Amrita Journal of Medicineamritahospitals.org/pdffiles/Journal-of-Medicine... · Renjini B A, Vinod...

Amrita Journal of Medicine

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3Original Article

Risk Factors of Fall among Elderly Persons: Results from a Community based Case-Control Study in Thiruvananthapuram, Kerala, India

Effectiveness of Hepatitis-B Vaccination Pro-gramme Among Grade II Health Personnel of Government Medical College, Thiruvananthapu-ram

Mathew J Valamparampil, Mohan Ananth, S R Ameena, K B Sreekanth, R S Reshma, Chandran Praseeda, T S Anish

Sharon Ann Georgy, Lakshmi R, Remya Sudevan

Lakshmi G G, Prathibha M T, Zinia T Nujum

Editorial Board

CONTENTS

14 To Assess Anxiety and Depression in Patients Un-dergoing Maintenance Haemodialysis in a Tertiary Care Hospital in Kerala

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Insulin Initiation And Titration Patterns In Type 2 Diabetes MellitusRevathi K Rajan, Mohammed Ashraf, Harish Kumar

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The Role of Antibiotics in the Treatment of General Pediatric Conditions: An Observational Study From a Tertiary Care Centre, India

Case Report41 Nephron Sparing Surgery for Large Extra Renal

Angiomyolipoma in First Trimester of PregnancyPraveen Sundar, Priyank Bijalwan, Appu Thomas

Vol. 14, No: 2Aprl - Jun 2018, Page 1 - 44

43 An Interesting Case of Aortoventricular TunnelRenjini B A, Vinod M, Aravind, Sujata Sridharan

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Bisna Abdul Kader, Dhanasekaran B S, Gireesh Kumar, Sreekrishnan T P

To Study The Aetiology of In- Hospital Cardiac Arrest in A Tertiary Care Hospital

Comparative Study on The Effect of Interferen-tial Current Therapy and Ultrasound Therapy in Post-Stoke Hemiplegic Shoulder PainReshma J, Ravi Sankaran, George Joseph, K Surendran

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Arya Jith, K Sreekumar, Chitra Venkateswaran

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Editorial BoardAdvisers

Dr. Prem Nair Dr. Vishal Marwaha

Editorial Board Chairman

Dr. D M Vasudevan

Chief Editor

Dr. Harish Kumar

Associate Editors

Dr. Manuraj R

Dr. Sandeep Sreedharan

Dr. Unnikrishnan K Menon

Dr. Vijayakumar K

Editorial Board Members

Dr. Anupama R

Dr. Beena K V

Dr. Devanarayanan Dutta

Dr. Gireesh Kumar K P

Dr. Hisham Ahammed

Dr. Meenakshi Dhar

Dr. P G Nair

Dr. Rakesh P S

Dr. Sundaram K R

Dr. Venkitachalom R

Publicity Officer

Mrs. Gita Rajagopal

Design & Artwork

Sivaprasad

Copyright Although every possible care has been taken to avoid any mistake and this publication is being sold on condition and understanding that the information it contains are merely for guidance and reference and must not be taken as having the complete authority. The Institu-tion and The Editors do not owe any responsibility for any action taken on the basis of this pub-lication. The copy rights on the material and its contents vests exclusively with the publisher. Nobody can reproduce or copy the prints in any manner.


Site Link: http//www.amritahospital.org/amrita_ journal


Indexed With Index Copernicus

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The Role of Antibiotics in the Treatment of General Pediatric Conditions: An Observational Study From a Tertiary Care

Centre, IndiaSharon Ann Georgy*, Lakshmi R*, Remya Sudevan**

ABSTRACTThe extensively prescribed therapeutic agents in paediatric age group for treating general conditions are antibiotics. The use of antibiotics has become a routine practice for the treatment of pediatric illness. The judicious use of antibiotics has definite role in treating children. The irrational use of antibiotic use has lead to bacterial resistance globally and exists as a major public health issue. The most significant target population aimed at reducing antibiotic resistance are children. So there exists the need to eval-uate the role of antibiotics in children with general pediatric conditions. Our study was aimed to identify the major therapeutic issues in antibiotic usage among pediatric population.

Key Words: Pediatrics, antibiotics, antimicrobial resistance.Corresponding Author: Remya Sudevan

INTRODUCTION Antimicrobial agents or antibiotics are substances produced by various species of microorganisms (bac-teria, fungi, actinomycetes) that suppress or inhibit the growth of other microorganisms and may eventually destroy them1 Various antibiotics act in different ways to destroy the pathogens. Antibiotics like penicillins and cephalosporins inhibits cell wall synthesis whereas tetracyclines, macrolides and clindamycin inhibits the protein sysnthesis. Agents like sulphonamides and tri-methoprim blocks the important metabolic steps of the microorganisms. Metronidazole and quinolones inter-fere with nucleic acid synthesis2. In childhood majority of the children suffer from variety of bacterial infections such as respiratory tract infections, sinusitis, otitis me-dia, pharyngitis, urinary tract infections etc. Antibiotics are the most commonly prescribed therapeutic agents in pediatric patients for the treatment of these bacterial infections3,4. Studies have shown that in antibiotic usage by age, preschool children were more exposed to anti-biotics due to their entry in community setting5. Some studies had reported that Pencillin group of drugs were the commonly used first line drugs in children every-where6,7,8. Recently there is a global shift in prescribing antibacterial agents towards not first line agents such as second generation macrolides, cephalosporins etc9,10,11. There exists geographical differences in antibiotic usage depending on the existing health care systems, physi-cian attitude, sociocultural and economic determinants of parents. Antibiotic resistance is a major public health issue globally due to the prolongation of patient suffer-ing, increased health care expenses and the economic implications for community5. Three important ways of antimicrobial resistance are enzyme degradation of *Dept. of Pharmacy Practice,**Dept. of public health research, AIMS, Am-rita Vishwa Vidyapeetham, Kochi, India.


antibacterial drugs, alteration of bacterial proteins that are antimicrobial targets and changes in the membrane permeability to antibiotics12. The key factors for bacteri-al resistance are overuse and misuse of antibiotics. An-tibiotics are prescribed incorrectly, used in conditions in which they are not indicated and also in sub-optimal amount5. More over there are potential adverse drug re-actions existing for antibiotic use. Adverse drug reaction (ADR) is defined as a response to a drug which is nox-ious and unintended and which occurs at doses normal-ly used in man for prophylaxis, diagnosis or therapy of disease or for modification of physiological function13. To improve the antibiotic prescribing pattern and appropriate use of antibiotics in children for common conditions, evidence based studies are needed from our country. To reduce the unnecessary antibiotic use we have to identify the conditions in which antibiotics are over prescribed. Our study aimed in evaluating the role of antibiotic use in children.

OBJECTIVESPrimary objective To assess the role of antibiotics for the treatment of general conditions in pediatric population.

Secondary objectives1. To identify the common conditions in which antibi-

otics are prescribed for children.

2. To identify the most commonly used antibiotic for general conditions in pediatric population.

3. To document adverse drug reactions when antibi-otics are administered.

4. To determine the duration of hospital stay in pedi-atric population with general conditions where an-tibiotics are used.

ORIGINAL ARTICLE

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The Role of Antibiotics in the Treatment of General Pediatric Conditions: An Observational Study From a Tertiary Care Centre, India

METHODOLOGY This is a prospective observational study. The study was carried out at the general ward of paediatrics de-partment in a tertiary care centre. A total of 200 patients in the age group of >1 month -18 years who were ad-mitted in the general ward for general conditions dur-ing the time period of July 2013 – May 2014 were en-rolled in the study. The study duration was 11 months. A standardised data collection form was used for collect-ing data from the patient’s case files. The data collected were compiled using Microsoft Excel. All statistical anal-yses were carried out using IBM Statistical Package for Social Science(SPSS version 20). To obtain the character-istics of categorical variables, frequency and percentage were used and that of numerical variables mean and standard deviation were applied.

Inclusion Criteria• All pediatric inpatients of age >1 month to 18 years

who were admitted in the pediatric ward for gener-al conditions.

• Pediatric patients who were prescribed with antibi-otics.

Exclusion Criteria• Patients admitted in NICU or any other wards.• Patients who were immunocompromised or who

were diagnosed with TB.

From this study it can be concluded that children be-low 5 years of age were more prone to infections. Major-ity of the children infected were male. All the patients were immunized as per age and71.5% were from rural area. Respiratory infections especially lower respiratory tract infections were the most common condition that required antibiotic prescription. The frequently pre-scribed antibiotics were ceftriaxone and amoxicillin with clavulanic acid. The mean duration of hospitalization was found to be 9.04 ± 4.64 days. As antibiotics share a very high percentage in any prescription, periodic study on the usage of antibiotics and sensitivity pattern in the hospital set up is needed. These studies will enable the health care professionals to select the appropriate antibiotic which helps in promoting the rational use of antibiotics as well as preventing antibiotic resistance in children.

RESULTS The mean age of the patients in this study was 4.21 ± 4.61 years with a minimum of 2 months and maximum 17 years. The maximum number of patients ie, 65(32.5%) were in the age group of 1-3 years and 39(19.5%) were in the age group of <1 year of age. Only 2 patients were in the age group 16-18 years. The age distribution of patients is shown in Figure1. The maximum number of patients ie, 65(32.5%) were in the age group of 1-3 years and 39(19.5%) were in the age group of <1 year of age. Only 2 patients were in the age group 16-18 years. The male to female ratio of the study patients was 1.47:1. All the 200 study patients were immunized as per the age. Almost 3/4th of the patients who were included in this study were staying in rural area ie, 143(71.5%) and only 57(28.5%) were staying in urban area. The common conditions in which antibiotics were pre-scribed were Lower respiratory tract infections (LRTI) (32%), asthma exacerbation (17%), Upper respiratory tract infections (URTI-10%), Urinary tract infection (UTI) - 8% and Gastroenteritis (GE)-3.5%. The distribution of cases are represented in Table 1. During the study period, 2 adverse drug reactions (ADRs) were observed due to the antibiotic therapy. They were skin rashes with injection Cefotaxime and rashes with itching for injection piperacillin/tazobac-tam( Piptaz).The causality was assessed using Naranjo

scale which was categorized to be ‘possible’ in both the cases. The mean number of days of hospital stay was 9.04±4.64. Majority of the patients (55.5%) stayed for 6-10 days and 0.5% stayed for more than 30 days. Long-est hospitalization was seen for pneumonia.

CONCLUSION

REFERENCES1. Novak E, Allen PJ. Prescribing medications in pediatrics: concerns

regarding FDA approval and pharmacokinetics. Pediatr Nurs 2007; 33(1):64-70.

2. Appl J. Mechanism of action of systemic antibiotics used in peri-odontal treatment and mechanisms of bacterial resistance to

LRTI

Percentage (%)

5.5%

No. of Patients

Nephrotic syndrome

64

Hepatitis

32%

URTI

3.5%

8%

3%

2%

1.5%

3Cholelithiasis

20

11

7

16

6

4

3

5

10%

1.5%

1.5%

2.5%

Diagnosis

Gastroenteritis

Asthma exacerbation

UTI

Sepsis

Dengue fever

34

Fever

Arthritis

GERD

2

3

1%

17%

Table 1 : Distribution of conditions prescribed with antibiotics

22 11%Emperical therapy

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these drugs. Oral Sci 2012; 20(3):1678-87.

3. Bowlware KL, Stull T (2004) Antibacterial agents in pediatrics. In-fect Dis Clin North Am 18:513–31.

4. Thrane N, Sørensen HT (1999) A one-year population-based study of drug prescriptions for Danish children. Acta Paediatr 88:1131–6

5. Rossignolia A, Clavenna A, Bonati.M Antibiotic prescription and prevalence ratein the outpatient paediatric population: analysis of surveys published during 2000–2005. Eur J Clin Pharmacol 2007 Dec;63(12):1099-106. Epub 2007 Sep 21.

6. American Academy of Pediatrics and American Academy of Fam-ily Physicians (2004) Clinical practice guideline. Diagnosis and management of acute otitis media. Pediatrics 113:1451–65

7. Scottish Intercollegiate Guidelines Network (2003) Diagnosis andmanagement of childhood otitis media in primary care. A nationalEur J Clin Pharmacol (2007) 63:1099–1106 1105 clinical guideline. Scottish Intercollegiate Guidelines Network,Edin-burgh

8. American Academy of Pediatrics and American Academy of Fam-ily Physicians (2001) Clinical Practice Guideline: Managementof Sinusitis. Pediatrics 108:798–808

9. Stille CJ, Andrade SE, Huang SS, Nordin J, Raebel MA, Go AS, Chan KA, Finkelstein JA (2004) Increased use of second genera-tion macrolide antibiotics for children in nine health plans in the United States. Pediatrics 114:1206–11

10. Resi D, Milandri M (2003) Antibiotic prescriptions in children. JAntimicrob Chemother 52:282–6

11. Otters HB, van derWouden JC, Schellevis FG, van Suijlekom-Smit-LW, Koes BW (2004) Trends in prescribing antibiotics forchildren in Dutch general practice. J Antimicrob Chemother 53:361–6

12. Mark S Smolinski, Margret A Hamburg, Joshua Lederberg. Com-mittee on emerging microbial threats to health in the 21st cen-tury. Microbial Threats to Health: Emergence, Detection and Response. Washington D, C: The National Accademics Press 2003

13. Walker C B. The acquistition of antimicrobial resistance in the periodontal microflora. Periodontal 2000 1996; 10(1):79-88.

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Insulin Initiation And Titration Patterns In Type 2 Diabetes Mellitus

Revathi K Rajan*, Mohammed Ashraf*, Harish Kumar*

ABSTRACTAim: The aim of the study was to understand the doses and types of insulin used to initiate insulin therapy in Type 2 diabetes patients and study the effect of insulin initiation on glycemic control and body weight.

Methods: A prospective study was performed using data from the healthcare management suite. Data on patient characteristics, metabolic and clinical outcomes were collected at baseline and during 3 months follow-up.

Results: In total 150 eligible adults [103 males, 47 female; mean age 55.59 ± 11.782 years; mean baseline HbA1c 10.33 ±1.57%] were initiated on insulin. Approximately half (59.3%) were initiated on premixed insulin twice daily, 30% on basal insulin, 4.0% on bolus twice and premixed, 4.0% on one basal and 3 bolus, 1.3% on 3 bolus, 1.3% on 2 bolus. Only 9.3% had mild hypoglycemic reactions. Mean Fasting glucose was decreased to 130.3mg/dl from 222.5mg/dl; mean Post prandial blood glucose was decreased to 209.8 mg/dl from 331.6mg/dl. Baseline HbA1c was decreased to 8.67% from 10.33%. Patients had a mean weight gain of 1.75kg and an increase of 0.928 in Body mass index (BMI).

Conclusion: Premixed insulin was the most commonly used insulin for initiation. Initiation of insulin therapy has shown a signifi-cant decrease in HbA1c (2.07%), and a modest weight gain with a lower incidence of hypoglycemia. The baseline HbA1c of 10.74% at initiation of insulin suggests that clinicians were waiting too long to initiate insulin in their clinical practice.

Corresponding Author: Harish Kumar

INTRODUCTION Diabetes Mellitus is a global problem with high social, health and economic consequences and the number of people affected is steadily increasing. Thus, not all pa-tients suffering from the disease can be treated by spe-cialized outpatient clinics, and the majority is treated by primary care physicians. The latter, however, might have time constraints and have to deal with many kinds of diseases or patients with multiple morbidities, so their focus is not so much on lowering high blood glucose values. Thus, the physicians, as well as the patients them-selves, are often reluctant to initiate and adjust insulin therapy, although basal insulin therapy is considered the appropriate strategy after oral anti diabetic drug failure, according to the latest international guidelines. Insulin therapy is recommended for patients with Type 2 Diabetes Mellitus and an initial HbA1C level greater than 9 percent, or if diabetes is uncontrolled despite optimal oral glycemic therapy1. Despite the many clinical benefits of insulin therapy for patients with Type 2 Diabetes, many patients and physi-cians are reluctant to initiate insulin treatment, even if it is clearly indicated to achieve optimal glycemic control. Barriers for insulin initiation includes patient’s miscon-ceptions regarding insulin therapy, injection phobia, hypoglycemia concerns, negative impact on social life and job and limited insulin self management training. Physicians are concerned about possible side effects and have limited time for patient education. These barri-ers lead to delay in initiation of insulin therapy in Type 2 Diabetes patients and thereby increasing their exposure to hyperglycemia. The clinical guidelines suggest once daily basal regi-men for initiation, but many physicians consider initiat-

*Dept. of Endocrinology, AIMS, Amrita Vishwa Vidyapeetham, Kochi, India.

ing other insulin regimens based on the clinical situa-tion of the patients. Insulin regimens should be tailored to the patient’s needs and lifestyle. One of the most im-portant considerations is the pharmacokinetics of dif-ferent insulin preparations. Titration of insulin is critical in improving glycemic control and preventing diabetes related complications2. This study was conducted to understand the insulin initiation and titration in type 2 diabetes and under-stand the effect of insulin therapy on these patients. This study looked at the initial HbA1C, fasting and post prandial blood glucose, initiated insulin regimen, effect on weight and incidence of hypoglycemia.

