Role of community based learning in creating self-driven learning and rural bias among medical undergraduates

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Index

S.

N.

Title Authors Page

No.

1 A Study on Nuclear Energy: Sustainable

Solution for Ensuring Energy Security or

Emerging Future Threat

Dewan Mowdudur

Rahman, Riasad

Amin, Navid Bin

Sakhawat, Md.

Zubaer Chowdhury

6

2 Isolation, Optimization And Production

Of Protease From Aspergillus Species

Through Solid State Fermentation

M. Saraswathi, R.

Dakshayani, P.

Muralikrishna

15

3

Cropping and Land use Pattern in

Himachal Pradesh: Case of District

Solan

Kumar Sanjay, Barik

Kaustauv, Prashar

Deepak

19

4

Are Lifestyle Disorders a Risk for

Periodontal Disease?

Manoj Raja

26

5

Blood Glucose Concentration - A Key to

Fix the Effective Dose for Herbal

Antidiabetic Drugs using Rat Model

R.Kannadhasan,

S.Venkataraman

32

6 Bilateral Variation in the Vascular

Pattern of Palm-A Case Report

A.Himabindu,

B.Narasing Rao

46

7 A Review on M-Health System and

Technologies

Arvind Rehalia,

Rajat Kumar

53

8 Treatment Seeking Behavior of Married

Women of Reproductive Age Belonging

to a Rural Community of India

Mohammad Shakil

Ahmad, Shaikh

Mohsin, Ritu Kumar

Ahmad

59

9 Trend Analysis of Northeast Monsoon

Rainfall of Tamil Nadu

Tamil Selvi .S ,

Samuel Selvaraj .R

70

10

Microbial, Sensory and Nutritional

Properties of Cauliflower, Preserved by

Hurdle Technology

Jyoti Sinha, Ramesh

Chandra

74

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Index

S.

N.

Title Authors Page

No.

11 Plat form Switching in Implant

Dent istry - A Review

Gayathri N, Lakshmi

S

81

12 Neonatal Mortality – An Experience by

Verbal Autopsy

Shaikh Mohsin,

Pathan Sameer

89

13

Esthetic and Functional Rehabilitation of

the Patient with Severely Worn

Dentition using Twin Stage Procedure:

A Case Report

Naresh HG Shetty,

Manoj Shetty,

Krishna Prasad D.

93

14

Evaluation of Yoga Therapy for the

Risk Factors of Cardiovascular

Disorders-A Review

Deepa.T,

N.Thirrunavukkarasu

100

15

Characterization of Fatty Acids in Melia

Azedarach l. Seed Oil

R. K. Bachheti,

Himanshu Dwivedi,

Vikas Rana, Indra Rai

Archana Joshi

108

16 Knowledge and Opinion of Caregivers

Regarding Childhood Additional

Vaccines in Agartala, West Tripura

Majumder Nilratan,

Datta Shib Sekhar,

Boratne Abhijit

Vinodrao, Majumder

Nilanjan, Basu

Majumder Chandrika

115

17 Evaluation and Comparison of

Remineralization Efficacy of CPP-ACP

and Fluoride Varnish using Diagnodent -

An In Vitro Study

R.Senthil, V. Rathna

Prabhu, J. Jeeva

rathan, A.

Venkatachalapathy

121

18 Mutational Analysis of Interferon-

Gamma Gene in Indian Women with

Female Genital Tuberculosis

Venkanna Bhanothu,

Jane Theophilus, Roya

Rozati

130

19 Ziziphus Mauritiana :A Review on

Pharmacological Potential of this

Underutilized Plant

Sukirti Upadhyay,

Prashant Upadhyay, A

K Ghosh, Vijender

Singh

141

20 Role of Community Based Learning In

Creating Self-Driven Learning and

Rural Bias Among Medical

Undergraduates

Shib Sekhar Datta,

Abhijit V Boratne

145

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ijcrr

Vol 04 issue 03

Category: Research

Received on:08/12/11

Revised on:14/12/11

Accepted on:19/12/11

ABSTRACT Sustainability is characterized by the environmental friendly process best fitted for eco-systems

and the capacity to maintain a process smoothly indefinitely. Maintaining sustainability in

every aspect is the key for continuing human race in the long run. Recent energy insecurity

problem and global climate change has led the concerned to take a fresh look at the benefits and

risks of nuclear power for better future and find out a sustainable solution. Risk from fatal

accident and radioactive waste management for a long period of time surely diminish the

benefits of nuclear power, such as no green house gas emission and significant amount of

power supply with minimum infrastructural development. As nuclear power is all about

balancing the benefit and the risk, therefore this paper summarizes the benefit and risk causing

from nuclear power to find out a sustainable choice for future energy demand.

______________________________________________________________________

Keywords: Nuclear energy, climate change

effects, radioactivity, energy demand,

sustainable development.

1. INTRODUCTION

Modern age is passing an energy deficient

time and the coming days will definitely be

starved for energy. About 1.4 billion

people (20% of the global population) do

not have access to electricity and 2.7 billion

people (40% of global population) rely on

traditional biomass for basic energy needs

such as cooking and heating [1]. Increasing

global energy demand combined with the

need to minimize Green House Gas (GHG)

emission will require the diversification of

energy sources, while still ensuring that the

bottom 2 billion people- those who live on

less than USD 2.5 per day have access to

modern energy services. Achieving the

goal set in April, 2010 by the UN Advisory

Group on Energy and Climate Change

(AGECC) for universal access to modern

energy by 2030 [2] is a daunting prospect,

given the intertwined challenges to tackle

natural resources security, energy

insecurity and climate change impact. At

present, nuclear power appears to be the

best choice for many nations. However,

integrating nuclear power into a country‘s

energy infrastructure is not without

challenges. It has a great prospect of

supplying sufficient amount of energy with

creating less impact to the environment but

in the long run there still remains a doubt

about its sustainability.

2. Sustainable Development

Human beings are said to be at the centre

of concerns for sustainable development.

We are entitled to a healthy and productive

life in harmony with nature. States are seen

A STUDY ON NUCLEAR ENERGY: SUSTAINABLE

SOLUTION FOR ENSURING ENERGY SECURITY OR

EMERGING FUTURE THREAT

Dewan Mowdudur Rahman1, Riasad Amin

1, Navid Bin Sakhawat

2,

Md. Zubaer Chowdhury1

1Department of EECE, Military Institute of Science and Technology, Dhaka,

Bangladesh 2Department of EEE, BRAC University, Dhaka, Bangladesh

E-mail of Corresponding Author: [email protected]



as having the right, within the principles of

international law, to exploit our own

resources and the responsibility to ensure

that any activities within our jurisdiction do

not cause damage to the environment or

other States. In addition, the right to

development must be fulfilled so as to

equitably meet the developmental and

environmental needs of present and future

generations. Eradication of poverty is seen

as a required element of sustainable

development. Climate change is a pressing

threat to the sustainability of life on earth

[3]. It is a highly complex problem that is

unpredictable, reflecting an intricate

interaction of organizational production

processes, government management and

regulation, natural forces, and individual

behaviour [4]. It is generally held that

sustainable development requires attention

to the following things:

Food availability and protection.

Water availability in adequate

quantities.

Disease prevention and medical

treatment.

Steady and abundant supply of

energy specifically, electricity.

Sewage treatment.

Infrastructure development such as

schools, factories and

transportation.

3. Global Climate Change Effects

In recent years, dramatic environmental

changes have caused extraordinary climate

changes around the globe. This has made

countries all over the world to focus on

greenhouse effect issue and consider it

seriously [5]. It is an important problem

that can‘t be ignored because the

greenhouse effect causes global warming

[6, 7]. In the past century, research and

literature has concluded that carbon dioxide

(CO2) concentration increased by 28%

following the industrial revolution [8]. The

global average temperature has increased

by 0.3˚C to 0.6˚C, and the sea level rose 10

to 15 cm in the past 100 years. If

greenhouse gas (GHG) emissions continue

to increase at the present rate, it is

predicted that the average global

temperature will increase by about 1˚C by

the year 2025 and by 3˚C at the end of the

century [9]. The increase of atmospheric

GHG concentration results to a large extent

from human activities [10, 11]. Scientists

predict if no effective protection policies

for the environment are put into place, the

global temperature will increase by 1˚C to

3.5˚C, and the sea level will increase by 15

to 95 cm. This will make many countries

uninhabitable by 2100 [12]. The second

assessment report of Inter governmental

Panel on Climate Change (IPCC) stated

that the CO2 concentration in the

atmosphere rose from 280 to 358 ppm in

1994 [13]. The World Meteorology

Organization (WMO) also pointed out in

greenhouse gas annual report in 2007 that

the CO2 concentration had already raised to

383 ppm [14]. CO2 is the main GHG

emitted from various sources and power

sector is solely responsible for 30%

emission of CO2 throughout the world [15].

4. Nuclear Energy: An Emerging

Source

The star, of which our sun is one, relies on

nuclear fusion for their output of heat, light

and other radiations. If one believes in the

Big Bang Theory, then the Earth may be

considered as a fragment of the Sun. Fusion

reaction is exactly what is happening on the

Sun. Energy from fission reaction is

derived from a nuclear reaction involving

uranium or plutonium as the fuel which

originally comes from the fragment of the

Sun. Nuclear reactors are either the slow

thermal kind using moderators or the fast



breeder type using purer fuels and able to

generate or ‗breed‘ new fuel form which is

useful in the context of renewability. It is

projected that world primary energy

demand will increase by 45 percent

between 2006 and 2030, an average

annual rate of growth of 1.6 percent

slower than the average growth of 1.9

percent per year from 1980 to 2006

[16]. The International Atomic Energy

Agency (IAEA), the most authoritative

international source of information on

nuclear energy, predicted in August 2009

that global nuclear power capacity would

be doubled by 2030, from the current 372

gigawats electric (GWe) to 807 GWe.

Today, about thirty countries are

harnessing nuclear energy in about 440

commercial reactors. Table I. shows the list

of countries with their respective nuclear

programme.

Table I. The list of countries with their respective nuclear programme [17].

Nuclear Programme Countries

Contracts signed, legal and regulatory

infrastructure well-developed

United Arab Emirates, Turkey.

Committed plans, legal and regulatory

infrastructure developing

Vietnam, Jordan, Belarus, Bangladesh.

Well-developed plans but commitment pending Thailand, Indonesia, Egypt, Kazakhstan, Poland,

Lithuania, Chile.

Developing plans Saudi Arabia, Israel, Nigeria, Malaysia,

Morocco, Kuwait.

Officially not a policy option at present Australia, New Zealand, Portugal, Norway, Ireland.

5. Problems With Nuclear Energy

The disadvantages of nuclear energy

include: the storage and management of

dangerous high level radioactive waste, the

possibility of proliferation of nuclear

materials and potential terrorist

applications, the high cost of building

nuclear facilities and the possibility of

accidents. Common people awareness is

another issue that may also regard as a bar

for nuclear energy programme. These

disadvantages are listed below with

respective description.

5.1 Radioactive Waste

High-level radioactive waste is very

dangerous. It lasts for tens of thousands of

years before decaying to safe levels. It is

highly radioactive and is a major barrier for

the expansion of nuclear power. More than

fifty years of commercial nuclear energy

use has left the world with a legacy of tens

of thousands of tons of highly radioactive

waste that will last for tens of thousands of

years [18]. On average, uranium ore

contains only 0.1% uranium. Most nuclear

reactors require one specific form of

uranium, uranium-235 (U-235). This form

represents only 0.7% of natural uranium.

To increase the concentration of U-235, the

uranium extracted from ore goes through

an enrichment process, resulting in a small

quantity of usable ‗enriched‘ uranium and

huge volumes of waste. If nuclear power

production expands substantially in the

coming decades, the amount of waste

requiring safe and secure disposal will also

significantly increase. High-level nuclear

waste can last for thousands of years before

being safe again, so this is a major hurdle

which must be overcome before nuclear

power can expand. Radioactivity can be

turned out fatal for human body. Table II.

shows major problems caused by

radioactivity.



Table II. Human tissues and organs ranked by sensitivity to radiation

induced cancer

High Risk Moderate Risk Low Risk

Bone Marrow

Breast (premenopausal

Thyroid (child)

Lung

Stomach

Ovary

Colon

Bladder

Skin

Brain

Bone

Uterus

Kidney

Esophagus

Liver

5.2 Proliferation

Some forms of nuclear reactor, known as

"breeder" reactors produce plutonium,

which can, conceivably, be used to make

nuclear weapons. This is a conventional

explosive mixed with radioactive material

with the intention of spreading the material

across a wide area to do even more

damage. As modern world politics is

circling to grab more power and get share

of energy of any rival country, therefore

any nuclear power generating project could

be turned into nuclear weaponry production

project at any time.

5.3 Fuel Supply

Nuclear fuels are, physically, even rarer

than fossil fuels. Fossil fuels at least are

made on Earth, albeit over millions of

years. Heavy elements like Uranium are

only made as stars die, in supernovas. Our

solar system actually formed from the

remains of another star, at which point

heavier elements were made. Essentially,

once they're gone, they are well and truly

gone. Only in particle accelerators can

heavier elements be made. Therefore the

type of fuel required for nuclear power

programme is not abundant at all.

5.4 Changing Perception of Common

People

Common people always posses a doubtful

mind regarding nuclear energy. They feel

free considering its capability to deliver

huge power but become fearful when they

consider its adverse effects. Table III. and

IV. are showing the drastic change of the

perception of common people and the

reflection of doubtful mind setup about

nuclear energy programme.

Table III. Global Views about Nuclear Energy before the Japan Earthquake (Fukushima

Nuclear Power Plant Tragedy) in 2011 [19].

Condition Globally (%) Japan (%)

Favourable 57 62

Unfavourable 32 28

No Response 11 10



Table IV. Global Views about Nuclear Energy after the Japan Earthquake (Fukushima

Nuclear Power Plant Tragedy) in 2011 [19].

Condition Globally (%) Japan (%)

Favourable 49 39

Unfavourable 43 47

No Response 8 14

This changing mind setup of common people create dilemma among decision makers to take

any major decision about launching nuclear power programme.

5.5 Accidents Happened So Far

Nuclear power generating programme have

been caused for some fatal accidents so far.

To judge the severity of those accidents

International Nuclear Events Scale (INES)

has been introduced starting from 0 to 7.

Table V. lists these accidents with

respective INES scale and International

Atomic Energy Agency (IAEA)

description.

Table V. Nuclear power station incidents since 1952 with respective INES level and IAEA

description [20].

Year Incident INES

level Country IAEA description

2011 Fukushima 5 Japan

Reactor shutdown after the 2011 Sendai

earthquake and tsunami; failure of emergency

cooling caused an explosion.

2011 Onagawa

Japan Reactor shutdown after the 2011 Sendai

earthquake and tsunami caused a fire.

2006 Fleurus 4 Belgium

Severe health effects for a worker at a

commercial irradiation facility as a result of high

doses of radiation.

2006 Forsmark 2 Sweden

Degraded safety functions for common cause

failure in the emergency power supply system at

nuclear power plant.

2006 Erwin

United States Thirty-five litres of a highly enriched uranium

solution leaked during transfer.

2005 Sellafield 3 United

Kingdom

Release of large quantity of radioactive material,

contained within the installation.

2005 Atucha 2 Argentina Overexposure of a worker at a power reactor

exceeding the annual limit.

2005 Braidwood

United States Nuclear material leak.

2003 Paks 3 Hungary

Partially spent fuel rods undergoing cleaning in

a tank of heavy water ruptured and spilled fuel

pellets.

1999 Tokaimura 4 Japan Fatal overexposures of workers following a

criticality event at a nuclear facility.

1999 Yanangio 3 Peru Incident with radiography source resulting in



Year Incident INES


severe radiation burns.

1999 Ikitelli 3 Turkey Loss of a highly radioactive Co-60 source.

1999 Ishikawa 2 Japan Control rod malfunction.

1993 Tomsk 4 Russia Pressure build up led to an explosive mechanical

failure.

1993 Cadarache 2 France Spread of contamination to an area not expected

by design.

1989 Vandellos 3 Spain Near accident caused by fire resulting in loss of

safety systems at the nuclear power station.

1989 Greifswald

Germany Excessive heating which damaged ten fuel rods.

1986 Chernobyl 7 Ukraine

(USSR)

Widespread health and environmental effects.

External release of a significant fraction of

reactor core inventory.

1986 Hamm-Uentrop

Germany Spherical fuel pebble became lodged in the pipe

used to deliver fuel elements to the reactor.

1981 Tsuraga 2 Japan More than 100 workers were exposed to doses

of up to 155 millirem per day radiation.

1980 Saint Laurent des

Eaux 4 France

Melting of one channel of fuel in the reactor

with no release outside the site.

1979 Three Mile Island 5 United States Severe damage to the reactor core.

1977 Jaslovské Bohunice 4 Czechoslovakia

Damaged fuel integrity, extensive corrosion

damage of fuel cladding and release of

radioactivity.

1969 Lucens

Switzerland Total loss of coolant led to a power excursion

and explosion of experimental reactor.

1967 Chapelcross

United

Kingdom

Graphite debris partially blocked a fuel channel

causing a fuel element to melt and catch fire.

1966 Monroe

United States Sodium cooling system malfunctions.

1964 Charlestown

United States

Error by a worker at a United Nuclear

Corporation fuel facility led to an accidental

criticality.

1959 Santa Susana Field

Laboratory United States Partial core meltdown.

1958 Chalk River

Canada Due to inadequate cooling a damaged uranium

fuel rod caught fire and was torn in two.

1958 Vinča

Yugoslavia

During a subcritical counting experiment a

power build up went undetected - six scientists

received high doses.

1957 Kyshtym 6 Russia Significant release of radioactive material to the

environment from explosion of a high activity



Year Incident INES


waste tank.

1957 Windscale Pile 5 United

Kingdom

Release of radioactive material to the

environment following a fire in a reactor core.

1952 Chalk River 5 Canada

A reactor shutoff rod failure, combined with

several operator errors, led to a major power

excursion of more than double the reactor's rated

output at AECL's NRX reactor.

6. Nuclear Energy: Sustainable Solution

or Future Threat

Nuclear energy is clean and has a potential

to guarantee the world to serve with an

everlasting supply of fuel without affecting

resources sorely needed for other

applications. However, so far little has

possibly been known about the damages

associated with nuclear power generation.

The valuation of damages is further

complicated because they are likely to

occur only after several decades. Therefore

it is difficult to estimate the benefit of

nuclear energy avoiding its risk. Nuclear

power generation is seemingly profitable.

However when real costs are taken into

account, nuclear is often more expensive

than fossil fuels. For instance, nuclear

energy takes a long time to produce. The

process of permitting, environmental

impact studies and the length of time from

planning to design and construction of the

nuclear infrastructure typically last no less

than several decades. Plus nuclear waste is

still considered to be more controversial

than fossil fuel emission, often requiring

large underground storage facility. Despite

these obvious hurdles, perhaps the most

important challenge for this industry is

about the risk of fatal accident and

spreading radiation. Because casualty and

fearful damage from such accident is not

that so easy to handle by sending

emergency rescue team and providing

immediate shelter or medicine, the brutal

effects of this type of damage pass from

one generation to another through

radioactivity and can be caused of an

everlasting suffering for human race.

Table VI. Cost of electricity estimated by Massachusetts Institute of Technology (MIT)

and University of Chicago report.

Electricity Generation Type MIT report (2003)

University of Chicago report (2004)

Cost (cents per kWh)

Coal 4.2 3.3 to 4.1

Natural Gas (Combined Cycle

Gas Technology) 3.8 to 5.6 3.5 to 4.5

Nuclear 6.7 6.2



7. CONCLUSION

The authors of this paper evaluated one of

the key debatable issues influencing the

achievement of energy security both at

present and in the foreseeable future. The

facts have raised from neutral point of view

considering their future impacts. The

present trend of switching source of energy

from classic fossil fuel to nuclear energy

for countries is seemingly attractive for the

long run of sustainability due to its

reduction in global warming, climate

change, and improvement in energy

security. But energy security is such a issue

that must be addressed considering an

energy policy include: security of supply,

environmental impact, national

competitiveness and social concerns.

Nuclear energy definitely has its potential

to meet worldwide increasing energy

demand but when security and safety issue

comes into account then it becomes a tough

situation to take it as a potential alternative

of energy. Therefore it can not be said that

nuclear energy is the only alternative and

utmost solution for future. Continuous

research and development programmes

should carried out on this regard to make it

best fitted for future and alternative options

should put under microscope to find their

feasibility for meeting the energy demand

in a sustainable way.

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.

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doi:10.1016/S1352-2310(01)00514-3

11. H. Hayami and M. Nakamura,

―Greenhouse Gas Emissions in Canada

and Japan: Sector-Specific Estimates

and Managerial and Economic

Implications,‖ Journal of

Environmental Management. Vol. 85,

No. 2, 2007, pp. 371-392.

doi:10.1016/j.jenvman.2006.10.002

12. F. Georgios and C. Paul, ―Global

Warming and Carbon Dioxide through

Sciences,‖ Environment International,

Vol. 35, No. 2, 2009, pp. 390-401.

doi:10.1016/j.envint.2008.07.007

13. Intergovernmental Panel on Climate

Change (IPCC), ―Second Assessment

Synthesis of Scientific Technical

Information relevant to interpreting

Article 2 of the UN Framework

Convention on Climate Change,‖

Intergovernmental Panel on Climate

Chang, Geneva,1995.

14. World Meteorological Organization

(WMO), ―WMO Greenhouse Gas

Bulletin 2007: Atmospheric Carbon

Dioxide Levels Reach New Highs,‖

Geneva, 2007.

15. T. Jilani, K. Gomi and Y. Matsuoka,

―Integration of sustainable and low

carbon society towards 2025 in

Bangladesh,‖ in International

Conference on Climate Change Effects

and Energy Development in

Bangladesh, Germany, July, 2011

16. International Energy Agency (2008),

World Energy Outlook 2008.

Available:

http://www.worldenergyoutlook.org

17. World Nuclear Association (online).

Available: http://www.world-

nuclear.org, accessed on 27th

November, 2011.

18. C.D. Ferguson, ―Nuclear Energy

Balancing Benefits and Risks,‖ council

on foreign relations, CSR No. 28,

April, 2007

19. WIN/Gallop poll, ―Japan Earthquake

Jolts Global Views On Nuclear

Energy,‖ April 19, 2011, Available:

www.nrc.co.jp

20. Nuclear power station incidents since

1952 with respective INES level and

IAEA description (online). Available:

http://www.guardian.co.uk, accessed

on 3rd

December, 2011.



ijcrr

Vol 04 issue 03

Category: Research


Revised on:10/12/11


ABSTRACT The production of enzymes by bioprocesses is a good value added to agro industry residues. A

comprehensive study was carried out on the production of protease using different agricultural

wastes like paddy straw, sugarcane bagasse, peanut hull and rice bran by Aspergillus species.

Among the all tested the maximum enzyme production was observed in paddy straw, while

minimum protease production noticed in rice bran under solid state fermentation conditions.

The optimal conditions for producing maximum yield of protease were incubated at 350C, 4

days, pH 6.The protease production from waste treatment could be commercially used in

detergents and leather industry.

______________________________________________________________________

INTRODUCTION

Enzymes are delicate protein molecules

necessary for life. Protease is the single

class of enzymes which occupy pivotal

position due to their wide applications in

detergents, pharmaceuticals, photography,

leather, food and agricultural industries

and representing worldwide sale at about

60% of total enzyme market

(Paranthaman et al., 2009; Rajmalwar and

Dabholkar, 2009; Das and Prasad, 2010).

Proteases of fungal origin have an

advantage over bacterial protease as

mycelium can be easily removed by

filtration. Proteases produced by

Aspergillus sp. is of greater importance

due to its higher protease producing

ability (Chakraborty et al., 1995; Nehra et

al., 2002). Solid state fermentation (SSF)

has many advantages including superior

volumetric downstream processing, lower

energy requirement and low wastewater

output (Malathi and Chakraborty, 1990;

Pandy et al., 1999). The present study

was undertaken to produce protease under

laboratory conditions by solid state

fermentation of Aspergillus sp. using

paddy straw, sugarcane bagasse, peanut

hull and rice bran as substrate and to

determine the effect of pH, temperature

and incubation period on protease

production.

MATERIALS AND METHODS

Isolation of Aspergillus sp:

For isolation of Aspergillus,

rhizosphere soil samples were collected

from paddy fields of Cherlopalli, near

Tirupati area of Andhra Pradesh. The

collected samples were subjected to

serial dilution method by using potato

dextrose agar medium. Then the isolate

was screened for their proteolytic

activity by using Skimmed Milk Agar

(SMA) medium and maintained on

PDA slants for further use.

ISOLATION, OPTIMIZATION AND PRODUCTION OF

PROTEASE FROM ASPERGILLUS SPECIES

THROUGH SOLID STATE FERMENTATION

M. Saraswathi1, R. Dakshayani

2, P. Muralikrishna

2

1Department of Applied Microbiology, Sri Padmavati Mahila University,

Tirupati, A.P

2Department of Microbiology, S.V.University, Tirupati, A.P




Production of protease though solid state

fermentation:

Inoculum preparation:

Three ml of 0.1% Tween 80 was added to

release the spores and this spore suspension

was used as inoculums for fermentation.

Substrate preparation and inoculation:

Four substrates i.e., paddy straw, sugarcane

bagasse, peanut hull and rice bran were

used for protease production. 5 g of each

substrate was taken into two separate was

taken in separate 250 ml conical flasks and

salt solution was added to maintain 70%

moisture. Then the flasks were sterilized at

1210C for 15 min. The above flasks were

inoculated with 1 ml of inoculum and

incubated at room temperature for 5 days.

Extraction of crude enzyme:

Seventy five ml of double distilled water

was added to the conical flasks and kept on

rotary shaker for about half hour to obtain

uniform suspension. The suspension was

filtered through Whatman No: 1 filter paper

and the filtrate were collected separately

and used as an enzyme extract.

Assay for neutral protease:

To 200 µl of crude enzyme extract, 500 µl

of 1% casein and 300 µl of 0.2 mol/l

phosphate buffer (pH 7.0) were added. The

reaction mixture was incubated at 600C for

10 min and arrested by the addition of 1 ml

of 10 % Trichloroacetic acid (TCA). The

reaction mixture was centrifuged at 8000 x

g for 15 min and to the supernatant, 5 ml of

0.4 ml Na2CO3, 1 ml of 3 fold diluted Folin

Ciocalteau‘s phenol reagent was added.

The resulting solution was incubated at

room temperature for 30 min and the

absorbance of the blue colour developed

was read at 660 nm using a tyrosine

standard. One unit of enzyme activity was

defined as the amount of enzyme that

liberated 1 µg of tyrosine from substrate

(casein) per minute under assay conditions

and reported in terms of protease activity

per gram dry fermented substrate.

Effect of pH:

Different levels of pH i.e., 4.0, 5.0, 6.0 and

7.0 were evaluated for protease production

of four substrates by using Aspergillus sp.

Effect of temperature:

The inoculated substrates were incubated at

different temperatures viz., 20, 30, 40, and

50 to find the effect of temperature on

protease production.

Effect of Incubation period:

The effect of incubation period on protease

production was determined by incubating

the production medium for different

incubation periods viz., 3, 4, 5 and 6 days,

respectively.

RESULTS AND DISCUSSION

The process parameters for the production

of protease by Aspergillus sp. grown on

different substrates (paddy straw, sugarcane

bagasse, peanut hull and rice bran) was

done under optimized condition (Sudto et

al., 2008; Gitishree Das and Prasad., 2010;

Vishalakshi et al., 2009). In the present

study the maximum enzyme production

was observed in paddy straw, while

minimum protease production noticed in

rice bran. As shown in Table 1, pH showed

effect on protease production because

microbial strains depends on extracellular

pH which strongly influences the many

enzymatic processes and transport of

various components across the cell

membrane which in turn support the cell

growth and product production

(Paranthaman et al., 2009).



Table 1: Effect of different ph of different on protease production by Aspergillus

species

Substrates

Different pH values

4.0 5.0 6.0 7.0

Paddy straw 1.9 2.4 4.8 3.4

Sugarcane bagasse 1.6 2.1 4.6 3.0

Peanut hull 1.3 2.0 4.1 2.9

Rice bran 1.2 2.2 4.1 2.7

The optimum pH for growth was

recorded at pH 6 in all substrates. A

notable decline in the enzyme

productivity occurred at both high and

lower pH values. Similar results were

also reported by several works

(Paranthaman et al., 2009; Teufel and

Gotz., 1993; Vishalakshi et al., 2009).

Temperature also showed maximum

variation in the protease production (Tab

2).

Table 2: Effect of different temperatures on protease production by Aspergillus species

Substrates Different temperatures(

0C)

20 30 40 50

Paddy straw 1.7 3.1 2.0 1.6


Peanut hull 1.2 2.3 2.0 1.2

Rice bran 1.3 2.8 2.4 1.4

Table 3: Effect of different incubation period on protease production by using

Aspergillus species

Substrates Incubation period(days)

3 4 5 6

Paddy straw 1.8 2.2 3.4 2.5


Peanut hull 1.2 2.1 3.0 2.1

Rice bran 2.2 2.5 3.2 2.0

The maximum activity was found at 300C

in all the substrates. Results in the table 3

indicate that maximum enzyme

production was observed at 5 days of

incubation period in all the substrates

(Rajmalwar, S. and Dabholkar, P.S.,

2009). A gradual decrease in enzyme

units was observed with increasing

incubation period clearly suggests that

enzymes role as a primary metabolite



being produced in the log phase of the

growth of the fungus for utilization of

proteins present in the solid substrates

(Sudto et al., 2008; Gitishree Das and

Prasad., 2010; Vishalakshi et al., 2009).

The subsequent decrease in the enzyme

production could be probably due to

inactivation of the enzyme by other

constituent protease.

CONCLUSION

The pH, temperature and incubation

periods showed much effect on

production of protease by Aspergillus

species.

REFERENCES

1. Chakraborty, R. and Malathi, S.1990.

Production of alkaline protease by a

new Aspergillus flavus isolate under

solid state fermentation conditions for

use as a depilation agent. Appld. and

Env. Micro.: 712-716

2. Ellaiah, P., Srinivasulu, K.,

Adinarayana, K. 2002. A review on

microbial proteases. J.Sci. Ind.Res:

61:690-704.

3. Gitishree Das and Prasad, M.P. 2010.

Isolation, purification and mass

production of protease enzyme from

Bacillus subtilis. Int. Res. J. Mic. Vol.

1(2): 26-31.

4. Lowry, O. H, Rosebrough, N.J., Farr,

A.L. and Randall, R.J. 1951. Protein

measurement with folin phenol

reagent. J.Biol.Chem.193:265-275.

5. Nehra, K.S, Dhillon, S., Kamala, C.

and Randir, S. 2002. Production of

alkaline protease by Aspergillus sp.

under submerged and solid substrate

fermentation. Indian Microbiol. 42:

43-47.

6. Pandey, A., Selvakumar, P., Soccol,

C.R. and Nigam, P. (1999). Solid

state fermentation for the production

of industrial enzymes. Curr. Sci 77:

149-162.

7. Paranthaman, R., Alagusundaram, K.,

and Indhumathi, J. 2009. Production of

protease from rice mill wastes by

Aspergillus niger in solid state

fermentation. W.J.Agri.Res. 5 (3): 308-

312.

8. Rajmalwar,S. and Dabholkar, P.S.

2009. Production of protease by

Aspergillus sp. using solid state

fermentation. Afr. J.Biotech. Vol. 8

(17): 4197-4198.

9. Sudto, A., punyathiti, Y. and pongslip,

N. 2008. The use of agricultural wastes

as substrates for cell growth and

carboxymethyl cellulose (CMCASE)

production by Bacillus subtilis,

Escherichia coli and Rhizobium sp.

KMITL Sci. Tech. J. Vol.8 No.2:84-90.

10. Teufel, P. and Gotz, F.1993.

Characterization of an extracellular

metalloprotease with elastage activity

from Staphylococcus epidermidis.

J.Bacteriol. 175: 4218-4224.

11. Vishalakshi, N., Lingappa, K., Amena,

S., Prabhakar, M. and Dayanand, A.

2009. Production of alkaline protease

from Streptomyces gulbergensis and its

application in removal of blood strains.

Ind.J.Boitech. Vol 8: 280-285.



ijcrr

Vol 04 issue 03

Category: Research


Revised on:08/12/11


ABSTRACT The present research paper deals with the issues like land use and cropping pattern of district

Solan of Himachal Pradesh. Change in these two factors determined the pace of agricultural

diversification. The process of diversification of agriculture reduces the risk of perishment of

crops and provides economical benefits to farm. Hence, it may prove helpful in alleviating rural

poverty. To know about the changes in area under various crops, percentage method was used

as a statistical tool. The result obtained in this study indicates that area under pulses shows

decreased behavior pattern whereas in case of vegetables significantly increase was resulted.

______________________________________________________________________

Keywords: Agriculture, Cropping pattern,

Land use, Crops, Food grains

INTRODUCTION

The agriculture plays a vital role in shaping

the Indian economy. In recent years though

its contribution to the Gross Domestic

Product is progressively declining

approximately from 50% in 1950-51 to

14.6% in 2009-10 however a substantial

proportion (64%) of population depends on

this sector. Scarcity of cultivated land

hampers the agricultural sector compare to

secondary and tertiary sectors (industrial

and service sector). Land use pattern has a

great impact on the agricultural economy.

The process of diversification within

agriculture has now switched on to high

value crops instead of low value crops

which causes change in land utilization in

agriculture. Change in cropping pattern is

an essential part and common mode of

diversification, which has great impacts on

agricultural development and alleviation of

rural poverty [1]. The rapid increase in

human and livestock population has

resulted in a change in cropping pattern and

intensity of land use [2]. In this situation

where the scope of bringing more land

under cultivation is very limited,

appropriate choice of cropping pattern can

prove to be helpful in raising income from

their limited land holdings. To generate and

sustain the farm income for a long period it

becomes necessary to use land optimally.

This also affects the productivity of soil in

a least hampered manner. Among the hill

states prevailing in India, Himachal

Pradesh is observed to be the most

progressive state, which has made

remarkable achievement in socio-economic

development of its people [3]. Himachal

Pradesh offers a model of hill farming in

India [4]. The agro climatic conditions of

the state ranging from sub tropical to

humid temperature and cold deserts.

Traditional field crop based farming is also

done by majority of farmer for sustaining

their rural economy. The growing interest

of the farmers to run farming from business

CROPPING AND LAND USE PATTERN IN HIMACHAL

PRADESH: CASE OF DISTRICT SOLAN

Kumar Sanjay1, Barik Kaustauv

2, Prashar Deepak

3

1Department of Economics, Govt. College Dharampur, Mandi (H.P.)

2Department of Economics, IGNOU, New Delhi

3Department of Pharmaceutical Sciences, Manav Bharti University, Solan

(H.P.)




purpose has also encouraged them to

reconstitute the cropping pattern and

related activities. Consequently, there is

wide difference in the system of

cultivation, cropping pattern and cropping

season between different regions and

districts. A study conducted [5] resulted

that food grains such as wheat, maize and

paddy play a dominant role and occupy

around 85 % of total area under food grains

in Himachal Pradesh. Many researchers

have carried out and utilize these cropping

patterns along with diversification in

different forms and in different

geographical areas [6-10].

The present paper aims at the analysis of

cropping pattern and land utilization in the

Solan district of Himachal Pradesh .This

district was specifically and purposively

selected due to its increasing emergence as

the most prominent and successful

diversified agrarian pocket of the state. The

farmers of the area have shown their

increased interest towards the adoption of

new crop enterprises. This district has total

geographical area of around 1936 sq. km.

and constitutes 3.49 % of the total area of

the state. Following two objectives were

selected as a criterion for the present

research work.

To study the change in the use of

land resources in the district Solan.

To examine the variations in

cropping pattern of the district.

METHODOLOGY

The present investigation is based on the

secondary data. The data on different land

use categories and cropping pattern of

Solan were drawn from various published

and reliable sources such as Annual Season

and crop reports, Statistical Outlines of

Himachal Pradesh etc. from 1993-94 to

2007-08. Annual Season and crop reports

presented the data from 1993-94 onwards

which is used as a platform for our present

study. Simple tabular analysis and

percentage method are used to fulfill the

objectives of the study. The calculation of

% area under land category, % area under

crop and % change in area under crop was

carried out utilising the formulas in

equation 1, 2 and 3.

Area under land category

% area under land category = -------------------------------------------------- *100

Total geographical area (1)

Area under crop

% area under crop = ----------------------------------------------------------- * 100

Total cropped area (2)

Area under crop period II –area under crop period I

% change in AUC = -------------------------------------------------------------------------*100

Area under crop in period I (3)

Where AUC is area under crop


Land Utilization Pattern in District

Solan

The percentage of different land categories

to total geographical area was computed to

evaluate the status of different categories of

the land and net sown area in district Solan

of Himachal Pradesh. This procedure was

carried out for three different years i.e.

1993-94, 2000-01 and 2007-08 to examine

the deviations over the different years.

Area and percentage for each land category

were given in Table 1.



The data indicated that the total

geographical area of district Solan has

increased from 180553 hectare during

1993-94 to 180923 hectare. This was due to

increase in forest area of 370 hectare under

forest land settlement of Tehsil Kandaghat

of district Solan. Out of the total

geographical area nearly 11 percent (20290

hectare) is covered by the forests. The net

area available for cultivation was decreased

from 22.35 % in 1993-94 to 20.62 % for

the year 2007-08. Current fallow was

increased from 2.40 % in 1993-94 to 2.62

% during 2007-08. There was decrease in

cultivated area merely 668 hectare from the

period 1993-94 to 2000-01. But there was

significant decrease of 1970 hectare in the

cultivated area from 2000-01 to 2007-08.

This change is due to rapid urbanization

and industrialization in the district. Solan

district has recorded the highest population

growth during the period 1991-2001. Its

total and urban population showed decadal

growth of 30.64 percent and 92.84 percent,

respectively. The main reasons for high

growth in urban population were ideal

location of Solan town in terms of

accessibility to various facilities, moderate

climate and nearest to state capital Shimla.

Large number of industrial units has

emerged at the industrial areas of Nalagarh,

Barotiwala, Parwanoo and electronic

complex at Chambaghat. Permanent

pastures area was declined from 44.15 % in

1993-94 to 42.71% in the year 2007-08.

Land available for non-agriculture uses was

increased from 5.83 % in 1993-94 to 6.74

% in 2007-08. It is also clear from the table

that over the time span forest, culturable

waste, other fallow including barren land

expressed increase in area whereas,

reverse phenomenon was observed in case

of land put under miscellaneous tree crops

and groove .

Area under Different Crops

Cereals such as maize and wheat are the

main cultivated crops. Even though, all the

important crops are grown in the area, yet

most of the demand of the cereals is

meeting out from outside supplies. Among

the income generating commercial crops

like tomato, peas, capsicum and potato are

important. Area and percentage area under

different crops is given in Table 2.

Study of area under various crops as a

percentage of total cropped area indicated

that percentage area under total cereals

exhibits marginal increase from 83.04 in

1993-94 to 83.98 in 2007-08. Although the

percentage change in area under total

cereals looks insignificant but, actually

there is significant decline of 2274 hectares

between 1993-94 and 2007-08. The

percentage area under wheat and paddy

expanded from 36.69 to 39.21 and 5.35 to

6.82, respectively during the period of

1993-94 and 2007-08. Area under maize

creeps down from 38.32% to 35.49%

while, barley and other cereals registered

marginal decline. Among pulses, area

under gram, black gram, peas and horse

gram over the period (1997-98 to2007-08)

had declined. Percentage area under total

pulses decreased from 6.75 in 1993-94 to

3.90 in 2007-08. The total cropped area

under total food grains decreased from

60321 hectares in 1997-98 to 55986

hectares in 2007-08. Area under vegetables

grew from 3.06 % in 1997-98 to 5.78 % in

2007-08. Tomato is most important crop

under which area increased more than

double from 1306 hectares in1997-98 to

2625 hectares in 2007-08. There is also

minor increase in the percentage area under

fruits and condiments and spices for the

same period. The deviation of area under

pulses during the period is compensated by

the expansion of area under these crops as

shown in Table 2. But, percentage area

under oilseeds decreased from 2.63 to 1.73

during the study period. There is slight

decline in percentage area under fodder

crops and other crops during the present

study period. This is mainly due to the



expansion in the area under vegetables in

the district Solan. The data of the year

2000-01 shows similarities and slight

deviation as compare to 2007-08 and the

continuation of this is carried till 2007-08

hence it is not used for comparison.

The total cropped area registered decline of

3455 hectares between 1993-94 and 2007-

08. Percentage area under net sown area

decreased from 60.08 to 58.57. Although

there is an increase in percentage area sown

twice in a year from 39.91 to 41.42 during

the study period.

Trends in Area under Different crops

The trend of increase or decrease in area

under different crops is given in Table 3. It

is revealed that during present investigation

period, area under food grains has

contracted. In 2000-01 there was decline in

area under food grains by 7.15% in

comparison to1993-94 and during the

period 2000-01 to 2007-08 there was

almost no change in area. Therefore, over

the study period, the percentage fall in the

area under food grains was almost constant

by 7.16%. This contraction resulted due to

expansion of area under vegetables and

decline in area under maize, barley and

pulses. Area under wheat showed mixed

trends over the study period. Percentage

area under wheat decline 5.71 in 2000-01

compared to 1993-94 and increase of 7.51

in 2007-08 in comparison to 2000-01. In

case of barley, trends showed decline and

percentage declination in area is 12.97

between the periods 1993-94 to 2007-08.

There is also decreasing trends of maize

cultivation, the total declination is 12.13%

over the study period. The major reasons

for this decline in these crops are:

(1) The problem of wild animals (monkey,

pigs and birds etc.) that mainly destroy the

maize crop in this area.

(2) Food habits of peoples also changed as

a result of adaptation, they prefer wheat

and rice in place of maize and barley. Table

3 shows that there is increase of 21.02% for

crop paddy. High price of rice inspired the

farmers to bring more area under

cultivation of this crop. Area under pulses

shows significant decline of 45.39% in

2007-08 in comparison to 1993-94. This

was due to expansion of area under

vegetables in the district Solan.

