibres join the lateral root of the median nerve and
the third head of biceps brachii were attributed to after some distance the musculocutaneous arise
evolutionary or racial trends (8). In the present from the median nerve. Type 5: The
study the incidence of occurrence of musculocutaneous nerve is absent and the entire
supernumerary head of the biceps brachii was fibres of musculocutaneous pass through lateral
12%. It was also interesting to note the gender root and fibres to the muscles supplied by
differences of the occurrence of humeral heads of musculocutaneous nerve branch out directly from
this muscle. The gender comparison of the median nerve. Venieratos and Anagnostopoulou
incidence implies that the supernumerary head of (20) also described three different types of
the biceps brachii is a predominantly male communication between musculocutaneous and
condition (3, 10). The results of the present study median nerve in relation to coracobrachialis
disagree with the gender comparison documented muscle. Type 1: communication between
in literature. In the present study the musculocutaneous and median nerve is proximal
supernumerary head was found in 3 female to the entrance of musculocutaneous into
specimens out of 10 female specimens (30%) and coracobrachialis. Type 2: communication between
in 3 male specimens out of 40 male specimens the two nerves is distal to the muscle. Type 3:
(7.5%). neither the nerve nor its communicating branch
Embryologically it has been stated that the third pierced the muscle. In the present study the three
head of biceps brachii arises from the brachialis specimens (50%) of supernumerary head of biceps
muscle and in such instances its distal insertion brachii muscle were supplied by median nerve.
has been translocated from ulna to the radius (2). The absence of musculocutaneous nerve was
The innervation and vascularization of the third coincided with type 5 of Lee Minor but did not
head of biceps brachii were from coincide with any of Venieratos's classification
musculocutaneous nerve and brachial artery. This (19, 20). The knowledge of such variations is
agrees with the normal embryologic development important during surgical corrections of the arm as
of the related dermatomes and myotomes. It is well as in diagnosing the nerve impairments.
presumed that the development of the biceps Furthermore, it has been mentioned that any
brachii muscle is likely to influence the course and variant nerve with an abnormal origin, course and

Page 174
distribution is prone to accidental injuries and REFERENCES

impairments (21). This is further proved by the 1. Standring S, Ellis H, Healy JC, Johnson D et
fact that supernumerary heads of the biceps brachii al. Gray’s Anatomy. In: General organisation
muscle have been reported to compress the and surface anatomy of the upper limb.39th
surrounding neurovascular structures leading to ed. Philadelphia Elsevier Churchill
erroneous interpretations during surgical Livingstone, 2005: 803-4.
procedures (18). The biceps brachii is known for 2. Testut, L. & Latarjet, A. Compendio de
its powerful elbow flexion and supination of the anatomia descriptive. 22nd Ed. Buenos Aires,
forearm. It can be argued that the presence of Salvat, 1981.
supernumerary heads of biceps brachii muscle 3. Asvat, R.; Candler, P. & Sarmiento, E. E.
increase its kinematics. Therefore, from High incidence of the third head of biceps
anatomical standpoint of view it can be presumed brachii in South African populations. J. Anat.,
that the presence of a third head may increase the 182:101-4, 1993.
power of flexion and supination of the forearm 4. Nakatani, T.; Tanaka, S. & Mizukami, S.
(13). In addition to allowing the elbow flexion Bilateral fourheaded biceps brachii muscles:
irrespective of the shoulder joint position, the the median nerve and brachial artery passing
supernumerary head of biceps brachii may through a tunnel formed by a muscle slip
enhance the strength of elbow flexion (16). from the supernumerary head. Clin. Anat.,
11:209-12, 1998.
Competing interests: 5. Nayak, S. R.; Ashwin, K.; Madhan, K. S. J.;
The authors declare that they have no competing Latha, V. P.; Vasudha, S. & Merin, M. T.
interests. Four-headed biceps and triceps brachii
muscles with neurovascular variation.Anat.
Authors' contributions: Sci. Intl., 83:107-11, 2008.
SPS wrote the case report, performed the literature 6. Sargon, M. F.; Tuncali, D. & Celik, H. H. An
review & obtained the photograph for the study. unusual origin for the supernumerary head of
RMM performed the literature search and assisted biceps brachii muscle. Clin. Anat., 9:160-2,
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8. Kopuz, C.; Sancack, B. & Ozbenli, S. On the
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to Dr. Arif A. Faruqui for his valuable help, Nippon., 74:301-5, 1999
support and inspiration. Authors also acknowledge 9. Rai, R.; Ranade, A. V.; Prabhu, L. V. &
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11. Torre, F. R. L.; Cegarra, J. N. & Berruezo, J. 17. Santo Neto, H.; Camilli, J. A.; Andrade, J. C.;
P. Biceps brachii muscle attached to the Meciano, F. J. & Marques, M. J. On the
extensor carpii radialis brevis muscle: an incidence of the biceps brachii third head in
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Anat. Anz., 176:319-21, 1994. 180:69-71, 1998.
12. Kosugi, K.; Shibata, S. & Yamashita, H. 18. Warner, J. P.; Palleta, G. A. & Warren, R. F.
Supernumerary head of biceps brachii and Supernumerary Head of the Biceps brachii,
branching pattern of the musculocutaneous Case report demonstrating clinical relevance.
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13. Kumar, H.; Das, S. & Rath, G. An anatomical and musculocutaneous nerves in man.
insight into the third head of biceps brachii Archieves Anatomy Histology Embryology
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14. Tountas, C. P. & Bergman, R. A. Anatomic 20. Venierators D and Anangnastopoulou S
variations of the upper extremity. New York, classification of communication between the
Churchill Livingstone, 1993. musculocutaneous and median nerves.
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The anatomic characteristics of the third head 21. Roberts, W. H. Anomalous course of the
of biceps brachii muscle in Colombian median nerve medial to the trochlea and
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ISSN: 2231-2196 (Print)