RESEARCH DESIGN AND METHOD This is a prospective study of type 2 Diabetic patients who came to our department of Endocrinology and Di-abetes at Amrita Institute of Medical Science during a time period of February 2015 to July 2015. We have se-lected patients with type 2 diabetes with uncontrolled blood glucose who were newly initiated on insulin. Inclusion criteria for the study are Type 2 Diabetes Mel-litus with uncontrolled blood glucose and newly initiat-ed on insulin. Exclusion criteria for the study are Type 1 Diabetes Mel-litus, Gestational Diabetes Mellitus and patients already on insulin. For the preparation of questionnaire certain literature related to insulin initiation and titration, various types of insulin, management of insulin therapy etc, were re-viewed. The search was performed using English word which as same as above words. In the study we have se-lected 150 patients who came to our department of En-docrinology at Amrita Institute of Medical Sciences. The patients were interviewed individually and all the data was collected based on the questionnaire. Patients were

ORIGINAL ARTICLE


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RESULTS In total 150 eligible adults [103 males, 47 female; mean age 55.59 ± 11.782 years; mean baseline HbA1c 10.33 ±1.57%] were initiated on Insulin. Approximately half (59.3%) initiated insulin as premixed insulin twice daily, 30% as basal insulin, 4.0% as bolus twice and premixed, 4.0% as one basal and 3 bolus, 1.3% as 3 bolus, 1.3% as 2 bolus. At the time of initiation on insulin 87.3% patients were previously on diet and Oral hypoglycemic agents, 5.3% were on diet control alone, 4.7% were newly di-agnosed and 2.7% were not on any therapy (fig:1).Hy-pertension was present in 40.7% and Dyslipidemia in 40%. When we asked about the duration of diabetes we found that 11.3% were newly diagnosed, 12% had less than 5years of duration, 38% with 5 to 10 years of du-ration, 29.3% with 11 to 20 years of duration, and 9.3% with duration of more than 20 years. The baseline mean fasting glucose was 222.5 mg/dl and mean post prandi-al glucose was 331.6 mg/dl and mean HbA1c level was 10.33%. Follow-up data at 3 months after initiation of insulin showed significant decrease of glucose values. Mean Fasting glucose was decreased to 130.3 mg/dl, mean post prandial glucose decreased to 209.8 mg/dl and mean HbA1c was decreased to 8.67 % after 3 months. The mean initial dose of insulin was 19.96 units which was titrated up to a mean of 25.36 units at the end of 3 months. Mild hypoglycemia was reported by 9.3%. There were no reports of severe hypoglycemia. This study population showed weight gain after the initiation of insulin therapy which could be caused due to the effect of insulin on body. Patients had a mean weight gain of 1.75kg after initiating insulin and an in-crease of 0.928 in BMI. The most common insulin initiation regimen was pre-mixed insulin twice daily (59.3%), and then was basal in-sulin (30%). Other regimens included were bolus twice and premixed (4.0%), one basal and 3 bolus (4.0%), 3 bolus (1.3%) and 2 bolus daily (1.3%) (Fig: 2). The most

common delivery device was found to be Vial and sy-ringe (59%), followed by temporary pen (28%), and per-manent pen (13%)(Fig:3).

advised to come for a follow up after 3 months. At the time of data collection their present blood glucose and HbA1c level was noted and entered into the database. Questionnaire included variables like Height, Weight, Body Mass Index (BMI), and Duration of Diabetes, Past treatment for Diabetes Mellitus, Insulin Regimen, and Name of Insulin, Presence or absence of Hypertension and Dyslipidemia, Date of insulin initiation, Presence of Micro vascular and Macro vascular complications, Total daily dose of Insulin. At the time of data collection the patient was advised about the proper management of Diabetes Mellitus. Patients were asked to report any hy-poglycemic events. Symptoms of hypoglycemia with or without documented blood glucose values below 70mg % were recorded as mild hypoglycemia. If the patient required assistance of another person to overcome the symptoms then it was documented as severe hypogly-cemia. After data collection insulin initiation and two months follow-up data were entered into the system and analyzed in the research lab of Amrita Institute of Medical Sciences and the data were analyzed by SPSS software version11.

01020304050607080

5.3

87.3

4.7

2.7

Diet

Diet+Ta

blet

Newely Diagnose

d Nil

90100

Percentage

Once D

aily B

asal

30

102030405060

04

59.3

4 1.3

Bolus twice

+ premixed

Premixed tw

ice

Once Basa

l 3 Bolus

2 Bolus

70

1.3

3 Bolus

Percentage

Figure 1: Previous treatment of Diabetes.

Figure 2: insulin regimens initiated.

Figure 3: Percentages of different Delivery devices used

DISCUSSION insulin should be added either as the first agent when clinically indicated or when A1C is not at goal on one to two oral hypoglycemic agents. Physicians, patients, and health care teams should carefully consider and over-come any psychological barriers to initiation and work closely together to prescribe a physiological regimen to

Permanent pen 13%

Temporary pen 28%

Vial 59%

Tempoary pen 28%

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CONCLUSION Insulin was effective and safe when added on to oral hypoglycemic agents in Type 2 Diabetes. It markedly im-

Insulin Initiation And Titration PatternsIn Type 2 Diabetes Mellitus

REFERENCES1. Holman RR, Thorne KI, Farmer AJ, Davies MJ, Keenan JF, Paul S,

Levy JC . Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes. N Engl J Med 2007; 357:1716–1730 CrossRefMedlineGoogle Scholar.

2. Turner RC, Cull CA, Frighi V, Holman RR. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple thera-pies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA 1999; 281:2005–2012 CrossRefMedlineGoogle Scholar.

3. Furler J, Spitzer O, Young D, Best. Insulin in general practice – bar-riers and enablers for timely initiation. Aust Fam Physician. 2011; 40:617-21.

4. Peyrot M, Rubin RR Khunti K. Addressing barriers to initiation of insulin in patients with type 2 diabetes. Prim care Diabetes. 2010;4(Suppl):S11-8.

5. Vaag A, Lund SS. Insulin initiation in patients with type 2 diabe-tes mellitus: treatment guidelines, clinical evidence and patterns of use of basal vs premixed insulin analogues. Eur J Endocrinol. 2012 Feb; 166(2):159-70. doi: 10.1530/EJE-11-0022. Epub 2011 Sep 19.

6. Ted Wu, Bryan Betty, Michelle Downier, Manish Khanolkar, Gary Kilov, Brandon Orr-Walker, Gordon Senator, Greg Fulcher Practi-cal Guidance on the Use of Premix Insulin Analogs in Initiating, Intensifying, or Switching Insulin Regimens in Type 2 Diabetes. Diabetes Ther (2015) 6:273–287 doi : 10.1007/s13300-015-0116-0.

7. Mohammad Ebrahim Khamesh, Gholamreza Yousefzade, Zahra Banazadeh 3 Sahar Ghareh.Practical focus on American Diabe-tes Association/ European Association for the Study of Diabetes Consensus Algorithm in Patients with Type 2 Diabetes Mellitus: Timely Insulin Initiation and titration (Iran – AFECT). Diabetes Metab J 2017; 41:31-7.

8. Olga K Lutzko, Helen Schifferle,Marita Ariola, Antonia Rich,Khen Meng Kon. Optimizing insulin initiation in primary care: the Dia-betes CoStars patient support program. Pragmatic and Observa-tional Research 2016: 7 3-10.

9. Jacober SJ, Scism-Bacon JL & Zagar AJ. A comparison of inten-sive mixture therapy with basal insulin therapy in insulin-naïve patients with type 2 diabetes receiving oral antidiabetes agents. Diabetes, Obesity & Metabolism 2006 8 448–455. (doi:10.1111/j. 1463-1326.2006.00605.x)

10. Ali A. Rizvi. Treatment of type 2 Diabetes with biphasic insulin Analogues. Eur Med J Diabetes. 2016; 4(1): 74–83.

11. Rubino A, McQuay LJ, Gough SC, Kvasz M & Tennis P. Delayed initiation of subcutaneous insulin therapy after failure of oral glucose-lowering agents in patients with type 2 diabetes: a population-based analysis in the UK. Diabetic Medicine 2007 24 1412–1418. (doi:10.1111/j.1464-5491.2007.02279.x).

12. Scheen AJ, Schmitt H, Jiang HH, Ivanyi T.Factors associated with reaching or not reaching target HbA1c after initiation of basal or premixed insulin in patients with type 2 diabetes. Diabetes Metab. 2017 Feb; 43(1):69-78. doi: 10.1016/j.diabet.2016.10.005. Epub 2016 Dec 14.

control fasting and postprandial blood glucose levels. Presently two of the most common approaches in in-itiating insulin are basal or premixed insulin regimens. In our study more than half the patients were initiated on Premixed insulin while basal insulin was the less pre-ferred regime. Use of analogue insulin was also less fre-quent. This is in contrast to reports from Iran7 and Aus-tralia8 where basal insulin Glargine was the preferred starting insulin. However a study comparing intensive mixture insulin with basal insulin as the start up insulin in Type 2 Diabetes showed that target glycemic levels could be achieved with both regimes9. Premixed insulin has a high patient acceptability however disadvantages include a more rigid regimen and a slightly higher de-gree of glycemic variability and hypoglycemia10. The baseline HbA1c of the patients in our study was 10.3% at the time that insulin therapy was initiated. There may be a number of reasons for this. Since our hospital is a tertiary care center many patients with un-controlled Diabetes are referred very late and present with very high HbA1c values. However, this very high baseline HbA1c reflects the fact that clinicians have been waiting too long and delaying insulin initiation. A large population based study from UK11 also reported that primary care physicians delay insulin initiation. Af-ter 3 months of insulin therapy the patients in our study showed a good HbA1c reduction of 2.07% showing that this treatment strategy is effective in this clinical con-text. The two common side effects of insulin therapy are hypoglycemia and weight gain. Both patients and the treating physicians are wary and concerned when using insulin therapy. We had a low incidence of reported hy-poglycemia as the insulin doses were titrated very grad-ually, the mean increase in insulin doses from baseline to 3 months was only 5.4 units. There were no reported severe hypoglycemic episodes. This data is reassuring that insulin treatment when added on to oral hypogly-cemic agents in this manner in Type 2 Diabetes is safe. This is particularly relevant as fear of hypoglycemia is one of the main barriers against initiation of insulin therapy3. Our study reported a mean weight gain of 1.75 kilograms over 3 months after insulin initiation, which is an expected occurrence with insulin therapy. Complex insulin regimens at the time of initiation of in-sulin therapy may confuse and dishearten the patients. Another important barrier for insulin initiation in pa-tients with Type 2 diabetes is starting with multiple daily injections of different types of insulin12. Often it is more manageable for patients and physicians to begin with a once-daily basal insulin or premixed regime instead of rapid acting insulin to be taken before meals for nutrient coverage along with a long acting basal analogue.

proved glycemic control with low rates of hypoglycemia and some weight gain. Premixed insulin was the pre-ferred insulin for initiation in our center. The high base-line HbA1c suggests that clinicians are waiting too long and delaying insulin initiation in Type 2 Diabetes.

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Risk Factors of Fall among Elderly Persons: Results from a Community based Case-Control Study in

Thiruvananthapuram, Kerala, IndiaMathew J Valamparampil*, Mohan Ananth*, S R Ameena*, K B Sreekanth*,

R S Reshma*, Chandran Praseeda*, T S Anish*

ABSTRACTAim: Proportion of elderly is rapidly increasing all over the world including in India. The realm of falls and injuries among this group is neglected due to various factors especially in the Low and Middle Income Countries (LMICs). This study is aimed at identifying the risk factors for fall among elderly persons residing in an urban area of Kerala.

Methods: A community based cross sectional study was conducted among 82 elderly people, aged 60 and above residing in an urban area of Thiruvananthapuram during January 2017. The cases were those who had sustained a fall in the past one year; con-trols, who had not sustained a fall in the same period. A semi structured questionnaire was used to obtain the details regarding various exposure variables.

Results: Mean (SD) age of the cases and controls were 75.05(7.93) and 70.60(6.95) respectively. Mean age and BMI were found to be higher among cases than controls. Presence of heart disease (p=0.02) and having slippery floor (p=0.035) were found to be significant predictors of fall among elderly. Diseases like Diabetes mellitus and hypertension were also found to be higher among the cases. Even though locomotor problems were more among cases, the presence of visual impairment and poly pharmacy were comparable between the two groups.

Conclusion: Prevention of cardiovascular diseases and provision of an elderly- friendly environment play a major role in preven-tion of falls in elderly individuals.

Key Words: Elderly, Fall, Case control studyCorresponding Author: T S Anish

ORIGINAL ARTICLE

INTRODUCTION The proportion of individuals aged above 60 years is growing at a rapid rate globally due to the advancing life expectancy and improving standards of living. By 2050, this section of the population is projected to grow to almost two billion1. This increasing number is posing newer concerns with regards to their health. Along with the increased occur-rence of diseases with advancing age, falls and fall relat-ed injuries are posing grave challenges with regards to their health. Around the world, approximately 28-35% of people aged of 65 and over fall each year increasing to 32-42% for those over 70 years of age. The average health system cost per one fall injury episode for people 65 year and older in Finland and Australia was found to be US$ 3611 and US$ 1049 respectively2. The problems associated with health among elderly are several of which falls constitute a major problem. The Global Burden of Falls among elderly constitute 1.36% of the total DALYs3.In India, more than 8% of the total population is consti-tuted by individuals aged above 60 years4. There are several risk factors for falls in elderly. These include increasing age, female gender, physical frail-

ty, unsteady gait and balance, impaired cognition etc. The risk of falling increases with a higher disease bur-den from chronic conditions such as cardiovascular dis-ease, diabetes and visual impairment. Home hazards, such as slippery floors and poor lighting, and features of the public environment, such as poor building design and uneven sidewalks, increase the risk of falls in old-er adults5. Interventions were found to be very useful in preventing and decreasing the morbidity associated with fall in elderly6. Prevention of falls is not given a high policy priority in many developing countries because of the lack of awareness about the problem and its burden. Elderly individuals constitute a sizeable proportion of the pop-ulation in Kerala. As per Census 2011, 12.6% of the pop-ulation is aged above 60 years4.It was found that falls among elderly were mostly as a result of intrinsic factors and fall related injuries that were found to be a major cause of their hospitalization in Kerala7. Strategies for reducing the frequency of this common cause of morbidity and mortality are needed. Effective preventive strategies require a better understanding of the causes and risk factors for fall among elderly per-sons. This study was undertaken to identify the risk fac-tors for falls in past one year among elderly persons re-siding in an urban area of Thiruvananthapuram, Kerala.


*Dept. of Community Medicine, Government Medical College Hospital, Thiruvananthapuram, India.

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The data for the current study was collected as a part of workshop on epidemiology organized by the Depart-ment of Community Medicine, Government Medical Col-lege, Thiruvananthapuram for postgraduate students from various medical colleges of Kerala, India during the month of January 2017. Training was given for tool development and a semi structured questionnaire was prepared by the participants themselves and modified by the facilitators. A case control study was conducted among elderly population, aged 60 and above residing in the Gandhipuram area under Medical College Health Unit at Pangappara, inside Thiruvananthapuram City Corporation. There is always a debate on the cut off age to call the older segment of population elderly. United Nations has agreed to use the cutoff of 60 years, espe-cially for the third world countries, even though 65years is the cutoff for most of the western studies8. We have used a cutoff of 60 years in the current study as it would increase the proportion of source popula-tion. Elderly people who had sustained a fall in the last one year were recruited as cases. Controls were the el-derly population who had not sustained a fall in the past year. Those who had severe cognitive impairment were excluded from the study. Hence fall was operationally modified as an event which results in the person com-ing to rest inadvertently on the ground or other lower level and other than as a consequence of the following: sustaining a violent blow, loss of consciousness, sudden onset of paralysis or an epileptic seizure9.

Information on socio-demographic variables, medi-cal history, anthropometry, known risk factors of fall like slippery floor, visual/cognitive/locomotor impairment, co-morbidities, substance use, exercise were elicited

METHODOLOGY

RESULTS

from the study participants. A comprehensive semi structured questionnaire was prepared as a part of the workshop with inputs from several experts/clinicians in the field of health and epidemiology.

After finalizing the tool and a detailed training, the group was divided into pairs. Each pair visited the con-secutive houses and those coming under eligibility criteria were identified. The examiners explained the details about study and informed written consent was obtained. Interview schedule was conducted to collect the required data. Quantitative parameters like height and weight were noted as reported by the participants.

Data collected were entered into Microsoft Excel and was analyzed using SPSS Trial version 16. Categorical variables were expressed as frequencies and proportion and Quantitative variables were expressed as means and standard deviation. Chi square test and independ-ent sample t test were used to find out the association between fall and selected variables. Multivariable anal-ysis was done Binary Logistic regression to find the pre-dictors of fall. Backward LR method was included.

Gender

Age (years)

BMI

Male

Table 1: Sociodemographic characteristics (original)

Mean(SD) Minimum

Case

Control

Case

Control

75.05(7.93)

70.60(6.95)

24.16(1.98)

23.90(3.69)

74.00

68.00

24.05

23.54

65

60

20.80

16.02

92

90

28.44

37.95

MaximumMedian(IQR)Variable

SES

Female

APLBPL

Case (%) Controls (%)

11 (50%)11 (50%)19(86.4%)

3 (13.6%)

33 (55%)27 (45%)52(86.7%)

8 (13.3%)

The total number of study participants was 82, with 22 cases (who had a reported history of fall within one year of the time of survey) and 60 controls (without a per-ceived history of fall). The cases had equal proportions (n=11) of males and females, while the control group had 55% (n=33) males and 45% (n=27) females (Table 1). All of the study participants were elderly (above 60 years). The mean(SD) age of the cases was 75.05(7.93) years, greater than the controls, who had a mean age of 70.60 (6.95) years (Table 2). The socioeconomic status was comparable in both the groups with 86.4% (n=19)

of the cases and 86.7% (n=52) of the controls belonging to the APL category. The mean (SD) BMI in the cases was 24.16(1.98) kg/m2while it was 23.90(3.69) kg/m2in the control group. Bivariable analysis was done on variables like slippery floor, elderly friendly house, visual impairment, loco mo-

tor problems, diabetes status, dementia, heart diseases, hypertensive status, usage of footwear inside house, polypharmacy, alcohol use, regular exercise and over-weight (all dichotomous in character) with history of fall as the outcome variable (Table 2). Slippery floor (P = 0.047), diabetes (P = 0.019) and heart disease (P = 0.024)


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Elderly friendly house

Slippery Floor 28 (46.7%)

Visually impaired

20 (33.3%)

Loco motor problems

0.023

22 (36.7%)

Alcohol use

Number

(Proportion)

of cases

33 (55%)

Variable

Dementia

Diabetes

Heart disease

Hypertension

Using footwear inside house

Polypharmacy

Overweight

Regular exercise

Table 2: Bivariable analysis (original)

16 (72.7%)

2 (9.1%)

15 (68.2%)

14 (63.6%)

7 (31.8%)

14 (63.6%)

Number

(Proportion)

of controls

OR

3.0

0.20 0.04 - 0.94

0.8

1.4

95% CI p value

1.05 – 8.86 0.047

39 (65%) 1.1 0.41 – 3.27 0.503

9 (40.9%) 15 (25%) 2.0 0.74 -5.83 0.130

21 (35%) 3.2 1.17 – 9.0 0.019

3 (13.6%) 3 (5%) 3.0 0.56 – 16.13 0.192

7 (31.8%) 6 (10%) 4.2 1.23 – 14.38 0.024

15 (68.2%) 30 (50%) 2.1 0.77 – 6.0 0.112

0.29 – 2.28 0.447

0.52 – 3.92 0.329

3 (13.6%) 6 (10%) 1.4 0.32 – 6.25 0.453

6 (27.3%) 26 (43.3%) 0.4 0.17 – 1.43 0.143

17 (77.3%) 38 (63.3%) 1.9 0.64 – 6.08 0.178

Slippery floor at housePresence of Heart Disease

0.035

95%CI of AOR

1.28-17.21Presence of Heart Disease

Table 3: Regression analysis (original)

1.09-10.27

Adjusted OR

4.69

3.35

B

1.546

1.207Slippery floor at house

Variables in Model 2

1

2

0.020

p value

Slippery floor at housePresence of DiabetesPresence of Heart DiseasePresence of HypertensionPresence of Regular Exercise

Cox and Snell R squareVariables in the modelModelNo

1

2

0.159

came out to be statistically significant risk factors for fall, whereas elderly friendly house (P = 0.023) was protec-tive. The cases had higher proportion of visual impair-ment, loco motor problems, dementia, hypertension, polypharmacy, alcoholism and were overweight than that of controls, but did not turn out to be significant. Usage of footwear inside the house and exercise had a

lower proportion in cases than in controls, which was also not significant. Multiple logistic regression with backward stepwise method was used to get prediction models. Model 1 was able to predict the probability of outcome with 15.9% variability whereas model 2 could do the same with 11.6% variability. The three additional variables

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REFERENCES1. World Population Prospects - Population Division - United Na-

tions [Internet]. [cited 2017 Jan 27]. Available from: https://esa.un.org/unpd/wpp/Download/Standard/Population/

2. WHO | Ageing and Life Course [Internet]. WHO. [cited 2017 Jan 27]. Available from: http://www.who.int/ageing/projects/falls_prevention_older_age/en/

3. Global Burden of Disease - Compare [Internet]. Annual Percent-age change 1990 - 2016. [cited 2017 Jan 27]. Available from: http://thelancet.com/gbd/gbd-compare-visualisation

4. Population Composition [Internet]. [cited 2017 Jan 28]. Avail-able from: http://www.censusindia.gov.in/vital_statistics/srs_re-

Slippery nature of the floor also has come out as sig-nificant risk factor for occurrence of fall among elderly. Slippery floors could be due to presence of water, cloth, polythene bags etc on the floor as seen previously7.

