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ATHLETES FOOT (TENIA
PEDIS)
A Project work submitted to
Hemwati Nandan Bahyguna Garhwal University,
Srinagar (U.K.)
In Partial Fulfillment of the Requirement for the
Bachelor of Physiotherapy
Under the guidance of
DR. P. NANDITA, PTMPT (Sports)
By
Aprana AgarwalDepartment of Physiotherapy
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Shri Guru Ram Rai Institute of Medical Health &
Sciences, Patel Nagar, Dehradun- 248001
(2006-2010)
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DECLARATION BY THE CANDIDATE
I hereby declare that the project entitled
Atheletes Foot (Tinea Pedis) embodies the work
done by me at Shri Ram Rai Institute of Medical
Health and Sciences, Patel Nagar Dehradun. This work
in part or full has not been submitted to any other
university.
(Aprana Agarwal)
(BPT IV year)
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CERTIFICATE BY THE GUIDE
This is to certify that the project work entitled
Athletes Foot (Tinea Pedis) submitted by Aprana
Agarwal in partial fulfillment of the requirements for
the award of degree of Bachelor of Physiotherapy of the
Hemwati Nandan Bahuguna University, Srinagar
(Garhwal), is a bonafide work carried out by her under
my supervision and guidance during the academic year
2006-2010. Neither this project nor the part of it has
been submitted for any degree or diploma.
(Signature of Guide)
Dr. P. Nandita, PT
M.P.T. (Sports)
Place:
Date:
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ENDORSEMENT BY THE HEAD OF THE
DEPARTMENT
This is to certify that the project entitled Athletes
Foot (Tinea Pedis) bonafied project work done by
Aprana Agarwal under the guidance of Dr. P. Nandita
PT, MPT (Sports) in the partial fulfillment of
requirement for the degree of bachelor of
Physiotherapy.
(Seal and Signature of HOI)
DR. TARANG SRIVASTAVA, PT
M.P.T. (Ortho)
Head of Department of Physiotherapy
SGRRIMHS of SMI Hospital Patel Nagar,
Dehradun (U.K.)
Place:Date:
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CERTIFICATE BY THE EXAMINER
This is to certify that the project entitled Athletes
Foot (Tinea Pedis) submitted by Aprana Agarwal in
partial fulfillment of the requirements for the award of
degree of bachelor of Physiotherapy of Hemwati
Nandan Bahuguna Garhwal University, Srinagar(Garhwal) has been thoroughly examined and approved
by us.
Accepted/Not accepted
(Sign. of Internal Examiner) (Sign. Of External Examiner)
Place:
Date:
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Copyright
DECLARATION BY THE CANDIDATE
I hereby declare that HNB Garhwal University,
Srinagar (Uttrakhand) shall have the rights to preserve,
use and disseminate this project in print or electronicformat for academic/research purpose.
Date: Aprana AgarwalPlace: Dehradun (BPT IV year)
HNB Garhwal University, Srinagar Garhwal (Uttrakhand)
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DEDICATED TO
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Acknowledgement
It gives me immense pleasure and satisfaction to place on
record my sincere thanks and appreciation with respect andregards for an adorable person, Dr. P. Nandita PT, NPT
(Sports), Department of Physiotherapy, SGRR Institute of
Medical Health and Sciences, Dehradun (U.K.), as it was her
blessings, guidance, valuable suggestions and constant
encouragement which helped me to greatly ease the task of
completing this project a reality.
I seek to express my indebted to the all teaching and non-teaching members of the department for their support and
assistance in any way during the work. I would like to thanks
Chirman Shri Mahant Devendra Das Ji Maharaj for
providing al the facilities to carry out the project work.
I also want to express my thanks to Principal Dr. J.B. Gogoi
for their support during the work.
Words fall short to express my gratitude to my father,
mother, brothers and friends whose inspiration, everlasting
moral support and love always elevated my confidence
during the work.
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CONTENTS
Page No.
Declaration by the Candidate iiCertificate (Guide) iii
Endorsement by the HOD iv
Certificate (Examiner) v
Copyright vi
Dedication vii
Acknowledgement viii
Chapters
1. Introduction 12. Anatomy
3. Pathogen
4. Pathogenesis
5. Aetiology
6. Types of Tinea Pedis
7. Clinical Features
8. Risk Factors9. Investigations
10. Differential Diagnosis
11. Diagnosis
12. Treatment
13. Discussion
14. Conclusion
15. References
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INTRODUCTION OF TINEA PEDISAthletes foot (also plus ringworm of the foot and Tinea Pedis) is a fungal
infection of the skin that causes scaling, flaking and itch of affected areas.