ISSN: 0975-5241 (Online)

“Let the Science be your passion”

International Journal of Current Research and Review

Vol 04 / Issue 20 / October 2012

1 International Journal of Current Research and Review www.ijcrr.com

Indexed in: Revistas Médicas Portuguesas, Index Copernicus, DOAJ, BOAI,

Title suggested in: Google Scholar, Scopus, Thomson Reuters.

Aims and Scope:

About the editors:

IJCRR is official publication of Radiance Research Academy, Nagpur, India

Administrative Office: Radiance Research Academy, 148, IMSR Building, Near

2 International Journal of Current Research and Review www.ijcrr.com

07 Significance of Various Sacral Mamatha H.,

3 International Journal of Current Research and Review www.ijcrr.com

16 Assessment of Knowledge and Yousef Aldebasi

“Let the science be your passion”

Vol 4 / Issue 20 / Oct 2012

4 International Journal of Current Research and Review www.ijcrr.com

STUDY OF SOCIO-DEMOGRAPHIC PROFILE OF POISONING CASES

INTRODUCTION which has been reported from southern and central

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

studies 4,8,15, 16,17,. In our study there is a male CONCLUSION

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

Tables Table 5- marital status

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

ACTINOMYCOSIS OF BREAST-A CASE REPORT

B. Arora1, Sumit Giri2 , D.R. Arora3

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

CELL ADHESION MOLECULE EXPRESSION PROFILING OF HUMAN

IJCRR S. Indumathi, Rashmi Mishra, R. Harikrishnan, J.S. Rajkumar, Neha Kantawala,

INTRODUCTION dynamic properties that make themselves a best

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

quantity of stem cells. Accumulating evidences MATERIALS AND METHODS

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

DISCUSSION MSC. CD90, ISCT defined MSC marker as well

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

REFERENCES 10. Rachakatla RS, Marini F, Weiss ML, Tamura M,

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

CLINICAL OUTCOMES OF AO PHILOS PLATING FOR PROXIMAL

IJCRR Annamalai Regupathy

INTRODUCTION AIM AND OBJECTIVES:

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

Figure 1 showing functional results based on Constant score

Figure 2 showing results revision surgery

Figure 3 showing the complications rate

30.00% Present study

Figure 4 showing the results of Constant score

Int J Cur Res Rev, Oct 2012 / Vol 04 (20) ,

X ray 2 showing screw back out and collapse