Also, sarcopenia is a common finding among elderly which in itself can prolong hospitalization following fall, leading to increased morbidity and mortality15.

For combating all these challenges, improving physi-cal activity may hold the key. Even though regular exer-cise was not found to have significant association with falls in the present study, the role exercise plays in low-ering BMI, decreasing CVD, improving muscle mass and countless other benefits points to the need to widen the scope of elderly-friendly physical activity. Regular exer-cise will improve the muscle tone and help increase the flexibility and balanced movements. Recent evidence from a large meta analytic study also points to signifi-cant role physical activity can make in the lives of elder-ly16.

The mean BMI was marginally higher for cases than controls. Studies done in foreign settings found higher rates of fall among elderly who are overweight13,14.

Increased weight is usually associated with other con-ditions like poor physical performance, decreased activ-ities of daily living(ADL), cardiovascular diseases(CVD) and imbalances12.

Hence, along with the conventional cardiovascular morbidities associated with increased BMI, increased risk of falls also pose an important challenge in elderly with higher BMI.

Presence of heart disease and having slippery floor were found to be significant predictors of fall in this study after multivariable analysis. Both have been found to be important risk factors for fall among elderly in the past7,12.

DISCUSSION The mean (SD) age of the individuals with fall was 75.05(7.93) years which was higher than those who did not fall 70.60(6.95).

Advancing age has been found to be having an associ-ation with increased frequency of falls10. It can be due to the presence of multiple factors as-sociated with aging. Studies have also documented increased occurrence of fall among females. Similarly, lower socio economic status has en found to be a risk factor in Indian scenario11.

Our study has not looked into such associations, but has found them to be distributed in similar proportions.

Lack of awareness regarding the measures to be adopt-ed for preventing slipping will be the greatest obstacle in tackling this. Evidence of lower grip strength in those who fall should make us look for means to tackle the challenges posed by slippery floors12.

Physical inability together with an environmental stressor like a slippery floor will more likely result in fall among aged17.

Poor vision, lowered reflexes and muscle strength as-sociated with old age cannot be corrected beyond a certain extent with advancing age. Tailored education programmes with house floor plans, usage of non-slip socks etc should be looked into for helping with the dai-ly locomotive problems of elderly18,19.

Designing optimal footwear for older population should also be considered. The findings of MOBILIZE Boston Study also had similar findings20.

In any place where an aged person lives it should be ideally free from hazards like unsafe furniture, unsafe mats, slippery items on the floor etc. Presence of rails in the bathrooms and slopes, good lighting, safe supports etc will help the aged to move around steadily. Falls-HIT trial which specifically addressed home modification showed a significant reduction in falls17.

Polypharmacy and alcoholism were proportionately higher among those who fell but were found to have no significant association with falls in this study. Medica-tions like oral hypoglycemics, antihypertensives etc can cause dizziness and precipitate fall. Supervised medica-tions and alcohol restriction will help elderly in avoid-ing preventable falls. Even though comorbidities like hypertension, locomotor problems, visual impairment, and dementia are more among cases, they were found to have no significant association.

Studies have shown that a previous history of fall itself is a risk factor for future falls21.

Hence, improved researches in this realm are the need of the hour to advocate control measures for preven-tion of falls among elderly. Prevention of cardiovascular diseases by improving physical activity together with building an elderly friendly environment are the meas-ures that we suggest in tackling this ever increasing challenge.

in model 1 were able to bring an increase in R2 by only 0.043. So model 2, with only two exposure factors, slip-pery floor at home (Adjusted OR 3.35) and presence of heart disease (Adjusted OR 4.69) was taken as the final multi-variate model to find out the independent predic-tors of fall among elderly (Table 3).


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13. Mitchell RJ, Lord SR, Harvey LA, Close JCT. Associations between obesity and overweight and fall risk, health status and quality of life in older people. Aust N Z J Public Health. 2014 Feb;38(1):13–8.

14. Volpato S, Leveille SG, Blaum C, Fried LP, Guralnik JM. Risk fac-tors for falls in older disabled women with diabetes: the wom-en’s health and aging study. J Gerontol A Biol Sci Med Sci. 2005 Dec;60(12):1539–45.

15. Malekpour M, Bridgham K, Jaap K, Erwin R, Widom K, Rapp M, et al. The Effect of Sarcopenia on Outcomes in Geriatric Blunt Trau-ma. Am Surg. 2017 Nov 1;83(11):1203–8.

16. Tricco AC, Thomas SM, Veroniki AA, Hamid JS, Cogo E, Strifler L, et al. Comparisons of Interventions for Preventing Falls in Old-er Adults: A Systematic Review and Meta-analysis. JAMA. 2017 07;318(17):1687–99.

17. Lord SR, Menz HB, Sherrington C. Home environment risk factors for falls in older people and the efficacy of home modifications. Age Ageing. 2006 Sep;35 Suppl 2:ii55-9.

18. Ueda T, Higuchi Y, Imaoka M, Todo E, Kitagawa T, Ando S. Tailored education program using home floor plans for falls prevention in discharged older patients: A pilot randomized controlled trial. Arch Gerontol Geriatr. 2017 Jul;71:9–13.

19. Hatton AL, Sturnieks DL, Lord SR, Lo JCM, Menz HB, Menant JC. Effects of nonslip socks on the gait patterns of older people when walking on a slippery surface. J Am Podiatr Med Assoc. 2013 Dec;103(6):471–9.

20. Kelsey JL, Procter-Gray E, Nguyen U-SDT, Li W, Kiel DP, Hannan MT. Footwear and Falls in the Home Among Older Individuals in the MOBILIZE Boston Study. Footwear Sci. 2010 Sep;2(3):123–9.

21. Pohl P, Nordin E, Lundquist A, Bergström U, Lundin-Olsson L. Community-dwelling older people with an injurious fall are likely to sustain new injurious falls within 5 years--a prospective long-term follow-up study. BMC Geriatr. 2014 Nov 18;14:120.

port/9chap%202%20-%202011.pdf

5. Stewart Williams J, Kowal P, Hestekin H, O’Driscoll T, Peltzer K, Yawson A, et al. Prevalence, risk factors and disability associated with fall-related injury in older adults in low- and middle-incom-ecountries: results from the WHO Study on global AGEing and adult health (SAGE). BMC Med. 2015 Jun 23;13:47.

6. Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, et al. A multifactorial intervention to reduce the risk of fall-ing among elderly people living in the community. N Engl J Med. 1994 Sep 29;331(13):821–7.

7. Ravindran RM, Kutty VR. Risk Factors for Fall-Related Injuries Leading to Hospitalization Among Community-Dwelling Older Persons: A Hospital-Based Case-Control Study in Thiruvanan-thapuram, Kerala, India. Asia Pac J Public Health. 2016 Jan;28(1 Suppl):70S–6S.

8. Trends in proportion of older persons; Elderly population. Health situation and trends assessment. World Health Organization. [In-ternet]. SEARO. [cited 2018 Jan 14]. Available from: http://www.searo.who.int/health_situation_trends/data/chi/elderly-popula-tion/en/

9. WHO | Falls [Internet]. WHO. [cited 2018 Jan 14]. Available from: http://www.who.int/mediacentre/factsheets/fs344/en/

10. Chu LW, Chi I, Chiu AYY. Incidence and predictors of falls in the chinese elderly. Ann Acad Med Singapore. 2005 Jan;34(1):60–72.

11. Sirohi A, Kaur R, Goswami AK, Mani K, Nongkynrih B, Gupta SK. A study of falls among elderly persons in a rural area of Haryana. Indian J Public Health. 2017 Jun;61(2):99–104.

12. Sharma P, Bunker C, Singh T, Ganguly E, Reddy P, Newman A, et al. Burden and Correlates of Falls among Rural Elders of South India: Mobility and Independent Living in Elders Study. Curr Gerontol Geriatr Res. 2017 Jun 13;

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To Assess Anxiety and Depression in Patients Undergoing Maintenance Haemodialysis in a Tertiary Care Hospital in

KeralaArya Jith*, K Sreekumar*, Chitra Venkateswaran*

ABSTRACTBackground: Chronic Kidney Disease has been increasing worldwide, so is the number of patients undergoing maintenance hae-modialysis. They have a higher prevalence of psychiatric co morbidities like depression and anxiety. However these problems remain undiagnosed and under treated. This study aim was to assess anxiety and depression in patients undergoing maintenance haemodialysis and also to assess the socio demographic variables.

Method : This cross-sectional study enrolled 110 patients >18 years on maintenance haemodialysis. Their symptoms was assessed using Hospital Anxiety Depression Scale (HADS) and other psychiatric co morbidities was assessed using M.I.N.I International Neu-ropsychiatric interview. Socio demographic data was also collected.

Results: Of 110 subjects 61.8 % had depressive symptoms and 54.5 % had anxiety symptoms. Depression and anxiety was signifi-cantly associated with abnormal BMI. In multivariate logistic regression depression was statistically associated with female sex(OR -5and with 95% CI ) and during the initial phase of haemodialysis (OR -2.5 with 95% CI) It was also found that suicidality was asso-ciated with depressive and anxiety symptoms.

Conclusion: Depression and anxiety symptoms are common in patients undergoing Haemodialysis. They are all the cause of increase in suicidality in these patients. It was also found that female sex and patients who had lesser number of haemodialysis sessions had more depression and anxiety symptoms.

Keywords: Depression, anxiety, haemodialyisCorresponding Author: Arya Jith

INTRODUCTION Chronic Kidney Disease has been increasing worldwide due to growing prevalence of diabetes and Hyperten-sion worldwide.1Depression and Anxiety are common psychiatric problems in patients with End Stage Renal Disease2. Approximately 20-25% of patients suffering from chronic medical problems also experiences clini-cally significant psychological symptoms.3Haemodial-ysis is a practical treatment for kidney failure and has increased survival rate of patients with Chronic Kidney Disease. But this method imposes restrictions in all di-mensions of life. An average haemodialysis session takes approximately 3-5 hours and will occur 3 times per week4 It will consume significant proportion of patients’ time4.

Dialysis patients also have to adhere to controlled diet, limit fluid intake and follow a complex regime of medication. There are many dietary restrictions which include protein, protein, potassium, sodium, calcium and phosphorous. As the patients survival rate also in-creased with better medical treatment, their depressive and anxiety symptoms increased over time6,7. The inci-dence of anxiety is a common disorder in haemodialysis patients is 27-46%6,7,8.Suicide may be the end result of depression. It was also found that depression was signif-icantly correlated with low BMI. Depression have more common suicidal ideation and poorer quality of life6.*Dept. of Psychiatry Amrita Vishwa Vidyapeetham, Kochi, India.

Currently the relationship between depression, suicide and anxiety remains poorly understood. Objective of this study was to assess the symptoms of anxiety and depression in patients undergoing maintenance hae-modialysis.

ORIGINAL ARTICLE

MATERIALS AND METHODSStudy Population A hospital based cross sectional study was conduct-ed in Haemodialysis Unit of Department of Nephrology, Amrita Institute of Medical Science ,Kochi from the year August 2014- August 2016.The sample size was calcu-lated based with a prevalence of 33.3 % reported in an urban population in Lucknow6. The sample size was estimated to be 110 with 95% confidence interval and 20% allowable error. Patients who has underwent at least one haemodialysis and who is above the age of 18 years was enrolled in the study. Patients who were able to read and write English or Malayalam were included. Patient who already had a past history of psychiatric di-agnosis was excluded from the study. Written informed consent was obtained from each patient before partici-pation. This study was approved by the ethical and re-search committee of AIMS Kochi to use human subjects in the research study.

Procedures In this cross- sectional study all Haemodialysis pa-


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tients underwent psychiatric diagnostic interview us-ing M.I.N.I(M.I.N.I International Diagnostic Interview).Depressive and Anxiety Symptoms were assessed using HADS ( Hospital Anxiety and Depression Scale). A semi structured proforma was used to record information regarding demographic and clinical details of the sub-jects.

M.I.N.I(M.I.N.I .International Neuropsychiatric Diag-nostic Interview) M.I.N.I is a short structured diagnostic interview for psychiatric disorders. This modules uses specific ques-tions to assess various psychiatric disorders. Suicidality is also assessed using M.I.N.I. It has been used reliably for multicentre clinical trials, epidemiological studies, outcomes research as well as in non research clinical settings9. M.I.N.I has been translated into Malayalam and has been validated25.

Hospital Anxiety and Depression Scale(HADS) HADS- is a 14 item questionnaire for assessing the severity of depression10. The HADS is commonly used in clinical practice and primary care, and for gener-al population. Seven items assess anxiety and seven items assess depression. Each items has four possible response(scored 0-3):the anxiety and depression sub-scales are independent measures. Patient with anxiety scores(HADS-A ) ≥8 are diagnosed as having anxiety symptoms(sensitivity: 0.89:specificity :0.75) and patients with depression scores (/HADS-D) ≥ 8 are diagnosed as having depressive symptoms10. English and Malayalam version of HADS was used as a license to use the same was obtained from respective organization by the De-partment of Psychiatry.

Statistical Analysis Data were analyzed using SPSS version 20 statistical software. Statistical software variables are expressed using frequency and percentage. Numerical variables were assessed using mean and Standard Deviation. A HADS score >8 is the dichotomous cut off for significant depression or anxiety symptoms.Multivariate analysis was performed to find out the significant factors associ-ated with depression and anxiety.

RESULTS Out of 110 subjects 67(60.9) were males and 43(39.1) were females. Minimum and maximum age of patients were 22 and 83 respectively. Mean Age of patients was 55.84 ± 14.23. In this study majority of the subjects were married 60 (54.5%) and lived in a nuclear family 46 (41.8%). Majority of the subjects had a secondary level of education 44 (40%) and more than half of the sub-jects were unemployed 77(70%). Majority of the sub-jects had a higher family income (Rs 20,000 per month ) and majority 70 (63.7%) had a normal Body Mass Index. The sociodemographic data is summarized in Table 1.

Out of 110 subjects 68 had depressive symptoms

(HADS score ≥8). Mean HADS-D score was 10.23 ±4.83.Mean HADS score of males was 8.69 ± 4.38. Mean HADS-D score of females was 12.63 ± 4.56.Out of 67 males 32 (47.8%) had depressive symptoms and out of 43 females 36 (83.7%) had depressive symptoms. There was statistically significant association between gender and depression (p value <0.001). Out of the 46 living in a nuclear family 22 (47.8 %) had depressive symptoms. Out of the 20 subjects who were living in a joint family 13 (65%) had depressive symptoms. All 8 subjects who were living alone had depressive symptoms. Out of 36 subjects who was living in other conditions( hostel,oth-er relatives) 25 (69.4%) had depressive symptoms. There was a statistically significant association between type of family and depression ( p value-0.0021). Out of the 25 subjects who had family income < Rs 10,000 per month 22 (88%) had depressive symptoms. Out of the 42 sub-jects who had income between Rs 10,000-Rs 20,000 per month 21 (50%) had depressive symptoms. Out of the 43 subjects who had family income of more than Rs 20000 per month, 25 (58%) had depressive symptoms. There was a statistically significant association between family income and depression (p value 0.007). Out of 19 subjects who had underwent haemodialysis of < 49 times 17 (89.5%) had depressive symptoms. Out of 16 subjects who had 50-99 number of haemodialysis 12(75%) had depressive symptoms and 4(25%). Out of the 75 subjects who had underwent >100 haemodial-ysis 39(52%) had depressive symptoms. There was sta-tistically significant association between depression and number of haemodialysis ( p value <0.006). Out of 25 subjects who had BMI of <18.5 all 25 (100%) had de-pressive symptoms. Out of 70 subjects whose BMI is be-tween 18.5-24.9, 33(47.1%) had depressive symptoms. Out of 15 who had BMI 25, 10(66.7%) had depressive symptoms. There was statistically significant association between depression and BMI (p value <0.001). Variables sex, Marital status type of family, number of haemodia lysis and BMI were entered in a multivariate regression model and female sex ( OR-4.98 with 95% confidence interval ) and lower number of haemodialysis(OR—2.50 with 95% confidence interval ) were statistically signif-icant. The association of sociodemographic variables with depression is summarized in Table 2.