Among the non food crops vegetables

registered an increase of 79.06 % during

the period 1993-94 to 2007-08. The decline

in area under cultivation of pulses was

compensated by the expansion of the area

under vegetables. Oilseeds, fodder crops

and others shows decline in area of about

37.66%, 20.79% and 39.31% respectively

over the study period. Fruits, condiments

and spices exhibit in area under these crops

i.e. 14.03% and 70.94%. The attractive

price of cash crops such as vegetables,

fruits, condiments and spices inspired the

farmer to increase production of these

crops on more and more area but, also

motivate them to shift the area from some

of the food crops to cash crop cultivation.

This may proves helpful to fulfill their

requirements and to get better prices from

the sale of their product.

Table 3 reveals that net sown area, area

sown more than once and total cropped

area has decreased about 7.52%, 1.55% and

5.14% respectively over the period 1993-94

to 2007-08. The major reason for this

decline in area under cultivation maybe the

problems of wild animals (monkey, pigs

and birds etc) that mainly destroys the

maize and other crops. So the people

restricts there cultivation and the far of land

(not protected from wild animals) remains

uncultivated during the last decade or so.

CONCLUSION

To evaluate the sequential variations of

land under different uses in district Solan

of Himachal Pradesh from 1993-94 to

2007-08 revealed that, there were some

notable variations under area in case of



permanent pastures and net sown area.

Moreover, other land categories had not

shown significant change under their area.

The study on the cropping pattern in

district Solan over the study period suggest

that among food crops area under wheat

and paddy has increased whereas, in case

of barley and maize it had declined

considerably. Area under non food crops

has shown increased trend for cash crops.

The result indicates that total cropped, net

sown area, and area sown more than once

decreased in period (1993-94 to 2007-08).

The trend of cropping pattern in Solan

district from 1993-94 to2007-08 disclosed

the fact that shifting of area from food

grains towards vegetables, fruits,

condiments and spices is considerably high.

It is clear from the above results and

suggestions that farmers of the area are

shifting towards commercial cropping.

ACKNOWLEDGEMENT





authors/ editors/ publishers of all those



and discussed.

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Diversification in Orissa. Agricultural

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Fertilizer. Productivity 1997; 38(1):

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West Bengal: A Spatio- Temporal

Analysis. Artha Vijnana 2000; 42(2);

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Agriculture: Concept, Rationale and

Approaches. Indian Journal of

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636-643.

10 Kumar U. Changing Cropping System

in Theory and Practice: An Economic

Insight into the Agrarian West Bengal.

Indian Journal of Agriculture

Economics 2003; 58(1): 64-83



TABLE 1: LAND USE PATTERN IN DISTRICT SOLAN

(Area in hectare)

S. No. Land category 1993-94 2000-01 2007-08

Area % Area % Area %

1 Forest 19911 11.02 20290 11.21 20290 11.21

2 Barren 11061 6.12 14372 7.94 12413 6.86

3 Non agricultural uses 10538 5.83 9561 5.28 12212 6.74

4 Permanent pastures 79729 44.15 78698 43.49 77278 42.71

5 Misc. tree crops and grooves 705 0.003 823 0.004 550 0.003

6 Culturable waste 13080 7.24 11958 6.60 15046 8.31

7 Other Fallow 830 0.004 1193 0.006 1076 0.005

8 Current Fallow 4341 2.40 5021 2.77 4741 2.62

9 Net Area Sown 40355 22.35 39007 21.56 37317 20.62

10 Total Geographical Area 180553 100 180923 100 180923 100

Source: Various issues of annual season and crop reports

TABLE 2: % AREA UNDER DIFFERENT CROPS IN DISTRICT SOLAN

(Area in hectare) S. No. Crop Name 1993-94 2000-01 2007-08

Area % Area % Area %

1 Wheat 24646 36.69 23237 36.47 24984 39.21

2 Barley 1788 2.66 1569 2.46 1556 2.44

3 Maize 25739 38.32 24421 38.33 22615 35.49

4 Paddy 3595 5.35 3552 5.57 4351 6.82

5 Other cereals 13 zero 01 zero 01 zero

6 Total Cereals 55781 83.04 52780 82.85 53507 83.98

7 Pulses 4540 6.75 3225 5.06 2489 3.89

8 Total Food grains 60321 89.80 56005 87.92 55996 87.88

9 Vegetables 2059 3.06 3397 5.33 3687 5.78

10 Oilseeds 1771 2.63 1278 2.00 1104 1.73

11 Fruits 734 1.09 779 1.22 837 1.31

12 Condiments & spices 265 0.39 560 0.87 453 0.71

13 Fodder crops 1630 2.42 1389 2.18 1291 2.02

14 Others 387 0.57 290 0.45 234 0.36

15 Net area sown 40355 60.08 39007 61.23 37317 58.57

16 Area sown more than once 26812 39.91 24691 38.76 26395 41.42

17 Total cropped area 67167 100 63698 100 63712 100




TABLE 3: TREND OF AREA UNDER DIFFERENT CROPS IN DISTRICT SOLAN

(Area in hectare) Sr.

No.

Crop Name 1993-

94

2000-01 2007-08

Area Area % change

compare

to1993-94

Area % change

compare to

2000-01

% change

compare to

1993-94

1 Wheat 24646 23237 -5.71 24984 +7.51 +1.37

2 Barley 1788 1569 -12.24 1556 zero -12.97

3 Maize 25739 24421 -5.12 22615 -7.39 -12.31

4 Paddy 3595 3552 -1.19 4351 +22.49 +21.02

5 Other cereals 13 01 -92.30 01 Nil -92.30

6 Total Cereals 55781 52780 -5.37 53507 +1.37 -4.07

7 Pulses 4540 3225 -28.96 2489 -22.82 -45.39

8 Total Food

grains

60321 56005 -7.15 55996 zero -7.16

9 Vegetables 2059 3397 +64.98 3687 +8.53 +79.06

10 Oilseeds 1771 1278 -27.83 1104 -13.61 -37.66

11 Fruits 734 779 +6.13 837 +7.44 +14.03

12 Condiments

& spices

265 560 +111.32 453 -19.10 +70.94

13 Fodder crops 1630 1389 -14.78 1291 -7.05 -20.79

14 Others 387 290 -25.06 234 -19.31 -39.31

15 Net area

sown

40355 39007 -3.34 37317 -4.33 -7.52

16 Area sown

more than

once

26812 24691 -7.91 26395 +14.49 -1.55

17 Total

cropped area

67167 63698 -5.16 63712 zero -5.14




ijcrr

Vol 04 issue 03

Category: Research


Revised on:15/12/11


ABSTRACT The main objective of this study was to identify certain lifestyle disorders like diabetes mellitus

and other medical conditions like hypertension and hyperlipedemia in an older adult population

and to verify their relationship with the periodontal health status in the same group of

individuals.

A total number of 600 patients between 35-75 years were selected for this study. Their lifestyle

habits were obtained through a questionnaire. It was followed by a periodontal examination,

blood pressure recording and a biochemical analysis of the blood samples taken from them.

Results of MLRA showed that diabetes mellitus, was clearly associated with attachment loss.

Hypertension was not associated with attachment loss, and elevated blood cholesterol levels

(hyperlipedemia) were associated only in univariate models.

It could be concluded that in the selected group of subjects aged 35-75 years, only diabetes

mellitus was associated with attachment loss in this cross-sectional study.

______________________________________________________________________

Keywords: Diabetes, Attachment loss,

Hypertension, Hyperlipedemia

INTRODUCTION

Diabetes mellitus is a bonafied risk factor

in periodontal disease. Type 2 is the form

of diabetes present in 90-95% of patients

with the disease and the risk of developing

this form of diabetes, increases with age,

obesity, previous history of gestational

diabetes and lack of physical activity.

(Brian L. Mealey and Gloria L.Ocampo) 1

The association between diabetes and

periodontal disease has been reported for

more than forty years. ―Chronic

Periodontitis‖ is now considered the sixth

complication of diabetes mellitus.2

Other general disorders like hypertension

and elevated blood cholesterol levels

(hyper lipedemia) often go hand in hand

with diabetes mellitus. They are proving to

be health epidemic in middle age

populations causing many reasons to panic.

This cross sectional survey aims to

correlate elevated blood sugar levels,

hypertension and elevated blood

cholesterol levels with Gingival and

Periodontal disease. It also helps to include

patient education and motivation in the

treatment plan, thus keeping a check on

these life style disorders in the long run.


The present study was using a stratified

randomly selected sample of 600 persons,

aged 35 to 75 years from the patients in a

private Dental College and Hospital. A

William‘s probe and a Shepherd‘s Crook

explorer were used for the examination of

the periodontal parameters in the study

ARE LIFESTYLE DISORDERS A RISK FOR

PERIODONTAL DISEASE?

Manoj Raja

Karpaga Vinayaga Institute of Dental Sciences, Maduranthakam TK, Chennai




namely Gingival Index (GI), Probing

Pocket Depth (PPD) and Clinical

Attachment Level (CAL).

The blood pressure reading (both systolic

and diastolic blood pressure) was recorded

for all the subjects, using a conventional

sphygmomanometer with the help of a

general physician. The blood pressure was

recorded in the morning time.

Each subject was then taken to the bio-

chemical laboratory of the hospital for the

assessment of Fasting blood sugar and

Total blood cholesterol levels. The

biochemical analysis was done in the

morning time. The subjects who were

included in the study were instructed to

come on an empty stomach (i.e) they

should not have consumed food for the past

12 hours. 3 ml of venous blood was drawn,

from the Median-cubital vein of each

subject using a 20- gauge needle connected

to a 10 ml syringe.

Statistical Methods

The association of the three periodontal

parameters namely Gingival Index (GI),

Probing Pocket Depth (PPD) and Clinical

Attachment Level (CAL) with three

variables namely hypertension, diabetes

and total cholesterol levels was estimated

using ―Chi-square test‖ to calculate the p -

value

RESULTS

348 subjects who did not have hypertension

showed a gingival index score less than or

equal to 2, where as 24 subjects who did

not have hypertension showed a gingival

index score greater than 2.216 subjects who

had hypertension showed a gingival index

score less than or equal to 2, where as 12

subjects who had hypertension showed a

gingival index score greater than 2.

The difference was not statistically

significant in both the subjects who did not

have hypertension and the subjects who

had hypertension (p = 0.68). 514 subjects

who did not have diabetes showed a

gingival index score less than or equal to 2,

where as 26 subjects who did not have

diabetes showed a gingival index score

greater than 2. 50 subjects who diabetes

had showed a gingival index score more

than 2, where as 10 subjects who had

diabetes showed a gingival index score

greater than 2. The difference was found to

be statistically significant in both diabetics

and non diabetics (p<0.0001). 532 subjects

with total cholesterol levels less than

200mg per dl showed a gingival index

score less than or equal to 2, where as 26

subjects with total cholesterol levels less

than 200mg per dl showed a gingival index

score greater than 2. 32 subjects with total

cholesterol levels greater than 200mg per dl

showed a gingival index score less than or

equal to 2, where as 10 subjects with total


showed a gingival index score greater than

2.The difference was found to be

statistically significant in both the subjects

with total cholesterol <200mg/dl and

subjects with total cholesterol levels >

200mg/dl (p<0.0001).


had a probing pocket depth less than or

equal to 5mm, where as 6 subjects who did

not have hypertension had a probing pocket

depth greater than 5mm. 222 subjects who

had hypertension had a probing pocket

depth less than or equal to 5mm, where as 6

subjects who had hypertension had a

probing pocket depth greater than 5mm.

The difference was not statistically

significant in both the subjects who did not

have hypertension and the subjects who

had hypertension. (p< 0.39).540 subjects

who did not have diabetes had a probing

pocket depth less than or equal to 5mm,

where as no subject who did not have

diabetes had a probing pocket depth greater

than 5mm. 48 subjects who had diabetes

had a probing pocket depth less than or

equal to 5mm, where as12 subjects who



had diabetes had a probing pocket depth

greater than 5mm. The difference was

found to be statistically significant in both

diabetics and non diabetics (p<0.0001).558


than 200mg per dl had a probing pocket

depth less than or equal to 5mm, where as

no subject with total cholesterol levels less

than 200mg per dl had a probing pocket

depth greater than 5mm.30 subjects with

total cholesterol levels greater than 200mg

per dl had a probing pocket depth less than

or equal to 5mm, where as 12 subjects with

total cholesterol levels greater than 200mg

per dl had a probing pocket depth greater

than 5mm. The difference was found to be



subjects with total cholesterol levels

>200mg/dl (p<0.0001).


showed clinical attachment levels less than

or equal to 4mm, where as 48 subjects who

did not have hypertension showed clinical

attachment levels greater than 4mm.192

subjects who had hypertension showed

clinical attachment levels less than or equal

to 4mm, where as 36 subjects who had

hypertension showed clinical attachment

levels greater than 4mm.The difference was

not statistically significant in both the

subjects who did not have hypertension and

the subjects who had hypertension. (p =

0.39).480 subjects who did not have

diabetes showed clinical attachment levels

less than or equal to 4mm, where as 60

subjects who did not have diabetes showed

clinical attachment levels greater than

4mm.36 subjects who had diabetes showed


to 4mm, where as 24 subjects who had

diabetes showed clinical attachment levels

greater than 4mm.The difference was found

to be statistically significant in both

diabetics and non diabetics (p<0.0001).498


than 200mg per dl showed clinical

attachment levels less than or equal to

4mm, where as 60 subjects with total

cholesterol levels less than 200mg per dl

showed clinical attachment levels greater

than 4mm.18 subjects with total cholesterol

levels greater than 200mg per dl showed


to 4mm, where as 24 subjects with total


showed clinical attachment levels greater

than 4mm. The difference was found to be



subjects with total cholesterol levels

>200mg/dl (p<0.0001).

Results of Univariate Logistic Regression

analysis showed that the factors such as

diabetes (OR= 5.33, p<0.0001) and total

cholesterol >200mg /dl (OR = 3.1,

p<0.0001) were significantly associated

with CAL. Hypertension was not

significantly associated with CAL (p =

0.32). (Table1)

Results of multiple logistic regression

analysis showed that only diabetes (OR =

4.3, p < 0.0001) was significantly

associated with Clinical Attachment Loss.

However the other variables like

hypertension and total cholesterol

>200mg/dl, were not significantly

associated with Clinical Attachment Loss.

DISCUSSION

Chronic periodontitis is ―an infectious

disease resulting in inflammation within

the supporting tissues of the teeth;

progressive attachment loss, and bone loss‖

(Flemmig TF 1999)3.

Risk assessment is defined by numerous

components4. Risk is the probability that

an individual will develop a specific

disease in a given period. The risk of

developing the disease will vary from

individual to individual. Genetic factors,

age, gender socioeconomic status and stress

are categorized as risk determinants 5.



Diabetes mellitus is an extremely important

disease from a periodontal standpoint. This

complex metabolic disorder, characterized

by chronic hyperglycemia, is an established

risk factor for periodontitis 6 and

periodontitis is now considered to be the

sixth complication in diabetes mellitus 2.Of

the systemic risk factors, it has been well

established that patients with diabetes have

atleast a two-fold increase in the severity of

periodontal disease as compared to non-

diabetics 7-9.

Overall, in the present study, there were 60

diabetics. Patients, who had a Fasting

Blood Sugar level (FBS) 126mg/dl, were

considered as diabetics. Their inclusion

was further substantiated through a

questionnaire, wherein 55 out of the 60

subjects confirmed their diabetic status.

Only 5 out of the 60 subjects came to know

their condition, after our present study.

There was a significant association

between the 3 periodontal parameters and

the diabetic patients in the study. Results

showed 24 diabetics, had CAL > 4mm as

against 36 diabetics, with CAL < 4mm.

Similarly 12 subjects with diabetics had

PPD > 5mm and 10 diabetic subjects had a

GI score 2. These values were highly

significant. The results of ULRA for CAL

showed an odds ratio of 5.33, in diabetic‘s

subjects while the results of MLRA for

CAL had the highest odds ratio of 4.33.

Considering the above results, diabetes

mellitus, was found to be most significantly

association with periodontal disease

progression, in our present study.

The mean FBS level, in subjects with PPD

> 5mm was found to be greater than

213mg/dl. This was in accordance with a

study by Richard C Oliver et al10, wherein

an increased prevalence and extent of

periodontal pockets was a consistent

finding of diabetics versus non-diabetics.

The Oulu study, reported more gingival

bleeding, as metabolic control worsened in

diabetics, despite similar plaque and

calculus scores in the diabetic subgroup.

Other studies also reported extensive

gingival inflammation in diabetics 8. These

results were similar to the one in our

present study.

Hyperlipidemia is essentially not a well

acknowledged risk factor for periodontal

disease11. It plays a larger role in

cardiovascular disease and stroke12.The

results in ULRA for CAL in our present

study showed an odds ratio of 3.1 for

subjects with a Total Blood Cholesterol

level >200mg/dl (42 subjects). However,

38 subjects in the group had an FBS level >

126mg/dl. So, the independent role of high

Total Blood Cholesterol level (>200mg/dl),

in periodontal disease could not be

established in our present study, as the

results of MLRA for CAL did not include

subjects with Total Blood Cholesterol

levels >200mg/dl as significant variables.

The role of hypertension in periodontal

disease progression was clearly negative,

from our present study. The results clearly

indicated that hypertension was a non

significant parameter in our present study

in periodontitis.These results in our study,

was in accordance to a similar study done

by Mattout C et al13, who included arterial

hypertension as a parameter, on a

population of 2144 adults, in France. The

results from the study yielded similar non-

significant values for hypertension.

Thus we can infer that certain risk elements

like Diabetes Mellitus play a major role in

increasing the probability for chronic

periodontal disease among older adults.

One possible bias which could have

occurred in our study is the relatively small

sample size of subjects, belonging to a

highly similar geographic area, and all of

them being subjects, seeking some form of

dental therapy, as they were selected from a

patient pool, at a dental hospital.



Table 1: RESULTS OF UNIVARIATE LOGISTIC REGRESSION ANALYSIS FOR

CAL

VARIABLE OR (95% CI)

p - value

HYPERTENSION

No

1.00

0.32(NS) Yes 1.27 (0.79 – 2.02)

DIABETES

No

1.00

<0.0001 (Sig)

Yes 5.33 (2.98 – 9.55)

TOTAL CHOLESTEROL

(>200mg/dl) No

1.00

<0.0001 (Sig) Yes 3.1 (2.5 – 4.9)

ACKNOWLEDGMENTS








and discussed. I also wish to thank my

professors T.Ramakrishnan,

N.Ambalavanan, Pamela Emmadi and

D.Deepalakshmi for their able guidance

provided for my study.

The study was conducted on a self

financing basis by the author Dr. Manoj

Raja.

REFERENCES

1. Brian L. Mealey and Gloria L.Ocampo:

Diabetes mellitus and periodontal

disease, Periodontology 2000: 127-153,

2007.

2. Loe H: Periodontal disease: the sixth

complication of diabetes mellitus,

Diabetes Care 16 (suppl 1):329, 1993.

3. Flemmig TF: Periodontitis, Ann

Periodontal 4:32, 1999

4. Page RC, Beck JD; Risk assessment for

periodontal diseases, Int Dent J 47:61,

1997.

5. Michalowicz BS, Diehl SR, Gunsolley

JC. Evidence of a substantial genetic

basis for risk of adult periodontitis. J

Clin Periodontol. 2000;71:1699–1707

6. Robert J Genco: Current view of risk

factors for periodontal diseases. J

Periodontol 1996; 67:1041 -1049

7. Tervonen T, and Knuuttila M: Relation

of diabetes control to periodontal

pocketing and alveolar bone level Oral

Surgery, Oral Medicine, Oral

Pathology 1986:61,346 -349

8. Taylor GW. Bidirectional

interrelationships. between diabetes,

and periodontal diseases: an

epidemiologic perspective. Annals of

Periodontology2001;6:99–112.

9. Soskolne W A and Klinger A: The

relationship between periodontal

diseases and diabetes an overview.

Annals of Periodontology 2001:6,91 -

98.

10. Richard C Oliver and Tellervo

Tervonen: Diabetes – A risk factor for

periodontitis in adults? J Periodontol

1994;65:530 -538.

11. Moeintaghavi A, Haerian-Ardakani A,

Talebi-Ardakani M, Tabatabaie I.

Hyperlipidemia in patients with

periodontitis. J Contemp Dent Pract.

2005 Aug 15; 6(3):78-85

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Moeintaghavi%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Haerian-Ardakani%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Talebi-Ardakani%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Tabatabaie%20I%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus



12. Moise Desvarueyx, Christial Schwahn

and Thomas Kocher. Gender

differences in relationship between

periodontal disease, tooth loss, and

atherosclerosis. Stroke, 2004; 35, 2029.

13. Mattout C, Bourgeois D, Bouchard P.

Type 2 diabetes and periodontal

indicators: epidemiology in France

2002-2003. J Periodontal Res. 2006

Aug;41(4):253-8.

GRAPH: 1 NUMBER OF SUBJECTS WITH ELEVATED FBS LEVELS (FBS > 126

mg/dl) AND NORMAL FBS LEVELS (FBS< 126 mg/dl)

60

540

0

100

200

300

400

500

600

Diabetics Non Diabetics

No

of

Su

bje

cts

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mattout%20C%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bourgeois%20D%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bouchard%20P%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus



ijcrr

Vol 04 issue 03

Category: Research


Revised on:16/12/11


ABSTRACT Sedimental Extract of Tinospora cordifolia (SETc), with no mortality rate at the maximum of

2000mg/kg/p.o., acute dose was found to show maximum number of deaths on chronic treatment

in the mid of 28 days repeated oral toxicity study. A trial made on SETc at incremental doses starts

from the minimum of 250 - 1000 mg/kg/p.o., were then subjected to modified IDF procedure, to

study their safer therapeutic margin. Sprague dawley rats were made diabetic with streptozotocin

(45mg/kg/i.p.) and the OGTT procedure was performed on those diabetic rats, fasted around 16

hours prior to the commencement of IDF study. Starting from the 30th min after glucose load

(1g/kg/p.o.), the incremental doses of SETc, from the minimum of 250mg/kg/p.o., to the

maximum of 1000 mg/kg/p.o., were administered to each group. The reduced blood glucose levels

from each group were analyzed and derived by means of AUC and thereby safer therapeutic &

effective dose of the test drug was fixed. The onset of action of all the doses of the SETc originates

from the 60th min of the drug administration and showed the biological responses in a

concentration dependant manner. Based on the IDF, AUC and EDF data‘s, it was found to be very

clear that the dose of 1000 mg/kg/p.o., of SETc was found to underlie the safer therapeutic margin

than the other doses. This evidences that the application of this modified method would be a

valuable tool for finding safer therapeutic marginal dose using BGC as a key factor.

______________________________________________________________________

Keywords Sedimental Extract of Tinospora

cordifolia (SETc), Oral Glucose Tolerance

Test (OGTT), Blood Glucose Concentration

(BGC), Incremental dose finding (IDF),

Area under the Curve (AUC), Effective dose

finding (EDF), Streptozotocin (STZ) induced

diabetic rats.

INTRODUCTION

The major hindrance to the use of the

herbal preparation in clinical practice is due

to the lack of preclinical data for

understanding the safety and efficacy of the

drugs. For the evaluation of various forms of

oral herbal preparations, instead of their

treatment profile there must be a need of

strong evidence, for its safer therapeutic

index.

Uncertainty, of dose fixation during

preclinical toxicity studies also rules a part.

Since it‘s in need and in deed to fix the

effective therapeutic dose of those herbal

preparation which would be safer enough

with good therapeutic outcome, for long

term therapy likely from fluctuating blood

glucose levels in diabetics. So it

necessitates a modified protocol along with

statistical approach, the dose response effect

of oral antidiabetic agents in animals could

be studied.

BLOOD GLUCOSE CONCENTRATION - A KEY TO FIX

THE EFFECTIVE DOSE FOR HERBAL ANTIDIABETIC

DRUGS USING RAT MODEL

R.Kannadhasan1, S.Venkataraman

2

1Department of Pharmacology, School of Pharmaceutical Sciences, Vels

University, Pallavaram, Chennai, Tamil nadu

2Dr.C.L.Baid Metha Foundation for Education and Research, Jyothi Nagar,

Thoraipakkam, Chennai, Tamil nadu




AUC has a number of important uses in

pharmacology, biopharmaceutics and

pharmacokinetics. Through biochemical

and hematological parameters, the bio

equivalency or bioavailability studies of a

compound could be analyzed by comparing

its AUC values [1]. But here, the

measurement of AUC after administration

of an herbal product plays an important

role in fixing safer therapeutic dose. Since

its diabetic case, the study of alterations in

the blood glucose concentration levels were

found to be quite worthy to give enough

surveillance to analyze the AUC which

necessitates its role over preclinical

evaluation of a drug dose.

The incremental dose finding [2]

method

adopted to study the dose response

relationship with AUC of the herbal

antidiabetic agent using linear regression

analysis.

Based on the priority of work done in

diabetes and ease of availability, a random

selection of a large, glabrous, succulent,

climbing shrub belonging to the family

Menispermaceae, namely Tinospora

cordifolia, which was used as a folklore

medicine in diabetes [3] were made. In

accordance to the work being carried out,

its planned to make a trial on raw portion

of the plant by means of sedimental

extraction from the plant stalk which

would be supportive than other solvents

with particular components. Some of the

antidiabetic works in various extracts of

Tinospora cordifolia reported as below

Aqueous, alcoholic and chloroform extracts

of the leaves of T. cordifolia showed

hypoglycaemic activity in both alloxan

diabetic and normal rabbits at 250 mg/kg of

the dose administered [4]. Daily oral

administration of an aqueous root extract of

T. cordifolia to alloxan diabetic rats for 6

weeks significantly reduced blood glucose

levels at 2.5 and 5.0 g/kg, but not 7.5 g/kg.

T. cordifolia was more effective than

glibenclamide, but less effective than

insulin (which restored parameters to near

normal values) at lowering blood glucose

levels. Instead of their biological action,

the rationality for the regression of

hypoglycaemic effect at these varying

doses was not provided [5, 6, 7& 8].

The current study focused on the dose

selectivity, that shows maximum

therapeutic efficacy of Sedimental Extract

of Tinospora cordifolia (SETc), an oral

herbal preparation through incremental

dose finding and area under the curve

determinations on the OGTT in diabetic

rats.

MATERIAL AND METHODS

Plant Collection

Tinospora cordifolia collected from Irulars

Tribal Women Welfare Society (ITWWS),

Thandarai, Thirukazhukundram, a southern

forest region of Tamil nadu, India. The stem

portions were cut, dried and collected in the

month of January 2007 and shade dried for

further processessing and studies. The

pharmacognositcal identity and

authentication was done by Plant Anatomy

research Centre, Chennai. A specimen of the

plant was kept in the Department of

Pharmacology, C.L.Baid Metha college of

Pharmacy, Chennai (Specimen No.

CLBMCP/102/2005).

Preparation of Plant Extract

The dried stem of Tinospora cordifolia, 2 kg

was grounded to a coarse powder and soaked

in 1000ml of distilled water for a period of

24 hrs, until the active portion to settle down.

The top layer was drained in a separate

vessel (leaving the debris to filter off) and

evaporated in a hot water bath at 100o C, and

this portion is considered as water soluble

portion. The sedimented portion after

removing the water soluble portion was

washed for 2-3 times with fresh distilled

water. The sedimented extract was admixed

with water soluble extract in the ratio of 3:1

to get the final sedimental extract of

Tinospora cordifolia (SETc) for screening.

http://www.boomer.org/c/p3/s21.html#s21

http://www.boomer.org/c/p3/s21.html#s21



Physico chemical properties

Slightly soluble in Ethanol < DMSO and not

in other solvents. A fine suspension of the

extract was obtained in 0.5 % Sodium

Carboxy Methyl Cellulose (Na.CMC).

Hence 0.5% Na.CMC suspension of this

drug is used for animal experiment. Buff

white powder. Bitter taste; Bitterness might

be due to admixture of water soluble portion

at the final preparation.

Chemicals and equipments

Streptozotocin, 97% pure dextrose and

Ready-to-use biochemical kits were

purchased from Sigma-Aldrich Pvt.ltd,

Mumbai. Ascensia One Touch glucometer

and strips (Code. No: 3110; 3112) was used

to measure the blood glucose concentration.

Animals

Male Sprague dawley rats 200-250 gm were

purchased from King‘s Institute, Guindy,

Chennai. Requirement of animals for this

study was authorized by Dr.C.L.Baid Metha

College of Pharmacy,

CLBMCP/131/IAEC/41 under CPSCEA

guidelines. All rats were randomly selected,

segregated and acclimatized for a period of 1

week with 12hr day light and 12 hours dark

cycle, with food and water ad libitum.

Toxicity studies

Acute Oral Toxicity Study

Acute oral toxicity studies were performed

following by OECD 423 Guidelines.

Maximum dose of 2000mg/kg was selected

and administered orally to a group of 3

animals in each step as shown in flow chart

of Annex 2d [9].

Animals (n=6) were fasted for a period of

12 hrs and weighed just prior to drug

administration. The test substance was

administered in a single dose using a

suitable intubation canula. After drug

administration, food was withheld for a

period of 3-4 hours. The animals were

observed closely for 3 hrs and observation

were continued for 24 hours. Any mortality

or toxic signs produced were noted.

Repeated Oral Toxicity Study

Repeated dose 28 day oral toxicity study was

carried out according to OECD guidelines

407 [10]. Animals were divided into four

groups of 6 each. Group I – received 0.5%

CMC orally and served as vehicle control

and groups II, III and IV – were received a

daily dose of SETc 500, 1000 and 2000

mg/kg/p.o., respectively for a period of 28

days. Adjustments were made as necessary

to maintain constant dose level in term of

animal body weight. Animals were observed

at least twice a week for 28 days, for any

mortality and morbidity. The doses at which

animals don‘t show any mortality or

morbidity were chosen for the dose finding

study. Animals that survived after 28 days

treatment were euthanized with excess ether

on 29th day and blood samples were

collected through cardiac puncture for

hematological and biochemical studies.

Liver, kidney and Pancreas were dissected

out for histopathological studies.

Histopathological Studies

Various tissues like liver, kidney and

pancreas were dissected out from each

group of normal control and normal

animals treated with SETc (500 & 1000

mg/kg/p.o., respectively). The collected

tissues of respective groups were dipped in

10% formalin solution and stained with

hemotoxylin and eosin for preparation of

section by using of microtome.

Histopathological observations were

studied in Vaishnave Clinic, Chennai – 17.

The histopathological studies carried out by

using the method described by Kanai

Mukherjee [11].

Effective dose finding-Experimental

design

Fasting of Animals & Induction of

Experimental Diabetes

Animals were fasted for 16 hours before the

induction of diabetes with Streptozotocin [2].

Animals made diabetic by an intraperitoneal

injection of freshly prepared solution of STZ



(45mg/ml in 0.01 m citrate buffer, pH 4.5).

The diabetic state assessed in STZ - treated

rats by measuring the non-fasting blood

glucose concentration 48 hours post STZ

injection using one touch glucometer. Only

rats with blood glucose levels ≤ 200mg/dl

were selected and used for experimental

studies.

Incremental dose finding experiment:

Modified method*

With a slight modification of the method of

Soon & Tan [2], the fasting glucose along

with oral glucose loading after the

administration of the incremental doses of

the test drug were used. Animals were

divided into 6 groups of 6 animals each. A

normal and a diabetic control both

receiving 0.5% of Carboxyl methyl

cellulose suspension and test groups with

diabetes receives Incremental Doses (ID)

of ID I, II & III (250, 500 &

1000mg/kg/p.o., respectively). Finally a

diabetic treated with Standard drug,

Glibenclamide - 600µg/kg (as calculated

from the human dose) kept studied for the

comparison of the test drug treated groups.

Blood glucose concentration was examined

at a regular interval for a period of 4 hrs

starting from 0 hr and at 1st, 2

nd, 3

rd, 4

th hr

after drug treatment using One Touch

Glucometer. Concentration response curve

and area under curve were studied.

Statistical analysis

Statistical analyses were done using

Graphpad prism software, Version 4. Dose

response effect were studied using Curves

and regression followed by Area under

Curve (AUC) and other biochemical,

hematological parameters were assessed

through One way anova using Tukey‘s

multiple comparison method, were values

are expressed as mean ± SEM (n=6).

RESULTS

Toxicity Studies

Prior to the clinical application of

experimental data, it is pertinent to

establish the safety of herbal preparation

through toxicological assessments. In the

current study therefore, the acute toxicity

and the liver and kidney function

parameters of animals treated with sub-

chronic doses of the crude sedimental

preparation of T.cordifolia were assessed.

In addition the microanatomical changes, if

any of the test drug in majors organs viz.,

liver, kidney and pancreas were also

studied.

Acute Toxicity study

Acute toxicity study under OECD 423

guidelines a maximum tolerable dose of

SETc (2000 mg/kg/p.o.,) was used to

assess the mortality or morbidity rate and

also toxic signs and symptoms of animals

were studied. The result showed neither

mortality nor signs of toxicity at this dose

(2000mg/kg/p.o.,) as shown in table no.1.

Repeated Oral Toxicity Study

The maximum tolerable dose assessed from

the acute toxicity study, i.e.,

2000mg/kg/p.o., along with its 1/2 and 1/4

portion of the corresponding doses, 1000

and 500 mg/kg/p.o., respectively, were

studied for 28 days repeated oral toxicity

under OECD 407 guidelines. The mortality

rate with 2000mg/kg found to show

maximum number of deaths within 15 days

from the start of the study. Animals treated

with 500mg/kg and 1000mg/kg/p.o., of

SETC respectively, didn‘t show any

mortality or morbidity throughout the

treatment period and there were no

significant changes in the biochemical and

hematological parameters when compared

to control animals. The results are depicted

in table nos.2 - 6.

There was no significant change in the

biochemical parameters including total

triglycerides, cholesterol, HDL-C, LDL-C

and VLDL-C in test animals treated with

SETc (500 and 1000mg/kg/p.o.,) compared

to control (Table No.2). There was no

significant alteration in the serum protein

level and the A: G ratio was found near to



the normal control (p=ns) as shown in

Table. 3. It was observed that the test drug

I and II do not showed any alterations in

the serum urea, uric acid, creatinine and

BUN level as compared with that of the

normal control (p=ns).

Sub chronic treatment of SETc did not

affect the AST and ALT levels in

comparison to normal animals (p=ns) as

shown (Table No.5). The RBCs and Hb

contents of SETc treated rats were found to

show no significant difference (p=ns) as

compared with that of the normal group

(Table No.6). The number of WBCs were

found to show a slight increase in test

group treated with 1000mg/kg/p.o., as

compared with that of the normal (p<0.05).

Histopathology of organs after 28 days of

repeated oral toxicity

The histopathological examinations of

liver, kidney and pancreas of SETc treated

animals showed normal architecture

suggesting no detrimental changes and

morphological disturbances in tissues

treated with the test drug at the doses (500

and 1000mg/kg/p.o.,) for 28 days are

depicted in figure no.3.

Effective dose finding

Incremental dose finding experiment

From the table no.7, it was observed that

the ID‘s I, II and III (250, 500 and 1000

mg/kg/p.o., respectively) showed

significant increase in BG after 30 min of

GTT as compared with that of the normal

(p<0.001). In addition, there was a

significant decrease in the BG level of

SETc treated diabetic animals when

compared with that of the diabetic control

(p<0.001).

The ID III (1000 mg/kg/p.o.,) was alone

found to maintain the BG level even after

90th,

120th, 240th min of glucose loading. It

was also noted that test drug at the dose of

1000mg/kg/p.o., maintained the plateau

range of BG level in GTT with that of the

standard drug treated and normal control

(Figure No.1).

Area under the Curve

As shown in the figure no.1, the filled area

under the curve denotes the blood glucose

concentration of the test drugs studied as

their percentage response. It was observed

from the table no.8; around 69.17 %

response was produced at single dose of ID

III (1000mg/kg/p.o.,) which was near to

that of the standard drug used.

Effective dose

Figure No.2 shows the effective dose

ranges of SETc where it reaches its

therapeutic margin. The test drug ID I, II,

III (200, 500 and 1000mg/kg/p.o.,

respectively) and standard drug (600

µg/kg/p.o, of glibenclamide) produced their

onset of action after 30th min of glucose

loading.

DISCUSSION

The toxicity profile of SETc at doses 500

and 1000mg/kg/p.o., after exposure to 28

days oral toxicity study, shown severe

hepatic injury as a result of the metabolism

of some of the toxic phytochemicals, found

in the medicinal plants and failure of the

elimination of those metabolized products

by the liver are reported in the literature

[12]. Albumin is the most abundant plasma

proteins with the physiological role of

maintenance of osmotic pressure,

transportation of both exogenous and

endogenous substances and serving as a

protein reserve. The ability of the liver to

synthesize albumin is diminished if the

synthetic function of the organ is affected

[13]. Increase plasma protein concentration

may be due to dehydration and vice versa.

From the result of the present study, serum

protein profiles were not significantly

different between the test group and

control. This shows that synthetic function

of liver of the animal exposed to sub-

chronic doses of 500 and 1000mg/kg/p.o.,

of SETc is not affected. Additionally there

was alteration neither in the globulin levels

nor in the A: G ratio of the animals treated



with sub-chronic doses of SETc. The total

lipid profile of the test drug treated animals

had no significant alterations in their levels

which might be due to the activities of

hepatic enzymes of test groups were not

affected by treatment of SETc [14].

There was no change in the serum alanine

aminotransferase (ALT) and aspartate

aminotransferase (AST) levels which are

useful indices for identifying inflammation

and necrosis of the liver [15]. ALT

measurements are more liver specific than

the AST and its activity is usually greater

than AST activity at early or acute

hepatocellular disease [13]. AST on the

other hand tend to be released more than

the ALT in chronic liver diseases such as

cirrhosis [13]. A marked elevation of ALT,

however, in the presence of mild to

moderate elevation of AST is suggestive of

either hepatic toxicity or hepatic injury

combined with other conditions [14].

Serum urea, uric acid, urea nitrogen and

creatinine were examined as indicators for

kidney function tests [16]. Hence there was

no sign of alterations in the indicators level,

it confirms that the kidney function of rats

treated with SETc was not affected. No

changes were observed in hematological

profile and the slight increase in the WBC

count was might be due to the

immunomodulatory activity of T.cordifolia,

as reported from the previous literature [17,

18 &19].

On surveillance of the hematological and

biochemical parameters, the toxicity profile

of 500 and 1000mg/kg/p.o., of SETc

showed neither mortality nor alterations in

the normal parametric results of rodents,

which appeared to be failed at dose

2000mg/kg/p.o., (the acute dose of OECD

423; 2d which showed maximum number

of deaths at the interval of 28 days repeated

oral toxicity study) and thus, the effective

dose for the primary study lies between

these two doses a maximum tolerable dose

and a mortality dose (1000 and

2000mg/kg/p.o., respectively) which were

elucidated by applying this modified

method of IDF procedure.

Effective dose findings

Even though, the onset of action of the

incremental doses ID I, II and III have

being started after 30th min of glucose load,

the durability and maintenance of plateau

of BGC was achieved only at ID III

(1000mg/kg/p.o.). This might be due to

satisfactory dose percent required for that

response and its continued hypoglycemic

effect (i.e. BG ≤ 100 mg/dl) even after

120th min evidences its effective onset and

longer duration of action, which was not

fulfilled by the prior low doses.

Furthermore, the AUC clearly denotes %

response for the drug used i.e. Blood

glucose concentration is indirectly

proportional to the percentage response.

From the above dose–response studies, it

was clear that the hypoglycemic activity of

SETc was dose dependant.

CONCLUSION

The overall findings clearly establishes the

fact, that the use of AUC with respect to

BGC levels will be easier to predict the

safer usage of oral chemical/herbal

therapeutic preparations for the use of

diabetes therapy with stabilized outcomes

from preclinical datas.

The statement is that, the use of this IDF

procedure after toxicity studies performed

with newer/forthcoming drugs for the

antidiabetic therapy would be a great

opportunity for the researcher to minimize

the mortality rate of the animals used. And

furthermore its glitters an awareness for

using safer dose particular in long term

therapy. This study could be serving as a

preliminary evaluation for the identification

of the safer therapeutic marginal dose with

less risk of adverse effects. Further the

levels of hypoglycemic action of this SETc

have yet to be studied in future.



Finally, it was concluded that, the blood

glucose concentration – a key factor for

determining the AUC thereby fixing the

effective concentration-response of the

drug dose, using this modified method of

incremental dose finding procedure.

ACKNOWLEDGEMENT




manuscript. The authors are grateful to

authors/editors/publishers of those articles,

journals and books from where the


and discussed.

Funding

This research received no specific grant

from any funding agency in the public,

commercial, or not-for-profit sectors.

REFERENCES

1. Goodman and Gilman's.

Pharmacokinetics and

Pharmacodynamics. In: Laurence L.

Brunton, Keith L. Parker, Donald K.

Blumenthal, Iain L.O. Buxton, editors.

Manual of Pharmacology and

Therapeutics. 11th ed. New York:

McGraw-Hill; 2008, pp.6-12.

2. Soon YY, Tan BKH. Evaluation of

Hypoglycemic and Antioxidant

activities of Morinda officinalis in

STZ-induced diabetic rats. Singapore

Med J 2002; 43(2): 077-085.

3. Singh SS, Pandey SC, Srivastava S,

Gupta VS, Patro B, Ghosh AC.

Chemistry and medicinal properties of

Tinospora cordifolia (guduchi). Indian

Journal of Pharmacology 2003; 35:

pp.83-91.

4. Wadood N, Wadood A, Shah SAW.

Effect of Tinospora cordifolia on

blood glucose and total lipid levels of

normal and alloxan-diabetic rabbits.

Planta Med. 1992; 58: 131-136.

5. Prince PSM, Menon VP, Gunasekaran

G. Hypolipidaemic action of

Tinospora cordifolia roots in alloxan

diabetic rats. Journal of

Ethnopharmacology 1999; 64: 53-57.

6. Prince PSM, Menon VP. Short

communication: Antioxidant action of

Tinospora cordifolia roots in

experimental diabetes. Journal of

Ethnopharmacology 1999; 65: 277-

281.