Although the condition typically affects the feet, it can spread to other areas ofthe body including the grain.
In fact, its so common that most people will have at least one episode at lead
once in their lives.
Its less often found in women and children under age 12.
Because the fungi grow well in worm, damp areas, they flourish in and around
swimming pools, showers and locker rooms.
Tinea Pedis got its common name because the infection was common among
athletes who often used these areas-
Carol A Tarkington
Synonyms :- Tinea Pedies, foot ringworm, Ringworm, Athletes foot
Tinea Pedis is used the most common form of ringworm in the UK and USA
and is usually caused by anthropophilie fungi such as Trichophyton rubrum,
T. mentagrophytes and Epidermophyton flouovem (Davidson).
These three species of fungi are together responsible for the vast majority of
cases of tinea pedis through out the world.
Trichophyton rubrum is the mostcommon pathogen associatd with
chronic tinea pedis, while other fungal pathogens have also been
associated with the disorder.
The factors affecting the transmission of these dermatophytic pathogens
are dependent on the source of inflation which is usually either human
(anthropophillic), animal (zoophilic) or Soil (geophilic).
Athletes foot spread into the American English vocabulary in a 1928
issue of literary digest: Athlete foot.. is a popular name for
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ringworm of the foot, from which more than ten million persons in the
United States are now suffering.
The association of athletes and this variety of ringworm had to wait
until the twentieth century, when Americans, including athletes finallybegan to take a serious interest in hygiene. Occasional baths had been
the limits of American cleanliness in previous centuries.
Now, not only did athletes have running water in their locker rooms
(itself a term of the first dude of the 20 th Century), they had communal
showers. Floors in the locker room environment are usually wet,
making ideal conditions for lurking fungi.
In fact, medical authorities say, the association with athletes is
unfounded. Most people already carry the fungi, one recent estimate is
that 70 percent of the population may be affected to one degree or
another.
The little organisms thrives in moist and airless environments like that
created by wet feet in shoes. If the skin between the toes is kept healthy
and dry, we rarely have problems with athletes foot.
How do you catch tinea pedis People often caqtch tinea pedis by
walking barefoot where there are fragments of skin or nail shed by an
influted person. This most commonly occurs around swimming pools
and public showers. It can also be picked up in showers at home.
If tinea pedis is not treated or is particularly bad sometimes the nails
can also become influted. This causes them to become chalky and
thickened.
Athletes foot can be treated but it can be tenacious and different to
clear up completely.
Athletes foot can be prevented by good hygiene, and is treated by a
number of pharmaceutical and other treatments.
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ANATOMY OF FOOT & SKIN
FOOT:
The foot is the region of the lower limb distal to the ankle joint. It is
subdivided into the ankle, the meta-travels & the digits.There are five digits consisting of the medially positioned great toe (digit I)
and four more laterally placed digit, ending laterally with the little toe (digitV)
The foot has a superior surface (dorsum of foot) and an inferior surface
(soles).
BONES:
There are three groups of bones in the foot:-
The seven tarsal bones which from the skeletal framework for the
ankle. Meta farsals ( I to V) which are the bones of the metatarsus.
The phalanges which are the bones of the toes-each toe has three
phalanges, except for the great toe, which has two-
o Proximal Group:-
It contains Talus: It is the superior bone of the foot. It articulates
with the tibia & fibula to form the ankle it.
o Callaneus: it is largest of tarsal bone. It articulate with one of the
distol group of tarsal bones.o Intermediate:
o Navicular: It is boat shaped. This bone articulates behind with the
talus and articulates in front & on the lateral side with the distol
group of tarsal bones.
o Distal Group:-
o Cuboid: Articulates behind with the caleaneus & in front with the
base of lateral two metatarsals.
o
Cuneiform: Lateral, medial & intermediate cuneiform bonearticulates with naucular bone & in front with bases of medial
three metatarsal.
o Metatarsals: There are five metatarsals in the foot, numbered I to
V from medial to lateral.
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Each metatarsal has a head at the distal end, an elongate shaft in
the middle & a pronimal base.
The head of each metatarsals articulates with the pronimal
phalamn of a toe and the base articulates with one or more of the
distal group of tarsal bones. Plantar surface of the head ofmetatarsal I also articulates with two lesamoid bones.
PHALANGES:
Are the bones of the toes. Each toe has three phalanges (Pronimal,
middle and distal) except for great toe which has only two (proximal & distal)
I. Appendix of skin:
a. Nails are hardened keratin plates on the dorsal surface of the lips of
fingers & toes.
b. Hairsc. Sweat glands
d. Sebaceous gland
Function of skin:
Protection
Sensory
Regulation of body temp
Absorption
Sevelion Regulation of pH
Synthesis
Repair alive
II. Superfival fascia: It is general coating of the body beneath the skin,
made up of loose areola tissue with varying amounts of fat.