Out of 110 subjects undergoing maintenance haemo-dialysis 60 had Anxiety (HADS score ≥ 8). Mean HADS– A score was 8.59 ± 3.77. Mean HADS –A score of males was 7.81± 3.61 and Mean HADS –A score of females was 9.81±3.68. Mean age of the Anxious patients was 55.77± 14.23. Out of 67 males 30(44.8%) had anxiety symptom. There was a statistically significant association between anxiety symptoms and gender. (p value-0.010). Out of 19 subjects who had underwent haemodialysis <49 times 12 (63.2%) had anxiety symptoms. Out of the 16 sub-jects who underwent haemodialysis about 50 -99 times

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18

Sex43

46

20

26

44

30

Variables

10

33

Sociodemographic Factors

Education

Occupation

25

Table 1:Distribution of Sociodemographic Factors

Male

Female

Nuclear

Joint

Living alone

Other

Graduate

Post Graduate

Employed

Frequency Percentage

39.1

41.8

18.2

23.6

40

27.3

9.1

30

22.7

Marital Status

67

8

Primary

Secondary

Unemployed

<1000

1000-20000Family Income

>20000

Number of Haemodialysis

BMI

50-99

>99

<18.5

<49

18.5-24.9

25-29.9

>30

7.3

60.9

36 32.7

77 70

42 38.2

43 39.1

19 17.3

16 14.5

75 68.2

25 22.7

70 63.7

12 10.9

3 2.7

MDD

67.3

20406080100120

Fig 1 : Distribution of various psychiatric comorbidities- an over view

0

34.5

5.5 5.5 2.7 4.5 9.13.6

11.82.7 0

Suicidality

Mania

Panic Diso

rder

Socialphobia

OCDPTSD

Alcohol

Agoraphobia

Substance

Psych

osis

0

60.9

100

0

Anorexia

Bulimia

GAD

Organic

Antisocia

l

11.8

Psychiatric disorders

%

To Assess Anxiety and Depression in Patients Undergoing Maintenance Haemo-dialysis in a Tertiary Care Hospital in Kerala

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19

Male

Female

Married

CategoryFactor

Gender

Marital Status

Depression

67

43

60

Total

32

36

36

n

47.8

83.7

60.0

%

35

7

24

n

52.2

16.3

40.0

%p value

0.066

<0.001 *

Divorced

Widow

Single 20

14

16

10 50.0

13

9

10

92.9

56.2

50.0

1

7

7.1

43.8

0.021*Type Of Family

Nuclear

Joint

Living alone

Other

46

20

36

8

22

13

25

8

47.8

65.0

65.0

100.0

24

7

11

0

52

35.0

30.6

0.0

Education

Primary

Secondary

Graduate / Post Graduate

26

40

44

18

24

26

69.2

60

59.1

8

16

18

30.8

40

40.9 0.670

OccupationEmployed

Unemployed

Family Income

<10,000

10,000-20,000

>20,000

Number of haemodial-ysis

<49

50-99

>100

BMI

<18.5

18.5-24.9

≥ 25

33

77

19

49

57.6

63.6

42.4

36.4

14

280.549

25

42

43

22

21

25

88.0

50.0

58.1

3

21

18

12.0

50.0

41.9

0.007*

19

16

75

17

12

39

89.5

75

52

2

4

36

10.5

25

48

0.006*

25

70

15

25

33

10

100

47.1

66.7

0

37

5

0

52.9

33.3

0.029*

Yes No

Table 2 : Association of Socio demographic variables with Depression.

17


20

Male

Female

Married

CategoryFactor

Gender

Marital Status

Anxiety

67

43

60

Total

30

30

32

n

44.8

69.8

53.3

%

37

13

28

n

55.2

30.2

46.7

%p value

0.993

0.010*

Divorced

Widow

Single 20

14

16

11 50.0

8

9

9

57.1

56.2

45.0

6

7

42.9

43.8

0.350

Type Of Family

Nuclear

Joint

Living alone

Other

46

20

36

8

24

8

23

5

52.2

40.0

63.5

62.5

22

12

13

3

47.8

60.0

36.1

37.5

Education

Primary

Secondary

Graduate / Post Graduate

26

40

44

16

21

23

61.5

52.5

52.3

10

19

21

38.5

47.5

47.7 0.715

OccupationEmployed

Unemployed

Family Income

<10,000

10,000-20,000

>20,000

Number of haemodial-ysis

<49

50-99

>100

BMI

<18.5

18.5-24.9

≥ 25

33

77

17

43

51.5

55.8

48.5

44.2

16

340.676

25

42

43

17

21

22

68.0

50.0

51.2

8

21

21

32.00

50.0

48.8

0.305

19

16

75

12

13

35

63.3

81.2

46.7

7

3

40

36.8

18.8

53.3

0.029*

25

70

15

21

30

9

84

42.9

60

4

40

6

16

57.1

40

0.002*

Yes No


Table 3 : Association of sociodemographic variables with anxiety

18


21

This study was undertaken in the background evi-dence that prevalence of Chronic Kidney Disease and patients undergoing maintenance haemodialysis has been increasing worldwide. Though studies have been done in India to assess the depression in these patients , most of the studies haven’t looked into other psychiatric co morbidity in these subjects.

The WHO World Mental Health (WMH) surveys on the global burden of mental disorders, 2009, concluded that, the lifetime prevalence of mood disorders and anx-iety disorders are approximately 12% and 16% respec-tively11. In our study using Hospital Anxiety Depression Scale(HADS) 61.8 % had score of ≥8 in depressive sub-scale. In a similar study bone by Patel.e.al in Lucknow

DISCUSSION

had 33.3 % had depressive symptoms.6In another study by Chen et.al had 35 % had depressive symptoms2. Mean HADS-D score was 10.23±4.83 (0- 21) and mean age is 56.34±13.25.In another study by Zhang.et.al showed that prevalence of depression was 39.3%12. In another study the overall meta-analysitic prevalence of depression was 22.8% in 249 individual study popu-lation and there was evidence of high level of hetero-geneity. The report also showed that self report scales may overestimate the presence of depression13. The prevalence of depression in our study is higher than that observed by most of the other studies. This varia-bility may be due to sample size, heterogeneity in CKD severity between samples and differences in scales used to assess the depressive symptoms. The Chennai Urban Rural Epidemiology Study (Cures – 70) was the largest population-based study from India to report on preva-lence of depression and showed that the prevalence of depression was 15.1%14. Thus the prevalence rates of de-pression in patients undergoing haemodialysis is higher than that reported in general population.

In the current study among sociodemographic factors including gender, marital status, education, type of fam-ily and income were taken into consideration. The fac-tors which were significantly associated with depression were gender, type of family and family income. Out of the 67 males 47.8% had depressive symptoms and out of 43 females 83.7% had depressive symptoms. In the general population also generally women had higher chance of being diagnosed of Major Depressive disor-der from adolescence to adulthood15. Mean HADS –D score for males was 8.69±4.38(0-21) and females was 12.63±4.56. (0-21)

In this study it was also found that patients who were living alone were more depressed. The findings can be correlated with a similar study done by Fischer.et.al where it was found that patients who were Living alone had 43% depression in BDI(Becks Depression Inventory) scoring16.

Another study done by Zalai.et.al found that the main factors which influenced the level of psychological dis-tress are patients sociodemographic characteristics (eg. age, gender and family income) and social support17. This might be due to the role changes within the marital dyad , family and community level.

In this study depressive symptoms had statistically significant association with BMI. Patients who were undernourished or overweight had more depressive symptoms. Thus there was an association between de-pression and BMI. In a study by Wit.et.al done in 43,534 individuals it was found that there was a U shaped

13(81.2%) had anxiety symptoms. Out of 75 subjects who had underwent haemodialyis more than 100 times 35 (46.7%) had anxiety symptoms. There was statistically significant association between anxiety and number of haemodialysis (p value- 0.029). Out of 25 subjects who had BMI of <18.5 21 (84%) had anxiety symptoms . Out of the 70 subjects whose BMI was between 18.5-24. 9 30 (42.9%) had anxiety symptoms. Out of 15 who had BMI ≥25 9 (60%) had anxiety symptoms. There was statisti-cally significant association between BMI and anxiety (p value<0.002).

The association of sociodemographic variables with anxiety is summarized in Table 3. Compared with non anxious patients subjects with anxiety had a statistical-ly significant association with gender, BMI and number of haemodialysis. Among multivariate logistic regres-sion it was found that female sex( OR-2.846 with 95 % confidence interval was statistically significant. In this study using M.I.N.I it was found that out of 110 sub-jects 6(5.5%) had mania, 6 (5.5%) had panic disorder, 3 (2.7%) had agoraphobia and 5(4.5%) had social phobia.OCD symptoms was found in 10 (9.1%) and Post trau-matic stress disorder symptoms was found in4 (3.6%)subjects. It was also found out of 110 subjects 3(2.7%) had features of alcohol dependence and 10 (9.1%) had features of abuse. It was also found that 13 (11.8%) sub-jects had features of abuse, and 3 (2.7%) had features of psychotic symptoms. The frequency distribution of all other psychiatric co morbidity in patients undergoing maintenance haemodialysis using M.I.N.I is summarized in Figure 1. It was also found out that the prevalence of all other psychiatric co morbidity was lower when com-pared to Depression and Anxiety. In our study it was also found that out of the 38 subjects who had suicidality all were depressed. It was also found that out of the 38 sub-jects who had suicidality 73.7 % had anxiety.

19


22

association between BMI and depression18. It was also found that people with low BMI had more anxiety symp-toms. But we should keep the fact that BMI may be af-fected by various other co morbid medical problems, environmental and genetic factors.

In the current study it was found that patients who had lower number of haemodialysis were more depressed than others. The findings were similar to a study done by Watnick.et. al in which 123 patients who was started on haemodialysis of which 44% patients scored ≥14 in BDI(Becks Depression Inventory)19. In multivariate logis-tic regression analysis, females were five times more depressed and subjects with lower number of haemo-dialysis was twice more depressed than other subjects in the study.

In our study using HADS(Hospital Anxiety Depression Scale) 54.5 %of the patients anxiety subscale ≥8 in anx-iety subscale. Mean HADS - A score was - 8.59±3.77. It is similar to a study done by Chen et.al 21% had anxiety symptoms2.

In another study done by Lee.et.al showed that preva-lence of anxiety in CKD is 27.6% and the prevalence did not differ across CKD stages.20In a similar study done by Reckert.et.al which was done in 2013 in 52 haemodialy-sis patients it was found that 17% had Generalized Anx-iety disorder using SCID(Structured Clinical Interview for DSM5) and 23 % scored ≥7 in HADS-A21. High preva-lence of anxiety symptoms can be explained by the fact that patient attending haemodialysis have significant apprehension about the prognosis of treatment, dura-tion of haemodialysis and anxiety concerning the finan-cial aspects of treatment. However these aspects were not methodologically studied. Hence further research focusing on the aspects of anxiety needs to be under-taken.

In the current study among sociodemographic factors including gender, marital status, education, type of fam-ily and income were taken into consideration. The fac-tors which was significantly associated with anxiety was gender. Among 43 females who underwent haemodial-ysis 69.8 % patient scored ≥8 in HADS-Anxiety subscale and among 67 males 44.8% scored more than ≥8 in anx-iety subscale. Mean HADS A score for females was 9.81± 3.68 and for females was 9.81±3.68. This result does not correlate with the findings got by Lee.et.al where there was no correlation between anxiety and sociodemo-graphic variables20. Mean age of patients with Anxiety was 55.77±14.23.In this study it was also found that pa-tient who had lesser number of haemodialysis (≤100) had a significant association with anxiety. In a study done by Lew.et.al to analyze psychosocial factors at the initiation of haemodialysis it was found that the lifestyle burden and losses associated with planning and initia-

tion of haemodialysis account for these observations22. In this current study it was also found that patients with lower BMI(<18.5) scored ≥ 8 in the anxiety subscale of HADS-A and there was a statistically significant associ-ation (p value-0.002). Poor nutrition may occur due to loss of appetite. But abnormal BMI can also be attributed to Chronic Kidney Disease or other co morbid illness23. The findings were similar in a study done by Zhao.et.al where subjects who had abnormal BMI had more anx-iety symptoms23. In multivariate logistic regression anx-iety symptoms was statistically associated with female subjects was three times more anxious than other sub-jects. In another study done by Livesley.et.al it is stated it showed that anxiety is more common in females24.

As the design of the study was a cross sectional, we were unable to assess the changes in depressive or anxiety symptoms with disease progression. Secondly, though M.I.N.I and HADS has been validated for the use in patients with ESRD, it has not been validated against a gold standard psychiatric diagnosis of depression in patients with CKD. Thirdly, to meet the diagnosis, DSM-5 or ICD 10 diagnostic criteria was not used. To meet the diagnostic criteria for DSM-5,the subjects needs to fulfill the exclusion criteria as quoted in DSM 5”The symptoms are not due to direct physiological effects of a medication/general medical condition.” DSM 5 criteria may have a higher specificity but a lower sensitivity than HADS. Authors used HADS to define case of depressive disorder and anxiety disorder. Lastly subjects from this study were from a single hospital. It will be better if we recommend further research with sample from multiple hospitals.

Limitations

It was found that anxiety and depression is the most common psychiatric co morbidity in patients undergo-ing maintenance haemodialysis. It was also found that females had more anxiety and depressive symptoms. By using M.I.N.I it was found that other psychiatric co mor-bidities prevalence rate was much lower. From this study it was also found that patients had more depressive and anxiety symptoms at the time of initiation of mainte-nance haemodialysis.BMI also had association with de-pressive and anxiety symptoms.

Depression and anxiety adversely affect the quality of life and survival of these patients. They are all treatable since patients undergoing maintenance haemodialysis are frequently seen by the doctor on a regular basis. Therefore there is no barrier in diagnosing or treating such conditions. So it is essential for the nephrologist to be aware of such symptoms in these patients. Time-ly treatment of such symptoms will reduce the disease

CONCLUSION


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REFERENCES1. Davison ,Cameron ,Grunfield, Ponticelii,Ritz Oxford Textbook

of Clinical Nephrology 3rd edtn;OUPUK publishers,2005 Jan 3(12);3402-808

2. Chen CK, Tsai YC, Hsu HJ, Wu IW, Sun CY, Chou CC, Lee CC, Tsai CR, Wu MS, Wang LJ. Depression and suicide risk in hemodialy-sis patients with chronic renal failure. Psychosomatics. 2010 Dec 31;51(6):528-

3. White CA. Cognitive behavioral principles in managing chronic disease. Western journal of medicine. 2001 Nov 1;175(5):338

4. Thorne SE. Negotiating health care: The social context of chronic illness. Sage Publications; 1993 Mar 24.

5. Kutner NG. Improving compliance in dialysis patients: does any-thing work?. InSeminars in Dialysis 2001 Sep 1 (Vol. 14, No. 5, pp. 324-327). Blackwell Science Inc.

6. PatelML, Sachan R,Nishal A,et al :Anxiety and Depression-A Sui-cidal Risk in Patients with Chronic Renal Failure on Maintanence HaemodialysisIJSR2012;2(3)78-83

7. Reiss D. Patient, family, and staff responses to end-stage re-nal disease. American Journal of Kidney Diseases. 1990 Mar 31;15(3):194-200.

8. Kimmel PL. Psychosocial factors in dialysis patients. Kidney inter-national. 2001 Apr 30;59(4):1599-613

9. Sheehan DV, Lecrubier Y, Sheehan KH, et al: The Mini-Interna-tional Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM–IV and ICD–10. J Clin Psychiatry 1998; 59(suppl 20):22– 33; Quiz: 34–57

10. Olsson I, Mykletun A, Dahl AA: The Hospital Anxiety and De-pression Scale: a cross-sectional study of psychometrics and

case-finding abilities in general practice. BMC Psychiatry 2005; 5:46

11. Kessler RC, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee S, Ormel J, Üstün TB, Wang PS. The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys. Epi-demiologia e psichiatria sociale. 2009 Mar 1;18(01):23-33.

12. Zhang M, Kim JC, Li Y, Shapiro BB, Porszasz J, Bross R, Feroze U, Upreti R, Martin D, Kalantar-Zadeh K, Kopple JD. Relation be-tween anxiety, depression, and physical activity and perfor-mance in maintenance hemodialysis patients. Journal of Renal Nutrition. 2014 Jul 31;24(4):252-60.

13. Palmer S, Vecchio M, Craig JC, Tonelli M, Johnson DW, Nicolucci A, Pellegrini F, Saglimbene V, Logroscino G, Fishbane S, Strippoli GF. Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies. Kidney inter-national. 2013 Jul 1;84(1):179-91

14. Poongothai S, Pradeepa R, Ganesan A, Mohan V. Prevalence of depression in a large urban South Indian population—The Chen-nai Urban Rural Epidemiology study (CURES–70). PLoS One. 2009 Sep 28;4(9):e7185.

15. Nolen-Hoeksema S. Gender differences in depression. Current directions in psychological science. 2001 Oct 1;10(5):173-6.

16. Fischer MJ, Kimmel PL, Greene T, Gassman JJ, Wang X, Brooks DH, Charleston J, Dowie D, Thornley-Brown D, Cooper LA, Bruce MA. Sociodemographic factors contribute to the depressive affect among African Americans with chronic kidney disease. Kidney international. 2010 Jun 1;77(11):1010-9.

17. Zalai D, Szeifert L, Novak M. Psychological distress and depres-sion in patients with chronic kidney disease. InSeminars in dial-ysis 2012 Jul 1 (Vol. 25, No. 4, pp. 428-438). Blackwell Publishing Ltd.

18. De Wit LM, Van Straten A, Van Herten M, Penninx BW, Cuijpers P. Depression and body mass index, a u-shaped association. BMC public health. 2009 Jan 13;9(1):1.

19. Watnick S, Kirwin P, Mahnensmith R, Concato J. The prevalence and treatment of depression among patients starting dialysis. American journal of kidney diseases. 2003 Jan 31;41(1):105-10.

20. Lee YJ, Kim MS, Cho S, Kim SR. Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease. International journal of clinical practice. 2013 Apr 1;67(4):363-8.

21. Reckert A, Hinrichs J, Pavenstaedt H, Frye B, Heuft G. [Prevalence and correlates of anxiety and depression in patients with end-stage renal disease (ESRD)]. Zeitschrift fur Psychosomatische Medizin und Psychotherapie. 2012 Dec;59(2):170-88.