7. Prince PSM, Menon VP.

Hypoglycemic and other related

actions of Tinospora cordifolia roots

in alloxan-induced diabetic rats.

Journal of Ethnopharmacology 2000;

70: 9-15.

8. Prince PSM, Menon VP. Antioxidant

action of Tinospora cordifolia root

extract in alloxan diabetic rats.

Phytotherapy Research 2001; 15: 213-

218.

9. OECD/OCDE 423. Test procedure

with a starting dose of 2000

mg/kg/bw. Annex 2d 2001; p.13.

10. OECD/OCDE 407. Repeated Dose

28-day Oral Toxicity Study in

Rodents 1995; pp. 1-8.

11. Mukherjee KI. Medical Laboratory

Technology. 1st

Edition. New Delhi:

Tata McGraw Hill Publications 1989:

p.124.

12. Geidam MA, Pakman I, Laminu H.

Effects of aqueous stem bark of

Momordica balsamin. Linn on serum

electrolytes and some haematological

parameters in normal and alcohol fed

rats. Pak. J. Biol. Sci. 2004; 7:

pp.1430-1432.

13. Abdollahi M, Farzamfar B, Salari P,

Khorram Khorshid HR, Larijani B,

Farhadi M, et al. Evaluation of acute

and sub-chronic toxicity of Semelil

(ANGIPARS™), a new

phytotherapeutic drug for wound

healing in rodents. DARU 2008:

16(1); 7-14.



14. Tilkian SM, Conover MB and Tilkian

AG. Clinical implications of

laboratory tests. London. C.V. Mosby

Company 1979: pp.3-44; 117-132;

154-159.

15. Whitby LG, Smith AF, Becket GJ.

Lecture notes on Clinical chemistry.

4th Ed. Oxford, London, Edinburgh,

Boston, Melbourne; Blackwell

Scientific Publications 1989; pp.38-

178.

16. Williams M.H. Nutrition for health,

fitness & sport. Boston; McGraw-Hill

1999; pp.178-203.

17. Thatte UM, Dahanukar SA.

Comparative study of

immunomodulating activity of Indian

Medicinal plants, lithium carbonate

and glucan. Methods and findings in

experimental and clinical

pharmacology 1988; 10(10): 639-644.

18. Thatte UM, Dahanukar SA.

Immunotherapeutic modification of

experimental infection by Indian

Medicinal Plants. Phytotherapy

Research 1989; 3: 43-49.

19. Mathew S, Kuttan G. Antioxidant

activity of Tinospora cordifolia and

its usefulness in the amelioration of

cyclophosphamide induced toxicity.

Journal of Experimental and Clinical

Cancer Research 1997; 16(4): 407-

411.



Table No.1 Acute Toxicity study and its Sign of Toxicity

1. Alertness; 2. Aggressiveness; 3. Pile erection; 4. Grooming; 5. Gripping; 6. Touch Response; 7. Increased Motor Activity; 8. Tremors; 9. Convulsions; 10.

Muscle Spasm; 11. Catatonia; 12. Muscle relaxant; 13. Hypnosis; 14. Analgesia; 15. Lacrimation; 16. Exophthalmos; 17. Diarrhoea; 18. Writhing; 19.

Respiration and 20. Number of Deaths (Mortality).

Table No.2 Total Lipid profile after 28 days Repeated Oral toxicity study in normal rats treated with SETC

n = 6; Values are expressed as mean ± S.E.M. using One way ANOVA followed by Tukey‘s Multiple Comparison method. p<0.05 is considered as

statistically significant.

a = normal control Vs Test I and Test II

b = Test I Vs Test II

* = p<0.001; @ = p<0.01; # = p<0.05; ns = non-significant.

Treatment Dose level 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

SETc 2000mg/kg/p.o. + - + - + + - - - - - - - + - - - - + -

Groups Treatment Lipid profile (Units measured in mg/dl)

Cholesterol Triglycerides HDL – C LDL – C VLDL – C

Control 0.5% CMC 76.100 ± 1.589 107.900 ± 1.926 31.03 ± 1.430 23.480 ± 1.442 21.080 ± 0.3768

Test I 500 mg/kg of

SETC 78.370 ± 1.146 a

ns 113.00 ± 3.335 a

ns 31.67 ± 1.7580a

ns 24.100 ± 2.341 a

ns 22.600 ± 0.6674 a

@

Test II 1000 mg/kg of

SETC 79.940 ± 0.9008 a

ns, b

ns 109.600 ± 3.5780 a

ns, b

ns 31.67 ± 1.7580 a

ns, b

ns

22.070 ± 1.839 ans

,

bns

21.930 ± 0.7157 a

ns, b

ns



Table No.3 Protein index after 28 days Repeated Oral toxicity study in normal rats treated with SETc






Table No.4 Estimation of liver function after 28 days Repeated Oral toxicity study in normal rats treated with SETc



Groups Treatment Protein Index (Units measured in gm/dl)

A/G ratio Total Proteins Albumin Globulin

Control 0.5% CMC 6.545 ± 0.2064 3.837 ± 0.1365 2.3070 ± 0.1621 1.4110 ± 0.1069

Test I 500mg/kg of SETC 6.338 ± 0.1909 ans

4.177 ± 0.1797 ans

2.605 ± 0.1204 ans

1.8610 ± 0.1599 a#

Test II 1000mg/kg of SETC 6.780 ± 0.2115 ans

, bns

3.665 ± 0.1404 ans

, bns

2.498 ± 0.1489 ans

, bns

1.415 ± 0.0581 a

ns,b

#

Groups Treatment Units measured in mg/dl

Serum Creatinine Serum Urea Uric acid BUN

Control 0.5% CMC 0.5633 ± 0.02704 21.020 ± 0.5211 1.3850 ± 0.04256 22.780 ± 0.8523

Test I 500 mg/kg of

SETC

0.5583 ± 0.03468 ans

22.270 ± 0.9220 ans

1.6480 ± 0.09793 ans

24.860 ± 0.9468 ans

Test II 1000 mg/kg of

SETC

0.6483 ± 0.03292 ans

, bns

23.570 ± 0.8312 ans

, bns

1.6650 ± 0.10530 ans

, bns

24.950 ± 0.3359 ans

, bns






Table No.5 Biomarkers level in normal rats after 28 days of repeated oral toxicity study with SETc






Table No.6 Hematological Profile of SETC after 28 days Repeated Oral Toxicity Study Groups Treatment RBC (No. of Cells x 10

12/L) WBC (No. of Cells/Cu.mm) Hb (gm %)

Control 0.5% CMC 5.118 ± 0.1564 7122 ± 194.4 14.60 ± 0.2490

Test I 500mg/kg of SETc 5.290 ± 0.2593 ans

7142 ± 297.3 ans

15.03 ± 0.2894 ans

Test II 1000mg/kg of SETc 5.187 ± 0.1780 ans

, bns

8261 ± 180.6 a#, b

# 15.18 ± 0.2638 a

ns,b

ns





* = p<0.001; @ = p<0.01; # = p<0.05; ns = non-significant

Groups Treatment SGOT (IU) SGPT (IU) SGOT/SGPT ratio

Control 0.5% CMC 57.780 ± 1.255 44.250 ± 0.4465 1.3060 ± 0.03263

Test I 500 mg/kg of SETC 62.020 ± 2.568 ans

44.680 ± 0.9749 ans

1.3890 ± 0.05438 ans

Test II 1000 mg/kg of SETC 65.980 ± 2.579 a#, b

ns 43.560 ± 0.7145 a

ns, b

ns 1.5140 ± 0.05012 a

#, b

ns



Table No.7 Incremental Dose Finding procedure and the Area under the Curve (AUC) of SETc in normal, diabetic and diabetic rats treated with

SETc



a = normal control Vs Diabetic Control, ID I, ID II, ID III and Standard

b = Diabetic control Vs Test I, Test II, Test III and Standard

c = ID I Vs ID II, ID III and Standard.

d = ID II Vs ID III and Standard.

e = ID III Vs Standard.


Groups Treatment Incremental Dose Finding: Blood Glucose concentration (mg/dl)

0 min 30 min 60 min 90 min 120 min 240 min

Normal

control 0.5% CMC 68.00 ± 2.503 86.00 ± 4.669 127.20 ± 3.060 109.80 ± 3.628 82.17 ± 2.072 76.17 ± 2.257

Diabetic

Control 0.5% CMC 133.80 ± 2.774 a* 119.70 ± 2.512 a* 281.30 ± 7.079 a* 379.00 ± 6.928 a* 397.00 ± 3.044 a* 389.70 ± 3.844 a*

ID I 250mg/kg of SETC 108.20 ± 2.786 a*,

b@

99.17 ± 1.973ans

,

b*

201.50 ± 3.686 a*,

b*

199.70 ± 4.295 a*,

b*

196.80 ± 5.822 a*,

b*

181.80 ± 4.362 a*,

b*

ID II 500mg/kg of SETC 106.00 ± 2.966 a*,

b@

, cns

87.67 ± 2.140

ans

,b*, cns

174.70 ± 4.462 a*,

b*, c@

184.80 ± 4.615 a*,

b*, cns

176.80 ± 6.220 a*,

b*, cns

153.20 ± 8.364 a@

,

b*, c*

ID III 1000mg/kg of

SETC

108.00 ± 4.597 a*,

b@

, cns

, dns

87.17 ± 3.928ans

,

b*, cns

, dns

119.70 ±3.333ans

,

b*, c*, d

*

100.00 ± 3.454 ans

,

b*, c*, d*

85.33 ± 3.029 ans

,

b*, c*, d*

83.17± 2.197ans

,

b*, c*, d*

Standard 600 µg/kg of

Glibenclamide

105.20 ± 4.498 a*,

b@

, cns

, dns

, ens

89.50 ± 2.232ans

,

b*, cns

, dns

, ens

109.80± 4.556ans

,

b*, cns

, d*, e

ns

91.500 ± 3.566 ans

,

b*, c*, d*, e

ns

83.33 ± 3.190 ans

, b*,

c*, d*, e

ns

80.17± 2.482ans

,

b*, c*, d*, e

ns



Table No.8: Percentage response of the incremental doses of SETC using Area under the Curve:

Groups Treatment Total Area (AUC) % Response

Normal control 0.5% CMC 21443 Nil

Diabetic control 0.5% CMC 78564 0.00

ID I 250mg/kg of SETC 42302 31.95

ID II 500mg/kg of SETC 37457 42.19

ID III 1000mg/kg of SETC 22216 69.17

Standard 600µg/kg of Glibenclamide 21362 71.93

Total area of Drug Used

% Response = [ -------------------------------------------X 100] - 100

Total area of the Diabetic Control

Figure No.1 Showing the Incremental Dose Response and Area under the Curve of Blood

glucose in normal, diabetic and diabetic rats treated with SETc

Figure No.2 Showing the Effective Dose Response and Therapeutic margin of SETc



Figure No.3 Histopathology of Liver, Kidney and Pancreas after 28 days of repeated oral

administration with SETc

Group Liver Kidney Pancreas

Normal

SETc

(500mg/kg/p.o.)

SETc

(1000mg/kg/p.o.)



ijcrr

Vol 04 issue 03

Category: Case Report


Revised on:16/11/11


ABSTRACT A bilateral variation in the pattern of arterial supply of the palm was observed during routine

dissection of a 65 years old male cadaver. The right hand received blood supply by ulnar, radial

and median arteries, with an arch of communication between radial and median arteries. In the

left hand superficial palmar arch was formed mainly by ulnar artery and completed by first

dorsal metacarpal branch of radial artery. In both hands deep branch of radial artery and a

branch from ulnar proper digital branch of little finger formed the deep palmar arch.

Knowledge of arterial variations provides an important source of information for vascular

surgeons for safe surgical procedures in the hand.

______________________________________________________________________

Keywords: superficial palmar arch, deep

palmar arch, ulnar artery, radial artery,

median artery.

INTRODUCTION

Arterial supply to the human hand is

derived from two main anastomotic

channels, superficial and deep palmar

arches. They are formed by radial and ulnar

arteries, which account for high vascularity

of the palm. So wounds of the palm bleed

profusely but heal rapidly because of this

rich anastomosis. Superficial palmar arch

is mainly fed by ulnar artery alone or

completed by superficial branch of radial

artery, by the arteria radialis indicis, a

branch of arteria princeps pollicis or by the

persistent median artery1. Very rarely it is

formed by anastomosis of median artery

with radial artery. This type of arch was

described as median –radial type of

superficial palmar arch2. SPA shows a

number of variations that it is difficult to

establish a type3.

Deep palmar arch is formed by anastomosis

of the deep palmar branch of the radial

artery with the deep palmar branch of the

ulnar artery. Jaschtschinski4and Coleman

and Anson1 described its variations.

Variations of deep palmar arch are less

common compared to superficial palmar

arch1,5

. So an injury to the ulnar artery or

the superficial palmar arch may

compromise the arterial supply of the

fingers, particularly if there is an

insufficient anastomosis between the

superficial and deep palmar arches6.

Thus familiarity of the possible variations

in arterial pattern of hand is especially

important for the vascular surgeons while

performing reconstructive hand surgeries

for restoration of the normal function of the

hand.

BILATERAL VARIATION IN THE VASCULAR

PATTERN OF PALM- A CASE REPORT

A.Himabindu, B.Narasing Rao

Department of Anatomy, Maharajah‘s Institute of Medical Sciences,

Nellimarla




Case report

During regular dissection for undergraduate

medical students, bilateral variations of

superficial palmar arch and deep palmar

arch were identified in a 65-year-old male

cadaver.

In the right hand, beneath the palmar

aponeurosis there were three vessels. From

medial to lateral side they were ulnar,

median and radial arteries respectively.

Ulnar artery gave one proper and two

common digital arteries, which supplied the

medial 2½ fingers. Arteria nervi mediana, a

branch of ulnar artery, accompanied by the

median nerve passing deep to flexor

retinaculum was found to be giving a

common digital branch that supplied radial

side of the middle finger and ulnar side of

the index finger. Superficial palmar branch

of the radial artery gave a common digital

branch that supplied the radial side of index

finger and the ulnar side of the thumb. A

loop of communication existed between the

radial artery and the arteria nervi

mediana(median artery) but not with the

ulnar artery.(Fig:1)

In the left hand, one proper and four

common digital arteries were branched out

from the ulnar artery. Through these

branches, the ulnar artery supplied entire

palm except radial side of thumb, which

got its nutrition from the radial artery. The

superficial palmar arch was completed by

the first dorsal metacarpal artery in the first

digital web space. First dorsal metacarpal

artery was a branch of radial artery, before

it pierced 1st dorsal interossei muscle.

These variant types of arterial anastamosis

should be kept in mind while performing

hand surgeries. (Fig.1),(Fig.2)

Deep palmar arch in both the upper limbs

was formed between deep branch of radial

artery, which entered the palm through 1st

dorsal metacarpal space piercing the 1st

dorsal interosseus muscle and inferior deep

branch arising from ulnar proper palmar

digital artery of little finger. Deep branch

of ulnar nerve accompanied the arch and

supplied interossei and adductor pollices

muscles. (Fig.3)

DISCUSSION

The arterial supply to the hand and its

variations were being reported since a long

time. Jaschtschinski4 in his study on 200

subjects, classified superficial palmar arch

into complete and incomplete types based

on the anastomosis between the vessels.

Complete SPA was ulnar type (38%),

radioulnar type (27%) and mediano ulnar

type (3%) and radio-mediano-ulnar (0.5%).

He also mentioned the absence of

superficial palmar arch.

A very rare type of superficial palmar arch

termed median –radial type existed

between median artery and radial artery2.

Superficial palmar arch was classified into

Group I (Complete arch) and Group II

(Incomplete arch)1

Group I was further divided into five types:

Type A: The classical radio ulnar arch

formed by superficial branch of radial

artery with large superficial branch of ulnar

artery.

Type B: This arch is formed entirely by

ulnar artery supplying thumb and index

finger.

Type C: Mediano ulnar arch formed

between ulnar artery and median artery.

Type D: Radio-mediano-ulnar arch, in

which three vessels enter into the formation

of arch.

Type E: It consists of a well-formed arch

initiated by ulnar artery and completed by a

large vessel derived from deep arch.

Group II: An incomplete arch exists when

the arteries forming superficial arch do not

anastomose or when the ulnar artery fails to

reach the thumb and index finger. It was

subdivided into

Type A: No anastomosis between

superficial palmar branch of radial artery

and ulnar artery.



Type B: Only the ulnar artery forms

superficial palmar arch.

Type C: Superficial vessels receive

contributions from both median and ulnar

arteries but without anastomosis.

Type D: Radial, median and ulnar artery all

give origin to superficial vessels but do not

anastomose.

The median artery forming superficial

palmar arch may arise from ulnar, anterior

interosseous, common interosseous and

from radial arteries7.

This persistent median artery has an

embryological correlation. The ante

brachial pattern of median artery ends at

the level of forearm and the palmar pattern

where the artery accompanying the median

nerve in the forearm and extending down to

the palm supplying the digits8.

A dorsally arising small radial artery

branch, coined as dorsalis pollicis artery by

Agur and Lee9 might complete superficial

palmar arch. McCormack et al. 10

also

reported a small vessel arising dorsally

from the radial artery passing into the palm

to join the ulnar artery in 51% of the hands

studied. First dorsal metacarpal artery often

had a fascial course on the dorsal surface of

the index head of first interosseus muscle,

this artery can be easily injured in an

intervention over the carpometacarpal joint

of the thumb, when approached from the

dorsum of this joint11

.

In the present case, right hand showed a

complete radio-median type of superficial

palmar arch as described by Keen2.Along

with this rare arch, ulnar artery was also

present in the hand without any

communication with the other two vessels.

In the left hand, an ulnar-radial type of

complete arch existed between ulnar artery

and first dorsal metacarpal artery of radial

artery coming from the dorsum. An arch

was seen in the first digital web space.

Eventhough it was not falling in any of the

major classifications of superficial palmar

arch, a dorsal artery completing the arch

was described by Agur and Lee9

McCormack et al10

Deep palmar arch:

Coleman and Anson1 had classified deep

palmar arch as follows:

Group I: Complete arch, further divided

into 4 types.

Type A: The deep palmar arch is formed by

the deep palmar branch of the radial artery,

which anastomoses with superior deep

palmar branch of ulna artery. The latter

follows the deep branch of ulnar nerve into

the palm.

Type B: The commonest pattern of deep

palmar arch that existed between deep

palmar branch of radial artery with the

inferior deep palmar branch of ulnar artery.

Type C: Both (superior &inferior) deep

palmar branches of ulnar artery join the

deep palmar branch of radial artery to

complete the arch.

Type D: It is formed by superior deep

palmar branch of the ulnar artery, which

anastomoses with an enlarged superior

perforating artery of the 2nd

inter

metacarpal space.

Group II: Incomplete arch, further divided

into:

Type A: The inferior deep branch of ulnar

artery anastomoses with the perforating

artery of the 2nd interspace without any

communication with deep palmar branch of

radial artery.

Type B: The deep branch of ulnar artery

ends in an anastomosis with perforating

artery of 3rd interspace as deep palmar

branch of radial artery anastomoses with

the perforating artery of the 2nd interspace.

Mezzogiorno12

identified the deep palmar arch

patterns as radioulnar (66.7%),) radial-

anastomotic (21.67%), radial (8.33%), and ulnar

(3.33%). Olave13

explained two groups of deep

palmar arches. In group I the radial artery passed

through the first interosseous space

anastomosing with one or two deep palmar

branches. These deep palmar branches originated

from the ulnar artery, ulnar proper palmar digital



artery of the little finger or the common palmar

digital artery of the fourth interosseous space. In

group II, the artery passed through the second

interosseous space, anastomosing with one deep

palmar branch, rarely with two deep palmar

branches.

In the present case both limbs showed the

commonest variety of complete deep

palmar arch (type B). This complete radio-

ulnar type of deep palmar arch existed

between deep palmar branch of radial

artery, which passed through the first

dorsal interosseous muscle anastomosing

with deep palmar branch of ulnar artery.

This deep palmar branch of ulnar artery

was arising from proper digital branch of

little finger as explained by Olave.13

Embryology

Shin Matsumoto14

explained the arterial

supply of the early upper limb bud

as subclavian-axillary-brachial trunk. The

main arterial supply to the developing hand

consisted of the brachial and interosseous

arteries that terminated in a capillary

plexus. A branch of the trunk- median

artery, temporarily replaced interosseous

artery in supplying the hand. The

connection between superficial brachial

artery and median artery became the main

route of blood supply for the finger arteries

up to the adult stage. Subsequently ulnar

and then radial arteries are formed from the

axis artery at the end of arterial

development and median artery regresses.

Ulnar artery joined the ulnar end of the

superficial palmar arch, radial artery with

deep palmar arch. Persistence of any of

these vessels leads to variations.

Conclusion:

The detailed knowledge of arterial arches

of the human hand, a prehensile organ, is

important to vascular surgeons while

correcting any traumatic events in the hand.

Success of surgical procedures depends on

the healthy function of the arterial arch that

exists between radial and ulnar arteries in

order to maintain normal blood flow to the

hand and digits. Otherwise it leads to

ischemia of soft tissues of the hand which

is the earn tool of mankind.

ACKNOWLEDGEMENTS








and discussed.

REFERENCES

1. Coleman,s.andAnson,j.(1961):Arterial

pattern in hand–based upon a

studyon650specimens.surgery.gynaec

ology.obstetrics.,(113(4))pp409-24.

2. Keen JA. Study of the arterial

variations in the limbs with special

reference to symmetry of vascular

pattern. Am J Anat. 1961; 108: 245-

61.

3. Poirier,P:Traite d‘Anatomie Humaine

L. Battlle&Co.Paris:pp 833 (1886)

4. Jaschtscinski SN(Morphologie und

Topographie des Arcus volaris

sublimes und profundus

desMenschen)Anat.Hefte 1897;7:

161-88

5. Karlsson,S.&Niechajev ,I.A.(1982):

Arterial anatomy of the upper

extremity.Acta Radiologica

Diagnosis.23: 115-121

6. Calenoff,L.Angiography of the

hand:guidelines for

interpretation.Radiology,102(2):331-

5,1972

7. Sujatha D‘costa,kilarkaje

Narayana,Prasanthi

Narayana,Jiji,Soubhagya R.Nayak,SJ

Madhan Occurance and fate of palmar

type of medaian artery.ANZ J SURG

2006;76,484-487



8. Rodriguez- NiedenfuhrM; Sando,J.R;

Vazquez,T;Nearn,L;Logan,B&Parkin,

I. Median artery revisited.J.Anat.,

195(1):57-63,1999

9. Agur AMR, Lee MJ. Grant‘s Atlas of

Anatomy. 9th Ed., Baltimore,

Williams & Wilkins. 1991; 434

10. McCormack LJ, Cauldwell EW,

Anson BJ. Brachial and antebrachial

arterial patterns: a study of 750

extremities. Surg Gynecol Obstet.

1953; 96: 43–54.

11. Wilgis EFS, Kaplan EB. The blood

and the nerve supply of the hand. In:

Morton Spinner, ed. Kaplan‘s

Functional and Surgical Anatomy of

the Hand. 3rd Ed., Philadelphia, J.B.

Lippincott Company. 1984; 206.

12. Mezzogiorno A.Passiatore C.

Mezzogiorno v. Anatomic variations

of deep palmar arteries in man. Acta

Anat,1994,149(3):221-4

13. Olave E.Prates JC. Deep palmar arch

patterns in Brazilian individuals. Surg

Radiol.Anat.1999:(21)267-71

14. Shin Matsumoto1, Hans-Jürg

Kuhn2,Hermann Vogt

3, Michael

Gerke3 Embryological development of

the arterial system of the forelimb in

Tupaia,Article first published online:

26 JAN

2005DOI: 10.1002/ar.1092400314



ABBREVIATIONS ANM- ARTERIA NERVI MEDIANA

FR- FLEXOR RETINACULUM

FDMA- FIRST DORSAL METACARPAL ARTERY

DPA- DEEP PALMAR ARCH

IDP.Br- INFERIOR DEEP PALMAR BRANCH OF ULNAR

ARTERY

RA- RADIAL ARTERY

SPA- SUPERFICIAL PALMAR ARCH

UA- ULNAR ARTERY

Fig.1-showing two different types of superficial palmar arches in the left and right hands



Fig:2 Showing radial artery and First dorsal metacarpal artery in the left hand

Fig.3-showing variant deep palmar arches in both hands



ijcrr

Vol 04 issue 03

Category: Research


Revised on:03/12/11


ABSTRACT Rapid advances and developments in information technology and telecommunication have brought in

picture a promising technology, called mhealth, for delivery of health-care facilities via mobile

communication technologies. For accelerating the potential of mhealth, it is important to carefully

study the barriers and gaps in policies and collaboration between governments and health-care

institutions. This paper presents a detailed analysis of current and emerging trends in mobile health,

with particular emphasis on case studies.

___________________________________________________________________________

Keywords : Child-Count, Colecta-Palm,

Mobile Midwife, mhealth.

INTRODUCTION

In 1983, the DynaTAC 8000X was the first

mobile phone to be commercially available.

From then onwards, mobile technologies have

grown many-folds with an initial start from

telephony systems to the modern systems that

support a large array of services like text

messaging, email, gaming, photography,

internet access, short range wireless

communication etc. Mobile phones have

successfully bridged the the digital divide

among different sections of developing

economies and have reached the bottom of the

economic pyramid. No other innovation has

ever provided such parallel and distinct

opportunities for instant communication and

thus the utilization of potential of such a

technology for health-care facilities has

become important and obvious.

Mhealth refers to the delivery of health care

facilities supported by mobile devices using

cellular, blue-tooth or wireless networks. The

field of mhealth has emerged in the last

decade or so and has put in place various

applications of health-care service delivery for

remote monitoring, emergency telemedicine,

telematics, tele-radiology, education,

awareness and other direct provisions of care.

In recent years, several mhealth technologies

have been implemented all across the globe

under various research and health-care

projects.

The objective of the current paper is to present

a review on mhealth systems and

technologies. This paper has been divided into

different independent sections and provides

analysis of the concerned section accordingly.

Next section presents a brief overview of

current mobile communication technologies

and their future design and considerations.

After that a section on overview of related

work done through published conference and

journal papers has been placed. Next, a

section on case studies has been presented and

finally the paper wraps up with concluding

remarks.

A REVIEW ON M-HEALTH SYSTEM AND

TECHNOLOGIES

Arvind Rehalia, Rajat Kumar

Dept. of Instrumentation and Control Engineering, Bharati Vidyapeeth's

College Of Engineering, New Delhi




CURRENT MOBILE TECHNOLOGIES

This section describes the main wireless

technologies used in mhealth systems and

their future designs and considerations. SMS

functions and real-time voice communication

collectively forms the backbone of cellular

communication. However with the

development of technologies like that of smart

phones and PDAs, the scope of mhealth is not

just limited to cellular network integration.

GSM is the current technology in use and was

developed by European Telecommunications

Standards Institute under the second-

generation (2G) technologies. GSM operates

under a carrier frequency range of 900 MHz

to 1800 MHz with a limited data transfer rate

of 9.6 Kbit/s. However, in recent years 2.5G

(iDEN, GPRS, EDGE) and 3G ( TD-CDMA,

W-CDMA, CDMA) technologies have

evolved having higher data transfer rates as

compared to GSM. Apart from GSM and 3G

systems, Wireless Local Area Network

(WLAN) and satellite systems also provide a

means for data transfer for mhealth systems.

The satellite systems provide global coverage

and can operate under various frequencies and

data transfer rates. WLAN links two or more

devices using speed spectrum or OFDM radio

methodology and provide data connectivity

with user mobility (roaming unit). After a

detailed analysis, the following limitations

were observed in the current mobile

communication technologies:

1. High cost of Communication Links and

Infrastructure.

2. Limited bandwidth and data transfer rate.

3. Lack of network reliability of cellular

networks.

4. Security challenges during data transfer.

5. Absence of guidelines for cellular phones to

be used as imaging device.

The next generation mobile technologies must

eliminate the limitations of the current system

and on the other hand it should seamlessly

integrate the current technologies for a better

and advanced design. It is expected that the

4G technology will incorporate the

fundamentals that will ensure cost-

effectiveness and high data transfer rates. The

LTE Advanced technology (4G) promises to

provide download speeds up-to 1Gbit/s and

100Mbit/s to mobile users. Further, the 4G

will be based on iPv6. Considering the

continuous improvements, it is almost certain

that the ability of mhealth will grow many

times as with larger bandwidths and faster

data transfer rates, good imaging will become

possible.

RELATED WORK

This section reports the related work done by

research community all across the globe for

development of an effective system for

implementation of mhealth for health-care

service delivery. Different databases like

IEEE, INSPEC etc. were searched and finally

a total of ten research papers published in

various journals and conference proceedings

were selected on the basis of the technologies

involved and the area of application. The

work listed table 1 provides a snapshot of

implementation and integration of different

technologies for health-care service delivery

by mhealth concept. It was found that the

current topic of focus among biomedical

researchers is about development of systems

for remote patient monitoring and wireless

BODY AREA NETWORK. Further, there has

been a continuous work going on for

improving and integrating ambulatory

emergency services and mhealth for better

care of patient. Table 1, clearly suggests that

mhealth is now not just confined to cellular

network technologies and other technologies

like ZigBee, Blue-tooth, satellite etc. have

also stepped in as other communication

network technologies for the development of

mhealth systems.

CASE STUDIES

A total of five case studies based on different

areas of application of mhealth along with

results, findings and other necessary details

are presented here in this section. They are as



under:

1. REAL TIME BIOSURVEILLANCE

PROGRAM [11]:

AREA OF APPLICATION : Disease and

Epidemic Outbreak Surveillance.

Description : This program was started in

India and Sri-Lanka with an objective to study

and analyze mhealth systems for improving

early detection and notification system for

disease and epidemic outbreak. Under this

program, 29 front line health workers in India

and 16 in Sri-Lanka were chosen for

digitizing the current paper based system of

forms and patient health records by using

mobile phones. The mobile phones were

equipped with a customized application,

called mhealthSurvey, developed jointly by

IIT Madras and Rural Technology and

Business Incubator. 4 primary health centres

and 25 health sub-centres located in Tamil

Nadu in India and 17 hospitals and clinics all

across the country in Sri-Lanka were selected

for implementation. Front line health workers

digitized the patient's data at health centres

and transferred them to central server. A

statistical data analysis software developed by

AUSTON LAB at Carnegie Mellon

University was used for analysis at central

server and results were sent to regional and

local health officials through mobile and other

communication technologies for issue of

notification, if required.

RESULTS AND FINDINGS

1. It was observed that in India about 86% of

the data was submitted in other-time and only

14% data in real-time. This suggests that the

health workers faced difficulty in real-time

submissions, mainly, due to high frequency of

visiting patients. On the other hand, in Sri-

Lanka around 70% of the data was submitted

in real-time.

2. Indian health workers were almost

accurate in data

submissions and 100% accurate in the last

four weeks of the

program. However, there was very large

amount of errors in submissions made by Sri-

Lankan health workers.

3. It was observed that in Sri-Lanka front line

health workers were aged 18-35 and were able

to complete the whole process easily.

However, in India front line health workers

aging 30-50, even many of them with

experience of 10 years or more were unable to

complete the process without guidance. This

suggests that younger generation is more

adaptive to newer technologies than the older

ones.

2. COLECTA-PALM [12]:

AREA OF APPLICATION : Patient

Monitoring and Support.

Description : This project was started in Peru

under the initiative of University of

Washington and Universidad Peruana

Cayetano Heredia Lima. Collecta-Palm is a

web based application delivered on PDAs to

HIV/AIDS patients for antiretroviral treatment

and reducing transmission by safer sex

behavior. This application uses intranet based

secure connection for transfer of web surveys

to HIV/AIDS patients. A research analysis on

15 people with HIV/AIDS (PWLHA) in two

clinics in LIMA was carried out.

RESULTS AND FINDINGS :

Nine out of fifteen patients were satisfied with

this technology and rated 3.7/5. They found

this system easy-to-use, private and

innovative.

3. CHILD-COUNT [13]:

AREA OF APPLICATION : Point-of-care

Support and Diagnosis.

Description : This program was started in July

2009 in Sauri, Kenya under the partnership of

Millennium Villages Project, The Earth

Institute at Columbia University, UNICEF

Innovation Group, Sony Ericsson and Zain.

Under this project, more than 9500 children

under five years of age were monitored for

community based management of acute

malnutrition by measuring a child's mid upper

arm circumference, home based testing of

malaria and home based treatment of children



with diarrheal illness using ORS and Zinc

supplements. The implementation was done

by using a mobile application based on

RapidSMS ( a free open-source framework for

data collection, logistics and communication

using SMS technology ) by 100 community

health workers. They used SMS messages to

register a patient with all the necessary details

and demographics.

RESULTS AND FINDINGS

1. Initially duplicate child registrations made

problems, however, changes made to the

registration algorithm later solved out this

issue.

2. It was found that community health

workers required additional training for

efficient use of the system.

3. It was found that about 10% of the total

registration messages sent by the community

health workers were rejected due to improper

formatting by them.

4. Many of the phones went missing or

needed replacement, thus adding to the overall

cost of the project.

4. m-MONEY FOR WOMEN WITH

FISTULA [14] :

AREA OF APPLICATION : Health Financing

Description : This project was started in

Kenya as a combination of mobile banking,

public information and free treatment. In

Kenya, money transfers through mobile

phones (Safaricom), constitute about 11% of

GDP. Also, in a statistical survey, called

msurvey, about 42% of the respondents didn't

have access to formal bank accounts but

use their mobile phone for financial

transactions.

Considering the potential of mobile banking

in Kenya, this project was started to address

the problems faced by poor rural women in

fistula repair services. The cost of

transportation to a fistula unit and lack of

information about treatment options are the

main problems of the concern. Under this

project, a women can call a free hot-line to

aquire information about fistula repair and if

money is needed by women for transportation

to a fistula unit, financial transfers are made

via M-PESA ( a mobile banking product of

Vodafone).

5. MOBILE MIDWIFE [15] :

AREA OF APPLICATION : Health Education

and Awareness.

Description : This project was started in east

Ghana, under the program, called, Mobile

Technology For Community Health

(MOTECH). This initiative is a result of

partnership among Ghana Health Service,

Grameen Foundation and Columbia

University's Mailman School Of Public

Health and is funded by Bill and Melinda

Gates Foundation. The objective of this

project is to improve the antenatal and

neonatal care of rural women. In this

community health workers, register the patient

using MOTECH forms on mobile phones and

issue a particular patient ID number. The

patient then receives voice or text messages

regularly regarding health information and

information on essential vaccination and

childhood diseases after the birth. In case a

patient has a query, then she can clarify that

by making a call citing reference to her patient

ID.

CONCLUSION

The current paper provided a brief overview

of mhealth systems and technologies. The

case studies clearly suggest the need for

development of low cost ,secure and effective

solutions for successful implementation of

mhealth. Education and awareness about new

technologies among community health

workers is important and organizational

changes should be incorporated for a better

future of the telemedicine industry. While

much research and development still needs to

be done, the mhealth technology has already

started making its impact and the future will

definitely witness a revolutionized health

system that will benefit the citizen and the

society as a whole.



ACKNOWLEDGEMENT


received from the scholars whose articles are

cited and included in references of the

manuscript. Authors are also grateful to

author/editor/publisher of all those

articles/journals and books from where the


and discussed.

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Passariello G, Carrault G. Real-time ECG

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Transactions on Information Technology in

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Katarzyna Wac, Dimitri Konstantas, Ing

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Table 1: Review of related work done regarding development of mhealth systems and technologies

YEAR AUTHOR AREA AND TECHNOLGY COMMENTS

2001 [1] Hernandez et al. Remote Monitoring, ECG, Internet. For drug therapy after infarction.

2004 [2] Halteren et al. Remote Monitoring, UTMS, GPRS. Body Area Network as roaming unit.

2004 [3] Yamada et al. Emergency, Quasi-Zenith Satellite. Ambulance Telemedicine.

2005 [4] Navarro et al. Emergency, 3G. Ambulance Triage support.

2007 [5] Pandian et al. Bio-signals, VSAT, WLAN. Store and Forward telemedicine system.

2009 [6] Zuehlke et al. Mobile Patient Health Record, Mobile

phone.

Use of video-games in physical therapy.

2009 [7] Sax et al. Emergency, Mobile Phone, Tablet PC. Portable Medical Monitoring Computer.

2009 [8] Shahriyar et al. Remote Patient Monitoring, Blue-tooth,

GPRS.

Intelligent mobile health monitoring system,

wearable body sensor network.

2010 [9] Minutolo et al. Emergency, Mobile Phone, PDA, Blue-

tooth.

Detection of 52 kinds of Arrhythmia.

2011 [10] Blumrosen et al. Remote Monitoring, Blue-tooth,

CMDISE utility (IEEE- 11073)

Physiological condition of Patient.



ijcrr

Vol 04 issue 03

Category: Research


Revised on:25/12/11


ABSTRACT Background: India is a country of villages where 72.2% of the people live in the rural area and

women of reproductive age group (15-49 years) constitutes 21% of the total population. Majority of

the women suffer from morbidity due to obstetric and gynecological problems.

Objectives:To know the health seeking behavior of a married women of reproductive age and to know

the types of health services utilized by them. Methodology:It is one year community based cross

sectional study. The study was conducted at Handignur PHC area in Belgaum district (India) from

January 2007- December 2007, with a sample size of 732 (total number of all women in reproductive

age group of selected villages under Handignur PHC area). All married women of reproductive age

group were included in the study, and data was collected by administering pre designed and pre tested

structured proforma. Data were analyzed using SPSS software. Results:The present study revealed

that, 22.03% of the women were in the age group of 35-39 years. The literacy rate of the women was

found to be 74.4%. The literacy rate of their husbands was found to be 82.4%. Joint family was the

commonest being 81.28%. 71.3% of the women belonged to the category V of modified Prasad‘s

group of socio economic status classification. All married women of reproductive age had the

knowledge of the facilities available near their homes. 79.09% of the women preferred to go the PHC/

sub center for general health problems. 99.59% said it was easy accessibility. 92.49% said that they

were satisfied by the treatment. In case of 75.18% of the study participants their husband‘s made

decisions for them regarding their general health problems. For obstetrics care all 732 women

preferred going to the PHC/ sub center. 39.34% said they made 1-2 visit for their ANC check up‘s.

And to be noted that 21.03% of the women did not make a single visit as there was no PHC‘s/ sub

center during the time of their pregnancy. 78.96% said they received iron and folic acid tablets during

the time of their pregnancy. 54.78% women said the doctor provided it to them. 78.96% said they

received injection tetanus toxoid injection during the time of their pregnancy. 66.12% said that they

preferred the PHC/ sub center for the choice of place for getting delivered. 47.00% preferred the

doctors conducting the deliveries. The choice of health facility opted for the gynecological problems;

81.42% said that they preferred the PHC/ sub center. 81.42% women said because it was near to the

house, all necessary and emergency drugs were available and all facilities were provided. 46.17% of

the women said it was their own decision. 91.25% women said they were practicing either temporary

or the permanent methods or their husbands were using temporary methods of family planning.

61.07% women were using copper T as the methods of family planning. 61.07% women said the

doctors at the PHC/ sub center helped them in providing them the family planning methods. 48.35%

women said it was their husband‘s decisions in case of family planning. Conclusion: The participants

had a fair knowledge regarding treatment seeking, the availability of health care services and the types

of services offered.

TREATMENT SEEKING BEHAVIOR OF MARRIED

WOMEN OF REPRODUCTIVE AGE BELONGING TO A

RURAL COMMUNITY OF INDIA

Mohammad Shakil Ahmad1, Shaikh Mohsin

1, Ritu Kumar Ahmad

2

1College of Applied Medical Sciences, Qassim University, Saudi Arabia

2Chettinad Hospital and Research Institute, Kelambakkam, Chennai




The key decision maker for general health problems, obstetric health problems and for family planning

was the husbands, where as for the gynecological problems the majority of women made her own

decisions.

___________________________________________________________________________

Key words: Treatment seeking behavior,

married women, reproductive age group, rural

community

INTRODUCTION

Health seeking behaviour is a topic which has

received considerable attention in recent

years. The ―quest for therapy‖, all over the

world is an important research issue since it

reveals essential elements of people‘s social

behavior and provides insight into their

perceived needs for different kinds of health

services. The community diagnosis is the

starting point for local health planning - at

least in theory- and the study of how people

use health care facilities is an important

component of it.1

Health care delivery in

developing countries have been typically

described in terms of insufficient medical and

paramedical staff, unequal access to services,

emigration of qualified personnel to jobs in

other countries, and the concentration of man-

power in the cities, leaving the under-served

rural areas, has caused more than 80% of the

population without access to appropriate

medical care.2

The rural areas of developing countries are

not ―health care deserts‖, but they have their

own systems of beliefs and customs and their

own kinds of indigenous health practitioners.

As their adaptation to the impact of western

medicine has become better understood, their

potential contribution to the primary health

care has been reconsidered.2

Health seeking

behavior refers to those activities undertaken

by individuals in response to symptoms

experienced. It is a dynamic process in the

house-hold, which combines knowledge,

resources, decision making power and the

availability of health facilities. It requires

some basic knowledge for seeking treatment

such as few repeated episodes of any disease

in household or any prior experience which

helps in making a decision.3

Situation in India: India is a country of

villages where 72.2% of people live in rural

areas.4

Because of ignorance, illiteracy,

cultural and religious factors, rural people are

at higher risk of illness. Many factors play an

important role such as socio-economic status,

cultural acceptability, decision making power,

the availability of health care services, or the

treatment seeking behavior of the people.

Health seeking behavior is influenced by

large number of factors apart from knowledge

and awareness like bio-social profile, their

past experiences with health services,

influences at community level, availability of

alternate health care providers and their

perceptions regarding efficiency and quality

of services.4 In India, women of reproductive

age group (15-49 years) constitute 21% of the

total population, apart from the morbidity

experienced by general population; women of

reproductive age group also suffer from

morbidity due to obstetric and gynecological

problems.5

Around 70% of the deliveries are

conducted by untrained personnel, which will

have an impact on maternal and infant

mortality as well as morbidity. As women of

reproductive age come under vulnerable

group, it is important to know their treatment

seeking behaviour, their decision making

power, and utilization of health care services

that are available. This study focuses how

efficient is the present woman, in making

decisions for availing the health care

facilities, while the country is talking of

women empowerment. The present study is

an attempt in this direction.