III. Deep fascia: is a fibrous sheet which invents the body beneath the
superfavial fascia. It is devoid of fat & is usually inelastic & touch.
SKINIt is the general covering of the entire internal surface of the body.
The colour of the skin is determined by at least five pigments present at
different levels and places of the skin. There are-
1. Melanin: brown in clour.
2. Melanoid : resembles melanin
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3. Carotene : yellow to orange in colour
4. Hemoglobin : Purple
5. Oxyhalmoglobin : Red
Thickness : The thickness of skin various from about 0.5 to 3 mm.
Structure of Skin:Skin is composed of two distinct layers, epidermis & dermis.
(A)Epidermis: It is the superficial, a vascular layer of stratified squamous
epithelium. It is ectodermal in origin and gives rise to the appendages
of the skin, namely hair, nails, sweat glands and sebaceous gland.
*Structurally, the epidermis is made up of
Superficial cornfield zone.
A deep germinative zone
The cornfield zone includes three strata of cells namely - Stratum corneum
Lucidum
granulosum
The Germinative zone inclues two strata-
Stratum Spinosum
basale (Stratum germinatium or malpighion layer) of a
single layer of columnar cells).
(B)Dermis or Corium: It is the deep, vascular layer of the skin, derivedfrom mesoderm, it is made up of connective tissue mined with blood
vessels, lymphaties and nerves.
The connective tissue is arranged into a superfivial papinary layer and a
deep reticular layer.
Synovial shealb in the ankle region:-
The tendons that cross the ankle joint are all deflated to some degree
from a straipht course, and must therefore be hold down by retinacula
and enclosed in synowal shealths.Plantas fascia: or aponeurosis is compound of densely con-paited collegen
fibres oriented mainly lorfiludinally, but also transversely. It have three parts=
(1)Central Part:- It is attached to the medial process of the caleaneal
tuberovity. It becomes broader and somewhat timers as it diverges
towards the metatarsal heads.
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(2)Lacteal part:- It forms a stronger band, sometimes containing nurell
fibers.
(3)Medial part:- It is continuous pronumally with the plen retin acleem.
Foxial Compartment of the foot:
There are four main compartments of the plants aspect of the foot (Jones1949) (Fog 115.7).
Medial Compartment
Central Compartment
Lateral Compartment
Interossous Compartment
Muscular of the sole of foot:
It have been divided into four layers:
Plants muscular of foot (first layer) Abductor nalluis: Abdwlion of xallure
Flenor degelorum breuis: flexes the lesser tol
Abdutos digiti mimimi: it is more a plenor of the little toe metatarso
phalangeal joint than an abduetor.
Pto Second layer: Intermsus numerals
Flexon diglorum layers
Flexon halluis layer
Hlenos dijitorum ouessoriusLumbrual muscles:
Entension of the interphalangeal joint of toes there are four muscle numbered
from medal to lateral:
Planfor third layer :
Hlexor Halluis breuis: flexes the pronemal phalamx of the halluse
Addiction halluis: partly flexes the pronemal phalamx of the halluse but also
stabeleres the metaforsal heads.
Flenon digiti mimimi breuis : flenes the M7PJt of little toePlantas fourth layer:
Dassal Interossei: Flex M7PJt & entend the JPJt of lesse toes the
hallum & little toe have their own abdutos.
Plantar interossei: Adduit the 3 & 4, J toes, flex the M7PJy & extend
the JPJt.
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Tibialis pusterion
Peroneur lonyus
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PATHOGENS
There are three species of fungi:
1. Trichophyton Rubrum
2. Trichophyton mentagropfytes
3. Epidermophyron flousoum
There are together responsible for the vast majority of cases of tinea pedis
through out the world.
1. T. rubrum: A recent study showed that T. rubrum accounted for over
76% of all dermatophite infections including tinea pedis and may
account for over 213 of all tinea pedis infections.
It appears in two forms:
a. The first is typically white and fluffy in appearance with several
aerial hypae and is called the downy form.
b. The second is granular form, however & flat and has no acuial
hyphae.
T.Rubrum not always, wine colored on the bottom.
2. T. mentaqrophytes: is morphologically and characteristically similar to
T. rubrum. Both have a downy or granular appearance and are
sometimes indistinguishable under the microscope.