22. Lew SQ, Piraino B. Psychosocial factors in patients with chronic kidney disease: quality of life and psychological issues in perito-neal dialysis patients. InSeminars in dialysis 2005 Mar 4 (Vol. 18, No. 2, pp. 119-123). Blackwell Science Inc.

23. Zhao G, Ford ES, Dhingra S, Li C, Strine TW, Mokdad AH. Depres-

progression, increases the survival rate, decreases the health care cost and increases the quality of life.

Suggestions for future research A long-term follow up study should be conducted in order to find out more about the long-term impact of depression and anxiety in dialysis patients. Further treatment studies of depression/anxiety should be per-formed, and their effectiveness for symptom reduction The etiology of depression is not known, so there are few studies that support a stress and inflammation hypothe-sis in depression in the general population. It would be interesting to further study the relationship between stress, inflammation and depression in dialysis patients.

Further study of comorbid depression and anxiety, as well as their associations with the Quality of life of di-alysis patients, is needed.Controlled clinical studies to assess coping style, social support and physical training as effective interventions for depression and anxiety are needed.

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sion and anxiety among US adults: associations with body mass index. International journal of obesity. 2009 Feb 1;33(2):257-66.

24. Livesley WJ. Symptoms of anxiety and depression in patients undergoing chronic haemodialysis. Journal of psychosomatic

research. 1982 Dec 31;26(6):581-4.

25. Sudhir kumar,Dinesh N,Cherikil.et.al An Introduction to M.I.N.I International Neuropsychaitric Interview and its Malayalam ver-sion, Kerala Journal of Psychaitry, 2010 July Vol-24,no -20).


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Bisna Abdul Kader*, Dhanasekaran B S*,Gireesh Kumar*, Sreekrishnan T P*

ABSTRACTBackground and methods: Cardiac arrest is the abrupt loss of heart function in a person who may or may not have a diagnosed heart disease due to the malfunction of the heart’s electrical system. The time and mode of death is usually unexpected. It occurs instantaneously or shortly after symptoms appear.

This prospective observational study was performed on 100 patients who suffered an In hospital cardiac arrest (IHCA) in a tertiary care hospital in south India, AIMS (Kochi).

Objective: The purpose was to identify the most common reversible cause of in-hospital cardiac arrest (IHCA) in adult patients, the most commonly affected population and the most common disease conditions associated with cardiac arrest and to investigate whether recognition of causes of arrest during the provision of ACLS resulted in improved survival.

Result: In all 100 episodes, the cause of In- Hospital Cardiac Arrest was reliably determined. Other conditions included sepsis, de-compensated liver failure and chronic kidney disease. The median values of Age group (59), total cycles of CPR (20), ETCO2 during CPR (18), ETCO2 at end of CPR (19), Adrenaline (4), shock (2) and RBS (192).

Conclusion: The major disease conditions associated with cardiac arrest were cardiac conditions (45%). Sepsis was found to be present in 23% of patients with IHCA. Among the causes within the 5H’s and 5T’s hypoxia dominated with 37%, followed by aci-dosis 23%. In the study we have found that the recognition of cause of arrest during the provision of ACLS resulted in improved survival.

Keywords: In- hospital cardiac arrest, advanced cardiac life support, cardiopulmonary resuscitation

Corresponding Author: Sreekrishnan T P

INTRODUCTION In hospital cardiac arrest (IHCA) is the ultimate compli-cation to critical illness among hospitalized patients. If the triggering causes of arrest are recognized by the in hospital emergency team, this may have crucial conse-quences for survival.

Improvement of the cardiac arrest (CA) chain of surviv-al (COS) has contributed to increased survival in many regions : early recognition of CA, immediate and good quality cardiopulmonary resuscitation (CPR), early de-fibrillation in case of pulseless and shockable cardiac arrhythmias, and proper care of immediate survivors1-7. Further elements for improvement should be sought.

From the early days of ‘modern resuscitation’ to the cur-rent guidelines for advanced cardiac life support (ACLS) and in hospital resuscitation, encouragement has been given to ‘recognize and treat’ and correct reversible causes during CPR 8-11. To what has not been thorough-ly investigated while return to spontaneous circulation (ROSC) ought to be improved by recognizing and treat-ing the underlying cause, survival to hospital discharge is likely to be less affected depending on additional fac-tors such as co morbidity.

If cardiac arrest (CA) occurs in a hospitalized patient, the primary intervention is cardiopulmonary resuscita-tion (CPR) following the current advanced cardiac life

*Dept. of Emergency Medicine, Amrita Vishwa Vidya peetham, Kochi, India.

support (ACLS) guidelines, which include a reminder of the causes of CA through the mnemonic 5H’s and 5T’s (hypoxia, hypovolemia, hypo/ hyperkalemia, hypother-mia, H+ ions,thrombosis pulmonary, thrombosis coro-nary, toxins, tamponade, tension pneumothorax.).

This study was conducted to investigate the reversible cause of IHCA with their respective survival rate.

ORIGINAL ARTICLE


METHODOLOGYInclusion Criteria:Patients 18 years or above who had an in hospital cardi-ac arrest (IHCA).

Exclusion Criteria:• Patients younger than 18 years of age

• Traumatic cardiac arrest

• Pregnancy

• Out of hospital cardiac arrest

Structure, material and location This was a prospective observational study which was conducted from July 2017 to December 2017 at Amrita Institute of Medical Sciences (AIMS), Kochi. The details concerning patients, inclusion strategy and the thor-ough investigation of the IHCA causes were collected. The code blue team consists of one resident anaesthe-siologist, one resident cardiologist and team leader of nurses and emergency medical technician (EMT). The EMT is set up to provide respiratory and circulatory sta-

23


26

RESULT This prospective observational study included 100 pa-tients who had in – hospital cardiac arrest (IHCA) who were selected from the Emergency Room, ICUs and wards of Amrita Institute of Medical Sciences and Re-search Centre from July 2017 to December 2017. Among 100 patients included in the study satisfying inclusion criteria, the episodes of IHCA, 94% (94) of cardiac arrest occurred in ICUs and remaining 6% (6) occurred in ward, because ICU patients were more critical. Amidst the 100 patients included in the study 32% (32) of patients needed 5-10 cycles of CPR, 21% (21) of patients needed 11-20 cycles of CPR, 26% ( 26) of patients needed 21-50 cycles of CPR and 21% of patients needed >50 cycles of CPR. In this study we have found that 80% (80) of pa-tients were already intubated, 10% (10) were intubated

bilizing measures at any time of the day. Patients were included with the age > 18 years who received chest compression and / or defibrillation by the EMT or ward personnel.

Data collection All relevant clinical data were extracted from the pa-tients’ records including age, sex, co morbidities, cause of arrest, surveillance, ETCo2 value, mode of ventilation, total cycles of CPR, number of Adrenaline given, number of shock, other illness, IV drugs given and RBS.

The primary variables of interest were: cause of arrest, suspected by the EMT; cause identified retrospectively by the authors; and whether the cause was recognized by the EMT.

Aetiology analysis The causes of cardiac arrest were categorized as 5H’s and 5T’s, namely:• Hypovolemia

• Hypoxia

• Hydrogen ion (acidosis)

• Hypo/hyperkalemia

• Hypothermia

• Tension pneumothorax

• Tamponade, cardiac

• Toxins

• Thrombosis pulmonary

• Thrombosis coronary

Statistical analysis The data collected were compiled using Microsoft Exe-cl. All statistical analyses carried out using IBM statistical Package for Social Science (SPSS version 20). We used frequency and percentage to present categorical varia-ble and median to present numerical variable.


01020

30

4050607080

Fig 1: Graph showing age distribution.

18-30 31-50 51-80

Age Distribution

Series 3

Fig 2: Pie diagram showing gender distribution.

Gender Distribution

78.00%

22.00%

Male

Female

during resuscitation and remaining 10% (10) were pro-vided by Bag and Mask ventilation.

The ETCo2 values during CPR in 19% (19) patients were <10 mmHg and it was advised to improve the quality of CPR in those patients. 38% (38) had 11- 20 mmHg, 35% (35) had 21-30 mmHg , and 8% (8) had >30 mmHg. ETCo2 at end of CPR were 44% (44) of patients had 0-10 mmHg, 10% (10) had 11- 20 mmHg, 18% (18) had 21-30 mmHg, and 28% (28) >30 mmHg. ETCo2 values were <10 mmHg at the end of 20 minutes of CPR in dead patients. The initial rhythm in 46% (46) of patients was Pulseless Electrical Activity (PEA) 31% (31) had Asysto-le, 12% (12) had pulseless Ventricular Tachycardia (pVT), and 11% (11) had Ventricular Fibrillation (VF). And 77% (77) of patients had non shockable rhythm and remain-ing 23% had shockable rhythm.

During resuscitation Adrenaline was administered as 1mg/ ml ampoule of 1:1000 dilution of and was re-peated in every 3-5 minutes. Here 64% of patients had received 1-5 ampoule of Adrenaline, 28% had received 6-10 ampoules of Adrenaline and remaining 8% had re-ceived >10 ampoules of Adrenaline.

24


27

37

1

Hypoxia

Highperkalemia

H+ ions

Toxins

Tamponade

Thrombosis

Coronary

Hypovolemia

Hyotherm

ia

Thrombosis

Pulmonary

Tensio

n Pneumothorax

1

17

2 2

23

3 3

10

4 45 5

6 67 7

138 8

9 91010

Fig 3: Graph showing distribution of causes of cardiac arrest.

causes of cardiac arrest

2%

Hypoxia

Highperkalemia

H+ ions

1%

17%

3%

7%

3%

Fig 4: Graph showing distribution of medicines used for reversible causes of cardiac arrest.

Drugs Used in Revesible Causes

Thrombosis

Hypovolemia

Sodium bicorbonate

Calcium gluconate

25


28

DISCUSSION This is a prospective observational study done on 100 patients who had in hospital cardiac arrest. Among which, 78% were males and remaining 22% were fe-males. The study was done to identify the most common cause of in hospital cardiac arrest. The age category was >18 years. The findings in this study reveal that, among the 5 H and 5 T causes, the majority of IHCA`s were due to hy-poxia 37% (37) and the condition for which they got admitted were cardiac in origin 45%.The prominence of different cardiac causes advocates the cardiologist to be immediately available in the post- ROSC period or to be a member of code blue team to ensure optimal follow up of cardiac conditions. A study conducted by Jones et al. demonstrated that among 37 doctors serving as ET physicians, 10 (27%) failed to recall the assumed most frequent causes of 5H’s and 5T’s, hypoxia and hypo-volemia, and the overall frequent causes of 5H and 5T causes was low12. In addition, these authors did not re-port how closely they examined the episodes with re-gard to etiology. Here in this study the most common cause within the 5H’s and 5T’s were hypoxia (37%), H+ ions (23%) followed by hyperkalemia (17%). This study demonstrates that the EMT was instrumental in recognizing the cause of arrest, i.e. in accordance with the finding of the etiology study group. In more than 90% episodes of cardiac arrest a reliable cardiac arrest cause could be determined by the EMT. An analogous consideration regarding the recognition of causes in 10% of all episodes remain unknown despite the close investigation and also were not able to decide wheth-er the EMT’s made the correct consideration about the causes of arrest in these episodes.A Finnish- Swedish study by Saarinen et al., including pa-tients with in-hospital cardiac arrest between 2003 and 2010 demonstrated superior 30 days survival among resuscitated patients whose underlying causes were appropriately treated15. Whether appropriate treatment

was based on the recognition of cause by the EMT’s was not reported in this study. In the present study, PEA and asystole were the first documented rhythm in 77% of episodes, in which 46% was PEA and a percentage of 31 were found to be asys-tole . However, this is not very different from 71% of PEA and asystole in a study by D. Bergum et al. or 79% in the Get with the Guidelines Resuscitation registry study by Girora et al. with 84,625 hospitalized patients13,14. When the initial rhythm was PEA or asystole, the causes were not strictly non-cardiac and approximately half of all cardiac episodes presented with PEA or asystole as well. In the current study, we found that the clinical condi-tions triggering IHCA becomes crucial for the choice of treatment. The appropriate timing, however, was not taken into account in this study. Cause specific treat-ment can be prepared and initiated immediately if ROSC is achieved. In certain cases of cardiac arrest, achieving ROSC may be fully dependent on a specific therapeutic measure, e.g. pericardiocentesis during cardiac tampon-ade or fluid resuscitation during shock. Yet another study by, D. Bergum et al. stated that the median delay from arrest to chest compression was only 1 minute, which was relatively fast compared to other studies. It is reasonable to associate the relatively high survival rate in this study to the high proportion of ob-served IHCA`s and immediately initiated CPR because an association has been well demonstrated between early CPR and a high probability of ROSC. In this study we found that local ward nurses or physicians had ini-tiated CPR in >90% episodes before the arrival of code blue team. Short intervals from collapse to CPR depend on immediate action by the local ward personnel, and they must be included in the hospital wide CPR or BLS training programme. In this we have strengthened that the fact that ETCO2 value of <10mmHg even after 20 minutes of high qual-ity CPR was associated with higher mortality, which has already been proven in many other studies. Most of the

43.00%

57.00%

Rosc Achieved

Rosc Not Achieved

Distribution of Rosc

Fig 5: Doughnut diagram showing distribution of outcome.


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CONCLUSION In conclusion, the majority of associated disease condi-tions with cardiac arrest were cardiac diseases 45% (45). Sepsis was found to be present in 23% (23) of patients with IHCA. Among the reversible causes within the 5H’s and 5T’s, hypoxia dominated with 37% (37), followed by acidosis 23% (23). Most commonly affected age group was 45-73 years, and males were affected almost 3 times more than fe-males. Maximum number of IHCA`s were observed in an ICU setting than ward because ICU patients were more critical. All the IHCA’s were witnessed. In the study we have found that the recognition of cause of arrest during the provision of ACLS resulted in improved survival. Cause – related survival was relatively high with the two largest groups- cardiac causes and sepsis. In patient who suffered an in hospital cardiac arrest, PEA was the first detected rhythm. No cause – specific ECG pattern was found during early phase of resuscitation, nor could survival be predicted based on the instantaneous ECG pattern defined in this study.

1. Schneider AP, Nelson DJ, Brown DD. In-hospital cardiopulmonary resuscitation: a 30-year review. J Am Board Fam Pract 1993;6:91–101.

2. Ballew KA, Philbrick JT. Causes of variation in reported in-hospital CPR survival: a critical review. Resuscitation 1995;30:203–15.

3. Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS. Trends in survival after in-hospital cardiac arrest. N Engl J Med 2012;367:1912–20.

4. Spearpoint KG, McLean CP, Zideman DA. Early defibrillation and the chain of survival in ‘in-hospital’ adult cardiac arrest; minutes count. Resuscitation 2000;44:165–9.

5. Herlitz J, Bang A, Alsen B, Aune S. Characteristics and outcome among patients suffering from in hospital cardiac arrest in rela-tion to the interval between collapse and start of CPR. Resuscita-tion 2002;53:21–7.

6. Sunde K. SOPs and the right hospitals to improve outcome after cardiac arrest. Best Pract Res Clin Anaesthesiol 2013;27:373–81.

7. Eftestol T, Sunde K, Steen PA. Effects of interrupting precor-dial compressions on the calculated probability of defibrilla-tion success during out-of-hospital cardiac arrest. Circulation 2002;105:2270–3.

8. Sloman JG, Hamer A, Ross D. A B C of the management of cardiac arrest: 2. In hospital. Med J Aust 1980;2:475–7.

9. Kirby BJ, McNicol MW. Results of cardiac resuscitation in one hundred patients: effects on acid–base status. Postgrad Med J 1967;43:75–80.

10. Kerber RE, Ornato JP, Brown DD, et al. Guidelines for cardiopul-monary resus-citation and emergency cardiac care. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Part I. Introduction. JAMA 1992;268:2171–83.

11. Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2010;81:1305–52.

12. Jones N, Lammas C, Gwinnutt C. Poor recall of “4Hs and 4Ts” by medical staff. Resuscitation 2010;81:1600.

13. Gwinnutt CL, Columb M, Harris R. Outcome after cardiac arrest in adults in UK hospitals: effect of the 1997 guidelines. Resuscita-tion 2000;47:125–35.

14. Girotra S, Nallamothu BK, Spertus JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med 2012;367:1912–20

15. Saarinen S, Nurmi J, Toivio T, Fredman D, Virkkunen I, Castren M. Does appro-priate treatment of the primary underlying cause of PEA during resuscitation improve patients’ survival? Resuscita-tion 2012;83:819–22.

REFERENCES

patients included in the study were intubated already, and the episodes of cardiac arrest were high in the ICUs. In this study we found out that the background disease condition to some extent can contribute in the recogni-tion of cause of arrest: e.g. most of the sepsis patients had cardiac arrest due to H+ ion (acidosis). An important question that arises is whether the rec-ognition of causes during ACLS in IHCA influences short term or long term survival. “Rate of recognition” may be relevant to future CPR guidelines and more studies are needed to clarify the potential role of such measures. A chief strength of this study is the prospective obser-vational design and the thorough investigation of all episodes with respect to etiology and causes. However this study also has several limitations. A consequence of this method is that a large proportion of episodes were categorized as unknown with respect to their etiology and causes due to the lack of objective diagnostic find-ings. The sample size is too small to investigate every possible sub-group. This applies especially to the other components of 5H’s and 5T’s where they never became a cause of arrest. The study is based on a single centre which limits the generalizability; however the patients and episode char-acteristics are in general comparable to what is being reported in international studies.

Early recognition of cause of cardiac arrest caused sig-nificant improvement in over-all survival of patient who suffered an IHCA.

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Effectiveness of Hepatitis-B Vaccination Programme Among Grade II Health Personnel of Government Medical College,

ThiruvananthapuramLakshmi G G*, Zinia T Nujum**, Prathibha M T***

ABSTRACTBackground: Health care workers are at increased risk of contracting Hepatitis B infection. The most effective way to prevent the in-fection and its consequence in susceptible is an effective vaccination strategy. Not only a vaccination strategy but post vaccination serology is essential to track the responders and non responders. Hence this study is being conducted to assess the effectiveness of a vaccination programme meant for vaccinating health care workers by estimating the sero-conversion rate for Hepatitis B vaccine. Materials and methods: A Cross sectional study was conducted among Grade II health workers of Medical College, Thiruvanan-thapuram, who have been fully vaccinated under Hepatitis B vaccination programme held in January 2014.75 study participants were recruited for the study following systematic random sampling. The study subjects were interviewed using a semi-structured questionnaire to collect the socio-demographic data and blood samples were collected to estimate Antibody titre during April 2015 to May 2015.Results: Mean age of the study subjects was 44.12 years (SD7.2). Majority of the study participants were females 61 (81.3%), rest were males 14 (18.7%). 14.66%) had inadequate Anti Hepatitis B antibody titre <100IU/L and 85.33% had adequate Anti Hepatitis B antibody titres ≥100 IU/L after three doses of vaccination. Bivariable analysis showed that temporary job status and presence of hypertension was associated with decreased antibody titre.Conclusions: The Seroconversion rate in our study population is fairly good but post vaccination serology is not routinely prac-ticed. This study showed insights on the need for pre placement Hepatitis B vaccination and subsequent follow up.