Objectives

1. To know the treatment seeking

behaviour of married women of reproductive

age (15-49 years).



2. To know the types of health services

utilized by them.

METHODOLOGY

This community based cross sectional study

includes all married women (732) of

reproductive age (15-49 years) living under

the sub center Handignur for a period of one

year. Questionnaires was prepared which

includes information on socio demographic

variables, treatment seeking behavior for

general health problems, obstetric care

gynecological problems, & family planning

the types of health services that are used by

them and who actually takes the decision for

seeking treatment. Study includes all married

women of reproductive age group (15-49

years), residing at their home since one year.

Research was conducted during January-2007

to December-2007. Place of study: Handignur

village is situated 12 kilometers North East of

Belgaum city. Handignur Primary Health

Center has four sub-centers; with a total

population of 24,160.Out of four one of the

sub-centers was randomly selected. All

villages under this sub-center were included

(total no. of household were 762) and from

these villages all married women (732) of

reproductive age were included in the study.

The required information was collected

through door to door personal interview after

informed, verbal and written consent. The

services utilized for some of the problems like

abortion and sexually transmitted diseases

were not included in the study.

Socio economic status: Per capita income in Rupees per month was classified using the

modified BG Prasad classification.6

Social class. Prasad‘s classification 1961

Modified Prasad‘s classification

In study period 2008 July

(per capita income in Rs/month)

I 100 and above 2534 and above.

II 50—99 1267 to 2058

III 30-49 760 to 1241

IV 15-29 380 to 735

V <15 Less than 380

Average consumer price index = 514.6

Modification was done with aid of multiplication factor, which was obtained as below:

Average consumer price index for the study period

M.F. = x 4.93 = 514/100x 4.93= 25.34

100

Results

Demographic profile of study participants: The

observation stated below are the findings of the

present study conducted upon 732 study

participants, married women of reproductive

age of Handignur sub centre, Belgaum district,

Karnataka state. Among the total 732 married

women studied majority of them were between

the age group of 35-39 years (22.03%). Mean

age of patients studied was 35.6 ± 8.87 years.

It was observed that out of 732 husbands of

study participants, 129 (17.6%) were illiterate

and out of 732 study participants (female), 187

(25.5%) were illiterate. While, 135 (18.44%)

belonged to nuclear family, 595 (81.28%)

study participants were from joint family, and

2 (0.27%) were from broken family. Out of

total, 352 (48.08%) were from village

Handignur where PHC and sub-center are

situated and rest were from other villages

under the same PHC. While evaluating

modified Prasad‘s classification, out of all

study participants, 11 (1.5%) women belonged

to category I, 40 (5.5%) women belonged to

category II, 60 (8.2%) belonged to category

III, 99 (13.5%) belonged to category IV and



522 (71.3%) belonged to category V. When

asked about any health facility located near the

residence, all of 732 (100%) study participants

were aware about PHC/ sub-centre and 352

(48.08%) had knowledge about private clinic.

General health problems : This study reveals

that, 579 (79.09%) study participants availed

the PHC/ Sub centre for general health

problems, 29 (3.96%) of the study participants

visited a private doctor for general health

problems. Out of 732 study participants, 677

(92.48%) women were satisfied with the

treatment given at the PHC/sub-centre. 153

(20.90%) women said it would be their own

decision for a health facility while 555

(75.18%) women said it would be their

husbands decision and rest would depend on

others decision to choose a health facility for

general health problems.

Obstetrics care: In this study out of 732 study

participants all women said they were using

the PHC/ Sub-centre for their obstetrics. 288

(39.34%) study participants had visited the

PHC/sub-centre once during ANC (Antenatal

Checkup), 290 (39.01%) women had visited

more than once while 154 (21.03%) did not

make any visit during ANC as there was no

health facility available in and around during

their pregnancy. In this study the 578

(78.96%) study participants received iron and

folic acid tablets during ANC, and 154

(21.03%) did not receive any iron and folic

acid tablets during ANC. 578 (78.96%)

participants received injection tetanus toxoid

and 154 (21.03%) women did not receive any

injection of tetanus toxoid. It was observed

that 154 (21.03%) study participants preferred

home for conducting delivery as there was no

health facility available during pregnancy, 484

(66.12%) preferred PHC / sub-centre for

conducting delivery, 24 (3.27%) preferred

district hospital, 43 (5.87%) preferred tertiary

care center, and 27 (3.68%) women preferred

private nursing homes for conducting delivery.

The decision makers for using the health

facilities for obstetric care were, 153 (20.90%)

women made their own decisions, 555

(75.82%) women‘s husbands made the

decision, 23 (3.14%) women‘s in laws made

the decision, and for one woman (.14%) others

who made decision to use the facilities for

obstetrics care.

Gynecological health problems: Out of 732

study participants who complained of

gynecological problems, there were 110

(15.02%) women who complained of

menorrhagia, 226 (30.87%) women

complained of white discharge, 321 (43.85%)

women complained of dysmenorrhoea, and 75

(10.24%) women had other problems.

The choice of health facility for gynecological

problems given as, 596 (81.42%) women

preferred PHC / sub centre, 32 (4.37%) women

preferred tertiary care center, 71 (9.69%)

preferred the district hospital, 18 (2.45%)

women preferred the private hospitals and 15

(2.04%) women preferred other places for

gynecological problems. The reasons given for

using this health facility for gynecological

problems were, 34 (4.64%) women said that it

was near to their house, 30 (4.09%) women

said it was because all drugs were available, 72

(9.83%) women said because all facilities were

provided their, and 596 (81.42%) females said

all the reasons were true and that was the

reason for using the facility. 338 (46.17%)

women made their own decision for using the

particular health facility for gynecological

problems while others 394 (53.81 %) depended

on others decision (Table -1).

Family Planning: Out of all participants, 668

(91.25%) women practiced family planning

and 64 (8.74%) women did not opt for family

planning. In this study out of 732 study

participants, 668 women were using any

method of family planning, 57 (8.53%) women

were using oral contraceptive pills as

contraceptive methods, 79 (67.06%) women

had got copper T inserted, 31 (23.80%) women

had undergone tubectomy, 6 (0.59%) women

said their husbands were using condoms. Total

668 couples were using family planning

methods. Out of 668 participants, 261

(39.07%) women made their own decision for



using for using contraceptive methods and 323

(48.35%) women had taken the advice of their

husbands for using contraceptive methods.

Impact of literacy status of the women on

utilization of general health problems (Table –

2): The decision making with respect to

education was as follows, in illiterates 27.80%

women made their own decision, 66.31%

women consulted their husbands, 5.88%

women consulted their in laws, and no women

consulted others. In primary school educated

group, 20.62% women made their own

decision, 77.18% women consulted their

husbands, and 2.18% women consulted their in

laws, In high school educated group, 16.41%


women consulted their husbands, and 1.99%

women consulted their in laws, In higher

secondary educated group, 9.37% women

made their own decision 82.60% women

consulted their husbands, 4.34% women

consulted their in laws for decision to take

treatment for general health problems.


utilization of Obstetrics problems: It was

observed that decision making with respect to

education was as follows, in illiterate group,

91.97% women made their own decision,

1.77% women consulted their husbands,

0.53%women consulted their in laws, and

0.53% women consulted others. In primary

school educated group, 39.06% women made

their own decision, 50.62% women consulted

their husbands, 6.25% women consulted their

in laws and 4.06% women consulted others. In

high school educated group, 35.32% women

made their own decision, 62.18% women


consulted their in laws and 1.49% women

consulted others. In higher secondary educated



husbands, and nobody consulted their in laws

or others for decision to take treatment for

obstetric care.


utilization of gynecological problems: It stated

that decision making with respect to education

was as follows; in illiterate group, 91.97%


woman consulted their husbands, 6.95%

women consulted their in laws, and 0.53%

woman consulted others. In primary school

educated group, 30.93% women made their

own decision, 16.56% women consulted their

husbands, and 45.93% women consulted their

in laws, and 6.56% women consulted others. In

high school educated group, 29.35% women



consulted their in laws, and 0.99% women

consulted others. In higher secondary educated



husbands, and 52.17% women consulted their

in laws. In graduate women, all women made

their own decision for treatment of

gynecological problems.


utilization of family planning methods: In this

study decision making with respect to

education was as follows; in illiterate group,


53.22% woman consulted their husbands,

0.53% women consulted their in laws, and

0.53% woman consulted others. In primary

school educated group, 38% women made



in laws and 11.07% women consulted others.

In high school educated group, 34.73% women

made their own decisions, 50% women


consulted their in laws, and 12.63% women

consulted others. In higher secondary school

educated group, 35% women made their own

decision, 60% women consulted their husband,

and 5% woman consulted others while all

graduate women consulted their husband for

family planning methods.

Decision making with respect to socio

economic status of family for general health

problems (Table – 3): It was as follows; in

category I, 9.09% woman made their own




husbands, 9.09% woman consulted their in

laws. In category II group, 12.5% women


consulted their husbands and 5% women

consulted their in laws. In Category III group,

23.33% women made their own decision while

76.66% women consulted their husbands. In

Category IV group, 20.20% women made their

own decision 76.76% women consulted their

husbands and 3.03% women consulted their in

laws. In Category V group, 21.83% woman

made their own decision, 74.90% consulted


in laws and none consulted others for treatment

of general health problems.


economic status of the family for obstetrics

care(Graph-1); in category I, 36.36% women


consulted their husbands and18.18% women

consulted their in laws. In category II group

women 35% women made their own decision,

25% women consulted their husbands, 25%

women consulted their in laws, and 15%

women consulted others. In Category III

group, 40% women made their own decision,

20% women consulted their husbands, 35%

women consulted their in laws, and 5% women

consulted others. In Category IV group,

32.32% women made their own decision


44.44% women consulted their in laws, and

5.05% women consulted others. In Category V

group, 27.96% woman made their own

decision, 18.19% consulted their husbands,

48.85% women consulted their in laws and

4.98% women consulted others for obstetric

care.


economic status of family for gynecological

health problems (Table -4); in category I,

9.09% woman made their own decision while

rest consulted their husbands. In category II



husbands, and 5% women consulted their in

laws. In Category III group, 23.33% women

made their own decision and 76.66% women

consulted their husbands. In Category IV




laws. In Category V group, 21.83% woman

made their own decision, 74.90% consulted

their husbands, and 3.25% women consulted

their in laws for treatment of gynecological

health problems.


economic status of family for family planning

(Table -5); In category I group, 9.09% woman

made their own decision while 90.90% women

consulted their husbands. In category II group,

12.5% women made their own decision, 82.5%

women consulted their husbands, and 5%

women consulted their in laws. In Category III



husbands, and no women consulted their in

laws. In Category IV group, 22.22% women

made their own decision 74.74% women

consulted their husbands, and 3.03% women

consulted their in laws. In Category V group,

21.83% woman made their own decision,

74.90% consulted their husbands, and 3.25%

women consulted their in laws for family

planning methods.

Decision making with respect to the type of

family for general problems; 16.93% women

who belonged to the nuclear family made their



laws. In women belonging to joint family,


74.91% women consulted their husbands, and

3.13% women consulted their in laws. And in

broken family 100% women took their own

decision for taking treatment for general health

problems.


family for obstetrics problems; 45.16% women



husbands, 33.87% women consulted their in



laws and 1.61% women consulted others. In

joint family women, 26.73% women made



in laws and 6.27% women consulted others,

while in broken family all women took their

own decision for obstetric care.


family for gynecological problems; 34.67%

women who belonged to the nuclear family


consulted their husbands and 53.22% women

consulted their in laws. In joint family women,



37.29% women consulted their in laws and

3.96% women consulted others.

Decision making with respect to type of family

for family planning (Table -6); 35.96% women



husbands, 0.87% women consulted their in

laws and 6.14% women consulted others. In

joint family women, 39.49% women made



in laws and 8.87% women consulted others.

DISCUSSION

The present study revealed that, 22.03% of the

women were in the age group of 35-39 years.

The literacy rate of the women was found to be

74.4%. The literacy rate of their husbands was

found to be 82.4%. Joint family was the

commonest being 81.28%. According to the

census data the literacy of females is 52% so

being significant.7

Three-forth of the women belonged to the

category V of modified B G Prasad‘s

classification of socio-economic status. All

married women of reproductive age had the

knowledge of the health facilities available

near their homes. Door steps services were

provided to all married women, 88.93% of the

study participants said ANM‘s provided them

these services. And all study participants said

that services provided were curative,

diagnostic, health education, natal services,

family planning and immunization. Out of the

732 women for general health problems,

79.09% of the women preferred to go the PHC/

sub-center. The reason that they gave was easy

accessibility, as agreed by 99.59%.of women.

92.49% were satisfied by the treatment given.

75.18% of women said their husband‘s were

the decision makers for their general health

problems.

For obstetrics care all 732 women preferred

going to the PHC/ sub center. 39.34% said

they made 1-2 visits for their ANC checkups,

and it was also noticed that 21.03% of the

women did not make a single visit during the

time of their pregnancy. 78.96% of women had

received iron and folic acid tablets during the

time of their pregnancy. More than half of

study participants told doctor providing it to

them. 78.96% had received injection tetanus

toxoid during the time of their pregnancy.

66.12% of women preferred the PHC / sub

center as a convenient place for getting

delivered. 47% preferred the doctors to

conduct their deliveries. Three forth of women

said their husbands took the decisions

concerned to obstetrics care. The choice of

health facility opted by 80% of women for

their gynecological problems was either PHC /

sub center. 81.42% women went there because

it was near to the house and all necessary and

emergency drugs were available and also all

facilities were provided.

More than 90% women said they were

practicing either temporary or permanent

methods or their husbands were using

temporary methods of family planning.

61.07% women were using copper T as the

method of family planning. 61.07% women

said the doctors at the PHC/ sub center helped

them in providing family planning services.

Around 50% women said their husband‘s

decided about the family planning.

CONCLUSION

In the present study, the women of

reproductive age group residing in PHC/sub



center Handignur had a fair knowledge

regarding treatment seeking, the availability of

health care services and the types of services

offered by them. Most of the women preferred

the PHC/ sub center for mostly obstetric care

as the new generation was more aware of the

health care system. However it was observed

that they utilized much of the services offered

by the PHC/ sub center for preventive services

as it was adequate and free of cost. For

obstetric care they did not hesitate in deciding

the choice of place to deliver as Handignur

PHC/ sub center is providing all modern

facilities, including a baby warmer and a neo

natal resuscitation kit.

Door steps services were provided by the

health workers uniformly at all the three

villages that come under the PHC/ sub center.

The frequency of the health visitor to the area

was also there for health education.

Antenatal care was provided by health workers

and utilized by the women of the PHC/ sub

center. Younger women availed the facility

more compared to the older generation, who

did not have the privilege women of a health

facility near their house at the time of their

pregnancy. Women‘s awareness towards

treatment seeking for obstetric care was also

found, as compared to the older generation.

The importance of attending the ANC clinics,

intake of iron and folic acid tablets, and the

two doses of tetanus toxoid injections was also

seen. This was due to the regular health

education conducted by the doctor, health

visitors, ANM‘s and the anganwadi workers.

The decision maker for general health

problems, obstetric care and for family

planning was still dependent on their husbands

where as for the gynecological problems the

majority of women made her own decisions.

ACKNOWLEDGEMENT



cited and included in references of this




literature for this article has been reviewed and

discussed.

REFERENCES

1. Pamela A Hunter & Farhat Sultana,

―Health Seeking Behaviour and the

meaning of Medications in Bolochisthan,

Pakisthan‖; Soc. Sci. Med. Vol. 34, No.

12, pp. 1385 – 1397, 1992.

2. Pierre Claquin ―Private Health Care

Providers in Rural Bangladesh‖, Soc. Sci.

Med. Vol. 15B, pp. 153 – 157, 1981.

3. Alex Kroeger, ―Anthropological & Socio-

Medical Health Care research in

developing countries‖, Soc. Sci. Med. Vol.

17, No. 3, pp. 147 – 161, 1983.

4. K Park, Text book of Community

Medicine, 18th Edition M/ s Banarasidas

Bhanot Publishers; 353- 383, 2005.

5. M Jain, D Nanda, S K Misra, ―Quality

assessment of Health Seeking Behaviour

& Perception regarding Quality of Health

Care Services among rural community of

District Agra‖, Indian Journal of

community medicine Vol. 31, No. 3, July

– September, 2006.

6. Kulkarni A P, Barde. J. P. Text book of

Community Medicine, Ist edi. Mumbai:

Vora Medical Publications: 1998.

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no. M- 12011/ 2/ 2005- PCL.



Table 01: Decision maker for using this health facility for gynecological problems

Decision makers No of women Percentage

Self 338 46.17

Husband 294 40.16

In laws 76 10.38

Others 24 3.27

Total 732 100.0

Table 02: Impact of literacy status of the women on utilization of general health problems

Literacy status of women Own Husband In laws Total

Illiterate 52

(27.80)

124

(66.31)

11

(5.8)

187

(100)

Primary school 66

(20.62)

247

(77.18)

7

(2.18)

320

(100)

High school 33

(16.41)

164

(81.59)

4

(1.99)

201

(100)

Higher secondary school 3

(9.37)

19

(82.60)

1

(4.34)

23

(100)

Graduation 0

(0)

1

(100)

0

(0)

1

(100)

Total 154

(21.03)

555

(75.81)

23

(3.14)

732

(100.0)

* (Figures in parentheses indicate row percentages) X2= 16.84, P<0.05

Table 03: Decision making with respect to socio economic status of family for general health

problems

Socio economic status of

family

Self Husband In laws Total

Category I 1

(9.09)

9

(81.81)

1

(9.09)

11

(100)

Category II 5

(12.5)

33

(82.5)

2

(5)

40

(100)

Category III 14

(23.33)

46

(76.66)

0

(0)

60

(100)

Category IV 20

(20.20)

76

(76.76)

3

(3.03)

99

(100)

Category V 114

(21.83)

391

(74.90)

17

(3.25)

522

(100)

Total 154

(21.03)

555

(75.18)

23

(3.14)

732

(100.0)

* (Figures in parentheses indicate row percentages) X2= 6.43, P= <0.05



Table 04: Decision making with respect to socio economic status of family for gynecological health

problems


family

Own Husband In laws Total

Category I 1

(9.09)

10

(90.90)

0

(0)

11

(100)

Category II 5

(12.5)

33

(82.5)

2

(5)

40

(100)

Category III 14

(23.33)

46

(76.66)

0

(0)

60

(100)

Category IV 22

(22.22)

74

(74.74)

3

(3.03)

99

(100)

Category V 114

(21.83)

391

(74.90)

17

(3.25)

522

(100)

Total

156

(21.31)

554

(75.68)

22

(0.27)

732

(100.0)


Table 05: Decision making with respect to socio economic status of family for family planning


family

Own Husband In laws Total

Category I 1

(9.09)

10

(90.90)

0

(0)

11

(100)

Category II 5

(12.5)

33

(82.5)

2

(5)

40

(100)

Category III 14

(23.33)

46

(76.66)

0

(0)

60

(100)

Category IV 22

(22.22)

74

(74.74)

3

(3.03)

99

(100)

Category V 114

(21.83)

391

(74.90)

17

(3.25)

522

(100)

Total 156

(21.31)

554

(75.68)

22

(3.0)

732

(100.0)

* (Figures in parentheses indicate row percentages) X2= 5.87, P< 0.05

Table 06: Decision making with respect to type of family for family planning

Type of family Own Husband In laws Others Total

Nuclear family 41

(35.96)

63

(55.26)

3

(0.87)

7

(6.14)

114

(100)

Joint family 218

(39.49)

260

(47.10)

25

(4.52)

49

(8.87)

552

(100)

Broken family 2

(100)

0

(0)

0

(0)

0

(0)

2

(100)

Total 261

(39.07)

323

(48.35)

28

(4.19)

56

(8.38)

668

(100.0)




Graph. 01 Decision making with respect to socio economic status of the family for obstetrics care

X2= 24.21, P<0.05

Decision making with respect to socio economic status of the family for obstetrics care

36.36 3540

32.3227.96

45.45

2520 18.18 18.1918.18

25

3544.44

48.85

0

15

5 5.05 4.98

0

20

40

60

80

100

Category I Category II Category III Category IV Category V

Economic

Pe

rce

nta

ge

of

wo

me

n

Own

Husband

In laws

Others



ijcrr

Vol 04 issue 03

Category: Research


Revised on:27/12/11


ABSTRACT Rainfall forecasting has been one of the most scientifically and technologically challenging problems

around the world in the last century. Statistical analysis of rainfall records for long periods is essential to

provide information about rainfall variability and to better manage the rainfed agricultural activities such

that the impact of climate change as well as changes in land use can be realistically assessed. This paper

analyse the northeast monsoon rainfall of Tamil Nadu from 1902 -2009 using linear regression

technique. The chi-square test was performed to test the hypothesis. This analysis revealed that the trend

of northeast monsoon rainfall of Tamil Nadu is decreasing and they are not statistically significant.

____________________________________________________________________________

Keywords: chi-square test , forecasting,

hypothesis, linear regression, statistical

analysis.

INTRODUCTION

The northeast (NE) monsoon season (October,

November and December) is the major period of

rainfall activity over south peninsular India. This

season is also known as the winter monsoon [1]

and post-monsoon season[2]

. The NE monsoon

season contributes to about 50% of annual

rainfall in the east coast of Indian peninsular [3]

.

Tamil Nadu is the only sub-division of the

Indian union which receives more rainfall in the

Northeast monsoon season than in the

Southwest monsoon.

India is basically an agricultural country and the

success or failure of the harvest and water

scarcity in any year is always considered with

the greatest concern [4]

. The term monsoon

seems to have been derived either from the

Arabic mausin or from the Malayan monsin.

The availability of adequate freshwater of

appropriate quality has become a limiting factor

for the development worldwide [5]

.

Understanding rainfall variability is essential to

optimally manage the scarce water resources

that are under continuous stress due to the

increasing water demands, increase in

population and the economic development [6]

.

Accurate and timely weather forecasting is a

major challenge for the scientific community.

Rainfall prediction modeling involves a

combination of computer models, observation

and knowledge of trends and patterns.

METHODOLOGY

We have used the Northeast monsoon rainfall

data of Tamil Nadu from the period 1902- 2009.

The data are obtained from the Regional

Meteorological centre, Chennai.

A wide range of rainfall forecast methods are

employed in weather forecasting at regional and

national levels. Fundamentally, there are two

approaches to predict rainfall. They are

Empirical method and dynamical methods.

Using these methods, reasonably accurate

forecasts can be made up. Several recent

research studies have developed rainfall

prediction using different weather and climate

TREND ANALYSIS OF NORTHEAST MONSOON

RAINFALL OF TAMIL NADU

Tamil Selvi .S

1, Samuel Selvaraj .R

2

1Deparment of Physics, Shree Motilal Kanhaiyalal Fomra Institute of

Technology, Chennai 2Department of Physics, Presidency College, Chennai




forecasting methods. Regression is a statistical

empirical technique and is widely used in

business, the social and behavioral sciences, the

biological sciences, climate prediction, and

many other areas. The most widely use

empirical approaches used for climate prediction

are regression, artificial neural network, fuzzy

logic and group method of data handling. This

paper describes empirical method technique

belongs to the regression approach which try to

make a short-term forecast of rainfalls in our

state. Generally, the study of the weather and

climatic elements of a region is vital for

sustainable development of agriculture and

planning. A declining and/or rising trend etc

may be quite instructive for different segments

of the human and natural systems [7]

.

The time series is made up of four components

known as seasonal, trend, cyclical and irregular [8]

. Trend is defined as the general movement of

a series over an extended period of time or it is

the long term change in the dependent variable

over a long period of time [9]

. Trend is

determined by the relationship between the two

variables rainfall and time. Trend analysis was

accomplished

with the line graphs as well as the least square

regression technique for hypotheses testing and

modelling. The chi-square test of association is

used to find whether there is significantly a

variation in the data having similar background.

A trend is the general pattern of fluctuation of

data over time [10]

. Many methods are available

for calculating trend but the most common ones

are the least square regression techniques [11]

.

For reasons of hypothesis testing, generalization

and projection, the study adopted the least

square regression method. The linear regression

line was fitted using the most common method

of least squares. This method calculates the best

fitting line for the observed data by minimizing

the sum of the squares of the vertical deviations

from each data point to the line. If a point lies

exactly on the straight line then the algebraic

sum of the residuals is zero. Residuals are

defined as the difference between an observation

at a point in time and the value read from the

trend line at that point in time. A point that lies

far from the line has a large residual value and is

known as an outlier or, an extreme value.

Though time – series data are not bivariate data,

a linear trend line can be obtained by using the

simple regression analysis technique [12],[10]

. In

the study therefore, time in years is one

independent variable (x) while North east

monsoon rainfall amount for 108 years (1902-

2009) is considered the dependent variable (y).

The equation of a linear regression line is given

as [13]

,

Y = a + bx + e

where;

Y = Dependent variable ( rainfall in mm)

X = Independent variable (time in years).

a = A constant and y – intercept

b = Regression coefficient

e = Error random term

In order to fit regression line the north east

monsoon rainfall (dependent variable) against

time (independent variable) in years were

plotted. Linear regression lines were then fitted

to determine the trends of rainfall.

The contingency test, k – sample chi-square test

of homogeneity is employed to associate the

rainfall data. The problem can be solved as a

contingency problem utilizing the rather normal

chi-square test formula. The use of the

conventional χ2 formula involves the calculation

of the expected frequencies is calculated.

The complete elements of the usual chi-square test is given below as;



The following research hypothesis are

formulated a prior for testing at 99% level of

confidence.

Hi: Northeast monsoon rainfall of Tamil Nadu

has varied insignificantly over time in the study

area

Decision Rule

Reject null hypothesis (Ho) and accept the

alternative research hypothesis (Hi) if critical χ2

value is lower than the calculated value at 99%

confidence interval.


As shown in Fig. 1, the north east monsoon

rainfall of Tamil Nadu is statistically defined by

the function

y = -0.0498x + 492.01 +e

It is significant at 99% confidence level with a

coefficient of determination figure of 0.0001 or

0.01 %. In our study, the calculated value is

much higher than the critical value so null

hypothesis is rejected and alternative research

hypothesis is accepted. i.e. Northeast monsoon

rainfall of Tamil Nadu has varied insignificantly

over time in the study area. The trend though

negative is statistically not significant at 99%

confidence; percentage explanation is equally

very low at 0.01%

CONCLUSION

Rainfall time series may be unfounded. The

topic of monsoon-rainfall data series is highly

complex; the role that linear regressions might

play in this topic is one for future research—it

appears, from the evidence here, not to be useful

as a predictive model. Whether it might be

useful for offering an approximate value of

future monsoon rainfall remains to be seen.

Rainfall is most essential for our life. So, we

predict that rainfall in the certain period.

Therefore, we avoid flood, cyclone, forest fire

detection, global warming etc. In future we

predict the rainfall forecasting and other

applications done by using the artificial

intelligence, neural

network and fuzzy sets etc. We do the research

on public sectors and save the world.

Figure 1. shows that the trend of northeast monsoon rainfall for Tamil Nadu is slightly decreasing

which indicates there is a negative linear relationship between rainfall and time.



REFERENCES

1. Nageswara Rao G. Variations of the SO

relationship with summer and winter

monsoon rainfall over India: 1872–1993. J.

Climate 1999; 12 : pp. 3486–3495.

2. Singh N and Sontakke N A . On the

variability and prediction of the rainfall in

the post-monsoon season over India. Int. J.

Climatol. 1999; 19: pp. 300–309.

3. Kumar P, Rupa Kumar K, Rajeevan M and

Sahai A K . On the recent strengthening of

the relationship between ENSO and

northeast monsoon rainfall over south Asia.

Climate Dynamics 2007; 28: pp. 649–660.

4. Rajeevan M . Prediction of Indian summer

monsoon: Status, problems and prospects.

Current Science. 2001; 81: pp. 1451-1457 .

5. Gat J.R . Planning and Management of a

Sustainable and Equitable Water Supply

under Stress of Water Scarcity and Quality

Deterioration and the Constraints of Societal

and Political Divisions: The Case for a

Regional Holistic Approach. Department of

Environmental Science and Energy

Research. The Weizmann Institute of

Science, 2004. 76100 Rehovot, Israel.

6. Herath, S. and Ratnayake, U. Monitoring

rainfall trends to predict adverse impacts-

acase study from Sri Lanka (1964-1993).

Global Environmental Change, 2004; 14:

pp. 71-79.

7. Afangideh, A. I., Francis, E. Okpiliya, Eja,

E. I. A Preliminary Investigation into the

Annual Rainfall Trend and Patterns for

Selected Towns in Parts of South-Eastern

Nigeria Journal of Sustainable Development

September 2010; 3: pp. 275-282.

8. Patterson, P. E. 1987, Statistical Methods,

Richard D. Irwin INC, Homewood, IL

9. Webber, J. and Hawkins. C. 1980, Statistical

Analysis Applications to Business and

Economics, Harper and Row, New York.

10. Okoko, E. 2001, Quantitative techniques in

urban analysis. Ibadan, Krafy Books

11. Box, GEP and Jenkins, G. M. 1976, Time

series Analysis Forecasting and control. San

Francisco, Holder Day Publishers.

12. Udofia, E. P. 2008. Fundamentals of social

science statistics, Enugu, Immaculate.

Books.

13. Hays, W. E. 1981, Statistics. CBS College

publishing, Tokyo.



ijcrr

Vol 04 issue 03

Category: Research


Revised on:20/12/11


ABSTRACT Objective: Develop suitable Hurdle treatment for preservation of cauliflower till 180 days of storage

period. Methods: Fresh cauliflower were preserved by combinations of hurdles i.e. blanching (100°C

for 60 sec.), steeped into different concentrations & combinations of preservatives – P0 (Control

sample- fresh without treatment), P1( 8% Salt + 500 ppm Potassium metabisulphite + 100 ppm

Sodium benzoate), P2 (10% Salt + 400 ppm Potassium metabisulphite + 200 ppm Sodium benzoate),

P3( 12% Salt + 300 ppm Potassium metabisulphite + 300 ppm Sodium benzoate), P4 ( 8% Salt +

0.3% Citric acid + 300 ppm Potassium metabisulphite + 300 ppm Sodium benzoate), P5 ( 10% Salt +

0.2% Citric acid + 400 ppm Potassium metabisulphite + 200 ppm Sodium benzoate) and P6 (12%

Salt + 0.1% Citric acid + 500 ppm Potassium metabisulphite + 100 ppm Sodium benzoate),

aseptically temperatures T1 (ambient- 30-37 °C) & T2 (refrigeration- 5-7 °C) for different time

intervals i.e. 0, 30, 60, 90, 120, 150 & 180 days respectively. This preserved cauliflower were studied

for their microbial, sensory & nutritional properties.

Results: The treatments which remained microbial safe till 180 days of storage period were P4/T1

(YMC- 23.14count/gm), P5/T2(YMC- 17.71count/gm) & P4/packed into food grade polyethylene

pouches and then stored at two different T2 (YMC - 8.43count/gm). Among these three, P4/T2 was

scored highest in sensory, lowest in physical and highest in nutritional evaluation. Conclusion: Best

hurdle treatment for preservation of cauliflower till 180 days of storage period was P4/T2.

___________________________________________________________________________

Keyword: Hurdle , YMC, ppm

INTRODUCTION

India is a leading vegetable producing country

in the world with the production of 113.5

million tons. The country is blessed with the

unique gift of nature of diverse climates and

distinct seasons, which makes it possible to

grow a variety of vegetables. The overall

productivity of vegetables is 14.4 tons per

hectare. The production of vegetables has taken

a big jump due to advent of many hybrid

varieties. But our market strategy is not

equipped with the handling of large quantity of

vegetables as a result quantities of vegetables

get spoil. Post harvest losses of horticulture

crops are immense. It varies between 5-39% of

the total production. The shelf life of perishable

vegetables is very low. In brinjal, cauliflower

and chilly post harvest losses were found to be

high (9Jayanthi 2005).

Preservation involves action taken to maintain

foods with desired properties or nature for as

long as possible. It lies at the heart of Food

Science & Technology & it is the main purpose

of Food Processing (3Barnettand & Blanchfield,

1995). The Hurdle concept was first introduced

by Prof. 10

Lothar Leistner of Germany & his

colleagues in 1978. The hurdle governs many

preservation processes. Intense heat (F)

MICROBIAL, SENSORY AND NUTRITIONAL

PROPERTIES OF CAULIFLOWER, PRESERVED BY

HURDLE TECHNOLOGY

Jyoti Sinha1, Ramesh Chandra

2

1Warner School of Food & Dairy Technology, Sam Higginbottom Institute of

Agriculture, Technology and Sciences, (Deemed-To- Be- University,

Formerly AAI-DU), Allahabad (U.P.) 2Centre of Food Technology, University of Allahabad, Allahabad




preserves canned foods, low water activity

prevents microbial growth in dried products,

low pH is responsible for prolonged shelf life

of fermented foods. This preservation technique

is also called combination techniques or barrier

technology or metodascombinados in Spanish,

technologia degli ostacoli in Italian, Hurdle

Technology in German. Potential hurdles for

food preservation are – Temperature (High or

Low), pH (High or Low), Water activity (High

or Low), Modified atmosphere (Co2, N2 etc),

Packaging (Vacuum packaging, aseptic

packaging, edible coating etc.), Radiation (UV,

microwave, irradiation etc), Preservatives

(Class I & II). Hurdle Technology is a

technology by which 2 or more hurdles are

employed in a suitable combination and every

hurdle is used at an optimum level so that

damage to the overall quality of food is kept to

the minimum. Hurdle Technology foods are

defined as ―Products whose shelf-life and the

microbial safety are extended by use of several

factors none of which individually would be

totally lethal towards spoilage or pathogenic

microbes‖ (5Berwal, 1994).

Justification for research objective –

1) Through hurdle technology it become

easy to preserve cauliflower at house

hold level.

2) Make available the cauliflower at

house hold level in off season.

3) Cauliflower preserved through hurdle

technology are free from hazardous

chemical which are used in cold

storage to keep it like a fresh

commodity.

Purpose – To preserve cauliflower through

hurdle technology till 180 days.


Cauliflower cords : The cords of cauliflower

were procured from local market of Naini.

Chemicals used in preservation : Food grade

(potassium metabisulphate, sodium benzoate &

citric acid) chemicals were used.

Polyethylene pouches : Food grade pouches

were used.

Reagents used in analysis : Analytical grade

reagents were used.

Method of preservation : First cauliflower

head (white curds) after sorting, were cut into

5×3×3 cm. pieces with sharp edged stainless

steel knife, then thoroughly washed in tap water

and distilled water. After washing blanched at

100°C for 60sec. then steeped into different

concentrations & combinations of

preservatives – P0 (Control sample- fresh

without treatment), P1( 8% Salt + 500 ppm

Potassium metabisulphite + 100 ppm Sodium

benzoate), P2 (10% Salt + 400 ppm Potassium

metabisulphite + 200 ppm Sodium benzoate),

P3( 12% Salt + 300 ppm Potassium

metabisulphite + 300 ppm Sodium benzoate),

P4 ( 8% Salt + 0.3% Citric acid + 300 ppm

Potassium metabisulphite + 300 ppm Sodium

benzoate), P5 ( 10% Salt + 0.2% Citric acid +

400 ppm Potassium metabisulphite + 200 ppm

Sodium benzoate) and P6 (12% Salt + 0.1%

Citric acid + 500 ppm Potassium

metabisulphite + 100 ppm Sodium benzoate).

Then aseptically packed into food grade

polyethylene pouches and stored at two

different level of temperatures- T1 (ambient

temperature – 30 to 37 °C) & T2 (refrigeration

temperatures – 5 to 7 °C) for different time

intervals i.e. 0, 30, 60, 90, 120, 150 & 180 days

respectively. This preserved cauliflower were

studied for their microbial , sensory, physical &

nutritional properties and data obtained after

analysis were statistically analyzed.

Microbial properties: Yeast & mold was

determined by Conventional method,

(14

Ranganna 2005).

Sensory properties : Sensory properties (color,

flavor, texture & overall acceptability) were

determined by 9 Point Hedonic Scale method

(17

Ranganna 2005).

Physical properties: Water activity was

determined by using Water Activity Meter

(2Aqua Lab Series 4TE- 2007). pH was

determined by using pH meter (Electronic

Corporation of India, Model 5652) as per

procedure described in 12

Ministry of Health &

Family Welfare, Manual of methods of analysis



of foods- Fruit and Vegetable Products ,

(2005)

Nutritional properties : Protein determined by

Micro-Kjeldahl / Kjeltec method (16

Ranganna,

2005), Vitamin A determined by method

mentioned in (18

Ranganna 2005), Vitamin C

determined by 2, 6-dichlorophenol-indophenol

visual titration method, (19

Ranganna 2005) &

potassium determined by Flame photometric

method, (15

Ranganna 2005).

Statistical analysis : Obtained data were

analyzed for ANOVA ( 3 Way Classification)

& critical difference (C.D.) technique,

described by 8Imran and Coover (1983). In

statistical analysis, data used were average of

replicates, total no. of treatments combinations

were 14 – P0/T1, P0/T2, P1/T1, P1/T2, P2/T1,

P2/T2, P3/T1, P3/T2, P4/T1, P4/T2, P5/T1,

P5/T2, P6/T1, P6/T2 (where P0, P1, P2, P3, P4,

P5 & P6 are different combination of

preservatives and T1 & T2 are different level of

temperatures, all are explained in Method of

preservation). Level of significance was

checked at 5% probability level.

RESULTS

Microbial properties of preserved

cauliflower : Yeast & mold count of preserved

cauliflower are given in Table 1. Treatments in

which Yeast & mold count were found lowest

with a storage period of 180 days are P4/T1,

P4/T2 & P5/T2. There were significant

difference between yeast & mold count of

treated samples due to combination of

preservatives & storage temperatures while

there was not significant difference due to days

of storage at 5% probability levels.

Sensory properties of preserved cauliflower :

In sensory properties, results of only overall

acceptability parameter was presented in Table

1. Treatment P4/T2 scored highest in overall

acceptability with a storage period of 180 days.

There were significant difference between

overall acceptability scores of treated samples

due to combination of preservatives & days of

storage while there was not significant

difference due to storage temperatures at 5%

probability levels.

Physical properties of preserved cauliflower

: From Table 1 - lowest water activity & from

Table 2 - lowest pH were found in P4/T2 in a

storage period of 180 days. There were

significant difference between water activity &

pH scores of treated samples due to

combination of preservatives & storage

temperatures while there was not significant

difference due to days of storage at 5%

probability levels.

Nutritional properties of preserved

cauliflower : From Table 2 - highest retention

of protein & vitamin A and from Table 3 -

highest retention of vitamin C & potassium

were found in treatment P4/T2 in a storage

period of 180 days. There were significant

difference between protein, vitamin A, vitamin

C & potassium scores of treated samples due to

combination of preservatives , storage

temperatures & days of storage at 5%

probability levels..

DISCUSSION

In microbial analysis, the increase in yeast &

mold count was observed in all treatments at

both the temperatures. In most of the treatments

yeast & mold count were found above from the

standard (as per 6 Food Safety & Standard

Authority of India, 2006-Yeast/Mold not more

than 100 count/gm) with increase in storage

period, which may be attributed during addition

of preservatives or during packaging which

could have been a carrier of microbes. While in

some treatments counts remained under control

as per above mentioned standard till 180 days

of storage, it might be due to better handling

procedure or different concentration &

combinations of class I & II preservatives &

low temperature of storage. The results are in

agreement of previous finding of 7Gould

(1995), observed that the food preservation

through hurdle technology cause interference

with the homeostasis of yeast & mold. 1Alzamora et al. (1989), also noticed that yeast

and mould counts remained below 100 cfu/gm



during 4 months of storage of pineapple slices

preserved through hurdle technology at 5°C. 11

Lopez- Malo et al. (1994), preserved papaya

through hurdles technology, found yeast &

smold counts < 10 CFU/g during 5 months

storage at 25°C.

In sensory evaluation, the difference &

decrease in overall acceptability scores was

observed which may be attributed due to

increase in microbial count with increase in

storage period. But at the same time, treatments

which remained microbial safe till 180 days of

storage period were best rated in sensory

evaluation. The results are in agreement of

previous finding of 13

Pruthi (1990), the

vegetables like potatoes, carrot, cauliflower,

cabbage, bitter guard, peas, mushroom and

animals foods (meat, fish and poultry)

preserved in an acidified sulphited brine

solution through steeping can be used for

pickling or home cooking after leaching out the

salt and acid. 4Barwal et al. (2005) standardized

the low cost and low energy processing

technology for preservation of cauliflower

involving different concentration and

combination of salt (5-10%), potassium

metabisulphite (0.2%) and citric acid (1%) after

blanching. The preserved cauliflower was

accepted in sensory evaluation after 90 and 180

days of storage by reconstituted in running

water for half an hour & evaluated for the

preparation of pickle and pakora.

In physical test, the reduction in water activity

& pH of preserved sample were found as

compare to initial or fresh commodity. Reduced

water activity & pH were found effective for

long time storage. The results are in agreement

of previous finding of 21

Vibhakara et al.(2005),

maintenance of pH< 4.5 helped in controlling

multiplication and survival of spores & also

helpful in achieving shelf stability. Low pH and

water activity solutions are used as

antimicrobial agent or as antioxidant to prevent

browning, to reduce discoloration of pigments,

and to protect against loss of flavor, changes in

texture (23

Wiley, 1994).

In nutritional evaluation, loss of nutrients were

found in each treatments but on other hand

better retention of protein, vitamin A, vitamin

C & potassium were also observed in

treatments of 180 days of storage period. The

results are in agreement of previous finding of 20

Srivastava & Kumar (2002), sulphur dioxide

is widely used throughout the world in the

preservation as it acts as an antioxidant and

bleaching agent. These properties help in the

retention of vitamin C, vitamin A and other

oxidizable compounds. Sulphur dioxide with

potassium metabisulphite (if added in the

solution) helps to retain vitamin C content of

the preserved material (22

Verma & Joshi,

2000). Low pH and water activity solutions

were also effective towards nutrient retention

(23

Wiley, 1994).