T. Mentaqrophytes species can be pale yellow on the underside.
3. Epidermophyton flouosum: is an anthrophilic fungus found worldwide
and has been ineriminated in several types of tinea inflections.
Colonies of this fungus are flat and grainy and range in colour from
yellow to brown.
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PATHOGENESIS
T. Rubrum, T. Mentagrophytes, Epidermophyton flououm most
commonly cause tinea pedis, with T. rubrum being the most common
cause world wide.
Trihopyton tonsurans has also been implicated in children.
Nondermatophyte causes include seytalidim dimidiatum, scytalidium
hyalinum an merely, candida species.
Using enymes called keratinases, dermatophyte fungi include the
superfinial keratin of the skin and the infection remains limited to this
layer. Dermatophyte cell walls also contains manners that may reduce
keratinoyte proliferation, hesulting in a decreased rate of sloughing anda chronic state of infection.
Temperature and serum factors, such as beta globulins and ferritin,
appear to have a growth inhibitory effect on dermatophytes; however
this patho genesis is not completely understood. Sebum also is
inhibitory,thus partly explaining the propensity for dermatophte
inflation of the feet, which have no sebaueous glands. Host factors such
as breaks in the skin and maceration of the skin may aid in
dermatophate incasion.
The cutaneous presentation of tinea pedis is also dependent on the
hosts immune system and the infecting dermatophyte.
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AETIOLOGY
Athletes foot is caused by a fungal infection of either one, or both of
your feet. All have bacteria and fungi on skin, most of which are
harmless. However, in some conditions, these organisms can multiply
and cause skin to become infected.
Athlete foot is caused by a group of fungi dermatophytes. These fungi
are parasitic, which means they feed off other organisms to stay alive.
Feet provide a warm, dark and humid environment, which are the ideal
conditions needed for dermatophyte to grow.
Mostly athletes foot is caused by one of two of types of fungus.
Truchophton mentagrophytes:- Often cause toe web or vericular
infection.
Trichophyton rubrum:- often causes moccasin type inflections. Thiscondition lasts for a long time (Chronic) and is difficult to treat.
Athlete foot when come in contact with the fungus, it begins to grow
on skin. Fungi commonly grow on or in the top layer of human skin
and may or may not cause infections.
Athlete foot is easily spread (containers):- we get it by touching the
affected area of a person who have it. More commonly, pick up the
fungi; from damp, contaminated surfaces, such as the floors in
public showers or locker rooms. Although athletes foot is contagious, some people are likely to get it
(susceptible) than others.
Susceptibility may increase with age. Experts dont know why some
people are more likely to get it. After athletes foot, people are more
likely to get it again.
After coming in contact with the fungi that cause athlete foot have
the channel of spreading the fungi to others, whether you get the
infection or not.Additional causes include irritant or contact dermatitis, allergic
rashes from shoes or other creams, dyshidrotic eczema (skin allergy
rash), psoriasis, keratodermie blenorrhagium, yeast inflections and
bacterial infections.
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TYPES OF TINEA PEDIS (FIGURES)
Depending on the pathogen and anatomical distribution, tinea pedis may
present in a given patient as one of several syndromes. Typically, three
variants are seen and include the interdigital, Bilateral moccasin and
vericobullous forms of the disease.
(1) Interdigital Tinea Pedis:- It is the most common form and usually
manifests in the inter space of the fourth and fifth digits and may spread to
the undervide of the toes (figure 1) (4,8) Patient complains of itching and
burning sensations on the feet auompainted by malodor. T. melagrophytes
are mainly isolated with this. There are generally two types of interdigital
tinea pedis:-
a. Moccasin type tinea pedis: It is a more severe, prolonged form oftinea pedis that covers the bottom and lateral aspects of the foot. Its
appearance is that of a slipper or moccasin covering the foot. T.
rubrum is most commonly associated with this 2A gif shows
xyperkerototc skin on the medial
(2) Vesiculabullous tinea pedis: Comprises pustules or vesicles on the instep
and adjunct planter surfaces of the feet and is less common.
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CLINICAL FEATURES
Chronic kyperkeratotic refers to patehy fine dry scaling on the sole
of the feet.
Moccasin tinea is entensive hyperkeratotic tinea: in which skin of
the entire sole, heal and sides of the foot is dry but not inflamed.
Athletes foot is most peeling irritable skin between the toes, most
often in the cleft between the fourth & fifth does.
Clusters of blisters or pustules on the sides of the feet or insteps
(more likely with T interdigitale)
Round dry patches on the top of the foot (ringworm like tineacorporals)
Ringworm
Jock itch
Dryness
Itching
Burning
Scaling
Gauked skin
Nail infection
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RISK FACTORS
Risk of getting athlete foot increase if, by mayo clinic staff.