Key words: Effectiveness, Health care personnel, Hepatitis B, Antibody titre.Corresponding Author: Prathibha M T

INTRODUCTION

*Dept. of Health Services, **Dept. of Community Medicine Government Medical College,Thiruvananthapuram.*** Dept. of Community Medicine Travancore Medical College,Kollam

ORIGINAL ARTICLE


The most effective way to prevent the infection and its consequence in susceptible is an effective vaccina-tion strategy. The Advisory Committee on Immunization Practices recommends that Health care and public safe-ty workers at risk for exposure to blood or blood-con-taminated body fluids should also take the vaccination. They should also undergo post vaccination testing 1-2 months after the vaccination series 7. In India, Hepatitis B vaccine is produced at the serum institute of India. GeneVac-B™ (Recombinant Hepatitis - B Vaccine, I.P.) is a non infectious recombinant DNA Hep-atitis B Vaccine. Primary Immunisation – a series of three intramuscular injections at 0,1,6 months is required to achieve optimal protection. Vaccination is successful if the antibody-titre (anti-HBs) is higher than 100 IU/L. If the anti-HBs level remains lower than 10 IU/L, there is no protection against hepatitis B and revaccination is rec-ommended. Seroconversion rate of the vaccine globally ranges from 85-90 %8. Of the umpteen number of diseases a health care worker is occupationally exposed to, hepatitis B is not only the most transmissible infection, but the only one that is preventable by vaccination 6.

Hepatitis B is incontrovertibly a major global health problem faced by mankind. The estimates that more than 2 billion people worldwide have been infected with HBV 1 and approximately 780 000 persons dieeach year from infection makes the point obvious. The infection can run an acute or chronic course. The chronic infection puts people at high risk of death from cirrhosis and liver cancer and around 650000 of such cases suc-cumb to death every year whereas around 130000 die from acute form of the disease 2. Hepatitis B prevalence is highest in sub-Saharan Africa and East Asia, where between 5–10% of the adult popu-lation is chronically infected. The prevalence of Hepatitis B prevalence in India ranges from ranges from 2 to 8%, in general population which places India in an interme-diate HBV endemicity zone 3. . Among the groups of people who are at risk of devel-oping hepatitis B, health care workers have well recog-nized occupational risk. The risk of contracting hepatitis B is four times greater than that of general population 4. In developed countries, HBV infections in health care workers were less than 10%, largely because of immu-nization and post-exposure prophylaxis. But in develop-ing countries, HBV infections in healthcare workers are

about 40-65% attributed to percutaneous occupational exposure 5. In India, a tertiary care hospital in Delhi reported that 1% of healthcare workers were HBsAg positive 6. .

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MATERIALS AND METHODS A Cross sectional study was conducted among Grade II health workers of Medical College, Thiruvananthapu-ram, who have been fully vaccinated under Hepatitis B vaccination programme held in January 2014. The study was carried out at Preventive Clinic under the depart-ment of Community Medicine Medical College, Thiruva-nanthapuram. The study subjects were interviewed and blood samples were collected after obtaining informed written consent. The study was conducted during the period April 2015 to May 2015. According to a study on “Evaluation of immune response to Hepatitis B vaccine in health care workers at a tertiary care hospital in Paki-stan”, the prevalence of sero conversion was found to be 85% 5.

Hence the sample size was calculated using the formu-lae for prevalence studies and it came out to be 75.Out of the total 300 grade 2 health workers vaccinated from preventive clinic under the programme, every third per-son was recruited by systematic random sampling into the study till the final sample size of 75 was met.

The outcome variable studied was Adequacy of An-ti-Hepatitis B antibody titre at the time of study (anti-body titre of ≥100 IU/L). The independent variables studied were Socio demographic variables namely age in completed years, sex, education, socioeconom-ic status, marital status and occupational Details. Oc-cupational details were collected under the following subheadings namely Type of employment (temporary/ permanent), work station (out patient departments/ward/ lab/Intensive Care Units/hospital premises/oth-ers), Number of working Hours per day and Number of working days per Month. History of Alcohol use, Tobac-co use, self reported occurrence of any co morbidities were also enquired. Timely Adherence to Vaccination schedule was also assessed .Height was measured us-ing a measuring tape and weight was measured using a digital weighing scale. Blood pressure was recorded

after completing interview, using a standardized digital upper arm BP monitor.

Among those health care workers fully vaccinated un-der this initiative, after obtaining detailed informed writ-ten consent, 75 workers were selected using systematic sampling from the register and was administered a semi structured questionnaire. Following this, the selected study subjects underwent blood testing to estimate the Anti-HBs antibody titre in Accredited Clinical Research Laboratory, Medical College, Thiruvananthapuram. The Anti-HBs kit used for assay is ARCHITECT Anti-HBs, a Chemiluminescent Microparticle Immunoassay (CMIA) which determines the concentration of antibody to Hepatitis-B surface antigen (anti-HBs) in human serum and plasma.

Data was entered into Microsoft Excel and analyzed using appropriate statistical software. The categorical variables are expressed in proportions and the quanti-tative variables are expressed with relevant measures of central tendency and dispersion. To find the factors associated with seroconversion, analysis was done us-ing chi-square test for qualitative variables and t-test for quantitative variables after checking for normality.

An ethical clearance from the Human Ethics Commit-tee, Medical College,Thiruvananthapuram, prior to the initiation of the study was obtained. The results of blood tests were communicated to the study subjects. Those who did not have protective antibody titres were ad-vised to take Hepatitis B vaccine booster dose and to check antibody titre after one month.

RESULTS The study included 75 grade II health professionals of Government Medical College,Thiruvananthapuram. The results are described under following subheadings:

General description of study participants1 Socio demographic profile Mean age of the study subjects was 44.12 years (SD7.2 ), minimum age was 24 and maximum age was 59.Majority of the study participants were females 61 (81.3%), rest were males 14 (18.7%). 70.7% (n=53) study participants had completed high school education. 45 (60 %) of study participants belonged to APL category, rest 30 (40%) belonged to BPL category. The Occupation details of the study participants are shown in Table No.1. The type of employment whether temporary or perma-nent and different work stations are mentioned in the table.

2 Habits of the study population 69(92%) of the study population were never users of tobacco. Among the 6 (8%) ever users, 2 were ex-users and only 4 (5.3%) were current users. Median duration of use was 20 years (IQR=4) the median number of cig-arette smoked per day was 5.5 (IQR=5). 6 (8%) of study population were ever users of alcohol and all of them were males. Among the 6 (8%) ever users, 2 were ex-us-

Although seroprevalence in general population has been estimated in many studies, only a few studies have been done in health care workers- especially among health care workers handling hospital waste. The most important approach for the prevention of occupation-al HBV infection is the use of hepatitis B vaccine among HCWs at risk. Sadly in developing countries like India, there is no standardized post vaccination protocol to confirm, monitor and maintain immunity. Most of the newly recruited grade II workers in Govt. Medical College, Thiruvananthapuram were not vac-cinated against Hepatitis B. So a vaccination drive was initiated by the administrative authorities. Hence the fol-lowing study is being conducted with an aim to assess the effectiveness of a vaccination programme meant for vaccinating health care workers b estimating the sero-conversion rate for Hepatitis B vaccine and also to assess the various factors related to adequate Antibody titre.

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ers and only 4 (5.3%) were current users. Median dura-tion of alcoholism was 10 years (IQR =7.5). None of the female subjects ever used tobacco or alcohol.

3 Medical history None of the study subjects had past history of Hep-atitis B.7 (9.3%) of the study subjects had one of their family members with Hepatitis B. 31 (41.3%) of study population suffered from one or more of the self report-ed chronic illnesses. The most common chronic ailment was hypertension with a prevalence of 16% among the study participants. The study subjects were classified as normotensives, prehypertensives and hypertensives according JNC 8 criteria. The findings are represented in Figure No.1. 21.3% of the study subjects were hyper-

tensive. 4(5.33%) of the study subjects were newly diag-nosed as hypertensive during the study.

4 Hepatitis-B Immunization and Antibody titre among study participants 96% (72) of the study subjects had taken all the 3 doses of Hepatitis B as per schedule. Only 4% (3) of the study subjects had not rightly adhered to the scheduled immunization timings. Out of the 3 study subjects, two had delayed the 3rd dose by 1 month and one of them delayed the 3rd dose by 3 months. 72 of the study sub-jects had not reported any adverse events following Hepatitis vaccination. 4% (3) study subjects had report-ed that they had pain on the injection site on the day of vaccination which lasted only for a day. None of the

Work stations

Frequency (%)

43(57.3%)

Category

Type of Employment Permanent 32(42.7%)

9(12%)

5(6.7%)

5 5(6.7%)

2(2.7%)

General services

Temporary

Operation theatre

Out-patient dept

Casualty

ICU

26(34.7%)

Occupational Details

Laboratory

Ward 17(22.7%)

11(14.7%)

Table 1 : Occupational details of the study subjects, N=75

GenderFemale

18.2

Antibody titre≥100(%)

Anti body titre<100(%)

Male 18.8

Co-morbidities

Smoking

Factor Category

0.96

p* value

Absent

Present

Never Smoker

Ever Smoker

Table 2: Bivariable analysis showing the factors associated with Adequate Antibody titre (cut off 100IU/L)

81.8 81.2

63.6 57.80.71

36.4 42.2

90.9 92.2

9.1 7.80.88

Body mass Index

Mean Age

Mean BMI 25.4 24.8

45 44.5

0.65

Age 0.66

Effectiveness of Hepatitis-B Vaccination Programme Among Grade II Health Personnel of Government Medical College, Thiruvananthapuram

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study subjects suffered from loss of working days due to adverse events. The median antibody titre of the study subjects was 1000 (IQR =781). The Geometric mean Antibody titre was 365.76. The distribution of antibody titre among the study population is shown in Figure No.2. Only 4% of the study participants had titre below 10IU/ and those peo-ple were recommended to take further vaccination and 53.3% were high responders. 11(14.66%) of the study subjects had inadequate Anti Hepatitis B antibody titre <100IU/L and 64(85.34%) of the study subjects had adequate Anti Hepatitis B anti-body titres ≥100 IU/L after three doses of vaccination. Bivariable analysis was done to find out the factors as-

sociated with adequate antibody titre which was taken as ≥ 100 IU/L for health workers as they are at high risk of developing occupational hazard of Hepatitis B. The factors analyzed were gender, Co morbidities, smok-ing status by Chi square test and Mean age and Mean BMI (Body mass Index) through Student t test. But none of the above factors were significantly associated .(p<0.05).The results are shown in table no.2 Bi variable analysis was done with anti-Hepatitis B antibody titre of 1000 IU/L as cut off. Those with antibody titre ≥ 1000 were considered as high responders and < 1000 as low responders. Employment status and presence of Hyper-tension were found significant (p< 0.05) in Chi square test and are shown in Table no 3.

Employ-ment

Permanent

71.4

Antibody titre ≥ 1000(%)

Anti body titre<1000(%)

Temporary 45 3.05(1.16-7.99)

3.32 (1.11-11.49)

Hypertension Status

Factor Category Odds Ratio (95% CI)

0.021

0.04

p value

Absent

Present

Cut off (≥1000 IU/L )

Table No 3: Factors significantly associated with high Anti Hepatitis B antibody titre

28.6 55

88.6 70

11.4 30

0510152025303540 35

24

16

Normotesiv

e

Prehypertesiv

e

Hypertensiv

e

Figure No 1: Showing the distribution of Blood Pressure types among study subjects.

01020304050607080

410.7

32

53.3

<10

10-99.99

100-999.99

>_1000

Figure No 2 : Showing the distribution of Antibody titre among the study subjects.

Frequency of blood relation type

Antibody titre

DISCUSSION Hepatitis B is the most important infectious occupa-tional disease for the health care workers. The high risk of being infected is the consequence of prevalence of virus carriers among health care workers, the high fre-quency of exposure to blood, body fluids and the high contagiousness of hepatitis B virus 9. Risk of transmission of Hepatitis B to health care work-

ers have been studied by many investigators. But studies focusing on grade 2 health care workers which include mainly the marginalized section and who are at greater risk owing to their activities at hospital waste collection and segregation are minimal. In our study the serologic immune status was assessed at the end of 9 months after the primary vaccination. 100 IU/L anti–HBs level was considered as base value for

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adequate antibody titre 10. Although in many other populations based studies 10 IU/L was considered as minimum value for adequate anti -HBs level. Our study involved higher base value (100 IU/L) because high risk group (grade 2 health work-ers) being evaluated. Moreover few studies also reveal that success of vaccination programme is established only if the antibody titre is above 100 and revaccination is recommended when the titre falls below 1011. The present study showed an antibody titre of > 100 IU/L among 85.34% of study participants and 96% had adequate antibody titres of >10 IU/L.A study conduct-ed in Germany on the course of antibody titre follow-ing vaccination also revealed 97% seroconversion after three doses12. The mean antibody titre in this study was 1095 com-parable to our study (1000 miu/ml). A systematic review of literature done in America also showed that 87% of individuals show seroprotection 13 and a study done inamong health care workers showed seroconversion in 90% of individuals14. A study conducted in AIIMS, a tertiary care hospital in India showed that only 79% of the health care workers had protective antibody level >10 IU/L which was fairly less compared to other studies. This may be because the titres were not assessed sufficient time after the third dose15. Another study done among the health care workers in tertiary hospitals of northern India also showed a pro-tective antibody titre in 67% of the subjects only and which waned off in time16. Study done in Karnataka (South India) showed sero-prevalence of 72% which is also less because it was esti-mated 10 years after the vaccination 17. Several studies have proved the waning of Antibody titre with time 18 and we and we couldn’t establish thesame because our study subjects were assessed follow-ing a vaccination drive conducted in same time. Although the studies done in Kerala is less a recent study on Health Care workers of a tertiary hospital in Central Kerala revealed a protective titre of 81%(>100IU/L) and 93.2%(>10 IU/L) which is in accordance with the present study19. Complementary studies, using an in vitro enzyme linked immunosorbent assay (spot-ELISA), showed that the number of memory B lymphocytes able to produce anti-HBs does not diminish as the level of antibody de-clines 20. Current studies suggest good retention of immuno-logic memory in healthy vaccinees over periods of 5-12 years. Post vaccination antibody testing and regular testing for antibodies is recommended only to high-risk subjects, especially to health care workers and subjects with immunodeficiency 21. . In this study out of 14 males, 12 males (85.7%) had

anti- HBs level more than 100 IU/L. Out of the 61 females 59(96.7%) had more 100 IU/L anti –HBs level. However, this male to female ratio was statistically non significant (p value = 0.96). Also we couldn’t find any association between age, obesity, smoking status, presence of co morbidities and antibody titre in the present study. These findings could be attributed to small sample size and cross sectional nature of study design. A study con-ducted in Sri Lanka among health care workers to assess the immune response to hepatitis b vaccination showed that the anti HBs response was significantly higher in females when compared to males(p=.027). The present study, but did not show any significant association be-tween age and immune response22. Another study done in Pakistan showed that male (18%) non responders were frequent than female non respond-ers(8%) 5.They also mentioned that when the age at vaccination is >40 years the rate of seroconversion to anti HBs is less than that of a subset of individuals with age <40. A study conducted by Rachel C Wood on Minnesota health care workers revealed that smoking status and Body mass Index are significantly associated with decreased anti HBsAg antibodies 23. Many of the studies done so far such as Weber et al, Simo Minnanna et al has substantiated that obese peo-ple with high BMI tend to have lesser immunological response to hepatitis b vaccination. A randomised con-trolled trial has mentioned a protection rate of 71% in obese individual versus 91% among lean individuals 24. Many studies have revealed that post immunization titre is important for the formation of an anamnestic re-sponse years after vaccination. Hence we did analysis based on high responders and low responders with a titre of 1000 as cut off 25. Based on the analysis we found employment status (p =0.021) and hypertension status(p=0.05) significantly associated with high titres. Hypertensives have low an-tibody response as compared to those without hyper-tension. Although poor immune response is established among diabetics and chronic kidney disease patients, hypertension may also contribute as these are diseases with common risk factors like obesity, smoking etc 26,27. Health workers who were temporarily recruited through Kudambasree exhibited low antibody ti-tre(<1000 IU/L),the reason for which is unclear but may be due to the characteristic related to the job and stress related to unemployment. According to a study 5-10% of the population will not respond to Hepatitis B vaccination28. Post vaccination testing is essential to find out these non responders as they are susceptible to Hepatitis B infection. Hence the study participants were informed about their immune status, those who were non immune(<10 IU/L) were rec-ommended for complete vaccination series and for fur-ther post vaccination serologic testing 29.


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REFERENCES1. WHO | Hepatitis B [Internet]. WHO. [cited 2017 Apr 27]. Available

from: http://www.who.int/mediacentre/factsheets/fs204/en

2. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2012 Dec 15;380(9859):2095–128.

3. Gupta S, Gupta R, Joshi YK, Singh S. Role of horizontal transmis-sion in hepatitis B virus spread among household contacts in north India. Intervirology. 2008;51(1):7–13.

There were few limitations for our study. Most of the studies involving HBV antibody titre were prospective nature with estimation of antibody titre being carried out at different intervals. Our study however was cross sectional in nature and antibody analysis was done only at one point of time. Even though the study was carried out on a small set of sample, the sample was scientifical-ly sufficient to generate information regarding adequa-cy of antibody titre which can also be generalized.