CONCLUSION

All the treatments combination were not

effective for preservation of cauliflower till 180

days of storage period. Only 3 treatments -

P4/T1, P4/T2 & P5/T2 were microbial safe till

180 days & among these 3, only P4/T2 was

found best in sensory as well in nutrient

retention in 180 days of storage period.

ACKNOWLEDGEMENT

I express my deep sense of gratitude for my

advisor (Prof.) Dr. Ramesh Chandra, (Dean)

Warner School Of Food & Dairy Technology,

to all member of advisory committee - Dr. D.B.

Singh, Dean of Horticulture Department,

(Prof.) Dr. Sarita Sheikh, Dean of Halina

School of Home Science, (Prof.) Dr. Sangeeta

Upadhayay, Assistant Professor

(Microbiology),Warner School Of Food &

Dairy Technology, (Prof.) Dr. Ram Lal, Dean

of Department of Statistics, Sam Higginbottom

Institute of Agriculture, Technology &

Sciences, Allahabad, for there sincere guidance,

suggestions, constructive work &

encouragement during the entire research work.

Sincere thanks to Honorable Vice-Chancellor,

Sam Higginbottom Institute of Agriculture,

Technology & Sciences, Allahabad, for



providing me necessary technical & financial

facilities.

I want to acknowledge the immense help



manuscript. I 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. Alzamora SM, Gerschenson LN, Cerrutti P,

Rojas A M. Shelf-stable pineapples for

long-term non refrigerated storage. J.

Lebensm-Wiss. u. – Tech 1996; 22:233-

236.

2. Sample Preparation & Taking a Reading.

In: Operator‘s manual AQUA LAB 4TE,

Water activity meter. Decagon Devices;

2007. p. 46-51.

3. Barnettend M, Blanchfield JR. What does

preservation mean. Food Sci. Technol

1998; 9:93-12.

4. Barwal VS, Sharma R, Singh R.

Preservation of cauliflower by Hurdle

Technology. Food Sci and Tech 2008;

42(1):26-31.

5. Berwal JS, Hurdle technology for shelf

stable food products. Indian Food Industry

1996; 13:40-43.

6. Ministry of Health & Family Welfare

(Food Safety & Standard Authority of

India) Part 4th New Delhi. Microbiological

Requirements of Food Products. Appendix

B, Table-4. 2006; p.665.

7. Gould GW. Interference in homeostasis.

In: Whitten bury R, Banks JG, editors.

Homeostatic Mechanism in

Microorganisms. 3rd ed.: Bath University

Press; 1995. p. 220.

8. Imran RL, Cover WB. Statistical analysis.

In: A modern approach to statistics. 2nd ed.

New York; 1983: p. 120.

9. Jayanthi M. Innovative solution to extent

the shelf life of fruits. Processed Food

Industry 2008; 9(1): 37-38.

10. Luthar L. Hurdle effect and energy saving.

In: Downey WK, editors. Food Quality and

Nutrition. 2nd ed. London: Applied Science

Publishers; 1990. p. 553-557.

11. Lopez-Milo A, Palou E, Welty J, Corte P,

Arias A. Shelf-stable high moisture papaya

minimally processed by combined

methods. International J. of Food Research

1995; 27(6):545-553.

12. Ministry of Health & Family Welfare

(India). Manual of methods of analysis of

foods: Fruit and Vegetable Products. New

Delhi: Government of India; 2005; 6.

13. Pruthi J S. Physiology, Chemistry and

Technology of Passion Fruits. In:

Advances in Food Research. Vol. 12. 2nd

ed. New York: Academic Press; 2000. p.

203-274.

14. Ranganna S. General instruction for

microbiological examination. In: Hand

Book of Analysis and Quality Control for

Fruit and Vegetable Products. 2nd ed. New

Delhi: Tata McGraw Hill Education Private

Ltd New York; 2005. p. 646-655.

15. Ranganna S. Minerals. In: Hand Book of

Analysis and Quality Control for Fruit and

Vegetable Products. 2nd ed. New Delhi:

Tata McGraw Hill Education Private Ltd

New York; 2005. p. 127-128.

16. Ranganna S. Proximate constituents. In:

Hand Book of Analysis and Quality

Control for Fruit and Vegetable Products.

2nd ed. New Delhi: Tata McGraw Hill

Education Private Ltd New York; 2005. p.

21-24.

17. Ranganna S. Sensory evaluation. In: Hand




Ltd New York; 2005. p. 623-624.

18. Ranganna S. Plant pigments. In: Hand




Ltd New York; 2005. p. 84-86.

19. Ranganna S. Vitamins. In: Hand Book of

Analysis and Quality Control for Fruit and



Vegetable Products 2nd ed. New Delhi:

Tata McGraw Hill Education Private Ltd

New York; 2005. p. 105-106.

20. Srivastava RP, Kumar S. Principles and

Methods of Preservation. In: Fruits &

Vegetable Preservation: Principles And

Practices. 3rd

rev. ed. International Book

Distributing Co; 2002. p. 93.

21. Vibhakara HS, Manjunath SS, Radhika M,

Gupta DK, Bawa AS. Effect of gamma-

irradiation in combination preservation

technique for stabilizing high moisture

spice based vegetables. J Foods Sci and

Techno 2007; 42 (5):434-438.

22. Verma LR, Joshi VK. Steeped preserved

products. In: Verma LR, Joshi VK, editors.

Post harvest technology of fruits and

vegetables. Indian publishing Co. New

Delhi; 2000. p. 861-867.

23. Wiley RC. Preservation of vegetables. In:

Chapman & Hall editors. Preservation

methods for processed refrigerated fruits

and vegetables. 2nd

ed. New York; 1994. p.

226-268.

Table 1. – Yeast & mold count, Overall acceptability & Water activity scores of preserved cauliflower

in different treatments with its shelf life

Treatments with its YMC/gm Overall acceptability Water activity(%)

Shelf life(in days)

P0/T1 -180 32.17* 9* 0.98*

P0/T2 -180 32.17* 9* 0.98*

P1/T1 - 30 65 7 0.78

P1/T2 -60 51 7 0.74

P2/T1 -60 35.75 6 0.71

P2/T2 -90 26.8* 6.25 0.69*

P3/T1 -90 52 6.25 0.76

P3/T2 -120 47.5 6.8 0.74

P4/T1 -180 23.14* 7.14* 0.67*

P4/T2 -180 8.43* 8* 0.63*

P5/T1 -150 40.29 7 0.74

P5/T2-180 17.71* 7.85* 0.66*

P6/T1-120 28.45* 6.6 0.69*

P6/T2 -150 26.5* 7.3* 0.67*

YMC/gm-Yeast & mold count/gm; All values are MEAN; *Significant values



Table 2. – pH, Protein & Vitamin-A scores of preserved cauliflower in different treatments with its

shelf life

Treatments with its pH Protein Vitamin-A

shelf life (in Days) (mg/100gm) (mg/100gm)

P0/T1 -180 6.2* 2.5* 50.23*

P0/T2 -180 6.2* 2.5* 50.23*

P1/T1 -30 4.5 2.1 49

P1/T2 -60 4.2 2.2 49.33

P2/T1 -60 4.4 2 48.4

P2/T2 -90 4.14 1.9 49.03

P3/T1 -90 4.2 1.72 47.5

P3/T2 -120 4.0 1.8* 48.2*

P4/T1 -180 3.5* 1.3* 45.2*

P4/T2 -180 3.3* 1.6* 47.2*

P5/T1 -150 3.9 1.5 43

P5/T2 -180 3.7* 1.4* 45.2*

P6/T1 -120 4.04 1.3 45

P6/T2 -150 3.8 1.82* 47*

All values are MEAN ; * Significant values

Table 3. – Vitamin -C & Potassium scores of preserved cauliflower in different treatments with its

shelf life

Treatments with its Vitamin-C (mg/100gm) Potassium (mg/100gm)

shelf life (in Days)

P0/T1 -180 55.56* 136.21*

P0/T2 -180 55.56* 136.21*

P1/T1 -30 49 134.5

P1/T2 -60 49.8 135.7

P2/T1 -60 49.5 132.2

P2/T2 -90 50.4* 135.5*

P3/T1 -90 46.6 131.9

P3/T2 -120 47* 135.11*

P4/T1 -180 33.5* 128.4*

P4/T2 -180 37.6* 132.1*

P5/T1 -150 35.2 128.2

P5/T2 -180 37.4* 130.8*

P6/T1 -120 37.7 130.2

P6/T2 -150 38* 133.2*

All values are MEAN ; *Significant values



ijcrr

Vol 04 issue 03

Category: Review


Revised on:20/11/11


ABSTRACT The success of dental implant is dependent upon the integration between the implant and the intraoral

hard/soft tissue. Crestal bone loss is one of the factors that affect the long term prognosis of a dental

implant. Platform switching is a concept recently introduced in implant dentistry. It is intended to

reduce the crestal bone loss that is commonly found around implants exposed to the oral environment.

The purpose of this review article is to discuss the mechanism, by which it contributes to preserve

crestal bone loss, literature review, benefits, limitations and consequence of platform switching; in

order to assess its clinical success in implant dentistry

___________________________________________________________________________

Keywords: Biological width, crestal bone loss,

platform switching, stress.

INTRODUCTION

Dentistry is now focused mainly on the fixed

replacement of lost teeth with priority given to

aesthetic and function. Patient‘s desire for fixed

restoration has increased over artificial

substitutes. With new trends in dentistry, dental

implants have taken the top position in fixed

restoration and also have been accepted by the

patient‘s widely.

Implants have been used for various purposes

such as single, multiple or full arch restoration.

It could be a single or two piece implant

system. Single implant system eliminates the

junction between implant platform and

abutment. Also have limitations of positioning,

integration and aesthetics. Traditional two-

stage implants have enjoyed a long history of

clinical success and have offered surgical and

prosthetic versatility. They have been used in

various situations with better emergence profile

as well as bone integration at the implant

abutment interface which gives rise to a new

concept called ―Platform Switching‖.

For two piece implant system, there exists two

potential pathways for bacterial penetration

resulting in crestal bone loss. One route is

through the inside of the abutment, along the

screw threads eventually at the implant

abutment interface or micro gap. Alternatively

bacteria can migrate along the outer surface of

the abutment. Ericsson et al, identified two

important entities in the implant crestal region

i.e. Plaque associated inflammatory cell

infiltrate and Implant associated inflammatory

cell infiltrate and he concluded that apical

border of an inflammatory cell infiltrate is the

aetiological factor for crestal bone loss which

was always separated from the bone crest at 1

mm of healthy connective tissue1.

However, early crestal bone loss has been

commonly observed. Adell et al was the first to

quantify and report marginal bone loss and

indicated greater magnitude of bone loss during

the first year of prosthesis loading. There are

many elements that can accelerate the

PLATFORM SWITCHING IN IMPLANT

DENTISTRY - A REVIEW

Gayathri N, Lakshmi S

Department of Prosthodontics, Meenakshi Ammal Dental College,

Alappakkam Main Road, Maduravoyal, Chennai




resorption of crestal bone, and they are

discussed below2.

Factors accelerating crestal bone loss:

1) Biologic Width

The crestal bone remodelling is an important

phenomenon that occurs around natural teeth

and implants called the biologic width – the

natural seal that develops around any object

protruding from the bone and through the tissue

into the oral environment. This seal isolates the

bone from the oral environment.

Biological width forms within the first 2-4

weeks after the implant abutment junction has

been exposed to the oral cavity. It is a barrier

against bacterial invasion and food ingress

implant-tissue interface. The ultimate location

of epithelial attachment following phase 2

surgery in part, determines early post-surgical

bone loss. Thus, implant bone loss is in part, a

process of establishing the biological seal.

When implants are initially placed within bone

and then covered with an adequate layer of soft

tissue (first-stage surgery), there is typically

little or no crestal bone resorption. When the

implant is uncovered (in second-stage surgery)

and connected to an abutment, the body then

reacts and in the process of creating the

biologic width, the crestal bone may resorb3.

2) Micro gap

In two stage implant systems, after abutment is

connected, a microgap exists between the

implant and the abutment at or below the

alveolar crest. The countersinking below the

crest is done to minimize the risk of implant

interface movement during bone remodelling,

to prevent implant exposure during healing and

also to enhance the emergence profile.

Countersinking places the implant micro gap

below the crestal bone. The microgap crestal

bone level relationship was studied

radiographically by Hermann et al, who for the

first time, demonstrated that the microgap

between the implant/abutment has a direct

effect on crestal bone loss, independent of

surgical approaches. Epithelial proliferation to

establish biological width could be responsible

for crestal bone loss found about 2mm below

the microgap3,4.

3) Surgical Trauma

Heat generated during drilling, elevation of the

periosteal flap and excessive pressure at the

crestal region during implant placement may

contribute to implant bone loss during the

healing period. Signs of bone loss from surgical

trauma and periosteal reflection are not

commonly observed at the implant stage II

surgery in successfully osseointegrated

implants3. Wildermann et al, reported that bone

loss due to periostium elevation was restricted

to the area just adjacent to the implant, even

though a larger surface area of the bone was

exposed during surgery. Thus, surgical trauma

is unlikely to cause early crestal bone loss5.

4) Stress

Cortical bone is least resistant to shear force,

which is significantly increased in bending

overload. Excessive stress on the immature

implant bone interface in the early stage of

prosthesis in function is likely to cause crestal

bone loss. However, bone loss from occlusal

overload is considered to be progressive rather

than limited to the first year of loading6.

The Need for Better Crestal Bone

Preservation Emerges

Crestal bone preservation should be thought

during the treatment planning stage itself.

There are various approaches described in the

literature to prevent crestal bone loss. One of

them is the Platform switching concept.

Platform switching ―is the use of prosthetic

components having an abutment diameter

undersized when compared to the diameter of

the implant platform‖.7

Platform switching is a restorative protocol

which has been reported by Dr. Richard

Lazzara as a means of limiting crestal bone loss

around dental implants. In this way, the

prosthetic connection is displaced horizontally

inwards from the perimeter of the implant

platform, creating an angle or step between the

abutment and implant; improving the

distribution of forces. So this article reviews

about the literature how platform switching has



contributed to implant dentistry especially for

crestal bone preservation7.

HISTORY OF PLS

In 1991, the 3i wide diameter 5.0 and 6.0 mm

implants were designed with a matching

diameter seating surface to be used however,

there were no matching diameter prosthetic

components available, and as a result, they

were restored with standard 4.1 mm diameter

components, which created a 0.45mm or 0.95

mm circumferential horizontal difference in

dimension. After the initial 5 year period,

radiographical reviews stated that the amount

of crestal remodelling was reduced and also

exhibited no vertical crestal bone loss.

These results have led many researchers to

become interested to perform investigations.

Various studies have been conducted in human

beings, animals and Finite element analysis

comparing the platform switched implants with

regular two piece implants.

Human Studies:

According to Lazzara and Porter, the deliberate

creation of a space for the physiological barrier

minimizes the space for repositioning of the

fibers. By displacing the junction with the

abutment to a more medial position with

respect to the axis, an increased surface

repositioning of the biological space occurs.

This space is created in the horizontal plane 1

mm from the implant-abutment junction,

supported over the external margin of the

platform. Implant design also influences the

morphology of the gingival margin – both the

neck micro and macrostructure, and the

macrostructure of the implant-abutment

junction7. In turn, ensuring a minimum

distance of 3 mm between implants allows

sufficient margin to restore the biological space

for restorations, as demonstrated by Tarnow a

decade ago8. In implants involving an

expanded platform integrated in their

macrostructure, and ensuring the above

mentioned distance between implants, bone

crest preservation is seen to be 57% greater

than with a traditional restoration design.

Trammell et al, in a case-control study,

measured the biological space with reduced and

conventional platform abutments in the same

individual. They concluded that bone loss was

significantly smaller with the expanded

platform9.

Vela Nebot et al assessed interproximal bone

resorption on the medial and distal of each

implant using digital radiography at 1, 4, and 6

months after abutment attachment. Platform

modification has been proposed to reduce the

biologic and mechanical aggressions on the

biologic width. The resulting peri-implant bone

preservation leads to better aesthetics results10.

Gardner presents a case study using platform

switching implants dealing with the changes

that occur when an implant is placed in bone.

He states that its main advantage is that it is an

effective way to control circumferential bone

loss around dental implants11.

Hurzeler M, showed that crestal bone height

around dental implants could be influenced

using a platform switch protocol and that the

bone level would remain stable within 1 year

after final prosthetic reconstruction. They

concluded the concept of platform switching

appears to limit crestal resorption and seems to

preserve peri-implant bone levels12.

Canullo L, Rasperini G, suggests that

immediate loading with platform switching can

provide peri-implant hard tissue stability with

soft tissue and papilla preservation13.

Degidi et al suggested that platform switching

in combination with an absence of micro

movement and micro gap may protect the peri-

implant soft and mineralized tissues, explaining

the observed absence of bone resorption and

also said that immediate loading did not

interfere with bone formation and did not have

adverse effects on osseointegration14.

Qian Li et al evaluated the clinical results of

dental implant treatment with platform

switching technique in esthetic zone and to

investigate its technical characteristics. He

concluded that platform switching is a simple

and reliable technique for dental implant

treatment, helping to control marginal bone loss



and ensure esthetic results in the esthetic

zone15.

Baumgarten et al describes that platform

switching technique and its usefulness in

situations where shorter implants must be used,

where implants placed in aesthetic zones and

where a larger implant is desirable but

prosthetic space is limited. They concluded that

sufficient tissue depth of approximately 3mm

or more is necessary to accommodate an

adequate biologic width and also, platform

switching helps to prevent the anticipated bone

loss and also preserves crestal bone16.

Cappiello M observed vertical bone loss

between 0.6mm and 1.2 mm in platform

switched implants comparatively lesser than

regular two piece implants17.

Hermann et al reviewed platform switching,

implant design in cervical region, nano

roughness, biological width, fine threads,

abutment designs and avoidance of micro

lesions in the peri implant soft tissue as factors

that determine the preservation of crestal bone

levels. He concluded that these factors

determine the aesthetic outcomes of implant

restorations18.

Vela Nebot et al concludes that platform

switching improves aesthetic results and that

when invasion of biologic width is reduced,

bone loss is reduced10.

Mangano et al evaluated 1920 Morse tapered

connection implants clinically and

radiographically at 12, 24, 36 and 48 months

after implant insertion. They noted an overall

cumulative implant survival rate of 97.56%

(96.12% in maxilla and 98.91% in the

mandible). The absence of an implant–

abutment interface (micro-gap) is associated

with minimal crestal bone loss19.

Animal Studies:

Becker et al in his histomorphometric study in

dogs, concluded that twenty eight days after

implant placement, both CAM (sand blasted

and acid etched screw type implants with either

matching) and CPS (smaller diameter healing

abutments) revealed crestal bone level changes

but they found no significant differences

between them20.

Sarment et al is found some changes in the

width and height of bone when using platform

switching implants21.

Weiner et al connects the development of

biologic width with the implant surface. They

did not mention platform switching but focuses

the study on the use of shift tissue engineered

collars with micro grooving22.

Histological Studies:

Luongo et al, examined biopsy specimens to

helps explain the biologic processes occurring

around a platform-switched implant. An

inflammatory connective tissue infiltrate was

localized over the entire surface of the implant

platform and approximately 0.35 mm coronal

to the implant-abutment junction, along the

healing abutment. A possible reason for bone

preservation around a platform switched

implant may lie in the inward shift of the

inflammatory connective tissue zone at the

implant-abutment junction, which reduces its

injurious effect on the alveolar bone23.

Degidi M et al evaluated the histology and

histomorphology of three morse cone

connection implants in a real case report and he

explains that when there is zero microgaps and

no micro movement, platform switching shows

no resorption. He also observes that this

method provides better aesthetic results24.

FEA Studies:

Hsu et al analyzed the behaviour of reduced

platform restorations in a 3 D FEA. Their

results showed a 10% decrease in all the

prosthetic loading forces transmitted to the

bone-implant interface. Similar finite elements

studies in two dimensions show great

variability in the results obtained25. In effect,

while some investigators report a decrease in

force to the cortical bone of less than 10%,

other authors such as Tabata et al have reported

a decrease of 80%26.

Rodriguez-Ciurana et al in a two-dimensional

biomechanical study involving platform

switching integrated into the implant design,

failed to obtain peri-implant bone force



attenuation values as high as those reported in

earlier studies, when comparing platform

expansion with a traditional restoration model.

In addition, the authors concluded that force

dissipation in the platform switching restoration

is slightly more favourable in an internal than

in an external junction, since it improves

distribution of the loads applied to the occlusal

surface of the prosthesis along the axis of the

implant. On the other hand, this concentration

of forces along the axis of the implant,

transmitted through the retention screw,

increases the possibility of abutment fracture,

and thus may lead to failure of the restoration.

All studies contrasting platform switching

versus continuity of the platform with the body

of the implant agree that force to bone diffusion

is improved by expanding the platform27.

However, Canay and Akça, in a three

dimensional finite elements analysis involving

different implant-free expanded platform

dimensions and a range of abutment designs,

claimed that the effect of platform expansion is

not attributable to the distribution of loads to

the peri-implant bone but rather simply to

redistribution of the new biological space.

Nevertheless, the authors pointed the need for

further research on the behaviour of the

marginal bone around the implants. The most

appropriate reduced platform abutment design

for securing lesser implant abutment material

fatigue is represented by conical emergence

abutments with a variable height of 1.5-2mm,

freeing extension of the implant platform

between 0.5-0.75mm. Such platform switching

is not advisable in mandibular implant mucosal

support prostheses, since reduction of the

diameter of the junction lessens the abutment

resistance in response to occlusal loading

applied in the posterior area of the over

dentures – fundamentally compromising the

connecting abutment closest to the area where

loading is applied28.

Maeda Y et al, showed that the stress level in

the cervical bone area at the implant was

greatly reduced when the narrow diameter

abutment was connected compared with the

regular-sized one. They suggested that the

platform switching configuration has the

biomechanical advantage of shifting the stress

concentration area away from the cervical

bone-implant interface. It also has the

disadvantage of increasing stress in the

abutment or abutment screw29.

Schrotenboer et al investigated the effects of

implant microthreads on crestal bone stress

compared to a standard smooth implant collar

and to analyze how different abutment

diameters influenced the crestal bone stress

level. They concluded that microthreads

increased crestal stress upon loading. Reduced

abutment diameter resulted in less stress

translated to the crestal bone in the microthread

and smooth-neck groups30.

DISCUSSION

According to review literature, the technique of

platform switching seems to have greatest

potential to limit the crestal resorption. The

inflammatory connective tissue infiltrate is

located at the level of the collar, and doesn‘t

migrate apically. Thereby resorption is avoided

and the crestal bone is stabilized at the level of

the implant collar. At the same time, the micro-

gap is shifted away from the crestal bone,

decreasing the probability of resorption by an

increased distance of the peripheral bone and

the base of the abutment.

To maintain the long term implant stability, it is

important to minimize crestal bone loss around

implant. Stress is concentrated around the

crestal region where 2 materials such as bone

and implant with different modulus of elasticity

interact. Peak bone stresses that appear in

marginal bone are believed to cause bone micro

fracture. So, decreased stresses may not be the

only reason for the positive results shown by

platform switching. Moreover, by decreasing

the abutment diameter, more stresses are

concentrated near the abutment, increasing the

likelihood of abutment fracture. The other

possible reason for the efficacy of the platform

switching configuration is that the

microorganisms are likely to move toward the



high-energy area or by the mechanism such as

interface micro movements that allow the

microorganisms to move into that area, it is

advantageous to have a large distance between

the stress concentration area and bone surface.

Hence implant abutment interface is a very

important criterion for implant success.

However, further studies utilizing modified 3D

finite element models and animal experiments

as well as longitudinal clinical observations are

still necessary.

A critical analysis of how platform switching

reduces crestal bone loss:

The mechanism by which platform switching

can contribute to maintain the crestal bone

height could be due to four reasons:

Shifting the inflammatory cell infiltrate

inward and away from the adjacent crestal

bone.

Maintenance of biological width and

increased distance of implant abutment

junction from the crestal bone level.

The possible influence of micro-gap on the

crestal bone is diminished.

Decreased stress levels in the peri-implant

bone (According to FEA studies).

Consequences of Horizontal Repositioning:

Reduction in the amount of crestal bone

resorption is necessary to expose a minimum

amount of implant surface to which the soft

tissue can attach.

Horizontal Repositioning of abutment

inflammatory cell infiltrate within less than

900 confined area of exposure decreases the

resorptive effect on the crestal bone.

Reduced diameter components beginning

with healing abutment must be used from

the moment the implant is exposed to the

oral environment, since the process of

biological width formation begins

immediately.

Limitations of platform switching

If normal size abutments are to be used,

larger size implants need to be placed. This

is not possible every time clinically,

especially if bone width is less.

If normal sized implants are placed, smaller-

diameter abutments are necessary, which

may compromise the emergence profile,

especially in anterior cases.

Benefits of platform switching

Improved aesthetics as crestal bone

preservation helps to preserve papilla.

Increased implant longevity.

The effect of inter-implant distance is

minimized.

A minimum of 3 mm inter implant distance is

needed to preserve marginal bone. Arthur et al,

found that distances of 1, 2 and 3 mm between

implants do not result in statistically significant

differences in crestal bone loss around

submerged or non-submerged implants with a

Morse cone connection and platform

switching31. The only requirement of platform-

switched implant is that the implant should be

placed crestally if sufficient soft tissue height

and inter occlusal space are present, or sub

crestally if insufficient soft tissue height and

inter-occlusal space are present. So, soft tissue

depth of approximately 3 mm should be present

to place platform switched implants or else

bone resorption is likely to occur, irrespective

of implant geometry. Also, sufficient bone

width should be present to accommodate the

larger-diameter implant.

CONCLUSION

The ultimate objective of implant dentistry is to

create optimal prosthetic restorations that are

surrounded by stable bone and a natural

gingival architecture that exists in harmony

with the other teeth. All authors agree that the

use of implants with platform switching

improves bone crest preservation, excellent

aesthetic outcomes and controlled biological

space reposition. Requirement of platform-

switched implant is that soft tissue depth of

approximately 3 mm should be present to place

platform-switched implants or else bone

resorption is likely to occur, irrespective of

implant geometry. Platform switching appears

to be simple, functional, and predictable

technique for preserving peri-implant crestal



bone and can be clinically applied when

clinical situation permits. Definitive clinical

trials are currently underway and further

clinical investigations are necessary to show

long term results.

ACKNOWLEDGEMENT








discussed.

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Peri-implant bone level around implants

with platform switched abutments:

preliminary data from a prospective study.

J Oral Maxillofac Surg. 2007:Jul;65(7

Suppl1):33-9.

13. Canullo L, Rasperini G. Preservation of

peri-implant soft and hard tissues using

platform switching of implants placed in

immediate extraction sockets: a proof-of-

concept study with 12- to 36-month follow-

up. Int J Oral Maxillofac Implants.

2007;22:995-1000.

14. Degidi M, Iezzi G, Scarano A, Piattelli A.

Immediately loaded titanium implant with a

tissue-stabilizing/maintaining design

('beyond platform switch') retrieved from

man after 4 weeks: a histological and

histomorphometrical evaluation. A case

report. Clin Oral Impl Res 2008

Mar;19(3):276-82. Epub 2007 Dec 13.

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Lazzara%20RJ%22%5BAuthor%5D



15. Qian Li, Ye Lin, Li-xin Qiu, Xiu-lian Hu,

Jian-hui Li, Ping DI. Clinical study of

application of platform switching to dental

implant treatment in esthetic zone. Chinese

journal of stomatology 2008; 43(9):537-41.

16. Baumgarten H, Cocchetto R, Testori T,

Meltzer A, Porter S. A new implant

design for crestal bone preservation: initial

observations and case report. Pract Proced

Aesthet Dent. 2005;17:735-40.

17. Cappiello M, Luongo R, Di Iorio D, Bugea

C, Cocchetto R, Celletti R. Evaluation of

periimplant bone loss around platform-


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Schoolfield JD, Cochrane DL. Influence of

the size of the microgap on crestal bone

changes around titanium implants. A

histometric evaluation of unloaded non-

submerged implants in canine mandible. J

Periodontol 2001; 72:1372-83.

19. Mangano C, Mangano F, Piattelli A, Iezzi

G, Mangano A, La Colla L. Prospective

clinical evaluation of 1920 Morse taper

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of functional loading. Clin Oral Impl Res

2009; 20:254-61.

20. Becker J, Ferrari D, Herten M, Kirsch A,

Schaer A, Schwarz F. Influence of platform

switching on crestal bone changes at non-

submerged titanium implants: a

histomorphometrical study in dogs. J Clin

Periodontol 2007;34:1089-96.

21. Sarment DP, Meraw SJ. Biological space

adaptation to implant dimensions. Int J Oral

Maxillofac Implants 2008; 23:99-104.

22. Weiner S, Simon J, Ehrenberg DS, Zweig

B, Ricci JL. The effects of laser micro

textured collars upon crestal bone levels of

dental implants. Implant Dent 2008;

17:217-28.

23. Luongo R, Traini T, Guidone PC, Bianco

G, Cocchetto R, Celletti R. Hard and soft

tissue responses to the platform switching

technique. Int J Periodontics Restorative

Dent 2008 Dec; 28(6):551-557.

24. Degidi M, Iezzi G, Scarano A, Piattelli A.

Immediately loaded titanium implant with a

tissue-stabilizing/maintaining design (‗beyond

platform switch‘) retrieved from man after 4

weeks: a histological and histomorphometrical

evaluation. A case report. Clin Oral Implants

Res 2008; 19:276-82.

25. Hsu JT, Fuh LJ, Lin DJ, Shen YW, Huang HL.

Bone strain and interfacial sliding analyses of

platform switching and implant diameter on an

immediately loaded implant: Experimental and

three-dimensional finite element analyses. J

Periodontol 2009 Jul; 80(7):1125-32.

26. Tabata LF, Assunção WG, Adelino Ricardo

Barão V, De Sousa EA, Gomes EA, Delben JA.

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approach using two-dimensional finite element

analysis. J Craniofac Surg 2010; 21(1):182-187.

27. Rodríguez-Ciurana X, Vela-Nebot X, Segalà-

Torres M, Calvo-Guirado JL, Cambra J,

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interimplant distance on the height of the

interimplant bone crests when using platform-


Restorative Dent 2009; 29:141-51.

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bone level diameter shifting at implant-

abutment interface. Implant Dent 2009; 18:239-

248.

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Biomechanical analysis on platform switching:

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Implants Res. 2007 Oct; 18(5):581-4. Epub

2007 Jun 30.

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1849



ijcrr

Vol 04 issue 03

Category: Research


Revised on:15/10/11


ABSTRACT Objective: To find out and understand the common causes of neonatal deaths using verbal autopsy as

a tool. Method: Open ended verbal autopsy Questioner Method applied to a cross section of 47

neonatal deaths that occurred in previous 6 months (Nov. 05 – April 06). Study was carried out on

purposively selected villages of four talukas of Vadodara district of Gujarat in India, during May

2006 to August 2006. Results: Out of 47 were neonatal deaths 36.2% died due to prematurity,

21.3% due to Birth Asphyxia and 10.6% of deaths were due to Septicemia. Deaths on the first day

were 42.6%; of whom 40% died due to birth asphyxia and 45% due to prematurity. Conclusion:

Using verbal autopsy tools, Common causes of neonatal deaths found, were prematurity, birth

asphyxia and sepsis. More number of deaths occurred during first day of life.

______________________________________________________________________

Keywords: verbal autopsy, neonatal deaths,

causes

INTRODUCTION

Each year, 20 percent of the world‘s infants-an

awesome 26 million-are born in this vast and

diverse country. Of this number, 1.2 million die

before completing the first four weeks of life, a

figure amounting to 30 percent of the 3.9

million neonatal deaths worldwide. India is

home to the highest number of both births and

neonatal deaths of any country in the world.

The current neonatal mortality rate (NMR) of

44 per 1,000 live births accounts for nearly

two-thirds of all infant mortality and half of

under-five child mortality. Over one-third of all

neonatal deaths occur on the first day of life,

almost half within three days, and nearly three-

fourths in the first week and same problem is

faced by Gujarat with NMR of 42 per

1,000(SRS 2000) which share 4.5 percent of

the total NMR burden in India.1

Reducing

neonatal mortality will be necessary for

achievement of the targets set for child

mortality reduction under the United Nations

millennium development goals (MDG) (Haines

and Cassels, 2004)2.

More than two-thirds of the world's population

lives in countries that lack a reliable system for

issuing medical death certificates, leaving the

true scale and distribution of disease in serious

doubt. The main tactic for filling that gap is

verbal autopsy, which assigns a probable cause

of death based on interviews with families

about the deceased's symptoms. ―Verbal

Autopsy‖ is the collection of post-mortem

information about a deceased individual

through questionnaire or interview of

household members, friends and others

(including health care workers) who cared for

the person at home or are familiar with the

circumstances of the death3. Verbal autopsy

methods are most often used in locales where

formal medical care is difficult to access. In

such locales, deaths often occur at home and

official records are inconsistently available.

NEONATAL MORTALITY – AN EXPERIENCE BY

VERBAL AUTOPSY

Shaikh Mohsin1, Pathan Sameer

2

1Qassim University of Kingdom of Saudi Arabia

2Indian Institute of Public Health (Public Health Foundation), New Delhi




Verbal autopsies may provide important public

health information about factors related to

deaths and actions taken to address the medical

problems and prevent the death. Investigators

must adhere to cultural norms and sensitivities

when approaching and asking for information

from family members and other informal

caregivers of the deceased person. Study teams,

especially research interviewers who will

conduct these interactions, require training in

local customs about these issues, particularly

regarding awareness of the pressures on

respondents to portray situations in a particular

manner, sensitivity to the distress respondents

may feel related to the interview/questionnaire,

and approaches for handling high levels of

distress. Cause-of-death data derived from

verbal autopsy (VA) are increasingly used for

health planning, priority setting, monitoring

and evaluation in countries with incomplete or

no vital registration systems. In some regions of

the world it is the only method available to

obtain estimates on the distribution of causes of

death. Currently, the VA method is routinely

used at over 35 sites, mainly in Africa and

Asia. The exact cause of death can be known

by postmortem autopsy. However, this is not

feasible on a large scale, particularly in

developing countries like India. In this difficult

situation, a post death analysis by verbal

autopsy is used as a proxy to determine the

possible causes of death. In this research we

used VA as a research tools to investigate the

neonatal deaths.


The present study was undertaken on selected

four talukas of Vadodara district (e.g. Chota

Udepur, Pavi- Jetpur, Kawant and Naswadi),

where a partnership was initiated between the

Health Department of Government of Gujarat

and a local NGO- Deepak Charitable Trust. The

study area covered 25 villages (out of

approximately 200 total villages of each

talukas) each in the selected four talukas,

spread over 29 PHCs and 4 CHCs which have

been designated First Referral Units (FRUs)

under RCH. Each of the taluka had one taluka

coordinator (TC) and 14 outreach worker

(ORWs), initial survey was carried out by

ORWs who identified the infant deaths and

finally TC and a team of doctors (Resident

Doctors of PSM dept. and Pediatric Dept. of

Medical College Baroda) went out there and

carried out verbal autopsy of neonatal deaths

that occurred in previous 6 months (Nov. 05 –

April 06). Study period consists of 4 months of

data collection from May ‘06 to August ‘06.

Final confirmation of verbal autopsy was

verified by associate professors of PSM dept.

and Pediatric dept. of Medical College Baroda).

Prior consent was taken for verbal autopsy

procedure. The standard verbal autopsy

questionnaire suggested by WHO3 was used for

the same. Questionnaire was administered to

the care giver (usually the mother) of the child.

The questions were explained by the

interviewer to the caregiver in local language.

Sufficient time was given to recall the events

during illness. It usually took 60 minutes to

complete an interview. Diagnosis was made on

the basis of the answer given by the caregiver

to the questions asked in the questionnaire.

Open-ended questions were freely probed to

follow up particular aspects as required. This

descriptive account also was taken into

consideration while arriving at the diagnosis.

Total no. deliveries (whether home delivery or

institutional delivery) occurred in Pavi

jetpur(2535), Chota Udepur(2692), Naswadi

(796) and Kawant(1053) during april 2004 to

march 2005 were reported by district health

office of baroda and with that information in

background we carried out this verbal autopsy.

RESULTS

Out of the 47 neonatal deaths reported (42.6 %

- Pavi jetpur, 23.4 % - Chota Udepur, 17 % -

Naswadi and 17 % Kawant), 36.2 %( 17) died

due to prematurity, 21.3 %( 10) due to Birth

Asphyxia and 10.6 % (5) of deaths were due to

Septicemia. Deaths on the first day were 42.6

% (20); of whom 40 %( 8) died due to birth

asphyxia and 45 %( 9) due to prematurity.



In 72.4% cases death occurred in early neonatal

period. 59.6 % patients were male and 40.4 %

were female. 80.9% mothers had not received

ANC during antenatal period, although TT

coverage was 68.1%. 80.9% deaths occurred in

cases where deliveries were conducted at home,

of which 48.9% deliveries were conducted by

untrained Dais. Treatment was not received in

case of 78.7% neonatal deaths. 29.8% deaths

occurred in case of fifth birth rank or more and

in 66% we found family size of >5 member.

63.8% of the deaths reported were in case of

illiterate mother. No neonates had received any

vaccine.

DISCUSSION

Majority of patients died during first seven

days of whom the majority died in first 24

hours Singhal et al reported 42% of total

neonatal deaths during the first seven days of

life.4 In majority of the cases mothers were

illiterate and received ANC rarely. At the same

time, more number of mothers delivered at

home by untrained die while in over three forth

of the neonatal deaths no treatment was

received. More number of mothers who lost

neonates had a big family size.

CONCLUSION

Common causes of neonatal deaths, as per the

Verbal Autopsy, were Prematurity, Birth

Asphyxia and Sepsis and more number of

deaths occurred during first day of life. Similar

observations have been made in earlier studies

of Singh V and Dutta N et al.5,6

Majority of

deaths occurred where mother had not received

any ANC visit. Birth rank makes a difference

along with the size of the family. The fact that

many babies (42.6%) died within 24 hours of

delivery, sometimes with no recognized

symptoms, indicates the need for early

intervention for those most a risk. The study

identified risk factors that could be identified

during delivery (complications, premature/

small babies, and multiple births). Attendants at

delivery could have a key role if trained in

resuscitation and through notifying paramedics

about high risk babies to be given an immediate

post-natal check-up in the home. This may be

feasible in areas served by NGOs, where efforts

can be augmented. Increasing the number of

institutional deliveries would be a relevant

strategy for the same.

ACKNOWLEDGEMENT

Author acknowledges with thanks the support

of Government of Gujarat & Deepak charitable

trust. Author acknowledges the immense help



manuscript. The author is also grateful to




discussed.

REFERENCES

1. Dadhich JP, Paul VK, State of India‘s

Newborns, National Neonatology Forum &

Save the Children. Available from

URL:http://www.savethechildren.org/publi

cations/technicalresources/saving-newborn-

lives. Accessed on February 1, 2007.

2. Haines A and Cassels A. Can the

millennium development goals be attained?

BMJ. 2004, 329: 394-397.

3. Martha et al., A Standard Verbal Autopsy

Method for Investigating Causes of Death

in Infants and Children, Department of

Communicable Disease Surveillance and

Response, WHO/CDS/CSR/ISR/99.4,

Accessed at

http://www.who.int/csr/resources/publicati

ons/surveillance/whocdscsrisr994.pdf on

January 1 2006.

4. Singhal PK, Mathur GP, Mathur S, Singh

YD, Neonatal Morbidity and Mortality in

ICDS urban slums. Indian pediatrics, 1990,

27: 485-488.

5. Singh V, Sachdev HPS, Mittal O, Sethi

GR, Choudhury P, Ramji S, et al., Causes

of under five mortality in Delhi slums _ An

evaluation by Verbal Autopsy technique:

in: 8th Asian Congress of Pediatrics



Scientific Abstracts. Eds. Chaudhary P,

Sachdev HPS, Puri RK, Verma I.C. Jaypee

Brother, New Delhi, 1994. p 135.

6. Dutta N, Mand M, Kumar V. Validation of

causes of infant death in the community by

autopsy. Indian J Pediatrics 1988; 55; 599-

604.

Table 1 Total number deliveries occurred during April 2005 to March 2006 in

selected 4 talukas of Vadodara district - India.

Name of Taluka Total No. of deliveries

Pavi Jetpur 2535

Chota Udepur 2692

Naswadi 796

Kawant 1053

Table 2 – Causes of Neonatal Mortality

SIDS – sudden infantile death syndrome

AGE – acute gastroenteritis

Illustration:

PSM – Preventive and Social Medicine

PHC – primary health care

CHC – community health center

SC - sub center

ANC – antenatal care

TT – tetanus toxoid

VA – verbal autopsy

NGO – Non Government Organization

No Causes 1st day of life 0-7 days 8-28 days 0-28 days

(Total)

Immediate Early Late Neonatal

1 Septicemia 0 2 3 5 (10.6%)

2 Prematurity 9 15 2 17 (36.2%)

3 Bronchopneumonia 1 2 1 3 (6.4%)

4 Birth asphyxia 8 9 1 10 (21.3%)

5 Hypothermia 1 2 0 2 (4.3%)

6 Neonatal seizures 0 1 0 1 (2.1%)

7 SIDS 0 1 1 2 (4.3%)

8 AGE 0 0 1 1 (2.1%)

9 Congenital anomaly 1 2 2 4 (8.5%)

10 Severe dehydration 0 0 1 1 (2.1%)

11 Intestinal obstruction 0 0 1 1 (2.1%)

Total

20 (42.6%)

34 (72.4%)

13 (27.6%)

47



ijcrr

Vol 04 issue 03

Category: Case Report


Revised on:28/12/11


ABSTRACT The form function and pathofunction of the dynamic masticatory system comprises one of the most

fascinating, basic and important areas of interest in dentistry. The explosion of technological and

procedural advances coupled with improved materials herald a new age in dentistry. In this age of the

‗esthetic revolution‘ and the ‗extreme makeover‘ factors that control occlusal stability are usually

overlooked. Even though a full-mouth reconstruction can be relatively complex, it does not have to be

a long or complicated process in patient‘s perspectives. The severe wear of anterior teeth facilitates

the loss of anterior guidance, which protects the posterior teeth from wear during excursive

movement. The collapse of posterior teeth also results in the loss of normal occlusal plane and the

reduction of the vertical dimension. This case report describes prosthetic rehabilitation using the

Hobo and Takayama twin-stage procedure for a patient with esthetically and functionally

compromised dentition. The final prosthesis with this twin-stage procedure ensured a restoration with

a predictable posterior disclusion and anterior guidance in harmony with the condylar path.