Are a man
Frequently wear damp socks re light filling shoes.
Wear closed shoes, especially if they are plastic lined.
Share mats, rugs, bed linens, clothes, shoes with someone who has a
fungal infection.
Sweat a lot.
Develop a menor skin or nail injury.
Frequently visit public areas where the infection can spread such as
locker rooms, saunad, swimming pools, communal baths & showers.
Have a weakened immune system.
Reference:
Nov. 22, 2008
1998-2010 Mayo foundation for medical education & research (MEMER)
Mayo Clinic, :Mayo Clinic.com.
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INVESTIGATION
Physician can perform a simple test called a KOH, or potassium
hydroxide for microscope fungal-examination, in the office or
laboratory to confirm the presence of a fungal infection. This test isperformed using small flakes of skin that are examined under the
microscope. Many dermatologists perform this test in their office
with results available within minutes. Rarely, a small piece of skin
may be removed and sent for biopsy to help confirm the diagnosis.
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DIFFERENTIAL DIAGNOSIS Psoriasis
Contact dermatitis
Dyshidrotic ecrema
Scabis Pithed kerololysis
Eczema
Erythema
Diabetes
Gout
Ingrown toe nail
Clelluclies
Phleliutes
Asteomy eliteb
Paronyehia
Pseudogoul
Psoriasis : It is a non-infectious, chronic inflammatory disease of the skin,
characterized by well defined erythematous plagues with slvery scale.
Contact Dermatitis:- Inflammation of skin caused by numerous condition
including contact with skin irritants. Marked by itching and redness.
Scabis:- A contagious infection of the skin with he itch mite, sarcoptes
scabiei. It typically presents as an intensely prurtic rash, composed of scaly
papules and secondarily infected lesion distributed in the webs between the
fingers.
Eczema :- It is an itchy red rash may result from various causes including
allergies, irritating chemicals, drys or rubbing the skin, sun exposure.
Dyshedrotic & Pompholyx
Erythema:- Reddening of the skin. It is a common but non specifc sign of
skin urrelalion, injury or inflammation.
Clelluclies :- A spreading bacterial infection of the skin, caused by
strephocoual or staphylocoual infections, result in severe information with
eryhema, warmth and localized edema.
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Phlebitis: - Inflammation of vein caused by chemical or mechanical
irritation of veins by thrombosis, indwelling catheter or venous infections vein
may be painful, tender, red or swollen.
Paronyehia:- Bacterial infection of the posterior nail folds.
Irgrown nail:- Causes severe pain in the distal nail folds with associated
erythema, edema and tenderness.
Gout:- Monosodium urate bustal deposition secondary to hypercurillmia
Severe pain, redness and swelling occurring in one joint usually of the lower
intermity, and mainly MJP joint of great toe (Podagra).
Pseudogout:- Calcium pyrophosphate deposition disease can affect the
toe, but the knee is most common.
Osteomyelitis:- Infection of the bone by micro-organism it is also used for
infection of the bone by pyogenic organism.
Diabetes
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DIAGNOSIS
Diagnosis of tenia pedis is based on history and clinical appearance of the feet
in addition to direct microscopy of a potassium hydroxide (KOX) preparation.
Cultures or histological examinations are rarely required.
A woods lamp is not usually helpful in diagnosing tinea Pedis but can be
used to rule out other diagnosis like infection with Malasseria furfur (1) or
ertthrasma.
Malasseria furfur and corynebaiterium minutissimum both fluoresce under
ultraviolet light while other common dermatophytes do not.
KOX preparations are simple, inexpensive, efficient and widely used.
KOX preparation has an excellent positive predictive value.
Occasionally, false negative results may be obtained, especially if treatment
has already begun.
DIAGNOSTIC TEST INCLUDE:
A CBC
Sedimentation rate
Chemistry Panel
VDRL test
X-ray of foot
If peripheral pulses are diminished, Doppler studies and angiography
should be considered.
If there is diffuse swelling and erythema: venography may need to be
done.
If there are neurologic findings: nerve condition velocity studies and
EMGs (electromyograms) may be helpful.
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PESTS
CONTROLA Project work submitted to
RAM LUBHAI SAHANI GOVT. MAHILA
MAHA VIDHYALAYA (PILIBHIT)
In Partial Fulfillment of the Requirement for the
Bachelor of Science (ZOOLOGY)
By
MAHIMA SAXENAB.Sc. (Final) Zoology
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Affiliated to M.J.P. Rohilkhand University, Bareilly