CONCLUSION The results of the study showed that the vaccina-tion programme was effective in providing protection to 85% which was consistent with the findings from similar studies across the globe. This study was also use-ful in identifying the individuals who were sero negative. They could be advised further vaccination strategies to look for non response and use of other protective meas-ures if required. These workers on account of their poor economic potential would not otherwise take vaccine or check their protection levels. We advocate this type of vaccination programmes to be taken up by the health authorities to protect these vulnerable grade II work-ers. HBV vaccination coverage is still inadequate in our country among high risk groups especially health care workers. The reason could be due to absence of vacci-nation policies by the hospital management and lack of awareness among health care workers. Three doses of Hepatitis B vaccination should be made mandatory for health care workers at the time of job entry and follow up antibody titre should be done at regular intervals as the cost of Hepatitis B Immunoglobulin given as post exposure prophylaxis is enormously high than the rou-tine vaccination.

Acknowledgement The authors would like to thank the Grade II health per-sonnel for their valuable time, cooperation and whole hearted participation which they rendered for the study. We would also be grateful to Dr Sara Varghese, HOD Community Medicine, Dr. Mohandas, Superintendent and Dr. Sreedevi Amma Director, ACR Lab, Medical Col-lege, Thiruvananthapuram, for their consistent support throughout the conduct of the study. We would also ex-press our gratitude to Dr Indu P S ,Convener, State Board of Medical Research for granting permission and finan-cial support for the study.

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11. Van Hattum J. [Hepatitis B vaccine: simple and effective]. Ned Ti-jdschr Tandheelkd. 1995 May;102(5):182–4.

12. Kätzner K, Kalitzky M, Steinhagen-Thiessen E, Gatermann S, Laufs R. Course of antibody titer following preventive hepatitis B vac-cination and a recommendation for renewal following the use of H-B-Vax vaccines. Z Gastroenterol. 1985 Jan;23(1):18–24.

13. Schillie SF, Spradling PR, Murphy TV. Immune response of hepa-titis B vaccine among persons with diabetes: a systematic review of the literature. Diabetes Care. 2012 Dec;35(12):2690–7.

14. Palmović D, Crnjaković-Palmović J. Vaccination against hepatitis B: Results of the analysis of 2000 population members in Croatia. Eur J Epidemiol. 1994 Oct 1;10(5):541–7.

15. Singhal V, Bora D, Singh S. Prevalence of Hepatitis B Virus Infec-tion in Healthcare Workers of a Tertiary Care Centre in India and Their Vaccination Status. J Vaccines Vaccin [Internet]. 2011 Apr 25 [cited 2017 Apr 27];2(2). Available from: https://www.omicson-line.org/prevalence-of-hepatitis-b-virus-infection-in-healthcare-workers-of-a-tertiary-care-centre-in-india-and-their-vaccina-tion-status-2157-7560.1000118.php?aid=569

16. Sukriti null, Pati NT, Sethi A, Agrawal K, Agrawal K, Kumar GT, et al. Low levels of awareness, vaccine coverage, and the need for boosters among health care workers in tertiary care hospitals in India. J Gastroenterol Hepatol. 2008 Nov;23(11):1710–5.

17. Doddaiah V, Janakiram K, Ramamurthy S, Sharathchandru M, Krishnamurthy YM, Seenivasen S. Serologic Hepatitis B Immu-nity in Vaccinated Health Care Workers. Am J Life Sci. 2015 May 12;3(3):162.

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25. Leonardi S, Praticò AD, Lionetti E, Spina M, Vitaliti G, Rosa ML. Intramuscular vs intradermal route for hepatitis B booster vac-cine in celiac children. World J Gastroenterol WJG. 2012 Oct 28;18(40):5729–33.

26. Eleftheriadis T, Pissas G, Antoniadi G, Liakopoulos V, Stefanidis I. Factors affecting effectiveness of vaccination against hepatitis B virus in hemodialysis patients. World J Gastroenterol WJG. 2014 Sep 14;20(34):12018–25.

27. Sit D, Esen B, Atay AE, Kayabaşı H. Is hemodialysis a reason for unresponsiveness to hepatitis B vaccine? Hepatitis B virus and dialysis therapy. World J Hepatol. 2015 Apr 18;7(5):761–8.

28. Puro V, De Carli G, Cicalini S, Soldani F, Balslev U, Begovac J, et al. European recommendations for the management of healthcare workers occupationally exposed to hepatitis B virus and hepati-tis C virus. Euro Surveill Bull Eur Sur Mal Transm Eur Commun Dis Bull. 2005 Oct;10(10):260–4.

29. [cited 2017 May 4]. Available from: http://www.who.int/occupa-tional_health/activities/3hepatiti.pdf

20. West DJ, Calandra GB. Vaccine induced immunologic memory for hepatitis B surface antigen: implications for policy on booster vaccination. Vaccine. 1996 Aug;14(11):1019–27.

21. Pallás Alvarez JR, Gómez Holgado MS, Llorca Díaz J, Delgado Ro-dríguez M. [Hepatitis B vaccination. Indications of the post-vac-cine serologic test and booster doses]. Rev Esp Salud Pública. 2000 Dec;74(5-6):475–82.

22. Chathuranga LS, Noordeen F, Abeykoon AMSB. Immune re-sponse to hepatitis B vaccine in a group of health care workers in Sri Lanka. Int J Infect Dis. 2013 Nov;17(11):e1078–e9.

23. Wood RC, MacDonald KL, White KE, Hedberg CW, Hanson M, Os-terholm MT. Risk factors for lack of detectable antibody following hepatitis B vaccination of Minnesota health care workers. JAMA. 1993 Dec 22;270(24):2935–9.

24. Comparison of a Triple Antigen and a Single Antigen Recombi-nant Vaccine for Adult Hepatitis B Vaccination [Internet]. PubMed Journals. [cited 2017 Apr 27]. Available from: https://ncbi.nlm.nih.gov/labs/articles/11424117.


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Comparative Study on The Effect of Interferential Current Therapy and Ultrasound Therapy in Post-Stoke Hemiplegic

Shoulder PainReshma J*, Ravi Sankaran*, George Joseph*, K Surendran*

ABSTRACTBackground: Shoulder pain is one of the most frequent complications in post-stroke hemiplegic patients, with an incidence of 9% to 73%. The etiology of hemiplegic shoulder pain is multifactorial eg. adhesive capsulitis, glenohumeral subluxation, rotator cuff injury, complex regional pain syndrome, subacromial bursitis, spasticity etc. Shoulder pain is of great concern as it interferes with rehabilitation, requires added medication, causes disturbed sleep and decreases the overall quality of life.

Aim: To prospectively evaluate the comparative efficacy of Interferential Current Therapy (IFT) and Ultrasound Therapy (UST) in patients with post stroke hemiplegic shoulder pain using Visual analogue scale (VAS), to compare the improvement in passive range of motion (PROM), the improvement in functional level of patients and adverse effects.

Methods: 32 patients satisfying inclusion criteria were allotted into two groups. Pre treatment pain, passive range of external rotation of shoulder and functional status of the patients in both groups were assessed using VAS, goniometer and Barthel Index respectively. Group A received 10 sessions of UST and Group B received 10 sessions of IFT. Patients in both groups received PROM for the shoulder after each treatment session. Post treatment pain and range of motion were reassessed. In the 1 month follow up pain, range of motion & functional status were reassessed

Results: In this study, there was statistically significant improvement in shoulder pain in Group B compared to Group B in the post treatment assessment, but no significant difference between the two groups were noticed in the 1 month follow up. There was sig-nificant improvement in the passive range of external rotation in Group B compared to Group B in both post treatment & 1 month follow up. There was no significant difference in functional status between the two groups in the 1 month follow up.

Conclusion: In this study, it was found that IFT is an effective short term treatment for post stroke hemiplegic shoulder pain com-pared to UST, with relatively no side effects.

Corresponding Author: K Surendran

INTRODUCTION

*Dept. of Physical Medicine and Rehabilitation, AIMS, Amrita Vishwa Vidyapeetham, Kochi, India.

Shoulder pain is one of the most frequent complications in post-stroke hemiplegic patients, with an incidence of 9% to 73%1. The etiology of hemiplegic shoulder pain is multifactorial eg. adhesive capsulitis, glenohumeral sub-luxation, rotator cuff injury, CRPS, subacromial bursitis, spasticity etc. Shoulder pain is of great concern as it in-terferes with rehabilitation, requires added medication, causes disturbed sleep and decreases the overall qual-ity of life2. Post stroke shoulder pain may be managed by pharmacotherapy, local heat and self mobilization, shoulder supports or institutional physiotherapy etc.

Interferential current therapy is used for relieving pain caused by deep tissue injury. Interferential current ther-apy is application of two medium frequency currents in opposing directions to get a low frequency current (beat frequency) in the tissue plane for therapeutic purposes. Interferential current therapy has been reported to re-lieve pain related to shoulder in experimental studies, but there is lack of evidence on effect of interferential current therapy in people with hemiplegic shoulder pain3.

Therapeutic ultrasound involves the use of high-fre-quency acoustic energy to produce beneficial effects in tissue. Ultrasonic signals are typically generated using


the reverse piezoelectric effect. The physiologic effects of ultrasound can be divided into thermal and non-ther-mal effects. Thermal effects are produced when acous-tic energy is absorbed, producing molecular vibration, which results in heat production. Nonthermal effects include cavitation, media motion and standing waves4.

Both interferential current therapy and ultrasound therapy are commonly employed physical modalities, but there have been no studies comparing the efficacy of these two modalities in post stroke hemiplegic shoul-der pain. This has prompted us to conduct a pilot study, to prospectively evaluate the comparative efficacy of interferential current therapy and ultrasound therapy in patients presenting with post stroke hemiplegic shoul-der pain to the Dept.of PMR, Amrita Institute of Medical Sciences, Kochi. This study also compares the functional improvement using Barthel Index, improvement in pas-sive range of motion assessed using goniometer and adverse effects.

METHODS

ORIGINAL ARTICLE

Selection and description of participants: This study was conducted among patients attending the outpatient clinic of Physical Medicine and Rehabil-itation Department, Amrita Institute of Medical Scienc-es and Research Centre, Kochi, who were diagnosed to have post-stroke hemiplegic shoulder pain based on history and clinical examination. The study was con-

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38

METHODS In this study the average age in UST group 59.53 ± 11.42 and that of IFT group is 60.53 ± 8.32. The p-val-ue is 0.778 (Table 1). There is no statistically significant difference in the distribution of age between the two groups. The percentage of males in UST group is 73.3 and that in IFT group is 70.6. The percentage of females in UST group is 26.7, and that in IFT group is 29.4 with a p-value of 1.00 (Table 1). Therefore the association of gender in both groups are comparable. The mean time from stroke (in months) in UST group is 3.58 ± 4.64 and that in IFT group is 1.88 ± 1.58 with a p-value of 0.165. There is no statistically significant difference in the mean time from stroke between the two groups. In this study, 13 patients (86.67%) in UST group and 13 patients (76.47%) in IFT group have ischemic stroke, while 2 pa-tients (13.33%) in UST group and 4 patients (23.53%) in IFT group have haemorrhagic stroke with a p-value of 0.4 Nine patients (60%) in UST group and 14 patients (82.35%) in IFT group have right sided hemiplegia, while 6 patients (40%) in UST group and 3 patients (17.65%) in IFT group have left sided hemiplegia. Both groups are comparable at baseline for distribution of sidedness with a p-value of 0.160.

Eight patients (53.33%) in UST group and 6 patients (35.29%) in IFT group are diabetic. Both groups are comparable at baseline with a p-value of 0.304. Twelve patients (80%) in UST group and 14 patients (82.35%) in IFT group are hypertensive. Both groups are compa-rable at baseline with a p-value of 0.864. Four patients

ducted as per the approval and guidelines of the ethical committee of AIMS – School of Medicine and with the informed, written consent of the participants over a pe-riod of 2 years from September 2015 to Sept 2017. Since no study could be located using same scoring pattern for the pain scale, this is a pilot study, which has generat-ed the appropriate hypothesis. A total of 32 cases were randomly distributed into two groups. This study was conducted as a prospective comparative study to com-pare the efficacy of interferential current therapy and ul-trasound therapy in patients with post-stroke hemiple-gic shoulder pain. Thirty two patients diagnosed with post-stroke hemiplegic shoulder pain satisfying inclu-sion and exclusion criteria were selected.

Inclusion criteria: i. Hemiplegic shoulder pain ii. Age 40 to 70yrs iii. Pain in hemiplegic shoulder >4 (on scale of 0 to 10) using Visual Analogue Scale (VAS) iv. Reduc-tion of passive external rotation of at least 20 degrees compared to normal sideExclusion criteria: i. Pacemaker ii. Skin wounds iii. In-fection of affected shoulder iv. Malignant tumours

Technical information: The study was conducted at Amrita Institute of Medical Sciences, Kochi, Kerala with the following objectives: Primary objective: To prospectively evaluate the com-parative efficacy of Interferential Current Therapy (IFT) and Ultrasound Therapy (UST) in patients with post stroke hemiplegic shoulder pain using Visual analogue scale (VAS).

Secondary objectives: To compare 1. The improvement in Range of motion (ROM) measured with goniome ter2. The improvement in functional level of patients us-ing Barthel index3. Adverse effects. The demographic data was obtained for each patient at the first visit to the outpatient clinic of our depart-ment. Also an elaborate history of the presenting com-plaints, past medical and surgical history, and associ-ated comorbidities were taken. This was followed by a detailed clinical evaluation. The intensity of shoulder pain was measured using VAS, where the score ranges from 0 (no pain) to 10 (worst pain). The functional lev-el of the patient was assessed using Barthel Index. The passive external rotation of the shoulder was measured using a goniometer. Patients with VAS score more than 4 and reduction in passive external rotation of atleast 20 degrees compared to normal side were included in this study. Of the 32 patients, 15 were treated with ultrasound therapy (Group A) and 17 patients were treated with in-terferential current therapy (Group B). Patients in Group A were treated with 10 sessions of ultrasound therapy of 1.5W/cm 2 for 7 minutes, followed by range of mo-tion (ROM) exercises for the affected shoulder. Post 10 sessions pain and passive external rotation of affected shoulder were reassessed using VAS and goniometer

respectively. Patients in Group B were treated with 10 sessions of interferential current therapy using medium frequency currents of 4000Hz & 4100Hz to produce am-plitude modulated frequency at 100Hz in vector mode, for 20 minutes, followed by ROM exercises for the affect-ed shoulder. After 10 sessions pain and passive external rotation of affected shoulder were reassessed using VAS and goniometer respectively. Patients were advised to continue ROM exercises as home program and to review after 1 month. Both Group A and Group B were reas-sessed after 1 month for pain, ROM and functional status using VAS, goniometer and Barthel Index respectively.

Statistics: Data of all subjects were entered into a com-puter database and analysis was performed using Sta-tistical Package for Social Sciences version 20 (SPSS Inc., Chicago, IL, USA) with advanced statistical programme.• To test the statistical significance of the difference in

mean changes of the VAS score from basal to follow up period between the two groups, student’s t test was applied. The same test was applied to test the difference in mean changes in functional levels be-tween the two groups.

• To compare change in ROM & adverse effects be-tween the two groups Fisher’s exact test was ap-plied.

Comparative Study on The Effect of Interferential Current Therapy and Ultrasound Therapy in Post-Stoke Hemiplegic Shoulder Pain

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39

Age (years)

Male

60.03

Type of stroke

0.778

26

Coronary artery disease

Category

6

Variable

Side of hemiparesis

Type II diabetes mellitus

Systemic hypertension

Dyslipidemia

Others (seizure, hypothy-roidism, chronic kidney disease, atrial fibrillation

Table 1: Comparison of baseline variables between groups

15 (68.2%)

Haemorrhage

Present

Present

Totaln = 32

Mean (SD) / n (%)

59.53 (11.42) 60.53 (8.32)

12 (80%)

4 (26.67%)

Mean (SD) / n (%)

p value

23 11 (73.3%) 12 (70.6%) 1.00

Ischemic 26 13 (86.67%) 13 (76.47%)0.460

6 2 (13.33%) 4 (23.53%)

Right 23 9 (60%) 14 (82.35%)0.160

Left 9 6 (40%) 3 (17.65%)

Present 14 8 (53.33%) 6 (35.29%) 0.304

14 (82.35%) 0.864

2 (11.76%) 0.281

Present 8 4 (26.67%) 4 (23.53%) 0.837

Present 6 2 (13.33%) 4 (23.53%) 0.460

UST n = 15

IFTn = 17

Group

Brunnstrom staging

Modified Ashworth Scale

Stage 1-2 13 6 (40%) 7 (41.2%)

0.758

Stage 3 9 4 (26.7%) 5 (29.4%)

Stage 4 9 4 (26.7%) 5 (29.4%)

Stage 5 1 1 (6.6%) 0 (0.0%)

Grade 0 5 3 (20%) 2 (11.8%)

0.876Grade 1 8 3 (20%) 5 (29.4%)

Grade 1+ 10 5 (33.3%) 5 (29.4%)

Grade 2 9 4 (26.7%) 5 (29.4%)

IFTn = 17

UST n = 15

10.53

SD MeanMean

13.99

SD0.788

P valueVariable

Barthel Index 19.33 18.82

Table 2: Comparison of difference in functional status as measured using Barthel Index pre and post 1 month between groups

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40


(26.67%) in UST group and 2 patients (11.76%) in IFT group are dyslipidemic. Both groups are comparable at baseline with a p-value of 0.281. Four patients(26.67%) in UST group and 4 patients (23.53%) in IFT group have coronary artery disease. Both groups are comparable at baseline with a p-value of 0.837. Two patients (13.33%) in UST group and 4 patients (23.53%) in IFT group have other comorbidities like seizure, hypothyroidism, chron-ic kidney disease, atrial fibrillation. Both groups are com-parable at baseline with a p-value of 0.460 (Table 1). The mean VAS score at baseline for UST group is 6.87 ± 0.64 and that for IFT group is 7.06 ± 0.827. The p-val-ue obtained is 0.473. Therefore the baseline VAS score of patients in both groups are comparable. The mean Barthel Index score at baseline for UST group is 24 ± 25.15 and that for IFT group is 22.94 ± 23.58. The p-val-ue obtained is 0.903. Therefore the functional status of patients in both groups are comparable at baseline. The mean PROM at baseline for UST group is 44 ± 11.05, and that for IFT group is 46.76 ± 9.34. The p-value obtained is 0.449. Therefore the passive range of external rotation of patients in both groups are comparable at baseline. The mean VAS score difference in pre and 10 days fol-low up for UST and IFT groups are 1.86 ± 0.74 and 3.41 ± 0.61respectively, with a p-value of <0.001 (Figure 1). There is highly significant statistical improvement in VAS score for IFT group in the post session assessment com-pared to UST group. The mean VAS score difference in pre and 1 month follow up for UST and IFT groups are 3.60 ± 1.72 and 4.11 ± 1.21 respectively, with a p-value of 0.371. There is no statistically significant difference between the two groups in the VAS score in post 1 month follow up assessment. The mean Barthel Index score for UST group is 19.33 ± 13.99, and that of IFT group is 18.82 ±10.53. The p-value obtained is 0.788 (Table 2). Therefore the improvement in the functional status achieved in both groups are al-most the same, and there is no statistically significant difference between the groups. The mean passive range of external rotation difference in pre and 10 days follow up for UST and IFT groups are 8.0 ± 4.14 and 17.05 ± 6.13 respectively, with a p-value of <0.001 (Figure 2). There is statistically highly signifi-cant improvement in passive range of external rotation for IFT group in the post session assessment compared to UST group. The mean passive range of external rota-tion difference in pre & 1 month follow up for UST and IFT groups are 12.33 ± 7.28 and 18.23 ± 8.82 respective-ly, with a p-value of 0.042 (Figure 3). There is statistically significant improvement of passive range of external rotation for IFT group in post 1 month follow up assess-ment, compared to UST group.