__________________________________________________________________________

Keywords: Full mouth rehabilitation, Hobo‘s

twin stage, Effective cusp angle, Posterior

disocclusion.

INTRODUCTION

Though the full-mouth rehabilitation and its

philosophies are often intrigue in nature, but

the esthetic and functional accomplishment of

rehabilitation is always satisfying. The gradual

wear of the occlusal surfaces of teeth is a

normal process during the lifetime of a patient.

However, excessive occlusal wear can result

in pulpal pathology, occlusal disharmony,

impaired function, and esthetic disfigurement.

Tooth wear can be classified as attrition,

abrasion, and erosion depending on its cause.

A differential diagnosis is not always possible

because, in many situations, there exists a

combination of these processes. Therefore, it is

important to identify the factor that contribute

to excessive wear and to evaluate alteration of

the vertical dimension of occlusion (VDO)

caused by the worn dentition. As teeth are

worn, the alveolar bone undergoes an adaptive

process and compensates for the loss of tooth

structure to maintain the vertical dimension of

occlusion. Therefore, vertical dimension of

occlusion should be conservative and should

not be changed without careful approach.

Anterior guidance is crucial in human

occlusion because it influences molar

disclusion that controls horizontal forces. This

case reports the satisfactory clinical outcome

achieved by restoring the vertical dimension

with an improvement in esthetics and function.

In this case Hobo-Takayama method was

incorporated for creating molar disclusion

using a twin-stage procedure.

ESTHETIC AND FUNCTIONAL REHABILITATION OF

THE PATIENT WITH SEVERELY WORN DENTITION

USING TWIN STAGE PROCEDURE: A CASE REPORT

Naresh HG Shetty1, Manoj Shetty

2, Krishna Prasad D.

3

1Senior Lecturer, Al Azhar dental college, Thodupuzha, Kerala

2Professor, Department of prosthodontics, A B Shetty Memorial institute of

dental sciences, Mangalore 3Professor and Head of the Department, Department of prosthodontics, A B

Shetty Memorial institute of dental sciences, Mangalore


mailto:[email protected]



CASE REPORT

A healthy 44 year-old woman patient was

reported to the department of prosthodontics,

A B Shetty Memorial Institute of Dental

Sciences, Mangalore, Karnataka, India, with a

chief complaint of severely worn dentition,

unpleasant smile, generalized sensitivity and

difficulty in chewing(Fig 1) .The medical

history was non-contributory. The patient‘s

dental history indicated faulty tooth brushing

habit, and extraction of 25,36 due to caries

.The patient denied for any symptoms of

temporomandibular joint disorder or

myofacial pain dysfunction syndrome.

Clinical findings

Extra oral findings; The patient had no gross

facial asymmetry, muscle tenderness. The

temporomandibular joints, muscles of

mastication, and facial expressions were

asymptomatic

Intraoral findings; The maxillary and

mandibular arch were partially dentate with

tooth 25, 36, 38, missing. No gross

abnormalities were noted in the overall soft

tissues of the lips, cheeks, tongue, oral

mucosa, and pharynx.

Occlusion; Generalized severe attrition was

noted. The patient presented with bilateral

class I molar and the patient‘s lateral

excursions showed canine guided occlusion.

The patient was diagnosed with severe

attrition with loss of vertical dimension.

Treatment goals

To restore the entire severely worn

dentition to function and optimal esthetics

Centric relation occlusion with maximum

number of tooth contacts with no change in

established vertical dimension

To develop a canine guided occlusion

Twin stage procedure to produce a definite

amount of disocclusion during eccentric

movements

Treatment procedure

The patient received oral prophylaxis, and

reinforcement of oral hygiene practises.

Patient was advised for intentional root canal

therapy for 31, 32, 41, and 42 due to decreased

tooth structure. As there was clinical

evaluation of reduced vertical dimension of

occlusion, full mouth rehabilitation with

increasing vertical dimension of occlusion was

planned. Patient‘s informed consent was taken

prior to treatment.

Two sets of diagnostic impressions were made

using irreversible hydrocolloid

and diagnostic casts were obtained. Maxillary

casts were mounted using an earpiece facebow

(Hanau springbow no. 0103280) onto a Hanau

arcon articulator (ALL 182/183 Wide –Vue

series, Waterpik, USA) and mandibular cast

was mounted using interocclusal aluwax

(Aluwax dental products, Michigan, USA)

record. Diagnostic wax up was prepared to

proper size shape and contour (Fig 2).

Mandibular posterior occlusal plane was

analysed using occlusal plane analyser (Fig 3).

On analysis all mandibular teeth followed the

curve of spee. Maxillary left third molar was

supraerrupted which required occlusal

correction. Mandibular anterior teeth required

intentional root canal treatment followed by

post and core .Maxillary occlusal wax up was

done to maximum intercuspation. Anterior

wax up was checked for proper anterior

guidance to achieve disocclusion in eccentric

movements

Meanwhile a maxillary occlusal splint was

fabricated at an increased occlusal vertical

dimension of 2 mm using heat cured acrylic

resin. The occlusal splint was inserted and

adjusted. Two weeks later the patient reported

with no difficulties in adapting to the new

position. Hence full mouth rehabilitation was

planned at increased vertical dimension of

2mm.

Tooth preparations for metal ceramic crowns

were completed for the entire dentition (Fig

4). A final full arch impression for maxillary

and mandibular teeth was made using poly

vinyl siloxane (Express™ XT ,3M ESPE)

impression material with double mix single

impression technique (Fig 5). The casts were

poured in die stone (Kalrock; Kalabhai

Pvt.Ltd, Mumbai, India), which was later

http://www.google.co.in/url?sa=t&source=web&cd=3&ved=0CCgQFjAC&url=http%3A%2F%2Fsolutions.3m.com%2Fwps%2Fportal%2F3M%2Fen_AE%2F3M-ESPE%2Fdental-professionals%2Fproducts%2Fcategory%2Fimpression%2Fexpress-2%2F&ei=cYA0TbzsGY23rAff_qXZCA&usg=AFQjCNESGgz5P8Km-s8xDmKhEDGyxWAaPQ



secured to a die lock tray. This assembly was

mounted on a Hanau arcon articulator using

face bow (Hanau springbow).Mandibular die

lock tray was mounted using centric

interocclusal record made in aluwax at

previously determined vertical dimension.

Provisional crowns were made (Protemp II,

3M ESPE dental products, St Paul, USA) from

diagnostic wax up. Provisional restorations

were cemented using zinc oxide non eugenol

temporary cement (Temp bond cement, Kerr,

USA). Articulator was programmed to

condition I twin stage procedure (As in Table

1) maxillary and mandibular anterior segment

was removed, and posterior teeth wax build up

was completed to achieve balanced

articulation, which helped in achieving

standard effective cusp angle of 25‘.(Fig

6)Then anterior wax build up was carried out

after the values had been adjusted to condition

II of twin stage procedure (Table 1) to achieve

an incisal guidance of 40‘which produced a

standard amount of disocclusion.(Fig 7)

All wax patterns were cast and metal units

were tried in and adjusted for proximal

contacts and occlusion. Definite restorations

with porcelain fused to metal crowns

exhibiting vital and natural appearance with

proper contour were designed. Completed

porcelain fused metal crown showing posterior

balanced articulation (Condition I)(Fig 8) and

uniform disocclusion Condition II)(Fig 9),and

intra orally showing the

same(Fig10).Permanent cementation was done

with glass ionomer Type 1 (GC Goldlabel, GC

Group. Tokyo luting cement). Oral hygiene

instructions were reviewed, emphasizing

brushing habits and the use of floss for better

maintenance of the prosthesis. Follow-up was

carried out at regular intervals and the patient's

post-operative condition was satisfactory (Fig

11, 12)

DISCUSSION

Aesthetic and functional restoration of the

severely worn dentition represents a

significant clinical challenge. The

complications with severely attrited teeth

demand a circumspect treatment plan and

proper sequencing of therapy to ensure an

optimal result for both the patient and the

clinician. Proper treatment sequencing is

critical when a patient requires multiple fixed

restorations. The vertical dimension, centric

relation, and occlusal plane must be

determined first, followed by a diagnostic wax

up which is essential for fixed prosthesis. An

accurate diagnostic and interdisciplinary

approach is necessary for obtaining improved,

conservative and predictable results. Full

mouth rehabilitation seeks to convert all

unfavourable forces on the teeth which

inevitably induce pathologic conditions, into

favourable forces which permit normal

function and therefore induce healthy

conditions.

A variety of techniques may be used in

simultaneous constructions to obtain complete

arch dies and mounted casts. When all of the

prepared teeth are on a single articulator, there

is flexibility in developing the occlusal plane,

occlusal theme, embrasures, crown contour,

and esthetics. The chairside disadvantages

include 1 arduous, unpredictable patient visits,

2 full arch anaesthesia,

3 full arch chairside

treatment restorations,4 multiple occlusal

records, and 5,6,7

possible loss of the vertical

dimension of occlusion. An alternative

approach to the full-mouth simultaneous

reconstruction is to complete one quadrant

before beginning another. The advantages of

this approach are that it is primarily chairside

and includes preparation and final impressions

of select teeth, maintenance of vertical

dimension, quadrant anaesthesia, and shorter,

predictable appointments. The disadvantages

of the quadrant reconstruction include

restrictions for achieving ideal occlusion when

altering the vertical dimension, occlusal plane,

and embrasure development. The existing

opposing dentition limits the reconstruction of

an isolated quadrant. Esthetic consistency can

be compromised because the porcelain

restorations are made in stages. The



advantages of the simultaneous and quadrant

full-mouth reconstruction are combined in the

present technique.8

The mechanism of anterior

guidance was reviewed from recent

mandibular movement studies to provide a

basis for understanding the twin-stage

technique, which is a practical method for

establishing anterior guidance from the

condylar path. 9,10

Hobo and Takayama studied the influence of

condylar path, incisal path and the cusp angle

on the amount of disocclusion. They

concluded that cusp angle was the most

reliable and was used as a new determinant of

occlusion. Twin stage procedure proposed by

Hobo and Takayama was adopted for wax

build up because studies have proposed that it

is possible to accurately control the amount of

disocclusion on the restoration without

measuring the condylar path.

Anterior guidance and the condylar path

previously were considered independent

factors. It is an established fact that anterior

guidance influences the working condylar path

and even changes when the lateral incisal path

deviates from the optimal orbit. This supports

the hypothesis that anterior guidance and the

condylar path are dependent factors. In setting

anterior guidance, it is recommended to set the

working condyle so that it moves straight

outward along the transverse horizontal axis.

The angle of hinge rotation produced by the

angular difference between anterior guidance

and the condylar path assists posterior

disclusion but is not solely responsible. The

anatomy of the cusps is created by establishing

the appropriate form of the posterior cusps

aligned to the condylar path; thus it also

contributes to posterior disclusion. Posterior

disclusion is crucial in controlling harmful

lateral forces but the factors that determine the

precise amount of disclusion have not been

established.10

As followed in this case twin

stage procedure helps in achieving a standard

disocclusion of 1 mm on protrusion, 1mm on

non working side, and 0.5 mm on working

side in centric movements at 3mm protrusion

from centric relation.

ACKNOWLEDGEMENT




manuscript. The authors are also greatful 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. Kazis H. Complete mouth rehabilitation

through restoration of lost vertical

dimension. J Am Dent Assoc 1948; 37:19-

39.

2. Hausman M, Hobo S. Occlusal

reconstruction using transitional crowns. J

Prosthet Dent 1961; 11:278-87.

3. Braly BV. A preliminary wax-up as a

diagnostic aid in occlusal rehabilitation. J


4. Hobo S. A kinematic investigation of

mandibular border movement by means of

an electronic measuring system: Part II: A

study of the Bennett movement. J Prosthet

Dent 1984; 51:642-6.

5. Hobo S. A kinematic investigation of

mandibular border movement by means of

an electronic measuring system: Part III:

Rotation centre of lateral movement. J


6. Hobo S. Formula for adjusting the

horizontal condylar path of the

semiadjustable articulator with

interocclusal records: Part I: Correlation

between the immediate side shift, the

progressive side shift, and the Bennett

angle. J Prosthet Dent 1986; 55:422-6

7. Hobo S. Formula for adjusting the

horizontal condylar path of the

semiadjustable articulator with

interocclusal records: Part II: Practical

evaluations. J Prosthet Dent 1986; 55:582-

8



8. Binkley TK, Binkley CJ. A practical

approach to full mouth rehabilitation. J


9. Hobo S, Takayama H. Effect of canine

guidance on the working condylar path.

Int J Prosthodont 1989; 2:73-9

10. Hobo S. Twin-tables technique for

occlusal rehabilitation: Part I: Mechanism

of anterior guidance. J Prosthet Dent

1991; 66:299-303

Table 1: Articulator adjustment values for the twin stage procedure

Condition

Condylar path Anterior guide table

Sagittal condylar path

inclination

Bennett angle Sagittal inclination Lateral wing angle

Condition 1;without

anterior teeth

25 15 25 10

Condition 2;with

anterior teeth

40 15 45 20

Figure 1: Preoperative view

Figure 2: Maxillary and mandibular diagnostic wax up



Figure 3: Occlusal plane analysis Figure 4: Maxillary and mandibular tooth preparation

Figure 5: Maxillary and Figure 6: Condition I(Cusp angle 25’)

mandibular impressions

Figure 7: Condition II with canine guided occlusion

Figure 8: Completed PFM crowns(Condition I)



Figure 9: Completed PFM crowns with canine guided occlusion

Figure 10: Intra orel view showing uniform disclusion

Figure 11: Intra oral view of cemented PFM crowns

Figure 12: Pre and postoperative view



ijcrr

Vol 04 issue 03

Category: Review


Revised on:31/12/11


ABSTRACT Yoga and Meditation techniques are growing popular worldwide in preventing or reducing

cardiovascular diseases. We reviewed the latest studies and recent literature concerning the use of

yoga in the treatment of cardiovascular disorders. The studies of yoga therapy on acute and chronic

hypertensive patients showed significant reduction in stress,stress related blood pressure, blood

cholesterol level and body weight. The studies showed significant improvement in cardiovascular

endurance and reduction in left ventricular mass. The purpose of this review is to evaluate the effect

of yoga therapy on hypertension, obesity and coronary heart disease.

______________________________________________________________________

INTRODUCTION

Yoga is an ancient cultural heritage of India,

designed to bring balance and health to the

physical, mental, emotional, and spiritual

dimensions of the individual. Yoga is often

depicted as a tree comprised of eight limbs,

such as yama (universal ethics), niyama

(individual ethics),asana (physical postures),

pranayama (breath control), pratyahara(control

of the senses), dharana (concentration),

dyana(meditation), and samadhi (bliss)1.Yoga

is described as comprising a rich treasure of

physical and mental techniques that can be

effectively used to create physical and mental

well-being through down-regulation of the

hypothalamic–pituitary–adrenal (HPA) axis

and the sympathetic nervous system (SNS).

As shown in fig 1,The HPA axis and SNS are

triggered as response to stress, leading to a

cascade of physiologic, behavioral, and

psychologic effects, as a result of the release

of cortisol and catecholamines. The repeated

firing of the HPA axis and SNS due to stress

can lead to dysregulation of the system and

ultimately produce diseases such as diabetes,

autoimmune disorders, depression, substance

abuse, and cardiovascular disorders.

Numerous studies have shown yoga to have an

immediate downregulating effect on both the

SNS and HPA axis response to stress2.

EVALUATION OF YOGA THERAPY FOR THE RISK

FACTORS OF CARDIOVASCULAR DISORDERS-A

REVIEW

Deepa.T1, N.Thirrunavukkarasu

2

1Saveetha dental college, Saveetha university

2TS 82/4,Achuthan nagar, Ekkaduthangal, Chennai




FIG. 1. The impact of stress on the hypothalamic–pituitary–adrenal axis and the sympathetic nervous

system2.

Yoga has been extensively studied for its

various effects in reducing salivary cortisol,

blood glucose, as well as plasma renin levels

and 24-hour urine norepinephrine and

epinephrine levels3. yoga reverses the negative

impact of stress on the immune system by

increasing levels of immunoglobulin A as well

as natural killer cells .Yoga has been found to

be useful on reducing BMR4,5

, improvement in

respiratory capacity 6and shift of autonomic

balance toward parasympathetic nervous

system dominance, possibly via direct vagal

stimulation7. It is also found to be useful in

treatment of diabetes8, asthma

9, epileptic

seizures10

and in anxiety disorders 11

.Yoga

employs simple postures (asana), controlled

breathing exercise(Pranayama)and meditation

admixed in varying proportions.

History of yoga

The origin of yoga is estimated to date back

to the period between 200 BC and 300 AD,

was written by a historically renowned yoga

teacher and Hindu philosopher named

Patanjali. The ancient Indian classic on the

practice of yoga, Gherananda–Samhita,

mentioned out of 840,000 asanas, only 84 are

in contemporary common practice. Of these,

only 32 are recommended by this ancient text

as being useful for regular practice28

.

Pranayama involves a slow deep inspiration

and the breath is held momentarily in full



inspiration, followed by slow and

spontaneous exhalation.

Hypertension and its management

Hypertension is the most common

cardiovascular disease affecting more than one

billion people throughout the world. It is a

major contributor of stroke, ischemic heart

disease, heart failure, renal dysfunction and

blindness43

.The seventh Joint National

Committee on Detection, Evaluation, and

treatment of high blood pressure (JNC VII

2003) defined hypertension as a systolic blood

pressure (SBP) of 140mmHg or greater and

diastolic blood pressure (DBP) of 90mmHg or

higher. Hypertension is further classified into

two groups based on etiology as essential or

primary hypertension and secondary

hypertension. Essential hypertension is

diagnosed when there is strong family history

and no identifiable cause can be found42

.

Hypertension is almost always easy to treat

but difficult to keep under control as blood

pressure is a continuous variable12

. The goal of

treatment is to lower the blood pressure as

early as possible and maintain it, thereby

preventing major complications of systemic

hypertension. Drugs are prescribed as first line

choice of treatment due to their significant,

cost-effective, immediate action on reducing

blood pressure. The utility of these agents is

limited by the narrow range between

therapeutic and toxic doses. These often

produce dose dependent side effects, adverse

reactions and rebound or overshoot

hypertension when drug therapy is

discontinued suddenly.13

The side - effects, life

long medical regimen, and cost of drugs have

stimulated the search for a non-drug therapy as

a primary treatment or as adjunctive

therapy.Many non-pharmacological measures,

such as 100mmol/day reduction in sodium

intake, have been associated with a decline in

blood pressure of about 5–7mmHg

(systolic)/2.7mmHg (diastolic) in hypertensive

subjects. Regular physical exercise such as

walking is added along with drugs for its

effect in managing hypertension. Many mind-

body interventional methods like relaxation,

biofeedback, stress management along with

lifestyle modification have been shown as

potential treatment for BP. Relaxation

therapies alone doesn‘t show significant result

in reducing BP. Hence progressive muscle

relaxation techniques are not considered as an

effective treatment method for high blood

pressure . In contrast, Stress management

therapies have some merits but are not widely

available nor practiced. Studies on various

non- drug modalities have shown more

benefits from Yoga and Meditation in long

term control of hypertension than any other

modality.14,15

.

Table-1 Studies of yoga and meditation on high blood pressure, Lipid profile, heart rate and body

weight

Author Name Year Type of

intervention

Used technique and Findings

Patel C and North 1975 Yoga and

biofeedback

compared to

general relaxation

Yoga showed reduction of B.P. maintained even

after 12 months40

Stone and Deleo 1976 Meditation The average drop in mean arterial pressure was

12mm of Hg after 6 months and showed decrease in

dopamine beta hydroxylase enzyme and plasma

Renin activity41

Agarwal et al 1977 Shavasana on

hyperreactors

usingCold Pressor

Test

Reduction of the rise in B.P due to cold application 34

Andrews et al 1982 Various non drug

treatments

Found yoga and meditation to be effective in long

term control of B.P14



Table-1 Studies of yoga and meditation on high blood pressure, Lipid profile, heart rate and body

weight

Author Name Year Type of

intervention

Used technique and Findings

Khanam et al 1996 yoga Decrease in heart rate and decrease in diastolic

blood pressure after Isometric Hand Grip test39

Schmidt et al. 1997 Yoga for 3 months

on healthy adults

Significant reduction in Urinary stress hormone

levels, body mass index,lipid profile27

Mahajan et al 1999 Yoga in Ischemic

heart disease

patients for 14

weeks

Reduction in lipid profile, body weight25

Jennifer et al 2000 Simplified

pranayama

Decrease in mean arterial pressure and heart rate38

Murugesan et al 2002 Selected yoga

practices for

11weeks

Yoga and drug group showed greater B.P. reduction

compared to only yoga group and drug group16

Damodharan et al 2002 yoga Reduction in VMA catecholamines and blood

glucose level36

Bharshankar et al 2003 yoga Reduction in pulse rate and increase in valsalva ratio

in yoga people44

Vijayalakshmi et al 2004 yoga Decrease in diastolic pressure,heart rate and rate

pressure product after hand grip17

test

Malhotra et al 2004 Yoga and OM

meditation in

normotensives

Improvement in cardiovascular performance and

increase in melatonin levels45

.

Bijlani et al 2005 8 day yoga

programme

Reduction in lipid profile except HDL35

Geetanjali et al 2007 Effect of

shavasana after

cold pressor test

The rise in parameters induced by stress test was less

in shavasana practitioners37

Indla Devasena et al 2011 Yoga Reduction in BP and heart rate31

Yoga therapy on hypertension

It has been demonstrated in a randomised

controlled Studies ,that even a short period of

yoga intervention (3 months ) is as effective

as drug therapy in reducing high blood

pressure16

and heart rate31

. The mechanism of

yoga-induced blood pressure reduction may be

attributed to its beneficial effects on the

autonomic neurological function. Impaired

baroreflex sensitivity has been increasingly

postulated to be one of the major causative

factors of essential hypertension. Regular

practice of yoga increase the baroreflex

sensitivity and decrease the sympathetic tone,

thereby restoring blood pressure to normal

level in hypertensive subjects17

. Similarly, the

decrease in sympathetic activity seen with

slow breathing might be beneficial in

hypertension, where sympathetic activation

has been linked to disturbed breathing patterns

and increased chemoreflex activity29

.

Meditation by modifying the state of anxiety

reduces stress induced sympathetic over

activity , decreases the arterial tone and

peripheral resistance, that lead to reduction in

diastolic blood pressure and heart rate. This

ensures better peripheral circulation and blood

flow to the tissues18,19

. Meditation is

associated with reduced sympathetic

adrenergic receptor sensitivity,which might

affect cardiovascular response during stress.

During meditation appearance of frontal

midline theta rhythm in electroencephalogram

reflects mental concentration as well as

meditative state of relief from anxiety and is

correlated negatively with sympathetic

activation. This suggests a close relationship

between autonomic functions and activity of

medial frontal neural circuitry and possibility



of controlling CNS functions through yoga

and meditation20

. Transcendental meditation

(TM) practice improves mood state,

adrenocortical activity and kidney functions

and believed to reduce stress and shows

significant reduction in ambulatory diastolic

BP21

.

Yoga on chronic hypertension

Yoga has proven its effect in modifying

secondary complications produced by chronic

hypertension. Left ventricular hypertrophy is

a common consequence seen due to systemic

hypertension.This may lead to many chronic

cardiac complications, such as myocardial

ischaemia, congestive cardiac failure and

impairment of diastolic function. Left

ventricular hypertrophy due to systemic

hypertension is indicated by the height of ‗R‘

wave in lead I, aVL, V5 and V6 in

electrocardiogram. In one study The height of

‗R‘ wave was taken prior to yoga practice and

three months after continuation of yoga

practice. The height of ‗R‘ wave has come

down appreciably in some patients indicating

the reduction of left ventricular mass22

.

Effect of yoga on body weight

Weight also has the strongest independent

correlation with the risk of hypertension.

Yoga has been found to be particularly helpful

in the management of obesity23

. A randomized

controlled study revealed that practising yoga

for a year helped significant improvements in

the ideal body weight and body density3. A

retrospective observational study showed that

a regular practice of yoga for 4 years was

significantly associated with weight loss by

overweight participants24

. After 4-day

residential yoga practice followed by 14

weeks of 1 h daily home practice, one study

found a significant loss in mean body weight

from 72.26 to 70.48 kg among subjects with

risk factors for coronary artery disease25

.

Other studies confirmed that yoga was

associated with significant weight loss by

subjects with Coronary artery disease. After

one year yoga practice coronary artery

diseased patients showed a 7% loss of body

weight26

and in a study by Schmidt and

colleagues, healthy adults lost an average of

5.7 kg after 3 months of yoga practice27

.

Effect of yoga on coronary artery disease

Systemic hypertension is one of the risk factor

for developing coronary artery disease.

Participants with risk factors of coronary

artery disease showed reduction in all

parameters such as Blood pressure, LDL, total

cholesterol, triglycerides except high density

lipoprotein.In a randomized controlled study,

patients with angiographically proven

coronary artery disease who practiced yoga

exercise for a period of one year showed a

decrease in the number of anginal episodes per

week, improved exercise capacity and

decrease in body weight28

. Thus yoga exercise

increases regression and retards progression of

atherosclerosis in patients with severe

coronary artery disease26

. Subjects who

practiced pranayama or controlled yogic

breathing could achieve higher work rates

with reduced oxygen consumption per unit

work and without an increase in blood lactate

levels. one study reported the effects of yoga

training on cardiovascular response to exercise

and found yoga training improved the

exercise tolerance to cardiovascular effects.

Yoga on the management of coronary artery

disease showed reduction in sympathetic tone,

decreased peripheral vascular resistance,

improved cardiac output, reduction in heart

rate , blood pressure, and improvement in

cardiovascular endurance3.

Effect of Yogic Practices in Prevention of

Diabetes

Yogic practices reduce body fat and increase

lean body mass, thereby help in improving

insulin sensitivity32

. The reduction in free

fatty acid levels have a significant effect on

beta cell function. hence yogasanas by

preventing beta cell exhaustion may prevent

diabetes. studies have confirmed the benefit of

yoga in the control of diabetes mellitus. All

the studies showed a significant fall in the

fasting and post-prandial blood glucose values

within 3 months and continued to have a



smooth and good control of diabetes during

the period of the study as evidence by a

normal glycosylated hemoglobin and blood

glucose levels33

. The drug requirements were

significantly reduced.

CONCLUSION

The beneficial effects of yoga to the heart

ailments is outstanding. However, the role of

yoga in the management of the hypertension

should be complementary to the conventional

modes of treatment. Regular yoga practice

involving simple postures, relaxation exercise

and respiratory exercise combined with drug

therapy showed superior results compared to

those who did not practice yoga. The reviews

showed that yoga had beneficial effects on

reducing BP , blood cholesterol level and

body weight .It also improves left ventricular

function and cardiovascular endurance.

Considering the scientific evidence discussed

so far, we can postulate that the practice of

yoga triggers neurohormonal mechanisms that

bring about health benefits by suppressing

sympathetic activity. hence we conclude that

yoga can be beneficial in preventing

cardiovascular disease and can play a

complementary role to drug therapy for

hypertension.Any persistent benefits require a

long-term adherence to yoga therapy and

subjects who have continued their programs

even at home showed better results30

.

Additional studies are needed to distinguish

between the different types of yoga and their

various techniques. The optimal duration, the

type of yoga program, and intensity of the

yoga program need to be described clearly in

many studies as they can affect the final

outcome.. Additional studies are needed to

find the effect of yoga on long term as only a

few follow up studies are available. All of

these studies need to use rigorous study

methodologies, including the use of larger

sample sizes, randomized samples, and

blinding of researchers.

ACKNOWLEDGEMENT



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.

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http://www.ncbi.nlm.nih.gov/sites/entrez?Db=PubMed&Cmd=Search&Term=%22Suryavansihi%20%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

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http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Khanam%20AA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Sachdeva%20U%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Guleria%20R%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Deepak%20KK%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://ncpad.org/refs/journals/index.php?id=18606&letter=






ijcrr

Vol 04 issue 03

Category: Research


Revised on:17/12/11


ABSTRACT The main objective of this study was to identify certain lifestyle disorders like diabetes mellitus and

other medical conditions like hypertension and hyperlipedemia in an older adult population and to

verify their relationship with the periodontal health status in the same group of individuals.

A total number of 600 patients between 35-75 years were selected for this study. Their lifestyle habits

were obtained through a questionnaire. It was followed by a periodontal examination, blood pressure

recording and a biochemical analysis of the blood samples taken from them.

Results of MLRA showed that diabetes mellitus, was clearly associated with attachment loss.

Hypertension was not associated with attachment loss, and elevated blood cholesterol levels

(hyperlipedemia) were associated only in univariate models.

It could be concluded that in the selected group of subjects aged 35-75 years, only diabetes mellitus

was associated with attachment loss in this cross-sectional study.

_____________________________________________________________________________

Key words: Melia azedarach, seed, oil.

INTRODUCTION

Melia azedarach L. (Sapindales: Meliaceae),

know as Chinaberry or Persian lilac tree, is a

deciduous tree native to northwestern India

and has long been recognized for its medicinal

and insecticidal properties but yet to be

properly analyzed. This tree typically grows in

the tropical and subtropical parts of Asia, but

nowadays it is also cultivated in other warm

regions of the world because of its

considerable climatic tolerance1. It has been

cultivated since the sixteenth century, chiefly

for ornamental purposes and has become

naturalized in most tropical and subtropical

countries2.

In Traditional Chinese Medicine, the plant is

used as an antiparasitic and antifungal agent,

but many of its constituent compounds have

been found to exhibit a wide range of other

biological properties3-10

. In addition, a number

of potent pharmaceutical limonoids and

triterpenoids have been isolated from fruits

and bark11

. The cytotoxic property of

limonoids is extensive and recent efforts are

designed to investigate the cellular and

molecular mechanisms by which such effects

are exerted in the tumorigenic cell lines12

.

Although the fruits are the poisonous part of

the tree, they have been used traditionally for

the treatment of a variety of diseases, specially

dermatitis and rubella11

. The bark and root-

bark mainly contain tetracyclic triterpenoids,

as well as flavones and anthraquinones, etc.

Pharmacological studies indicate that the bark,

fruit, seed and leaf have the effects of

expelling parasites, suppressing bacteria and

anti-virus, etc13

.

In some parts of Tamil Nadu, India the

decoction of the leaves of the tree is used

under traditional system of medicine to cure

CHARACTERIZATION OF FATTY ACIDS IN MELIA

AZEDARACH L. SEED OIL

R. K. Bachheti1, Himanshu Dwivedi

2, Vikas Rana

3, Indra Rai

1

Archana Joshi4

1Department of Chemistry, Graphic Era University, Dehradun (Uttarakhand)

2Department of Biochemistry C.C.S University, Meerut (U.P.), India.

3Bio-prospecting & Indigenous Knowledge Division, Rain Forest Research

Institute, Jorhat (Assam) 4Department of Environmental Science, Graphic Era University, Dehradun

(Uttarakhand)




the problem of dysmenorrhoea (pain and

discomfort during menstruation). They gave

the suffering patients the decoction of the

leaves of Persian Lilac tree, `Malaivembu' in

Tamil, Melia azedarach and it is known to

cure the conditions very fast.

The object of this study was therefore to

extract oil from Melia azedarach seeds and

assessment of the physical and chemical

characteristics of the oil as a prelude to an

investigation into the scientific basis for its

best end uses.


Collection of plant materials

The seeds of Melia azedarach L. are small

(about 6-7 mm long) and enclosed in a thick

hard bony endocarp commonly known as

stone. The fruits of Melia azedarach were

collected from Sahestra Dhara road,

Dehradun in month of December 2010. The

fruit were cleaned and stones were separated.

The stones were broken manually to obtain

seeds. The seeds were air dried in the shade

for few days and kept in colour bottles until

analyzed.

Extraction of seed oil

100 gm of seeds were grounded into powder

form with high speed blender and dried in an

air circulating oven at 50oC for 1 h. Oil was

extracted from the dried grounded seeds with

petroleum ether (boiling point 60-80oC) using

a Soxhlet extractor. The solvent was distilled

off at 80oC. Oil content was calculated on the

basis of dry seeds weight and expressed in

g/100g.

Analysis of seed oil

Oil density was determined picnometrically,

Refractive index was determined at 25°C with

Abbey Refractometer, viscosity was

determined by Ostwald method14

. The oil

extracted from the seeds was assessed for

various chemical properties. Standard methods

described by Association of Official

Analytical Chemists15

were used for the

determination of moisture, crude fibre and ash

contents of the seed samples. Physical and

chemical analyses of the extracted oil were

carried out by using AOAC methods15

. Iodine

value was determined using Wij‘s method as

reported in AOAC methods15

. The procedures

of Egan et al.16

were adopted for the

estimation of saponification values,

unsaponifiable matter content and acid value

of the oil sample. Protein content in seeds and

oil sample was determined using micro-

Kjeldhal method as described by Allen and

Quarmby17

. A factor of 6.25 was adopted for

protein content estimation. Carbohydrate

content was determined by colorimetric

method17

.

The metal composition Zinc, Iron, and

Manganese of the seeds were determined by

using an Atomic Absorption

Spectrophotometer (Model Varian

240FS+GTA120), after acid digestion.

Calcium and magnesium was determined by

complexometric titration with 0.1M EDTA, by

using Erichome black T indicator and

calculated. Phosphorus was determined by the

precipitation of phosphorus in the form of

phospho molybdate by using the reagent

ammonium molybdate. Precipitate was filtered

from asbestos, then residue obtained was taken

in Conical Flask and dissolved in 0.1 M NaOH

and titrate with 0.1 M HCl by using indicator

Phenolphthalein. Potassium was determined

by flame photometer model No. ESICO 1381

by using the reference standard (Merck) and

calculated on the basis of reading and dilution

of the sample.

GC and GC-MS analysis

The Fatty acids were derivatized by using the

boron trifluoride method as described by

Hisil18

. Samples were injected as 2 µl into a

Nucon model 5700 equipped with 10% DEGS

(Diethylene Glycol Succinate) + 1% H3PO4

constant phase, a flame ionization detector

(FID) and chromosorb G (100/120 mesh)

support matter, internal diameter (2mm) and

stainless steel (190 cm) column. Column

temperature was programmed from 70°C to

200°C with the increasing rate of temperature

6°C/Minute. Injector and detector



temperatures were set at 225°C. Nitrogen (N2)

(25 ml/min) was used as the carrier gas.

Hydrogen (40ml/min) and Air (60ml/min)

were used as burnt and dry gas respectively.

Fatty acid methyl esters were identified by

comparison with fatty acid internal standards,

Individual fatty acid concentration was

expressed as percent


The seeds of Melia azedarach were collected

in the month of December, 2010 from

Dehradun (Uttarakhand), India. The seeds

were dark brown in colour and evaluated for

physical properties. Analysis results of seeds

are given in table-1. Seeds are rich in protein,

oil and fibre. Oil extracted (yield; 39.6

%w/w) from Melia azedarach seeds is dark

brown in colour and free from sediments. It is

liquid at room temperature (27± 2OC). It

contains 20.13% protein, 19.45%

carbohydrates and 15.40% crude fibre. The

physico-chemical properties of Melia

azedarach seed oil is given in table-2. The

results of GC (figure-1) and GCMS analysis of

oil is listed in table-3 and showed that the oil

contain both saturated (9.0226%) and

unsaturated fatty acids (90.9774). The main

acids present in the oil were Palmitic acid

(5.68%), Linoleic acid (74.57%), Oleic acid

(16.39%), Stearic acid (3.33%).

Acid value is an indicator for edibility of oil

and suitability for industrial use. Melia

azedarach seed oil has an acid value 2.25.

This falls within the recommended codex of

0.6 and 10 for virgin and non virgin edible fats

and oil respectively19

. The iodine value of

Melia azedarach oil is 9.14 which indicate

that it is drying oils. The low iodine value in

this study indicate the oil contain low level of

polysaturated fatty acids. The seed oil studied

have a significant saponification value 84.15,

the high saponification value recorded for the

seed oil suggested that the oil contain high

molecular weight fatty acid and low level of

impurities. This is evidence that the oil could

be used in soap making industry20, 21

.

The main chemical component of the fatty

acids in Melia azedarach is Linoleic acid.

Linoleic acid is the essential amino acid, and

be supplied to the human beings only by food

sources. It helps low blood pressure in

hypertensive patients, and also be useful to

protect human cardiac system22, 23

. It is used

for manufacturing margarine, shortening, and

salad and cooking oils as well as soaps,

emulsifier, and quick drying oils24

. The other

main chemical component is Oleic acid, it

reaches 16.39%. Oleic acid is the most

abundant fatty acid in human adipose tissue25

.

Oleic acid may hinder the progression of

adrenoleukodystrophy (ALD), a fatal disease

that affects the brain and adrenal glands26

.

Oleic acid is also responsible for the

hypotensive effects of olive oil27

. As an

excipient in pharmaceuticals, oleic acid is used

as an emulsifying or solubilizing agent in

aerosol products28

. In Melia seed oil the

palmitic acid and stearic acid contributed 5.68

and 3.33% respectively. Palmitic acid is used

in the manufacture of soaps, candle, cosmetic

formulations, food grade additives,

waterproofing agents, lube oils, and non

drying oils (surface coatings). Whereas the

presence of stearic acid in Melia seed oil

indicates the potential use of oil for

pharmaceutical preparations, dietary

supplements, oil pastels, soaps, food

packaging, deodorant sticks, toothpaste and

softening rubber29, 30

.

The mineral composition of Melia azedarch is

summarized in table-4. It is rich in Calcium,

Magnesium, Potassium and Iron which make

it quite suitable as edible and commercial oil.

Considering the results obtained in this

preliminary study, it is noticeable that the

seeds oil had a high content of linoleic acid

and oleic acid and also has a healthy

composition for nutrition. It turned out that

Melia azedarach could be good source of

natural oil rich in Linoleic acid and Oleic acid.

This work might be useful for exploring the

applications of Melia azedarach seeds and its

oil. Further by cultivation and breeding of



capers plants regularly, a more productive

quality raw matter would be obtained.

ACKNOWLEDGEMENT






journals and books from where the literature

for this article has been reviewed and

discussed.

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Cranin D, Campbell B, Avigan J.

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Alvarez R, Bressani R, Halver Je, et al.

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2008; 105 (37): 13811–6.

28. Smolinske S C. Handbook of Food,

Drug, and Cosmetic Excipients. New

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29. Okieimen F E, Eromosele C O. Fatty acid

composition of Khaya senegalensis.

Bioresource Technol. 1999; 69: 279-280.

30. Wootthikanokkhan J, Tunjongnawin P.

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http://www.standardbase.hu/tech/SITechVisc.pdf

http://www.standardbase.hu/tech/SITechVisc.pdf



Table 1. Physicochemical properties of Melia azedarach seeds.

Table 2. Physicochemical properties of Melia azedarach seed oil

Characteristics Values

Colour Dark Brown, clear and transparent

Taste Neutral, free of bitter taste, free of after

taste

Sediments Free of sediments

State at room temperature Liquid

Refractive Index 40

Dn 1.3655

Specific Gravity 25

20d 0.8074 g/cm

3

Yield (%) 39.6

Moisture (%) 6.86

Protein (%) 20.13

Fiber (%) 15.40

Carbohydrate (%) 19.45

Acid Value (mgKOH/g) 2.25

Iodine value 9.14

Saponification value (mgKOH/g) 84.15

Unsaponifiable matter (%w/w) 0.71

Total saturated (%) 9.02

Total unsaturated (%) 90.97

Table 3. Fatty acid composition of Melia azedarach seed oil

Fatty acid %

Palmitic acid (C16:0) 5.68

Linoleic acid (C18:2) 74.57

Oleic acid (C18:1) 16.39

Stearic acid (C18:0) 3.33

Properties Values

1000 seeds (g) 25.4

1000 seeds (ml) 52.0

Colour Brown

Water (%) 6.48

Crude oil (%) 39.6

Crude protein (%) 18.77

Crude fibre (%) 24.77

Ash (%) 3.6513



Table 4. Mineral content (mg/100g) of Melia azedarach seed oil

Mineral Content

Calcium 1230

Magnesium 990

Phosphorous 213

Potassium 121

Zinc 3.12

Manganese 3.4

Iron 19.52

Fig.1. Gas chromatogram of fatty acid profile of Melia azedarach seed oil



ijcrr

Vol 04 issue 03

Category: Research


Revised on:27/12/11


ABSTRACT Introduction: Despite growing vaccine-preventable infections, immunization campaigns still suffer

due to parental resistance. Knowledge and opinion of caregivers about childhood additional vaccines

becomes imperative before we stress upon any such promotion under UIP. Objective: To assess

knowledge and opinion of caregivers regarding childhood additional vaccines in Agartala, Tripura.

Methods: Present study was undertaken during Jul-Dec 2011 in a child clinic at Agartala. Data was

collected using pre-designed and pre-tested proforma by interview technique. Information regarding

background characteristics of parents, source of information, knowledge and opinion regarding

childhood additional vaccines was collected after obtaining written consent. Data analysed using

Microsoft Excel and Epi_Info version 6.04. Chi-square test was used and p<0.05 considered

statistically significant. Results: Information was gathered from parents of 180 children. Doctors

(73.33%) were main source of information followed by television (18.89%). 26.67% and 32.78%

parents respectively knew timing and against which diseases additional vaccines are used. 73.89%

parents reported vaccination as best way to prevent these diseases. 76.11% opined additional vaccines

should be available at govt. hospitals. 46.67% recognized polyvalent vaccines better than monovalent.

Numbers of injections (89.29%), cost (21.43%), numbers of visits (16.67%) and less complications

(15.48%) were cited for such preference. Financial constrain (46.11%), family disagreement (26.67%),

time constrain (20%), fear of complication (18.89%) and non-availability (8.89%) were stated as

barriers. Parents‘ education (69.44%) and economic status (41.11%) were stated as family related

reason for poor acceptance of additional vaccines. Conclusion: Parents‘ knowledge-gap, opinion and

operational issues should be addressed before launching and promoting any childhood additional

vaccine campaign.

____________________________________________________________________________

Keywords: Care givers, Childhood Additional

vaccine, Immunization, Parents

INTRODUCTION

Immunizing children against vaccine

preventable diseases responsible for child

mortality and morbidity is not an easy task. In

a resource poor developing country like India,

the numbers of target population across

geographically diverse regions and difficult

areas make universal immunization a

mammoth task.1 Immunization coverage in

India are still lagging and current level of

‗fully immunized‘ children under the national

immunization programme is quite low, as

pointed by previous studies.2,3

Factors such as

parents‘ knowledge about routine and

additional vaccination and their attitudes

towards them does influence vaccine

coverage. Despite growing and emerging

vaccine-preventable infections, reassurance

from researchers on safety and efficacy of

KNOWLEDGE AND OPINION OF CAREGIVERS

REGARDING CHILDHOOD ADDITIONAL VACCINES

IN AGARTALA, WEST TRIPURA

Majumder Nilratan1, Datta Shib Sekhar

2, Boratne Abhijit Vinodrao

2,

Majumder Nilanjan3, Basu Majumder Chandrika

4

1Dept. of Paediatrics, Agartala Govt. Medical College, Agartala

2Dept. of Community Medicine, Mahatma Gandhi Medical College and

Research Institute, Puducherry 3Agartala Govt. Medical College, Agartala

4Department of Political Science, Tripura University




vaccines, and tremendous efforts by health

care professionals, immunization campaigns

still suffer on accounts of parental

resistance.4,5

It is imperative to understand the

current level of knowledge and opinion of

caregivers about childhood additional vaccines

before we put emphasis on any such

promotion to be included under the national

immunization schedule as suggested by Indian

Academy of Paediatrics (IAP) 6

in India and

especially

in remote and difficult part of

north-east India like Tripura state.

Objective: The present study was conducted

to assess knowledge and opinion of caregivers

regarding childhood additional vaccines in

Agartala, West Tripura.


Study setting: The present facility based

observational study was undertaken during

July-December 2011. For this purpose, a

specialist child clinic situated in the urban area

of Agartala, Tripura served as study center.

The child clinic has a regular OPD attendance

of around 20-25 children (upto 12 years age)

per day. The clinic is run by a senior child

specialist and 2 trained medical assistants.

Data collection: Data was collected by a pre-

designed and pre-tested proforma using

interview technique by senior child specialist

at the child speciality clinic. Each parent(s) of

children aged 2-5 years attending the clinic

were explained about need of the study and

those who consented to participate in the study

after proper description and rationale of the

interview questionnaire, were included in the

study. Information regarding background

characteristics of parents, source of

information, knowledge and opinion regarding

childhood additional vaccines was collected.

Additional vaccines: For study purpose,

optional vaccines recommended by IAP6 such

as H influenza B (HiB), Hepatitis A, Chicken

Pox, Meningococcal Vaccine, Pneumococcal

Vaccine, Influenza Vaccine and Rota Virus

Vaccine were considered as childhood

additional vaccines.

Data analysis: The data were analysed using

Microsoft Excel and Epi_Info software

package version 6.04. To compare data sets

Chi-square test was used and p < 0.05 was

considered statistically significant (Yates‘

correction applied wherever applicable).

Ethical consideration: Written consent was

obtained from all the study participants before

assessing their knowledge and opinion about

childhood additional vaccines.

RESULTS

Knowledge and opinion regarding childhood

additional vaccines were gathered from

parents of total 180 children. Among them,

112 (62.22%) were parents of male and 68

(37.78%) parents of female children. Majority

(96.67%) of the respondents were Hindu and

104 (57.78%) belonged to joint families. 131

(72.78%) mothers of children were graduate

and 144 (80%) were housewives. 151

(83.89%) fathers were graduate and 107

(59.45%) were in service. (Table 1)

Knowledge regarding additional vaccines

Doctors (73.33%) were main source of

information regarding childhood additional

vaccines followed by television (18.89%) and

friends (17.78%). 48 (26.67%) and 59

(32.78%) parents respectively knew the timing

of these additional vaccines and against which

diseases these vaccines are being used. 133

(73.89%) parents reported vaccination as best

way to prevent these diseases. 86 (76.79%)

parents of male children reported that

vaccination is the best approach to prevent

these diseases as compared to 47 (69.12%)

parents of female children (p=0.033). Further,

101 (56.11%) parents correctly knew the

routine immunization schedule. (Table 2)

Opinion regarding additional vaccines

137 (76.11%) parents opined that additional

vaccines should be available at govt. hospitals.

84 (46.67%) parents recognized polyvalent

vaccines better than monovalent vaccine.

Numbers of injections (89.29%), cost

(21.43%), numbers of visits (16.67%) and less

complications (15.48%) were cited for such



preference. Financial constrain (46.11%),

family disagreement (26.67%), time constrain

(20%), fear of complication (18.89%) and

non-availability (8.89%) were stated as

barriers; and parents‘ education (69.44%) and

economic status (41.11%) were stated as

foremost family related reason for poor

acceptance of childhood additional vaccines.

(Table 3)

DISCUSSION

Study findings indicate that knowledge and

opinion of parents regarding childhood

additional vaccines pose as significant factor

towards successful immunization campaign.

Doctors remained important source of

information (73.33%) for parents in regard to

childhood additional vaccines. Majority of

parents opined that vaccines are best method

to prevent these diseases (73.89%) and those

vaccines should be made available in govt.

hospitals (76.11%). These results are similar

to findings documented by previous

researchers. 7,8

However, in the present study,

only 26.67% and 32.78% parents respectively

knew the timing and rationale of selected

childhood additional vaccines. Previous

researchers have mentioned that modus-

operandi towards knowledge and concerns

raised by parents regarding childhood

immunization determines action taken by

parents, and thus immunization coverage in

particular area.9,10

It has been recommended

that parents who resist immunization

campaign because of background

characteristics, traditional beliefs or situational

perceptions; health care providers must assess

the socio-cultural, economic and scientific

basis for resistance before promoting such

campaign.11

Financial constrain, parental knowledge,

family disagreement, fear of complication and

non-availability of additional vaccines were

stated as main barriers for poor acceptance and

coverage of childhood additional vaccines.

Similar findings has already been compiled

and documented in this respect through studies

conducted in Africa and Asia.12

In general,

parents‘ knowledge about childhood

additional vaccines still remains poor in third

world countries. However, it has been argued

that public often accepts vaccination despite

limited knowledge about it.13

It is

recommended that parents‘ knowledge and

concerns must be addressed to promote and

maintain childhood additional vaccination

campaign once we plan to start this campaign.

Further, to improve vaccination coverage and

child survival, a sense of urgency is must from

national as well as community level.14

Measures which can lever promotion and

popularization of childhood additional

vaccination may include addressing

knowledge gap among parents and their

concerns, making these vaccines available at

govt. hospitals, engaging private health

providers/facilities and monitoring the

progress to sustain the impact. Performance of

MCH services still remains a matter of

concern in India and it has been recommended

to engage and monitor services rendered by

anganwadis towards improvement of

immunization services. 15

The strong

association between parents‘ education and

vaccination coverage has been recognized in

NFHS-3 and UNICEF coverage surveys in

India and other developing countries. 16, 17

This

fact may also be may be utilized considering

higher education level of parents in the study

area to promote and sustain coverage of

childhood additional vaccines in the study are

as suggested by Indian Academy of

Paediatrics.

Limitations:

Debatable limitations of the present study may

include urban setting of the study and already

sensitized respondents otherwise clients of the

same private health care facility. This arguably

may have led to an inflated response and thus

puts question on application of the study

findings in other difficult, remote and rural

India.



CONCLUSION

Parents‘ knowledge and opinion regarding

childhood additional vaccines is a matter of

concern. This knowledge-gap and other

operational issues should be addressed before

launching and promoting any such campaign.

ACKNOWLEDGEMENT

We acknowledge all study participants for

valuable information towards improving

vaccination coverage among children. We

acknowledge the immense help received from

the scholars whose articles are cited and

included in references of this manuscript. We

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.

Source of financial support: Nil

Conflict of interest: None declared

REFERENCES

1. Sharma R, Bhasin SK. Routine

immunization - Do people know about it?

A study among caretakers of children

attending pulse polio immunization in east

Delhi. Indian Journal of Community

Medicine 2008; 33(1):31-34.

2. Bhatia V, Swami HM, Rai SR, Gulati S,

Verma A, Parashar A, et al. Immunization

status in children. Indian J Pediatr 2004;

71:313-315.

3. Yadav RJ and Singh P. Immunization of

children and mothers in northeastern

states. Health and Population -

Perspectives and Issues 2004; 27(3):185-

93.

4. Chen RT, DeStefano F, Pless R, Mootrey

G, Kramarz P, Hibbs B. Challenges and

controversies in immunization safety.

Infect Dis Clin North Am. 2001; 15(8):21-

39.

5. Offit PA, Jew RK. Addressing parents‘

concerns: Do vaccines contain harmful

preservatives, adjuvants, additives, or

residuals? Pediatrics. 2003; 112:1394-

1397.

6. Singhal T. Recommendation: Consensus

recommendations on immunization, 2008.

Indian Academy of Pediatrics Committee

on Immunization (IAPCOI). Indian

Paediatrics 2008; 45(8):635-48.

7. Gellin BG, Maibach EW and Marcuse EK.

Do parents understand immunizations? A

national telephone survey. Pediatrics.

2000;106(5):1097-1102.

8. Manjunath U, Pareek RP. Maternal

knowledge and perceptions about the

routine immunization programme: A study

in a semi-urban area in Rajasthan. Indian J

Med Sci 2003;57:158-63.

9. Gust DA, Kennedy A, Shui I, Smith PJ,

Nowak G and Pickering LK. Parent

attitudes toward immunizations and

healthcare providers: The role of

information. Am J Prev Med.

2005;29:105-112.

10. Keane MT, Walter MV, Patel BI, et al.

Confidence in vaccination: a parent

model. Vaccine. 2005;23:2486-2493.

11. Dawson A. The determination of ―best

interests‖ in relation to childhood

vaccinations. Bioethics. 2005;19:188-205.

12. Jheeta M and Newell J. Childhood

vaccination in Africa and Asia: the effects

of parents‘ knowledge and attitudes. Bull

World Health Organ 2008;86(6):419-420.

13. Nichter M. Vaccinations in the Third

World: A consideration of community

demand. Soc Sci Med 1995; 41: 617-632.

14. Kumar S. Indians can do better at

improving child survival. Indian Journal

of Community Medicine 2011; 36(3):

171-173.

15. Datta SS, Boratne AV, Cherian J, Joice

YS, Vignesh JT and Singh Z. Performance

of anganwadi centers in urban and rural

area: A facility survey in coastal south

India. Indian Journal of Maternal and

Child Health 2010; 12(4): 1-9.

16. Luman ET, McCauley MM, Shefer A,

Chu SY. Maternal characteristics

associated with vaccination of young



children. Pediatrics 2003; 111(5 Part 2):

1215-1218.

17. International Institute for Population

Sciences (IIPS) and ORC Macro. National

Family Health Survey (NFHS-3), 2005-

06. Mumbai, India: IIPS; 2007.

Table 1: Background information of study population

Characteristics Total

N=180

Male Child

N=112

Female Child

N=68

Chi-square

[p value]

Religion

Hindu

Other

174 (96.67)

6 (3.33)

107 (95.54)

5 (4.46)

67 (98.53)

1 (1.47)

0.43

[0.511]

Type of family

Nuclear

Joint

76 (42.22)

104 (57.78)

43 (38.39)

69 (61.61)

33 (48.53)

35 (51.47)

1.78

[0.182]

Mother‘s Education

Upto 12 std

Graduate and above

49 (27.22)

131 (72.78)

33 (29.46)

79 (70.54)

16 (23.53)

52 (76.47)

0.75

[0.386]

Father‘s Education

Upto 12 std

Graduate and above

29 (16.11)

151 (83.89)

17 (15.18)

95 (84.82)

12 (17.65)

56 (82.35)

0.19

[0.662]

Mother‘s Occupation *

House wife

Service

Other

144 (80)

32 (17.78)

4 (2.22)

95 (84.82)

14 (12.5)

3 (2.68)

49 (72.06)

18 (26.47)

1 (1.47)

5.78

[0.056]

Father‘s Occupation

Service

Business

Other

107 (59.45)

65 (36.11)

8 (4.44)

62 (55.36)

45 (40.18)

5 (4.46)

45 (66.18)

20 (29.41)

3 (4.41)

2.19

[0.334]

(Figures in parenthesis indicate percentages)



Table 2: Knowledge of care givers regarding additional vaccines


N=180

Male Child

N=112

Female Child

N=68

Chi-square

[p value]

Source of information *

Doctor

TV

Friends

Posters

Radio

Other Sources

132 (73.33)

34 (18.89)

32 (17.78)

17 (9.44)

4 (2.22)

12 (6.67)

79 (70.54)

19 (16.96)

22 (19.64)

10 (8.93)

1 (0.89)

9 (8.04)

53 (77.94)

15 (22.06)

10 (14.71)

7 (10.29)

3 (4.41)

3 (4.41)

4.43

[0.489]

Have knowledge about routine

immunization schedule 101 (56.11) 54 (48.21) 47 (69.12)

7.51

[0.006]

Know schedule of additional vaccines 48 (26.67) 25 (22.32) 23 (33.82)

2.86

[0.091]

Have knowledge against which

diseases additional vaccines are being

used 59 (32.78) 42 (37.5) 17 (25)

3.00

[0.083]

Best way to prevent such diseases

Vaccination

Healthy diet and hygiene

No idea

Other

133 (73.89)

23 (12.78)

16 (8.89)

8 (4.44)

86 (76.79)

17 (15.18)

7 (6.25)

2 (1.78)

47 (69.12)

6 (8.82)

9 (13.24)

6 (8.82)

8.71

[0.033]

(* Multiple responses, Figures in parenthesis indicate percentages)

Table 3: Opinion of care givers about additional vaccines


N=180

Male Child

N=112

Female Child

N=68

Chi-square

[p value]

Additional vaccines should be

available in Govt. Hospitals 137 (76.11) 80 (71.43) 57 (83.82)

3.58

[0.059]

Recognize combination vaccines better

than single vaccine 84 (46.67) 51 (45.54) 33 (48.53)

0.15

[0.696]

Reason *

Less number of Injections

Cheaper

Less visits

Less complications

[N=84]

75 (89.29)

18 (21.43)

14 (16.67)

13 (15.48)

[N=51]

51 (100)

8 (15.69)

11 (21.57)

5 (9.80)

[N=33]

24 (72.73)

10 (30.30)

3 (9.09)

8 (24.24)

8.22

[0.042]

Barriers of additional vaccination *

Financial constrain

Family disagreement

Time constrain

Afraid of complications

Non-availability

Other

83 (46.11)

48 (26.67)

36 (20)

34 (18.89)

16 (8.89)

18 (10)

47 (41.96)

30 (26.79)

28 (25)

25 (22.32)

6 (5.36)

11 (9.82)

36 (52.94)

18 (26.47)

8 (11.77)

9 (13.24)

10 (14.71)

7 (10.29)

10.86

[0.054]

Reason for poor acceptance of

additional vaccines *

Parents‘ education

Economic status

Number of children

Parents‘ occupation

Sex of the child

Other

125 (69.44)

74 (41.11)

8 (4.44)

6 (3.33)

4 (2.22)

21 (11.67)

85 (75.89)

41 (36.61)

6 (5.36)

5 (4.46)

3 (2.68)

13 (11.61)

40 (58.82)

33 (48.53)

2 (2.94)

1 (1.47)

1 (1.47)

8 (11.77)

4.89

[0.429]

(* Multiple options, figures in parenthesis indicate percentages)



ijcrr

Vol 04 issue 03

Category: Research


Revised on:23/12/11


ABSTRACT Aim: To evaluate the remineralization efficacy of CPP-ACP and Fluoride Varnish using Diagnodent

and to compare the remineralization efficacy of CPP-ACP and Fluoride Varnish.

Methodology: Sixty freshly extracted non carious premolars were selected and randomly divided into

three groups of twenty samples each. Group A: (Control), Group B: Fluoride Varnish (Fluorprotector),

Group C: CPP – ACP (Tooth mousse). The baseline values for all the samples were recorded using

diagnodent (KaVo). After demineralizing the samples, values were again measured. Fluorprotector

(Ivoclar Vivadent) and GC Tooth mousse (Recaldent) were applied on to the buccal surface of the

samples in group B and group C respectively with group A as control. Twenty minutes later the

readings for Group B and Group C were obtained. All the samples in the three groups were immersed

in artificial saliva and the readings obtained were statistically analyzed.

Results: The mean value for group B was (5.6+/-0.9) and for group C was (7.2+/-1.6). This was

statistically significant (P<0.0001) and the remineralization was found to be more in CPP-ACP group.

Conclusion: CPP-ACP has a statistically significant remineralization potential than fluorprotector.

There was no statistical significance when Group A, Group B and Group C were compared

individually with artificial saliva.

____________________________________________________________________________

Keyword: Remineralization, CCP-ACP,

Fluoride varnish, Artificial saliva, Diagnodent.

INTRODUCTION

The development of dental caries is a complex,

multistage and a dynamic process which can be

conceptualized as an imbalance between

mineral loss called demineralization and

mineral gain called remineralization. The cycle

of remineralization and demineralization is a

constant process in the normal oral

environment, and only when the speed and the

level of demineralization become dominant the

actual surface cavitation becomes possible.

This multifactorial infectious disease which is

initiated and progressed by Mutans streptococci

should be quickly detected for an effective

treatment plan that reverses the progression

from white spot lesion to cavitation.

The ability to promote mineralization can be

achieved using various remineralizing agents

such as Fluoride varnish (Fluorprotector) and

CPP-ACP (Casein Phosphopeptide Amorphous

Calcium Phosphate). CPP-ACP a water based

sugar free cream when applied to the tooth

surface binds to biofilm, plaque, bacteria,

hydroxyapatite and surrounding soft tissue,

localizing bioavailable calcium and phosphate,

there by buffering plaque pH and enhancing

remineralization. In a human in situ

demineralization study, 1.0%w/v CPP-ACP

solution used twice daily produced a 51%

reduction in enamel mineral loss caused by

frequent sugar solution exposure1. CPP-ACP

EVALUATION AND COMPARISON OF

REMINERALIZATION EFFICACY OF CPP-ACP AND

FLUORIDE VARNISH USING DIAGNODENT - AN IN

VITRO STUDY

R.Senthil1, V. Rathna Prabhu

1, J. Jeeva rathan

2, A. Venkatachalapathy

1

1Department of Pedodontics and Preventive Dentistry, Meenakshi Ammal

Dental College and Hospital, Chennai 2Department of Pedodontics and Preventive Dentistry, Balaji Dental College

and Hospital, Chennai




solutions have shown to promote

demineralization of the enamel sub surface

lesions 2

.

On the other hand, use of fluoride is the pivot

of preventive dentistry which continues to be

the cornerstone of caries prevention program.

The decline of dental caries prevalence in

recent decades has been explained by

widespread use of fluoride. The ability of

fluoride to facilitate remineralization process is

presently believed to be more significant than

its inhibition of demineralization3. The

absorption of calcium fluoride on the tooth

surface and the release of ions during low

plaque pH promotes remineralization. Among

various topical fluorides, fluoride varnish plays

an important role in preventing the enamel sub

surface lesion because of high fluoride

concentration and also the ability to adhere to

the enamel thereby extending the exposure time

to several hours forming a depot from which

fluoride is released slowly 4.

The DIAGNOdent system is a part of an

exciting new generation of dental equipment.

This system employs laser light of a defined

wave length to help detect and quantify broken

down tooth substance without x-ray exposure.

It is also a quick, easy and pain free diagnostic

aid with 90% success rate in caries detection,

pathological changes and initial

demineralization. This laser-fluorescence

device is suitable for monitoring small caries

lesions as well as occlusal caries5. In this study

this investigation tool is used for assessing the

demineralization as well as the subsequent

remineralization by using two materials such as

CPP-ACP (Tooth mousse) and Fluoride varnish

(Fluorprotector) on the extracted human

premolars.

MATERIAL AND METHOD

Sixty freshly extracted non carious premolars

were selected and cleaned thoroughly with

ultrasonic scaler and polished with pumice

slurry. The samples were then preserved in a

beaker containing thymol. A 4x4mm sticker

paper was cut and stuck on the buccal surface

of all the samples to create a window. The

remaining surfaces of the samples were coated

with acid resistant nail varnish and then the

sticker paper was removed. Each tooth was

kept in a separate plastic tube with a rubber

stopper and was numbered from 1 to 60

individually on the tubes and kept in a stand.

The samples were then randomly divided into

three groups of twenty samples each.

Group A: Control

Group B: Fluoride Varnish (Fluorprotector)

Group C: CPP – ACP (Tooth mousse)

The laser tip of DIAGNOdent was kept in free

air and the calibrating button in the instrument

was pressed for thirty seconds until the monitor

displayed the indication ―CAL‖ on it. Then the

tip was placed in a ceramic calibrating block

given by the manufacturer and again the

calibrating button was pressed till the indication

―CAL DONE‖ was displayed on the monitor.

The calibrated tip was then kept in the window

created on the buccal surface of the tooth and

the peak value displayed in the diagnodent was

recorded as the baseline value. Similarly the

baseline values (V1) for all the samples were

recorded after calibrating the tip between each

sample readings.

The samples were immersed in their respective

tubes containing 2ml of demineralization

solution and kept for 4 hours6. Later they were

taken from the tubes, washed with de-ionized

water and dried with soft tissue paper.

DIAGNOdent values were again measured

(V2) with the same tip as before for all the

samples on the same surface.

Fluorprotector (Ivoclar Vivadent ) and GC

Tooth mousse (Recaldent) were applied on the

buccal surface of the samples in group B and

group C according to manufacturer‘s

instructions. The group A (control) was left

without any application. Twenty minutes later

the DIAGNOdent readings (V3) for Group B

and Group C were again obtained after

calibrating the equipment. All the samples in

the three groups were kept undisturbed in

individual tubes containing 2ml of artificial

saliva for 24 hours7,8

. The diagnodent readings



(V4) of all the samples in the three groups were

again obtained. Statistical analysis was done

using paired‗t‘ test and student‘s ‗t‘ test

appropriately (p <0.05).

RESULTS

The sample distribution was given as group A(

control), group B ( fluoride varnish) and group

C (cpp – acp) with 20 samples each

respectively (table 1). The mean ± SD values

between the groups B and C at V3 was about

(5.6 ± 0.9) and (7.2 ± 1.6) which was

statistically significant (p<0.0001) (table 2)

.The mean value of group A and B at V1 was

increased from (5.8± 1.6) to (7.2 ± 1.1) which

was statistically significant. The other values

V2 and V4 were not statistically significant

(table 3).The mean value of group A and C at V

1 was (5.8 ± 1.6) which increased to (6.7 ± 0.9)

and was statistically significant. The other

values V2 and V4 were not statistically

significant (table4).

DISCUSSION

Dental hard tissues are constantly undergoing

cycles of demineralization during periods when

the pH is low, followed by repair when

conditions favour remineralization leading to

variations in the mineral status of teeth many

times in a day9. The widespread use of many

remineralizing agents has increased the rate of

remineralization and has dramatically reduced

the prevalence of dental caries and the rate of

progression of caries lesion. This present study

was done to analyze the efficacy of

remineralization by using two remineralizing

agents Fluoride varnish (Fluorprotector) and

CPP-ACP (Tooth mousse). The samples

selected were sixty premolars which were

extracted for orthodontic purpose (n = 60).

They were selected because of the ease of

availability and free of carious lesion than any

other teeth. All the selected samples fulfilled

the inclusion criteria which are absence of

incipient carious lesions, white spot lesions,

subsurface demineralization or cavitation in

any of the surfaces. All the samples were

coated with acid resistant varnish except the

buccal surface in which a 4×4 mm window was

made for examination. The buccal surface of

the tooth was selected because it is often free of

carious lesions when compared to the occlusal

surface which might have pit and fissure

lesions.

Table 1 shows the distribution of the samples

which were divided into three groups with

group A as control. All the samples were kept

in separate plastic tubes with a rubber stopper

in order to prevent cross contamination during

the study. In this study laser emitting

fluorescent device (DIAGNOdent) was used to

assess the remineralization efficacy of the

samples10, 11

. The base line values for all the

samples were derived from the DIAGNOdent

by calibrating the equipment individually for all

the sample group (V1). This was done to

prevent any error in the readings as shown in

(table 1). Demineralization of the samples was

done with a standardized demineralization

solution for 4 hours. In this study we used 10%

acetic acid along with (CaCl2, NaH2PO4 ) at a

pH of 5.2 which was almost equal to that of

commercially available soft drinks that could

erode the enamel surface. After drying the

samples with tissue paper, the diagnodent

readings were measured as (V2)8,12

.

Fluorprotector fluoride varnish was applied to

group B and CPP-ACP (Tooth mousse) to

group C and the DIAGNOdent values were

measured as (V3) as shown in (table 2). All the

samples were then immersed in artificial saliva

for 24 hours and the DIAGNOdent readings

were taken after drying the samples (V4) as

shown in (table 3). The value at V1 showed a

mean increase at V2 in all the three groups

which was found to be statistically significant

with a p value (p<0.0001). This is because there

was an increase in the values of diagnodent

from initial base line which showed that all the

samples have been demineralized. The value at

V2 showed a decrease at V3 with a mean

decrease of (4.7 ± 1.1) in group B which was

found to be statistically significant with a p

value (p< 0.0001) (Table 3).The reduction in



the values are due to the action of silane

fluoride present in the fluorprotector which

have the ability to adhere to enamel, thereby

extending the fluoride exposure time to several

hours forming a depot from which fluoride is

released, thus enhancing remineralization13,14

.

The value at V2 showed a decrease at V3 with

a mean decrease of (3.4 ±1.1) in group C which

was found to be statistically significant with the

p value (p<0.0001).

CPP-ACP in this present study produced

potential remineralization because of its ability

to replace calcium and phosphate and the

anticariogenic mechanisms of CPP-ACP that

stabilizes the CPP and localizes ACP at the

tooth surface, thereby buffering plaque pH and

depressing enamel remineralization and

enhancing remineralization. This was shown by

the decrease in the value of DIAGNOdent from

the demineralized value. Thus there was an

initial remineralization in both group B and

group C .The mean value of V2 – V3 in group

B was found to be (4.7 ± 1.1) and the mean

value of V2 – V3 in group C was found to be

(3.4 ± 1.1). The value was found to be less in

the group C sample. This implies that the

samples in group C (CPP – ACP) has better

remineralization efficacy than (Fluorprotector)

group B (Table 3 and 4). This may be due to

the low fluoride content present in the

fluorprotector (1000ppm)15

. When the mean

values of V3 – V4 in group B and group C

were compared it was found to be (2.7 ± 1.3)

and (2.7 ± 1.3) respectively which was also

found to be statistically significant. But this

implies that there was only a minimal

remineralization occurred after immersing the

samples in artificial saliva, when compared

with the samples after applying remineralizing

agents .The mean value of V2-V4 in group A,

group B and group C was found to be

statistically significant (Table 2, 3 and4). This

implies that there was no significant difference

when all the three sample groups were

immersed in artificial saliva for 24 hours 16,17

.

Human saliva is acknowledged to possess a

remineralizing potential, as demonstrated both

through observations of reversals in clinical

caries diagnosis and through in vitro studies on

enamel rehardening18

. Nevertheless, when

saliva is compared to inorganic remineralizing

solutions, its capacity to deposit mineral is

notably less. This has generally been attributed

to an interfering effect by the organic

components of the natural fluids. The practical

application of synthetic solutions however, has

been limited by the long contact times needed

to achieve significant remineralization of

carious tooth enamel. Due to short contact time

with this solutions the precipitation have

resulted in surface deposition, with little

remineralization occurring in the subsurface

region of the enamel lesions. In this study the

sub surface remineralization which has been

enhanced may be due to the tri calcium

phosphate that has been used as a constituent in

artifical saliva. Since saliva continuously bathes

the oral dentition, a more practical means of

achieving reversal of incipient demineralization

may result from techniques aimed at enhancing

this natural process.

SUMMARY AND CONCLUSION

CPP-ACP has a statistically significant

remineralization potential than fluorprotector

fluoride varnish. There was no statistical

significance when Group A, Group B and

Group C were compared individually with

artificial saliva.

The constituents of human saliva also play an

important role in the remineralization cycle.

This varies between individuals and its effect is

reduced in those having a disturbance in the

composition of human saliva. Thus

remineralizing agents will have a greater

additive effect when used in patients with

altered salivary constituents.

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Retention in plaque and remineralization of

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and artificial saliva. J Oral Rehabil 2006;

33(1):26-30.

8. Eisenburger M, Addy M, Hughes JA,

Shellis RP. Effect of time on the

remineralisation of enamel by synthetic

saliva after citric acid erosion. Caries Res

2001; 35(3):211- 5.

9. John Hicks, Catherine F. Biological factors

in dental caries: role of remineralization

and fluoride in the dynamic process of

demineralization and remineralization. J

Clin Pediatr Dent 2004; 28: 203.

10. Bader J, Shugars DA. A systematic review

of the performance of a laser fluorescence

device for detecting caries. J Am Dent

Assoc 2004; 135: 1413-1426.

11. Shinohara T, Takase Y, Amagai T,

Haruyama C, Igarashi A, Kukidome N,

Kato J, Hirai Y. Criteria for a diagnosis of

caries through the DIAGNOdent.

Photomed Laser Surg 2006; 24(1):50-8.

12. Tanaka M. Comparative Reduction of

Enamel Demineralization by Calcium and

Phosphate in vitro. Caries Res 2000;

34:241-245.

13. De Bruyn H, Buskcs JA, Arends J. The

inhibition of demineralization of human

enamel after fluoride varnish application as

a function of the fluoride content. An in

vitro study under constant composition

demineralising conditions. J Biol Buccale

1986; 14(12): 133-138.

14. Munshi AK, Reddy NN, Shetty V. A

comparative evaluation of three fluoride

varnishes: an in - vitro study. J Indian Soc

Pedod Prev Dent 2001; 19:92-102

15. Reynolds EC, Cai F, Shen P, Walker GD.

Retention in plaque and remineralization of

enamel lesions by various forms of calcium

in a mouthrinse or sugar-free chewing gum.

J Dent Res 2003; 82(3):206-11.

16. Attin T, Buchalla W, Gollner M, Hellwig

E. Use of variable remineralization periods

to improve the abrasion resistance of

previously eroded enamel. Caries Res

2000; 34(1):48-52.

17. Amaechi BT, Higham SM. In vitro

remineralisation of eroded enamel lesions

by saliva. J Dent 2001; 29(5): 371-6.

18. Silverstone Poole. Human saliva as

potential remineralizing agent. Caries Res

1968; 2:87.



Table – 1 : Distribution of samples

GROUP A B C

NO. OF SAMPLE 20 20 20

A - Control

B - Fluoride Varnish

C - CPP – ACP

Table – 2 : Comparison of mean values between Group B and Group C

Time Points B C p – Value

Mean ± S.D Mean ± S.D

V1 7.2 ± 1.1 6.7 ± 0.9 0.12 (NS)

V2 10.3 ± 1.1 10.6 ± 1.3 0.36 (NS)

V3 5.6 ± 0.9 7.2 ± 1.6 0.001 (Sig)

V4 4.4 ± 0.8 4.5 ± 0.8 0.57 (NS)

V 1 - Baseline value

V2 - Demineralization after 4hrs

V3 - 15 minutes after application of CPP-ACP and Varnish.

V4 - 24 hours after immersing the samples in artificial saliva

(Sig) = Significant

(NS) = Non significant In Table 2, mean ± SD values between group B and C at V3 was about (5.6 ± 0.9) and (7.2 ± 1.6)

which was statistically significant (p<0.0001). Student‘s independent t-test was used to evaluate the p-

value.

Table – 3 : Comparison of mean values between Group A and Group B

Time Points A B p – Value


V1 5.8 ± 1.6 7.2 ± 1.1 0.004 (Sig)

V2 10.1 ± 1.3 10.3 ± 1.1 0.70 (NS)

V4 4.7 ± 1.3 4.4 ± 0.8 0.33 (NS)

In table 3, the mean value at V1 was increased from (5.8± 1.6) to (7.2 ± 1.1) which was statistically

significant. The other values V2 and V4 were not statistically significant. Student‘s independent t-test

was used to evaluate the p-value.



Table – 4 : Comparison of mean values between Group A and Group C

Time Points A C p – Value


V1 5.8 ± 1.6 6.7 ± 0.9 0.05 (Sig)

V2 10.1 ± 1.3 10.6 ± 1.3 0.23 (NS)

V4 V4 4.7 ± 1.3 4.5 ± 0.8 0.57 (NS)

In table 4, the mean value at V 1 was (5.8 ± 1.6) which increased to (6.7 ± 0.9) and was statistically

significant. The other values V2 and V4 were not statistically significant. Student‘s independent t-test

was used to evaluate the p-value.

Fig I : Armamentarium

Fig II: Diagnodent Kit



Fig III: Laser Tips

Fig IV: Calibrating the Unit

Fig V : Samples with Individual Numbering



Fig VI : Measuring the values

LEGENDS

Figure I - Armamentarium.

Figure II - Diagnodent kit (KaVo).

Figure III - Three laser tips for measuring the remineralization as well as the

demineralization.

Figure IV - Calibration of the unit is done to prevent any error.

Figure V - Sixty samples of extracted premolars for orthodontic purpose.

Figure VI - Measuring the values with the diagnodent kit.



ijcrr

Vol 04 issue 03

Category: Research


Revised on:18/12/11


ABSTRACT FGTB is usually a silent disease evidencing itself only when really looked for. It usually affects

females of reproductive age group. Disruption of the IFN-gamma gene in mice infected with M.

tuberculosis has resulted in exacerbation of disease, progressive and widespread tissue destruction and

necrosis with numerous bacteria. We therefore proposed, to study the possible association of IFN-γ

gene polymorphism in Indian women with female genital tuberculosis. It is a prospective case-control

study. Screening of genomic DNA samples were carried out from clinically definite 106 FGTB

patients and 100 unaffected patients aged between 18 to 40 years. +874 (T→A) IFN-γ genotyping was

carried out by using sequence specific primer polymerase chain reaction (SSP-PCR) method.

Statistical tests were performed using pantaray software systems.

According to our investigation, FGTB patients showed more or less similar TT (30.18% vs. 30.0%),

higher AA (19.81% vs. 9.0%) genotypes compared to controls and the frequency of AT genotypes

decreased significantly. Distribution of IFN- γ genotypes between patients and controls were have

statistical disparity. This study suggests that IFN-γ +874 T to A polymorphism have an etiological

association with susceptibility of female genital tuberculosis.

____________________________________________________________________________

Keywords: Mycobacterium tuberculosis;

Interferon-γ gene polymorphism; Female

Genital Tuberculosis (FGTB)

INTRODUCTION

Female genital tuberculosis (FGTB) is usually a

symptom-less disease diagnosed during

investigations for infertility (Namavar Jahromi

et al., 2001). It represents 15-20% of extra

pulmonary tuberculosis (Rajamaheshwari,

2009). In 80-90% cases, FGTB affects women

between 18-38 years of age with menstrual

irregularities accounting for nearly 27% of

manifestations of FGTB (Chakrabarti et al.,

1998). Primary infection may occur when the

male partner has active genitor-urinary TB and

transmission takes place by sexual intercourse

(Richards and Angus, 1998). It is usually a

result of reactivation of a silent bacillemia,

primarily from lungs and also thought to be

from cervical TB infections (Richards and

Angus, 1998; Sutherland et al., 1982). The

seeding of bacilli usually occurs immediately

after puberty as blood supply to the pelvic

organs increases and as a result, more bacilli

can reach genital organs and infect them

(Crofton et al., 1992). Infection of vulva,

vagina and cervix may result from direct

inoculation and ascending spread to other

genital organs may occur (Haas et al., 2002).

The incidence of infertility in genital TB

worldwide varies from 44-74%; in India it is

reported to be 58% (Dam et al., 2006) and

majority are in the same age group (Crofton et

al., 1992). In western countries the incidence of

FGTB is estimated to be <1%, whereas in some

MUTATIONAL ANALYSIS OF INTERFERON-GAMMA

GENE IN INDIAN WOMEN WITH FEMALE GENITAL

TUBERCULOSIS

Venkanna Bhanothu1, Jane Theophilus

1, Roya Rozati

2

1Dept. of Zoology, UCS, Osmania University, Hyderabad

2MHRT Hospital & Research Centre, Road # 3, Banjara Hills, Hyderabad




African and Asian countries it reaches 15–19%

(Punnonen et al., 1983; Giannacopoulos et al.,

1998). Recently, Jindal et al., 2010 have been

suggested the use of Endo TB-PCR for high

specificity and early diagnosis of female genital

tuberculosis as performed by laparoscopy and

so laparoscopy can be avoided in TB-PCR-

positive patients for diagnosis keeping the

PCR-negative cases in mind (Majumdar and

Satwik, 2011). Due to its rarity and mild

clinical picture, the index of suspicion for the

diagnosis of FGTB among gynecologists is

usually low. Some times, immune and genetic

susceptibility of host may not help in early

detection by Endo TB-PCR. Therefore, remains

to be an increasing public health concern

worldwide. Mycobacterium tuberculosis (M.

tuberculosis) is a facultative intracellular

pathogen capable of producing both a

progressive disease and an asymptomatic latent

infection (Parrish et al., 1998). The role of IFN

gamma (IFN- γ) as the main macrophage-

activator Th1 cytokine has been clearly

established in animal models infected with M.

tuberculosis by Flynn et al. and Dalton et al., in

1993. In human, single nucleotide

polymorphisms (SNPs) located in the first

intron of the IFN-γ gene (at position +874) has

shown variable associations with disease

susceptibility and severity (Pacheco et al.,

2008). On other hand, several studies have

demonstrated that ethnicity and cytokine

polymorphism plays a significant role in the

susceptibility to a wide range of diseases

(Hoffmann et al., 2002; Newport et al., 1996)

including FGTB. IFN-γ modulates a number of

functions in addition to MHC expression,

including the activation of macrophages, NK

cells and the inhibition of the Th2 phenotype in

T cells (Maher et al., 2007). Exactly which

function is undermined in +874A individuals

have not been determined yet. Pravica et al.,

2000 noted a novel single nucleotide

polymorphism (SNP), T to A, located at the

+874 position from translation start site in the

first intron of IFN-γ gene, which coincides with

a putative NF-κB binding site that could play a

fundamental role in the induction of

constitutively high IFN-γ production. The

differences in the magnitudes of the responses

that were seen may reflect the environment in

which the cohorts live, or they may reflect the

nature of the patients‘ infections (Cahn et al.,

2003). Disruption of the IFN-gamma gene in

mice infected with M. tuberculosis has resulted

in exacerbation of disease, progressive and

widespread tissue destruction and necrosis with

numerous bacteria (Dalton et al., 1993).

Therefore, alteration in IFN-γ production may

influence the susceptibility to FGTB and this

alteration could be due to gene polymorphism.

The homozygous T/T, A/A and heterozygous

A/T alleles are associated with any increase or

decrease in production of IFN-γ, this cytokine

can affect the outcome of the disease severity.

We therefore, hypothesized that the IFN-γ

+874T/A gene polymorphism might be

associated with female genital tuberculosis.

This gene was chosen due to its essential

central regulator role in response to infection

that may be involved in FGTB pathogenesis

and their potential regulation on gene

expression.


This is a prospective case-control study, which

recruited women visiting the gynecology

clinics at two collaborating centers, which

register cases from all over the region of

Andhra Pradesh, India, complaining for

infertility and suspected of having genital

tuberculosis (TB) on clinical grounds. During

the period of our study (2006–2011), the

samples from the consecutive women in these

two centers were analyzed. The ethical

committee of Hospital and Research Centre

approved the research protocol. Informed

written consents were obtained from all the

participants. Proforma to obtain information on

the general, obstetric and gynaecological details

including family history, marital status, age at

menarche, length of menstrual cycle, associated

symptoms, duration and amount of blood loss,

duration of infertility, and socio demographic



details like social status, occupation, lifestyle,

age, body mass index (BMI), limited

information on diet was used and a thorough

clinical examination done. General

characteristics for all patients were recorded in

the medical chart. Apart from routine

hematological investigations, specialized

investigations consisting of transvaginal

sonography of uterus and adnexa, hormone

profiles, immunological assays, and endoscopy

were performed as and when needed.

Surgically removed tissue was taken from both

groups for laboratory examination, including

AFB using light microscopy following

concentration, staining by Ziehl–Neelsen stain

as well as culture and M. tuberculosis specific

PCR (Abebe et al., 2004), the diagnostic

criteria by which tuberculosis was confirmed.

All patients met the inclusion criteria: 18-40

years of age having irregular periods, with past

history of having Genital TB and Tubal

blockage, experiencing infertility (in >60% of

cases), pelvic pain and scanty menstruation and

amenorrhoea, and histopathological evidence in

biopsy of premenstrual endometrial tissue or

demonstration of tubercle bacilli in culture of

menstrual blood or endometrial curetting.

Exclusion criteria were as all the following:

Women above 40 years of age, symptoms

suggestive of pulmonary TB/Extra pulmonary

TB except infertility, with normal abdomenal

and vaginal examinations, other chronic

disease, pregnancy or nursing, severe

psychiatric dysfunction, multiple sclerosis or

other autoimmune disorders, pulmonary

infections, HIV co-infection, women with

diabetes, malnutrition and other medical

disorders like hypertension were excluded.