DISCUSSION To the best of our knowledge this is the first study com-paring the efficacy of ultrasound therapy and interfer-

0

0.51

1.5

22.5

33.5

UST IFT

4

Fig 1: Comparison of mean difference of pre and post session VAS scores between the two groups

1.86

3.41

02468

101214

UST IFT

16

Fig 2: Comparison of mean difference of pre and post session passive range of external rotation between the two groups

8

17.0518

Fig 3: Comparison of mean difference of pre and post 1 month follow up passive range of external rotation between the two groups

02468

101214

UST IFT

16

12.33

18.291820

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41

ential current therapy in post-stroke hemiplegic shoul-der pain. Ultrasound therapy and interferential current therapy are frequently used modalities for shoulder pain but there is paucity of studies to prove its efficacy in post-stroke hemiplegic shoulder pain. In this study the baseline age, sex distribution, Mod-ified Ashworth scale, Brunnstrom staging, VAS score, Barthel Index and passive range of external rotation were comparable between the two groups. The patient demographics and baseline outcome measures are shown in table11. Out of the 32 patients included in the study, 23 (71%) were males, which is similar to the study by Rah UW et al5. But in the studies by Chae J et al6., Wis-sel J et al7. Leandri M et al8. and Suriya-amarit D et al3. have female preponderance in their studies. In this study the mean age is 60 ± 9.74, which was simi-lar to the studies by Chae J et al6. Wissel J et al7. and Rah UW et al5. Out of 32 patients 26 (81%) have ischaemic stroke and 6 (19%) have hemorrhagic stroke. Among the 32 patients in this study, 23 (71%) had right sided hemiplegia. Lindgren I et al. found that left sided hemiparesis, frequently reported pain and reduced pas-sive abduction of affected shoulder are risk factors for long lasting post-stroke shoulder pain9. Thirty one patients had various comorbidities. The most frequently reported comorbidities were hyperten-sion and type 2 diabetes mellitus, which were present in 26 and 14 patients respectively. Predictors of post-stroke shoulder pain are decreased motor function9, diabetes, age10, diminished proprioception and tactile extinction11. The mean time of onset of shoulder pain after stroke in Group A (ultrasound therapy) is 3.58 ± 4.64 months and that of Group B (interferential current therapy) is 1.88 ± 1.58 months. Broeks J G et al12 found that occurrence of shoulder pain after stroke and the prevalence over time varies considerably in literature. This could be due to dif-ferences in inclusion criteria and length of follow up. Both groups showed improvement in pain, but Group B was found to have better improvement in pain than Group A as evidenced by the significant reduction in mean VAS score (p value <0.001). This improvement is short term, as there was no significant difference in VAS score (p value 0.371) between the groups at 1 month follow up. Two patients in Group A had increase in VAS score in 1 month follow up compared to 10 days follow up. The exact mechanism of interferential current thera-py in reducing pain is not known. This short term advan-tage of interferential current therapy over ultrasound therapy could be attributed to the Wedensky inhibition. Both groups showed improvement in passive range of movement, with statistically significant improvement in Group B compared to Group A in both 10 days and 1 month follow up. This could be attributed to better pain relief in Group B, resulting in better patient compliance

CONCLUSION This study suggest that interferential current therapy is an effective short term treatment for post-stroke hemi-plegic shoulder pain compared to ultrasound therapy as evidenced by the significant reduction in the mean VAS score in the 10 days follow up. But in the 1 month follow up there was no significant difference in the VAS score between the two groups. The increase in the passive range of motion of shoul-der is better for the interferential current therapy group than for the ultrasound therapy group as evidenced by the significant increase in range of motion using goni-ometer in both 10 days and 1 month follow up. Both groups show improvement in functional status, but there is no statistically significant difference in be-tween the two groups. Both modalities are relatively safe as there were no side effects noted during the study.

in the rehabilitation programme. Both groups showed functional improvement, but there was no statistically significant difference in Barthel Index score between the two groups at 1 month follow up. In a study on the effect of interferential current ther-apy in hemiplegic shoulder pain by Suriya-amarit D et al.3 they found that there was statistically significant improvement in pain as measured using 11-point Nu-merical Rating Scale (NRS) and range of motion in the treatment group compared to control group.In another study by Rahman et al.4 to compare the ef-ficacy of pregabalin and therapeutic ultrasound versus therapeutic ultrasound alone on patients with post-stroke shoulder pain, they found that there was statis-tically significant improvement in pain as measured us-ing VAS score in patients receiving both pregabalin and therapeutic ultrasound compared to therapeutic ultra-sound alone. These are the only two studies were either therapeu-tic ultrasound or interferential current therapy has been used for the treatment of post-stroke hemiplegic shoul-der pain, There were no studies found comparing the ef-ficacy of these two modalities in post-stroke hemiplegic shoulder pain. Both modalities are relatively safe, with no adverse effects noted during the study. The results of this study should be validated in further studies before being used to inform patients.

Limitations of the Study There was no control group in this study. Patients with diverse etiologies for post-stroke shoulder pain were included in the study. As the sample size was small, our ability to generalize the results of this study to the broader stroke population and clinical practice is limit-ed.

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REFERENCES1. Ricardo Viana MD, Richard Wilson MD, John Chae MD, Miller T,

Teasell R. Painful Hemiplegic Shoulder.

2. Chauhan S, Kothari SY, Laisram N. Comparison of Ultrasonic Therapy, Sodium Hyaluronate injection and Steroid injection in the treatment of Periarthritis Shoulder. IJPMR Sep. 2012; Vol 23 (3):105-10.

3. Suriya-Amarit D, Gaogasigam C, Siriphorn A, Boonyong S. Effect of interferential current stimulation in management of hemiple-gic shoulder pain. Archives of physical medicine and rehabilita-tion. 2014 Aug 31;95(8):1441-6.

4. Rahman MS, Uddin MT. Comparative efficacy of pregabalin and therapeutic ultrasound versus therapeutic ultrasound alone on patients with post stroke shoulder pain. Mymensingh Medical journal: MMJ. 2014 Jul;23(3):456-60.

5. Rah UW, Yoon SH, Moon DJ, Kwack KS, Hong JY, Lim YC, Joen B. Subacromial corticosteroid injection on poststroke hemiplegic shoulder pain: a randomized, triple-blind, placebo-controlled trial. Archives of physical medicine and rehabilitation. 2012 Jun 30;93(6):949-56.

6. Chae J, Jedlicka L. Subacromial corticosteroid injection for poststroke shoulder pain: an exploratory prospective case se-ries. Archives of physical medicine and rehabilitation. 2009 Mar 31;90(3):501-6

7. Wissel J, Ganapathy V, Ward AB, Borg J, Ertzgaard P, Herrmann C, Haggstrom A, Sakel M, Ma J, Dimitrova R, Fulford-Smith A. On-abotulinumtoxinA improves pain in patients with post-stroke spasticity: Findings from a randomized, double-blind, place-bo-controlled trial. Journal of pain and symptom management. 2016 Jul 31;52(1):17-26.

8. Leandri M, Parodi CI, Corrieri N, Rigardo S. Comparison of TENS treatments in hemiplegic shoulder pain. Scand J Rehabil Med. 1990 Jan 1;22(2):69-71.

9. Lindgren I, Lexell J, Jönsson AC, Brogårdh C. Left-sided hemipare-sis, pain frequency, and decreased passive shoulder range of ab-duction are predictors of long-lasting poststroke shoulder pain. PM&R. 2012 Aug 31;4(8):561-8.

10. Ratnasabapathy Y, Broad J, Baskett J, Pledger M, Marshall J, Boni-ta R. Shoulder pain in people with a stroke: a population-based study. Clinical rehabilitation. 2003 May;17(3):304-11.

11. Roosink M, Van Dongen RT, Buitenweg JR, Renzenbrink GJ, Geurts AC, IJzerman MJ. Multimodal and widespread somato-sensory abnormalities in persistent shoulder pain in the first 6 months after stroke: an exploratory study. Archives of physical medicine and rehabilitation. 2012 Nov 30;93(11):1968-74.

12. G. Broeks J, Lankhorst GJ, Rumping K, Prevo AJ. The long-term outcome of arm function after stroke: results of a follow-up study. Disability and rehabilitation. 1999 Jan 1;21(8):357-64.


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Nephron Sparing Surgery for Large Extra Renal Angiomyolipoma in First Trimester of Pregnancy

Praveen Sundar*, Appu Thomas*, Priyank Bijalwan*

Corresponding Author: Priyank Bijalwan

INTRODUCTION

*Dept. of Urology, AIMS, Amrita Vishwa Vidyapeetham, Kochi, India.

CASE REPORT

CASE REPORT 27 year old primi gravida with 12 weeks of gestation, married 9 months back, presented with left sided loin pain. On examination, she was pale and had mild loin tenderness. Her haemoglobin was 11 gm%. Renal func-tion was normal. Ultrasonogram (USG) showed a retrop-eritoneal mass around the left kidney if size 16x13 cms, with the kidney being pushed medially. Magnetic Reso-nance Imaging (MRI) was done, which showed a tumour with fat content, with cystic areas within and evidence of intralesional haemorrhage suggestive of AML The pa-tient had normal neurologic and skin examination, thus excluding Tuberous Sclerosis. In consultation with the Obstetrician, excision of the AML (attempting NSS) was planned after termination of pregnancy as the chance of Intra Uterine Death was high during prolonged expo-sure to general anaesthesia. Computed Tomogtam (CT) angiogram was done after therapeutic abortion which showed a feeding vessel to the tumour that was distinct from the renal artery. The intratumoural vessels showed multiple aneurysmal dilatations with evidence of bleed-ing. In view of these CT findings, exsanguinating bleed was anticipated during the procedure. AML excision was done three weeks after therapeutic abortion. Intra-oper-atively, there was a well encapsulated 16x13 cm tumour encasing the kidney with a single large feeding vessel distinct from the renal artery. The tumour was extra-re-nal and had minimal adhesions to the kidney. Tumour excision was done preserving the kidney. Post operative period was uneventful and patient was discharged on

Neoplasms are rare in pregnancy; they present a chal-lenge because of the special considerations and impli-cations in treatment. We report a large Angiomyolipoma (AML) in a 27 year old lady, presenting in the first trimes-ter of pregnancy and managed by nephron sparing sur-gery (NSS).


DISCUSSION According to Martin et al, second most common renal tumours detected in pregnancy2. The mean gestational age of patients at the time of diagnosis is 27.7 weeks. Most of the cases reported are less than 10 cms and are incidentally detected in the thrid trimester, of which, to were larger than 9 cms (Table 1). Both required Ne-phrectomy, either due to bleeding or fetal death3.

Figure 1(Left): MRI image of the AML and the Gravid Uterus. (Right): CT image showing a vascular extra-renal AML.

Figure 1(Left): Extra-Renal location of the AML, just abutting the Kidney. (Right): Excised tumour specimen.

post operative day4. Histopathology was suggestive of epitheloid Angiomyolipoma. HMB 45 ImmunoHisto-Chemistry (IHC) confirmed the diagnosis.

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REFERENCES1. Martin FM, Rowland RG. Urologic malignancies in pregnancy.

Urol Clin North Am. 2007 Feb;34(1):53–9.

2. Storm DW, Mowad JJ. Conservative management of a bleed-

ing renal angiomyolipoma in pregnancy. Obstet Gynecol. 2006 Feb;107(2 Pt 2):490–2.

3. Çetin C, Büyükkurt S, Demir C, Evrüke C. Renal angiomyolipoma during pregnancy: Case report and literature review. Turk J Ob-stet Gynecol. 2015 Jun;12(2):118–21.

4. Morales JP, Georganas M, Khan MS, Dasgupta P, Reidy JF. Em-bolization of a bleeding renal angiomyolipoma in pregnan-cy: case report and review. Cardiovasc Intervent Radiol. 2005 Apr;28(2):265–8.

5. Koh J-L, Lee Y-H, Kang C-Y, Lin C-N. Simultaneous cesarean sec-tion and radical nephrectomy for angiomyolipoma with sponta-neous bleeding during pregnancy: a case report. J Reprod Med. 2007 Apr;52(4):338–40.

6. Patil SR, Pawar PW, Sawant AS, Savalia AJ, Tamhankar AS. Wun-derlich Syndrome due to Ruptured Pseudoaneurysm of Angio-myolipoma in First Trimester: A Rare Case Report. J Clin Diagn Res JCDR. 2017 Jun;11(6):PD16-PD18.

Nephron Sparing Surgery for Large Extra Renal Angiomyolipoma in First Trimester of Pregnancy

30

28

31

Ferianec (2013) 3

Morales (2005) 4

Koh (2007) 5

Reference Age (Years) Gestational Week

Table 1. Comparison of cases of AML reported in the First Trimester of Pregnancy

10

12

9

Size of Tumour (cm)

10

21

Tumour Man-agement

Not Reported

Nephrectomy

Embolisation

Pregnancy Management

Vaginal Delivery

Nephrectomy Term C/S

Therapeutic Abortion

The tumour in our patient was missed during the first trimester USG. Thus, there is deficiency when scanning patients by confining the study to the pelvis during first trimester obstetric ultrasonographic evaluation. This could be the reason why most AMLs are diagnosed in the third trimester of pregnancy. There is a possibility of hormonal influence on these tumours which cause them to increase rapidly in size during the course of pregnan-cy6. Early diagnosis can obviate the catastrophes of a later diagnosis, which may necessitate nephrectomy or unintentional termination of pregnancy.

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An Interesting Case of Aortoventricular TunnelRenjini B A*, Vinod M*, Aravind*, Sujata Sridharan*

INTRODUCTION

*Dept. of Social Pediatrics, Stanley Medical College, Chennai, India

CASE REPORT

CASE SUMMARY 11 year old male child, born to parents of 3 degree consanguinous marriage, from a middle class socio eco-nomic status presented to us with complaints of palpita-tions. Parents revealed past history of being diagnosed as a case of congenital heart disease at 4 months of age following complaints of failure to thrive and recurrent respiratory tract infections. The child was put on an-ti-failure medication till the age of 5 years. Child was lost to follow up from the hospital from 5 years of age. Currently on examination his pulse was high volume, collapsing and peripheral signs of aortic regurgitation were present. There was evidence of cardiomegaly, S1

Aorto Left Ventricular Tunnel is an extremely rare con-genital cardiac malformation with good long-term outcome after early surgery. The exact incidence is un-known, estimates ranging from 0.5% of fetal cardiac malformations to less than 0.1% of congenitally mal-formed hearts in clinico-pathological series1 About 130 cases have been reported in the literature2.

soft, Hills sign +, Duroseiz sign + Grade 4/6 harsh systo-lo-diastolic murmur heard all over the precordium with diastolic component more over the upper left sternal border. Echo reported at 4 months of age revealed small VSD and Mild AR. Repeat Echo at 2 years of age showed 12 mm tunnel along right side of aorta and sub pulmon-ic VSD. Cardiac catheterization was done at 4yrs of age which showed no evidence of VSD, Separate channel from aorta to LV just above RCA, Regurgitation through tunnel with normal aortic valve. Current CXR confirmed cardiomegaly and ECG showed LVH. Echo showed non valvular AR. 64 SLICE CT showed a tunnel of length 2cm & caliber 7mm originates from the aorta just above the right coronary sinus and cours-ing posteriorly around the aorta and traversing through the interventricular septum and terminating into the superior most part of Lt ventricle just below aortic an-nulus. LV dilated 7 X 7.7cm (Fig 1). Child underwent patch closure of the distal aortic end, direct closure of the proximal LV tunnel and External plication of the ex-ternal tunnel. He is doing well now.

Fig 1: 64 slice CT picture revealing Aortoventricular Tunnel

Corresponding Author: Renjini B A

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REFERENCES 1. Martins JD,Sherwood MC,Mayer LE,Keane JF:Aorto left ventricu-

lar tunnel:35 year experience. J Am coll Cardiol2004,44:446-50.

2. Roxane McKay. Aortoventricular Tunnel. Orphanet journal of Rare Diseases 2007,2:41doi:1186/1750-1172-2-41.

3. Cook AC,Fagg NKL, Ho SY, Groves AMM,Sharland GK. Echocardio-graphic anatomical correlation in aortoleft ventricular tunnel. Br Heart J 1995,74:443-8.

An Interesting Case of Aortoventricular Tunnel

DISCUSSION AV tunnel is an extracardiac channel which connects the ascending aorta above the sino-tubular junction to the cavity of ventricle. Associated defects involving proximal coronary artery and semi-lunar valves are seen. The aetiology is the maldevelopment of cushions which form the aortic and pulmonary root, and the abnor-mal separation of these structures. Although extremly rare AV tunnel is the most common cause of abnormal blood flow from aorta to ventricle in infancy. It usually presents as heart failure in first year life and signs of AR will be prominent. Differential Diagnosis of the condi-tion includes VSD with AR, Sinus of Valsalva aneurysm, Aorto-Pulmonary window, valvular AS with AR. Inves-tigations include Echocardiogram, cardiac catheteriza-

Acknowledgements: Department Of Paediatric Cardiothoracic Surgery In-stitute Of Child Health, Department Of Cardiology, Govt Stanley Medical College, Department Of Radiodiagnosis Govt General Hospital, Chennai

tion, Cardiac CT. Surgical correction is the treatment of choice1,3.

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