Details of laparoscopy findings like unilateral

or bilateral tubal block with hydrosalphinx,

omental adhesions, frozen pelvics, tubo-ovarian

masses, tubercular salphingitis and tubercles

were noted in Table 1. Symptoms included

pelvic pain, irregular menstrual bleeding,

scanty menstruation, dysmenorrhoea

oligomenorrhea, amenorrhea and infertility. A

pelvic mass in variable combination aroused a

suspicion. Constitutional symptoms such as

sweating, increase in temperature and weight

loss were not major complaints while local

organ dysfunction manifested in amenorrhea,

omental adhesions and bilateral tubal blockage

seen on hysterosalpingographic study. The

median age of the subjects was 29 (range 18-

40) years. All subjects were HIV negative and

normal for pulmonary TB on the basis of

complete history, physical examinations; chest

X-ray, lung plain X-ray and by appropriate tests

such as tuberculin test, sputum smears and

sputum cultures (Raut et al., 2001; Saracoglu et

al 1992). The study population is from the state

of Andhra Pradesh, which is known for ethnic

variations.

Study group: Tube ovarian biopsy was taken

from 106 women during laparoscopy; from 45

women endometrium was obtained by curettage

and 61 women with biopsy for smear

microscopy, histopathology, culture and PCR

for mycobacterium. All these women were

infertile: primary infertility in 81 (76.4%)

women and secondary infertility in 25

(23.58%) women with mean age of 29.16 ±

3.73 years, mean age at menarche of 12.53

±1.01 years, mean duration of infertility of 3.97

± 2.91 years. Other gynaecological pathology

like dysmenorrhoea in 49 (46.2%) women,

tubal block with hydrosalphinx in 57 (53.77%)

women, omental adhesions in 41 (38.68%) and

tubercular salphingitis in 51 (48.1%) were

reported. Blood samples were collected in

heparinised tubes. The specimens were

received and preserved in 10% formalin,

processed in routine manner and embedded in

paraffin wax. Three-micron thick sections were

cut and stained by haematoxylin and eosin

(Namavar Jahromi et al., 2001). The diagnosis

was undertaken on morphological grounds

(Raut et al., 2001). Erythrocyte sedimentation

rate (ESR) was performed on all the patients,

which showed readings of between 57 and 123.

Tissue specimens were examined by a

pathologist for granulomatous reactions,

fibrosis suggestive of mycobacterium disease.



Control group: Out of one hundred women

who attend the same clinic for other

gyaecological disorders and tubal sterilization,

92 (92%) women were proven fertile. Eight

(8%) women were infertile: primary infertility

in 7 (7%) women, secondary infertility in 1

(1%) women with other gynaecological

pathology (3 polycystic ovaries, 1 idiopathic

infertility, 4 pelvic inflammatory disease) and

were laparoscopically confirmed to be without

female genital tuberculosis. All the women in

this group were asymptomatic with mean age

of 26.11 ± 4.57 years, mean age at menarche of

12.03 ± 0.84 years and mean duration of

infertility of 0.174 ± 0.184 years. The following

symptoms were also present in the control

group: abdominal pelvic pain was observed in 2

(2%) women, dysmenorrhoea in 25 (25 %),

oligomenorrhoea in 3 (3%), there were 2 (2%)

mild menorrhagia, and 1 (1%) general malaise

cases. There were no severe cases as shown in

the Table 1.

Table I. Comparison of Socio-Demographic and Clinical details among Female Genital TB cases and

Controls

Characteristics

Female Genital TB

Cases (n=106)

Control group

(n=100)

Age (years) 29.16 ± 3.73 26.11 ± 4.57

Body mass index (kg/m2) 24.34 ± 1.46 23.86 ± 1.85

Age at menarche (years) 12.53 ± 1.01 12.03 ± 0.84

Infertility Symptoms

Duration of infertility (years) 3.97 ± 2.91 0.174 ± 0.184

Primary infertility [n (%)] 81 (76.4) 7 (7)

Secondary infertility [n (%)] 25 (23.58) 1 (1)

Proven fertility [n (%)] NA 92 (92)

Menstrual irregularity

Dysmenorrhoea [n (%)] 49 (46.2) 25 (25)

Mild [n (%)] 28 (26.4) 17 (17)

Moderate [n (%)] 11 (10.37) 6 (6)

Severe [n (%)] 9 (8.5) 2 (2)

No dyspareunia & dysmenorrhoea [n (%)] 27 (25.47) 48 (48)

Amenorrhea [n (%)] 7 (6.6) 1 (1)

Menorrhagia [n (%)] 4 (3.77) 2 (2)

Oligomenorrhea [n (%)] 13 (12.26) 3 (3)

Abdomeninal pain [n (%)] 15 (14.15) 2 (2)

General malaise [n (%)] 5 (4.7) 1 (1)

Laparoscopy findings

Tubal block with Hydrosalphinx [n (%)] 57 (53.77) NA

Omental Adhesions [n (%)] 41 (38.68) NA

Frozen pelvis [n (%)] 27 (25.47) NA

Tubo-ovarian mass [n (%)] 23 (21.7) NA

Tubercular salphingitis [n (%)] 51 (48.1) NA

Note: Some patients had more than one abnormal finding

Data are presented as mean ± SD, NA: not applicable



Culture

Homogenized samples were cultured on

Lowenstein Jensen egg medium for acid-fast

bacilli and incubated for 3 to 8 weeks. Ziehl-

Neilsen staining was used to identify the bacilli

(Abebe et al., 2004).

DNA Preparation

Five ml of whole blood from patients and

controls were used for DNA extraction by a

modified proteinase-K/salting-out method

(Miller et al., 1988). Polymorphism at position

+874 of IFN-γ gene was identified using

sequence specific polymerase chain reaction

(PCR-SSP) as described by Pravica with some

modifications (Pravica et al., 2000). Briefly,

red blood cells were lysed using cold Lysis

buffer-I (0.3 M sucrose, 10mM Tris-HCl (pH:

7.4), 5 mM MgCl2, 1% Triton x-100). The

pellet was washed with phosphate buffer saline

(PBS) once. To the pellet 3 ml Lysis buffer-II

(10mM Tris-HCl, 400mM NaCl, 2mM Na2-

EDTA), 200μl of 10% SDS and 40μl

proteinase-K were added and incubated in 37°C

overnight. To remove proteins, 1 ml of 6M

NaCl was added and centrifuged for 5 min at

1500g. For extraction of DNA, 2 volumes of

absolute ethanol were added to the supernatant.

The extracted DNA was washed twice in 70%

ethanol, dried at 37°C, and recovered in sterile

water. Extracted DNA was stored at -20°C until

utilization.

PCR-SSP Amplification

IFN-γ polymorphism at position +874 in the

first intron (T versus A) was determined by

sequence-specific primer-PCR (PCR-SSP)

according to manufacturer‘s recommendations

(QPS Bioserve India (P) Ltd, Hyderabad,

India). Briefly, the PCR was performed in a

final volume of 50μl with 100-200ng of

isolated genomic DNA as template in reaction

mixture containing 200μM (each) dNTPs and

0.5 U Taq DNA polymerase, 1X reaction buffer

(Bangalore Genie, Bangalore, India), 3.5mM

MgCl2 (GENETIX, New Delhi, India), 0.5μM

each specific primers (antisense: TCA ACA

AAG CTG ATA CTC CA; sense +874 T: TTC

TTA CAA CAC AAA ATC AAA TCT; or

sense +874A: TTC TTA CAA CAC AAA ATC

AAA TCA), and 0.2 μM of each internal

control primers (QPS Bioserve India (P) Ltd,

Hyderabad, India). Internal control primers

amplify a human β-globin sequence (forward

primer: ACA CAA CTG TGT TCA CTA GC;

reverse primer: CAA CTT CAT CCA CGT

TCA CC). PCR amplification was performed

using a touch down method that included initial

denaturation at 95oC for 5 minutes followed by

two loops; loop 1 which consisted of 10 cycles

with the following program: 95oC for 30

seconds, 62oC for 50 seconds, and 72

oC for 40

seconds and loop 2 included 20 cycles with the

following program: 95oC for 30 seconds, 56

oC

for 50 seconds and 72oC for 40 seconds and a

final extension step at 72oC for 5 minute. The

amplified products were run on 1% agarose gel

that was in a buffer containing 0.5 μg/ml

ethidium bromide (Figure-1). Later it was

visualized under UV light and photographs

were documented.



STATISTICAL ANALYSIS

Statistical analysis was performed using

pantaray software systems (Uitenbroek and

Daan, 1997). Comparison of age, menarche

age, body mass index, duration of infertility in

the study groups and control group was

performed using the independent two-sample

Student‘s t test and data are presented as mean

±SD. The odds ratio (OR) and p-values were

used to measure the strength of the association

between genotypes and female genital

tuberculosis. Hardy– Weinberg equilibrium

(HWE) analysis was performed to compare

genotypes frequencies between patients and

controls by using χ2 analysis (df=1). All odds

ratios (OR) were calculated as estimates of the

confidence intervals (CI) were calculated at

the 95% level (95% CI). p -value <0.05 is

considered significant.

RESULTS

A total of 206 women were enrolled in the

study. Symptoms are found mild and local,

such as abdominal pain or menstrual

irregularities, tubal blockage, tubercular

salphingitis and infertility are the most

common consequences (Namavar Jahromi et

al., 2001), clinical signs of the FGTB patients

(case group) versus control groups were given

in the Table 1. Once fibrosis is established,

fertility is generally difficult to restore even

with appropriate treatment (Lamba et al.,

2002). Therefore, this prospective large case-

control cohort study was commenced for the

SNPs of IFN-γ +874T/A in Indian women

with FGTB (n=106) for the first time along

with 100 controls. The 106 (51.45%) of FGTB

patients were confirmed to have the evidence

of M. tuberculosis infection by either AFB

smear microscopy, or positive culture, or

histopathology, or PCR or a combination of

these (Abebe et al., 2004). 93.44% (57/61)

from biopsy specimens and 68.89% (31/45) of

positive cases from the curettage specimens

were identified by PCR for mycobacteriums as

shown in Table-II.

Figure-I: PCR-SSP Amplified product of IFN-γ (+874 T→A) gene SNP from FGTB patients

were electrophoreses on 1% agarose gel; 262 bp size bands correspond to IFN-γ A or T allele and

the 100 bp size bands correspond to internal controls.

50bp DNA marker is loaded in first well; lanes 1 and 2 show homozygosity for T allele; lanes 3

and 4 show heterozygosity for A and T alleles; lanes 5 and 6 show homozygosity for A allele;

lanes 7, 8, 9 and 10 show homozygosity for T allele; lanes 11 and 12 show homozygosity for A

allele.



Table-II: Comparison of the diagnosis yield of female Genital TB by different methods

Type of Specimens Smear Microscopy Culture Histopathology PCR for

mycobacterium

Case (n=106)

Curettage (n=45) 0 3 11 31

Biopsy (n=61) 19 32 42 57

Total 19 (17.92%) 35 (33.01%) 52 (49.05%) 88 (83.01%)

Control (n=100)

Curettage (n=37) Not detected

Biopsy (n=63) Not detected

The IFN- gamma (+874) genotypes and allele

frequencies of all FGTB patients and controls

are shown in Table-III. Distribution of the

genotypes in all groups was consistent with the

Hardy-Weinberg equilibrium. The IFN-γ

+874AA genotype was overrepresented in

FGTB patients 19.81% when compared with

the controls (9.0%) (Raut et al., 2001). Most of

the FGTB patients and controls showed TA

genotype (50.0% and 61.0% respectively)

which is associated with intermediate IFN-γ

production. However, FGTB patients also

showed slight increase in frequency of TT

(30.18% versus 30.0%) in comparison with

controls. An increasing number of studies have

shown that single nucleotide polymorphisms

(SNPs) located in the promoter or coding

regions of cytokine genes result in differential

cytokine secretion due to altered transcriptional

activation. It may be possible that different

stimuli result in differential transcription of the

same gene (Henao et al., 2006).

Table III: 2x2 Contingency analysis of IFN gamma (+874) genotypes and allele frequencies distribution in

Female Genital TB and Healthy Controls a

IFN-γ

genotype/Alleles AA AT TT TT+AT AA+AT 874A 874T

Case (%) n=106 21 (19.81) 53 (50) 32 (30.18) 85 (80.18) 74 (69.81) 37 (34.91) 42 (37.73)

Control (%)

n=100 9 (9.0) 61 (61.0) 30 (30.0) 91 (91.0) 70 (70.0) 35 (35.00) 46 (46.00)

Pb value

NA

0.0219 0.0943 0.0279 0.0625

NA

0.645

X2 value 5.254 2.798 4.834 3.469 0.212

OR (95%CI) 2.685(1.132-

6.367

2.187(0.866-

5.523)

2.498(1.0839-

5.7574)

2.207(0.9467-

5.146)

0.8636

(0.463-

1.611)

Note: a Values are given as number (percentage) unless otherwise indicated.

The Pb value was evaluated by χ2 test with a 2 x 2 contingency table (genotypes) and a 2 x 2 table

(allele frequencies) versus control women. b- Significance set at P ≤ 0.05.

Analysis of our results showed that there was

significant association in IFN-γ genotypes

(AA vs. AT) between FGTB patients and

control women (p value=0.0219, χ2

value=5.254, OR=2.685, 95% of CI=1.132-

6.367). i.e., individuals with IFN-γ +874 AA

and (TT+AT) genotype had chi- squared value

equals to 4.834, p value equals to 0.0279 and



OR (95%CI) =2.498 (1.084 -5.757). No

significant differences was established in IFN-

γ +874AA vs. TT and AA vs. (AA+ AT)

genotype frequencies between the case-control

groups (p value=0.0943, X2=2.798, OR

(95%CI) =2.187 (0.866-5.523) and p

value=0.0625, X2=3.469, OR (95%CI) = 2.207

(0.946-5.146) respectively). Statistical

analysis using risk of A and T alleles

frequencies of FGTB patients with controls

demonstrates no association with

susceptibility to FGTB per se (p value=0.645).

Our results are in the line with recent studies

which have been reported an association

between the +874 A/T SNP in the first intron

of the IFN-γ gene and pulmonary TB,

(Rossouw et al., 2003) suggesting that the TT

genotype which is associated with lower IFN-

γ production confers susceptibility to FGTB.

Therefore, higher levels of IFN-γ can cause

more effective cell-mediated immunity against

mycobacterium. A single nucleotide

polymorphism (SNP), T to A, located at

position +874 in the first intron could

influence IFN- γ production levels. The

association of different genotypes at this

position, with a low (AA), medium (AT) and

high (TT) cytokine production has been shown

in vitro (Lopez-Maderuelo et al., 2003). This

is the first study investigating the genetic

association of polymorphisms in the +874

IFN-γ gene with FGTB patients using SSP-

PCR.

DISCUSSION

Female genital tuberculosis is an important

cause of infertility, rarely diagnosed in

developed countries. It often has low-grade

symptoms with very few specific complaints

have been explained in the Methods and

Materials. IFN-γ is required for host defense

against a broad range of pathogens and is

especially critical for mycobacterial immunity.

Lack of production and mutations in the

cytokine gene (Cooper et al., 1993) is

associated with the most lethal forms of

infections and increase the susceptibility to

develop the disease. IFN-γ +874A allele has

been previously reported to be associated with

infectious diseases such as tuberculosis,

hepatitis B virus infection, and parvovirus

infection, (Tso et al., 2005; Ben-Ari et al.,

2003) revealing its potential role in host

defense against microbial infections. The

mechanism by which the IFN-γ +874T/A

allele influences the susceptibility to FGTB

may depend on its role in the regulation of

IFN-γ production. The T allele of IFN-γ

+874A/T provides a binding site for the

transcription nuclear factor-κB (NF-κB),

which is able to regulate IFN-γ expression

(Pravica et al., 2000). In particular, the +874A

polymorphism in the gene for IFN-γ results in

decreased IFN-γ expression (relative to the

+874T variant) and has been associated with

susceptibility to TB in some but not all studies

(Moran et al., 2007; Vidyarani et al., 2006).

Heterozygous carriers have an intermediate

phenotype, suggesting that more subtle

variation in the IFN-γ response pathway may

underlie susceptibility to TB in outbreed

human populations (Levin et al., 1995). Our

observation shows that the individuals with

IFN-γ +874 AA genotype is more prevalent in

patients with FGTB associated clinical

findings like tubal block with hydrosalphinx,

tubercular salphingitis and Omental adhesions.

These were not distinguished in pulmonary

TB and controls as well. This nature of disease

may be due to genetic variations in the

bacterial strain and extraordinary virulent

nature of mycobacterium. Depending upon the

geographic locality and ethnicity of a

population, variations have been reported in

various studies regarding the occurrence and

frequency of extrapulmonary tuberculosis

(EPTB) in the two sexes, in different age

groups and the organs involved (Kadivar et al.,

2007; Sreeramareddy et al., 2008). The

differences in transmissibility and virulence

among M. tuberculosis strains are related to

the genetic background and different lineages

with specific geographical regions of the

organisms (Caminero et al., 2001; Gagneux



and Small, 2007). Animal infection models

suggests haematogenous dissemination of

infection occurs before the onset of T-cell

mediated immunity (Chackerian et al., 2002)

and supports the hypothesis that the ability of

different strains of M. tuberculosis to produce

different clinical phenotypes varies dependent

upon their interaction with the host innate

immune response, but the relevance of these

findings to human disease remains uncertain

(Manca et al., 2005). Nonetheless, it is

possible that more common genetic variants

such as promoter region polymorphisms that

influence gene expression are associated with

the disease. Therefore we suggests that, the

IFN-γ +874 (A/T) alleles polymorphism were

significantly associated with tuberculous

bacillus infectivity and likely plays role as a

genetic risk factor for the pathogenesis of

FGTB in Indian women. It is also possible

that low IFN-γ production may impair

antimycobacterial response against FGTB

infection, rendering these individuals more

susceptible to Tuberculous bacillus infection

other than pulmonary TB (Vidyarani et al.,

2006). Although IFN-γ can overcome these

phenomena in vitro, M tuberculosis can

interfere with IFN-γ signaling and down

regulate the transcription of IFN-γ inducible

genes (Ting et al., 1999). Further, we also

suggested that asymptomatic nature of the

disease, accessibility of reproductive clinics,

and elucidation of genes associated with

virulence, pressure of susceptible factors,

detection of intraspecies differences in

genome sequences and gene expression

studies should not be neglected during the

description of FGTB.

ACKNOWLEDGEMENT








discussed.

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Figari IS, Bradley A and Stewart TA.

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gamma genes. Science, 259:1739-42.

10. Dam P, Shirazee HH, Goswami SK,

Ghosh S, Ganesh A, Chaudhury K, and



Chakravarty B. 2006. Role of latent

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Papanicolaou NC, Relakis KJ, Kokori HG,

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14. Haas DW. 2000. Mycobacterial diseases.

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15. Henao MI, Montes C, Paris SC and Garcia

LF. 2006. Cytokine gene polymorphisms

in Colombian patients with different

clinical presentations of tuberculosis.

Tuberculosis., 86: 11–19

16. Hoffmann SC, Stanely EM and Cox ED,

et al. 2002. Ethnicity greatly influences

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17. Jindal UN, Bala Y, Sodhi S, Verma S and

Jindal S. 2010. Female genital

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18. Kadivar MR, Ghaneh-Shirazi R,

Khavandegaran F and Karimi M. 2007.

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24. Manca C, Tsenova L, Freeman S, Barczak

AK and Tovey M, et al. 2005.

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in the IFN-gamma gene and susceptibility

to TB. Int. J. Tuberc. Lung Dis., 11:113–

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Ghane-Shirazi R. 2001. Female genital

tuberculosis and infertility. Int J Gynaecol

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and Hutchinson IV. 2000. A single

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L. 1983. Female genital tuberculosis and

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238.

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tuberculosis. Ind. J. Med. Microbio.,

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D. van Helden, and E. G. Hoal. 2003.

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40. Tso HW, Ip WK and Chong WP, et al.

2005. Association of interferon gamma

and interleukin 10 genes with tuberculosis

in Hong Kong Chinese. Genes Immun.,

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42. V. S. Raut, A. A. Mahashur, and S. S.

Sheth. 2001. The Mantoux test in the

diagnosis of genital tuberculosis in

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Gynecology and Obstetrics., 72 (2):165–

169.

43. Vidyarani M, Selvaraj P, Adnand AP,

Jawahar MS and Adhilakshmi AR, et al.

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Indian J Med Res., 124: 403–410.



ijcrr

Vol 04 issue 03

Category: Review


Revised on:12/12/11


ABSTRACT Ziziphus mauritiana is one of the underutilized herbs having potential to heal various ailments. It is

reported in the ancient literature that whole plant as fruits, leaves , seed and root posses

pharmacological activity . So this article is focused on potential and reported pharmacological

activities of the whole plant.

___________________________________________________________________________

Keywords :- Ziziphus mauritiana , root ,seed,

fruit

INTRODUCTION

Ziziphus mauritiana a tropical fruit tree

species. It is a spiny, evergreen shrub or small

tree up to 15 m high, with trunk 40 cm or more

in diameter; spreading crown; stipular spines

and many drooping branches. The fruit is of

variable shape and size. It is oval, obovate,

oblong or round, and it can be 1-2.5 in (2.5-

6.25 cm) long, depending on the variety. The

flesh is white and crisp. When slightly unripe,

this fruit is a bit juicy and has a pleasant aroma.

The fruit's skin is smooth, glossy, thin but

tight.It is the most commonly found in the

tropical and sub-tropical regions. Originally

native to India it is now widely naturalized in

tropical region from Africa to Afghanistan and

China, and also through Malaysia , Australia

and in some pacific regions. It can form dense

stands and become invasive in some areas,

including Fiji and Australia and has become a

serious environmental weed in Northern

Australia. It is a fast growing tree with a

medium life span that can quickly reach up to

10–40 ft (3 to 12 m) tall.

VERNACULAR NAMES:

English: Chinee apple, Chinese date, cottony

jujube, Indian cherry, Indian jujube,

Indian plum, jujube

Fijian: baer

French: jujubier, massonnier

Hindi: baher, bahir

Spanish: azufaifo africano

ZIZIPHUS MAURITIANA : A REVIEW ON

PHARMACOLOGICAL POTENTIAL OF THIS

UNDERUTILIZED PLANT

Sukirti Upadhyay1, Prashant Upadhyay

1, A K Ghosh

1, Vijender Singh

2

1 College of Pharmacy, IFTM, Moradabad (U.P)

2 School of Pharmacy, KIET, Ghaziabad (U.P)


http://en.wikipedia.org/wiki/Tropical

http://en.wikipedia.org/wiki/India

http://en.wikipedia.org/wiki/Africa

http://en.wikipedia.org/wiki/Afghanistan

http://en.wikipedia.org/wiki/China

http://en.wikipedia.org/wiki/Malaysia

http://en.wikipedia.org/wiki/Australia

http://en.wikipedia.org/wiki/Fiji



CLASSIFICATION

Kingdom: Plantae

Division: Magnoliophyta

Class: Magnoliopsida

Order: Rosales

Family: Rhamnaceae

Genus: Ziziphus

Species: Z. mauritiana

Binomial name Ziziphus mauritianaLam.

CHEMICAL CONSTITUENTS:

It is a rich source of cyclopeptide alkaloids

lupane and triterpenes.

cyclopeptidmacrocycles of Ziziphus species

showed interesting biological properties,

including sedative, analgesic, antibacterial ,

antifungal and, antiplasmodial activity etc .It

have 14-membered ring cyclopeptides to be

the largest subgroup of alkaloid obtained,

whereas only one 13-membered macrocyclic

alkaloid isolated from this plant. These

included the 4(14)-membered ring class:

mauritineC, amphibine F and frangufoline the

5(14)-membered ring type: mauritines A and

B. It also contain protein ,carotene and vitamin

C. The fruit is eaten raw or pickled or used in

beverages. It is quite nutritious and rich in

vitamin C. It is second only to guava and

much higher than citrus or apples. In India, the

ripe fruits are mostly consumed raw, but are

sometimes stewed. Slightly unripe fruits are

candied by a process of pricking, immersing in

a salt solution. Ripe fruits are preserved by

sun-drying and a powder is prepared for out-

of-season purposes. It contains 20 to 30%

sugar, up to 2.5% protein and 12.8%

carbohydrates. Fruits are also eaten in other

forms, such as dried, candied, pickled, as

juice, or as ber butter. In Ethiopia, the fruits

are used to stupefy fish.The leaves are readily

eaten by camels, cattle and goats and are

considered nutritious.In India and Queensland,

the flowers are rated as a minor source of

nectar for honeybees. The honey is light and

of fair flavor.1

MEDICINAL PROPERTIES

Plant pacifies vitiated pitta, kapha, obesity,

fever, burning sensations, cough, wound, skin

disease, ulcers, stomatitis, diarrhea, sexual

weakness, and general debility.

Useful part : Fruit, Seed, Leaves, Root, Bark. 2

http://en.wikipedia.org/wiki/Plant

http://en.wikipedia.org/wiki/Flowering_plant

http://en.wikipedia.org/wiki/Magnoliopsida

http://en.wikipedia.org/wiki/Rosales

http://en.wikipedia.org/wiki/Rhamnaceae

http://en.wikipedia.org/wiki/Ziziphus

http://en.wikipedia.org/wiki/Binomial_nomenclature

http://en.wikipedia.org/wiki/Jean-Baptiste_Lamarck

http://en.wikipedia.org/wiki/Vitamin_C

http://en.wikipedia.org/wiki/Ethiopia

http://en.wikipedia.org/wiki/Queensland



PHARMACOLOGICAL REVIEW OF

LITERATURE:

The alcohol and aqueous extract of

Z.mauritiana leaves stimulates cell-mediated

immune system by increasing neutrophil

function and phagocytic activity. 3

Free radical scavenging activity & inhibitory

response of Ziziphus maurtiana seed extract

exert on alcohol induced oxidative stress.4

Anticancer potential of aq. ethanolic extract of

Ziziphus maurtiana was found against cancer

cell liner by MTI assay. 5

Ziziphus maurtiana root exert antidiarrhoeal

activity of in rodents . The antidiarrhoeal

effect of the methanolic extract as evaluated

exhibited a concentration dependent inhibition

of the spontaneous pendular movement of the

isolated rabbit jejunum and inhibited

acetylcholine induced contraction of rat ileum.

A dose dependent decrease of gastrointestinal

transit was observed with extracts (25 and 50

mg/kg) which also protected mice against

castor oil induced diarrhea and castor oil

induced fluid accumulation, respectively. The

presence of some of the phytochemicals in the

root extract may be responsible for the

observed effects, and also the basis for its use

in traditional medicine as antidiarrhoeal drug. 6

Chronic alcohol ingestion is known to increase

the generation of reactive oxygen species

(ROS), thereby leading to liver damage. Pre-

treatment of rats with 200, 400 mg/kg body

weight of aqueous leaf extract of Z.mauritiana

resulted reduced the morphological changes

that are associated with chronic alcohol

administration .Rat liver administered with

only alcohol resulted in severe necrosis,

mononuclear cell aggregation and fatty

degeneration in the central and mid zonal

areas which was a characteristic of a damaged

liver. 7

Ziziphus maurtiana aqueous ethanol seed

extract exert hypoglycemic activity in alloxan

induced diabetic mice. 8

The aqueous extract of Ziziphus maurtiana

leaf lowers cholesterol and triglycerides level

in serum & liver of rats Aqueous extract of

Ziziphus maurtiana leaf can be used for the

prevention and treatment of fatty liver,

atherosclerosis and other diseases associated

with high levels of cholesterol and

triglyceride. Pretreatment was found to confer

more protection than co-treatment, hence

pretreatment should be preferred. 9

The methanolic extract of Z.mauritianastem

bark was evaluated for its antiulcer activity

using two models. Models are ethanol induced

gastric ulcers model and aspirin induced

gastric ulcer model in mice. It was found that

the methanolic extract of stem bark have

significant antiulcer activity in dose dependent

manner where 3 different oral doses prepared

(100 mg/kg of body weight, 250 mg/kg of

body weight and 500 mg/kg of body weight).

Evaluation was done on both models

comparing with reference standard ranitidine

(80 mg/Kg/ p. o.). The above result shows that

Z.mauritianastem bark probably contains

some active ingredients that could be

developed for above mentioned abnormal

condition as have been claimed by traditional

system of medicine. 10

The antimicrobial effects of ethanolic extracts

of leaves of two species of genus Ziziphus

were determined against Escherichia coli,

Staphylococcus aureus, Streptococcus

pyogenes, Aspergillus niger and Candida

albicans. S. pyogenes was the most susceptible

followed by E. coli while S. aureus was the

least susceptible. 11

Investigation of the MeOH extract that

alkaloids isolated exhibited potent

antiplasmodial activity against the parasite

Plasmodium falciparum with the inhibitory

concentration (IC50) ranging from 3.7 to

10.3 μM. Compounds 2 and 3 also

demonstrated antimycobacterial activity

against Mycobacterium tuberculosis with the

MIC of 72.8 and 4.5 μM, respectively. 12

The aqueous, methanolic and saponin extracts

of Zizyphus mauritiana bark were screened for

spermicidal activities against human

spermatozoa.Saponin extract is found to be



more active to cause immobilization then

aqueous and methanolic extract.13

CONCLUSION

Thus from traditional and reported activities of

Z.mauritiana it may be concluded that this herb

has great potential as antimicrobial ,

hepatoprotective , anticancer , contraceptive and

antidiarrhoel agent other activities mentioned in

the literature have to explore for further

development of potential medicinal agent.

ACKNOWLEDGEMENT

I would like to acknowledge Prof R L Khosa

conveyer of GBTU for encouragement in doing

research work.

REFERENCES

1. www.ayurvedicmedicinalplants.com

2. http://commons.wikimedia.org

3. Wadekar R.Effect of Ziziphus maurtiana

lea.f extract on phagocytosis by human

neutrophills. Journal of Pharmacy

Research 2008;1 (1).

4. Bhatia A and Mishra T ,Free radical

scavenging activity and inhibitory

responces of ziziphus maurtiana seed

extract on alcohol induced oxidative

stress. An international forum for

Evidence Based Practices 2009,;( 1): 8

5. Mishra T , Kullar N and Bhatia

A.Anticancer potential of Aqueous

ethanol seed extract of Ziziphus maurtiana

against cancer cell lines and Ehrlich

Ascites Carcinoma. Evidence Based

Complementary And Aleternative

medicines 2011;.2011:11.

6. Dahiru D, Sini J.M.and John Africa L

Antidiarrhoeal activity of Ziziphus

maurtiana root extract in rodents. African

Journal of Biotechnology 2006; 5 ,10.

7. Dahiru D , Obidoa O. Evaluation of the

Antioxidant Effects of Z.mauritianaLam.

Leaf Extracts Against Chronic Ethanol-

Induced Hepatotoxicity in Rat Liver Afr J

Tradit Complement Altern Med 2007 ;

5(1): 39–45

8. Bhatia A and Mishra T ,Hypoglycemic

activity of Ziziphus maurtiana aqueous

ethanol seed extract in alloxan induced

diabetic mice.Pharmaceutical biology

2010; 48,604.

9. Dahiru D, Obidoa O,Effect of aqueous

extract of Ziziphus maurtiana leaf on

cholesterol and triglycerides level in

serum & liver of rats administered

alcohol.2009, Pakistan j of nutrition ,

2009:1884-1888.

10. Panchal S, Panchal K, Vyas N, Modi K,

Patel V, Bharadia P, Pundarikakshudu K.

Antiulcer Activity of Methanolic Extract

of Z.mauritiana stem Bark International

Journal of Pharmacognosy and

Phytochemical Research,2010 2(3): 6-11.

11. M. E. Abalaka1, S. Y. Daniyan1 and A.

Mann2 M. E. Abalaka1, S. Y. Daniyan1

and A. Mann Evaluation of the

antimicrobial activities of two Ziziphus

species (Z.mauritianaL. and Ziziphus

spinachristi L.) on some microbial

pathogens. African Journal of Pharmacy

and Pharmacology 2010. 4(4): 135-139.

12. Panomwan P., Kanlaya L., Samran P.,

Palangpon K., Apichart S, Somsak R and

Sunit S .Antiplasmodial and

antimycobacterial cyclopeptide alkaloids

from the root of Ziziphus mauritiana

,Phytochemistry 2011,72 : 909-915 .

13. Dubey R, Dubey K, Sridhar C, Jayaveera

K N. Sperm immobilization activity of

aqueous, methanolic and saponins extract

of bark of Ziziphus Mauritiana.Pelagia

Research Library.Der Pharmacia Sinica,

2010 , 1 (3): 151-156.

http://www.ayurvedicmedicinalplants.com/

http://commons.wikimedia.org/



ijcrr

Vol 04 issue 03

Category: Research


Revised on:08/12/11


ABSTRACT Introduction: Currently medical education is dominated by examination and product oriented didactic

lecture sessions in most of the medical schools. Innovation in medical education is required to reorient

current medical curricula. Objective: The present study aimed to explore the scope of community

based learning at village set-up in creating self driven learning and rural bias among medical

undergraduates. Methods: Using a village posting, students were made aware of community needs

through social mapping, transect walk and discussion on various issues pertaining to rural health. A

triangulation of qualitative methods like free list, pile sort exercise and focus group discussion was

undertaken to understand the perception of students regarding various teaching methods. Results:

Student could notice existence of different teaching methods: classroom based didactic lecture,

OHP/PPT guided session, group discussion, problem based learning, field visit based learning, port

folio driven learning and community based learning. Community based learning, problem based

learning and filed visit guided learning motivated students towards self-driven learning and created a

sense of rural bias among them. However, competitive examination oriented lecture sessions were

cited as poor teaching methods and fail to motivate them. Conclusion: Community based learning has

the potential of creating self-driven learning among medical undergraduates

____________________________________________________________________________

Key words: Community based learning,

Medical education, Pile sort analysis

INTRODUCTION

The role of innovation in medical education is

becoming increasingly important and it will be

vital for all nations to reorient their education

systems.1Advances in the learning sciences

have expanded our understanding of how

student‘s learning and how the mind converts

information into useful knowledge.2 Indian

education system is based upon British colonial

legacy: educational levels, curriculum

frameworks, physical structure of colleges and

classrooms, and timing of examinations.1

The

education system is characterized by didactic

teaching, individual work, a product oriented

approach, absence of

independent thinking, and presence of

unquestioned obedience to authority.3

Skill

building in research methods is increasingly

being seen as integral component of medical

education, and community based learning can

be one of them.4-5

Garg6 and Narayanan

7 have

already described the role of community based

teachings in creating rural bias among medical

undergraduates and social revolution.

The teaching model of Mahatma Gandhi

Institute of Medical Sciences (MGIMS),

Sewagram is based on Gandhian ideology. The

institute aims at evolving a pattern of medical

education suitable for developing countries. To

orient the students and provide them with a

ROLE OF COMMUNITY BASED LEARNING IN

CREATING SELF-DRIVEN LEARNING AND RURAL BIAS

AMONG MEDICAL UNDERGRADUATES

Shib Sekhar Datta, Abhijit V Boratne

Department of Community Medicine, Mahatma Gandhi Medical College and

Research Institute, Pillayarkuppam, Puducherry




personal experience of rural life, ‗Social

Service Camp‘ is held in a village adopted each

year for the purpose for a period of 15 days.

During this period, first year medical students

are asked to stay in the village under the

guidance of faculty of Community Medicine.

They carry out health, sanitation and nutrition

surveys.8 The theme for the 2008 batch medical

undergraduates camp was ‗Community Based

Learning‘. The aim was to explore the scope of

community based learning in creating self

driven learning and rural bias among medical

undergraduates.


Study setting: The current study was

undertaken during ‗Social Service Camp‘

organized for 2008 batch of medical

undergraduates at Pulai village of Wardha

district, Maharashtra with a total population of

846 and 217 households. Students were

oriented about socio-demographic profile of the

village and community needs using different

Participatory Rural Appraisal tools and

techniques and utility of community based

learning cum research in rural development.

Preparation of self portfolio and discussion on

topics ranging from rural health, gender bias,

and leadership among doctors was undertaken.

Students participated in social mapping, did

transect walk to have better understanding of

rural community. In addition, they did

anthropometric measurements of 0-20 years

age group population and dietary survey in one

allotted families. They also participated in

microbiological and pathological sample

collection for the entire village which extended

till management of positive cases in the village.

Information collection: These were carried

out at the end of the Social Service Camp. A

triangulation of qualitative methods like free

list, pile sort exercise9 and Focus Group

Discussions (FGDs)10

, which are useful to

explore the perceptions of students regarding

better teaching-learning methods was

undertaken. Initially, students (n=64) were

asked to individually enlist the various teaching

methods they have observed during the camp

posting. Later, 9 various types of teaching

methods (Figure 1) with relatively high Smith‘s

S value were pile sorted. In pile sort exercise,

12 purposively selected students, who were

willing to participate and talk freely, were

individually asked to form the groups of these 9

methods which they felt went together. This

was followed by 4 FGDs, consisting of 6-8

students for each session (both boys and girls),

to understand perception and attitude towards

different teaching methods. These FGDs were

facilitated by a faculty of Community Medicine

using semi-structured guidelines and note taker

(post graduate of Community Medicine)

recorded all discussions. The numbers of FGDs

were decided by saturation point i.e. where it

stopped yielding any new information. The

facilitator encouraged the participants to freely

exchange their perception and experiences

related to various teaching methods. The

sampling technique adopted for the present

study was purposive with maximum variance.

Data analysis: A two dimensional scaling and

hierarchical cluster analysis was completed

with pile sort data to get collective picture of

their perceptions. The analysis of free list and

pile sort data was undertaken using Anthropac

4.98.1/X software.11

RESULTS

Various teaching methods which students could

observe to be in practice during their initial six

month career as medical undergraduates

including current camp posting in decreasing

order of frequency are: classroom based

didactic lecture sessions, sessions using over

head projectors (OHP)/power point

presentations (PPT), and group discussion

(GD); which are mostly examination oriented.

To a lesser extent they could also observe the

existence of problem based learning (PBL),

field visit guided learning and learning through

community based posting, especially during

this camp. Community based learning as per

their experience has triggered among them need

for exploration of social issues related to health



and disease, and has been able to create a sense

of rural bias and better understanding of disease

process. Portfolio aimed at self driven learning

revealed ‗what they want to learn?‘ ranging

from personal hygiene, communication skills,

geriatric care, nutrition, environment and

sanitation to health care delivery at village

level.

Examination oriented study however, they feel

has failed to motivate them to explore the core

need of the community. Most of the classroom

based lecture sessions they observe are

curriculum guided and do not address the needs

of the rural poor. Such competition oriented

curriculums are often examination oriented and

record book or theoretical knowledge aimed.

Community based learning, portfolio guided

study and PBL were recognized as better

learning methods; whereas examination guided

didactic lecture sessions, sessions using

OHP/PPT were cited as poor teaching methods.

However, they also mentioned that institutional

credibility played an important role in

establishing such teaching-learning setting at

village level.

In pile sort exercise, four major groups of

teaching-learning methods were formed. The

first major group comprised of better ones

comprising of community based learning, PBL

and field visit guided learning. Students felt

that, these should be encouraged in medical

institutions to promote rural health and also

they found them interesting and better methods

to understand the Community Medicine

subject. The second group of portfolio based

learning and GD was considered to be better

during initial days of the professional course to

guide their future career. Remaining groups of

classroom based didactic lecture sessions, and

OHP/PPT guided sessions; and examination

oriented study, they commented to be the

inferior ones which do not serve the purpose of

learning and rather demotivate the students and

creates a picture of casualness on part of a

teacher. (Figure 1)

DISCUSSION

In the present study, usefulness of various

teaching methods has been re-invented. Need

for innovative learning methods in medical

institutions; like learning through community

based posting, PBL and learning through filed

visits has again been well established. On the

other hand, lecture guided teaching sessions,

which currently is being practiced in most of

the medical schools has been viewed as one of

the negative factor and demotivate students.

Medical teaching in developing countries aims

to impart skills to students to critically appraise

evidence, promote, prevent, and manage health

in the community.9 Community based learning

has been shown to have the potential to

motivate students to appreciate the learning

process with greater community involvement. 12-13

In the present formative research, the ‗Social

Service Camp‘ approach and application of

community based posting to learn social issues

and appreciate self-motivated learning as an

effective method has been well established. The

attribute can be because of their continuous

presence in the rural community for a descent

period and better interaction with the

community. Dongre et al14

has already well

documented role of community based study in

motivating students for self-driven learning.

The teaching approach in such camps is an

integration of task oriented assignments,

integration of social sciences within medical

domain and active involvement with the

community. Notably, the student centered

educational innovation is not quite evident in

Asia as seen in other parts of the world.13

Students reported that examination oriented

teaching are ineffective in guiding them

towards self-driven learning. This has again

reiterated that most of the medical schools in

Asia have traditional, teacher centered and

hospital based education which fail to produce

complete doctors required for the rural

poor.15,16

Few researchers also feel medical

curricula should formulate flexible syllabus

rather than a rigid one, but this has not been



popular and on the contrary created lot of issues

rather than solution.5 Research particularly at

community set-up has also been used as a tool

to teach epidemiology in some medical schools

in India.17

Self-driven learning thus should be

promoted to guide medical education in

resource poor developing countries to cater for

the rural masses in better way.18

Such self-

driven learning can be facilitated through

community based learning.

CONCLUSION

Community based learning is one important

teaching method which has the potential of

creating self-driven learning among medical

undergraduates, and is better compared to

classroom based lecture sessions or similar

other examination oriented teaching methods.

Community based learning at village set-up

promotes rural bias among medical

undergraduates and should be incorporated in

current medical curricula.

ACKNOWLEDGEMENT

We thank staff of Dr. Sushila Nayar School of

Public Health incorporating Department of

Community Medicine, Sewagram for their

support during the Social Service Camp.






journals and books from where the literature for

this article has been reviewed and discussed.

Source of financial support: Nil

Conflict of interest: None

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Figure 1: Perception of medical undergraduates regarding various teaching methods: Two

dimensional scaling and hierarchical cluster analysis

1-Community based learning 4-Port folio based learning

2-Problem based learning 5-Group discussion

3-Filed visit guided learning

6-OHP /PPT guided session 8-Competition based study

7-Didactic lecture session 9-Examination oriented study

1

2

3

4 5

6 7

8 9

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Role of community based learning in creating self-driven learning and rural bias among medical undergraduates